Periodontal Plastic

Soft Tissue
Grafting
Surgery

Indications and Procedures

Robert C. Cain, DDS
First Mondays CE Club
November 4, 2013

Objectives
To understand some of the different
types of grafts used in Periodontal
Plastic Surgery (Mucogingival Surgery)
To understand the indications for the
different types of mucogingival
surgeries
To show some examples of one of the
most common grafting procedures, the
FGG and CTG.
To understand when a condition would
not benefit from Mucogingival Surgery

Common Questions (FAQs):

When is gingival grafting needed and
when is it not?
Why do I need it? What happens if I
dont do it?
Does it hurt?
What is the recovery time?
Does it work? Does it have to be
redone?
Does brushing too hard cause
recession?
How much does it cost?

Definitions
Attached Gingiva The portion of
the gingiva that is firm, dense, stippled
and tightly bound to the underlying
periosteum, tooth, and bone.
Free Gingiva That part of the
gingiva that surrounds the tooth and is
not directly attached to the tooth.

Definitions
Mucogingival Junction the area of
union of the gingiva and alveolar
mucosa
Alveolar Mucosa Loosely attached
mucosa covering the basal part of the
alveolar process and continuing into the
vestibular fornix and the floor of the
mouth

Definitions
Mucogingival Defect a departure
from the normal dimension and
morphology of the relationship
between the gingiva and the alveolar
mucosa

Definitions
Free Gingival Graft (FGG) - A soft
tissue graft that is completely
detached from one site and
transferred to a remote site. No
connection with the donor site is
maintained
Subepithelial Connective Tissue
Graft (CTG) - A detached connective
tissue graft that is placed beneath a
partial thickness flap. This variation of
the free gingival graft provides the
tissue graft with a nutrient supply on

History of Periodontal Plastic

Surgery
1930s Frenectomies and

vestibuloplasties
1948 First Gingivoplasties
1956 Grupe and Warren publish
Laterally Positioned Flap
1963 Bjorn publishes the Free
Gingival Graft
1982 P.D. Miller introduces the FGG
for root coverage. Fernandez does first
CT graft
1989 AAP renames Mucogingival
Surgery to Periodontal Plastic Surgery

Indications for Perio Plastic

Surgery
Gingival Augmentation
Free Gingival Graft
Connective Tissue Graft

Root Coverage
Coronally positioned flap
Semilunar flap
Laterally positioned flap
Double papilla flap
Free Gingival Graft
Connective Tissue Graft
Guided Tissue Regeneration using

Grafting Decision Tree

Leong and Wang. IJPRD 2011; 31 (3) 307 - 313

When is Grafting Needed?

How much keratinized gingivae is
needed?
Bowers 1963 felt that gingival health
could be maintained with a narrow
zoned of KG (<1mm) but some was
required for healing
Lang & Loe 1968 suggested 2mm
Maynard and Wilson 1979 5mm of KG
with 3mm attached when subgingival
restorations are planned
Kennedy 1985 over a 6 year period,
patients with inconsistent OH saw

When is Grafting Needed?

Is the recession progressing?
Is the tooth treatment planned for
orthodontic care or prosthetic
treatment?
Is there root sensitivity?
Is there difficulty cleaning the root
surface by the patient?
Is there an esthetic concern?

Free Gingival Autografts

Indications
To increase keratinized tissue around
teeth, implants or crowns
To increase keratinized tissue under
removable prostheses
To increase vestibular depth

Disadvantages

Difficult to achieve root coverage

High esthetic demand
Large, uncomfortable donor site
Graft site, slow uncomfortable healing

Free Gingival Autografts

Classic Gum Graft
Will increase keratinized gingivae
Results in Tire Patch look

Free Gingival Graft

Pre-op

Pre-op

Courtesy of Barry R. Wohl, DDS

Free Gingival Graft

Donor Site

Recipient
Site
Courtesy of Barry R. Wohl, DDS

Free Gingival Graft

Before

Long-term follow-up

Courtesy of Barry R.
Wohl, DDS

Receding Gums

Miller Classification of
Class I. Recession
Recession
that has not extended
to MGJ. No bone loss
Class II. Recession to
or beyond the MGJ.
No bone loss
Class III. Recession
to or beyond MGJ.
Bone loss. Papilla
recession
Class IV. Recession
beyond MGJ. Bone

Causes and Predisposing

Factors in Gingival Recession
Predisposing Factors:
Minimal attached gingiva/thin tissue
biotype
Frenum pull / shallow vestibule
Tooth malposition

Precipitating Factors:
Inflammation related to plaque
Restorations adjacent to thin tissue
Occlusal Trauma including orthodontic
treatment

Connective Tissue Graft

Advantages
Very predictable for root coverage
Smaller donor site (than FGG)
Smaller recipient site (than FGG)
Less soreness overall (than FGG)
Uses patients own tissue
Excellent esthetics
Can cover multiple, large recessions even
on teeth with a previous restorations

Connective Tissue Grafts

Disadvantages
Two surgical sites
Technique sensitive
Bleeding from palate (potential)

Connective Tissue Grafts

Surgical technique
Root preparation
Thorough root planing of exposed root to
remove cementum and affected dentin
Etch root surface with tetracycline (pH 2.0)
Exposes collagen tufts to promote fibroblast
adhesion

Connective Tissue Graft

Surgical Technique

Incision design (tunnel technique)

Create pouch using full/split thickness incision
between gingiva and bone/root
Maintain papilla for bilaminar blood supply
Extend incision to adjacent teeth
Undermine flap

Connective Tissue Graft

Surgical Technique
Donor site incision (Buser)
First palatal incision perpendicular to long axis
of teeth

Connective Tissue Graft

Surgical Technique

Donor site incision (Buser)

Second palatal incision parallel to long axis of tee

Connective Tissue Graft

Donor Site
Harvest Tissue
Suture Palate

Connective Tissue Graft

Surgical Technique
Recipient site
Insert graft into tunnel
Suture using interrupted and sling sutures

Connective Tissue Graft

Before

After

Connective
Tissue Graft
Pre-op
Occlusal
Trauma

Postop

Connective Tissue Grafts

Miller Class IV with supra-eruption of
central incisor
Only minimal root coverage was
possible

Connective Tissue Grafts

Before

3 years post-op

When is a CTG not

indicated?
All exposed dentin is gingival
recession
Abfraction
Tissue at or near the CEJ

When is a CTG not

indicated?
Gingival
hyperplasia
adjacent to
normal gingival
contours

Brushing TOO Hard?

Does brushing cause

recession?
Does brushing too hard causes gum
recession? Not really.
Toothbrushing and Gingival Recession. Litonjua,
LA, et al. Int Dent J 2003 53(2) a literature
review showed no direct relationship between
toothbrushing and gingival recession
Trauma from toothbrushing may contribute to
recession in a minor way, but other more
important factors should be treated first
Abrasion of the hard surfaces of the teeth are
likely caused by abrasives in the toothpaste

Does it HURT?
The common perception is that
Connective Tissue Grafting is VERY
PAINFUL!!
This is often the patients
perception
This perception is usually the result
of hearsay from friends and
relatives
The origins probably go back to the
days of the Free Gingival Grafts

FEAR

Does it HURT?
Reality
In 20 years of performing CT grafts, very
few patients ever complain about
significant pain afterwards
Most are pleasantly surprised at how
little pain they had
Very little post-op bleeding, swelling or
bruising
Of course, everyones pain threshold is
different

What is the Recovery Time?

Recovery times vary from individual to
individual
Post-op instructions include:
Soft foods for a week
Avoid chewing in the donor or recipient
sites if possible for the first week
Bleeding from the palate is possible for
the first 24 hours and sometimes longer
Dont brush the donor site for 1 week;
the recipient site for 3 weeks.
Chlorhexidine mouthwash in the

What is the Recovery Time?

Most patients report some soreness
during the first week, but most do not
take anything more than the Ibuprofen
800 mg
Some swelling of the recipient site is
normal and occasionally some bruising
Sutures resorb in the palate in 2 3
days and in about 1 week in the
recipient site
Most people resume normal activities
either the next day or two days after

Conclusions
Mucogingival defects are very
common across all age groups and
both genders
Mucogingival defects can be either
congenital or acquired with both
predisposing and precipitating factors
Periodontal Plastic Surgery can be
used to correct mucogingival defects
via a variety of methods and
techniques
Indications for Periodontal Plastic

Thank You!

Questions?