MUCOGINGIVAL SURGERY
DR. BEENA VIJAYAN PARVATHY
II ND YR PG

CONTENTS
• DEFINITION
• INDICATION AND OBJECTIVES
• PROCEDURES FOR INCREASING WIDTH OF ATTACHED
GINGIVA
• PROCEDURES FOR ROOT COVERAGE
• TECHNIQUES FOR CORRECTION OF ABERRANT FRENUM
• PAPILLA RECONSTRUCTION
• RIDGE AUGMENTATION
• PROCEDURES FOR INCREASING VESTIBULAR DEPTH
• CROWN LENGTHENING PROCEDURES

DEFINITION
• AAP/ GPT 2001 MUCOGINGIVAL THERAPY
• Nathan Friedman 1957 MUCOGINGIVAL SURGERY
• Miller 1993 PERIODONTAL PLASTIC SURGERY
• World Workshop in Periodontics 1996 PERIODONTAL
PLASTIC SURGERY

OBJECTIVES
• Gingival augmentation
• Coverage of the denuded root surface
• Periodontal prosthetic corrections
• Crown lengthening
• Ridge augmentation
• Esthetic surgical corrections
• Esthetic surgical correction around implants
• Reconstruction of papillae
• Surgical exposure of unerupted teeth for orthodontics
• Lip repositioning
• Removal of aberrant frenulum
• Prevention of ridge collapse associated with tooth extraction

INDICATIONS
• Attached gingiva
• Before restoration
• Vestibular depth
• Soft tissue recession
• Frenal pull
• Esthetic corrections

PROCEDURES FOR INCREASING WIDTH OF
ATTACHED GINGIVA
• Friedman et al 1922
• Lang and Loe 1972
• Gosalind et al 1977
TREATMENTS
• Gingival Augmentation Procedures
• FGG- Free Gingival Grafts/Auto grafts
• Modifications of FGG : Variant Technique
Accordion Technique
Strip Technique

GINGIVAL AUGMENTATION PROCEDURES
Vestibular/Gingival Extension
Denudation Technique
Ochsenbein 1960, Corn 1962, Wildermann 1964
Split-Flap Procedure
Staffileno et al 1962, Wildermann 1963, Pfeifer 1965, Staffileno et al
1966

DENUDATION TECHNIQUE
HEALING

SPLIT-FLAP PROCEDURE
HEALING

FREE GINGIVAL AUTOGRAFT
• Bjorn 1963 and Sullivan & Atkins 1968
• Nabers 1966
CLASSIC TECHNIQUE
• Preparation of the recipient site
• Obtain graft from donor site/Preparation of the donor site
• Suturing of the graft/Transferring & Immobilization of graft

CLASSIC TECHNIQUE

CLASSIC TECHNIQUE

ACCORDION TECHNIQUE
• Rateitschak et al

STRIP TECHNIQUE
• Han et al

COMBINATION TECHNIQUE
• A deep strip graft taken from palate and is split into both an epithelial-
connective tissue strip and a pure connective tissue strip.
• Obtained by;
3-4mm thick strip is placed between two wet tongue depressor and a
split it longitudinally with #15c blade.
The superficial portion consists of epithelium and connective tissue.
Deeper portion, only connective tissue.
• Placed on recipient site as strip technique.

HEALING OF THE GRAFT
• Oliver et al 1968 & Nobuto et al 1988
– The Initial Phase (from 0-3 days)
– Revascularization Phase (from 2-11 days)
– Tissue Maturation Phase (from 11-42 days)

PROCEDURES FOR ROOT COVERAGE
Classification for Treatment Modalities
I) PEDICLE SOFT TISSUE GRAFTS
 Rotational Flaps:
 Laterally Positioned Flap
 Transpositional Flap
 Double papilla Flap
 Advanced Flaps:
 Coronally Positioned Flap
 Semilunar Coronally Positioned Flap
 Lateral Coronally Positioned Flap
 Multiple Recession by Coronally Positioned Flap

II) FREE SOFT TISSUE GRAFTS
Non-submerged Grafts:
One Stage (FGG)
Two Stage (FGG+Coronally Positioned Flap)
Modifications
Submerged Grafts:
Connective Tissue Grafts (CTG)+Coronally Positioned Flap (Sub epithelial
CTG)
CTG+Double Papilla Flap (Sub pedicle CTG)
CTG+Laterally Positioned Flap
Envelope Technique
Pouch & Tunnel Technique

III) ADDITIVE TREATMENTS
Root Surface Modification Agents
Enamel Matrix Proteins
Guided Tissue Regeneration
Non-resorbable membrane barriers
Resorbable membrane barriers

PEDICLE SOFT TISSUE GRAFTS
ROTATIONAL FLAPS
LATERALLY POSITIONED FLAPS
• Grupe & Warren
• Guinard & Caffesse – Reported recession
• Grupe 1966 and Zucchelli 2004 - Confirmed

MODIFICATIONS
• In Incisions:
Modified incision to protect
marginal gingiva
Grupe & Warren 1956
The cut back incision
Corn 1964

Modified incision to protect marginal gingiva
Zucchelli 2004

• In Deflection:
 Staffileno- Used partial-thickness to avoid recession on donor site.
 Pfeifer & Heller- Reattachment on the exposed root surface occur with
full-thickness laterally positioned flap.
• Knowles & Ramfjord used FGG to cover donor site

PROCEDURE

Bahat et al modified the oblique rotated flap by Pennel et al.
TRANSPOSITIONAL FLAPS

• Cohen & Ross
DOUBLE PAPILLA FLAPS

HEALING OF PEDICLE SOFT TISSUE GRAFT
• Wilderman & Wentz 1965
– The Adaptation Stage (from 0-4 days)
– The Proliferation Stage (from 4-21 days)
– The Attachment Stage (from 21-28 days)
– The Maturation Stage (from 28 days-6 months)

• Bernimoulin et al 1975 - Coronally Positioned Flaps
• Harlan 1907 & Tarnow 1986 – Semilunar Coronally Positioned Flaps
• Zucchelli et al 2004 – Laterally moved Coronally Positioned Flaps
• Zucchelli & De Sanctis 2000 - Coronally Positioned Flap for Multiple
Recessions
ADVANCED FLAPS

CORONALLY POSITIONED FLAPS

SEMILUNAR CORONALLY POSITIONED FLAPS

LATERALLY MOVED CORONALLY ADVANCED
FLAP

CORONALLY POSITIONED FLAP FOR
MULTIPLE RECESSIONS

• Langer & Langer -Subepithelial CTG-Root coverage
• Raetzke – CTG+Envelope Flap-80% Root coverage
• Nelson – Subepithelial CTG-88% Root coverage(Height) “Recession
coverage”
• Jahnke et al -FGG+CTG-Complete coverage
FREE SOFT TISSUE GRAFTS
SUBMERGED GRAFTS
CONNECTIVE TISSUE GRAFTS (CTG)

SUBEPITHELIAL CONNECTIVE TISSUE GRAFT

MODIFIED TECHNIQUE OF LANGER &
LANGER
• Bruno modified Langer & Langer.

SUBPEDICLE CONNECTIVE TISSUE GRAFT
• CTG with pedicle flap (Double papilla or Laterally positioned )
• Nelson & Borghetti and Louise – Full-thickness pedicle flap
• Harris – Partial-thickness pedicle flap

CTG USING ENVELOPE FLAP
• Ratzke et al

CTG USING POUCH & TUNNEL TECHNIQUE
• Zabalegui et al 1999

TECHNIQUES FOR CORRECTION OF
ABERRANT FRENUM
FRENECTOMY & FRENOTOMY
CONVENTIONAL (CLASSICAL) FRENECTOMY
• Archer 1961 & Kruger 1964

• P D Miller 1985
MILLER TECHNIQUE

• Modification of conventional frenectomy technique.
V-Y PLASTY

Z-PLASTY

FRENECTOMY USING ELECTROSURGERY

FRENECTOMY USING LASER

PAPILLA RECONSTRUCTION
• Beagle 1992
• Utilizing palatal soft tissue.

• Han & Takei 1996
• Semilunar coronally repositioned papilla with use of CTG.

• Azzi et al 1999
• Envelope type flap with CTG.

RIDGE AUGMENTATION
Classification of Soft Tissue Ridge Augmentation Techniques
• PEDICLE GRAFT PROCEDURE
Roll Flap Procedure
• FREE GRAFT PROCEDURE
Pouch Graft Procedure
Interpositional Graft Procedure
Onlay Graft Procedure

• Abrams
ROLL FLAP PROCEDURE

POUCH GRAFT PROCEDURES

INTERPOSITIONAL GRAFT PROCEDURE

ONLAY GRAFTING PROCEDURE

COMBINED OVERLAY AND INTERPOSITIONAL
GRAFTING PROCEDURE

PROCEDURES FOR INCREASING VESTIBULAR
DEPTH
• Labial Vestibule
Kazanjian’s Technique
Godwin’s Technique
Lip Switch Technique
Clark’s Technique
Obwegeser’s Technique
• Lingual Vestibule
Trauner’s Technique
Caldwell’s Technique

KAZANJIAN’S TECHNIQUE

GODWIN’S TECHNIQUE

LIP SWITCH TECHNIQUE
•Transpositional Flap Vestibuloplasty or Edlan Vestibuloplasty

CLARK’S TECHNIQUE

OBWEGESER’S TECHNIQUE

TRAUNER’S TECHNIQUE

CALDWELL’S TECHNIQUE

CROWN LENGTHENING
Classification of Procedures
• Gingival reduction only (bone removal not required)
Gingivectomy
Gingival Flap Surgery
• Mucoperiosteal Flap with Ostectomy (bone removal required)
One-Stage procedures, which require one the following:
Flap elevation, ostectomy, apical positioning of the flap.
Internal bevel gingivectomy, flap elevation, ostectomy, flap suturing
Two-Stage procedure, which requires:
Flap elevation, ostectomy, flap suturing at its original position
Gingivectomy, 4 to 6 weeks later

GINGIVAL REDUCTION ONLY (BONE
REMOVAL NOT REQUIRED)

MUCOPERIOSTEAL FLAP WITH OSTECTOMY
(BONE REMOVAL REQUIRED)

CONCLUSION
Periodontal plastic surgery refers to soft tissue relationships and
manipulations. In all of these procedures, blood supply is the most
significant concern and must be the underlying issue for all decisions
regarding the individual surgical procedure. A major complicating factor
is the avascular root surface, and many modifications to existing
techniques are used to overcome this. The practitioner should be aware
that new methods sometimes are published without adequate clinical
research to ensure the predictability of the results and the extent to which
the techniques may benefit the patient. Critical analysis of recently
presented techniques should guide the evolution toward better clinical
methods.

REFERENCES
• Atlas Of Cosmetic And Reconstructive Periodontal Surgery -Third
Edition
• Clinical Periodontology and Implant Dentistry-Sixth Edition Niklaus P.
Lang and Jan Lindhe
• Periodontal Surgery A Clinical Atlas – Naoshi Sato
• Periobasics – Nithin Saroch