Periodontal Plas-c and Esthe-c Surgery

The term mucogingival surgery was ini4ally introduced in the literature by

Friedman 1953 to describe à surgical procedures for the correc4on of
rela4onships between the gingiva and the oral mucous membrane,

with special reference to three problem areas: a@ached gingiva, shallow

ves4bules, and a frenum interfering with the marginal gingiva.
The 1996 World Workshop in Clinical Periodon4cs renamed mucogingival surgery
as “periodontal plas-c surgery”

It was broadened to include the following areas:

• Periodontal-prosthe4c correc4ons
• Crown lengthening
• Ridge augmenta4on
• Aesthe4c surgical correc4ons
• Coverage of the denuded root surface
• Reconstruc4on of papillae
• Aesthe4c surgical correc4on around implants
• Surgical exposure of unerupted teeth for orthodon4cs

Defini-on:
Periodontal plas4c surgery is defined as: Surgical procedures performed to correct
or eliminate anatomic, developmental, or trauma4c deformi4es of the gingiva or
alveolar mucosa.

Mucogingival therapy is a broader term that includes non-surgical procedures

such as papilla reconstruc4on by means of orthodon4c or restora4ve therapy.
Periodontal plas4c surgery includes only the surgical procedures of mucogingival
therapy.

The most common mucogingival surgical procedures aim to increase the

dimensions of a@ached kera4nized 4ssue and gingival thickness and achieve root
coverage. These procedures are oQen indicated before or in conjunc4on with
restora4ve-prosthe4c den4stry and orthodon4c tooth movement.

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 Mucogingival deformi-es and condi-ons around teeth

1. Periodontal biotype (phenotype)

• Thin scalloped
• Thick scalloped
• Thick flat
2. Gingival/soF -ssue recession
• facial or lingual surfaces
• interproximal (papillary)
• Severity of recession (Cairo RT1,2,3)
• Gingival thickness
• Gingival width
• Presence of NCCL/ cervical caries
• Pa4ent esthe4c concern (smile esthe4c index
• Presence of hypersensi4vity
3. Lack of kera-nized gingiva
4. Decreased ves-bular depth
5. Aberrant frenum/muscle posi-on
6. Gingival excess
• pseudo-pocket
• inconsistent gingival margin
• excessive gingival display
• gingival enlargement
7. Abnormal color

Periodontal biotype (phenotype)

The “biotype” has been labeled by different authors as “gingival” or “periodontal”
“biotype”, “morphotype” or “phenotype.
The dis4nc4on among different periodontal biotypes is based upon:
• gingival biotype, which includes in its defini4on gingival thickness (GT) and
kera4nized 4ssue width (KTW)
• bone morphotype (BM)
• tooth dimension.

Periodontal biotype (phenotype)

Thin scalloped: Slender triangular crown, interproximal contact close to incisal
edge and a narrow zone of KT, clear thin delicate gingiva and thin alveolar bone.
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Thick Flat :Square shaped tooth, large interproximal contact located more
apically, broad zone of KT ,thick fibro4c gingiva and a thick alveolar bone.
Thick scalloped: thick fibro4c gingiva, slender teeth, narrow zone of KT and
pronounced gingival scalloping.

Methods to detect gingival thickness

1. Visual examina-on
2. Transgingival probing
(accuracy to the nearest 0.5 mm)by topical applica4on of an anesthe4c gel, an
endodon4c spreader with a rubber stop/ caliper is inserted thin (˂1.5 mm) or
thick (≥2 mm), possible pa4ent discomfort.
3. Probe transparency
according to the visibility of the underlying periodontal probe through the gingival
4ssue (visible = thin, not visible = thick).
4. CBCT
measure the thickness of both hard and soQ 4ssues, however exposure to
radia4on should be limited.

Clinical significance
• In the event of inflamma4on or any other type of insult, soQ 4ssue in a thick
biotype responds by more fibro4c changes and pocket forma4on,
• however in thin biotype, we see more inflammatory changes and recession
of gingiva. This cons4tute a risk when applying orthodon4c, implant, and
restora4ve treatments
• A thin biotype can be converted to a thick biotype via the use of subepithelial
connec4ve 4ssue graQ in a process known as Periodontal Biotype
modifica-on.

Lack of kera-nized -ssue

Problems associated with a1ached gingiva
• The width of the a@ached gingiva varies in different individuals and on
different teeth of the same individual.
• The width of the a@ached gingiva is determined by subtrac4ng the depth of
the sulcus or pocket from the distance between the crest of the gingival
margin and the mucogingival junc4on.

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Clinical tests to detect adequacy of the a@ached gingiva:
• visual examina4on
• Rolling test
• Tension test
• Iodine test
Ø No minimal width of a@ached gingiva has been established as a standard
necessary for gingival health.
Ø However, a@ached gingiva is important to maintain gingival health in
pa4ents with subop4mal plaque control.
Ø Lack of kera4nized 4ssue is considered a predisposing factor for the
development of gingival recessions and inflamma4on.
Ø The current consensus, based on case series and case reports (low level of
evidence), is that about 2 mm of KT and about 1 mm of a@ached gingiva are
desirable around teeth to maintain periodontal health.

Significance of aVached gingiva

• It provides kera4nized gingival 4ssue that can withstand mechanical forces
of mas4ca4on, brushing.
• It prevents free gingiva to be pulled away from the tooth when tension is
applied to mucosa.
• Its fibrous nature hinders spread of inflamma4on.

Ø A wider zone of a@ached gingiva is needed around teeth that serve as

abutments for fixed or removable par4al dentures.
Ø Teeth with subgingival restora4ons and narrow zones of kera4nized gingiva
have higher gingival inflamma4on scores than teeth with wide zones.
In these cases, techniques for widening the a@ached gingiva are considered pre-
prosthe4c periodontal surgical procedures.

Widening the a1ached gingiva accomplishes four objec:ves:

• Enhances plaque removal around the gingival margin.
• Improves aesthe4cs.
• Reduces inflamma4on around restored teeth.
• Allows gingival margin to bind be@er around teeth and implants with
a@ached gingiva.

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Causes of reduced or absent a1ached gingiva:
• The base of the periodontal pocket being apical or close to the
mucogingival line.
• Frenal and muscle a@achments that encroach on periodontal pocket and
pull them away from the tooth surface.
• Recession causing denuda4on of root surfaces.

Techniques to Increase AVached Gingiva

Gingival augmenta-on apical to the area of recession. The donor graQ 4ssue (i.e.,
pedicle or free) is placed on a recipient bed apical to the recessed gingival margin.
No a@empt is made to cover the denuded root surface where there is gingival and
bone recession.

Gingival augmenta-on coronal to the recession (i.e., root coverage). The donor
graQ 4ssue (i.e., pedicle or free) is placed covering the denuded root surface.

Gingival augmenta4on apical to recession

1. Free gingival autograQ (FGG)
2. Free connec4ve 4ssue autograQ in a recipient site created in a area apical to
the recession.
3. Apically posi4oned flap

1. Free gingival autograFs

The classic technique

1: Prepare the recipient site. A firm connec4ve 4ssue bed is prepared to receive
the graQ by incising at the exis4ng mucogingival junc4on to the desired depth
Extend the incisions to approximately twice the desired width of the a@ached
gingiva, allowing for 50% contrac4on of the graQ when healing is complete
The periosteum along the apical border of the graQ is some4mes penetrated in an
effort to prevent postopera4ve narrowing of the a@ached gingiva
2: Obtain the graQ from the donor site
a par4al-thickness graQ is used. The palate is the usual site from which the donor
4ssue is removed. The graQ should consist of epithelium and a thin layer of
underlying connec4ve 4ssue 1.0-1.5 mm

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3: Transfer and immobilize the graQ
A space between the graQ and the underlying 4ssue (i.e., dead space) impairs
vasculariza4on and jeopardizes the graQ. Suture the graQ. The graQ must be
immobilized.
4: Protect the donor site.
pressure has been applied over the site at the comple4on of the surgery, A
surgical stent is used to cover the wound site. several products can be placed over
the wound (e.g. hemosta4c gauze )

Disadvantages
• Color mismatch, not suitable for areas with high esthe4c demand
• Donor site heals by secondary inten4on

Variant techniques
To avoid the large wound area leQ some4mes in the donor site, some alterna4ve
methods have been proposed
1. The accordion technique: a@ains expansion of the graQ by alternate
incisions on opposite sides of the graQ
2. The strip technique
consists of obtaining two or three strips of gingival donor 4ssue about 3 to 5 mm
wide and long enough to cover the en4re length of the recipient
3. The combina4on graQ.
A deep strip graQ is taken from the palate and is split into an epithelial donor graQ
and the undersurface por4on of a connec4ve 4ssue donor graQ.
The 4ssue is obtained by removing a strip of 4ssue from the palate that is about 3
to 4 mm thick. Place it between two wet tongue depressors and split it
longitudinally with a sharp #15 blade.
Both are used as free graQs. The superficial por4on consists of epithelium and
connec4ve 4ssue, and the deeper por4on consists only of connec4ve 4ssue.

Healing of the graF

The success of the graQ depends on survival of the connec4ve 4ssue. Sloughing of
the epithelium occurs in most cases,
• Plasma-c diffusion:The graQ is ini4ally maintained by diffusion of fluid
(plasma) from the host bed, adjacent gingiva, and alveolar mucosa.

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 • Cappilary circula-on stage: Capillaries from the recipient bed proliferate
into the graQ to form a network of new capillaries and anastomose with
preexis4ng vessels
• Organiza-on; 4ssue matura4on

2. Free connec-ve -ssue autograFs

The connec4ve 4ssue autograQ technique was originally described by Edel and is
based on the fact that the connec4ve 4ssue carries the gene4c message for the
overlying epithelium to become kera4nized. Only connec4ve 4ssue from beneath
a kera4nized zone can be used as a graQ.
Techniques to obtain C.T gra@:
a. Trap door technique
b. Single line incision
c. De-epitheliza4on of a free kera4nized graQ
d. Tuberosity CT graQ

The advantages of this technique are:

• Healing of donor site by first inten4on. The pa4ent has less discomfort
postopera4vely at the donor site.
• improved aesthe4cs can be achieved because of a be@er color match of the
graQed 4ssue to the adjacent areas.

3. Apically displaced flap

This technique uses a par4al-thickness or full-thickness, apically posi4oned flap to
increase the zone of kera4nized gingiva.

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