all about mucogingival surgeries

2. INTRODUCTION
Periodontal plastic surgery - the term initially proposed by
miller in 1993 and broadened to include the following areas:-
Periodontal prosthetic corrections
Crown lengthening
Ridge augmentation
Esthetic surgical corrections
Coverage of the denuded root surface
Reconstruction of the papillae
Esthetic surgical correction around implants
Surgical exposure of unerupted teeth for orthodontics

3. 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.
Periodontal plastic surgery include only the surgical
procedure of mucogingival therapy.

4. Periodontal plastic surgical procedures include widening of attached
gingiva,deepening of shallow vestibules, and resection of aberrant
frena,periodontal prosthetic surgery,esthetic surgery around implants and
surgical exposure of teeth for orthodontic therapy.
Mucogingival therapy is a broader term that includes non surgical
procedures such as papilla reconstruction by means of orthodontic or
restorative therapy

5. CRITERIA FOR SELECTION OF MUCOGINGIVAL
TECHNIQUE
1. Surgical site free of calculus, plaque and inflammation -enable
the clinician to manage gingival tissue that is firm ,meticulous
precise incision and flap reflection cannot be achieved when
gingival tissue edematous.
2. Adequate blood supply to donor tissue
3. Anatomy of recipient and donor tissue
4. Minimal trauma to surgical site
5. Stability of the grafted tissue to the recipient site.

6. The three objectives of periodontal plastic surgery,
 Problem associated attached gingiva
with shallow vestibule
aberrant frenum

7. PROBLEM ASSOCIATED WITH ATTACHED
GINGIVA
 The original rationale for muco gingival surgery predicted
on the assumption that a minimal width of attached
gingiva was required to maintain optimal gingival health.
 A wide attached gingiva is more protective against the
accumulation of plaque than a narrow or a non existent
zone.
 Persons who practice excellent oral hygiene may maintain
healthy areas with almost no attached gingiva.

8.  Recession of anterior maxillary tooth cause an
esthetic defect in individual with high smile line.
 The coverage of denuded root for esthetic
purposes also widens the zone of attached
gingiva.
 Wider zone of attached gingiva around the teeth
serve as the abutment for fixed or removable
partial denture.

9.  Teeth with subgingival restorations and narrow zone of
keratinized gingiva have higher gingival inflammation scores
than teeth with similar restorations and wide zone of attached
gingiva.
 Widening of attached gingiva accomplishes the following
three objectives:
 Enhances plaque removal around the gingival margin
 Improves esthetics
 Reduces inflammation around restored teeth

10.  PROBLEMS ASSOCIATED WITH SHALLOW
VESTIBULE.
Proper oral hygiene measures are jeopardized.
Sulcular brushing technique requires placement of
toothbrush at the gingival margin, which may not be
possible 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.

11.  Minimal amounts of keratinized attached gingiva with no
vestibular depth usually benefit from mucogingival
correction.Proper placement of removable prosthesis may not
be possible without adequate vestibular depth.

12.  PROBLEMS ASSOCIATED WITH ABERRANT
FRENUM
A frenum that encroaches on the margin of the gingiva
may interfere with plaque removal, and tension on
this frenum may tend to open the sulcus. In this case,
surgical removal of frenum is indicated.

13. TECHNIQUES TO INCREASE ATTACHED
GINGIVA
 GINGIVAL AUGMENTATION APICAL TO
RECESSION
 GINGIVAL AUGMENTATION CORONAL TO
THE RECESSION (root coverage)

14. GINGIVAL AUGMENTATION APICAL TO THE
RECESSION
 A graft ,either pedicle or free, is placed on a recipient
bed apical to recessed gingival margin. No attempt
is made to cover the denuded root surface.
 TECHNIQUES
 Free gingival autograft
 Free connective tissue autograft
 Apically positioned flap

15. FREE GINGIVAL AUTOGRAFT
Free gingival graft are used to create a widened zone of
attached gingiva.
Initially described by bjorn in 1963
THE CLASSIC TECHNIQUE
STEP 1: PREPARE THE RECIPIENT SITE
The purpose of this step is to prepare firm connective tissue
bed to receive the graft .The recipient site can be prepared
by incising at existing mucogingival junction with a #15
blade to the desired depth. Periosteum should be left
covering the bone.

16. recipient site
prepared for free
gingival graft
Before treatment

17.  Extend the incisions to approximately twice the
desired width of the attached gingiva ,allowing for
50% contraction of the graft when healing is
complete.
 The amount of contraction depend on the extent to
which the recipient site penetrates the muscle
attachments. The deeper the recipient site, greater is
the tendency for the muscles to elevate the graft and
reduce the final width of the attached gingiva.

18.  Insert a #15 blade along the cut gingival margin
and separate a flap consisting of epithelium and
underlying connective tissue without disturbing the
periosteum.
 Extend the flap to the depth of the vertical
incisions.
 If a narrow band of attached gingiva remains after
pockets are eliminated ,it should be left intact,and
the recipient site should be started by inserting the
blade at the mucogingival junction instead of at the
cut gingival margin.

19.  Suture the flap where the apical portion of the free
graft will be located. Three to four independent gut
sutures are placed. The needle is first passed as a
superficial mattress suture perpendicular to the
incision and then on the periosteum parallel to the
incision.
 Make an aluminum foil template of the recipient site
to be used as a pattern for the graft.

20.  Graft can also be placed directly on the bone tissue ,
for this technique flap should be separated with a
blunt dissection with a periosteal elevator.
ADVANTAGE
 Less swelling
 Better haemostasis
 Less shrinkage
 Less post operative mobility

21. STEP 2; OBTAIN A GRAFT FROM DONOR
SITE
 Transferring a piece of keratinized gingiva
approximately the size of the recipient site.
 Palate is the usual site from which donor tissue is
removed
 The graft should consist of an epithelium and a
layer of connective tissue.

22.  Place the template over the donor site,and
make a shallow incision around it with a #15
blade.
 Insert the blade to the desired thickness at
one edge of the graft.
 Elevate the edge and hold it with tissue
forceps.

23.  Template placed

24. Graft procured

25. FREE GRAFT

26.  Proper thickness is important for survival of graft. it
should be thin enough to permit ready diffusion of
nutritive fluid from the recipient site .
 A graft that is too thin may necrosis and expose the
recipient site.
 if it is too thick its peripheral layer is jeopardized
because of the excessive tissue that separate it from
new circulation and nutrients.

27.  Thick graft also create a deeper wound on donor
site with possibility of injuring major palatal
arteries, the ideal thickness of graft is between1
and 1.5 mm.
 After the graft is separated remove loose tissue
tags from the under surface. Thin the edges to
avoid bulbous marginal and interdental contours.

28.  STEP 3: TRANSFER AND IMMOBILIZE THE GRAFT
Remove the sponge from the recipient site; reapply it, with
pressure if necessary, until bleeding is stopped. Remove the
excess clot. A thick clot interferes with vascularization of the
graft.
Position the graft and adapt it firmly to the recipient site. A space
between the graft and the underlying tissue(dead space) impairs
vascularization and jeopardizes the graft.
Suture the graft at the lateral borders and to the periosteum to
secure it in position. The graft must be immobilized, any
movement interfere with healing.

29. Graft transferred to recipient site

30.  Avoid excessive tension which can distort the graft from
the underlining surface.
 STEP 4: PROTECT THE DONOR SITE.
Cover the donor site with a periodontal pack for one week.
If facial attached gingiva was used , the pack may be
retained by locking it through the inter proximal spaces on to
the lingual surface .
If there are no open interdental spaces ,the pack can be
covered by a plastic stent wired to the teeth.
A modified Hawley retainer is useful to cover the pack on
the palate and over edentulous ridges.

31. VARIANT TECHNIQUES
Variant techniques attempt to minimize the donor
site wound by removing the donor tissue in a
different configuration and altering the shape to
maximize coverage over the recipient site.
These techniques are:-
1) The accordion technique
2) The strip technique
3) The combination epithelial – connective tissue strip
technique
All are modifications of the free gingival grafts.

32. THE ACCORDION TECHNIQUE
 Described by Rateitschak et al
 Attains expansion of graft by alternate
incisions in opposite sides of the graft.
 This technique increases the donor graft
tissue by changing the configuration of the
tissue

33. STRIP TECHNIQUE
 Developed by Han et al
 Consists of obtaining 2 or 3 strips of gingival
donor tissue about 3-5mm wide and long
enough to cover the entire length of the
recipient site.
 These strips are placed side by side to form one
donor tissue and sutured on the recipient site.
 The area is then covered with aluminum foil and
surgical dressing.

34. Mucosal tissue around implants

35. Recipient site prepared

36. Donor site with strips of free graft removed Donor strips of free graft

37. Strips placed side by side on recipient site

38. Healing of the recipient site after 3 months

39.  The advantages of this technique are:-
 Rapid healing of the donor site.
 The epithelial migration of the close wound
edges (3-5mm) allows rapid epithelialization of
the open wound.
 The donor site usually does not require suturing
and heals uneventfully in 1-2 weeks.

40. COMBINATION TECHNIQUE
 A deep strip graft is taken from the palate
and is split into both an epithelial-connective
tissue strip and a pure connective strip.
 The tissue is obtained as follows:-
1. Remove a strip of tissue from the palate about
3 to 4 mm thick
2. Place it between two wet tongue depressors
3. Split it longitudinally with a sharp #15 blade.
Both will be used as free grafts.

41.  The superficial portion consists of
epithelium and connective tissue
 Deeper portion consists of only connective
tissue
 These donor tissues are placed on the
recipient site as in the strip technique.
 Advantage : minimal donor site wound
obtained by two donor tissues from one
site.

42.  Alternative donor tissue:
Use of palate as a donor site for gingival
augmentation has numerous disadvantages.
 Patients are fearful of palatal surgery
 Limitation on the amount of tissue that can be removed.
 Currently used substitute for palatal donor tissue:
Acellular dermal matrix(ADM)
Commercial name: alloderm
Derived from donated human skin.
 Other techniques to avoid palatal donor site morbidity
involve biologic mediators.

43. HEALING OF THE GRAFT
 The success of the graft depend on the survival of
the connective tissue. Fibrous organisation of the
interface between the graft and the recipient bed
occurs within 2 to several days.
 The graft is initially maintained by diffusion of fluid
from the host bed, adjacent gingiva, and alveolar
mucosa. The fluid provide nutrition and hydration
essential for the initial survival of transplanted
tissues.

44.  During the first day , the connective tissue
becomes edematous and disorganized and
undergoes degeneration and lysis of some of
its elements.
 As healing progresses,the edema is
resolved,and degenerated connective tissue
is replaced by new granulation tissue.

45.  Revascularisation of the graft starts by the second or
third day.
 Many of the graft vessels degenerate and are
replaced by new ones,and some of these participate
in the new circulation. The central section of the
surface is the last to vascularize,but this is complete
by the 10th day.
 The epithelium undergoes degeneration and
sloughing,with complete necrosis occuring in some
areas. It is replaced by new epithelium from the
borders of the recipient site.

46.  A thin layer of new epithelium is present by the
fourth day,with retepegs developing by the 7th day.
 Healing of the graft of intermediate thickness
(0.75mm) is complete by 10.5 weeks, thicker
grafts(1.75mm) may require 16 weeks or longer.
 Functional integration of the graft occurs by 17th day
but the graft is morphologically distinguishable from
the surrounding tissue for months.

47. FREE CONNECTIVE TISSUE AUTOGRAFT
 It is based on the fact that the connective tissue carries the
genetic message for the overlying epithelium to become
keratinized. Therefore connective tissue from keratinized zone
can be used as graft.
 The advantage of this technique is that the donor tissue is
obtained from the under surface of the palate flap which is
sutured back in primary closure, there for healing is by first
intention. The patient has less discomfort post operatively at the
donor site.
 Better esthetics can be achieved because of a better colour
match of the grafted tissue to adjacent areas.

48. A) Lack of keratinized attached gingiva buccal to cenral incisor; B)vertical incisions
to prepare recipient site

49. C) recipient site prepared E) removal of connective tissue

50. donor site sutured connective tissue for graft
connective tissue placed at donor site

51. final healing at 3 months
Better esthetics can be achieved because of a better
colour match of the grafted tissue to adjacent areas.

52. APICALLY DISPLACED FLAP
 This technique uses the apically positioned flap
either partial thickness or full thickness, to increase
the zone of keratinized gingiva.
 This technique increase 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.

53.  Accomplishments :
The apically displaced flap technique
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.

54.  The edge of the flap may be located in 3
positions in relation to the bone:-
1) Slightly coronal to the crest of the bone
2) At the level of the crest
3) 2mm short of the crest
Other techniques : vestibular extension technique
described by Edlan and Mejchar
Produced significant widening of attached
nonkeratinized tissue.

57. GINGIVAL AUGMENTATION CORONAL TO
RECESSION (ROOT COVERAGE)
Sulivan and Atkins classified gingival recession based on 4
anatomic categories:
1. Shallow – narrow
2. Shallow - wide
3. Deep - narrow
4. Deep - wide

58. CLASSIFICATION OF GINGIVAL RECESSION BY MILLER
CLASS 1: Marginal tissue recession does not extend to the
mucogingival junction. No bone loss or soft tissue in the
interdental area.
CLASS 2: Marginal tissue recession extends to or beyond the
mucogingival junction. . No bone loss or soft tissue in the
interdental area.
CLASS 3: Marginal tissue recession extends to or beyond the
mucogingival junction. Bone and soft tissue loss interdentally or
malpositioning of the tooth.
CLASS 4: Marginal tissue recession extends to or beyond the
mucogingival junction. Severe bone and soft tissue loss
interdentally or severe tooth malposition.

59. P.D. Miller’s classification of denuded roots

60. A graft is placed covering the denuded root surface. Both
apical and coronal widening of attached gingiva enhance oral
hygiene procedures.
TECHNIQUES USED :-
 Free gingival autograft
 Free connective tissue autograft.
 Pedicle autograft
 Laterally(horizontally) positioned pedicle flap
 Coronally positioned flap; includes semilunar pedicle
(Tarnow)
 Subepithelial connective tissue graft
 Guided tissue regeneration
 Pouch and tunnel technique.

61. FREE GINGIVAL AUTOGRAFT
 The classic technique: Miller applied the classic free
gingival autograft with a few modifications:-
STEP 1: Root planing. Root planing is performed with the
application of saturated citric acid for 5 min on the root
surface.
STEP 2 : Prepare the recipient site, make a horizontal
incision in the interdental papillae at right angles to create
a margin against which the graft may have a butt joint
with the incision. Vertical incisions are made at proximal
line angles of adjacent teeth and the retracted tissue is
excised. Maintain an intact periosteum in the apical area.
STEP 3 and 4 : Similar to the classic technique described
earlier.

62. FREE CONNECTIVE TISSUE AUTOGRAFT
 STEP1:DIVERGENT VERTICAL INCISION
Divergent vertical incision are made .At the
line angle of the tooth to be covered, creating a
partial thickness flap to atleast 5mm apical to the
receded area .
 STEP 2: SUTURING
Suture the apical mucosal border to the
periosteum using a gut suture.

63.  STEP3: SCALING AND ROOT PLANING.
Scale and plane the root surface, reducing any
prominence of root surface.
 STEP 4:OBTAIN THE GRAFT
From the palate obtain a connective tissue graft.
Donor site is sutured after the graft is removed.

64.  STEP 5: TRANSFER THE GRAFT
Transfer the graft to the recipient site, and suture
it to the periosteum with the gut suture. Good
stability of the graft must be attained with adequate
suture.
 STEP 6:COVER THE GRAFT
Cover the grafted site with aluminium foil and
periodontal dressing.

65. PEDICLE AUTOGRAFT
 LATERALLY DISPLACED FLAP
The laterally displaced flap can be used to cover isolated
,roots that have adequate donor tissue laterally and vestibular
depth.
STEP 1: PREPARE THE RECIPIENT SITE
Epithelium is removed around the denuded root
surface. The exposed connective tissue will be the recipient
site for the laterally displaced flap.

66.  Pre operative view,maxillary bicuspid
 Recipient site is exposed by preparing the
connective tissue around the recession

67. STEP 2: PREPARE THE FLAP
The periodontium of the donor site should have a satisfactory
width of attached gingiva and minimal loss of bone without
dehiscence or fenestration. A full thickness or partial thickness flap
may be used.
With a #15 blade make a vertical incision from the gingival
margin to outline a flap adjacent to the recipient site. Incise to the
periosteum and extend the incision into the oral mucosa to the base
of the recipient site .
The flap should be sufficiently wider than the recipient site to cover
the root and provide a broad margin for attachment to the
connective tissue border around the tooth.

68.  Incisions are made at the donor site in preparation
of moving the tissue laterally

69.  STEP 3:TRANSFER THE FLAP
Slide the flap laterally on to the adjacent root
,making sure that it lies flat and firm without excess
tension on the base. Fix the flap on the adjacent
gingiva and alveolar mucosa at the distal corner of
the flap.
Pedicle flap is sutured in position

70.  STEP 4:PROTECT THE FLAP AND DONOR
SITE
Cover the operative field with aluminium foil and
a soft periodontal pack extending it interdentally
and onto lingual surface to secure. Remove the
pack and suture after one week.

71. Post operative result at 1 year

72. VARIANT TECHNIQUES:-
 There are many variations in the incisions for the laterally
displaced flap.
 Use of converging oblique incisions over the recipient
site and a vertical or oblique incision at the distal end of
the donor site so that the transposed flap is slightly wider
at its base.
 The marginal attachment at the donor site is preserved to
reduce the likelihood of recession and marginal bone
resorption , but this requires a donor site with wider zone
of attached gingiva.

73.  Sliding partial thickness grafts from neighboring
edentulous areas (pedicle grafts) can be used to
restore attached gingiva on teeth adjacent to
edentulous spaces with denuded roots and a
small vestibular fornix ,often complicated by
tension from a frenum.
 “double papilla flap” attempts to cover roots
denuded by isolated gingival defects with a flap
formed by joining the contiguous halves of the
adjacent interdental papillae.

74. CORONALLY DISPLACED FLAP
The purpose of coronally displaced flap procedure is
to create a split thickness flap in the area apical to the
denuded root and position it coronally to cover the
root.
 STEP 1: With two vertical incisions ,delineate the
flap ,these incisions should go beyond the
mucogingival junction. Make a internal bevel
incision from the gingival margin to the bottom of
the pocket to eliminate the diseased pocket wall.

75.  STEP 2: Scale and plane the root surface.
 STEP 3: Return the flap and suture it at a level
coronal to the pretreatment procedure. Cover the
area with a periodontal pack, which is removed
along with the suture after one week.

76. VARIANTS TO FIRST TECHNIQUE:-
 Results with the coronally displaced flap technique
are often unfavourable because of insufficient
keratinized gingiva apical to the recession.
 To overcome this problem and to increase the
chances of success ,a gingival augmentation
procedure with a free autogenous graft can be
performed before the coronally positioned graft.
 This creates several millimeters of attached
keratinized gingiva apical to the denuded root.

77.  2 months after this surgery,a second ctage
procedure is performed,coronally positioning
the flap that includes the free autogenous
graft.
 Use citric acid with a pH 1.0 for conditioning
the root surface.

78. Preoperative view
flap has been raised

79. The composite resin restoration removed
Close suturing of the flap to cover the exposed
root surface

80. Healing outcome 1 year postoperatively

81.  SECOND TECHNIQUE
Tarnow has described the semilunar coronally
repositioned flap to cover isolated denuded
root surfaces.
STEP 1: A semilunar incision is made following
the curvature of the receded gingival margin
and ending about 2-3mm short of the tip of
the papillae.

82.  STEP 2: Perform a split thickness dissection
coronally from the incision and correct it to an intra
sulcular incision.
 STEP 3: The tissue will collapse coronally covering
the denuded flap. It is then held in its new position for
a few minutes with a moist gauze. Many cases donot
require either sutures or periodontal dressing. This
technique is simple and predictably provides 2 to
3mm of root coverage.
This technique is indicated where the recession is not
extensive (3mm) and the facial gingival biotype is
thick.

83.  Semilunar coronally positioned flap. A. slight recession in facial of the upper left
canine B. After thorough scaling and root planing of the area,a semilunar incision
is made and the tissue separated from the underlying bone. The flap collapses
,covering the recession.

84.  C. appearance after 7 weeks

85. SUBEPITHELIAL CONNECTIVE TISSUE GRAFT
 Indicated for larger and multiple defects with
good vestibular depth and gingival thickness to
allow a split thickness flap to be elevated.
adjacent to the denuded root surface the donor
connective tissue is sandwiched between the split
flap.

86.  STEP 1: Raise the partial thickness flap with a
horizontal incision 2mm away from the tip of the
papilla and two vertical incision 1-2 mm away
from the gingival margin of the adjoining teeth.
extend the flap to the mucobuccal fold without
perforation

87.  STEP 2 : Thoroughly plane the root, reducing its
convexity.
 STEP 3: Obtain a connective tissue graft from
the palate by means of horizontal incision 5-6
mm from the gingival margin of the molar and
premolars. The connective tissue is carefully
removed along with all adipose and glandular
tissue.

88. “Trap-door technique for harvest of a free
connective tissue graft.
Horizontal incision , perpendicular to the
underlying bone surface,is made approximately
3 mm apical to the soft tissue margin.

89. Mesio-distal extention of the incision is determined by the graft size
required,which is 6mm longer than the width of the dehiscence measured at the
level of the CEJ. To facilitate removal of the graft,a vertical releasing incision may
be made at the mesial termination of the primary incision.An incision is then
placed from the line of the first incision and directed apically to perform a split
incision of the palatal mucosa.

91.  STEP4: Place the connective tissue on the
denuded root. Suture it with resorbable sutures to
the periosteum.
 STEP5: Cover the graft with the outer portion of
partial thickness flap and suture it interdentally.
At least half to two third of the connective tissue
graft must be covered over the denuded root.

92.  STEP 6: Cover the area with dry foil and
surgical pack after 7 days dressing and sutures are
removed.

93. GUIDED TISSUE REGENERATION TECHNIQUE
Pini – Prato et al described a technique based on
the principle of guided tissue regeneration.
GTR should result in reconstruction of the
attachment apparatus, along with coverage of the
denuded root surface.
GTR technique is better when the recession is
greater than 4.98mm apico coronally

94.  STEP1 : A full thickness flap is reflected to
mucogingival junction, continuing as a partial
thickness flap 8mm apical to the mucogingival
junction.
 STEP 2: A microporous membrane is placed
over the denuded root surface and the adjacent
tissue.

95.  STEP 3: A suture is passed through the portion of the
membrane that will cover the bone. This suture is knotted
to the exterior and tied to bend the membrane .Creating a
space between root and membrane.
This space allow growth of tissue beneath the membrane.
 STEP 4: the flap is then positioned coronally and
sutured. Four weeks later a small envelop 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.

96.  Membranes used are
Titanium-reinforced membranes
Resorbable membranes
 GTR technique is better when the recession
is greater than 4.98mm apicocoronally

97.  Coronally advanced flap procedure combined
with titanium reinforced non biodegradable
membrane barrier
 Trapezium shaped full thickness flap is raised
beyond the bone dehiscence.

98. C. Membrane barrier placed and anchored to the tooth by a sling
suture placed at the level of CEJ.
D. Mobilized flap is positioned coronally and secured by
interdentally placed interrupted sutures.Membrane should be
completely covered by the flap to reduce the risk of bacterial
contamination during healing.

99.  The use of non-biodegradable membrane
barriers requires a second surgery for
membrane removal,usually after 5-6 weeks.A
partial thickness flap is raised to expose the
membrane.

100. The 1 year post operative result.

101. POUCH AND TUNNEL TECHNIQUE
 Also referred to as coronally advanced tunnel technique.
 To minimize incisions and reflection of flaps and to
provide abundant blood supply to the donor tissue ,the
placement of sub epithelial donor connective tissue into
pouches beneath papillary tunnel allow for intimate contact
of donor tissue to the recipient site.
 Effective for the anterior maxillary area, where the
vestibular depth is adequate and there is good gingival
thickness.

102.  Advantage:
The thickening of the gingival margin
after healing. The thicker gingival margin is
stable to allow for possibility of “creeping
attachment” o0f the margin.
The use of small contoured blades
enable the surgeon to incise and split the
gingival tissues to create the recipient
pouches and tunnels.

104.  STEP 1: Using a blade a sulcular incision is made
around the teeth adjacent to the recession .This
incision separate the junctional epithelium and the
connective tissue attachment from the root.
 STEP2: Using either a curette or a small blade
such as the #15 , a tunnel is created beneath the
adjacent buccal papilla into which the connective
tissue is placed.

105.  STEP 3: A split thickness pouch is created apical to
the papilla ,which has been tunneled ,this pouch
may extend 10-12 mm apical recessed gingival
margin and papillla and 6-8mm mesial and distal
denuded root surface.
 STEP 4: The size of the pouch which include area
of denuded root surface is measured so that an
equivalent size of donor connective tissue can be
procured from the palate.

106.  STEP 5: Using suture ,curettes and elevator the
connective tissue is placed under the pouch and
tunnel with a portion covering denuded root
surface.
 STEP 6: The mesial and distal end of the donor
tissue are secured by gut suture. The gingival
margin of the flap is coronally placed and secured by
horizontal mattress suture that extend over the
contact of two adjacent teeth

107.  STEP 7: Other holding sutures are placed
through the overlying gingival tissue and donor
tissue to the underlying periosteum to secure and
stabilize the donor tissue beneath the gingiva.
 STEP 8: A periodontal dressing is used to cover
the surgical site.

108. A. Preoperative view
b. Sulcular incision is made mesial to the line angles

109. C.A tunnel is made through the papilla using a blunt incision
d. A connective tissue graft is taken from the palate

110. E. The connective tissue is placed through the papillary tunnel
and apically beneath the pouch.
F. The facial gingival margin covers the connective tissue using
horizontal mattress sutures interdentally

111. Post operative view

112. TECHNIQUES TO DEEPEN VESTIBULE
 Another objective of periodontal plastic surgery is the
creation of some vestibular depth when this is lacking
 Gingival recession displaces the gingival margin apically
thus reducing vestibular depth.
 Adequate vestibular depth is important for both oral
hygiene and retention of prosthetic appliance.
 Deepening of vestibule can only accomplished by use of
free autogeneous graft.

113. VESTIBULOPLASTY TECHNIQUES
1. Mucosal advancement vestibuloplasty
a) Closed submucosal vestibuloplasty
b) Open submucosal vestibuloplasty
2. Secondary epithelialization(Reepithelialization
vestibuloplasty)
a) Kazanjian’s technique
b) Clark’s technique
3. Grafting vestibuloplasty

114. CLOSED SUBMUCOSAL VESTIBULOPLASTY
(OBWEGESER, 1959)
 Can be done under local anesthesia
 A vertical incision is made through the
mucosa only which extend from
mucogingival junction to labial mucosa

116. Blunt dissection is done to separate mucosa
from submucosa

117.  The vertical incision is then deepened to
reach periosteum
 Blunt dissection is then made in a
subperiosteal plane and similar tunnels are
created

119. A wedge shaped strip of connective
tissue remains between submucosal
tunnel and subperiosteal tunnel
This wedge shaped tissue is excised
Mucosa become freely movable

121.  It is now adapted to the deepened sulcus
and a stent is placed to retain the mucosa in
that position
 Stent is removed in one week when
adequate healing has taken place

122. OPEN SUBMUCOSAL VESTIBULOPLASTY
(WALLENIUS ET AL, 1963)
A horizontal incision is made through the
mucosa only at the mucogingival junction
Mucosa is dissected or separated from the
submucosa towards the lip so that a large
mucosal flap is formed

123. MGJ

124.  Subperiosteal dissection is then done to the
desired extend of the vestibular deepening
 Stay sutures are placed in the flap to fix it to
the periosteum deep in the vestibule
 The free margins of the flap are returned to
their original position and sutured

126.  Presence of adequate amount of bone and
healthy mucosa is an important criteria to
perform both mucosal advancement
vestibuloplasty techniques
 If mucosal flaps are adequately stabilized for
about ten days, relapse is usually minimal

127. KAZANJIAN’S TECHNIQUE
 Incision is made on the labial mucosa
 The labial and vestibular mucosa is reflected
 Vestibule is deepened to the desired depth
by supraperiosteal stripping

129.  Mucosal flap is turned down from its attachment
on alveolar ridge and is placed against the
periosteum and sutured to its depth that is
created
 The labial or soft tissue surface is left to
granulate and heal by secondary
epithelialization
 A stent is placed and left in place for atleast a
week for healing to take place and to maintain
the depth of the vestibule

130.  This technique leaves a raw surface on the
labial side of the sulcus to heal by secondary
epithelialization
 This soft tissue surface tend to contract as it
heals
 This could lead to further loss of sulcus depth

131. Inadequate depth of vestibule
Two vertical incisions
extending into the alveolar
mucosa, joined by a horizontal
incision

132. Releasing the
mucosal attachment by sharp
dissection
Releasing the muscle
attachment by periosteal
elevator

133. Mucosal flap sutured to
the underlying periostium
Placement of a
periodontal dressing

134. Increased vestibular depth six weeks
post surgically

135. LIPSWITCH VESTIBULOPLASTY
 Described by Kethley and Gamble.
 Also known as transpositional vestibuloplasty
 Modification of kazanjian’s technique
 Adequate mandibular bone height is
necessary

136.  Labial incision is made and mucosal flap is
raised from labial surface
 Supraperiosteal dissection is done on
anterior part of mandible
 Periosteum is incised on the crest of the
alveolar ridge and reflected away from the
bone with lower edge attached

138.  Free end of periosteum is sutured to denuded
labial submucosal surface
 Mucosal flap is sutured over denuded bone to
inferior attachment of periosteum at the depth of
the vestibule
 This is known as transposition technique
because labial flap and periosteal flap are
interchanged or transpositioned to line the
opposing surfaces

140. CLARK’S TECHNIQUE
 Horizontal incision is made on alveolar ridge
just buccal to crest of the ridge
 A supraperiosteal dissection is done till the
desired depth of the vestibule

142.  The mucosa of the lip is undermined till the
vermillion border
 The free margin of the mucosal flap is
sutured to the depth of the newly created
vestibule

143. Clark's vestibuloplasty incision and
reflection of the supraperiosteal flap

144.  Therefore, the mucosal surface or the soft
tissue side of the vestibule is covered with
mucosa
 Whereas on the osseous side the raw periosteal
surface is left to granulate and epithelialize
secondarily ; but this raw surface covering bone
cannot contract
 This is its advantage over kazanjian’s technique

145.  Drawback of the technique is that relapse is
common since the attachment of the lip
musculature tot the alveolar bone shift
towards the alveolar crest,obliterating the
sulcus.

146. GRAFTING VESTIBULOPLASTY
 Done when there is inadequate labial
vestibular mucosa to deepen the vestibule
 Clark’s vestibuloplasty can be done, followed
by covering of the raw periosteal surface with
a graft to hasten the healing procedure

147. Pre –op : Reduced vestibular
depth
Half of the prepared bed was covered
with alloderm and the other half with
mucosal graft (immediately after
surgery)

148. After 1 month
After 6 months

149. TECHNIQUE TO REMOVE FRENUM
 A frenum is a fold of mucous membrane ,usually
with enclosed muscle fibers, that attach lips and
cheeks to the alveolar mucosa and gingiva .
 Frenum become a problem if the attachment is
too close to the marginal gingiva .Tension may
pull the gingival margin away from the tooth.
 This condition may be conductive to plaque
accumulation and inhibit proper tooth brushing.

151.  FRENECTOMY
Complete removal of the frenum ,including its
attachment to underlying bone and may be
required in the correction of an abnormal
diastema between the maxillary central
incisors.
 FRENOTOMY
Relocation of the frenum usually in more apical
position.

152. PROCEDURE
STEP 1: After anesthetizing the area engage the
frenum with a hemostat inserted to the depth of the
vestibule.
STEP 2: Incise along the upper surface of the
hemostat extending beyond the tip.
STEP 3: Make a similar incision along the under
surface of the hemostat.

153.  STEP 4: Remove the triangular resected portion of
the frenum with the hemostat. This exposes the
underlining brush like fibrous attachment to the
bone .
 STEP 5: Make a horizontal incision separating the
fibers and bluntly dissect to the bone
 STEP 6: If necessary extend the incision laterally
and suture the labial mucosa to the apical
periosteum.

154.  STEP 7: Clean the surgical field and pack with gauze
sponges until bleeding stops.
 STEP 8: Over the area wit dry aluminium foil and
apply the periodontal pack.
 STEP 9: Remove the pack after two weeks and
repack if necessary. One month is usually required
for the formation of intact mucosa with the frenum
attached in its new position.

155. A) Preoperative view of the frenum between two maxillary central incisors
B) Removal of frenum from both the lip and the gingiva

156. Site is sutured after it is placed over the wound postoperative view at 2 weeks

157. CONCLUSION
 Newer techniques are constantly being developed
and are slowly being incorporated into periodontal
practice.
 The practitioner should be aware that, at times, new
methods are published without adequate clinical
research to ensure the predictability of the results and
the extent to which the techniques may benefit the
patient.
 Critical analysis of newly presented techniques
should guide our constant evolution toward better
clinical methods.

158. THANKYOU