Bedah Mukogingival

BEDAH MUKOGINGIVAL drg. Citra Lestari, MDSc., Sp. Perio

TUJUAN BEDAH MUKOGINGIVAL 1. Menciptakan zona gingiva cekat yang adekuat Mengapa terjadi zona yang inadekuat? - Dasar saku berada dekat, pada atau apikal Batas mukosa gingival - Perlekatan frenulum/otot yang mencapai saku periodontal - Resesi yang menyebabkan tersingkapnya permukaan akar gigi 2. Menutup kembali akar gigi yang tersingkap karena resesi gingiva 3. Menciptakan vestibulum yang cukup dalam

TEKNIK BEDAH MUKOGINGIVAL UNTUK MEMPERLEBAR GINGIVA CEKAT

1. • • •

Cangkok Gingiva Bebas Cangkok gingiva konvensional Cangkok jaringan ikat epitel Cangkok Jaringan ikat subepitel

2. Flep Posisi Apikal

Cangkok Gingiva Bebas Tahapan prosedur : - Anestesi - Penyingkiran saku periodontal - Mempersiapkan sisi resipien - Pengambilan cangkok dari sisi donor - Penempatan dan imobilisasi cangkok - Pemasangan pembalut periodontal

Cangkok Gingiva Bebas

Inadequate attached gingiva and associated recession

Ukur dengan almunium foil

Muscle dissected back and sutured, creating bed for new graft

Outline in roof of mouth of the donor site Graft removed from roof, leaving a skinned knee appearance

Dressing placed over site

Graft glued to position on bed

Gingiva removed from palate

Final healing of graft, restoring band of hard gum

A class II GR, 3 mm in height and 4 mm in width on a mandibular left central incisor.

Ten days after an FGG used for covering the GR

One year after an FGG for covering the class II GR

Apa masalah pada cangkok gingiva bebas sehingga para ahli mengembangkan teknik variasi? 1. Luka pada sisi donor yang lebar menyebabkan rasa kurang nyaman bagi pasien 2. Warna cangkok yang sedikit berbeda dengan jaringan sekitarnya

Contoh variasi : 1. Cangkok jaringan ikat bebas 2. Cangkok jaringan ikat subepitel

CANGKOK JARINGAN IKAT BEBAS Note: patient exhibits generalized gingival recession in upper and lower right, anterior, and left hextants. The cause of these defect is identified to be tooth brush abrasion. Many of these defects has been filled with composites and were popping off during flossing.

Note: Scale and root plane thoroughly to prepare the root surface for graft adaptation. Split thickness flap with vertical releasing incision perform. Flap is reflected leaving the periosteum with blood vessel open to supply nutrient to the graft. Now the recipient site is ready to receive the connective tissue graft from the donor site

Note: connective tissue harvested from the palatal area on the between the first premolar and the mesial half of the first molar is usually a preferred donor site. The graft consists of connective tissue only, no epithelium is removed except for the small 12mm width at the top of the graft. This portion of epithelium needed to be trim as to avoid cleft in the healing area.

Notes: Graft adapted and sling sutured with resorbable resolut suture. The apical area of the graft also stabilized with subperiosteal suture. Finally, the split thickness flap is coronally reposition as to fully cover the graft. The graft now is sandwiched with two sources of blood supply for feeding, from the flap and from the periosteum. Final suture performed with goretex suture.

Seven days postop healing

Nine months postop healing

Figure 2. Patient with a high smile that exposes a discrepant architecture of the gingival margins due to recession.

Figure 5A. Primary closure of the palatal donor site with 5-0 gut sutures.

Figure 5B. One-week healing of the palate Figure 4A. Palatal donor site for a connective illustrating typical slight connective tissue tissue graft. The graft has been removed and a exposure with minimal discomfort for the strip of connective tissue approximately 1.5 patient. mm wide has been left coronal to the donor site to aid in primary closure.

Figure 4B. The connective tissue graft free of epithelium.

Figure 6A. Slight wide recession on Nos. 7 and 8 with moderately wide recession and a lack of attached gingiva on No. 9.

Figure 6B. Incisions and split thickness flap with papillary preservation.

Figure 6C. Connective tissue graft in place on Nos. 8 and 9. Coronally positioned flap planned for No. 7.

Figure 6D. Six-0, 7-0, and 9-0 microsutures used for flap closure and graft stability.

Figure 6E. One-year result with root coverage to the cementoenamel junction, increased dimensions of the gingiva, and inconspicuous blending of the grafted tissue into the site.

FLEP POSISI APIKAL TAHAPAN PROSEDUR Penempatan flep sebelum dijahit : - Sedikit koronal dari tepi tulang alveolar - Pada tepi tulang alveolar - 2mm apikal dari tepi tulang alveolar RUMUS PRAKIRAAN LEBAR GINGIVA CEKAT PASCA BEDAH - Kedalaman saku pra-bedah = 5 mm - Lebar gingiva berkeratin = 6 mm - Berapa prakiraan lebar gingiva cekat pasca bedah - KS prabedah/2 + lebar gingiva cekat prabedah

FLEP POSISI APIKAL

TEKNIK BEDAH MUKOGINGIVA UNTUK MENUTUP AKAR GIGI YG TERSINGKAP KARENA RESESI GINGIVA • FLEP POSISI KORONAL FLEP POSISI KORONAL SEMILUNAR • FLEP POSISI LATERAL  FLEP POSISI PAPILA GANDA  KOMBINASI FLEP PAPILA GANDA DENGAN CANGKOK GINGIVA BEBAS • CANGKOK GINGIVA BEBAS  CANGKOK JARINGAN IKAT SUBEPITEL • TEKNIK REGENERASI JARINGAN TERARAH

FLEP POSISI KORONAL • TAHAPAN PROSEDUR : 1. Anestesi 2. Insisi krevikular 3. Insisi vertikal 4. Pembukaan flep 5. Penempatan flep 6. Penjahitan 7. Pemasangan pembalut periodontal

FLEP POSISI KORONAL

Figure 1. Clinical measurements on the recession-involved tooth: AA’ = BB’= CC’= X = recession depth; area of de-epithelization is colored in red.

Figure 2. Pretreatment view of surgery site on tooth No. 12 with 6 mm of recession.

Figure 3. Incision design: recreation of papilla and de-epithelialization of the current papilla.

Figure 3. Incision design: recreation of papilla and de-epithelialization of the current papilla.

Figure 4. Releasing of the flap: full thickness then partial thickness at the vestibule; no tension.

Figure 5. Scaling and root planning: odontoplasty if necessary; remove any composite if present.

Figure 6. Application of EMD: root conditioning; dry and apply EMD.

Figure 7. Securing the flap: coronally position the flap without tension and match the newly created papilla to the existing papilla.

Figure 8. Result at 1 week following surgery.

Figure 10. Result at 4 years following surgery.

Figure 9. Result at 6 months following surgery.

FLEP POSISI KORONAL SEMILUNAR (TEKNIK TARNOW)

FLEP POSISI LATERAL • TAHAPAN PROSEDUR : 1. Anestesi 2. Penyiapan resipien 3. Insisi krevikular 4. Pembukaan flep 5. Penempatan flep 6. Penjahitan 7. Pemasangan pembalut periodontal

CANGKOK GINGIVA BEBAS (TEKNIK MILLER) • TAHAPAN PROSEDUR 1. Anestesi 2. Penyiapan sisi resipien 3. Pengambilan donor 4. Penjahitan 5. Pemasangan pembalut periodontal •

Beda penempatannya dengan yang dilakukan untuk tujuan memperlebar gingiva cekat

CANGKOK JARINGAN IKAT SUBEPITEL (TEKNIK LANGER) • TAHAPAN PROSEDUR 1. Anestesi 2. Insisi dan pembukaan flep 3. Penyerutan akar 4. Pengambilan jaringan cangkok 5. Penempatan jaringan cangkok 6. Penutupan flep 7. Pemasangan pembalut periodontal

TEKNIK LANGER

REGENERASI JARINGAN TERARAH • TAHAPAN PROSEDUR 1. Anestesi 2. Insisi dan pembukaan flep 3. Penyerutan akar 4. Penyiapan membran 5. Penjahitan membran 6. Penutupan flep 7. Penjahitan flep