Mucogingival Surgey

1. MUCOGINGIVAL SURGERY
Dr. Hema
Reader
Department Of Periodontology

2. Contents:
 Terminology
 Objectives of MGS
 Anatomy
 Definition
 Indications
 Predisposing factors
 Presicipitating factors
 Classification
 Methods to increase the width of attached gingiva
 Root coverage procedure
 references

3. Terminology
 Periodontal Plastic Surgery was previously termed
as Muco-Gingival surgery
 The term Periodontal Plastic Surgery was originally
introduced by Miller in 1993.
 AAP world workshop 1996 renamed Mucogingival
Surgery as Periodontal Plastic Surgery.

4. Objectives
To correct the problems associated with inadequate
attached gingiva.
To correct the problems associated with shallow
vestibule.
To correct the problems associated with high frenum
attachment.

5. Anatomy:
Attached gingiva
The portion of the gingiva that is tapere, firm,
dense, stippled and tightly bound to the underlying
periodontium, tooth & bone

6.  The width of attached gingiva differs in different
areas of the mouth. Greatest in the incisor
region(3.5-4.5mm in the maxilla, 3.3 -3.9mm in the
mandible)

7. Definition
Mucogingival surgery: Periodontal surgical procedures
used to correct defects in the morphology, position,
and/or amount of gingiva (AAP Glossary).
 Mucogingival surgery was introduced by Friedman
1957

8. “surgical procedure designed to preserve gingiva,
remove aberrant frenulum or muscle attachments
and increase the depth of the vestibule”
 In 1993 Miller proposed the term “Periodontal
Plastic Surgery” is defined as the procedures
performed to correct the anatomical, developmental
and traumatic deformities of gingiva and alveolar
mucosa.

9. Indications of MGS
 Periodontal prosthetic surgery
 Crown lengthening surgery
 Ridge augmentation surgery
 Esthetic surgical correction.
 Coverage of denuded root surface
 Reconstruction of papilla.

10. Predisposing Factors
1- Minimal attached gingiva
2- Frenum pull
3- Tooth malposition
Precipitating factors:
1- Inflammation related to plaque
2- Improper brushing
3- Iatrogenic dental care

11. Problems Associated With Inadequate Width of
Attached Gingiva:
1. Difficulty in maintaining Optimum Gingival
Health.
2. Improper plaque control.
3. Inadequate keratinized tissue for placement of RPD.

12.  Width of attached gingiva can be measured by
subtracting pocket depth from the distance between
free gingival margin to the mucogingival junction.

13. Advantages of Creating Adequate Width of
Attached Gingiva:
1. Proper plaque removal.
2. Improved esthetics.
3. Reduces inflammation around restored teeth.

14. Problems Associated With Shallow Vestibule:
1. Improper plaque removal,
2. Difficulty in placement of removable prosthesis.
Measurement of Vestibular Depth
 Depth of vestibule is measured from gingival
margin to the bottom of the vestibule.

15. Advantages of Creating Adequate Vestibular
Depth:
1. Proper plaque control.
2. Proper tooth brushing.
3. Proper placement of removable prosthesis.

16. Classification of Gingival Recession
 Sullivan and Atkins (1968)
 Shallow-narrow
 Shallow-wide
 Deep-narrow
 Deep-wide

17.  Miller (1985)
Class I: Marginal tissue
recession that does not
extend to the MGJ.
There is no periodontal
loss (bone or soft tissue)
in the interdental area,
and 100% root coverage
can be anticipated.

18. Class II
 Marginal tissue
recession which
extends to or beyond
the MGJ , No
periodontal loss in the
interdental area.

19. Class III:
 Marginal tissue recession
that extend to or beyond
the MGJ.
 Bone or soft tissue has
been lost from the
interdental area, partial
root coverage can be
anticipated

20. Class IV:
 Marginal tissue
recession that extend to
or beyond the MGJ.
 Sever bone or soft tissue
has been lost from the
interdental area, root
coverage can not be
attempted.

23. Methods of Mucogingival surgery
1.Increasing the width of attached gingiva
a. Partial thickness, apically repositioned flap
b. pedicle gingival graft (full or partial thickness)
• Laterally positioned flap
• Double papilla flap
• Multiple interdental papilla grafts
• Edentulous area pedicle grafts
c. Free autogenous gingival grafts
d.Connective tissue grafts
• Free connective tissue grafts
• Subepithelial connective tissue grafts
2.Root coverage
3.Frenum surgery

24. Techniques to increase the width of attached
gingiva:
 Apically repositioned flap
 Free autogenous gingival grafts
 Free connective tissue grafts
 Multiple Interdental Papilla Grafts
 Edentulous-Area Pedicle Grafts

25. A. Partial thickness, Apically Repositioned
flap(ARF)
(Norberg,Nabers, and friedman 1962)
Advantages of ARF:
 Ability to fix flap to optimal position with
periosteal suture
 Periodontal flap eliminated and width of
attached gingiva increased with one treatment
 Marginal alveolar bone can be protected by
periosteum connective tissue site.

26. Disadvantages:
 Technically demanding
 Danger of penetrating flap during incision,
necrosis may results because of severe damage
to the blood vessels.
 Difficulty in manipulating suture
 Healing by secondary intention

27. Indications :
 Increase the AG in the area with narrow AG
 Extension of clinical crown length for
restorative and prosthetic treatment.
Contraindications :
 Thin gingiva
 Lack of KG at gingival margin
 Extreamly thin alveolar ridge

28. This technique uses the apically positioned flap, either partial thickness or
full thickness to increase the zone of attached gingiva.
TECHNIQUE
STEP I
 An interval bevel incision is made about 1mm from the crest of the
gingiva and directed to the crest of the bone
STEP 2
 Crevicular incisions are made, followed by initial elevation of the flap;
then inter dental incisions are performed and the wedge of tissue that
contains the pocket wall is removed.
STEP 3
 Vertical incisions are made extending beyond the mucogingival junction.
A full thickness or split thickness flap is elevated.

29. STEP 4 :
 The flap is displaced apically,Slightly coronal to the crest of
the bone – preserves the attachment of supra crestal fibers.
 Two millimeter short of the crest – produces the most
desirable gingival contour.
 New tissues cover the crest of the bone to produce a firm,
tapered, gingival margin.

30. STEP 5
 In case of a full – thickness flap, sling sutures around the
tooth prevents the flap from sliding .
 A partial thickness flap is sutured to the periosteum using a
direct loop surface or a combination of loop and anchor
suture.
 Apically displaced flap increases the width of the keratinized
gingiva but cannot predictably deepen the vestibule with
attached gingiva.

31.  Apically repositioned flap technique:

32. Originally Modified apically repositioned flap:
Initial horizontal beveled incision within the keratinized tissue
Incision extended in the mesio-distal direction of involved teeth ,two
vertical incision were on the mesial and distal ends connecting the
horizontal incision
The gingiva coronal to the initial incision remained intact around the
teeth
Elevation of a split-thickness flap
The flap was moved apically and suturing of the flap to the periosteum
in an apical position with non- absorbable suture of 4-0.

33. Variations Modified apically repositioned flap:
Initial horizontal incision within the keratinized tissue
Incision should be parallel and 0.5 mm coronal to the
mucogingival junction in the mesio-distal direction of
involved teeth .
The gingiva coronal to the initial incision remained intact
around the teeth
Elevation of a split-thickness flap
The flap was moved apically and suturing of the flap to the
periosteum in an apical position with non- absorbable suture
of 4-0

34. CARNIO and MILLER ., 1999 introduced the original
MARF and its modification of apically repositioned flap.
MARF technique preserve the marginal gingiva thus avoid
in the risk of recession.
CARNIO and CAMARGO in 2006 described a variation of
the MARF.
In original MARF vertical incision into the buccal
mucosa tent to generate excessive bleeding and is
contraindicated in the mandibular premolar and molar
because presence of mental foramen.

35. Free autogenous graft
 the free autogenous gingival graft is widely
used. Introduced by Bjorn and King and
Pennel.
 it is a highly predictable technique used to
increase the width of attached gingiva.
Advantages:
 High success rate
 Applicable for multiple teeth
 Simple procedure
 Techniques used for root coverage

36. Disadvantages :
 Requires two surgical site
 An open wound left on the palate
 Poor blood supply to grafts
Indications:
To increase the width of attached gingiva
To remove abbarent frenum
To cover the exposed root surface

37. Technique:
 Make a partial-thickness horizontal incision
along the mucogingival junction
 Horizontal incision were extented mesiodistally
and CT recipient bed were prepared.
 Resect the gingival epithelium on the coronal
portion of the recipient site and make periosteal
suture of the partial thickness flap apical to the
recipient site.
 Graft was harvested from the palate and graft
sutured with gingival margin

39.  Variant of free gingival grafts

40. Gingival unit transfer graft:
Advantage
 It can also used for millers class III gingival
recession
 Gingival unit (GU) graft with site specific
vascular supply placed on traditionally
prepared recipient area may have capacity for
survival on root surfaces and results in
predictable root coverage.

41. Technique:
 The recipient site was prepared by two vertical
beveled incisions that extending apically to
adjacent teeth,3-4mm across to the marginal
gingiva.
 The surface of IDP was removed
 At the mucogingival line vertical incision were
connected by a horizontal incision.
 Partial thickness dissection was made apical to
alveolar mucosa.
 The base of the recipient site was ≥5mm apical
to exposed root surface

42.  Gingival unit graft was harvested from the
palatal part of premolar area including
marginal gingival tissue and the papillae
 The graft was sutured at the level of CEJ.

44. Multiple Interdental Papilla Grafts
 Hattler" described the modified laterally positioned
flap using the interdental papilla as the donor tissue
to gain attached gingiva.
 This method was later related in detail as multiple
interdental papilla grafts by Corn."'

45. Advantages:
 The method is available for areas were lacking of
attached gingiva but where there is IDP of sufficient
width and length
 Can be used for cases with shallow vestibule
 Clinical crown length can be extended
Indications
 Interdental papilla with sufficient thickness
 Interdental periodontal pockets are to be
eliminated and the with of AG increased

46. Technique:
 Incision on the lingual aspect. An internal bevel incision is
made to the alveolar bone crest on the lingual aspect.
Incision on the buccal aspect.
a. A vertical incision is made on the mesial aspect at the surgical
site and the alveolar mucosa incised without making contact
with the bone.
b. A scalloped partial-thickness internal bevel incision is made
in the interdental papilla. A partial-thickness pedicle flap
with sufficient interdental papilla is prepared.
c. A vertical incision is made and the blade advanced coronally
from apical of the alveolar mucosa. A partial-thickness flap
is prepared

47.  A periosteal relieving incision to the alveolar
mmucosa apical to the flaps is made to permit flap
migration without tension.
 Displace the flap apically and half of tooth distally
and make a periosteal suture on the marginal
alveolar bone crest

49. Edentulous-Area Pedicle Grafts
 In the edentulous-area pedicle graft, the edentulous
area is used as a donor site.
 This procedure was introduced by Corn and
Robinson.“
Advantages
1. There is no danger of exposing thin marginal bone,
which prevents the problems of bone loss and
gingival recession at the donor site.
2. There is a greater likelihood that the exposed root
surface will be covered because the thick full-
thickness flap can be used as the pedicle graft.

50. Indications
1. To increase the width of the attached gingiva.
2. To form new attached gingiva.
3. To cover exposed root adjacent to the
edentulous area.
Technique:
Make a horizontal and prepare a partial thickness
vertical incision from the end of horizontal incision
of the edentulous alveolar ridge area to alveolar
mucosa .

51.  Reflection of partial-thickness pedicle flap
 Prepare a releasing incision of the periosteum at
the base of the flap so the flap can be moved
freely. The keratinized periosteum connective
tissue site is prepared.
 Rotate the pedicle flap distally and displace it
laterally. Place the flap on bone margin and make
a periosteal suture on the distal part of the flap.
 Make a horizontal matress suture for closer
adaptation

53. Connective tissue grafts:
 The connective tissue graft was first introduced as a
technique to increase the width of the gingiva. Later,
the technique was used to cover exposed roots and
augment the alveolar ridge .
 The two methods used in connective tissue grafts to
increase the width of attached gingiva are free
connective tissue grafts and subepithelial connective
tissue grafts.

54. Advantages:
 The width of AG is increased and root covered
simultaneously
 It is possible to acquire and increase the width of
attached gingiva in multiple teeth
 The graft receives abundant blood supply from both
the inside of the flap and the periosteum connective
tissue
Disadvantages:
 Technically demanding
 Compared to FGG the epithelialization takes longer

55. Root coverage
Condition necessary for successful root coverage
 Appropriate case selection
 Sufficient blood supply ensure to donor site
 Root surface covered with thick donor site
 No severe decay or abrasion on exposed root

56. Criteria of successful root coverage
 The gingival margin is on CEJ in class I and II GR
 The depth of sulcus within 2mm
 There is no bleeding on probing
 There Is no hypersensitivity
 Color match with adjacent tissue is esthetically
harmonious

57. Techniques used for root coverage:
1.Pedicle gingival grafts
 Laterally positioned flap
 Transpositional flap
 Double papilla flap
2. Advanced flaps
 Coronally positioned flap
 Semilunar coronally repositioned flap
3. Free autogenous gingival grafts
4.Connective tissue grafts or sub epithelial connective
tissue grafts
5.GTR

58. Pedicle gingival grafts
Advantages:
 One surgical area
 Blood supply of pedicle flap covering the root
surface is preserved
 Post-Op color is in harmony with surrounding tissue
Disadvantages:
 Applicable for relatively minor gingival recession or
for recession limited to one tooth
 Success rate is not high

59. Transpositional Flaps
 Bahat et al" modified the oblique rotated flap
introduced by Pennel et al the transpositional flap
Advantages
1. Predictability in areas of narrow root exposure
2. Possible to avoid gingival recession at the donor site
Disadvantages
1. Sufficient length and width of the interdental papilla
adjacent to the gingival recession area necessary
2. Not suitable for multiple tooth root coverage

60. Transpositional flap

61. Double Papilla Flaps
 Cohen and Ross" introduced the method in which
bilateral interdental papilla is used as donor tissue
for localized root coverage.
Indication
1. Sufficient width and length of the interdental papilla
on both sides of the gingival recession.

62. Advantages
1. The amount of donor tissue is small because
interdental papilla adjacent to the gingival recession
area is displaced
2. While interdental bone is exposed if a full-thickness
pedicle flap including interdental papilla is used,
there is little damage to the alveolar bone because
interdental alveolar bone is thick.

63. Disadvantages
1. Technically demanding.
2. Limited application. The technique is generally used
for multiple interdental papilla grafting, not for root
coverage.

64. Double Papilla Flap

65. Coronally advanced Flap:
 It has long been used as a means of gaining
root coverage.
 Norberg (1926) introduced the coronally
repositioned periosteal flap procedure.

67. Semilunar coronally repositioned flap:
 Introduced by tarnow1986 for the treatment of
deep isolated recession.
Advantages
 No tension on coronal migration of semilinar
flap
 Good esthetics
 Simple and minimal surgical time
 Minimal post – op discomfort

68. Disadvantages:
 Thick keratinized gingiva necessary for adequate
thickness of the partial-thickness flap apical to the
gingival recession area.
 Where an osseous dehiscence or fenestration exists
apical to the gingival recession area, FGG or CTG
sholud be performed apically after coronal
migration of semilunar flap

70. Semilunar vestibular incision technique
The technique described by Dr. P.D Miller
Limitation:
-the presence of shallow vestibule
Disadvantage:
-Extensive wound with moderate pain for 2 days
post surgically

71.  Semilunar vestibular incision technique

72. Connective Tissue Grafts
 Langer and Langer introduced the use of
subepithelial connective tissue grafts for root
coverage
Advantages
1. High predictability.
2. The graft receives abundant blood supply from both
the inside of the flap and the periosteum connective
tissue.
3. Wound closed at palatal donor site after harvest of
connective tissue graft.
5. Applicable for gingival recession on multiple teeth.

73. Disadvantages
1. Technically demanding.
2. Because a thick graft is used, the grafted tissue is
thick. gingivoplasty may be necessary
postoperatively to obtain better morphology.
Indications
 Root coverage necessary in the gingival recession
area

74. Contraindications
 In adequate thickness of donor tissue. The necessary
thickness of the connective tissue
 graft for root coverage is 1.5-2.0 mm, and the
thickness of the palatal flap should be
 1.5-2.0 mm after graft harvest to prevent necrosis.
Therefore, at least 3-mm thickness is necessary in
the palatal soft tissue of the donor site.

76. Modifications of Langer and Langer
1.Do not use a vertical incision when preparing a
recipient site
 Ensure excellent blood supply to flap.
 Alleviate postoperative discomfort.
 Avoid scarring.
2.Make a partial-thickness horizontal incision
perpendicular to the interdental papilla of the
recipient site.

78. Connective Tissue Graft Using an Envelope Flap
 Raetzke introduced a connective tissue graft using an
envelope technique
Limitation:
The envelope flap is that it cannot be displaced coronally.
 The envelope flap is also not applicable in areas of
extensive gingival recession
 because there is a limit to the size of the graft that can
be placed in the envelope flap.
 Therefore, the technique is used only with localized
gingival recession limited to one to two teeth.
 Allen"' modified this procedure to include areas of
gingival recession on multiple teeth.

80. Sub pedicle Connective Tissue Grafts
 Connective tissue grafts may be used with a pedicle
flap (double papilla or laterally positioned flap).
Advantage:
of this technique is that a pedicle flap can cover
connective tissue grafts on root surfaces lacking a
vascular supply.
 In addition to root coverage, the width of the
keratinized gingiva can be increased.
 Therefore, the technique may be used in areas of
gingival recession with narrow keratinized gingiva.
 This use, however, is more technically demanding.

82.  GTR(guided tissue regeneration)
Advantages:
 Gain new attachment
 Donor site not necessary
 Root coverage is highly predictable
Disadvantages:
 Technically demanding
 Second surgery required to removal of
membrane
 Cost effective

83. Technique:
 Prepare a full-thickness trapezoidal flap.
 Horizontal incision to the mesiodistal interdental
papilla at the level of the CEJ, Two vertical incisions.
 Prepare a full-thickness flap 3-4 mm apical to the
crest of the osseous dehiscence. Apically, prepare a
partial thickness flap.
 Remove the epithelial tissue in the interdental
papilla area
 Bend the membrane in a tentlike fashion with
suture thread.
 Stabilize the membrane with a sling suture
 Displace the flap coronally and cover the membrane
completely

85.  Cairo et al in 2008-CTG or EMD in conjuction
with CAF enhances the probability of obtaning
complete root coverage in class I & II gingival
recession.
 Hui yann ko et al in 2016-CTG was satistically
significant and more effective than GTR

86.  References :
 Carranza 10th
edition
 Sato,Periodontal surgery
 Lindhae 5th
edition