Mucogingival surgery

1. Prepared by:
Athraa A. Mahmood
M.Sc. of Periodontics

2. Mucogingival surgery (M.G.S)
• They are surgical procedures designed to correct defects in the morphology,
position &or amount of the gingiva &or oral mucous membrane surrounding
the teeth that complicate PD and may interfere with the success of periodontal
treatment.
• Recently, it has been renamed as “Periodontal Plastic Surgery”.

3. Indications of M.G.S
1. The change in the morphology will facilitate
proper plaque control
e.g. correction of high frenum attachment.
2. With localized soft tissue recession that creates
esthetic or root sensitivity problems.
3. With a thin gingiva facial to a tooth planned
for orthodontic movement when the final
position expected to result in an alveolar bone
dehiscence and fenestration.

4. Types of M.G.S
I. Techniques to increase width of attached gingiva & depth of vestibules:
A. Gingival augmentation coronal to the recession .
1. Free gingival autograft.
2. Subepithelial connective tissue graft:
3. Pedicle autografts:
 Laterally positioned flap.
 Coronally positioned flap.
4. GTR using allograft
5. Pouch & tunnel technique
B. Gingival augmentation apical to the recession:
1. Free gingival autograft.
2. Free connective tissue autografts.
3. Vestibular extension technique.
4. Apically positioned flap.
II. Frenectomy & Frenetomy.
III. Techniques to improve esthetics:
A. Root coverage.
B. Papilla reconstruction.
C. Therapy to correct excessive gingival display.
IV. Tissue engineering.

5. If the width of the attached gingiva is adequate in the donor site, , includes:
I. Techniques to increase attached gingiva & depth of vestibules:
A- Gingival augmentation coronal to the recession (Root coverage):
Advantages
• Increase keratinized tissue around teeth, implants
or crowns and under removable prostheses.
• Increase vestibular depth.
Disadvantages
 Difficult to achieve root coverage.
 High esthetic demand.
 Large, uncomfortable donor site.
1. Free gingival autograft: that consist of epithelium and a thin layer of underlying CT
completely detached from one site and transferred to a remote site.

6. Surgical technique
• Step 1: Prepare the recipient site.
• Step 3: Obtain the graft from the donor site:
The ideal thickness of a graft is 1.0 - 1.5 mm.
• Step 4: Graft transferred to recipient site.
• Step 5: Protect the donor site.
• Step 2: Root preparation:
 Root planing of exposed root to remove
cementum and affected dentin.
 Etch root surface with tetracycline (pH 2.0).

7. 2. Subepithelial connective tissue graft:
A detached CTG that is placed beneath a partial thickness flap.
Step 3: Donor site incision.
Surgical technique:
Step 1: Recipient site incision.
Step 2: Root preparation.

8. Step 4: Transfer the graft and suturing.

9. 3. Pedicle autografts: A soft tissue graft that is not completely detached from one site
and transferred to another site. There are connection with the donor site is maintained.
A. Laterally positioned flap:
Step 1: Prepare the recipient site
Step 2: Prepare the flap of the donor site.
Step 3: Transfer the flap.
Step 4: Protect the flap and donor site.

10. B. Coronally positioned flap:
First technique:
Step 1: With 2 vertical incisions.
Step 2: Root preparation
Step 3: Return the flap and suture it coronal to the pretreatment position.
Step 4: Cover the area with a periodontal dressing.

11. Second Technique (Semilunar coronally positioned flap):
Step 2: Perform a split-thickness
dissection coronally from the
incision, and connect it to an
intrasulcular incision.
Step 3: The tissue will collapse coronally,
covering the denuded root. then held in
its new position for a few minutes with a
moist gauze. Many cases do not require
either sutures or periodontal dressing.
Step 1: Semilunar incision is made
and ending about 2 to 3 mm short
of the tip of the papillae.

12. 4. Guided Tissue Regeneration using allograft:
Step 1: A full-thickness flap is reflected
to MGJ, continuing as a partial-thickness
flap 8 mm apical to MGJ.
Step 2: Root preparation.
Step 3: A membrane is placed over the
root surface and the adjacent tissue at
least 2 mm of marginal periosteum.
Step 4: The flap is then positioned coronally and sutured.

13. 5. Pouch and Tunnel technique:
• Create “pouch” using full thickness incision and maintain papilla for bilaminar
blood supply.
• Extend incision to adjacent teeth and undermine flap beyond MGJ, which
allows the coronal positioning of the flap.
• Insertion of CTG and suture.

14. B- Gingival augmentation apical to the recession:
If the donor site is associated with the inadequate width, includes:
1. Free gingival autograft.
2. Free connective tissue autografts.
3. Vestibular extension technique:

15. 4. Apically positioned flap:
Step 1: The facial and lingual flaps have been elevated.
Step 2: Debridement of the areas.
Step 3: The sutures are in place.

16. Frenectomy is complete removal of the frenum including its attachment to the
underlying bone.
While Frenetomy is the incision and relocation of the frenum to create a zone of
attached gingiva between the gingival margin and the frenum.
II. Frenectomy and Frenetomy:

17. Step 1: Hold the frenum with a hemostat
inserted to the depth of the vestibule.
Step 2: Incise along the uppersurface of the
hemostat, extending beyond the tip and make a
similar incision along the undersurface of the
hemostat.
Surgical technique:
Step 3: Remove the triangular resected
portion of the frenum with the hemostat.
This exposes the underlying fibrous
attachment to the bone.
Step 4: Make a horizontal incision, separating
the fibers and bluntly dissect to the bone.
Undermined for CT.
Step 5: Suturing the area.

18. III. Techniques to improve esthetics:
1. Root coverage.
2. Papilla reconstruction:
• The semilunar surgical pouch and CTG.
• Then, suture to reconstruct the interdental papilla.

19. 3. Therapy to correct excessive gingival display:
• Excision of marginal gingiva to expose full anatomic crown.
• Full-thickness flap elevation then ostectomy and osteoplasty completed.
• Flap repositioned and sutured with interrupted sling sutures.

20. Correction of gummy smile by crown lengthening and lip repositioning
• The coronal and apical incisions met in the first or second bicuspid regions
in a rounded fashion along the MG line.
• The frenum between the two centrals was left intact as a reference point so
the incisions did not extend across the mid-line.
• The epithelium was dissected as a partial thickness flap.
• The mucosal flap was advanced and sutured at the MG line using interrupted
sutures.

21. IV. Tissue engineering:(biologic mediator)
• Root surface exposed to Recombinant Human Platelet-Derived (rhPDGF), then β-
TCP and collagen wound dressing.
• Suture the area.
• Root surface preparations with a chisel & EDTA.
• Horizontal and vertical incisions.