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Jessica Cruz
Jessica Cruz

Mucogingival Esthetic Surgery Zucchelli Extra Quality Free Pdf

Dr. Zucchelli is Professor of Periodontology at the University of Bologna and author of more than 100 scientific publications in the field of periodontology including a book on esthetic mucogingival surgery (Quintessence).

Mucogingival Esthetic Surgery Zucchelli Free Pdf

This beautifully illustrated ebook explains the art and technology of esthetic surgical strategies on the mucogingiva around natural enamel and implants. the author draws upon his considerable enjoy to expose readers how to diagnose and deal with mucogingival defects, with precise insurance of the analysis of and the surgical alternatives for masking varying tiers of gingival recession.

Successful coverage of exposed roots for esthetics and functional reasons has been the objective of various mucogingival surgeries. When adequate gingiva exists, repositioning it over the denuded root surface provides the most esthetic result [1]. However, this may not be seen in all the cases. Various factors need to be taken into consideration before deciding on the technique for root coverage [2]. Procedures are being constantly modified or used in combination to achieve successful and predictable root coverage [3, 4].

The first step of the surgery used a free gingival graft (FGG) technique as given by Miller Jr. [7]. The recipient site was prepared under local anesthesia. The outline of the graft was obtained using a tin foil template with number 15 BP blade. The FGG was harvested from palate (Figures 3 and 4). The graft was adapted over the root and stabilized by horizontal and circumferential sutures using 4.0 vicryl sutures (Figure 5). The patient was recalled for review once every week for two months.

REFERENCES:1. Zucchelli G, Stefanini M, Ganz S, Mazzotti C, Mounssif I, Marzadori M, et al. Coronally advanced flap with different designs in the treatment of gingival recession: A Comparative controlled randomized clinical trial. Int J Periodontics Restorative Dent. 2016 May-Jun;36(3):319-27 [PubMed]2.Allen EP, Miller PD Jr. Coronal positioning of existing gingiva: Short term results in the treatment of shallow marginal tissue recession. J Periodontol. 1989 Jun;60(6):316-9. [PubMed]3.De Sanctis M, Zucchelli G. Coronally advanced flap: A modified surgical approach for isolated recession-type defects: Three-year results. J Clin Periodontol. 2007 Mar;34(3):262-8 [PubMed]4.Zucchelli G. (Quintessenza Edizioni) Mucogingival esthetic surgery. 2013, Chapter 17, p. 257-3295.Francetti L, Del Fabbro M, Calace S, Testori T, Weinstein RL. Microsurgical treatment of gingival recession: A controlled clinical study. Int J Periodontics Restorative Dent. 2005 Apr;25(2):181-8 [PubMed]6.Chambrone L, Salinas Ortega MA, Sukekava F, Rotundo R, Kalemaj Z, Buti J, et al. Root coverage procedures for treating localised and multiple recession-type defects. Cochrane Database Syst Rev. 2018 Oct 2;10(10):CD007161. [PubMed] [Crossref]7.Cairo F, Nieri M, Pagliaro U. Efficacy of periodontal plastic surgery procedures in the treatment of localized facial gingival recessions. A systematic review. J Clin Periodontol. 2014 Apr;41(Suppl 15):S44-62. [PubMed] [Crossref]8.Andrade PF, Grisi MF, Marcaccini AM,Fernandes PG, Reino DM, Souza SL, et al. Comparison between micro- and macrosurgical techniques for the treatment of localized gingival recessions using coronally positioned flaps and enamel matrix derivative. J Periodontol. 2010 Nov;81(11):1572-9 [PubMed] [Crossref].

Palatal rugae in a sample of a Jordanian population extends beyond the mesial aspect of the upper second premolar which may cause a substantial limitation for graft harvesting from the palate. The hard palate of Jordanian patients may not be a reliable source of soft tissue grafts required for aesthetic mucogingival surgery. No significant association existed between the most posterior extent of palatal rugae and gender, gingival phenotype or palatal shape. Other possible sources should be explored.

The posterior extent of the rugae plays an important role in limiting the anterior extension of the soft tissue graft donor site [9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39]. The hard palate and tuberosity is the preferred site for harvesting full epithelialized free grafts or subepithelial connective tissue grafts for oral and periodontal soft tissue augmentation procedures [4,5,6,7,8,9,10,11,12,13,14, 41]. The procedures include the augmentation of the width of keratinized tissue, treatment of gingival recession over teeth and surgical correction of localized alveolar ridge defects [40,41,42,43,44,45,46,47,48]. The attached keratinized mucosa palatal to the maxillary premolars is the preferred source of such grafts. If harvested within a soft tissue graft, rugae could cause a persistent esthetic problem because it has the tendency to survive with its distinct shape [9] and if incised from the free gingival graft, they re-establish themselves. This property poses an anatomical barrier since palatal rugae have an unaesthetic appearance and should not be included in free gingival grafts [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32]. The posterior extent of the palatal rugae may pose important limitations for the hard palate as a potential donor site for soft tissue grafts in mucogingival surgeries. It is important to be knowledgeable about the posterior extent of the palatal rugae as it may limit the anterior extent of the soft tissue palatal graft.

The consequences of transplanting tissue from the anterior palate, which contains rugae, has not been documented extensively. Soehren et al. reported, in a clinical and histological study, only 2 cases of retained rugae in 20 free gingival graft biopsies examined [39], and Breault et al. reported a retained palatal rugae in a free gingival graft 9 years after the surgery, despite the fact that a gingivoplasty was performed 2-months post-surgery. The transplanted rugae remained a permanent part of the recipient site, regardless of the efforts to eliminate them. The group recommended avoidance of these anatomic landmarks when harvesting the graft tissue for esthetic reasons [5]. The characteristics of the epithelium are determined by the underlying connective tissue [9, 10, 20] and the clinical removal of rugae in the palatal donor tissue is not a permanent correction of the topography, since they tend to reappear several months post-treatment, as reported by Coslet et al. and Breault et al. [5,6,7,8,9]. It is only natural that the structural characteristics of the palatal mucosa are conserved as free mature gingival grafts, as reported by Matter et al. [25]. Rateitschak et al. stated that grafts must not contain rugae from the anterior area of the hard palate nor encroach on the soft palate [47]. Cohen recommended that the donor tissue should be harvested from the posterior part of the palate, distal to the anterior rugae as this area contained the widest gingival zone and the least amount of submucosa [8].

The strengths of the current study include the exclusion of participants wearing removable appliances, which minimizes the risk of mechanical trauma of the palatal mucosa. The consequence would be minimalizing the potential interference or contribution of confounding factors and other factors that may influence the rugal morphology and the reported outcomes of this clinical study. The majority of the sample (91.4%) was between 15 and 30 years, the age range that is referred for periodontal mucogingival surgery requiring soft tissue graft harvesting from the hard palate. In addition, our study had an equal distribution of male and female and indicated a significant difference between gender and the distal extension of the rugae. A previous study reported significant gender differences in the characteristics of palatal rugae in a Jordanian population, however, the distal extension of the rugae was not investigated [11]. Our major limitation includes the involvement of a single examiner and an inadequate sample size which limits the possibility to extrapolate the results of our study to the broader population.

One of the chief goals of periodontal plastic surgery is establishment of ideal pink esthetics through the reconstruction of gingival recessions. A gold standard treatment approach for coverage of gingival recession with predictable esthetic outcomes is the transplantation of autogenous soft tissue grafts. Various surgical techniques can be used in combination with autogenous soft tissue grafts for gingival recession coverage.

Recreation of optimal pink esthetics is the ultimate goal of periodontal plastic surgery. This can be achieved by reconstructing the existing gingival recessions. Autogenous soft tissue grafts are considered as a gold standard treatment approach for gingival recession coverage with predictable tissue stability and esthetics. These grafts can be applied in combination with several different surgical techniques for coverage of gingival recession.

Autogenous free soft tissue grafts are harvested from a remote and esthetically irrelevant region of the oral mucosa and are entirely detached from the donor site. This is useful in avoiding donor site complications surrounding the adjacent teeth. Therefore, minimal risk of impaired esthetics and root hypersensitivity is present because of wound healing via secondary intention at the adjacent sites. However, free autogenous soft tissue grafts application needs a second surgical site with a risk for possible complications like infection, pain, swelling and necrosis that cannot be completely eliminated even through meticulous treatment planning and good surgical skills.


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