Periodontal plastic & esthetic surgery

Periodontal Plastic & Esthetic Surgery
DR. OINAM MONICA
DEVI

Contents
• Introduction
• Types of Mucogingival Surgery
• Objectives
• Etiology of marginal tissue recession
• Factors that affect surgical outcome
• Techniques to increase attached gingiva
• A. Gingival augmentation apical to the area of recession
• B. Gingival augmentation coronal to the recession (root coverage)
• Techniques for deepening the vestibule
• Techniques to remove the frenum
• Techniques to improve esthetics
• Crown Lengthening
• Criteria for selection of techniques
• Conclusion
• References

• The term mucogingival surgery was initially introduced in the literature by
Friedman to describe surgical procedures for the correction of relationships
between the gingiva and the oral mucous membrane, with special reference to three
problem areas: attached gingiva, shallow vestibules, and a frenum interfering with
the marginal gingiva.
• 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 1996 World Workshop in Clinical Periodontics renamed mucogingival
surgery as periodontal plastic surgery, a term originally proposed by Miller in 1993.
• Mucogingival surgery includes:
1. Periodontal-prosthetic corrections
2. Crown lengthening
3. Ridge augmentation
4. Aesthetic surgical corrections
5. Coverage of the denuded root surface
6. Reconstruction of papillae
7. Aesthetic surgical correction around implants
8. Surgical exposure of unerupted teeth for orthodontics

• The periodontal plastic surgical techniques included in the traditional definition of
mucogingival surgery are
(1) Widening of attached gingiva
(2) Deepening of shallow vestibules
(3) Resection of the aberrant frena
• Other aspects of periodontal plastic surgery, such as periodontal-prosthetic
surgery, aesthetic surgery around implants, and surgical exposure of teeth for
orthodontic therapy.

Objectives
• Five objectives of periodontal plastic surgery are
1. Problems associated with attached gingiva
2. Problems associated with a shallow vestibule
3. Problems associated with an aberrant frenum
4. Aesthetic surgical therapy
5. Tissue engineering

Problems Associated With Attached Gingiva
• The ultimate goal of mucogingival surgical procedures is the creation or widening of
attached gingiva around teeth and implants.
• The width of the attached gingiva varies in different individuals and on different teeth
of the same individual.
• The original rationale for mucogingival surgery was predicated on the assumption that
a minimal width of attached gingiva was required to maintain optimal gingival health.

• No minimal width of attached gingiva has been established as a standard necessary
for gingival health.
• People who practice good, atraumatic oral hygiene can maintain excellent gingival
health with almost no attached gingiva.
• Individuals whose oral hygiene practices are less than optimal can be helped by the
presence of keratinized gingiva and vestibular depth.

• To improve aesthetics, the objective is the coverage of the denuded root surface.
• Recession and the resultant denuded root surface have special aesthetic concerns for
individuals with a high smile line.
• A wider zone of attached gingiva is also needed around teeth that serve as abutments for
fixed or removable partial dentures and in the ridge areas bearing a denture.
• Teeth with subgingival restorations and narrow zones of keratinized gingiva have higher
gingival inflammation scores than teeth with similar restorations and wide zones of
attached gingiva.

Widening the attached gingiva accomplishes four
objectives:
1. Enhances plaque removal around the gingival margin
2. Improves aesthetics
3. Reduces inflammation around restored teeth
4. Allows gingival margin to bind better around teeth and implants with attached gingiva.

Problems Associated With a Shallow Vestibule
• Gingival recession displaces the gingival margin apically, reducing vestibular
depth, which is measured from the gingival margin to the bottom of the vestibule.
• With minimal vestibular depth, proper hygiene procedures are jeopardized.
• The sulcular brushing technique (i.e., Bass technique) requires placement of the
toothbrush at the gingival margin, which may not be possible with reduced
vestibular depth
• Minimal attached gingiva with adequate vestibular depth may not require surgical
correction if proper atraumatic hygiene is practiced with a soft brush.
• Minimal amounts of keratinized attached gingiva with no vestibular depth benefit
from mucogingival correction.
• Adequate vestibular depth is also necessary for the proper placement of
removable prostheses.

Problems Associated With an Aberrant Frenum
• A frenum that encroaches on the margin of the gingiva caninterfere with biofilm
removal, and the tension on the frenum tends to open the sulcus.

Aesthetic Surgical Therapy
• Recession of the facial gingival margin alters the proper gingival symmetry and
results in an aesthetic problem.
• The interdental papilla is also important to satisfy the aesthetic goals of the patient.
• A missing papilla creates a space that many call a black hole.
• Regeneration of the lost or reduced papilla is one of the most difficult goals in
aesthetic periodontal plastic surgery.
• Another area of concern is an excessive amount of gingiva in the visible area (
gummy smile), corrected surgically by crown lengthening.

Etiology of Marginal Tissue Recession
1. The loss of attached gingiva is abrasive and traumatic toothbrushing habits.
2. The bone and soft tissue anatomy of the facial, radicular surface of the dentition is
usually thin, especially around the anterior area.
3. Teeth positioned facially may have an even thinner bone and gingiva.
4. The areas have a complete absence of bone beneath the thin overlying gingival
tissue combined with external trauma from overzealous brushing can lead to the
loss of gingival tissue.
5. Periodontal disease and chronic marginal inflammation.
6. Frenal and muscle attachments that encroach on the marginal gingiva.
7. Orthodontic tooth movement through a thin buccal osseous plate can also lead to
the recession of the gingival margin.

Factors That Affect Surgical Outcome
1. Irregularity of Teeth
• Location of the gingival margin, width of the attached gingiva, and alveolar bone
height and thickness are affected by tooth alignment.
• On teeth that are tilted or rotated labially, the labial bony plate is thinner and located
further apically than on the adjacent teeth.
• The level of gingival attachment on the root surfaces and the width of the attached
gingiva after mucogingival surgery are affected as much by tooth alignment as by
variations in treatment procedures.

2. Mucogingival Line
• Normally, the mucogingival line (i.e., junction) in the incisor and canine areas is
located approximately 3 mm apical to the crest of the alveolar bone on the radicular
surfaces and 5 mm interdentally.
• In periodontal disease and on malposed, disease-free teeth, the bone margin is located
further apically and may extend beyond the mucogingival line.
• The distance between the mucogingival line and the CEJ before and after periodontal
surgery is not necessarily constant.
• After inflammation is eliminated, the tissue tends to contract and draw the
mucogingival line in the direction of the crown.

Techniques to Increase Attached Gingiva
Gingival augmentation apical to the area of
recession
•The donor graft tissue (i.e., 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
•The donor graft tissue (i.e., pedicle or
free) is placed covering the denuded root
surface.
•Apical and coronal widening of the
attached gingiva enhances oral hygiene
procedures, but only the latter can
correct an aesthetic problem.

Gingival Augmentation Apical to Recession
• Techniques for gingival augmentation apical to the area of recession place the free
gingival autograft or the free connective tissue autograft in a recipient site created
in a area apical to the recession.
• Another technique is the apically positioned flap, which is possible if there is some
keratinized gingiva that can be placed in a more apical position.

Free Gingival Autografts
• They were initially described by Bjorn12 in 1963
• Used to create a widened zone of attached gingiva

1. The Classic Technique
Step 1: Prepare the recipient site
• Prepare a firm connective tissue bed to receive the graft
• Incising at the existing mucogingival junction with a
#15 blade to the desired depth
• Periosteum should be left covering the bone.

• Another technique- two vertical incisions from the incised gingival margin into the
alveolar mucosa. Extend the incisions to Approx. twice the desired width, allowing for
50% contraction of the graft
• Superficial flap can be removed using scissors or it should be sutured below the graft
• An aluminum foil template of the recipient site can be made to be used as a pattern for
the graft.
• Grafts can be placed directly on bone tissue/ Blunt dissection Advantages, less
mobility of the graft, less swelling, better hemostasis, 1.5 - 2 times less shrinkage.
BUT healing lag period for first 2 weeks

Step 2: Obtain the graft from the donor site
Donor Site (Reiser et al. 1996)- A partial-thickness flap, between the palatal root of the
first molar and the distal line angle of the canine.
•Average distance from CEJ to the neurovascular bundle is 12 mm
•Needle sounding useful tool in approximating the location of the palatal artery
•Avoid Rugae (esthetic)

GRAFT
THICKNESS
Sullivan & Atkins
1968
Difference Thin graft (0.5 to 0.75 ) Thick graft (1.25 to 2 mm)
Recommended for Increasing the zone of
keratinized attached gingiva
Root coverage and ridge
augmentation
Esthetically Pleasing Unaesthetic patch-like graft
Primary contraction
(Elastin Fiber)
Minimal Greater , collapse blood vessel
, Revascularization Delay,
decrease bridging
Secondary contraction
(Cicatrization)
25 to 45% Minimal ( due to thick lamina
propria )
Resistance to functional
stresses
Less greater

1.5 mm= length of the bevel on a no. 15
blade
No. 15 blade kept parallel to the epithelial
outer side of the graft ( not the long axis
of the tooth)
Insert the blade to the desired thickness at
one edge of the graft.
Elevate the edge and hold it with tissue
forceps.
Placing sutures at the margins of the graft
helps control it during separation and transfer
and simplifies placement and suturing to the
recipient site.

Remove the loose tissue tags from the
undersurface of graft.
Thin the edge to avoid bulbous marginal and
interdental contours.
The submucosa in the anterior
region is thick and fatty and should
be trimmed
Grafts tend to reestablish their original
epithelial structure, so mucous glands may
occur in grafts obtained from the palate.
Thinning done by holding it b/w two
wet wooden tongue depressors and
slicing it longitudinally with sharp
#15 blade.

Step 3: Transfer and immobilize the graft
• Stop the bleeding at recipient site by applying pressure with wet sponge.
• Remove the excess clot (interferes with vascularization)
• Position the graft and adapt it firmly to the recipient site (No dead space)
• Suture the graft at the lateral borders and to the periosteum to secure it in position.
Immobilize the graft
• Avoid excessive tension, which can distort the graft from the underlying surface.
• Avoid trauma to the graft. Tissue forceps should be used delicately and a minimum
number of sutures used, avoid unnecessary perforations

Graft suturing-
• Single interrupted sutures are usually placed
to secure the graft mesially and distally
• A mesiodistal horizontal suture could be
added to wrap the lower half of the graft .
• Variations include intraperiosteal X sutures.
Advantage
• Immobilizing the graft
• Decrease the amount of dead space
• Minimize the size of the blood clot, better
adaptation

• Applying some pressure with wet gauze over the sutured graft for a few minutes will
displace the blood under the graft, reducing hematomas, and closely position the
graft to the recipient bed.
• Plasma will be converted to fibrin, and this fibrin clot will anchor the graft to its bed
and enable rapid penetration by capillaries. It will act as a matrix through which
metabolites and waste products diffuse.
• A good test for checking the immobility of the graft is to pull the lip or cheek gently
once the graft has been sutured. If the graft moves, then the suturing or the size of
the recipient bed was inadequate.

Step 4: Protect the donor site.
• Hemostasis can be achieved with hemostatic agents such as absorbable gelatin sponge
(Gelfoam), oxidized cellulose (Oxycel), etc.
• A sterile aluminum foil is placed over the wound before the periodontal dressing is
used to cover the wound for 1 week.
• Cover the donor site with a periodontal pack for 1-2 weeks, and repeat if necessary.
• Initial healing usually complete within 2 weeks.
• A modified Hawley retainer is used to cover the pack on the palate and over edentulous
ridges.

2.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
(a) The accordion technique
(b) The strip technique
(c) The combination epithelial-connective tissue strip technique

(a) The Accordion Technique
• Described by Rateitschak et al. 1985
• Attains expansion of the graft by alternate incisions in opposite sides of the graft.
• Increases the donor graft tissue by changing the configuration of the tissue.

(b) The strip technique (Han et al. 1993)
• 2-3 strips of gingival donor tissue (3-5 mm wide and long).
• 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.
• The donor site usually not require suturing and heals uneventfully in 1 to 2 weeks.
Advantage-
• Rapid healing of the donor site.
• The epithelial migration of the close
wound edges (3 to 5 mm) allows rapid
epithelialization of the open wound.

( c) Combination technique
A deep strip
of tissue
from the
palate about
3 - 4 mm
thick is
taken
Place it b/w
two wet
tongue
depressors,
& split it
longitudinall
y with a
sharp #15
blade
Split into
an
epithelial-
connective
tissue strip
and a pure
connective
strip.
Both will be
used as free
grafts.
These donor
tissues are
placed on the
recipient site

Plasmatic Circulation Stage (0-3 Days):
A. Connective tissue:
• Immediately after surgery the graft bed presented a relatively thin layer of
fibrous periosteum which was separated from the graft by a thin layer of fibrin.
• Connective tissue becomes edematous and disorganized and undergoes
degeneration
• Plasmic circulation (diffusion from its host bed) occurs through the fibrin clot.
B. Epithelium:
• Degeneration was apparent with desquamation of the outer Layers.
• Color, pallor changes to an ischemic grayish white.

2. The Revascularization Phase (4-11 days)
• Fibroblasts had proliferated into the area between the graft and periosteum by the
fourth day.
• Granulation tissue was gradually replaced by fibroblastic proliferation. By the seventh
day.
• At the 11th day, a dense fibrous union existed between the graft and the periosteum the
connective tissue of the graft appeared fairly normal.

• Revascularization occurred initially by anastomoses between vessels of the graft bed
and pre-existing vessels in the graft and later by capillary budding which penetrated the
graft.
Epithelium:
• Virtually all of the graft epithelium was degenerated and desquamated by the fifth day .
• The deepest portions of the epithelial ridges may have persisted and contributed to re-
epithelialization of the graft.
• At the same time, a thin layer of new epithelial cells proliferated over the graft from
the adjacent tissue.
• New epithelium form graft smooth and shiny.

III. Tissue Maturation Phase (11-42 days)
• Connective tissue: At 14 days, increased density and further orientation of the
connective tissue fibers at the graft-bed interface.
• Epithelium- increased thickness, and epithelial ridges had developed more fully at 14
days.
• Keratinization was first apparent at 28 days.
• Vascularization: A reduction in the number of vessels throughout the connective tissue
of the graft occurred with increasing density of the connective tissue.

PALE
EMPTY GRAFT VESSEL
PINK
VASCULARIZATION
BEGINS, SMOOTH &
SHINY
LOSS OF
EPITHELIUM

• Graft shrinkage 33% (Egli et al. 1975).
• Heterotopically placed grafts maintain their structure , Suggests a genetic
predetermination of the specific character of the oral mucosa, Basis for the
technique that uses grafts composed only of connective tissue
• Microscopically, healing of a graft of intermediate thickness (0.75 mm) is complete
by 10.5 weeks; thicker grafts (1.75 mm) may require 16 weeks or longer.

Advantages
• Ability to treat multiple teeth at the
same time
• Can be performed when keratinized
gingival adjacent to the involved area
is insufficient
Disadvantages
• Two operative sites
• Compromised blood supply
• Greater discomfort
• Poor hemostasis
• Scarring occurs with wound healing,
therefore esthetic results may be
inferior to other method

Reasons for graft failure
•If the area of exposed root to be covered is
small, the blood vessels of the periosteum
will maintain graft vitality (left).
•Graft necrosis occurs when the blood
vessels from the periosteum cannot bridge
the gap (right).
B. Close graft-periosteum adaptation
(left) will prevent hematoma
formation (right) and graft necrosis.

C. Because of poor stabilization will result in failure.
D. Residual fatty or glandular tissue may prevent graft take.

Studies…
Matter J,
1976
After 24 weeks, grafts placed on denuded bone shrink 25%, whereas grafts
placed on periosteum shrink 50%. The greatest amount of shrinkage occurs
within the first 6 weeks
Silva C et
al. 2010
Evaluated the influence of cigarette smoking on free gingival graft (FGG)
healing.
• At 90 days postoperatively, FGG width, length, and area were respectively
reduced by 31%, 22%, and 44% in nonsmokers and by 44%, 25%, and 58%
in smokers.
• Significant KT increases were observed in both non-smokers and smokers
(5.4 and 4.8mm, respectively).
• Donor-site immediate bleeding was significantly more prevalent in non-
smokers (75%) compared to smokers (30%)
• At 15 days postoperatively, donor site complete epithelialization was much
more prevalent in non-smokers (92%) than in smokers (20%) Smoking
altered FGG donor-site wound healing by reducing immediate bleeding
incidence and by delaying epithelialization, although it does not have
discernible effects on postoperative FGG dimensional change

Alternative Donor Tissue
• Palatal tissue harvesting may cause patient morbidity and not as esthetically
pleasing as native tissue.
• Alternative treatment approaches, such as dermal substitutes, growth factors, and
other tissue-engineered products, are considered
• These are as following;
1. Alloderm
2. ECM Membrane
3. Bilayer collagen Matrix
4. Living Cellular Construct
•

1. Alloderm
• Source: human donor skin, in which the epidermis and
cellular components of the dermis have been removed, but
the basement membrane and extracellular matrix (ECM)
matrix in which collagen bundles and elastic fibers are the
main component.
 Nondenatured 3-D arrangement of intact collagen fibers,
ground substance, and vascular channels.
Indications
•Soft tissue augmentation
• Multiple adjacent gingival recessions
•Lack of graftable palatal tissue
•Patient reluctant to have a second surgical site

Surgical Techniques
Two surgical techniques are suggested for use of ADM in treating gingival recession.
Each is a coronally positioned pouch method.
1. Alternate papilla tunnel (APT) method
2. Papilla retention pouch (PRP) method

Alternate papilla tunnel (APT) method
• Incision is made in a papilla adjacent to a tooth (next papilla) with recession while
the adjacent/ following papilla is tunneled.
• At each incised papilla, a V-incision (or inverted V in the mandibular arch) is made
to form a new surgical papilla tip approximately 3 mm from the anatomic papilla
tip.
• The papilla in the anatomic midline is always tunneled to reduce tension and retraction
of the recipient pouch.

• The portion of the anatomic papilla coronal to the surgical papilla is denuded to
expose a vascular recipient bed for the surgical papilla when coronally advanced.
• Intrasulcular incisions are made facial to each tooth and interproximally at
each tunneled papilla.

• Blunt dissection- The initial dissection with a micro-periosteal elevator, extending
apically past the Mucogingival junction and laterally under the facial aspect of
the tunneled papillae. The tunneled papillae are lifted from the interdental crest by
blunt reflection with a curette.
• Following this supraperiosteal sharp dissection is used to deepen and mobilize the
recipient pouch.

• On completion of the recipient site preparation, the length of graft needed is measured
and trimmed so that the graft will extend 3 mm past the last tooth with recession at
each end of the prepared site.
• The vertical dimension of the graft should be 6 to 8 mm. The rehydrated and
trimmed allograft is then placed into the surgical pouch, with the basement
membrane surface facing outward

• The graft should be well with strips of free graft adapted to the root surface, extending
to but not coronal to the CEJ and to the apical margin, but not over the papillary
recipient beds.
• The pouch is then coronally advanced to completely cover the allograft and secured
with 6-0 or 7-0 sling sutures.
– The APT method combines the advantages of surgical access at the incised
papillae with retraction resistance and wound stability at the tunneled
papillae.

Papilla retention pouch (PRP) method
• In the PRP method, all papillae are tunneled.
• Initially, intrasulcular incisions are made facial and proximal to all teeth to be
treated plus an additional tooth at each end.
• Next, full-thickness elevation of the margin
is initiated with a microperiosteal elevator
extending apically past the mucogingival junction
& laterally under the facial aspect of the papillae.
• The pouch is extended apically and mobilized by supraperiosteal sharp dissection,
and the papillae are lifted from the interdental crest

• The allograft is rehydrated (two consecutive 10- to 15- min sterile saline baths)
measured, and trimmed.
• The graft is inserted into the pouch with the connective tissue side—the bloody
side—against the recipient bed.
• The papillae are de-epithelialized, and the graft is immobilized with resorbable
sutures at the level of the cemento-enamel junction.
• Placement of the allograft within the pouch may be accomplished by drawing it in
with a suture or placing it through the sulcus with a curette so that it is aligned
within the pouch over the exposed roots.

 The buccal flap is then sutured over the AlloDerm to cover the graft as much as
possible. It is important to not leave any AlloDerm exposed.
• The unique feature of this method is the suturing of the allograft with a subgingival
continuous subgingival double-back sling suture.
• Advantages of the PRP method include enhanced retraction resistance, graft
containment, and wound stability.
• Commercially available products- AlloDerm®, Puros® Dermis, PerioDerm™,
Oracell®, SureDerm.

Graft healing
• 1 week: Significant revascularization
• Next 3–6 months :Allo Derm is repopulated with cells and will begin remodeling into the
patient’s own tissue {41% graft shrinkage (Batista et al. 2001)}
• Do not be concerned by the whitishness of the graft after surgery; it is not tissue necrosis.
This color reflects normal healing.
• 2–3 years later- final results are seen, sometimes with a creeping attachment.

Possible complications
1. Exfoliation of the Allo Derm if it is not well secured.
2. Allo Derm tends to swell during the week after surgery.
3. Infection of the graft, necessitating its removal.
***Having the patient take antibiotics the day before surgery can prevent this. The
patient can also be given anti-inflammatory drugs (steroidal and nonsteroidal) to
control postoperative swelling and pain

• Postoperative migration of the gingival marginal tissue in a coronal direction over
portions of a previously denuded root.
• Best observed on mandibular anterior teeth with narrow recessions. Detected 1 to 12
months after graft surgery with an average coverage 1 mm.
Creeping attachment???
 A patient with bilateral mucogingival defects in the canine and premolar areas.
Received an autogenous graft on one side and a dermal matrix allograft on the
contralateral side.
 After 12 months of healing, 1.23 mm of creeping attachment was measured on FGG
side and 0.96 mm with the dermal matrix allograft.
Haeri et al. 2000
Goldman and Cohen 1973

Wei et al. 2000
• Recruited 12 patients with good oral hygiene presenting with ≤ 1 mm of attached gingiva on
the facial aspect of the mandibular anterior teeth.
• The ADM was less effective and less predictable than the AGG in terms of increasing the
zone of attached KT, After 6 months due to considerable shrinkage (71% versus 16% in the
FGG )
• FGG-treated sites gained statistically greater KT increase (5.57 V/S versus 2.59 mm)

Suggested the following:
1) The resultant tissue types of ADM grafts were similar to ‘scar’’ tissue
2) An inflammatory response within the grafted tissue resembled a foreign body reaction.
Scarano
et al. 2009,
10 patients with ≤ 1 mm
band of lacking vestibular
depth, 3months
• Increased mean gain in width of KT
• Highly acceptable color matching
with the surrounding gingival tissue.
• Greater shrinkage of the graft
compared with autogenous CT
Cummings
L et al.
2005
4 patients indicated for
extractions of 3 -4 anterior
teeth, CT or ADM graft
beneath a coronally advanced
flap (tests) or CAF alone
(control), 6 month postop
block sections were made
• Histologically, both the CT and ADM
were well incorporated within the
recipient tissues. New fibroblasts,
vascular elements, and collagen were
present throughout the ADM, similar
attachments and no adverse healing
was reported

2. ECM Membrane
• An ECM membrane obtained from the sub-mucosa of the small intestine of pigs
• Nevins et al. 2010, 6 patients presenting with <2 mm of attached gingiva bilaterally on
the facial aspect of the mandibular posterior teeth.
• AGG on one side and the ECM (DynaMatrix) on the contralateral side
• There was an increase of 5.3 ±1.3 mm of KT for the AGG group and 2.6± 1.1 mm for the
ECM group at 13 weeks
• A better color match and tissue blend was noted for the ECM sites
• Histologic evaluations : Similar

3. Bilayer Collagen Matrix
A xenogenic porcine bilayer collagen matrix (BCM) that is composed of pure Type I and
III collagen.
Nevins et al. 2011
• Collagen membrane (CM) versus AGG in augmenting KT.
• 5 patients with <2 mm of attached gingiva bilaterally on the facial aspect of the
mandibular posterior teeth.
• Tissue contour, color, and texture of the CM-treated sites blended nicely with the
adjacent soft tissues compared with the AGG-treated sites after 1 year.
• The mean dimensional change of KT was 3.1 mm for FGG and 2.3 mm for CM.
• The histologic observations were remarkably similar for both treated sites.

4. Living Cellular Construct
• Composed of living allogeneic human fibroblasts and keratinocytes, bovine
collagen, and human extracellular proteins.
• Produces growth factors and cytokines, that influence the patient’s own cells to
differentiate into site-appropriate tissue.

Test Material
Living human fibroblast-derived dermal substitute
(HFDDS)
• 3-D cultivation of human diploid fibroblast cells (newborn foreskins) on a polymer
scaffold.
• Scaffold bioabsorbable polyglactin mesh, degrades by hydrolysis & lost after
transplantation.
• CELLS & ECM - The fibroblasts secrete a mixture of growth factors and matrix proteins to
create a living dermal structure, following cryopreservation remains metabolically active.
• Deliver growth factors, key to neovascularization, cell migration and differentiation.
• Does not stimulate an immune response.

Mcguire et al. 2005
Living human fibroblast-derived dermal substitute (HFDDS), compared to a FGG.
25 patients with insufficient attached gingiva associated with at least two teeth in
contralateral quadrants of the same jaw were treated.
The control group exhibited an average of 1.0 to 1.2 mm more keratinized tissue over time
than the test group & about half as much shrinkage as the test group over 12 months.
Test sites demonstrated significantly better color match & tissue texture over time
compared to control sites.

2. Connective Tissue Autograft
Edel (1974)
• Based on the fact that the CT carries the genetic message for the overlying
epithelium to become keratinized. Therefore only connective tissue from beneath a
keratinized zone can be used as a graft.
Advantage
1. Donor tissue is obtained from the undersurface of the palatal flap, which is
sutured back in primary closure; therefore healing is by first intention.
2. Less discomfort postoperatively at the donor site.
3. Improved esthetics (better color match)

Two horizontal incisions. These are placed 2 to
3 mm apical to the free gingival margin. are
connected by vertical incisions which facilitate
flap elevation and connective tissue graft
removal.
After the palatal flap has been elevated, the
underlying connective tissue and island of
epithelium are removed. This will serve as the
donor tissue. The customary thickness of the
connective tissue is between 1 and 2 mm.

Wessel et al. 2008
• Compared patient-based outcomes for CTGs and FGGs.
• Postoperative questionnaires at 3 days and 3 weeks to assess pain, number of analgesic
pills taken, and number of days pills were taken. Postoperative pain was assessed using a
visual analog scale (VAS).
• The proportion of subjects reporting pain in the palate at 3 days was significantly greater
for FGG.
• There were no significant intergroup differences at 3 weeks.
• FGG is associated with a greater incidence of donor site pain compared to CTG at the
early postoperative period.

3. Apically Displaced Flap, Friedman (1962)
• At the end of the surgical procedure, the entire complex of the soft tissues (gingiva and
alveolar mucosa) was displaced in an apical direction.
• Adequate vestibular depth must be present before the surgery to allow apical
positioning of the flap.
• Can be used on buccal surfaces in both jaws and on lingual surfaces in the lower jaw

Partial-thickness flap:
• Crestal incision with blade parallel to long axis of tooth.
• Flap raised by sharp dissection Periosteum retained over bone.
• Flap is apically positioned at or below alveolar crest.
Indications
1. Areas of thin periodontium or prominent roots in which dehiscences or fenestrations
may be present.
2. A need to increase the zone of keratinized gingiva.

A
E
C
B
F D
(A,B)The flap is dissected from an apico-
occlusal direction as tension is applied to the
flap with tissue pliers
(C,D)A horizontal incision is made just
above the crest of bone to permit removal of
the inner flap
(E) Scalers and curets are now used to
remove the inner flap and residual
granulation tissue
(F) Periosteal sutures permit exact flap
placement at or below the crest of bone

Advantages
1. Eliminate pockets
2. Protect underlying bone (ie, donor site of pedicle flap)
3. Can be combined with other mucogingival procedures to increase the zone of keratinized
gingiva
4. Permit periosteal suturing for flap stabilization and exact positioning
Disadvantages
1. Cannot be used for osseous surgery
2. High degree of difficulty to perform
3. Secondary intention healing

Modified Apically Repositioned Flap
Carnio et al. 1999
• Consists of a single horizontal incision within keratinized tissue, elevation of a split-
thickness flap, and suturing of the flap to the periosteum in an apical position.
• The periosteum is left exposed so that the full perimeter of the wound is surrounded by
keratinized tissue.
• Allow formation of new keratinized and attached tissue in the area where periosteum
is left exposed.

• A horizontal beveled incision was made with a #15C blade; 0.5 mm coronal to the
mucogingival junction into the attached gingiva.
• The gingiva coronal to the initial incision remained intact around the teeth.
• Mesio-distal extension allowed for apical repositioning of the flap without the use of
vertical releasing incisions.

• A split-thickness flap was elevated, and the dissection was extended in the apical
direction as far as deemed necessary.
• The flap was moved apically and secured to the periosteum with simple interrupted
sutures.
• Using a moist 2x 2-inch gauze pad, gentle digital pressure applied for 3 to 5 minutes
• Endpoint for the surgical procedure- a thin and homogenous layer of periosteum with no
movable tissue (neither elastic nor muscular fibers)

Carnio et al. 2007
• 37 areas in 33 systemically healthy patients.
• In a case series, the amount of KT increased from a baseline mean of 2.14 ± 0.78 mm to
approximately double (4.25 ± 1.03 mm) after 6 months.
But , there is only minimal evidence to support this conclusion from one author.
• Advantages- MARF may be an effective technique in increasing the apico-coronal
dimension of the KT and attached gingiva without donor areas or use of commercial
products.
• Disadvantage: need for > 0.5 mm of attached gingiva to be present

Consensus Reports Related To The Gingival
Augmentation Non Root Coverage Procedures

Periodontal Soft Tissue Non–Root Coverage Procedures: A Consensus Report From
the AAP Regeneration Workshop. (Scheyer et al. 2015)
Gingival augmentation procedures around natural teeth that are not aimed at achieving root
coverage are performed
• To facilitate plaque control
• To improve patient comfort
• To prevent future recession
• Used in conjunction with restorative, orthodontic, or prosthetic dentistry.

CLINICAL QUESTIONS
a. Is There a Need for a Minimum Amount of Keratinized Tissue (KT)?
Under optimal plaque-control conditions resulting in the absence of clinical inflammation,
there is no need for a minimum amount of KT for preventing attachment loss (AL).
b. Which Clinical Scenarios Require a Minimum Amount of KT?
• In the presence of suboptimal plaque control and clinical inflammation, AL and recession
may result unless there is a minimum amount of KT.
• In presence of sub-gingival restorative margins or clasps from removable appliances,
specific orthodontic tooth movement.
• A minimum amount of 2 mm of KT with 1 mm of attached gingiva has been
recommended under these circumstances.

c. How Relevant is the Recipient Site Periodontal Biotype?
• There is a general assumption that individuals with a thin periodontal biotype (include
not only soft tissue thickness but also bone thickness and tooth position) will be more
prone to recession.
• Although there is consensus on the need for a minimum tissue thickness, there is no
evidence defining this thickness.
d. Is There a Standard Procedure for KT Augmentation?
• In situations in which gingival augmentation is indicated, autogenous gingival grafts
have been considered to be the method of choice.

e. How Relevant is Graft Thickness?
• 0.75 to 1.25 mm to ensure that the graft will have an adequate amount of connective tissue
to allow for graft survival.
F. What are the Alternatives to Autogenous Graft Tissue for Gingival Augmentation
Procedures?
• Few studies with short-term reported outcomes (<1 year).

Gingival Augmentation Coronal to Recession
(ROOT COVERAGE)

Classification of Gingival Recession (Miller)

The following is a list of 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 pedicle flap
4. Coronally positioned flap; including semilunar pedicle (Tarnow)
5. Subepithelial connective tissue graft (Langer)
6. Guided tissue regeneration (GTR)
7. Pouch and tunnel technique (coronally advanced tunnel technique)

Classification of Root coverage techniques
(Bouchad et al. 2001 )
1. Pedicle soft tissue grafts
• Rotational flaps
• Laterally positioned flap
• Double papilla flap
• Advanced flaps
• Coronally positioned flap
• Semilunar flap
2. Free soft tissue grafts
• Non-submerged graft
• One stage (free gingival graft)
• Two stage (free gingival graft + coronally positioned
flap)

• Submerged grafts
• Connective tissue graft + laterally positioned flap
• Connective tissue graft + double papilla flap
• Connective tissue graft + coronally positioned flap (sub-epithelial
connective tissue graft)
• Envelope techniques
3. Additive treatments
• Root surface modification agents
• Enamel matrix proteins
• Guided tissue regeneration
• Nonresorbable membrane barriers
• Resorbable membrane barriers

Rotational flap procedures
• The use of a laterally repositioned flap to cover areas with localized recession was
introduced by Grupe and Warren which was called the laterally sliding flap operation.
• In order to reduce the risk for recession on the donor tooth, Grupe suggested that the
marginal soft tissue should not be included in the flap.
• Staffileno and Pfiefer & Heller advocated the use of split thickness flap to minimize
the potential risk for the development of dehiscence at the donor tooth.

Laterally positioned flap
• Grupe & Warren introduced contiguous soft tissue autografts to the literature under the
term “lateral sliding flap” currently known as the laterally positioned pedicle graft.
• For successful root coverage using laterally positioned pedicle graft, these three
criteria must be met.
1. Adequate donor tissue laterally.
2. Normal to deep vestibule.
3. Recession involving only one tooth.

Double papilla repositioned flap
• Double papilla graft is the variation of the laterally positioned graft which was given by
Cohen and Ross.
• It is indicated in where there is recession of labial or lingual gingiva, but destruction of
the interdental papillae on either side of the denuded area has not occurred.
• Recession of this type is observed in areas where trauma from incorrect tooth brushing
has destroyed the gingiva and cleft formation develops.
• This pattern of gingival recession is noted on the labial or buccal surfaces of roots
where the involved tooth is in labial version to the approximating teeth.
• If the adjacent area to the recession is intact with no pocket formation or minimal in the
proximal areas, then joining both papillae together to form a flap will repair the area of root
exposure.
• This procedure may also permit the covering of the margin of a restoration which has been
exposed by recession.

Pedicle soft tissue graft procedures combined with
membrane barriers:
• The use of membrane barrier, according to the principles of guided tissue regeneration
(GTR), in conjunction with pedicle soft tissue graft procedures was introduced as a
treatment modality for root coverage.
• A membrane barrier is placed between the graft and the root in order to favor the
regeneration of the periodontium.

1. Free Gingival Autograft (Bjorn,1963)
The Classic Technique ( Miller 1987)
Step 1: Root planing
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 the
proximal line angles of adjacent teeth
and the retracted tissue is excised.
• Maintain an intact periosteum in the
apical area.

Steps 3, 4 and 5. Obtain the graft from the donor site, transfer and immobilize the graft &
protect the donor site.

For root coverage purposes
1. The graft should be sutured coronally to the cementoenamel junction (to compensate
for soft-tissue shrinkage)
2. Thickness should be >1 mm (to increase root coverage predictability)
3. Should be adapted to the convexity of the crown (to minimize coagulum exposure and
destabilization)
• Disadvantages-
1. An unfavorable esthetic outcome (white-scar)
2. Grafted tissue contrasts with the adjacent soft tissues
3. Malalignment of the mucogingival line

Indications
1. Augment keratinized tissue height (especially in mandibular incisors without attached
gingiva and with aberrant frenuli)
2. Increase the thickness of gingival tissue
3. Increase vestibulum depth
Contraindications
1. In patients with esthetic demands
2. In deep and wide recession defects
3. In the presence of deep facial probing pockets associated with gingival recession

2. Free connective tissue auto graft (Levine, 1991)
• Step 1: Divergent vertical incisions: Divergent vertical incisions are made at the
line angles of the tooth to be covered, creating a partial-thickness flap to at least 5
mm apical to the receded area.
• Step 2: Suturing: Suture the apical mucosal border to the periosteum using a gut
suture.
• Step 3: Scaling and root planing: Thoroughly scale and root plane, which also
reduces any prominence on the root surface.

• Step 4: Obtain the graft: From the palate, obtain a connective tissue graft. The
donor site is sutured after the graft is removed.
• Step 5: Transfer the graft: Transfer the graft to the recipient site, and suture it to the
periosteum with a gut suture. Good stability of the graft must be attained with
adequate sutures.
• Step 6: Cover the graft: Cover the grafted site with dry aluminum foil and
periodontal dressing.

3. Pedicle Autograft
• It is a mucogingival flap designed to serve as a soft tissue graft that maintains an intact
blood supply from the donor site.
History
• In 1956, Grupe and Warren- full-thickness flap to the mucogingival junction, after
which a partial-thickness flap was raised.
• Grupe (1966) modified a sub-marginal incision at donor site
• Corn (1964) added a cutback incision to release tension
• Dahlberg (1969) rotated pedicle flap, which did not require a cutback incision
• Goldman and Smukler (1978) periosteally stimulated flap & a partial-full rotated flap in
1983

Indications
1. An isolated area of soft tissue recession with no bone loss on the proximal surface
2. The adjacent donor tooth should have adequate soft tissue width and thickness, as well
as vestibular depth
Contraindications
1. Presence of deep interproximal pockets
2. Excessive root prominences
3. Deep or extensive root abrasion or erosion
4. Significant loss of interproximal bone height

A. Laterally (Horizontally) Displaced Pedicle Flap
• First determine the bone level at the facial of the donor site by bone sounding after
local anesthesia.
• The distance from the bone to the CEJ ≈1 to 2 mm on facial Surface on donor site

A wide external bevel incision on the distal aspect and
an internal bevel incision on the mesial aspect create
close adaptation of the flap.
Step-1 Preparation of recipient site

Remove the V-shaped
gingiva and make a bevel
for flap adaptation.

Step 3: Transfer the flap.
• Slide the flap laterally onto the adjacent root, flat and firm without excess tension on the
base.
• The first suture is placed in the mucosa close to the mucogingival line on the leading edge
of the flap with a 5–0 or 6–0 interrupted suture.
• This will allow for some stability of the flap before suturing the coronal edge of the flap
to the non donor papilla.

• Suturing of the trailing edge is the same on the opposite papilla between the donor and
recipient teeth.
• The lip should be moved to make sure the graft is immobile.
• The trailing edge of the pedicle graft is the weakest link because of the lack of stable
tissue on which to suture this edge of the flap.
• Holding a moistened gauze over the sutured area for 5 minutes will assist in stabilizing the
area.

Step 4: Protect the flap and donor site.
• Cover the operative field with aluminum foil and a soft periodontal dressing,
• Periodontal dressing must be stable.
• Dressing that moves when the patient talks or chews can severely disrupt the
healing process.
• Remove the dressing and sutures after 1 week.

1. Edentulous Ridge
Modification
Variant Techniques
(A) Molar with recession
( B,C) V-shaped incision
(D, E, F) With the removal of the
V-shaped incision, a partial-
thickness pedicle flap is raised.
(G) Dissection on the partial-
thickness pedicle flap is
completed in an apico-occlusal
direction.
(H) Flap reflected.
( I) A bevel is placed on the distal
side of the V-shaped incision to
permit flap overlap.
( J) A full-thickness pedicle flap.
(K and L) Sutured flaps of
partial- and full-thickness
designs, respectively. B = bone; P
= periosteum.

3. Periosteally Stimulated Pedicle Flap (Goldman and Smukler, 1978)
• Used a stimulated periosteum, (activated state) - a sharp instrument or 25-gauge needle is
used to make sharp penetrations through the gingivae that firmly engage the underlying
bone.
• Carried out under anesthesia 17 to 21 days prior to surgery to slightly damage the
periosteum and induce healing.
• Healing activates primordial cells capable of bone and cementum formation.

4. Partial-Full-Thickness Pedicle Flap

Advantages
1. Donor site is adjacent to the recipient site, which produces only one surgical wound,
decreases the postoperative pain and bleeding concerns.
2. The pedicle maintains a blood supply through the base of the flap and improves the
chances of graft survival and root coverage.
Disadvantages
1. Donor tissue is often thin and prone to future recession.
2. Limited by the amount of adjacent keratinized attached gingiva
3. Dehiscence or fenestrations at the donor site
4. Limited to one or two teeth with recession

Double-papilla flap (Cohen DW, 1968)
Incisions outlined and the probe in place, showing the
mucogingival problem.
V-shaped incision begun V-shaped wedge removed
• Two horizontal incisions are made on both sides, parallel to the CEJ.
• Vertical incisions are made on the mesial and the distal aspects at the surgical site and
placed at the line angles of adjacent teeth.

Papillary flap completed with dissection in an apico-occlusal
direction.
Papillary flaps reflected with periosteum.
Papilla held with Corn tissue pliers as suturing is begun.

Double-papillae flap sutured and stabilized
• Suture both papilla flaps at the center of the root surface to ensure coverage of the
denuded root surface.
• Place interrupted sutures (7-0 vicryl) across the medial surface of the two papilla flaps,
beginning apically and working coronally.
• No more than two or three sutures are usually necessary.
• A sling suture is carried around the tooth and tied facially to prevent the graft from
slipping apically.

Advantages
• Less chance of flap necrosis and suture is easy as interdental papilla is thick.
• The amount of donor tissue is small
• Less tension to the pedicle flap.
• Little damage to the alveolar bone because interdental alveolar bone is thick.
Disadvantages
• Technically demanding
• Limited application.
Indication
• Sufficient width and length of the interdental papilla on both sides of the area of
gingival recession

Wound healing
• By connective tissue attachment, a long junctional epithelium, or a combination of the two.
• Avoid probing 6 months. Coverage of the exposed root surfaces varied from 60% to 72% .
• Slight recession at the donor site. (thin biotype)
• Necrosis or loosening of the flap. (flap is too thin, dissection was insufficient, and the
flap was sutured with tension)

Chambrone LA et al. 2009
• 32 patients, with one Miller Class I or II buccal GR of > or = 3 mm, were treated
with a LPF.
• At 24 months postsurgery,
– Mean root coverage obtained with the laterally positioned flaps was 93.8%.
– Complete root coverage was obtained in 62.5%

4. Coronally Displaced Flap
Bernimoulin et al. (1975)
Prerequisite-
• The ideal case - adequate thickness and width of the gingiva on the leading edge of the
flap to be advanced.
• Flap thickness that approaches 1.0 mm (>0.8 mm) has a better probability of covering
a root surface than a flap thickness of 0.8 mm or less.
• There should be adequate quality and height of tissue adjacent to the recipient site to
anchor the suture to the desired height.
• Frenum attachments can limit the amount of coronal positioning, must be eliminated

Advantages
• Only one surgical site is involved
• Excellent color match
• Basic technique for many of the future combined techniques
Disadvantages
• If the grafted tissue is too thin, only partial root coverage is achieved, and that
tissue is prone to future recession
• Difficult to properly stabilize because of the difficulty in suturing

First Technique:
Step-1
• Measure the amount of root to be covered
• This measurement will be the distance
between the coronal and apical horizontal
incisions
• The first two small coronal horizontal incisions are made at the proposed coronal
edge of the recipient bed
Step-2
• The vertical incisions are extended perpendicular to the first two incisions and
well into the alveolar mucosa

• Step-3 The surface epithelium is removed from the rectangular area yield a connective
tissue recipient bed for the graft.
• Step-4 The pedicle flap is then advanced in a coronal direction. The fit should be a butt
joint
• The donor tissue should stay in place passively, suturing is accomplished with 5–0 / 6–0
sutures.

Bernimoulin et al. in 1975
Two-stage procedure
• First stage of surgery- free gingival graft is performed to increase the keratinized tissue
height apical to the gingival recession
• Second stage- grafted tissue is coronally advanced to cover the exposed root surface (Two
months after first surgery)
• Root coverage ranging from 65% to 72%
• A significant degree of reduction in recession treated by this double-step procedure was
reported after 2 years by Bernimoulin et al 1975 .
Variations to First Technique

Disadvantage
• Not well accepted by the patient because of the two surgical stages
Indications
1. Lack of keratinized tissue apical and/or lateral to the root exposure
2. Gingival cleft extending beyond the mucogingival line
3. Presence of a shallow vestibulum depth

Semilunar coronally repositioned flap (Tarnow DP,1986)
Step 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. blood supply from the papillary areas.
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. It is then held in its new
position for a few minutes with moist gauze. Many cases do not require either sutures or
periodontal dressing.
Indications-
• Recession is not extensive (< 3 mm) & facial gingival biotype is thick.
• It is successful for the maxilla, It is not recommended for the mandibular dentition.

Advantages
• Good esthetics
• Simple surgical procedure and minimal surgical time
• Minimal postoperative discomfort
• The vestibular depth stays the same
• The papillae stay intact, with no aesthetic compromise
• Suturing is not needed
Disadvantages
• Not applicable in cases of extreme gingival recession
• Where an osseous dehiscence or fenestration exists apical to the gingival recession
area, free autogenous gingival grafts or connective tissue grafts should be performed

Periosteal pedicle graft (PPG) procedure (Mahajan et al. 2012 )
1. A full thickness trapezoidal flap was raised 3- 4 mm apical to the osseous crest.
2. The process of harvesting the periosteal graft was initiated at the apical extent of the
periosteum which was lifted slowly in a coronal direction. not separated completely
from the underlying bone, leaving it attached at its coronal most ends.

3. Periosteal pedicle graft obtained was then turned over the exposed root surface and sutured
with a synthetic 5-0 bioabsorbable suture.
4. After stabilizing the periosteal graft, the flap was coronally positioned and sutured using a
sling suture technique.
The releasing incisions were closed with interrupted sutures after which the operated site
was covered with noneugenol periodontal dressing for protection.

• The periosteum as a graft material provides progenitor cells(osteoblasts and
fibroblasts) which can regenerate the lost periodontal tissues and dual blood supply –
from the pedicled periosteum & underlying periosteum.
• Single stage technique for vestibular deepening and recession coverage utilizing the
periosteum as autograft
Advantages
• High vascularity, single surgical site, patient comfort.

CAF procedure + orthodontic button application
CAF+B (Ozcelik O et al. 2011)
Pre-operative Orthodontic buttons placed
Elevation of flap CAF sutured around button

Zucchelli’ s technique modified CAF (Zucchelli G et
al. 2000)
a. Schematic representation
b. Submarginal oblique
incisions
c. Split-full-split thickness
flap
d. Deepithelization of
anatomic papillae
e. Coronal mobilization and
suturing
a b c
d e

Santama
ria MP,
2008
Both procedures CAF & CAF+R (in combination with a resin-modified
glass ionomer) provided similar soft tissue coverage after 6 months .
Despite a greater reduction in DS was observed after CAF+R.
Santana
RB et al.
2010
Compared the semilunar coronally re-positioned flap (SLCRF) and
coronally advanced flap (CAF). The stability of RC were detected earlier
and maintained better with the CAF design.
Studies…

5. Subepithelial connective tissue graft
(Langer & Langer 1985)
• Combines the use of a partial thickness flap with the placement of a connective tissue
graft.
Indication:
• For larger and multiple defects with good vestibular depth and gingival thickness to
allow a split-thickness flap to be elevated.

Step 1: Raise a partial-thickness flap with a horizontal incision 2 mm away from the tip of
the papilla and two vertical incisions 1 to 2 mm away from the gingival margin of the
adjoining teeth. Extend at least one tooth wider mesiodistally & to the mucobuccal fold.
Step 2: Thoroughly plane the root, reducing its convexity.
Step 3: Obtain a connective tissue graft from the palate. The palatal wound is sutured
in a primary closure.

Step 4: Place the connective tissue on the denuded root Suture it with resorbable sutures
to the periosteum. If possible, the flap is pulled over a major portion of the graft.
Step 5: Cover the graft with the outer portion of the partial thickness flap and suture it
interdentally.
Step 6 : Cover the area with dry foil and surgical dressing.

Advantages:
• Double-blood supply at the recipient site from the underlying periosteum and the
overlying recipient flap.
• The donor site is a closed wound, less postoperative discomfort.
• CT carries the genetic message for the overlying epithelium to be keratinized
• Esthetically pleasing.
• Applicable for gingival recession on multiple teeth.
Disadvantages:
• Technically demanding.
• Because a thick graft is used, the grafted tissue is thick.
• Gingivoplasty may be necessary postoperatively to obtain better morphology.

Modifications of Langer and Langer” (Bruno)
1. Do not use a vertical incision when preparing a recipient site to:
• 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.
3. Close adaptation to donor tissue is obtained with a butt joint.

a. Make a partial-thickness horizontal incision on the CEJ
b. Connect each horizontal incision with a
sulcular incision.
c. After reflecting a partial-thickness flap, Extend the partial-thickness incision apically for
coronal migration of the flap.
d. Cover the exposed root with a connective
tissue graft and suture.
e. Cover the graft completely with the flap

Variant technique
Subpedicle (bilaminar) connective tissue graft Nelson 1987)
• This technique uses a pedicle over the connective tissue that covers the denuded root
surface.
Advantage
• A pedicle flap can cover connective tissue grafts on root surfaces lacking a vascular
supply
• Width of the keratinized gingiva can be increased
Disadvantage
• More technically demanding

a. Double papilla flap design in
recipient site.
b. Prepare the partial-thickness pedicle flap,
which includes mesiodistal interdental papilla.
c. Prepare the recipient site, which consists
of periosteum-connective tissue.
d. Suture and stabilize the connective
tissue graft.

e. Connect each papilla flap to make a double papilla flap.
f. Cover the connective tissue graft on the root surface with the double
papilla flap. Make a sling suture.

Harris et
al. 2005
CPF + CT
v/s DP + CT
v/s TUN-
LAT + CT,
mandibular
incisors
• DP + CT and TUN- LAT + CT had greater mean root
coverage (95.5% and 90.5%) than the CPF + CT group
(80.2%).
• DP+ CT produced a greater increase in keratinized tissue
(3mm) than CPF + CT (1.4mm) or TUN-LAT + CT (1.9
mm) .
• The CPF + CT produced less mean root coverage (68.4%)
when treating defects ≥ 3 mm deep.
Zucchelli
G et al.
2012,
Coronally
advanced flap
versus
Bilaminar
technique
Statistically greater probability of complete root coverage
and greater increase in gingival thickness were observed in
the BT group.

6. Guided tissue regeneration technique for root coverage
• Regenerate lost periodontal structures through differential tissue responses (AAP 1996).
• Resorbable or nonresorbable barriers (membranes)
• Reconstructing the attachment apparatus rather than just root coverage.
Pini-Prato et al. (1992)
• Reported a mean root coverage for the GTR procedure of 72.7%, versus for the two-step
procedure of 70.9%.
• Defects with preoperative recession depths of > 4.98 mm had greater root coverage when
treated with GTR WHILE Defects with recession depths <4.98 mm would have greater
root coverage when treated with the two-stage procedure.

Indications
• Moderate to severe gingival recessions
• Thin palate
• Patient reluctant to have a second surgery site
Procedure
a. Tooth 11 with a moderate gingival recession.
b. The exposed root surface is thoroughly scaled
c. Two vertical incisions are placed, avoiding the interproximal papillae.
d. The flap is reflected exposing some of the alveolar bone.
a
d
c
b

A full-thickness flap is reflected to the Mucogingival junction, (that will enable bone visibility
3 mm apical to the exposed root) continuing as a partial-thickness flap 8 mm apical to the
mucogingival junction.
• The papillae are de-epithelialized, and the membrane is trimmed and adjusted to cover the
recession. Extend 2 mm beyond the borders of the recession mesially, distally, and
apically. coronally placed at the level of the CEJ and sutured in place with a
circumferential suture.
• This suture is tied to bend the membrane, creating a space between the root and the
membrane. The knot is then palatally tucked into the gingival sulcus.

• The releasing incisions are secured with single
interrupted sutures on both sides.
• It is important to not leave the membrane exposed.
• Buccal flap is usually placed 0.5–1.0 mm coronal to
the cemento-enamel junction to cover the underlying
membrane.
1. Teflon/ePTFE membranes
• Nonresorbable, biocompatible membranes that require a second surgery (4-6
weeks after) for removal.
2. Polylactic acid membranes
• Biodegradable membranes degraded by hydrolysis.

1. Membrane exposure. (An infected nonresorbable membrane should be
removed .
2. Another complication is the perforation of the flap because of the inappropriate
trimming of the membrane. (membrane is stiff and the trimming has left sharp
edges)
Rosetti et al. 2013
 Compared (SCTG) and GTR combined with demineralized freeze-dried bone allograft.
24 defects were treated in 12 patients. Both procedures promoted similar RC (GTR-
DFDBA: 87% and SCTG: 95.5%) and similar reduction in GR (GTR-DFDBA: 3.25
mm and SCTG: 3.9 mm). The increase in KTW was significantly higher in the SCTG
group (3.5 mm) than in the GTR-DFDBA group (2.4 mm).

7. Pouch and tunnel technique (Coronally advanced
tunnel technique) (Zabalegui et al. 1999)
Indication
• Anterior maxillary area in which vestibular depth is adequate and there is good
gingival thickness.
Advantages
• Minimize incisions and the reflection of flaps
• Provide abundant blood supply to the donor tissue,
• Allows for intimate contact of donor tissue to the recipient site.
• Excellent esthetic result
• Thickening of the gingival margin after healing, which is stable to allow for the
possibility of “creeping reattachment” of the margin.

Step 1: Initial sulcular incisions are made using 15c / 12d blades.
Step 2: Using either a curette or a small blade, a tunnel is created beneath the adjacent
buccal papilla.
Step 3: A split-thickness pouch is created apical to the papilla, This pouch may extend
10- to 12-mm apical to the recessed gingival margin and papilla and 6- to 8-mm
mesial and distal.

Step 4: Muscle fibers and any remaining collagen fibers on the inner aspect of the flap,
which prevent the buccal gingiva from being moved coronally, are cut using
Gracey curettes.
Step 5: The papillae are kept intact and undermined to maintain their integrity and carefully
released from the underlying bone, which allows the coronal positioning of the
papillae.
Step 6: The size of the pouch, is measured so that an equivalent size donor connective
tissue can be procured.

Step 7: A mattress suture placed at one end of the graft is helpful in guiding the
graft through the sulcus and beneath each interdental papilla. The border
of the tissue is gently pushed into the pouch and tunnel using tissue forceps
and a packing instrument.
Step 8 : A vertical mattress suture is used to hold the connective tissue in
position beneath the gingiva.
Step 9: The entire gingivopapillary complex (buccal gingiva with the underlying
connective tissue graft, and papillae) is coronally positioned using
a horizontal mattress suture anchored at the incisal edge of the contact area.

Vestibular incision subperiosteal tunnel access (VISTA)
(Zadeh H, 2010)
Step-1: A vestibular access incision mesial to the recession defect was made.
Step-2: Subperiosteal tunnel was created, exposing the facial osseous plate
with microsurgical periosteal elevator (VISTA 1 and VISTA 2).
• Extended at least one or two teeth beyond the teeth requiring root coverage

• Step-3: Subperiosteal tunnel was extended interproximally under each papilla as far as
the embrasure space permits, without making any surface incisions through the
papilla, it is achieved by using elevator with bayonet curves (VISTA 3 and VISTA
4).
• Step-4: Once coronal advancement of the gingival margin was established, connective
tissue graft cover the dehiscence on root through the subperiosteal
were placed.

Step-5 : The graft and mucogingival complex were then advanced coronally and
stabilized in the new position with a coronally anchored suturing, by
placing a horizontal mattress suture at approximately 2 to 3 mm apical
to the gingival margin of each tooth .
Step-6 : The suture was then tied to position the knot at the mid coronal point
of the facial aspect of each tooth, which was secured with help
of composite resin, prevent apical relapse of the gingival margin during
initial stages of healing.

Connective tissue graft using an
envelope flap by Raetzke (1985)
Perform root planning of the
exposed root and use a finishing bur
to recontour it.
Envelope flap is prepared (3-5
mm)
•Cover the exposed root with
the connective tissue graft and
perform compressive
hemostasis.
•No suture is required.
Cyanoacrylate may be used to
hold the graft.

Periodontal Soft Tissue Root Coverage Procedures: A
Systematic Review From the AAP Regeneration Workshop
Miller Class I and II GR
• All RC procedures can provide significant reduction in recession depth and CAL gain
without alteration of PD for Miller Class I and II localized recession-type defects.
• SCTG-based procedures provided the best outcomes
Chambrone L 2015

Miller Class III and IV GR
• Class III defects may significantly benefit from the use of RC procedures (in the short
term) when SCTG-based procedures are used.
• Class IV recessions, the data from the limited number of case reports suggest that
these defects may be improved after treatment, but the amount of RC cannot be
anticipated

Techniques To Deepen The Vestibule
• Important for both oral hygiene and retention of prosthetic appliances.
• Clinical studies by Bohannan 1960, vestibule deepening by non–free-graft
procedures were not successful years later.
• Clinical aspect- The donor tissue either free gingival or connective tissue, must be
placed over a nonmobile recipient site (immobile periosteal tissue or bone).

Kazanjian’s method (1935)
Described a method for deepening the vestibule in which a labial flap pedicle off the
alveolar process was used to cover the newly exposed bone while the lip surface was
permitted to reepithelialise.
Drawback – severe scarring of the lip is seen which will further restrict the movements of
the lower lip
Secondary epitilization vestibuloplasty
 The mucosa of the vestibule is used to line one side of the extended vestibule, and the
other side heals by growing a new epithelial surface or by secondary intention healing,
mainly two types
1. Kazanjian
2. Clark

A. Incision is made through of inner surface of lip.
B. Mucosa is dissected back to a base on crest of alveolar ridge. Flap is held out of the way
with an instrument while sulcus depth is obtained by supraperiosteal dissection.
C. Mucosal flap is sutured to periosteum. A rubber or polyethylene tube is held in place
at bottom of new sulcus by circumferential sutures tied around cotton rolls.

CLARK’S TECHNIQUE (1953)
• Incision is made on the alveolar ridge and a supraperiosteal dissection is done to the
desired depth . Mucosa of the lip is undermined till the vermillion border. Soft tissue
side of the vestibule is covered with mucosa, whereas on the osseous side the raw
periosteal surface is left.
Flap was pedicled off the lip rather than the alveolar process. Since the raw surface is on
the bone rather than the lip, less contracture occurs

• Vertical incision mesial to one of the mandibular canines and starting at the junction of
the attached and free gingiva , 10 to 12 mm extending on to the lower lip.
• A similar incision was given parallel to the other canine and these two incisions were
joined by a horizontal incision across the midline.
The vestibular extension technique
Edlan and Mejchar (1963)

• A split thickness flap then separated the loose labial mucosa from the underlying
muscle.
• Horizontal incision was made on the periosteum, The periosteum was then separated
from the bone, forming a second flap with its base on the apical portion of the mandible.
• The loose flap of labial mucosa was folded back and placed on the bone from which the
periosteum was removed. It was fixed with interrupted sutures to the inner surface of the
periosteum, which was removed from the bone.
• The upper edge of the periosteum was also sutured to the mucous membrane of the lip to
cover the area denuded by the reflection of the first (labial mucosal) flap.

Advantage –
• Healing occurs by first intention and no bone is left exposed, thereby minimizing the
chances of bone resorption and further recession.

Techniques to remove the frenum
• A frenum is a fold of mucous membrane, usually with enclosed muscle fibers, that
attaches the lips and cheeks to the alveolar mucosa and/or gingiva and underlying
periosteum.
• It must be removed or it can result in the following
• 1. Gingival recession
• 2. Diastema formation
• 3. Accumulation of debris by reflection and opening of the sulcus

Labial frenal attachments classified by Placek et al 1974
1. Mucosal – when the frenal fibres are attached up to the mucogingival junction.
2. Gingival – when the fibres are inserted within the attached gingiva.
3. Papillary – when the fibres are extending into the interdental papilla.
4. Papilla penetrating – when the frenal fibres cross the alveolar process and
extend up to the palatine papilla.

Frenectomy and Frenotomy
• Frenectomy is 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 is the relocation of the frenum, usually in a more apical position.
VARIOUS TECHNIQUES OF FRENECTOMY
1. The classical technique
2. Miller’s Technique
3. Z-plasty
4. V-Y plasty
5. Electro Surgery

Broad release of tissue even
without total excision of tissue.
Tissue suture with almost primary
closure to reduce trauma and prevent
muscle reattachment
Frenulotomy / frenotomy

1. The Classical technique
Archer (1961) and Kruger (1964)
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 undersurface of the hemostat.
Step 4: Remove the triangular resected portion of the frenum with the hemostat.
This exposes the underlying fibrous attachment to the bone.

Step 5: Make a horizontal incision, separating the fibers, and bluntly dissect to the bone.
Step 6: After frenulum removal, tissue sutured
Step 7: Clean the surgical field with gauze sponges until bleeding stops.
Step 8: Cover the area with dry aluminum foil apply periodontal dressing.
Step 9: Remove the dressing after 2 weeks and redress if necessary.
One month is usually required for the formation of an intact mucosa with the frenum
attached in its new position.

Frenulotomy with pedicle flaps.
A. Gingival recession associated with frenum pull.
B. Submarginal partial thickness pedicle graft.
C. Final frenum displacement, root coverage, increased keratinized gingiva.
2. Miller’s Technique 1985

3. Z-plasty
First incision made at
the base of the frenum.
Two triangular flaps are made
following the incision (Z-shape
Flaps repositioned
prior to closure.
Removal of
scar tissue.
Indicated for hypertrophic thick frenula with a
low insertion and a shallow sulcus

4. V-Y Plasty
Indicated in a case of a papilla type
frenal attachment

5. Electro Surgery
• Recommended in cases of non-compliant patients.
• The frenum was held with the haemostat and by using a loop electrode tip, it was
excised.
• Advantage of minimal procedural bleeding and there was no need of sutures.
• The healing was by secondary intention, as the wound edges were not approximated
with sutures

TECHNIQUES TO IMPROVE ESTHETICS
Esthetic zone:
The maxillary anterior area in a patient with a high lip line presents a visible area in which
patients are concerned with the esthetic appearance.
The therapy to correct these gingival conditions are:
1. Root coverage
2. Papilla reconstruction
3. Therapy to correct excessive gingival display
4. Gingival depigmentation

2. Papilla Reconstruction
• Loss of the interdental papilla “black triangle or hole” is a major esthetic problem
for many patients.
• Most difficult and unpredictable problem in esthetic periodontal therapy.
• The interdental papilla is gingival tissue supported and created by two adjacent
teeth in contact and the underlying bone beneath this tissue.
• The loss of this bone as the result of periodontal disease or the loss of the contact
alters the support of the interdental tissue

• Tarnow 1992, distance from the crest of the interdental bone to the apical portion of the
contact above this bone determines whether the interdental papilla is absent or present.
• Orthodontics and restorative therapy play an important role
• Grafting bone or gingiva of minimal size to a small recipient site is unpredictable
because of the lack of blood supply from the recipient site to the donor tissue.
• Technique like pedicle graft and tunnel and pouch technique preferred.

Azzi et al 2002, concepts for papilla reconstruction are:
(1) Semilunar pedicle design
(2) Both connective tissue and bone grafting into the interdental area
(3) Restorative dentistry to place the apical portion of the contact closer to the crestal bone

3. Therapy to correct excessive gingival display
• Excessive gingival display/ “gummy smile,” esthetic concern
• Caused by skeletal problem (vertical maxillary excess by dentoalveolar extrusion)
or by incomplete exposure of the anatomic crown ( altered passive eruption).
A pleasant smile line

Surgical Techniques
The determinates for choice of surgical procedure are:
• The need to leave a minimum of 3.0 mm of keratinized marginal tissue.
• The possible need for osseous surgery.

Gingival Depigmentation
• The activity of the melanocytes, which are nonkeratinocytes present in the gingival
epithelium, varies among individuals.
• Physiological gingival hyperpigmentation can be treated but results last from 6 to 36
months.
• Gingival depigmentation involves the removal of the superficial epithelium by one of
the following methods.
1. Mucosal Excision/ stripping by a BP blade
2. Rotary instrument
3. Electro surgery
4. Cryosurgery
5. Lasers

Scalpel
• Uppermost layer of the gingiva was scraped
using 15 numbers blade. The blade was held
parallel to the long axis of the teeth with
Minimum pressure.
• Allow the denuded connective tissue to heal by
secondary intention.
• Bleeding was controlled with a sterile gauze
pressure pack

Gingival abrasion technique using diamond bur
• Similar to the scalpel technique.
• Simple, and non-aggressive method that can be easily
performed.
• Extra care to control the speed and pressure of the hand
piece bur so as not to cause unwanted abrasion or pitting
of the tissue.
• Minimum pressure with feather light brushing strokes with
copious saline irrigation should be used without holding
the bur in one place.

Electrosurgery
• Exploding cell theory- electrical energy leads to the molecular disintegration of melanin
cells of the operated and surrounding sites.
• Electro surgery retard migration of melanin cells.Used in light brushing strokes and the
tip has to be kept moving. cervico-apical direction. Every five minutes, the operation
field will be wiped with sterile gauze soaked in 1% normal saline solution.
• Avoid contact of current with the periosteum and vital teeth
Disadvantages:
• Require more expertise.
• Prolonged or repeated application of current to the tissues induces heat accumulation
and undesired tissue destruction.

Cryosurgical Depigmentation
• It is a method of tissue destruction by rapid freezing
• The cytoplasm of the cells freezes, leading to denaturation of proteins and cell death.
• It does not require use of local anesthesia or periodontal dressing, is relatively painless
and has shown excellent results lasting for several years.
• The cryotherapy procedure requires a special container for storage of liquid nitrogen.
• The depth of penetration is difficult to control and prolonged freezing may cause
excessive tissue destruction.

• The Dip-stick method utilizes a small cotton bud/swab dipped in LN, which can be
applied on the pigmented area and maintained in contact for around 20–30 s

Chemical agents (chemoexfoliation)
• Destroys using a chemical peeling agent.
• A variety of chemical peeling agents are available; phenols, salicylic acid, glycolic
acid, trichloracetic acid, etc.
• Phenol penetrates the subepithelial connective tissue and causes necrosis or
apoptosis of melanocytes. It result in incapacity of melanocytes to normally
synthesize melanin.
• It requires the area to be air-dried before application. The phenol pellet is applied
and maintained for 1 min and the area needs to be rinsed with 99% alcohol

Lasers
• Different lasers have been used including
1. Carbon dioxide (10.600 nm)
2. Diode (810 nm)
3. Neodymium: Yttrium Aluminium garnet (1.064 nm)
Technique- Light brushing strokes and the tip was kept in motion all the time. Remnants of
the ablated tissue were removed using sterile gauze dampened with saline solution.

Advantages
• Effective, pleasant and reliable techniques
• Do not require any periodontal dressing
• Reduced pain and discomfort due to formation of protein coagulum
• Allows clean and dry operating field and stable results
• Laser light may also seal free nerve endings
Disadvantages
• Delayed wound healing
• Thermal damage
• Deep penetration
• Comparably high costs of the procedure

Crown Lengthening
• The surgical procedure is designed to increase the extent of the supragingival tooth
structure by apically positioning the gingival margin, removing supporting bone, or
both.
• There are two aspects to the crown lengthening procedure:
1. Aesthetic
2.Functional
 The biological width is defined as the sum of the junctional epithelium and supracrestal
connective tissue attachment.
 Gargiulo et al. (1961)- average space is 2.04 mm.

• Violation of that space by restorations causes gingival inflammation, discomfort, gingival
recession, alveolar bone loss, pocket formation.
• Ingbert et al. (1977) advocated 3 mm of sound supracrestal tooth structure between
bone and prosthetic margins for the reformation of the biological width plus sulcus depth
• Achieved surgically (crown lengthening) or orthodontically (forced eruption) or by a
combination of both

Indications
• To improve the gummy smile of a patient with a high smile line
• To rehabilitate dentition that is compromised by the presence of extensive caries,
short clinical crowns, traumatic injuries, or severe parafunctional habits.
• To restore gingival health.
In majority of cases bone recontouring and gingival resection to accommodate aesthetics and
function is required.
After the procedure, wait 6–8 weeks before cementing the final restoration. In the aesthetic
zone, at least 6 months is recommended before final impression (Pontoriero & Carnevale
2001). This reduces the chances of gingival recession following prosthetic crown insertion (
Mainly in thin biotype).

Criteria for selection of mucogingival surgery techniques
1. Surgical site free of plaque, calculus, and inflammation
2. Adequate blood supply to the donor tissue
3. Anatomy of the recipient and donor sites
4. Stability of the grafted tissue to the recipient site
5. Minimal trauma to the surgical site

Conclusion
• Periodontal plastic surgery refers to soft tissue relationships and
manipulations. In all of these procedures, blood supply is the most
significant concern and must be the underlying issue for all decisions
regarding the individual surgical procedure. The future of periodontal
plastic surgery will encompass the use of tissue-engineered products at the
recipient site to reduce donor site morbidity.

References
• Newman, Takei, Fermin A Carranza. Clinical periodontology, 12th Edition. Jan Lindhe. Clinical
Periodontology and Implant Dentistry, 10th Edition
• Pini Prato GP, Tinti C, Vincenzi G, Magnani C, Cortellini , Clauser C. Guided tissue regeneration versus
mucogingival surgery in the treatment of human buccal recession. J Periodontol 1992;63:919-928.
• Kumar PM, Reddy NR, Kumar SS, Chakrapani S. Double papilla ﬂap technique for dual purpose. J Orofac
Sci 2012;4:75-8. • Harris RJ. Double pedicle flappredictabilityand aesthetics using connective tissue.
Periodont s2000, Vol.11,1996,3948
• Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol
1985;56:715-720.
• Carranza FA, Jr, Carraro JJ: Mucogingival techniques in periodontal surgery. J Periodontol 41:294, 1970. •
Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinised gingiva.
Journal of Clinical Periodontology. 1974: 1: 185- 196.
• Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinized
gingiva. J Clin Periodontol. 1974;1:185–96.
• Chao JC. A novel approach to root coverage: The pinhole surgical technique. International Journal of
Periodontics and Restorative Dentistry. 2012 Oct 1;32(5):521
• Tarnow, D.P. (1986) Semilunar coronally repositioned flap. Journal of Clinical Periodontology 13, 182–185
.

• Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, Chambrone LA, Lima LA.
Root‐coverage procedures for the treatment of localized recession‐type defects: A
Cochrane systematic review. Journal of periodontology. 2010 Apr;81(4):452-78.
• Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for
treatment of localized gingival recessions: a systematic review. Journal of clinical
periodontology. 2002 Dec;29:178-94.
• Oates TW, Robinson M, Gunsolley JC. Surgical therapies for the treatment of
gingival recession. A systematic review. Annals of periodontology. 2003
Dec;8(1):303-20.

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