PERIODONTAL PLASTIC

AND ESTHETIC SURGERY

Dr. Esam Dhaifullah
 INTRODUCTION
Define mucogingival surgery
Understand importance of adequate attached gingiva
Gingival recession, definition, classification, etiology and treatment
Varies technique to increase width of attached gingiva
 TERMINOLOGY
periodontal plastic surgery is defined as surgical procedures performed to correct or eliminate
anatomic, developmental, or traumatic or diseased induced defects of the gingiva, alveolar
mucosa.
In 1996 World Workshop in Clinical Periodontics renamed mucogingival surgery as “periodontal
plastic surgery, a term originally proposed by Miller in 1993 and broadened to include the
following areas:

1. Gingival augmentation
6. Coverage of the denuded root surface
2. Periodontal-prosthetic corrections
7. Reconstruction of papillae
3. Crown lengthening
8. Esthetic surgical correction around implants
4. Ridge augmentation
9. Surgical exposure of unerupted teeth for orthodontics
5. Esthetic surgical corrections
 DEFINITION OF PERIODONTAL PLASTIC SURGERY

1.Problems associated with attached gingiva

2. Problems associated with a shallow vestibule
3. Problems associated with an aberrant frenum
 HOW MUCH GINGIVA IS REQUIRED
1mm may create no
problems in patients with
good oral hygiene
 The need for widening the attached gingiva
Widening the attached gingiva accomplishes the following four
objectives:

1. Enhances plaque removal

2. Improves aesthetics
3. Reduces inflammation around restored teeth
4. Gingival margin binds better around teeth and implants with attached
gingiva.
 Problems Associated with Shallow
Vestibule:
 Minimal attached gingiva with adequate vestibular depth may not require surgical
correction if proper atraumatic hygiene is practiced with a soft brush.
 Minimal amounts of keratinized attached gingiva with no vestibular depth may need
for surgical correction.

tab2
 Aberrant Frenum
Problems:
*when invades on the margin
of the gingiva interfere with
plaque removal
*tension on the frenum open the
sulcus.
 GINGIVAL RECESSION
Gingival recession is characterized by displacement of the
soft tissue margin apically from the cementoenemel
junction (or from the former location of the CEJ in which
restorations have distorted the location

Prevalence:
• 8 % of people 9 - 12 of age (Parfitt & Mjör 1964)
• 50 % of people 18 – 64 years of age
• 88 % of people ≥ 65 of age (Kassab & Cohen 2003)
 Etiology of gingival recession
• Anatomical & morphological

• Trauma
• Aging
• Quality of the oral hygiene
• Orthodontic therapy !
• Bacterial infection (periodontitis)
 ANATOMICAL AND MORPHOLOGICAL ANOMALY
Fenestration & dehiscence of the alveolar
bone

Abnormal tooth position in the arch

Aberrant path of eruption of the tooth &

individual tooth shape

High muscle attachments and fernule pull

 ORTHODONTIC TREATMENT
Orthodontic movement  buccolingual

dimension  GR

Surgical procedures  increase the

gingival dimension eliminate GR

 CHRONIC TRAUMA OF ORAL HYGIENE

Hard-bristle brush

Improper toothbrush technique, or a faulty

toothbrush (e.g Horizontal method)

Improper frequency of toothbrushing (brush

three or more times daily)
 Factors That Affect Surgical Outcome
1. Irregularity of Teeth
• Orthodontic correction is indicated when mucogingival surgery is performed
on malposed teeth in an attempt to widen the attached gingiva or to
restore the gingiva over denuded roots.

• If orthodontic treatment is not possible, the prominent tooth should be

reduced to within the borders of the alveolar bone, with special care taken
to avoid pulp injury.
 TECHNIQUES TO INCREASE
ATTACHED GINGIVA

Gingival augmentation apical Gingival augmentation coronal to

to the area of recession the recession (root coverage)
GINGIVAL AUGMENTATION APICAL TO
RECESSION

Free Connective Apically

Gingival tissue graft positioned
graft flap
Gingival Augmentation Apical to Recession
1. Free Gingival Autografts
2. Free connective graft
 Classification of recession
Miller’s
:
Class I (shallow narrow and shallow wide)
Includes marginal tissue recession that does not extend to the
mucogingival junction.
:
Class II (Deep narrow and deep wide)
Include marginal tissue recession that extends to or beyond
the mucogingival junction.
:
Class III Marginal tissue recession that extends to or beyond the
mucogingival junction associated with bone or soft tissue loss.

Class IV :
Marginal tissue recession that extends to or beyond the
mucogingival junction associated with severe bone or soft
tissue loss interdentally
Gingival recession Level of receded Interalveolar septa Prospect of root
marginal tissue and interdental coverage
gingiva

Class I Coronal to MGJ No loss Excellent

100%

Class II Extends to or beyond No loss Excellent

the MGJ

100%
 Gingival Level of receded Interalveolar septa Prospect of root
recession marginal tissue and interdental coverage
gingiva

Class III At the MGJ or Apical Loss or tooth Good-Fair

to MGJ Malposition

Partial root
coverage

Class IV At the MGJ or Apical Extreme loss or Cannot be

to MGJ Extreme tooth anticipated
malposition

0%
Free Connective Tissue Autografts
Is based on the fact that the connective tissue transmits the genetic message for
the overlying epithelium to become keratinized. Therefore only connective tissue
from beneath a keratinized zone can be used as a graft
Advantages:
Donor site heals by 1° intention
Better aesthetics
 Gingival Augmentation Coronal to Recession (Root Coverage)

following is a list of techniques are used for root coverage:

Free gingival autograft

Pedicle autografts
• Laterally positioned

• Coronally positioned

• Semilunar pedicle

Subepithelial connective tissue graft

Guided tissue regeneration

Pouch and Tunnel technique

 Pedicle flap
a soft tissue graft that is not completely detached from one site and transferred to another. There are connection with the donor
site.

According to direction of flap migration

 Rotational flap –flap rotated or displaced laterally

Laterally positioned flap

Double papillae flap

Trans positional flap

 Advanced flap-flap placed with out rotation or lateral migration

Coronally positioned flap

Semilunar flap
• Advantages

One surgical site (no donor tissue)

Blood supply of pedicle flap covering root surface is preserved

Postoperative color is in harmony with surrounding tissue

o Disadvantages

-Applicable for relatively minor gingival recession (narrow and shallow) and recession limited to one

tooth

-Success rate is not high

 Coronally positioned flap
PREOPERATIVE
SEMILUNAR PEDICLE (TARNOW PROCEDURE)
 POUCH & TUNNEL TECHNIQUE(CORONALLY
ADVANCED TUNNEL TECH.)
Create “pouch “ using partial thickness incision and maintain papilla for bilaminar blood supply
To minimize incisions and the reflection of flaps
provide profuse blood supply to the donor tissue
It is indicated when the esthetic is considered
In anterior maxillary area in which vestibular depth is adequate and there is good gingival
thickness
 One of the advantages to this technique is the thickening of the gingival margin after healing
POUCH & TUNNEL TECHNIQUE(CORONALLY
ADVANCED TUNNEL TECH.)
 SUBEPITHELIAL CONNECTIVE TISSUE GRAFT (LANGER)

Described by Langer and Langer in 1985

For larger and multiple recessions
Partial thickness flap in area with good vestibular depth and gingival
thickness
GUIDED TISSUE REGENERATION TECHNIQUE FOR ROOT
COVERAGE
 THERAPY TO CORRECT EXCESSIVE
GINGIVAL DISPLAY

Excessive gingival display

“gummy smile
Causes:
-skeletal problem “vertical maxillary excess”
incomplete exposure of the anatomic crown
“altered passive eruption”

It may be associated with a short upper lip or

excessive lip translation.
PAPILLA RECONSTRUCTION