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DENS 3723
Advance Periodontics
Course Director
Srinivas Ayilavarapu BDS,DSc
Associate Professor
Dept of Periodontics & Dental
Hygiene
January 7, 2016

Mucogingival Surgery

A surgical procedure indicated to

correct or enhance the thickness or
amount of, or change the position
of, mucogingival tissue.

American Academy of Periodontology 2012 Glossary of Periodontal Terms, On-line access

Periodontal Plastic Surgery

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

Gingiva

Keratinized tissue composed of a

dense, collagen rich connective
tissue, covered by a keratinizing
epithelium.
Gingiva extends from the free
gingiva margin to the
mucogingival line.

Free gingiva:
depth of the
sulcus
Attached gingiva:
width of gingiva
minus probing
depth

Why do we need attached or

keratinized gingiva??
Function against mechanical
and microbial damage.
Barrier to penetration by
microbes and their toxic
agents into deeper tissues

How to detect muco-gingival junction?

How much attached gingiva is necessary to

maintain gingival health?
Lang & Loe, 1972:
Proposed that the movability of the soft tissue
margin at sites with minimal attached gingiva
(<1mm) may favor the establishment of
subgingival plaque, and thus make the tissues
more vulnerable to destruction.
Dorfman, etal; Miyasato etal; Wennstrom
etal:
Clinical studies evaluating the signs of
inflammation or progression of recession over one
month to 6 years, found that teeth exhibiting
minimal attached gingiva or mucosal margins
were compatible with periodontal health.
AAP World Workshop,1996:
A minimal amount or absence of gingiva
alone is NOT justification for gingival
augmentation.

Will Gingival Dimensions Influence

Restorative Therapy?
Studies by Ericsson & Lindhe (1984) and Stetler & Bissada (1987);
1. ) Subgingival restorations in areas of narrow gingiva will lead to
plaque
related inflammation and recession.
2.) To prevent this either the plaque control standard has to
be improved
or the thickness of the gingival margin has to be
increased.

Indications for
Mucogingival Surgery
Gingival Augmentation:

Where tooth movement results in

alveolar bone dehiscence.
To halt progressive marginal tissue
recession.
Around teeth or implants to facilitate
plaque control and or improve
patient comfort.
In conjunction with prosthetic
dentistry:
Teeth with intracrevicular
restoration margins
Where major or minor connectors
or removable partials infringe
upon the marginal mucosa.

Indications for
Mucogingival Surgery
Root Coverage:

Reduce root sensitivity

Improve esthetics
Manage defects resulting
from root caries removal or
cervical abrasion
Manage mucogingival
defects which fail to respond
to altering abusive
toothbrushing techniques and
or plaque removal

Free Soft Tissue Grafts

Free Gingival Graft
(Epithelialized)

Connective Tissue Graft

(Non-epithelialized)

Pedicle Grafts: Rotational Grafts

Lateral sliding graft

Double papilla graft

Pedicle Grafts: Advanced Flaps

Coronally Positioned
Flap
Semilunar Flap

Combination Grafts
One-stage procedures:
Connective tissue graft plus pedicle flap
Biodegradable membrane plus pedicle flap
Two-stage procedures:
Coronally positioned previously placed free gingival graft
Non-resorbable barrier plus pedicle flap:

GINGIVAL AUGMENTATION
Indications to increase the band of attached gingiva:

The placement of a restoration with an

intracrevicular margin
Instances where major and minor connectors
of RPD infringe upon the gingiva
Orthodontic movement
Association with a frenum pull
Around implants
Vestibular elongation
Halt progression of recession

Free Gingival Graft

Indications:
increase the width of attached
gingiva
increase vestibular depth
root coverage

If root coverage is needed, root

plane the exposed root surface.

Preparation of the recipient bed:
Remove surface mucosa
maintaining an intact periosteum
Apico-coronal dimension
should be twice the desired
width of attached gingiva

Tech
niq

ue fo
r Fre
e
Ging
Graf
ival
t

Obtain the graft from the donor site:

Keratinized gingiva taken from
the palate or an edentulous ridge
Graft should be thin enough to
allow diffusion of nutrients from
the recipient site vasculature (11.5mm)
Transfer and immobilize the graft

Technique for Free Gingival Graft

Technique for Free Gingival

Graft

Free Gingival Graft for Root Coverage

Technique for Free

Gingival Graft

Free Gingival Graft: Increase

the Band of Keratinized Tissue
in Preparation for Orthodontics

Technique for Free Gingival Graft

Technique for Free Gingival Graft

Controversy over the need for keratinized

attached gingiva around implants:
Sevor etal., 1993: Attached gingiva is more
securely attached to the underlying bone and
contains connective tissue in the form of circular
fibers. This may render attached gingiva more
resistant to deflection and abrasion
Wennstrom etal., 1994; Strub etal., 1991: Lack of
attached gingiva did not adversely affect the
maintenance of soft tissue health around dental
implants.

Peri-implant Gingival Tissues

Bed Preparation

Graft secured

Two weeks post-op

Free Gingival Graft at Implant

Exposure

Healing
Fibrous organization of the
interface between the graft
and recipient bed occurs
within 2 days.
The graft is initially maintained
by a diffusion of nutrient fluid
from the bed, adjacent gingiva
and alveolar mucosa.
Revascularization of the graft
starts by the second or third
day. Vessels from the
recipient bed proliferate into
the graft and anastomose with
pre-existing vessels.

Healing
The graft epithelium undergoes
degeneration and sloughing and is
replaced by new epithelium from the
borders of the recipient site. (The
character of the epithelium is
determined by the underlying
connective tissue.)
Functional integration of the graft
occurs after 2-3 weeks.
Microscopically, healing of the graft
may take up to 4 months. The
greatest amount of shrinkage occurs
within the first 6 weeks.

Gross Appearance of the Healing

Graft
Surgery: pale white (graft vessels
are empty)
First week post-op:

ischemic gray (sloughing

epithelium)
reddish-pink
(vascularization
of the graft)
Up to 16 weeks post-op: coral pink
(epithelial maturation)

Frenectomy
Indications:
To relieve muscle pull on
the gingiva
Closure of a diastema
space associated with
orthodontic movement

Frenectomy
Engage the frenum with a
hemostat inserted to the
depth of the vestibule.
Incise both sides of the
hemostat removing the
tissue. (This exposes the
underlying fibrous
attachment to the bone.)

Frenectomy
Make a horizontal incision,
separating the fibrous
attachment; bluntly dissect to
the bone.
If necessary, extend the
incision laterally and suture
the labial mucosa to the
apical periosteum. Sometimes
the exposed area is covered
with a free gingiva graft.

Frenectomy

Depending on the amount and need for

keratinized gingiva, the frenectomy is
performed in conjunction with a free

To Summarize
Mucogingival surgeries are performed to improve the quality and
quantity of
gingival tissues which will facilitate plaque control, improve patient
comfort
and overall tooth prognosis.
Common indications are gingival recession, lack of vestibular
depth,
and keratinized gingiva, in conjunction with restorative and
orthodontic procedures.
Techniques routinely utilized are free soft tissue grafts with or
without pedicle flaps, frenectomy.