periodontal plastic surgery

1. PERIODONTAL PLASTIC AND AESTHETIC
SURGERY

2. CONTENTS
• Introduction
• Objectives
• Gingival augmentation---
i. Gingival dimensions and periodontal health
ii. Indication for gingival augmentions
iii. Gingival augmentation procedure
• Removal of aberrant frenum
• Root coverage
• Interdental papilla reconstruction
• Crown lengthening procedure
• Prevention of tooth extraction associated ridge collapse
• Augmentation of edentulous ridge

3. INTRODUCTION
• Friedman in 1957 introduced the term Mucogingival surgery
• Mucogingival surgery can be defined as “surgical procedures designed to preserve
gingiva, remove aberrant frenulum or muscle attachments, and increase the
depth of the vestibule.” (Wennstrom and Zucchelli, 2015)
• Special reference to three problem areas: attached gingiva, shallow vestibules,
and a frenum interfering with the marginal gingiva.
• In the year 1993, P. D. Miller introduced the term Periodontal Plastic Surgery,
considering that mucogingival surgery had moved beyond the traditional treatment
of problems associated with the amount of gingiva and recession type defects to
also include correction of ridge form and soft tissue esthetics.

4. Periodontal plastic surgery can be be defined as “surgical procedures performed to
prevent or correct anatomic, developmental, traumatic or disease induced defects of the
gingiva, alveolar mucosa or bone” ( World Workshop in Periodontics 1996).
Among treatment procedures that may fall within this definition are various soft
and hard tissue procedures aimed at:--
• Gingival augmentation
•Removal of aberrant frenum
• Root coverage
• Crown lengthening
• Gingival preservation at ectopic tooth eruption
• Reconstruction of papillae
• Prevention of ridge collapse associated with tooth extraction
• Augmentation of the edentulous ridge.
•Correction of mucosal defects at implants

5. Objectives
1. To create an adequate zone of attached keratinized gingiva
2. To eliminate pockets that extend beyond the mucogingival line
3. To eliminate muscle and frenulum pull
4. To deepen the vestibule
5. To cover denuded root surfaces for esthetics or hypersensitivity
6. To overcome the anatomic factors of tooth position, thin alveolar housing, and
large prominent roots, which promote dehiscence and/or fenestration formation
with gingival accession.
7. To minimize recession during orthodontic movement
8. To overcome the trauma of prosthetic restorative dentistry requiring subgingival
Placement
9. To stabilize and maintain a healthy mucogingival complex
10. To correct areas of progressive gingival recession
11. To correct ridge deformities and undercuts

6. Gingival augmentation
Surgical procedures for gingival augmentation was based on the opinion:-
 The presence of a wide band of keratinized and attached mucosa around the tooth
is critical for---
 maintaining gingival health
 preventing attachment loss and soft tissue recession
(Nabers 1954; Ochsenbein 1960; Friedman & Levine 1964; Hall 1981; Matter 1982).

7. Tissue Barrier Concept (Goldman and Cohen 1979)
 A dense collagenous band of connective tissue 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 tissue to achieve an
adequate tissue barrier (thick tissue), thus limiting recession as a result of inflammation.

8. The original rationale for mucogingival surgery was predicated on the assumption
that a minimal width of attached gingiva was required to maintain optimal gingival
health .
The ultimate goal of mucogingival surgical procedures is the creation or widening of
attached gingiva around teeth and implants.
(American Academy of Periodontology. Proceedings of the 1996 World Workshop in
Periodontics, Lansdowne, Virginia, July 13-17. Ann Periodontol. 1996;1:1–947.)
Gingival dimensions and periodontal health

9. Narrow zone of gingiva was insufficient
• to protect the periodontium from injury caused
by friction forces encountered during mastication
to dissipate the pull on the gingival margin
created by the muscles of the adjacent alveolar
mucosa (Friedman 1957; Ochsenbein 1960).
facilitate sub gingival plaque formation because
of the improper pocket closure resulting from
the movability of the marginal tissue (Friedman
1962)
favor attachment loss and soft tissue recession
because of less tissue resistance to apical spread
of plaque‐associated gingival lesions (Stern
1976; Ruben 1979).

10. • Corn 1962, stated that the apicocoronal height of keratinized
tissue ought to exceed 3 mm
• According to Friedman 1962; De Trey &Bernimoulin 1980, an
adequate amount of gingiva is any dimension that is compatible
with gingival health and/ prevents retraction of the gingival
margin during movements of the alveolar mucosa
• Bowers 1963 suggested that <1 mm of gingiva may be sufficient
for maintaining periodontal health.

11.  Lang and Loe (1972) suggested that 2 mm of gingiva is an adequate width for
maintaining gingival health.
 Wennstrom and Lindhe (1983a, b) utilizing the Beagle dog model, stated that
careful plaque control measures, gingival health could be established and
maintained without sign of recession of the gingival margin or loss of attachment,
independent of
(1) presence or absence of attached gingiva,
(2) width of keratinized gingiva or
(3) height of the supporting attachment apparatus.
• Further support for the conclusion that a minimal zone of gingiva may not
compromise periodontal health is available from a number of other longitudinal
clinical studies
( De Trey & Bernimoulin 1980; Hangorsky & Bissada 1980; Lindhe & Nyman 1980; Schoo & van
der Velden 1985; Kisch et al. 1986; Wennstrom 1987; Freedman et al. 1999).

12. Marginal tissue recession
• Displacement of the soft tissue margin apical to the
cementoenamel junction (CEJ)
• Exposure of the root surface
• Is a common feature in populations with high standards of
oral hygiene
( Sangnes & Gjermo 1976; Murtomaa et al. 1987; Loe et al. 1992; Serino et al.1994),
• As well as in populations with poor oral hygiene
(Baelum et al. 1986; Yoneyama et al. 1988; Loe et al. 1992; Susin et al. 2004).

13. • Three different types of marginal tissue recessions may be
defined:--
1) Recessions associated with mechanical factors, predominately
toothbrushing trauma (mainly for young people)
2) Recessions associated with localized plaque‐induced inflammatory
lesions
3) Recessions associated with generalized forms of destructive
periodontal disease. (mainly for adult patient).
Evidence from prospective longitudinal studies shows that the gingival
height is not a critical factor for the prevention of marginal tissue
recession, but that the development of a recession will result in loss
of gingival height.
[Lindhe and Nyman 1980, Dorfman et al. 1982 , Schoo & van der Velden 1985; Kisch et al. 1986; Wennstrom 1987; Freedman et
al. 1999]

14. Marginal tissue recession and orthodontic treatment
Tooth Movement within the envelope of the alveolar process
the risk of harmful side effects on the marginal tissue is minimal,
irrespective of the dimensions and quality of the soft tissue
surrounding the tooth.
 Tooth movement is expected to result in the establishment of
an alveolar bone dehiscence the volume (thickness) of
the covering soft tissue ( should be considered as a factor that )
may influence the development of soft tissue recession during,
as well as after the phase of active orthodontic therapy.

15. Gingival dimensions and restorative therapy
Subgingival placement of the margin of a restoration ----
May result in soft tissue recession over time.
Experimental and clinical data suggest that the thickness of the marginal gingiva( but
not the apicocoronal width of the gingiva) may influence the magnitude of recession
taking place as a result of direct mechanical trauma during tooth preparation and
bacterial plaque retention.
Evidence suggests that with good oral hygiene, peri‐implant soft tissue health can be
maintained even when keratinized mucosa is lacking. There is no evidence in support
of an “adequate” width of keratinized mucosa as a superior protective soft tissue
barrier around dental implants.
However, it is recommended to maximize efforts to preserve existing keratinized
mucosa during implant treatment procedures.

16. Indications for gingival augmentation
The apicocoronal width of gingiva and the presence of
an attached portion of gingiva are not of decisive
importance for the maintenance of gingival health and
the height of the periodontal tissues.
Consequently, the presence of a narrow zone of gingiva
per se cannot justify surgical intervention (Lang & Karing
1994; Proceedings of the 1996 World Workshop in Periodontics
1996).

17. 1. Gingival augmentation should be considered in situations where, for
example, the patient experiences discomfort during tooth brushing and/or
chewing due to interference from a lining mucosa at teeth or implants.
2. Orthodontic tooth movement is planned and the final positioning of the
tooth can be expected to result in an alveolar bone dehiscence, an
increase of the thickness of the covering soft tissue may reduce the risk for
development of soft tissue recession.
3. An increase of the thickness of the gingiva may also be considered when
subgingival restorations are placed in areas with a thin marginal tissue.

18. Gingival augmentation procedures
The earliest of these techniques are the “vestibular extension
operations”, which were designed mainly with the objective of
extending the depth of the vestibular sulcus.
(Bohannan 1962a, b).
At present commonly used techniques in the management of “insufficient”
gingival dimensions, because of higher predictability of the healing result----
 Pedicle flap or
 free soft tissue grafts

24. The apically repositioned flap procedure (Friedman 1962)----
Involved the elevation of soft tissue flaps
 Their displacement during suturing in an apical position
Leaving 3–5 mm of alveolar bone( interdental crest) denuded in the coronal part
of the surgical area.
Resulted in the same risk for extensive bone resorption as with other “denudation
techniques”.
Though Friedman (1962) stated that a post‐surgical increase of the width of the
gingiva can be predicted with the “apically repositioned flap”, but several studies
indicated that the presurgical width most often was retained or was only slightly
increased
(Donnenfeld et al. 1964; Carranza & Carraro 1970).

25. Based on a systematic review of soft tissue augmentation techniques by Thoma et al.
(2009) concluded that:---
1.There is evidence for an increased width of keratinized tissue and attached gingiva
following apically repositioned flap/vestibuloplasty
2. The addition of an autogenous tissue graft significantly increases the width of attached
gingiva.
3. The use of allogenic grafts produces dimensional increases in keratinized tissue
similar to those produced with autogenous tissue.
a collagen matrix of porcine origin (MucograftR) was shown to be as effective and
predictable as the free autogenous graft in increasing the band of keratinized tissue at
teeth and implants with significantly lower patient morbidity
(Sanz et al. 2009; Nevins et al. 2011; Lorenzo et al. 2012).

26. Grafting procedures
• Maintain their connection
to the donor site after
placement at the recipient
site
Pedicle
Graft
• Palatal donor area
• Acellular freeze‐dried
dermal matrix (ADM)
• Human fibroblast derived
dermal substitute
Free
graft

28. Techniques to Remove the Frenum
A frenum is a-- -Fold of mucous membrane
- Usually with enclosed muscle fibers
- Attaches the lips and cheeks to the alveolar mucosa or gingiva
and underlying periosteum.
A frenum causes a problem if the attachment is too close to the marginal gingiva.
(may be genetic condition or the result of recession of the gingival margin).
Hirshfield" first drew attention to the frenum as an etiologic factor in periodontal
disease in 1939, it was not until 19 54 that Stewart and Gottsegen* introduced
surgical methods for its elimination.
Tension on the frenum can pull the gingival margin away from the
Tooth and causes---
Biofilm accumulation and inhibit proper placement of the toothbrush at the gingival
margin.( mainly in anterior mandibular areas. )
The aberrant frenum located between the maxillary central incisors may cause an
aesthetic problem in a patient with a high lip line.

29. Frenectomy and Frenotomy
Frenectomy is complete removal of the frenum including its attachment to underlying
bone, and it may be required in the correction of an abnormal diastema between the
maxillary central incisors.
Frenotomy is relocation of the frenum, usually in a more apical position.
Frenectomy and frenotomy can be performed in conjunction with other periodontal
treatment procedures, such as a free gingival graft procedure to deepen the vestibule
in the mandibular anterior area.
Frenal problems occur most often on the facial surface between the maxillary and
mandibular central incisors and less often on the lingual surface of the mandible.

30. Mucosal Gingival
Papillary
Papilla
penetrating
Placek et al (1974)

31. 1. Mucosal – when the frenal fibres are attached up to the mucogingival junction.
2. Gingival – when the fibres are inserted within the attached gingiva.
3. Papillary – when the fibres are extending into the interdental papilla.
4. Papilla penetrating – when the frenal fibres cross the alveolar process and extend
up to the palatine papilla.

32. Indications
The frenum is characterized as pathogenic and is indicated for removal
when---
• An aberrant frenal attachment causing midline diastema.
• A flattened papilla with the frenum closely attached to the gingival
margin is present, which causes a gingival recession and a hindrance in
maintaining the oral hygiene.
• An aberrant frenum with an inadequately attached gingiva and a shallow
vestibule is seen.

33. The techniques which were employed were:
• Conventional (Classical) frenectomy
• Miller’s technique
• V-Y Plasty
• Z Plasty
• Frenectomy which was done by using electro cautery

34. Classical Frenectomy :----
Introduced by Archer (1961) and Kruger (1964).
 This approach was advocated in the midline diastema cases with an aberrant
frenum to ensure the removal of the muscle fibres which were supposedly
connecting the orbicularis oris with the palatine papilla .
 This technique is an excision type frenectomy which includes the interdental
tissues and the palatine papilla along with the frenulum.

35. Miller’s Technique
•Advocated by Miller PD in 1985.
• This technique was proposed for the post-orthodontic diastema cases.
The ideal time for performing this surgery is after the orthodontic movement is
complete and about 6 weeks before the appliances are removed.

36. Z Plasty
•This technique is indicated when there is hypertrophy of the frenum
•associated with an inter-incisor diastema, and
• when the lateral incisors have appeared without causing the diastema to
disappear
• In cases of a short vestibule.
V-Y Plasty
V-Y plasty can be used for lengthening the localized area, like the broad frenum
in the premolar-molar area.

37. Root coverage
INDICATIONS----
•Esthetic/cosmetic demands
•Root sensitivity
•Changing the topography of the marginal soft tissue in order to facilitate plaque control
•Root abrasion/caries

38. Anatomical factors
•Fenestration and
Dehiscence
•Abnormal tooth position
in the arch
•Aberrant path of
eruption of the tooth
Physiological factors
•Active orthodontic
movement of the teeth
outside the alveolar
bone may be
considered as an
etiological factor
Pathological factors
•Tooth brushing
•Improper flossing
techniques
•Direct trauma
associated with
malocclusion
•Bacterial plaque
•Partial
denture/restorative
therapy
•Herpes simplex virus
Etiology of gingival recessions

39. Miller (1985a) classification of recession

40. Doubts relates to the Miller’s class of gingival recession (Class I or Class II) extending
beyond the mucogingival line, but conserving a small, probable height of keratinized
tissue apical to the root exposure

41. Unclear procedures to ascertain the amount of soft-/hard-tissue loss in the
interdental area to differentiate Class III and Class IV

42. Unclear influence of tooth malpositioning

43. Cairo et al. (2011) suggested a simplified classification of buccal recessions for
prediction of the final root coverage outcome, based on clinical assessments of inter
proximal attachment levels
RT1
• Buccal tissue recession with no loss of
interproximal attachment
RT2
• Buccal tissue recession associated with loss of
interproximal attachment less than or equal to
the buccal attachment loss
RT3
• Buccal tissue recession associated with loss of
interproximal attachment greater than the
buccal attachment loss.

44. Root coverage surgical procedures
Pedicle soft-tissue graft procedures: Free soft-tissue graft procedures
1. Rotational flap procedures (laterally sliding flap,
double papilla flap, oblique rotated flap);
2. Advanced flap procedures (coronally
repositioned flap, semilunar coronally repositioned
flap);
3. Regenerative procedures (with barrier membrane
or application of enamel matrix proteins)
1.Epithelialized graft;
2. Subepithelial connective tissue
graft

45. Before root coverage is attempted--
Free from bacterial biofilms
Rubber cup and a polishing paste can be used.
Controlled clinical trials showed no differences in terms of root
coverage or residual probing depth between teeth that had been
instrumented (root planed) or polished
only (Oles et al. 1988; Pini Prato et al. 1999)

46. Root conditioning
To detoxify, decontaminate and demineralize the root surface
Removing the smear layer and exposing the collagenous matrix of dentin and
cementum
Various acids have been used for chemical root-surface conditioning.
• Citric (pH 1.0 ) and Phosphoric acids (37%) (Register A, Burdick F,1975),
• Ethylene Diamine Tetraacetic Acid(pH 7.0) (Lasho D,1983)
•Tetracycline hydrochloride(pH 7.0) (Labahn R,1992).

47. In an animal model, these procedures are believed to be able to induce
cementogenesis and enhance attachment by connective tissue ingrowth
and/or demineralization(Garrett J et al, 1975. Wilson T., et al, 2005)
However, in human studies, no clinical advantages were observed
(Egelberg J.1995. Lowenguth R, Blieden T, 1993).
Based on a systematic review on the efficacy of root surface conditioning, Oliveira and
Muncinelli (2012) concluded that there is no evidence that root surface
biomodification by, for example, citric acid, EDTA or laser prior to soft tissue root
Coverage improves the clinical outcome of root coverage procedures.

48. Rotational flap procedures
Laterally repositioned flap to cover areas with localized recession was introduced by
Grupe and Warren (1956).
To reduce the risk for recession on the donor tooth, Grupe (1966) suggested
that the marginal soft tissue should not be included in the flap.
Staffileno (1964) and Pfeifer and Heller (1971) advocated the use of a split‐thickness flap
to minimize the potential risk for development of dehiscence at the donor tooth.
Corn (1964b) further modified this by adding a cutback incision to release tension
Dahlberg (1969) used engineering principles with the rotated pedicle flap, which did
not require a cutback incision
Goldman and Smukler (1978) added the periosteally stimulated flap and a partial-full rotated
flap in 1983, which allowed a full-thickness flap to cover the denuded root surface and a
partial-thickness flap to cover the exposed bone

53. Oblique Rotated Pedicle Flap
Dahlberg (1969) designed incisions for pedicle flaps based on a center of
rotation about an axis at the base of the vertical donor incision. This permitted
the pedicle to be moved over the donor site without tension and without the
need for releasing incisions.

55. Double-Papillae Laterally Positioned Flaps
This procedure, first described by Wainberg as the double lateral repositioned flap
( Goldman and colleauges, 1964), was refined by Cohen and Ross (1968) as the double-
papillae flap
Indications.
1. When the interproximal papillae adjacent to the mucogingival problem are
sufficiently wide
2. When the attached keratinized gingiva on an approximating tooth is insufficient to
allow for a laterally positioned flap
3. When periodontal pockets are not present

56. Advantages—
1. The risk of loss of alveolar bone is minimized because the interdental bone is more
resistant to loss than is radicular bone.
2. The papillae usually supply a greater width of attached gingiva than can be gotten
from the radicular surface of a tooth.
3. The clinical predictability of this procedure is fairly good.
Disadvantage.
1. The primary disadvantage of this procedure is in having to join together two small
flaps in such a way that they act as a single flap.

58. Advanced flaps
Since the lining mucosa is elastic, a mucosal flap raised beyond the mucogingival
junction can be stretched in the coronal direction to cover the exposed
root surfaces
The coronally advanced flap can be used for root coverage of a single tooth as well as
multiple teeth
In situations with only shallow recession defects and minimal probing pocket depth labially,
the semilunar coronally repositioned flap may offer an alternative approach
Tarnow 1986).
For the treatment of an isolated deep gingival recession affecting a lower incisor, or
the mesial root of the first maxillary molar, Zucchelli et al. (2004) suggested the use of
a laterally moved, coronally advanced flap.

67. Pedicle soft tissue graft procedures combined with a barrier membrane
Use of a barrier membrane, according to the principles of guided tissue regeneration
, in conjunction with pedicle soft tissue graft procedures was introduced as a
treatment modality for root coverage by Pini Prato et al. (1992).

70. Pedicle soft tissue graft procedures combined with enamel matrix proteins
Abbas et al. (2003) described a surgical procedure for periodontal regenerative therapy of
recession defects utilizing enamel matrix derivative (EMD) bioactive
material (EmdogainR):

71. 1. The surgical technique utilized in the coronally advanced flap---
The interdental papillae should be de‐epithelialized to allow for maximum coronal
positioning of the tissue flap over the exposed root surface at suturing.
2. Following preparation of the coronally advanced flap, the exposed root surface is
conditioned with PrefGelTM (24% EDTA‐gel, pH 6.7; Straumann Biologics, Switzerland)
for 2 minutes to remove the smear layer.
3. After thorough rinsing with sterile saline, the EMD gel (EmdogainR; Straumann
Biologics) is applied to the exposed root surface. The pedicle graft is advanced
coronally and secured at a level slightly coronal to the CEJ by suturing the flap to
the de‐epithelialized papilla regions using nonirritating sutures.
4. The vertical incisions are then closed with two to three sutures.

72. Free soft-tissue graft procedures
The free soft tissue graft is the most widely used, most predictable technique for
increasing the zone of attached gingiva
Historical Background
Published reports on gingival grafting began appearing in the American literature in the
1960s (Bjorn, 1963; King and Pennel, 1964; Cowan, 1965; Nabers, 1966b; Haggerty, 1966)
Sullivan and Atkins (1968) published their of articles on indications,
techniques, and wound healing and grafting that grafting became popular.
With the exception of certain modifications, the principles and techniques outlined then are
still valid today

73. 1. Gargiulo and Arrocha (1967) used gingivectomy tissue as donor tissue.
2. Sullivan and Atkins (1968) published classic articles on the free gingival graft
technique.
3. Pennel and colleagues (1969) developed the submarginal technique and
supplemental combined use of periosteal fenestration.
4. Karring and colleagues (1972, 1974) showed that the connective tissue
determines the nature of graft tissue and described the use of connective tissue
autografts.
5. Dordick and colleagues (1976) placed grafts directly on bone for a firmer
attachment.
6. Carvalho and colleagues (1982) used a periosteal pedicle as an aid in root
coverage.
7. Holbrook and Ochsenbein (1983) demonstrated a refined suturing technique for
root coverage.
8. Ellegaarde and colleagues (1974) used free gingival grafts to retard epithelial
migration over osseous grafts.

74. The epithelialized free soft tissue graft procedure can be performed either as a
 two‐step surgical technique, where an epithelialized free soft tissue graft is placed
apical to the recession and following healing is positioned coronally over the denuded
root . (Bernimoulin et al. 1975; Guinard & Caffesse 1978), or
As a one‐step technique by which the graft is placed directly over the root surface
(Sullivan & Atkins 1968a, b; Miller 1982)
The latter technique has been the most commonly used.

75. Advantages
1. High degree of predictability
2. Simplicity
3. Ability to treat multiple teeth at the same time
4. Can be performed 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
Disadvantages
1. Two operative sites
2. Compromised blood supply
3. Lack of predictability in attempting root
coverage
4. Greater discomfort
5. Poor hemostasis
6. Retention of graft

81. Graft Thickness

82. Thin or intermediate-thickness grafts of approximately 0.5 to 0.75 mm are the ideal
thickness for increasing the zone of keratinized attached gingiva (Soehren and
colleagues, 1973) and at the same time producing a result that is
esthetically pleasing.
Grafts of this thickness undergo minimal primary contraction because of the small
amount of elastic fibers (Orban, 1966).
On the other hand, they do undergo a good deal of secondary contraction of
approximately 25 to 45% (Ratertschak and colleagues, 1979; Seibert, 1980;Ward, 1974)
as a result of cicatrization (Scar formation) , which binds the graft to the underlying bed
(Barsky and colleagues, 1964).
This shrinkage can be compensated for by making the graft appropriately wider at the
time of operation.

83. Thick or full-thickness grafts of 1.25 to 2 mm or greater are indicated for root
coverage and ridge augmentation procedures.
They are thick enough to sustain themselves over avascular root surfaces while
thinning without splitting until the plasmatic diffusion can be effective.
They also tend to create an unesthetic patch-like graft
They have greater primary contraction owing to the large amount of elastic fibers
(Davis and Kitlowski, 1931) but minimal secondary contraction because of the thicker
lamina propria (Barsky and colleagues, 1964)
The greater primary contraction tends to delay revascularization by closing down
the blood vessels (Davis and Davis, 1966).

84. Common Reasons for Graft Failure
1. Their use for root coverage.-----If the denuded root defect is small enough, the collateral
circulation will be adequate to support bridging. On the other hand, when prominent roots with
relatively wide areas of root exposure are grafted, two-point collateral circulation is insufficient
for graft support. As a result, the center of the graft thins and becomes necrotic, and the graft
splits and ultimately fails .
2. Proper graft adaptation to the underlying periosteum is important. After suturing,
slight pressure is applied to the graft with gauze moistened with saline for 5 minutes to
permit fibrin clot formation and prevent bleeding. Bleeding will result in a hematoma
under the graft, with subsequent necrosis

85. 3. To permit adequate transfusion of the graft, it has been recommended that all fat
and glandular tissue be removed prior to suturing to prevent possible necrosis
and/or inadequate take . Even though the need for this has been questioned, it is still
a generally accepted procedure.
4. Graft movement as a result of inadequate or insufficient suturing will surely result
in failure
because no plasmatic diffusion will occur.
5. The final failure is often seen only after the graft has healed. The clinical
appearance is acceptable, but the graft is totally movable when probed. This is a
failure of technique and results from not removing all loose connective tissue and
muscle fibers from the periosteal bed prior to placement and not making sure that the
bed is firmly attached to the underlying bone.

86. • Free gingival graft is not a predictable root coverage technique( specially in term
of complete root coverage due to the fact that graft survival on an avascular root
surface is entirely dependent on blood vessels bridging between grafted tissue and
the periosteal bed surrounding the root exposure.
• To increase a graft’s chance to survival over the root it must cover at least 3mm
periosteal bed mesial, distal and apical to bone dehiscence.
• So a FMG can be used as a root coverage technique only with narrow , shallow
recession defects.
The use of a free gingival graft to treat recession defects in patients with
aesthetic requests is not recommended because of the poor aesthetic outcome
and the low root coverage predictability (Wennstrom 1994).

87. Two stage technique
• Bernimoulin 1975
• Ist stage FMG done with CAF after 3 months.
Indication---
1) No CAF or lateral pedicle flap is possible
2) Contraindication for FMG.

88. Contra indicating to pedicle flap---
• Absence of keratinized tissue apical and/ lateral to the root exposure
• Presence of frenula inserting into the margin
• Shallow vestibule
• Gingival cleft
Local condition unfavorable for a free gingival graft as a root coverage technique are -
---
• Wide, deep areas of root exposure giving poor root coverage predictibility and deep
buccal probing depth in association with the recession defects.

89. Indication for two step technique
• For treatment of multiple recession defects on adjacent teeth, specially the
mandibular incisors where a pedicle flap for covering a connective tissue graft
( bilamilar technique ) is contradicted because of presence of frenulam inserting
marginally or shallow vestibule.
• Indicated when the gingiva adjacent to the teeth with defects is pale pink and
therefore more similar in colour to the paltal mucosa. The purpose of this procedure
is to recreate a band of keratinize tissue covering the exposed root whose height and
colour is as similar as possible to the keratinized gingiva of the adjacent teeth.

90. Advantage--
• The possibility of obtaining both root coverage
for a tooth with gingival recession and
increase in buccal keratinized tissue and
vestibular depth for the adjacent tooth or
teeth.

91. Free gingival graft with laterally moved coronary advanced flap
• Some recession defects present a combination of contradictions for
• a free gingival graft ( a very deep recession defect or deep buccal pocket in
association with the recession defect),
• a pedicle flap as a root coverage technique ( the absence of apical and lateral
keratinized tissue and/ or a shallow vestibule),
• a free gingival graft apical to the exposed roots as the first procedure in a two –
step technique( very deep root exposure, the presence of external oblique line of the
mandible , the proximity of the buccal emergence of the mandibular nerve.)

93. Connective tissue graft
Connective tissue graft (CTG) is used for---
• increasing the width of keratinized gingiva,
• root coverage procedure
• Alveolar ridge deficiencies
• Management of peri-implant tissue abnormalities
• papillary loss.
• Alan Edel first delineated CTG in 1974 for increasing the width of gingiva and since then
its functions have increased tremendously.
• Currently, for most of the soft-tissue augmentation surgeries, it is still deemed as the gold standard
treatment.

94. • In 2010, a Cochrane systematic review stated that, in cases where gain in
keratinized tissue and root coverage is anticipated, the use of CTGs seems to be
more adequate than others, which was also supported by Chambrone and Tatakis
• Buti et al. in a meta-analysis also stated that coronally advanced flap + CTG might
be contemplated as the gold standard in root coverage procedures.

96. In an anatomical study of the GPA and related bony structures of the hard palate in
41 cadavers, Klosek and Rungruang found that the GPF was most frequently found in
the region near the apices of the second and third molars, in the area where the
vertical and horizontal segments of the palatine bone come together
(Klosek & Rungruang 2009).
Ikuta and coworkers found in a cone beam computed tomography study that the GPF
was located in 92 of 100 cases in the third molar region and in an average distance
of 7.9 mm from the alveolar ridge (Ikuta et al. 2013),
In Indian skulls observed the GPF to be in the third molar region in only 73% of the
cases (Sharma & Garud 2013).
Monnet-Corti and coworkers, who measured the distance of the main branches of the
GPA from the palatal gingival margin in 198 periodontally healthy patients, found that
the average distance from the gingival margin to the GPA ranged from approximately
12 mm in the canine area to roughly 14 mm at the second molar level
(Monnet-Corti et al. 2006).

97. • Why palate is the routinely used donor site?
CTG can be procured from the edentulous ridges,
maxillary tuberosity, and palate
Palate being the most frequently used donor site due to
the large dimensions of graft that could be obtained
and also the presence of histological similarity between
the palatal mucosa and keratinized attached mucosa of
alveolar ridge.

98. Sub epithelial connective tissue graft ----
involve the placement of the graft directly over the exposed root and the mobilization
of a mucosal flap coronally or laterally for coverage of the graft .
(Langer & Langer 1985; Nelson 1987; Harris 1992; Bruno 1994; Zucchelli et al. 2003)
Alternative technique is to place the base of the connective tissue graft within an
“envelope” prepared by an undermining partial‐thickness incision from the soft
tissue margin, that is part of the graft will rest on the root surface coronal to the soft
tissue margin.
(Raetzke 1985; Allen 1994)
For the treatment of multiple adjacent recessions, a multi‐envelope recipient
bed (“tunnel”) may be prepared (Zabalegui et al. 1999).

100. connective tissue graft combined with a coronally advanced flap is

101. The “tunnel” technique

102. The “envelope” technique

103. Bilaminar procedure described by Raetzke (1985)
The literature indicates the bilaminar techniques (i.e. partially disepithelized
or connective tissue graft covered by a pedicle flap) as highly predictable root
coverage surgical procedures (Wennstrom 1994), even if the reported percentage of
complete root coverage with the bilaminar procedures ranges from 42% (Raetzke
1985) to 89% (Harris 1992).
These modifications related both the type of graft (partially or completely de
epithelized) harvested from the palate and the design (envelope-type or with
vertical releasing incision) of the covering flap.

104. Selection of surgical procedure for root coverage
Tooth position,
Recession depth and width
Tissue thickness and quality apical and lateral to the recession
Esthetic demands, and compliance.
From an esthetic point of view, the soft tissue coverage of exposed root surfaces
should be in harmony with the adjacent tissue and hence a pedicle graft would be
the preference.

105. For maxillary teeth------the coronally advanced flap may be considered as the basic
procedure to be used for single as well as multiple recessions.
If the quality of the mucosa apical to the recessions is considered inadequate for root
coverage, the procedure is combined with the placement of a connective tissue graft.

106. In the mandible----the placement of a free connective tissue graft with an
“envelope” or a “tunnel” preparation is preferred because of a thin mucosa
apical to the recession and often the presence of multiple
frenula, that is conditions not suitable for a coronally advanced flap.
In case of a localized single recession defect of moderate depth, a rotational
flap may be used if keratinized mucosa of sufficient dimensions
are available lateral to the recession

107. Soft tissue recessions at dental implants are commonly associated with a thin mucosa .
Hence the surgical approach to regain soft tissue coverage of the implant unit has to
involve a connective tissue graft, ------
Either in a combined procedure with a coronally advanced flap or in a two‐stage
procedure with the placement of the connective tissue graft with an “envelope”
procedure, followed by a coronally advanced flap as a second procedure.

108. Root coverage
An analysis with regard to initial Miller class I–II recession defects that may be
successfully covered following treatment with coronally advanced flaps, based on the
data from randomized controlled studies included in systematic reviews (Cairo et al. 2008;
Chambrone et al. 2009), shows that
on average about 70% root coverage may be expected (range 34–87%).
Complete coverage of the recession defect, which is the ultimate goal of the therapy,
may be reached in approximately 35% of treated cases (range 15–60%).

109. Soft tissue healing against the covered root surface
Healing of pedicle soft tissue grafts
In the areas surrounding the recession defect, that is where the recipient bed consists
of bone covered by connective tissue, the pattern of healing is similar to
that observed following a traditional flap operation.
Healing in the area where the pedicle graft is in contact with the denuded root surface
was studied by Wilderman and Wentz (1965) in dogs.
According to Wennstrom and Zucchelli. 2005, the healing process can be divided
into four different stages :

110. 1. Adaptation stage (from 0 to 4 days). ----
The laterally repositioned flap is separated from the exposed root surface by a thin
fibrin layer. The epithelium covering the transplanted tissue flap starts to proliferate
and reaches the tooth surface at the coronal edge of the flap after a few days.
2. Proliferation stage (from 4 to 21 days)----
• Fibrin layer between the root surface and the flap is invaded by connective tissue
proliferating from the subsurface of the flap.
• After 6–10 days, a layer of fibroblasts is seen in apposition to the root surface. (These
cells are believed to differentiate into cementoblasts at a later stage of healing. )
•At the end of the proliferation stage, thin collagen fibers are formed adjacent to the
root surface, but a fibrous union between the connective tissue and the root has not
been observed.

111. •From the coronal edge of the wound, epithelium proliferates apically along
the root surface.
•According to Wilderman and Wentz (1965), the apical proliferation of
epithelium may stop within the coronal half of the defect, although further
down‐growth of epithelium was also frequently observed.

112. 3. Attachment stage (from 27 to 28 days)----thin collagen fibers become inserted into a
layer of new cementum formed at the root surface in the apical portion of the
recession.
4. Maturation stage-----characterized by continuous formation of collagen fibers.
After 2–3 months, bundles of collagen fibers insert into the cementum layer on the
curetted root surface in the apical portion of the recession.

113. Healing of free soft tissue grafts
Survival of a free soft tissue graft placed over a denuded root surface depends on ---
•Diffusion of plasma and subsequent revascularization from those parts of the graft that are
resting on the connective tissue bed surrounding the dehiscence. The establishment
of collateral circulation from adjacent vascular borders of the bed allows the healing
phenomenon of “bridging” (Sullivan & Atkins 1968a).
[Hence, the amount of tissue that can be maintained over the root surface is limited by the size
of the avascular area (Oliver et al. 1968; Sullivan & Atkins 1968). Other factors
considered critical for the survival of the tissue graft placed over the root surface are]
•Sufficient vascular bed is prepared around the dehiscence and that a thick graft is used (Miller
1985b).

114. Another healing phenomenon frequently observed following free graft procedures
is “creeping attachment”, that is coronal migration of the soft tissue margin. This
occurs as a consequence of tissue maturation over a period of about 1 year post
treatment

115. Interdental papilla reconstruction
There may be several reasons for loss of papilla height and the establishment of
“black triangles” between teeth.
The most common reason in the adult individual is loss of periodontal support due to
plaque‐associated lesions.
Abnormal tooth shape, improper contours of prosthetic restorations, and traumatic
oral hygiene procedures may also negatively influence the outline of the interdental
soft tissues.

116. Nordland and Tarnow (1998)

118. Considering that a supracrestal connective tissue attachment zone of approximately 1
mm is normally found (Gargiulo 1961), the observation indicates that the biologic
height of the interdental papilla may be limited to about 4 mm.

119. Hence, before attempts are made to surgically reconstruct an interdental papilla, it is important
to carefully assess—
(1) the vertical distance between the bone crest and the apical point of the contact area
between the crowns
(2) the soft tissue height in the interdental area.

120. If the bone crest–contact point distance is ≤5 mm and the papilla height is <4 mm,
surgical intervention for increasing the volume of the papilla could be justified
in order to solve the problem of an interdental “black triangle”.
.

121. Surgical techniques
Several case reports have been published regarding surgical techniques for the
reconstruction of deficient papillae (e.g. Beagle 1992; Han & Takei 1996; Azzi
et al. 1999).
However, the predictability of the various procedures has not been documented
and no data are available in the literature providing information on the long‐term
stability of surgically regained interdental papillae.

122. Beagle (1992) described a pedicle graft procedure utilizing the soft tissues
palatal to the interdental area.

123. Han and Takei (1996) proposed an approach for papilla reconstruction
(“semilunar coronally repositioned papilla”) based on the use of a free
connective tissue graft.

124. Azzi et al. (1999) described a technique in which an envelope‐type flap is
prepared for coverage of a connective tissue graft.

125. Ectopic tooth eruption
Surgical intervention is often indicated for teeth erupting ectopically, that is with an
eruption position facial to the alveolar process .
Three different techniques have been described for the interceptive mucogingival
treatment of buccally erupting teeth, depending on the distance from the
donor site (entrapped gingiva) to the recipient site (area located facially–apically to
the erupting permanent tooth) (Agudio et al. 1985; Pini Prato et al. 2000b):

126. Double pedicle graft

127. Apically positioned flap Free gingival graftapically positioned flap

128. Deformed edentulous ridge
Procedures proposed for prevention of ridge collapse in conjunction with tooth
extractions include----
(1) Flap elevation for complete soft tissue closure of the extraction sites (Borghetti &
Glise 2000)
(2) Placement of connective tissue grafts over the extraction sites (Nevins & Mellonig
1998)
(3) Placement of bone grafts (Becker et al. 1994)
(4) Utilization of barrier membranes (Lekovic et al. 1997).

129. Correction of ridge defects by the use of soft tissue grafts
According to eibert (1983) ridge defects can be divided into
three classes:S--
• Class I: loss of buccolingual width but normal apicocoronal height
• Class II: loss of apicocoronal height but normal buccolingual width
• Class III: a combination of loss of both height and width of the ridge.

130. The following factors should be determined prior to the initiation of therapy:
• Volume of tissue required to eliminate the ridge deformity
• Type of graft procedure to be used
• Timing of various treatment procedures
• Design of the provisional restoration
• Potential problems with tissue discolorations and matching tissue color.
The procedures may be grouped according to the methods used for ridge
augmentation as
(1) Soft tissue augmentation procedures
(2) Hard tissue augmentation procedures.

131. • Pedicle graft procedure:
Roll flap procedure
• Free graft procedures:
Pouch graft procedure
 Interpositional graft procedure
 Onlay graft procedure.
Studer et al. (1997) proposed the use of the pedicle graft procedure for correction of a
single‐tooth ridge defect with minor horizontal and vertical loss, whereas
submerged free connective tissue graft procedures should be selected for larger
defects.

132. “Roll flap procedure”
The “roll flap procedure” (Abrams 1980) involves the preparation of a
de‐epithelialized connective tissue pedicle graft, which is subsequently placed in a
subepithelial pouch

133. Pouch graft procedures
Surgical concept
A subepithelial pouch is prepared in the area of the ridge deformity, into which a free graft of
connective tissue is placed and molded to create the desired contour of the ridge.
The entrance incision and the plane of dissection may be made in different ways
(Kaldahl et al. 1982; Seibert 1983; Allen et al. 1985;Miller 1986; Cohen 1994):----
• Coronoapically: the horizontal incision is made on the palatal or lingual side of the
defect and the plane of dissection carried in an apical direction
• Apicocoronally: the horizontal incision is made high in the vestibule near the
mucobuccal fold and the plane of dissection is carried coronally to the crest
of the ridge
• Laterally: one or two vertical entrance incisions are started from either side of the
defect .
The plane of dissection is made laterally across the span of the deformity.

134. Indication:---
The technique is used to correct class I defects.
Patients with large‐volume defects may have thin palatal tissues, which are
insufficient to provide the volume of the donor tissue necessary to fill the
deformity.
In such cases, various procedures for hard tissue augmentation may be selected

136. Interpositional graft procedure Surgical concept
Interpositional grafts are not completely submerged and are covered in the manner
that a subepithelial connective tissue graft is placed (Seibert 1991, 1993a, b).
Therefore, there is no need to remove the epithelium from the surface of the donor
tissue. If augmentation is required not only in the buccolingual but also in the
apicocoronal direction, a portion of the graft must be positioned above the surface of
the tissue surrounding the recipient site .
Indications
Interpositional graft procedures are used to correct class I as well as small and moderate
class II defects.

138. Onlay graft procedures Surgical concept
The onlay procedure was designed to augment ridge defects in the apicocoronal
plane, that is to gain ridge height (Meltzer 1979; Seibert 1983).
Onlay grafts are epithelialized free grafts which, following placement, receive their
nutrition from the de‐epithelialized connective tissue of the recipient site.
The amount of apicocoronal augmentation that can be obtained is related to the
initial thickness of the graft, the events of the wound healing process, and the
amount of graft tissue that survives .
If necessary, the grafting procedure can be repeated at 2‐month intervals to gradually
increase the ridge height.

139. Indications----
•Onlay graft procedures are used in the treatment of large class II and III defects.
•They are not suitable in areas where the blood supply at the recipient site has
been compromised by scar tissue formation from previous wound healing.

141. Combined onlay–interpositional graft procedures
Class III ridge defects pose a major challenge to the clinician since the ridge has to be
augmented in both vertical and horizontal dimensions.
The combined onlay–interpositional graft procedure may successfully be used in such a
situation (Seibert & Louis 1996).
The combined graft procedure may offer the following advantages:
• Submerged connective tissue section of the interpositional graft aids in the
revascularization of the onlay section of the graft, thereby gaining a greater percentage
take of the overall graft

142. • Smaller postoperative open wound in the palate donor site
• Faster healing in the palate donor site with less patient discomfort
• Greater latitude or ability to control the degree of buccolingual and apicocoronal
augmentation within a single procedure
• Vestibular depth is not decreased and the mucogingival junction is not moved
coronally, thereby eliminating the need for follow‐up corrective procedures.

144. Crown‐lengthening procedures
“gummy smile
it is possible by a combination of periodontal
and prosthetic treatment measures to improve
dentofacial esthetics in this category of
patient.
If excessive gingival exposure is due to insufficient length of the clinical crowns,
a crown‐lengthening procedure is indicated to reduce the amount of gingiva
exposed, which in turn will favorably alter the shape and form of the anterior
teeth.
To select the proper treatment approach for crown lengthening, an analysis of
the individual case with regard to crown–root–alveolar bone relationships
should also be included.

145. The concept of tooth lengthening was first introduced by D. W. Cohen (1962) and is
presently a procedure that often employs some combination of tissue reduction or
removal, osseous surgery, and/or orthodontics for tooth exposure.
In the young adult with an intact periodontium, the gingival margin normally resides
about 1 mm coronal to the CEJ.
However, some patients may have a height of free gingiva that is >1 mm, resulting in a
disproportional appearance of the clinical crown.
If such a patient complains about his/her “small front teeth” and the periodontium is of
a thin phenotype, full exposure of the anatomic crown can be accomplished by a
gingivectomy/gingivoplasty procedure

146. If the periodontium is of the thick phenotype and there is a bony ledge at the
osseous crest, an apically positioned flap procedure should be
performed. This will allow for osseous recontouring.

147. Apically repositioned flap
In the 1950s and 1960s new surgical techniques for the removal of soft and, when
indicated, hard tissue periodontal pockets were described in the literature.
The importance of maintaining an adequate zone of attached gingiva after surgery was
now emphasized. One of the first authors to describe a technique for the
preservation of the gingiva following surgery was Nabers (1954).
The surgical technique developed by Nabers was originally denoted “repositioning of
attached gingiva” .
In 1962, Friedman proposed the term apically repositioned flap to describe more
appropriately the surgical technique introduced by Nabers.

148. Friedman emphasized the fact that, at the end of the surgical procedure, the entire
complex of the soft tissues (gingiva and alveolar mucosa), rather than the
gingiva alone, was displaced in the apical direction.
Thus, rather than removing gingiva which would be in excess after osseous surgery (if
performed), the whole mucogingival complex was maintained and repositioned
apically.
This surgical technique was used on buccal surfaces in both upper and lower jaws
and on lingual surfaces in the lower jaw.

151. Clinical Evaluation
1. Sulcus depth
2. Biologic width
3. Osseous crest
4. Pulpal involvement
5. Apical extent of fracture
6. Gingival health
7. Furcation location
8. Loss of mesial, distal, or occlusal space
9. Anticipated final margin placement

152. Radiographic Analysis---
1. Level of alveolar crest
2. Apical extent of fracture or caries
3. Pulpal involvement
4. Root length
5. Root form
6. Furcation
7. Crown-to-root ratio (at present or posttreatment)
8. Root trunk length

153. Contraindications and Limiting Factors----
1. Inadequate crown-to-root ratio
2. Non restorability of caries or root fracture
3. Esthetic compromise
4. High furcation
5. Inadequate predictability
6. Tooth arch relationship inadequacy
7. Compromise of adjacent periodontium or esthetics
8. Insufficient restorative space
9. Non maintainability

154. Presurgical Analysis---
Smukler and Chaibi (1997) recommended the following presurgical clinical analysis
prior to crown-lengthening procedures:
1. Determine the finish line prior to surgery.
2. If non determinable, it should be anticipated.
3. Trans crevicular circumferential probing prior to surgery is performed for
establishing the biologic width.
a. Surgical site
b. Contralateral site
4. The biologic width requirements will determine the amount of alveolar bone
removal.

155. 5. The combination of biologic width and prosthetic requirements determines the total
amount of tooth structure necessary for exposure.

156. Exposure of sound tooth structure
Crown‐lengthening procedures may be required to
solve problems such as
(1) inadequate amount of tooth structure for proper restorative therapy,
(2) subgingival location of fracture lines
(3) subgingival location of carious lesions.

157. Apically positioned flap with bone recontouring
The apically positioned flap technique with bone recontouring (resection) may be
used to expose sound tooth structure. As a general rule, at least 4 mm of
sound tooth structure must be exposed at the time of surgery.
During healing, the supracrestal soft tissues will proliferate coronally to cover 2–3
mm of the root (Herrero et al. 1995; Pontoriero & Carnevale 2001; Lanning et al.
2003), thereby leaving only 1–2 mm of supragingivally located sound tooth
structure.

158. .
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