Running Time: 40 min
Decision Making in Plastic Esthetic Periodontal Surgery
Release Date: January 26, 2018Subtitle:
[MUSIC PLAYING] Thank you gIDE for the very kind invitation. And thanks to my personal friend, Sasha Yovanovich, for the kind invitation to share with you what we know in this topic that is very interesting. It’s the decision-making in plastic aesthetic periodontal surgery. Because this procedure– first of all, do we need the plastic aesthetic periodontal surgery? Second is, there are different techniques available. And I can see around the world, there is people that masters and learns one technique– take a course with of the other authors– and then always will perform the same technique. Of course, there are some leaders in each technique that can select this technique for all cases. But in general, there are some indication, for one or the other technique, and how to modify these techniques. So we will go into details of this topic today. Do we need, first of all, mucogingival surgery? How often do we need? Yes we do, no we don’t, and why we need the mucogingival surgery. The evidence from the European Federation of Periodontology, the consensus of the 2014 from this paper from Francesco Cairo, and the consensus from all the Committee of the European Federation, about the efficacy in periodontal plastic surgery. As well as the American Academy Periodontology had a consensus in 2015. This was an hot topic in this period, because aesthetic is always more important, et cetera. And what we learn from this two consensus is that the procedure can be supported. The mucogingival procedures offer a significant improvement for the aesthetics of our patient. And some techniques are not indicated by the others. Like coronary advanced flap. And especially coronary advanced flap together with connective tissue graft. Or with collagen matrix, added with the aim to increase the thickness and stabilize the margin and the clot. But if we do nothing, what happen? If we have a gingival recession, we have the same biotype, and we do nothing, what happens to the area in the years? That is the very interesting paper from Giancarlo Agudio. Giancarlo Agudio is a active member of the Italian Society of Periodontology, and is a very elegant clinician. And he evaluated his patient, and he saw long-term– up to 27 years. From 10 to 27 years, all the cases where he did a graft one side, and did it nothing to the other side. And he did two type of graft. The free gingival graft was placed submarginal, or was placed marginal. And he tried to understand what happened to this. As you can see in the graphics below, the left side, you can see where nothing has been done. The control side. There is the tendency, the gingival recession will proceed. When he placed the graft, after 27 years, you see there is a regrow of the tissue. The tissue not only is where has been placed with the surgery, but has the tendency to regrow. Same for when the free gingival graft is placed at the marginal level. As you see, when it’s placed nothing, the control side will continue the recession. When you place the free gingival graft, there is the tendency to regrow over 27 years. You have more details of this paper that are being published on Journal Clinical Periodontology in 2009. And you see, there is a significant number of patients, because it’s 55 patients that offer 73 sites as a test group. So it’s a significant number, it’s a good statistics to know. Especially this patient has been followed for a period of– as I said before– for 27 years. Very interesting data, so read this paper when you find the time. Another literature review– very important– is this from Leandro Chambrone and Dimitris Tatakis, that they published on the Journal of Periodontology in 2016. That untreated recession differed in subject with good oral hygiene have a high probability of progressing during long-term follow-up. Because gingival recession in same biotype, if you do nothing, and the patient continue to brush in a very aggressive way, have the tendency to continue to improve. So it’s very important to balance, and oral hygiene is very important for our patients. Some patients, they just brush, let’s say, too much. And in a wrong way, too aggressive way, and they destroy their own gums. It’s very important to put under control the hygiene phase of our patient, even before surgery. Because there is a risk that you will regrow the tissue, you will recapture the tissue, the gingival margin high. And then they go home, and with the same way that they were brushing before, they will cut again your gums, and you will have gingival recession again. So we performed a study to try to understand if the manual brush was better than the soft toothbrush. And this study is very interesting about the soft bristle toothbrushes. Manual and powered toothbrush. We did in this study a comparison in a very weak moment just after mucogingival surgery, when we removed the suture. And we gave to the patient in a randomized way– 60 patient, 30 and 30– two different type of information. How to brush and how to clean. And we were very surprised to find that the patient that– this, you see the [? anagraphic ?] of this has been published on Journal Periodontology. You can find it. And the mean of root coverage– what we found– was 91% at one month with the manual, and 96% with the powered. But as you can see, after six month was a little bit less. It was 86% with the manual, and was 99% with the power. So there has been a recapture of the gingival margin. There has been a rebound, a regrow of the soft tissue, like a creeping attachment. Cleaning properly. Not in aggressive way, but efficacy. Removing the plaque properly in that area. And as well as in terms of complete root coverage, we have a little bit less result after a month. But as you can see, after six months, there is an improvement when the patient were using the power toothbrush, compare when they were using the manual toothbrush. This result were very surprising for us too, but it’s very interesting to see the data of this study, and how important is the maintenance phase for this patient that have gingival recession. So we do need the mucogingival surgery for what? To boost the gums’ biotype, and for aesthetic purpose. This is the most reason why we do. It’s actually not to change the prognosis of the teeth, just to have a more stable. But if in 27 years tell us, our friend Giancarlo Agudio, that we will lose one, two millimeters, OK, the tooth is still there. If he had a pocket, we have lost the tooth after 27 years. But with a little gingival recession, it will continue. So of course, we want to have perfect patient, so make sense to boost the biotype of our patient, in this case. And teach them how to clean properly. By the way, the aesthetic is something that is very subjective. And in this study from Roberto Rotundo, he saw that the aesthetic perception from our patients is that complete root coverage is the main successful outcome, typically. But a partial root coverage is usually accepted when– in case we have a very deep recession. And in case of non-dischromic root. The root is colored, it is black, that this is going to be a problem. But if the root has the same natural color as the crown, it’s going to be good and acceptable for our patients. And when you have cases like this– this Is a study done from Francesco Cairo. As you can see, all the cases are before after, before after, before after. Do you like all these cases? Or in some cases, like in the case up to the right– you see the case up to the right– do you like that case? This is a complete root coverage, but do you like it? Or maybe this vertical incision that you can see. The difference of color, of blending of the tissue, or maybe the tissue too bulky, you maybe don’t like. In some other cases as well. You can choose which one you like, which one you don’t like. And so it’s not only the root covers that is important. Sometimes, we are too focused on complete root coverage, and we don’t care about the other things. [? Never, ?] one of your patients complain about the fact that the tissue was too bulky when you grafted the side. Now this side is too thick, is too bulky. For us as a dentist, it’s a perfect case. But the patient maybe doesn’t like, because it’s a patient with same biotype everywhere, except in one area where it’s too bulky. The patient see this as a scar in his body. A perfect aesthetic is when everything is done in a way, and you don’t even see that has been done a surgery. This is a good aesthetic case. And so the root coverage aesthetic score, published by Francesco Cairo and coworkers. I was in the group that gave a contribute to this paper. It’s interesting to see, we analyzed the gingival margin level. It’s very important, it’s the key factor. But it’s very important, also, the marginal tissue contour, the soft tissue texture, the mucogingival junction, and the gingival color. All these parameters contribute, not only the complete root coverage or not. Even if it gives the best– of course, it’s the principal aim that we have. There are some surgical factors where we perform a surgery. Some surgical factors that will influence the outcome. And there are especially three points. Then, you can use the technique that you like more. But you have to be successful, you need to respect these three points. The first point is the flap tension. You should use a flap that has no tension. Because Penny Prato and coworkers in 2000 Journal Periodontology published that if you have a residual tension of four millimeter, or less, you have 100% of success. When you have a residual tension of 50– sorry, of 10 grams, then you have 50% of failure, and 50% of success. And this is the difference. You need to have less than four grams. The flap need to be very, very free, and with not tension. With some technique, it’s very difficult to make the flap free of tension. For example, when you don’t release– you don’t cut the papillas, and you do like a tunneling procedure, this is going to be very difficult– at least for me– to release the periosteum and advance the flap properly. At least, if you perform the surgery in three, four teeth, you want to be beneath more teeth involved in the procedure. In other cases, when you want to avoid– in general– the verticals, it’s more difficult when the verticals is maybe a little bit easier to have this tension control of our flaps. And then to have the– I can show you a little video, how do we release the flap tension. In case we cut the papilla, this is Giovanni Zucchelli procedure. And as you can see, through the periosteum, we release the muscles from the flap. We try to make the flap as thinner as we can, in a way that we detach the muscles from the flap, and we leave the muscles attached to the bone. So we want to be very, very free. And we want to be able to displace our flaps significantly more coronal. Otherwise, it will recede, and we will not have success. The second surgical factor– very important– is the flap thickness. So again, the group of Pini Prato with Baldi and coworkers in 1999 on Journal Periodontology. They published that if the tissue is thick– at least 0.8 millimeter– and this 0.8 millimeter, we have 100% of success. And you don’t need to graft, because it’s already successful. But when you have– the thickness is 0.4 millimeter, you have 66% of success. And you see, the percentage of success change according to the thickness of the flap. So probably, in this difference of thickness, we can also address the type of graft that we will need. For example, if the biotype is very thin– if we have 0.4– probably, we will need a connective tissue graft, definitely. In the other cases– maybe when you are in the middle– you probably can use– you can be successful also with the collagen matrices and some soft-tissue substitute. But you have to know that the literature says that the best material is always the connective tissue graft. But I know that sometimes, in very extensive cases with some palatal anatomy– palatal characteristic of the patient, also physical characteristics of the patient– this is very difficult to have with the connective tissue. In this case, when is this medium type of biotype, maybe we can use some substitute. And this is the thickness of the tissue. You see in this case, we were removing Gore-Tex membrane placed for bone regeneration, vertical augmentation. You see a nice soft tissue thickness of this case. And to assess the biotype of the patient, this Colorvue Biotype Probe from Hu-Friedy available. This biotype probe has three colors, white, green, and blue. And in case you can see all the tips into the circles, that means it’s the same biotype. If you don’t see the white, but you see the green and the blue, means it’s a medium biotype. If you don’t see the white or the green, but you see the blue, it’s a thick biotype. If you don’t see any, it’s a very thick biotype. So according to this, you can choose which procedure to use. And you can use the graph of the substitute. Or nothing in case of very thick biotype. And the third factor is the gingival margin position. This, again, is a very important issue. As you can see, if you place the gingival margin at the level of the CEJ, you have only 15% of success. If you place the gingival margin half millimeter more coronal than the CEJ, you have 40% of success. If you place the gingival margin one millimeter more coronal than the CEJ, you have 71% of success. You need two, 2.5 millimeters more coronal than the CEJ to be 100% success. So you really need to place your gingival margin significantly coronal, respect to the CEJ, to be successful. And this is the third factor. So the three factors are, the flap should be with not tension. The flap should be thick, otherwise, we need to graft. And the gingival position should be at least two, 2.5 millimeter more coronal than the CEJ. Now you can use the technique that you want. You want to use coronally-advanced flap, use that. You want to use the double papilla, use the double papilla. You want to place the laterally-positioned flap, use that. You want to use the tunneling technique, use the tunneling technique. It’s important to train ourself to learn and to master more than one technique, I would suggest. Because all can help, can be needed, in several different cases. And these are, for example, some of the cases. The coronally-advanced flap, the double papilla flap, the laterally-positioned flap, the multiple type of defects, and the connective tissue graft. In this topic about the decision making, Kenneth Korman asked me to write the first paper for clinical advances in periodontics. Is edit by the American Academy of Periodontology. And so we submitted this paper. In 2011, it was published. And there is very good rationale, which technique to use in which case. And the parameter that we took were based on the anatomy of the defect. First of all, if it’s a single or multiple type of recession. The presence or not of keratinized tissue. If you have at least one– I would say two, but is acceptable– one millimeter of keratinized tissue apical to the gingival margin, you can apply the coronally advanced flap. Otherwise, you will need to find another solution. The biotype of the patient, that will tell you if you need to graft or not. Because if it’s a very thick biotype, you just do coronally advanced flap, that’s it. If it’s a thin biotype, very thin biotype, you will need to do a coronally advanced flap, or one of the other techniques, but for sure with the connective tissue graft. In case of vestibule depth– that is another anatomical parameter– that is very shallow, you will need to find another solution. You cannot displace the flap coronal, or you will need to find other solutions. In case of very deep depth of the vestibule, you will be able to advance the flap coronally very easily. And it’s very important to see also the neighbor tissue. Because in case you need, for example, a laterally-positioned flap, but you don’t have any neighbor’s tissue available, so this is not possible, of course. And also the size of the papilla, in case you want to do the double papilla flap, you need to have anatomical characteristics that allow you this procedure. To find the best for each patient, for each site, every time. In case of Miller Class III, we know that tunneling technique is most indicated. It’s the most successful procedure in case of Miller Class III, when you miss the complete representation of one of the both papillas in the coronal part, in coronal aspect. And when we do the coronally-advanced flap, technically, it is important to perform our horizontal incision according to– this is the procedure described by Zucchelli and de Sanctis. And at the base of the papilla, mesial and distal, you perform two horizontal incision that are generally three millimeters– depend how the convexity of the root can be also 3 and 1/2, 4 millimeters, in cases very convex. Or can be 3 as a normal base. And then we perform mesial and distal to vertical-releasing incision until the mucogingival lining. We need to cross the mucogingival line, and to go five millimeters more apical than the mucogingival line. And then we can de-epithelialize our– you see, we can elevate the flap, mesial and distal, partial thickness with a scalpel. The corner of the new papilla just elevated with a scalpel. In the level where there is the recession, it’s important to go full thickness with the elevator. Because it is the weakest part of the– the most delicate area where we are working. So we need to maintain all the thickness as possible, so we go full thickness in this area. And then we go partial thickness again to release the periosteum, as we have seen before, so we will be able to advance the flap. Now we de-epithelialize the papilla, as we’ve seen. And we can suture our flap, because in this case, for example, it’s a thick biotype. So it’s enough to advance the flap coronally, and to suture the flap coronally, with a sling suture to keep the papilla very stable. And as you can see, several suture in the apical direction that will stabilize the two verticals incision. These verticals, they goes from apical to coronal in a way that they help the sling suture to keep the flap as coronal as possible, and with not tension. You can tell in this photo that the flap is there, stable with no tension, and will be successful. And you see in this video how to de-epithelialize the papilla, mesial and distal, with the scalpel 15C. Very often, they ask me if you can do that with a drill, with a burr. Don’t do that, because if you use a burr, you can touch the neighbor teeth. And you are more precise with a scalpel. You go from apical to coronal. It is very important to reach the tip of the papilla. Sometimes, when the root are very prominent, it’s difficult to reach the tip of the papilla. So in case you cannot– you see we are doing this in the video in the left. And now, you see when the root are very prominent, you can’t reach the tip with the scalpel. You can use the scissors. So you will just remove the epithelium up to the tip, mesial and distal, the papillae in this nice and easy way. This is a key point. This is very important to achieve a good optimal aesthetics of our cases. We can see a video of how to perform the sling suture. The sling suture can go into the flap, turn around the tooth, into the flap again, as you can see. And then we turn around the tooth one more time, and we close the suture. In this case, we like to have the two sutures that stay outside, and we create some compression on the flap, and we keep the flap stable coronally. And that will keep stable and well-attached to the tooth. And this is the knot. I move a little bit forward in this case, but you see the nice knot. And this suture is just into the soft tissue, the buccal soft tissue, into the flap. And keep the flap as coronal and as attached to the the tooth as maximum as it can. Now, sometimes you need this link blocked. For example, when it’s a multiple recession, you need not only to place the flap more coronal, but to stabilize in that precise place. So you go into the flap, in this case, and you go into the de-epethilialized papilla also. So you block your flap in that position that you decide. And then you turn around the tooth. Again, you enter into the flap. You enter exactly where you like into the de-epithelialized papilla. And in this case, again when you close your suture, you will block the flap exactly in that position. And one more time, I like the two sutures that are outside, and will create a gentle compression of your papilla, or your flap, on the tissue that are below. And so that will be very stable and very nice. This is another type of flap, again described by Giovanni, Giovanni Zucchelli. This is a triangular type of defect, the flap design. As you can see, we can have this– in case we have these two millimeters more possibility of keratinized tissue, this is allowed. This type of procedure will give you a better aesthetics immediately, immediately after. It’s a little bit more sensitive. It’s a little bit more complicated to do. You need some training. But it’s important. The concept is about the fact that you evaluate the distance. You can see in the third photo, when there is the red line with the dot. You see, you take the measurement of exactly how long you want the gingival merging from one papilla to the other papilla. And where do you want, he goes. Now you take this measurement, and you go on the recession that you have, the soft tissue that you have. So you will have the exact measurement where you need to start with your vertical releasing incision. So you will need to do the two vertical releasing incision that should be significantly divergent. And you can do partial thickness, as you can see. And you will elevate your papilla with, again, with a scalpel. You go full thickness at the level of the recession, so you will maintain– preserve– the thickness of your tissue as much as you can. In this case, you can, again, replace your– you release the periosteum, you advance your flap. And you stabilize your flap coronal with this suture that goes from the flap– apical– to attached gingival– coronal. So this will help your sling suture to keep all the tissue stable and coronal, to have a very good healing. In case of same biotype, you will place a connective tissue graft as well. But this is very important. Don’t modify. You see the aesthetic? It’s pretty good, because you don’t see that has been done a surgery. If you see that has been done a surgery– because it’s very thick, the tissue, compared to the neighbor’s teeth– it’s not good. You shouldn’t have scar tissue around. It looks pretty and good. And about the double papilla. In this case, for example, we have a very thin layer of keratinized tissue, so it’s very difficult to move this flap more coronal. There is a good mesial and good distal papilla. So in a case like this, I would recommend, for example, to go with the double papilla. You keep all the mesial and distal papilla, you go a little bit more apical to the mucogingival line. You can release your flap partial thickness, you suture the two papilla, and then you stabilize your papilla again with a sling suture. And you stabilize the flap– the two papilla attached to the tissue. And in this case, was the same biotype, so we place the connective tissue graft below. And as you can see, the result was pretty good. And as well in this case, it’s a very minimum recession, but there is a nice mesial and distal papilla. And also in this case, we did double papilla flap, and that was again, successful. This other case has keratinized tissue apical to the mucogingival line, but there is a very good donor-side distal. So in this case, we did the laterally-positioned flap. The laterally-positioned flap, it’s– the design– it’s based on the fact that the length of the tissue should be– you should consider that the flap need to overlap the mesial part. If you harvest the tissue from distal, you need to overlap at least three millimeters of connective tissue mesial to the tooth. And three millimeters distal. And you have to keep in mind that you also add the convexity of the root. So you have to keep all the length of the root, three millimeters mesial, and three millimeter distal. So cannot be a very small flap. Need to be a little bit wide, as you can see here. And you can see in the first photo below on the left that the flap is very nicely adapted. And you can see it’s not pulled there. It’s there very naturally, even if it’s stabilized with the suture. And you will need the suture to stabilize also the distal part to the periosteum in a way that you can create a very stable type of environment for our wound. The mesial part has been de-epithelialized in a way that our flap can be well adapted. And as you can see, the result is pretty significant. So now I want to give you some data, because this is a very important topic, I think. The stability of the root coverage outcome at single maxillary gingival recession. We published– and now I’m showing you, before– we are going to publish now. But I want to show you the results at nine years, what we found. Because together with Cortellini, Pini Prato, Tonetti, and all the group, we published in 2009 on JCP a randomized controlled clinical trials in a single gingival recession treated with a coronally-advanced flap alone, or with a connective tissue graft. And the result was that after sixth month, was better to place the connective tissue graft. So I in my clinical center continue to follow the patient. All the patient receive the information to brush and clean with soft bristle power toothbrush. So all my patients were continuing to brush with this technique. It’s important, because when you evaluate the nine years’ result, the maintenance is the key factor, more than the surgical– surgery that has been done, I think. But actually, the surgery that has been done is an influence. But all the patient were standardized with power toothbrush, oscillating, rotating, and very stable. So the question is, the use of the connective tissue graft– together with the coronally-advanced flap– increase the stability long term of the outcomes, or not? So I cannot give you all the data, because as I told you, it’s not published yet. I think it should be published soon. But we submitted to the JCP, Journal Clinical Periodontology. But I show you this graphic that gives you the final outcome. As you can see from the left, at the baseline, the CEJ, in case of connective tissue graft, there was a recession average of 2.4 millimeter. After six month, was average 0.8. After one year, was average 0.6. After nine year, it’s 0.5. You see, that is a continual regrow of the soft tissue. There is the tendency of the tissue to be more thick with both the techniques. But let me stress this point. This study is a randomized controlled clinical trial. What does it mean? That means that we can have patients that are thin, medium, thick, and very thick biotype. So we know that the same biotype with the graft will be thicker. A medium biotype will be thicker, and will turn at least medium or thick. When the tissue biotype is already thick, will be very thick. But in case we have a thick biotype– very thick biotype already– we don’t need to graft and to have a very, very, very thick biotype. Sometimes it’s just too much. It’s an over-treatment for our patients, and that can create us a problem. So when we randomize the patient, we have different type of patient. We don’t randomize this in our studies. So in randomized clinical trials, you don’t know your patients, what’s the biotype. In the one published, at least. So we know we have this for population of patient. Very thin, thin, medium, and very thick biotype. So the population can be mixed, and we can have these two group. We can have this two group. And this two group could be, like for example, in this way. So in the left group, we could have a significant benefit from the connective tissue graft. But in the right group, we don’t, for example. So if we have this two group and we graft this area, we will have this situation in the right side and in the left side. Of course we lose. In the other hand, if we have a different situation, we will have a better benefit. So we should balance– in the next randomized controlled clinical trial in soft tissue– we should randomize also the biotype of the patients to have benefit. Because who benefit from the graft is only the thin biotype and the medium biotype. The thick and very thick, they don’t benefit from the graft. So it’s just a over-procedure for them, most of the time. So I recommend, again, to have a look of this paper about the decision-making in gingival recession treatment. Because in this paper we go into details, and you will have all the indication for each case, which one to use. And again, the decision is taken on the presence of keratinized tissue or not, the biotype of the patient, the vestibule depth, and the neighbor tissue. And if you’d like to understand better this suturing technique, you can download for your iPhone the Oral Surgery Suture Trainer. It’s an app on sutures done together with Quintessence. And it’s a significant success, It’s very useful, I think. And if you like these publications, you can download my publication scanning this square. I keep it updated, so you can just have a look of my publications, and we can keep in touch with that. We can keep in touch through the website also iperio.org. And I hope to see you soon here in Los Angeles, or around with this fantastic group of gIDE, or with a group of iPerio in Italy and in Europe. And I like to see you and hope to see you soon, and keep in touch. Ciao, thank you.