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Periodontal Surgery /Soft tissue surgery

Periodontal surgery is now used less frequently than in the past but still is applied in the
treatment of periodontal diseases. It may be used either to treat damage to the
periodontium and alveolar bone and/or to facilitate the effective removal of calculus.
There are different types of periodontal surgery, so before the operation treatment plan
should be established. It should be remembered that every periodontal treatment plan must
be designed to establish and preserve the dentition as a functioning unit! Soft tissue
surgery (frenuloplasty, frenectomy) is sometimes performed, because e.g. labial frenulum
causes diastema or linqual frenulum disturbs neonates sucking.
• Open curattage
• Gingivectomy, Gingivoplasty
• Frenuloplasty, Frenectomy
• Vestibuloplasty
• Vestibule and floor-of-mouth extension procedures
• Root amputation and hemisection
• Soft-tissue grafts
• Guided tissue regeneration
• Bone grafts
Open curettage
Open curettage is performed for the removal of subgingival calculus, granuloma under eye
control, which is done after detachment of gingiva. Sutures should be inserted without tension
and not through the papilla.
Gingivectomy/Gingivoplasty
Gingivectomy is the surgical excision of the soft-tissue wall of a pocket. Gingivoplasty is the
shaping of the gingiva in overgrowths.
In the technique of gingivectomy, pocket depths are marked on the outside of the gingiva with
a periodontal probe. After incision detachment of mucoperiosteal flap is performed. Next
removal of calculus, granuloma, changed bone is done. The excision of changed gingiva is
started about 1-2 mm apically to the bleeding points that were marked as the base of the
pockets and runs obliquely through the inner surface. This excision causes crown
lengthening. The wound is covered by periodontal pack. Periodontal dressing is no longer
used routinely after surgery but dressing may reduce the postoperative discomfort and
improve healing /this is not always necessary if a chlorhexidine is used/.
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Gingivoplasty is done without the detachment of gingiva. This procedure is a surgical

excision of an overgrowth and removal of gingival pockets.
Radical flap operation (Cieszyński-Widman-Neumann)
Indications:
• Bone pockets
• Interradicular septum defects
• Marginal alveolar bone defects
Excision of marginal gingiva is performed as deep as the base of pathological pockets.
Changed bone is completely removed. Flap is sutured in interdental spaces after periosteum
mobilization (periosteum undercutting).
Labial frenectomy
Strong and wrong labial frenulum attachment cases diastema, crowded teeth and sometimes
problem with denture stabilization. There are different methods of labial frenuloplasty
/Dieffenbach, Schuchardt, Mathis/. The most popular are Dieffenbach V-plasty and
Schuchardt Z-plasty.
During labial frenectomy removal of frenulum is performed. After procedure denuded
periosteum is present. The wound can be closed by suturing or by cementing. Frenectomy is
more common in the frenulum of the lower lip, frenuloplasty is more common in the frenulum
of upper lip.
Linqual frenectomy
Wrong linqual frenulum attachment causes problem during neonate sucking and in the future
leads to slurred speech. Besides, it can impair periodontal tissue and cause problem with
denture stabilization in the future. During this procedure transverse cutting of the frenulum is
performed. Wound suturing is done along the tongue base and on the mouth floor.

Vestibuloplasty
Vestibuloplasty is a procedure, which is performed when soft tissue attachment pull immobile
gingiva from tooth cervix. This operation is done to prevent root dehiscence (gingival
recession). The most popular is Clark vestibuloplasty. Other methods are useful as
preprosthetic procedures to increase vestibular depth.
Kazanjian vestibuloplasty
A mucosal flap pedicled from the alveolar ridge is elevated from the underlying tissue and
sutured to the depth of the vestibule. The inner portion of the lip is allowed to heal by
secondary epithelialization.
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Clark vestibuloplasty
Clark’s vestibuloplasty technique uses mucosa pedicled from the lip. Horizontal incision is
performed from canine to canine between immobile gingiva and mobile gingiva. After
supraperiosteal dissection the mucosa is sutured at the depth of the vestibule. The denuded
periosteum heals by secondary epithelialization. It is possible to use tissue graft on exposed
periosteum. The healing process is more rapid then.
Corn vestibuloplasty
This vestibuloplasty is similar to Clark’s vestibuloplasty.
Difference:
Horizontal incision is through soft tissue /mucosa and periosteum/ so the mucoperiosteal flap
is dissected and the bone is exposed.
Disadvantages:
More painful procedure;
The healing process is longer;
Radical vestibuloplasty /Nabers method/
After detachment of mucoperiosteal flap, it is sutured apically. Removal of calculus,
granuloma and changed bone is done.
Laterally repositioned flap
Laterally repositioned flap may be used to treat a localized area of gingival recession as an
alternative to the free gingival graft. The flap is rotated to cover the exposed root surface and
sutured without tension.
Soft-tissue grafts
Soft tissue grafts may be used in periodontal surgery during gingival recession treatment,
during vestibuloplasty to cover denuded periosteum or bone. The keratinized gingiva of the
palate is the preferred donor site.
Root amputation and hemisection
The loss of both the hard and soft supporting structures of multiroot teeth is frequent and
sometimes root amputation or hemisection is alternative to the extraction of the involved
tooth. Root amputation means only removal of root. Hemisection with extraction means
removal of root with part of crown. Hemisection can be without extraction (premolarization).
Indications:
• Severe vertical bone loss involving either one root of a mandibular molar or one or
two roots of a three-root maxillary molar;
• Multiroot teeth with fractures of individual roots complicating endodontic treatment;
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• Single roots of multiroot pulpless teeth which are not accessible to normal endodontic
procedures;
Prior to periodontal surgery endodontic therapy should be undertaken. Amalgam should be
inserted into the root canal just apically to the planned level of root section.

Classification of Gingival
Recession
• Class I
Marginal tissue recession which does not extend to the
mucogingival junction
No periodontal bone loss in the interdental area
100% root coverage
• Class II
Marginal tissue recession which extends to or beyond the
mucogingival junction
No periodontal bone loss in the interdental area
100% root coverage

Classification of Gingival
Recession
• Class III
Marginal tissue recession which extends to or beyond the
mucogingival junction
Bone or soft tissue loss in the interdental area or
malpositioning of the teeth, preventing 100% root
coverage
partial root coverage
• Class IV
Marginal tissue recession which extends to or beyond the
mucogingival junction
Severe bone or soft tissue loss in the interdental area
and/or malpositioning of the teeth
No root coverage