1. Periodontal Plastic and Esthetic Surgery

2. Definitions
Attached Gingiva – The portion of the gingiva that is firm, dense, stippled and tightly bound to the underlying periosteum, tooth, and bone.
Free Gingiva – That part of the gingiva that surrounds the tooth and is not directly attached to the tooth.

3. Definitions
Mucogingival Junction – the area of union of the gingiva and alveolar mucosa
Alveolar Mucosa – Loosely attached mucosa covering the basal part of the alveolar process and continuing into the vestibular fornix and the floor of the mouth

4. Definitions
Mucogingival Defect – a departure from the normal dimension and morphology of the relationship between the gingiva and the alveolar mucosa

5. Definitions
Free Gingival Graft (FGG) - A soft tissue graft that is completely detached from one site and transferred to a remote site. No connection with the donor site is maintained
Subepithelial Connective Tissue Graft (CTG) - A detached connective tissue graft that is placed beneath a partial thickness flap. This variation of the free gingival graft provides the tissue graft with a nutrient supply on two surfaces

6. The term mucogingival surgery was introduced to describe surgical procedures for the correction of relationships between the gingiva and the oral mucous membrane with reference to three specific problems: those associated with attached gingiva, shallow vestibules, and a frenum interfering with the marginal gingiva. that complicate periodontal disease & may interfere with the success of periodontal treatment.

7. With the advancement of periodontal surgical techniques, Recognizing that a multitude of areas were not addressed in the past.
mucogingival surgery is renamed as→→→ periodontal plastic surgery (World Workshop 1996)

8. Periodontal plastic surgery is defined as the surgical procedures performed to correct or eliminate anatomic, developmental, or traumatic deformities of the gingiva or alveolar mucosa.
The term mucogingival therapy is a broader one, since it also includes nonsurgical procedures such as papilla reconstruction by means of orthodontics or restorative dentistry.
Periodontal plastic surgery includes only the surgical procedures of mucogingival therapy.

9. periodontal plastic surgery include the following areas:
Periodontal-prosthetic corrections
Crown lengthening
Ridge augmentation
Esthetic surgical corrections
Coverage of the denuded root surface
Reconstruction of papillae
Esthetic surgical correction around implants
Surgical exposure of unerupted teeth for orthodontics

10. Objectives of periodontal plastic surgery:
1. Problems associated with attached gingiva 2. Problems associated with shallow vestibule 3. Problems associated with aberrant frenum

11. Problems Associated with Attached Gingiva:
The width of the attached gingiva is determined by subtracting the depth of the sulcus or pocket from the distance between the crest of the gingival margin to the mucogingival junction.

12. Causes of reducedd or absent attached gingiva:
1- the base of the pocket apical or close to MGJ. 2- high frenum attachment. 3- gingival inflammation. 4- traumatic tooth brushing habits 5- orthodontic tooth movement through a thin buccal osseous plate →→dehiscence→→gingival recession

13. Widening the attached gingiva to:
Enhances plaque removal around the gingival margin
Improves esthetics
Reduces inflammation around restored teeth

14. Techniques for increasing attached gingiva:
Gingival augmentation apical to the area of recession.:
A graft, either pedicle or free, is placed on a recipient bed apical to the recessed gingival margin.
No attempt is made to cover the denuded root surface where there is gingival and bone recession.
Gingival augmentation coronal to the recession
A graft (either pedicle or free) is placed covering the denuded root surface

15. Both the apical and coronal widening of attached gingiva enhance oral hygiene procedures, but only the coronal augmentation can correct an esthetic problem.
For preprosthetic purposes, the combination of widening keratinized gingiva apical and coronal to the recession would satisfy this objective.

16. Gingival Augmentation Apical to Recession:
Techniques for this procedure include the following:
1- Free gingival autograft,
2- free connective tissue autograft,
3-apically positioned flap

17. Free Gingival Autografts:
prepare a firm connective tissue bed to receive the graft.
The recipient site can be prepared by incising at the existing mucogingival junction with a #15 blade to the desired depth.
Periosteum should be left covering the bone.
The palate is the usual site from which donor tissue is removed. The graft should consist of epithelium and a thin layer of underlying connective tissue.
The ideal thickness of a graft is between 1.0 and 1.5 mm

18. Diagram of graft bed suture.

19. Free Gingival Graft
Pre-op
Pre-op
Courtesy of Barry R. Wohl, DDS

20. Free Gingival Graft Donor Site Recipient Site
Courtesy of Barry R. Wohl, DDS

21. Free Gingival Graft Before Long-term follow-up
Courtesy of Barry R. Wohl, DDS

22. Free gingival graft. A, Before treatment; minimal keratinized gingiva
Free gingival graft. A, Before treatment; minimal keratinized gingiva. B, Recipient site prepared for free gingival graft. C, Palate will be donor site. D, Free graft. E, Graft transferred to recipient site. F, At 6 months, showing widened zone of attached gingiva.

23. Drawbacks of Free Gingival Autografts:
Blood supply to the graft is available on only one surface, rather than two, as with connective tissue graft.
Color match of the tissue is a proplem between the grafted area and the adjacent tissues.
Palatal wound is more invasive, more prone to hemorrhhage and slower to heal
It is sensitive and time consuming technique.

24. Free connective tissue autografts:
the connective tissue carries the genetic message for the overlying epithelium to become keratinized. Therefore only connective tissue from a keratinized zone can be used as a graft.

26. Advantages of free connective tissue autografts:
the donor tissue is obtained from the undersurface of the palatal flap, which is sutured back in primary closure; therefore healing is by first intention.
There is less discomfort for the patient postoperatively at the donor site.
better esthetics can be achieved because of a better color match of the grafted tissue to adjacent areas.

27. The Apically Positioned Flap:
The apically positioned flap operation increases the width of the keratinized gingiva but cannot predictability deepen the vestibule with attached gingiva.
Adequate vestibular depth must be present before the surgery to allow apical positioning of the flap.

28. Gingival Augmentation Coronal to Recession (Techniques for Root Coverage)

29. Gingival Augmentation Coronal to Recession (Root Coverage):
Classifications of gingival recession

30. Sullivan and Atkins (1960)
classified gingival recession into four morphologic categories:
1) shallow-narrow
2) shallow-wide
3) deep-narrow
4) deep-wide.

31. Miller’s classification (1985)
This includes marginal tissue recession that does not extend to the mucogingival junction.
There is no loss of bone or soft tissue in the interdental area.
This type of recession can be narrow or wide.
100% root coverage

32. Class II:
marginal tissue recession extends to or beyond the mucogingival junction.
no bone or soft tissue loss interdentally.
This type of recession can be subclassified into wide and narrow.
100% root coverage

33. Class III:
marginal tissue recession extends to or beyond the mucogingival junction;
there is bone and/or soft tissue loss interdentally or there is malpositioning of the tooth.
Partial tooth coverage.

34. Class IV:
marginal tissue recession extends to or beyond the mucogingival junction
Severe bone and soft tissue loss interdentally and/or severe tooth malposition.
Root coverage can’t be attempted.

36. techniques used for gingival augmentation coronal to the recession (root coverage):
1. Free gingival autograft 2. Free connective tissue autograft 3. Pedicle autografts • Laterally (horizontally) positioned • Coronally positioned • Semilunar pedicle (Tarnow) 4. Subepithelial connective tissue graft (Langer) 5. Guided tissue regeneration (GTR) 6. Pouch and tunnel technique

37. 1- Free Gingival Autograft
Prepare the Recipient Site:
Horizontal incision in the interdental papillae at right angles
Vertical incisions are made at the proximal
line angles of adjacent teeth, and the retracted tissue is excised.
The periosteum is intact in the apical area.
Prepare the donor Site:
Advantage: predictable root coverage.
Disadvantages: lighter color (esthetic problem)

39. 2- Free connective tissue autograft
Prepare the Recipient Site
Obtaining C.T autograft
Transferring the graft & suture it to the periosteum
Periodontal dressing.

40. 3. Pedicle autografts: A- Laterally (horizontally) displaced.
cover isolated, denuded roots that have adequate donor tissue laterally and vestibular depth.

42. step-by-step procedure for this technique:
Prepare the Recipient Site:
Make an incision, resecting the gingival margin around the exposed roots .
Remove the resected soft tissue and scale and plane the root surface

43. Prepare the Flap:
The periodontium of the donor site should have a adequate width of attached gingiva and minimal loss of bone and without dehiscences or fenestrations.
A vertical incision from the gingival margin to outline a flap adjacent to the recipient site.
extend the incision into the oral mucosa to the level of the base of the recipient site
Short releasing oblique incision into alv.mucosa at the distal corner of the flap, pointing in the direction of the recipient site to avoid tension on the base of the flap that can impair the circulation when the flap is moved

44. 3- Transfer the Flap.
Slide the flap laterally onto the adjacent root
Interrupted and suspensory suture made around the involved tooth to prevent the flap from slipping apically

45. 4- Protect the Flap and Donor Site:
Cover the operative field with aluminum foil and a soft periodontal pack, extending it interdentally and onto the lingual surface to secure it. Remove the pack and sutures after 1 week

46. Variant techniques: Douple papilla flap
Used to cover denuded roots by isolated defects with a flap formed by joining the contiguous halves of the adjacent IDP.
-- poor results →→→ because blood supply is impaired by suturing the 2 flaps over the root surface.

49. B- Coronally Displaced Flap:
The purpose of the coronally displaced flap operation is to create a splitthickness flap in the area apical to the denuded root and position it coronally to cover the root.
It is limited by the height & thickness of the gingiva apical to the recession (3mm of gingiva)

52. Free gingival autograft is 2months later –a coronally & displaced flap
Variations: if insufficient keratinized gingiva present
2 stage procedure
↙ ↘
Free gingival autograft is months later –a coronally & displaced flap
Placed apical to the defect

53. C- semilunar coronally repositioned flap
1- A semilunar incision is made following
the curvature of the receded gingival margin and ending about 2 to 3 mm short of the tip of the papillae.
The incision may have to reach the alveolar mucosa if the attached gingiva is narrow.

56. 2- Perform a split-thickness dissection coronally from the incision and connect it to an intrasulcular incision.

57. 3- The tissue will collapse coronally, covering
the denuded root. It is then held in its new position for a few minutes with moist gauze; there is no need to suture or to pack.
Advantages :
Simple technique
2-3 root coverage
Successful for max. teeth
Several adjoining teeth

58. Subepithelial connective tissue graft (langer 1985).
Indications
1- for larger and multiple defects
2- good vestibular depth and
3- good gingival thickness to allow a split thickness flap to be elevated.
----the donor C.T is sandwiched between the split flap.

60. Technique:
Raise a partial-thickness flap with a horizontal incision 2 mm away from the tip of the papilla
two vertical incisions 1- to 2-mm away from the gingival margin of the adjoining teeth
Obtain a connective tissue graft from the palate
Place the connective tissue on the denuded root(s). Suture it with resorbable sutures to the periosteum.

61. Cover the graft with the outer portion of the partial-thickness flap and suture it interdentally
At least one half to two thirds of the C.T graft must be covered by the flap for the exposed portion to survive over the denuded root.
Cover the area with tinfoil and surgical pack.
----The esthetics are favorable with this technique since the
donor tissue is connective tissue .The donor site heals by primary intention, with considerably less discomfort than after a free gingival graft.

62. GUIDED TISSUE REGENERATION TECHNIQUE FOR ROOT COVERAGE:
This results in reconstruction of the attachment apparatus, along with coverage of the denuded root surface.
Technique:
1- A full-thickness flap is reflected to the mucogingival junction continuing as a partial-thickness flap 8 mm apical to the mucogingival junction.

64. 2- A microporous membrane is placed over the denuded root surface and the adjacent tissue & suturing it creating a space between the root & the membrane ( allow the growth of tissue beneath the membrane) 3- The flap is then positioned coronally and sutured. Four weeks later, a small envelope flap is performed, and the membrane is carefully removed. The flap is then again positioned coronally to protect the growing tissue and sutured. One week later, these sutures are removed.

65. Pouch and tunnel technique

66. Advantages: Minimize incisions.
Provide abundant blood supply to the donor site.
Pouch allows intimate contact of donor tissue to the recipient bed.
Esthetic improvement.
Good results with maxillary anterior with sufficient vestibular depth.

67. Thank you