Periodontal plastic surgery-1 PRESENTER DR. REBICCA RANJIT IIIrd YEAR RESIDENT

2. Periodontal plastic
surgery-1
PRESENTER
DR. REBICCA RANJIT
IIIrd YEAR RESIDENT

3. Mucogingival therapy: A general term used to describe
periodontal treatment involving procedures for corrections
of defects in morphology, position, &/or amount of soft
tissues & underlying bone support at teeth & implants.
GPT-2001

4. A more specific term;
Introduced by Nathan Friedman in 1957.
Surgical procedures designed to preserve gingiva, remove
abberant frenum, or muscle attachments, and increase the
depth of vestibule.
Mucogingival surgery:

5. Periodontal plastic surgery is defined as the surgical
procedures performed to correct or eliminate anatomic,
developmental, or traumatic or disease induced defects of
the gingiva, alveolar mucosa or bone.
1996, World Workshop in Clinical Periodontics renamed mucogingival
surgery as “periodontal plastic surgery,” which was originally proposed
by Miller in 1993

6. Mucogingival surgery,
Nathan Friedman, 1957
Periodontal plastic surgery,
Miller, 1993
World Workshop in Clinical
Periodontics,1996
Periodontal &
Reconstructive surgery

7. Periodontal plastic surgery - broadened to include following areas
Periodontal prosthetic corrections
Crown lengthening
Ridge augmentation
Esthetic surgical corrections
Esthetic surgical correction around implants
Reconstruction of the papillae
Surgical exposure of unerupted teeth for orthodontics
Lip repositioning
Gingival augmentation
Coverage of the denuded root surface

8. The 3 objectives of periodontal plastic surgery:
Problem associated with:
Aberrant
frenum
Shallow
vestibule
Attached
gingiva4. Esthetic surgical therapy
5. Tissue engineering

9. ATTACHED
GINGIVA

10. It is the distance between the projection on the external
surface of bottom of gingival sulcus or periodontal pocket
(A) & mucogingival junction (B).
Firm, resilient & tightly bound to underlying periosteum & is
continuous with marginal gingiva.

11. Width of attached gingiva is greatest at the incisors and least
at
premolars of facial aspect (Bowers)
Facial aspect Incisors (maximum) Ist Premolars
(minimum)
Maxilla 3.5-4.5 mm 1.9mm
Mandible 3.3-3.9mm 1.8mm
 Width = Total width of gingiva - Depth of sulcus
AB = BC - AC

12. Function
 Prevents apical spread of inflammation.
 Deflects food away from gingival margin.
 Braces gingiva firmly against teeth.
 Acts as buffer between 2 moveable mucosa
 Bear the compressive & shear forces during mastication
 Prevents transmission of frenal pull.

13. METHODS TO MEASURE
THE WIDTH OF ATTACHED GINGIVA

14.  AG = Total width of gingiva  Depth of sulcus
• This is done by stretching the lip or cheek to demarcate the
mucogingival line while the pocket is being probed.
• The amount of attached gingiva is considered to be insufficient when
stretching of the lip or cheek induces movement of the free gingival
margin.
Visual method

15. Pushing the adjacent mucosa coronally with a dull
instrument helps in demarcating mucogingival
junction
Roll test

16. Histochemically , by application of Schiller’s or Lugol’s potassium iodine
solution which stains glycogen content.
 Lugol's iodine helps to better visualize the mucogingival junction in the mouth.
Alveolar mucosa has a high glycogen content that gives a positive iodine
reaction.
Histochemical staining method
Fasske and Morgenroth

17. Tension test
Tension applied to lip in outward, downward/upward, & lateral
directions.
Gingival margin is observed
Any movement of the free gingiva is recorded as representing a
positive response to the tension test

18. Adequate attached gingiva??

19. VARIOUS AUTHORS ADEQUATE ATTACHED GINGIVA
Corn, 1962 > 3mm (Keratinized gingiva)
Bowers, 1963 <1 mm
Friedman, 1962; De
Trey & Bernimoulin,
1980
Gingiva that is compatible to gingival
health & that prevents retraction of
gingival margin during movement of
alveolar mucosa
Lang & Loe, 1972 2mm

20. TISSUE BARRIER CONCEPT
 Outlined by Goldman & Cohen, 1979
 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 attached
gingiva to achieve an adequate tissue barrier (thick tissue).

21. WIDENING OF ATTACHED GINGIVA
accomplishes following 4 objectives:
a) Enhances plaque removal around gingival margin
b) Improves esthetics
c) Reduces inflammation around restored teeth
d) Gingival margin binds better around teeth & implants
with attached gingiva

22. SURGICAL TECHNIQUES TO
INCREASE THE WIDTH OF
ATTACHED GINGIVA
Minimal attached gingiva with adequate vestibular depth
may not require surgical correction

23. SURGICAL TECHNIQUES TO
INCREASE THE WIDTH OF ATTACHED
GINGIVA
Gingival augmentation
apical to recession
Gingival augmentation
Coronal to the
recession
(root coverage)

24. Gingival augmentation apical to
recessionFree
connective
tissue
autograft
Apically
reposition
ed flap
Free gingival
autograft
Bjorn,1963
Alan Edel, 1974 Introduced by Nabers,
Coined by Friedman
Classic technique Variant technique
Accordion technique
Strip technique
Combination epithelial-
connective tissue
strip technique

25. Free gingival
autograft
 Introduced by Bjorn, 1963
 Nabers introduced the term “Free gingival graft”, 1966
 Described by Sullivan & Atkins, 1968

26. Classic technique
Step 1: Prepare the recipient site
The recipient site prepared by incising at the existing
mucogingival junction with a #15 blade to the desired depth with
periosteum left intact.
To prepare a firm connective tissue bed to receive the graft.

27. An aluminum foil template of the recipient site
can be made to be used as a pattern for the
graft.
Palate
This is the area where the thickest tissue can be found
(Reiser et al. 1996)
DONOR SITE
• Palate,
• Maxillary tuberosity
• Edentulous ridges,
• Retromolar areas, and
• Wide zones of gingiva;
• Operculum over an erupting tooth

28. Step 2: Obtain the graft from the donor site:
Place the template over the donor site, and make a shallow
incision around it with a #15 blade
Insert the blade to the desired thickness at one edge of the graft.
Elevate the edge & hold it with tissue forceps
Continue to separate the graft with the blade, lifting it gently
as separation progresses to provide visibility.
A partial-thickness graft (epithelium + a thin layer of underlying connective
tissue)
5 to 6 mm

29. The ideal thickness of a graft = 1.0 - 1.5
mm
• Peripheral layer is jeopardized due to
excessive tissue that separates it from
new circulation and nutrients.
• Also creates a deeper wound at the
donor site, with the possibility of injuring
major palatal arteries
(Thin enough to permit diffusion of fluid from the recipient
site, which is essential in the immediate post-transplant
period)
Too thin graft
Necrosis and
exposure of the recipient site.
Too thick graft

30. Step 3: Transfer and immobilize the graft.
• Position the graft and adapt it firmly to the recipient site.
• A space between the graft and the underlying tissue
(dead space) impairs vascularization and jeopardizes the
graft.
• Suture the graft at the lateral borders and to the periosteum to
secure it in position.

31.  The graft must be immobilized (Any movement interferes with
healing.)
 Avoid excessive tension(Can distort the graft from the underlying
surface.)
 Avoid trauma to the graft. (Tissue forceps should be used
delicately)
 Minimum number of sutures used to avoid unnecessary tissue
perforation
PRECAUTIONS

32. Step 4: Protect the donor site.
with a periodontal dressing for 1
week
A modified Hawley retainer is useful
to cover the pack on the palate and
over edentulous ridges.

33. Gingival augmentation apical to
recession
Free gingival
autograft
Bjorn,1963
Classic technique Variant technique
Accordion technique
Strip technique
Combination epithelial-
connective tissue
strip technique
attempt to minimize
the donor site morbidity

34. Accordion technique
• Rateitschak et al
• Expansion of the graft by alternate incisions in
opposite sides of the graft.
• It increases the donor graft tissue by changing the
configuration of the tissue.

35. Gingival augmentation apical to
recession
Free gingival
autograft
Bjorn,1963
Classic technique Variant technique
Accordion technique
Strip technique
Combination epithelial-
connective tissue
strip technique

36. Strip technique
• Developed by Han et al.
• 2/3 strips of gingival donor tissue about 3 to 5 mm wide and long
enough to cover the entire length of the recipient site.
• These strips are placed side by side to form one donor tissue and
sutured on the recipient site.
• The area is then covered with aluminum foil and surgical dressing.

37. Gingival augmentation apical to
recession
Free gingival
autograft
Bjorn,1963
Classic technique Variant technique
Accordion technique
Strip technique
Combination
epithelial-
connective tissue
strip technique

38. A deep strip graft (3 to 4 mm thick) is taken from the palate
Placed between two wet tongue depressors & split it longitudinally with a
sharp #15 blade.
Both will be used as free grafts.
Split into and
Advantage:- The minimal donor site wound obtained by two donor
tissues from one site.
Combination technique
superficial epithelial-connective tissue strip
deeper pure connective strip.

39. Healing of free soft tissue grafts placed entirely on a connective tissue
recipient bed were studied in rhesus monkeys by Oliver et al. (1968) and
Nobuto et al. (1988).
Healing can be divided into three phases:-
Tissue
maturation
phase (from
11–42 days).
Revascularizatio
n phase (from
2–11 days)
Initial phase
(from 0–3
days)

40. • Thin layer of exudate between graft & recipient
bed
• Grafted tissue survive with an avascular
Plasmatic
circulation from the recipient bed.
• Epithelium of FGG Degenerates &
desquamates
• Anastomoses established between blood
vessels of recipient bed & those in the
grafted tissue.
• Circulation of blood is re-established in the
pre-existing blood vessels of the graft.
• Fibrous union.
• Re-epithelialization of the graft.
• No. of blood vessels in transplant gradually
reduced.
• After 14 days, vascular system appears
normal.
• Epithelium matures with formation of
keratin layer.

41. Alternative Donor Tissue:- acellular dermal matrix (ADM)
• Acellular. non-immunogenic scaffolds which heals by repopulation &
revascularization
• Derived from donated human skin; multistep proprietary process that removes
epithelium with intact basement membrane to promote faster
reepithelialization.
RCTs have demonstrated outcomes with ADM equivalent to palatal donor tissue in treatment of gingival
recession.

42. Free connective
tissue autograft
Originally described by Alan Edel, 1974
Donor connective tissue is obtained from the undersurface of
the palatal flap
Sutured back; therefore healing is by first intention

43. Free connective tissue
autograft
Step 1: Prepare the recipient site

44. Step 2: Obtain the graft from the donor site
Donor connective tissue is obtained from the undersurface of the
palatal flap
Sutured back; therefore healing is by first intention

45. Step 3: Transfer and immobilize the graft.

46. Advantage
 Connective tissue carries the genetic message for the
overlying epithelium to become keratinized.
Better color match of the grafted tissue to the adjacent
areas.
Improved esthetics can be achieved
 Healing is by first intention: Less discomfort postoperatively
at the donor site.

47. Gingival augmentation apical to
recessionApically
repositione
d flap
Can be used for pocket eradication, widening the
zone of attached gingiva,or both
An internal bevel incision (about 1 mm from the crest of gingiva)
made
Crevicular incisions followed by initial elevation of flap
Interdental incision given
Vertical incisions are made extending beyond the mucogingival
junction

49. The edge of the flap may be located in 3 positions in relation to the
bone:
3. 2mm short of the crest:
Produces the most desirable (a firm, tapered gingival
margin) gingival contour and the same post-treatment
level of gingival attachment as obtained by placing the
flap at the crest of the bone.
2. At the level of the crest:
satisfactory gingival contour, provided that
the flap is adequately thinned
1. Slightly coronal to the crest of the bone:
Preserve the attachment of supracrestal fibers;
Result in thick gingival margins and interdental papillae with
Deep sulci with the risk of recurrent pockets

50. SURGICAL TECHNIQUES TO
INCREASE THE WIDTH OF ATTACHED
GINGIVA
Gingival augmentation
apical to recession
Gingival augmentation
Coronal to the
recession
(root coverage)

51. SURGICAL
NON-
SURGICAL

52. NON-SURGICAL
Periodontal
management
Orthodontic
management
Esthetic
dentistry
Prosthodontic
management
• Desensitizing
toothpastes/agents
• SRP
• Polishing (Aimetti et al,2005)
Gingival veneer:-
pink autocure and heat-cured acrylics,
porcelains,
composite resins
thermoplastic acrylics,
silicone-based soft materials.
New resin-based gingival-colored composites

53. New resin-based
gingival-colored composites

54. Gingival
veneer

55. SURGIC
AL
Pedicle soft-tissue graft procedures:
a) Rotational flap procedures
(laterally sliding flap, double papilla flap, oblique rotated flap);
b) Advanced flap procedures
(Coronally repositioned flap, Semilunar coronally repositioned
flap);
c)Regenerative procedures
(With barrier membrane or application of enamel matrix
Free soft-tissue graft
procedures:
a) Epithelialized graft;
b) Sub-epithelial connective tissue
graft

56. Free gingival autograft Miller
Free connective tissue autograft
Levine,1991
Pedicled autograft:- Laterally displaced /Coronally advanced flap
Sub-epithelial connective tissue graft Langer & Langer, 1985
GTR with pedicled soft tissue graft Pini Prato et
al,1992
Pouch & tunnel technique Azzi et al
Pinhole surgical technique John C. Chao
SURGIC
AL

57. Step 1: Root planning
Step 2: Prepare the recipient site:
• Horizontal incision in IDP at right angles
• Divergent vertical incisions made at the line angles of tooth to be
covered, creating a partial-thickness flap to at least 5 mm apical to the
receded area
Steps 3 : Obtain the graft from the donor site:
• 1-1.5mm partial-thickness graft harvested from palate
Step 4: Transfer & immobilize the graft:
• Position the graft and adapt it firmly to the recipient site; Avoid movement,
excessive tension & trauma to the graft ; Cover the graft.
Free gingival autograft Miller
5 mm

58. The difference between this technique and the free gingival
autograft is that the donor tissue is
Free connective tissue autograft Levine,199
connective tissue.

59. Pedicle Autograft

60. Laterally (Horizontally) Displaced Pedicle Flap:
• Originally described by Grupe and Warren in 1956.
• To cover isolated, denuded root surfaces
• Criteria:- Donor site with adequate width of attached gingiva,
minimal bone loss, & without
dehiscence/fenestration.
:- Adequate vestibular depth

61. Step 1: Prepare the recipient site. Epithelium around the
denuded root surface is removed followed by thorough SRP.
Step 2: Prepare the flap. Partial-thickness flap > full-thickness
Rapid healing at the donor site
Reduces the risk of loss of facial bone
height.
Only if gingiva is thin;
But some loss of radicular
bone (0.5mm) & recession
(1.5mm)

62. A releasing incision (a short oblique
incision into the alveolar mucosa at
the distal corner of the flap, in the
direction of the recipient site) to avoid
tension
Corn,1964

63. • Incomplete root coverage
• Recession in the donor area
• Need for an adequate donor area adjacent to the area
to be treated.
DISADVANTAG
ES

64. Healing of pedicle soft tissue grafts by Wilderman & Wentz (1965)
in dogs.
Adaptation
stage (0–4
days)
Proliferation stage
(4–21 days)
Attachment
stage (27–28
days)
Maturation
stage

65. Epithelium covering the transplanted tissue flap
starts to proliferate and reaches contact with the
tooth surface
at the coronal edge of the flap after a few days
Fibrin layer between the root surface and the flap
is invaded by connective tissue proliferating
from the subsurface of the flap.
6–10 days: a layer of fibroblasts in apposition to
root which differentiate into cementoblasts
Thin collagen fibers formed adjacent to the root
surface.
Epithelium proliferates apically along root
surface
Thin collagen fibers become inserted in a
layer of new cementum.
Continuous formation of collagen fibers.
After 2–3 months bundles of collagen fibers insert
into the cementum layer on the curetted root
surface

66. Double-Papilla Procedure
Introduced by Waienberg, 1964
Modified by Cohen & Ross, 1968
indicated in Millers Class II recession with
inadequate attached gingiva but presence
of sufficient width and length of interdental
papilla on both sides of the area of gingival
recession.
Complication :-
• Necrosis of the flap
• Swelling & bruising at the recipient
site
• Deep & narrow cleft at middle
surface of the root

67. Purpose :- To create a split-thickness flap in the area apical to
the denuded root and position it coronally to cover
the root.
Coronally Displaced Flap
2 techniques are available for this purpose

68. First Technique
• 2 vertical incisions extending beyond the mucogingival
junction.
• An internal bevel incision to eliminate diseased pocket wall.
• Elevate split thickness flap followed by SRP
Suture the flap at a level coronal to the pretreatment position.
Periodontal dressing

69. Variations to First Technique
(In cases with insufficient keratinized gingiva apical to the
recession)
Double-step procedure (Initially by Harvey, 1970
Bernimoulin et al, 1973):-
Gingival augmentation procedure with free autogenous graft
2 months
Coronally positioned graft

71. Second Technique:
2)Semilunar coronally repositioned flap
Tarnow (To cover isolated denuded root surfaces or on several
adjoining teeth)

72. Semilunar incision made following the
curvature of the receded gingival margin &
ending about 2-3 mm short of tip of papillae.
Split-thickness dissection
coronally from the incision, and
connect it to an intrasulcular
incision.
Tissue will collapse
coronally, covering the
denuded root

73.  Indication:
• Where the recession is not extensive (3 mm):-Provides 2
to 3 mm of root coverage
• Facial gingival biotype is thick.
• It is successful for the maxilla,
 Not recommended for the mandibular dentition
Semilunar coronally repositioned flap

74. Larger and multiple defects with good vestibular depth and gingival
thickness to allow a split-thickness flap to be elevated.
Adjacent to the denuded root surface, the donor connective tissue
is sandwiched between the split flap.
Subepithelial Connective Tissue Graft (Langer & Langer in 1985)

75. Partial-thickness flap with:
• Horizontal incision 2 mm away from the tip of
papilla
• 2 vertical incisions 1-2 mm away from gingival
margin of the adjoining teeth
Favorable esthetic result
Primary healing of donor
site

76. Bilaminar reconstruction of the gingiva using both free and pedicle layers to
preserve graft viability over denuded root surfaces.
Increased blood supply over the donor tissue & the gingival margin is
thickened for better marginal stability.
A variant of the subepithelial connective tissue graft, called a
subpedicle (bilaminar) connective tissue graft, was described by
Nelson in 1987.
SECTG + Double papilla

77. Wennstorm & Zucchelli, 1996

78. GTR Technique for Root Coverage Pini-Prato et
al, 1992
Full-thickness flap is reflected to the
MGJ, continuing as a partial-thickness flap
8 mm apical to the MGJ
Membrane placed over the denuded
root surface and the adjacent tissue;
trimmed & adapted to root surface to
cover at least 2mm of marginal
periosteum.
suture passed through the portion of membrane; knotted on the
exterior;
Non-resorbable
Ti-reinforced; (Tinti
& Vincenzi)
Resorbable

79. Flap is then positioned coronally & sutured.
4 weeks later, a small envelope flap is
performed, and the membrane is carefully
removed. The flap is then again positioned
coronally, to protect the growing tissue, &
sutured.
One week later these sutures are removed

80. GTR technique better when the recession is > 4.98 mm apicocoronally.
Coronally displaced flap Vs GTR technique by Pini Prato

81. Reported:-
• 3.66 mm of new connective tissue
attachment
• 2.48 mm of new cementum and
• 1.84 mm of bone growth

82. Pouch & Tunnel Technique (Coronally Advanced Tunnel
Technique)
• Effective for the anterior maxillary area ; with adequate vestibular
depth and good gingival thickness.
Outlined by Azzi

83. Patient preparation: Plaque control instruction; SRP before the surgical
procedure.
Composite material stops are placed at the contact points (temporary) to
prevent the collapse of the suspended sutures into the interproximal spaces
before the surgery
On the buccal aspect, sulcular incisions are made around the necks of
the teeth using15c & 12D blades; extended to 1 adjacent tooth both
mesially & distally .

84. Small, contoured blades & mini curettes are used to create the recipient
pouches and tunnels.
Dissect the connective tissue beyond the mucogingival line and free the
buccal flap from its insertions to the bone around each tooth.
Muscle fibers, any remaining collagen fibers are cut & papillae carefully
undermined to allow the coronal positioning of entire gingivopapillary
complex.
Papillae are kept intact

85. Size of the pouch (including the area of the denuded root surface, is
measured so that an equivalent size donor connective tissue can
be procured from the tuberosity.
Connective tissue harvested from the tuberosity area is contoured to
fit into the recipient tunnel & pouch.
mattress suture placed at one end
of the graft is helpful in guiding the
graft

86. • Tissue is gently pushed into pouch & tunnel with tissue forceps & packing
instrument.
Mattress suture will help maintain the graft in position

87. The entire gingivopapillary complex (buccal gingiva with the
underlying connective tissue graft, and papillae) is coronally
positioned using a horizontal mattress suture anchored at the
incisal edge of the contact area. The contact areas are splinted
presurgically using a composite material.
• Vertical mattress suture: To hold the graft in position beneath the
gingiva.

88. • Minimize incisions & the reflection of flap.
• Provides abundant blood supply to the donor tissue,
• Placement of donor connective tissue into pouches beneath papillary
tunnels allows for intimate contact of donor tissue to the recipient site.
• The positioning of the graft in the pouch and through the tunnel and the
coronal placement of the recessed gingival margins completely covers the
donor tissue.
• Excellent esthetic result
• Thickening of the gingival margin after healing:- stable to allow for the
possibility of “creeping reattachment” of the margin
ADVANTAG
ES

89. • Requires 2 surgical sites;
• Delicate harvesting of graft;
• Prolonged healing time.
DISADVANTAG
ES

90. VISTA Technique
Vestibular Incision Subperiosteal Tunnel Access

91. Pin hole surgical technique: John C.
Chao
 Using PST, mean % defect coverage was 94%.

92. CONCLUSION
New techniques are constantly being developed and are slowly being
incorporated into periodontal practice. Critical analysis of newly
presented techniques should guide our constant evolution toward better
clinical methods.

93. BIBLIOGRAPHY…..
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Assoc 2003; 69(7):432–5
• Informational Paper: Oral Reconstructive and Corrective Considerations in
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tissue regeneration versus mucogingival surgery in the treatment of human
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attachment following the treatment of a human buccal recession by means of
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Therapy. J Periodontol 1968;39:65-70.
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