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Dr. Fatin Awartani.  Width of AG differs in different areas of the mouth. Greatest in the incisor region (3.5-4.5 mm in the max, 3.3-3.9 mm in the man).

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Presentation on theme: "Dr. Fatin Awartani.  Width of AG differs in different areas of the mouth. Greatest in the incisor region (3.5-4.5 mm in the max, 3.3-3.9 mm in the man)."— Presentation transcript:

1 Dr. Fatin Awartani

2  Width of AG differs in different areas of the mouth. Greatest in the incisor region ( mm in the max, mm in the man). Least width in the 1 st premolar area (1.9 mm in the max, 1.8 mm in the man) Anatomy Dr. Fatin Awartani

3 Literature Review  No standard width of keratinized attached gingiva has been established.  In people with good oral hygiene 1 mm or less may be sufficient for health (Lang and loe, 1972; Dorfman et al., 1980).  Kirch et al (1986) and Wennstrom (1987) have shown that even a movable marginal tissue of alveolar mucosa can be maintained stable over a long period of time Dr. Fatin Awartani

4  Trauma of prosthetic treatment (Maynard and Wilson, 1979; Ericsson and Lindhe, 1984)  Orthodontic restoration (Maynard and Ochsenbein, 1975; Coatoam et al., 1981)  Frenulum pull (Gottsgen, 1954; Gorman, 1967)  Rapidly progressing recession (Baker and Seymour, 1976) Literature Review Dr. Fatin Awartani

5  Tissue barrier concept:  Goldman and Cohen (1979) outlined a “tissue barrier” concept  They postulated that a dense collagenous band of CT retards or obstructs the spread of inflammation better than does the loose fiber arrangement of the alveolar mucosa.  They recommended increasing the zone of keratinized attached gingiva tissue to achieve an adequate tissue barrier (thick tissue). Literature Review Dr. Fatin Awartani

6 Literature Review  Wennstrom (1985) states,”A thin marginal tissue, in particular in the absence of underlying alveolar bone, will be at greater risk of recession since the plaque-induced inflammatory lesion may occupy and cause destruction of the entire CT portion of the gingiva” Dr. Fatin Awartani

7 Widening the attached gingiva accomplishes the following objectives: 1. Enhances plaque removal around the gingival margin. 2. Improve esthetics 3. Reduces inflammation around restored teeth. Dr. Fatin Awartani

8 Techniques to Increase Keratinized Attached Gingiva Widening the of the keratinized attached gingiva (apical or coronal to area of recession) can be accomplished by many techniques:  Free gingival auto graft  Free connective tissue graft  Lateral pedicle flap  Apically displaced flap Dr. Fatin Awartani

9 Free Gingival Graft  Advantages 1- High degree of predictability 2- Simplicity 3- Ability to treat multiple teeth at the same time 4- Can be preformed when keratinized gingiva adjacent to the involved area is insufficient 5- As the first step in a two-stage procedure for attaining root coverage 6- As a single step for attaining root coverage Dr. Fatin Awartani

10  Disadvantages 1- Two operative sites 2- Compromised blood supply 3- Greater discomfort 4- Poor hemostasis 5- Retention of graft Free Gingival Graft Dr. Fatin Awartani

11  Factors: 1- Graft thickness (1.5 mm to 2 mm is recommended) 2- Suturing techniques 3- Entrapment of a blood clot between the graft and the roots, as well as the adjacent soft tissue recipient bed 4- Mechanical root preparation (Sc/Rp) 5- Flattening of the root surface with Sc and Rp or rotary instrumentation 6- Chemical root conditioning (citric acid and tetracycline) Free Gingival Graft Dr. Fatin Awartani

12  Contraindications 1- A perceptible mismatch in color between donor site and gingiva adjacent to recipient site 2- A lack of thick donor tissue 3- A class III or class IV recession defect 4- A root surface of excessive mesiodistal width coupled with interproximal tissue that is too narrow to support the blood supply Free Gingival Graft Dr. Fatin Awartani

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14 Free Gingival Graft  Common reasons for graft failure:  use of root coverage (prominent roots, wide areas of root exposure)  proper graft adaptation  adequate transfusion of the graft  graft movement (plasmatic diffusion) Dr. Fatin Awartani

15 Subepithelial Connective Tissue Graft  Advantages 1- It is predictable for obtaining root coverage 2- The technique results in good gingival color match 3- The palatal donor site is less prone to bleeding, and healing is easier than FGG 4- The double blood supply created in this approach is advantageous 5- The surgeon’s ability to control the thickness is greater than is possible with the FGG Dr. Fatin Awartani

16  Indications 1- A lack of adequate donor tissue for a lateral sliding flap 2- The presence of root recession 3- The presence of isolated wide recession 4- The presence of multiple root recession 5- The presence of recession adjacent to an edentulous area requiring ridge augmentation 6- The presence of recession in an area where esthetics is often great concern Subepithelial Connective Tissue Graft Dr. Fatin Awartani

17 Before Sub epithelial CT After Dr. Fatin Awartani

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22 Laterally Positioned Pedicle Graft  Advantages: 1- One surgical site 2- Good vascularity of the pedicle flap 3- Ability to cover a denuded root surface  Disadvantages: 1- Limited by the amount of adjacent keratinized attached gingiva 2- Possibility of recession at the donor site 3- Dehiscence or fenestration at donor site 4- limited to one or two teeth Dr. Fatin Awartani

23  Contraindications: 1- Presence of deep interproximal pockets 2- Excessive root prominence 3- Deep or extensive root abrasion or erosion 4- Significant loss of interproximal bone height Laterally Positioned Pedicle Graft Dr. Fatin Awartani

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25 Apically displaced flap Dr. Fatin Awartani

26 Flap apically displace and sutured Before After Dr. Fatin Awartani


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