Periodontal Plastic and

Esthetic Surgery
Clinical Periodontology 2019: Chapter 65
Clinical Periodontology and Implant Dentistry 2022: Chapter 39
Abstract

• In addition to periodontal pocket reduction and access for root planing, one of
the objectives of periodontal surgery is the correction of anatomic defects that
may favor plaque/biofilm accumulation, pocket recurrence, and impair
aesthetics.
• The lack of keratinized attached gingiva around the dentition may make it
difficult for the patient to practice good plaque/biofilm removal.
• The surgical correction of these anatomic defects by gingival augmentation
(grafts) is an example of utilizing periodontal plastic surgery to alter the gingival
anatomy that would have otherwise predisposed the gingiva to periodontal
disease.
• Periodontal plastic surgery can also help improve gingival aesthetics where there
is excessive gingival margin recession. The numerous periodontal plastic surgical
techniques available today and the future of tissue engineering to allow
minimally invasive surgical procedures will be presented in this chapter.
Terminology

• mucogingival surgery (Friedman, 1957)

“surgical procedures designed to preserve gingiva, remove aberrant frenulum
or muscle attachments, and increase the depth of the vestibule”

• periodontal plastic surgery (Miller, 1993)

“surgical procedures performed to prevent or correct anatomic,
developmental, traumatic or disease‐induced defects of the gingiva, alveolar
mucosa or bone”
• Gingival augmentation
• Root coverage
• Correction of mucosal defects at implants
• Crown lengthening
• Surgical exposure of unerupted teeth for orthodontics
• Removal of aberrant frenulum
• Prevention of ridge collapse associated with tooth extraction
• Ridge augmentation
• Reconstruction of papillae
• The periodontal plastic surgical techniques included in the
traditional definition of mucogingival surgery are
1) widening of attached gingiva,
2) deepening of shallow vestibules, and
3) resection of the aberrant frena

• Aesthetic surgical therapy for natural dentition and tissue

engineering (i.e., biologic mediators) also are addressed.
Classification of periodontal surgery
Objectives

• Five objectives of periodontal plastic surgery are addressed in this

chapter:

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 original rationale for mucogingival surgery was predicated on
the assumption that a minimal width of attached gingiva was
required to maintain optimal gingival health.
• However, several studies have challenged the view that a wide,
attached gingiva is more protective against the accumulation of
biofilm than a narrow or a nonexistent zone.
• 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.
• However, individuals whose oral hygiene practices are less than
optimal can be helped by the presence of keratinized gingiva and
vestibular depth.
• Vestibular depth provides space for easier placement of the
toothbrush and prevents brushing on mucosal tissue.
• To improve aesthetics, the objective is the coverage of the denuded root
surface. The maxillary anterior area, especially the facial aspect of the
canine, often has extensive gingival recession. In these cases, the covering
of the denuded root surface widens the zone of attached gingiva and
creates an improved aesthetic result. 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

• Another objective of periodontal plastic surgery is the creation of

vestibular depth when it is lacking.
• 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

• An important objective of periodontal plastic surgery is correction

of frenal or muscle attachments that may extend coronal to the
mucogingival junction.
• If adequate keratinized, attached gingiva exists coronal to the
frenum, it may not be necessary to remove the frenum.
• A frenum that encroaches on the margin of the gingiva can
interfere with biofilm removal, and the tension on the frenum
tends to open the sulcus. In these cases, surgical removal of the
frenum is indicated.
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. This condition is often called as a gummy smile, and it
can be corrected surgically by crown lengthening. Correction of these
anatomic defects has become an important part of periodontal plastic
surgery.
Tissue Engineering

• The future of periodontal plastic surgery will encompass the use of

tissue-engineered products at the recipient site to reduce donor
site morbidity.
• Results of numerous experimental and clinical studies support the
clinician's use of a minimally invasive approach to periodontal
plastic surgery.
Cause of Marginal Tissue Recession
• The most common cause of gingival recession and the loss
of attached gingiva is abrasive and traumatic
toothbrushing habits.
• The bone and soft tissue anatomy of the facial, radicular
surface of the dentition is usually thin, especially around
the anterior area.
• Teeth positioned facially may have an even thinner bone
and gingiva.
• In many instances, the areas have a complete absence of
bone beneath the thin overlying gingival tissue. This
defect in the bone is called a dehiscence.
• This anatomic status combined with external trauma from
overzealous brushing can lead to the loss of gingival tissue.
• Recession of the gingival tissue and bone exposes the cemental
surface of the root, which results in abrasion and ditching of the
cemental surface apical to the cementoenamel junction (CEJ).
• The cementum is softer than enamel and is destroyed before the
enamel surface of the crown.
• Another cause of gingival recession is periodontal
disease and chronic marginal inflammation. The
loss of attachment caused by the inflammation is
followed by the loss of bone and gingiva.
• Advanced periodontal involvement in areas of
minimally attached gingiva results in the base of
the pocket extending close to or apical to the
mucogingival junction. Periodontal therapy for
these areas results in gingival recession caused
by the loss of gingiva and bone.
• Frenal and muscle attachments that encroach on the marginal
gingiva can distend the gingival sulcus, which creates an
environment for biofilm accumulation. This condition increases
the rate of periodontal recession and contributes to the
recurrence of recession, even after treatment.
• These problems are more common on facial surfaces, but they
may also occur on the lingual surface.
• Orthodontic tooth movement through a thin buccal osseous plate
may lead to a dehiscence beneath a thin gingiva. This situation
can also lead to the recession of the gingival margin.
Factors That Affect Surgical Outcome
Irregularity of Teeth

• Abnormal tooth alignment is an important cause of

gingival deformities that require corrective surgery and
an important factor in determining the outcome of
treatment. 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 gingival margin is recessed
apically to follow the bone, which leads to the exposure
of the root. On the lingual surface of these teeth, the
gingiva is bulbous, and the bone margins are closer to
the CEJ.
• 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.
• Orthodontic correction is indicated when mucogingival surgery is
performed on malposed teeth in an attempt to widen the attached
gingiva or to restore the gingiva over denuded roots.
• If orthodontic treatment is not feasible, the prominent tooth
should be reduced to within the borders of the alveolar bone, with
special care taken to avoid pulp injury.
• Roots covered with thin bony plates pose a hazard in mucogingival
surgery. Even the most minimally invasive flap, such as the
partial-thickness flap, creates the risk of bone resorption on the
periosteal surface.
• Resorption in amounts that ordinarily are not significant may cause
loss of bone height when the bone plate is thin or tapered at the
crest.
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
• To simplify and better understand the techniques and the result of
the surgery, the following classifications are presented:
 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 (i.e., root coverage). 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.
 For pre-prosthetic purposes, the combination of widening keratinized
gingiva apical and coronal to the recession can satisfy this objective.
• Widening of the keratinized attached gingiva (i.e., apical or
coronal to the area of recession) can be accomplished by
numerous techniques.
• The donor graft tissue can be a free gingival autograft, free
connective tissue autograft, or a lateral pedicle flap, which can be
used for either objective.
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. This is essentially an apical pedicle flap.
Free Gingival Autografts

• Free gingival grafts are used to create a widened zone of attached

gingiva. They were initially described by Bjorn in 1963 and have
been extensively used since that time.
The Classic Technique
• Grafts can also be placed directly on bone tissue. For this
technique, the flap should be separated by blunt dissection with a
periosteal elevator.
• The advantages of this variant are less postoperative mobility of
the graft, less swelling, better hemostasis, and 1.5 to 2 times less
shrinkage. However, a lag in the healing period is observed for the
first 2 weeks.
Variant Techniques

• The free gingival graft technique is a predictable procedure, but

the donor site (i.e., palate) is left with an open wound that must
heal by secondary intention.
• The following 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.
• The accordion technique, the strip technique, and the combination
epithelial-connective tissue strip technique are modifications of
the free gingival graft.
• The accordion technique, described by Rateitschak and
colleagues, attains expansion of the graft by alternate incisions on
opposite sides of the graft. This technique increases the donor
graft by changing the configuration of the tissue.
• The strip technique, developed by Han and associates, consists of
obtaining two or three strips of gingival donor tissue about 3 to 5 mm
wide and long enough to cover the entire length of the recipient site.
• These strips are placed side by side to form one donor tissue and
sutured on the recipient site. donor tissue and sutured on the
recipient site.
• A variant of the strip technique is the combination graft. A deep strip
graft is taken from the palate and is split into an epithelial donor
graft and the undersurface portion of a connective tissue donor graft.
• The minimal donor site wound obtained by two donor tissues from
one site is the advantage of this technique.
Alternative Donor Tissue

• Another technique to minimize the use of the palate as a donor

site is the use of acellular dermal matrix (ADM) as a substitute for
palatal donor tissue. The use of the palate as a donor site for
gingival augmentation has numerous disadvantages.
• Many patients are fearful of palatal surgery for procurement of
donor, and there is a limitation on the amount of tissue that can be
removed.
• Numerous clinicians advocate the use of ADM as a substitute for
palatal donor tissue. This product is commercially available under
the name AlloDerm, and it is derived from donated human skin.
• Commercial preparation of this tissue includes a multistep process
that removes the epidermis and the cells that can lead to tissue
rejection and graft failure without damaging the matrix. The
remaining ADM consists of a nondenatured, three-dimensional
arrangement of intact collagen fibers, ground substance, and
vascular channels.
• In addition to avoiding palatal donor surgery, ADM offers the
advantage of availability of unlimited donor tissue for the
treatment of multiple teeth in a single surgical appointment.
alternate papilla tunnel (APT) method
• The APT method combines the advantages of surgical access at the
incised papillae with retraction resistance and wound stability at
the tunneled papillae.
• Advantages of the PRP method include enhanced retraction
resistance, graft containment, and wound stability.
the papilla retention pouch (PRP)
• Postoperative care is similar for both methods and includes the
following:
1. Systemic antibiotics for 10 days
2. Chlorhexidine mouthrinse for 2 to 3 weeks
3. Pain medication as needed
4. Inactivity for 24 hours
5. Ice applied to face for 24 hours
6. Cold liquids for the first three meals
7. No mastication or toothbrushing at the surgical site for 2 to 3 weeks
8. Removal of surface sutures at 2 to 4 weeks
9. Removal of the subgingival graft suture at 2 months
• Developed 2 decades ago, ADM is a safe and effective biomaterial for use as
a substitute for palatal connective tissue in root coverage grafting.
• There have been no reports of disease transmission in medical or dental
applications during this period.
• ADM has proven equivalence to palatal connective tissue for root coverage
procedures in randomized, controlled clinical trials.
• It produces a thicker marginal tissue and has a higher percentage of root
coverage than a coronally advanced flap alone.
• It provides advantages over palatal connective tissue in that it does not
require a second surgical site to obtain donor tissue and provides an
unlimited amount of tissue to treat multiple teeth in one appointment.
• The use of AlloDerm under a coronally advanced flap extends the application
of the most aesthetic procedure in root coverage.
Healing of the Graft

• The success of the graft depends on survival of the connective

tissue.
• Fibrous organization of the interface between the graft and the
recipient bed occurs in 2 to several days.
• Revascularization of the graft starts by the second or third day.
• The epithelium undergoes degeneration and sloughing, with
complete necrosis occurring in some areas. A thin layer of new
epithelium is present by the fourth day, with rete pegs developing
by the seventh day.
• As seen 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.
• The gross appearance of the graft reflects the tissue changes within
it.
• At transplantation, the graft vessels are empty, and the graft is pale.
• The pallor changes to an ischemic grayish white during the first 2
days, until vascularization begins, and a pink color appears.
• Loss of epithelium leaves the graft smooth and shiny.
• New epithelium creates a thin, gray, veil-like surface that develops
normal features as the epithelium matures.
• Functional integration of the graft occurs by the 17th day, but the
graft is morphologically distinguishable from the surrounding tissue
for months.
Accomplishments

• Free gingival grafts effectively widen the attached gingiva.

• Several biometric studies have analyzed the width of the attached
gingiva after the placement of a free gingival graft.
• After 24 weeks, grafts placed on denuded bone shrink by 25%,
whereas grafts placed on periosteum shrink by 50%.
• The greatest amount of shrinkage occurs in the first 6 weeks.
• The indication for a free gingival graft should be based on
progressive gingival recession and inflammation.
Free Connective Tissue Autografts
• The connective tissue autograft technique was originally described
by Edel
• Only connective tissue from beneath a keratinized zone can be
used as a graft
• The advantage of this technique is that the donor tissue is
obtained from the undersurface of the palatal flap, which is
sutured back in primary closure. Healing is by first intention.
• The patient has less discomfort postoperatively at the donor site.
• Another advantage of the free connective tissue autograft is that
improved aesthetics can be achieved because of a better color
match of the grafted tissue to the adjacent areas.
Apically Displaced Flap
• This technique uses a partial-thickness or full-thickness, apically
positioned flap to increase the zone of keratinized gingiva.
• The apically displaced flap technique increases the width of the keratinized
gingiva but cannot predictably deepen the vestibule with attached gingiva.
Adequate vestibular depth must be present before the surgery to allow
apical positioning of the flap. The edge of the flap may be located in three
positions in relation to the bone:
1. Slightly coronal to the crest of the bone. This location attempts to preserve the
attachment of supracrestal fibers; it may also result in thick gingival margins and
interdental papillae with deep sulci and may create the risk of recurrent pockets.
2. At the level of the crest. This results in a satisfactory gingival contour, provided that
the flap is adequately thinned.
3. Two millimeters short of the crest. This position produces the most desirable gingival
contour and the same posttreatment level of gingival attachment as obtained by
placing the flap at the crest of the bone. New tissue covers the crest of the bone to
produce a firm, tapered gingival margin.
• Placing the flap short of the crest increases the risk of a slight reduction in
bone height, but the advantage of a well-formed gingival margin
compensates for this.
Other Techniques
• The vestibular extension technique, originally described by Edlan
and Mejchar, produced statistically significant widening of
attached nonkeratinized tissue.
• The fenestration operation was designed to widen the zone
of attached gingiva with a minimal loss of bone height.
(periosteal separation technique)
Gingival Augmentation Coronal to Recession

• Understanding the different stages and conditions of gingival

recession is necessary for predictable root coverage. Several
classifications of denuded roots have been proposed. In the
1960s, Sullivan and Atkins classified gingival recession as four
anatomic categories:
1) shallow-narrow,
2) shallow-wide,
3) deep-narrow, and
4) deep-wide.
• This early classification helped to categorize the lesion but did
not enable the clinician to predict the outcome of therapy.
• The predictability of root coverage can be enhanced by the
presurgical examination and the correlation of the recession by using
the classification proposed by Miller, as follows:
• Class I. Marginal tissue recession does not extend to the mucogingival
junction. There is no loss of bone or soft tissue in the interdental area. This
type of recession can be narrow or wide.
• Class II. Marginal tissue recession extends to or apical to the mucogingival
junction. There is no loss of bone or soft tissue in the interdental area. This
type of recession can be subclassified as wide and narrow.
• Class III. Marginal tissue recession extends to or apical to the mucogingival
junction. There is bone and soft tissue loss interdentally or malpositioning of
the tooth facially.
• Class IV. Marginal tissue recession extends to or apical to the mucogingival
junction. There is severe bone and soft tissue loss interdentally or severe
tooth malposition.
• The prognoses for classes I and II are good to excellent; whereas
for class III, only partial coverage can be expected. Class IV has a
very poor prognosis with current techniques.
• Several techniques are used for gingival augmentation coronal to
recession (i.e., root coverage):
1. Free gingival autograft
2. Free connective tissue autograft
3. Pedicle autografts
• Laterally (horizontally) positioned pedicle flap
• Coronally positioned flap; includes semilunar pedicle (i.e., Tarnow method)
4. Subepithelial connective tissue graft (i.e., Langer method)
5. Guided tissue regeneration (GTR)
6. Pouch and tunnel technique (i.e., coronally advanced tunnel technique)
• Some of the techniques used for widening the attached gingiva
apical to the area of recession can also be used for root coverage.
• The free gingival graft and the connective tissue autograft used
for apical widening can be used for coronal augmentation by
incorporating some modifications.
• In using the free grafts for root coverage, the recipient bed
surrounding the denuded root surface must be extended wider to
allow for better blood supply to the donor free graft. This is
necessary because a portion of the donor tissue overlies the root
surface, which does not have blood supply.
Free Gingival Autograft
• Successful and predictable root coverage has been reported using
free gingival autografts.
The Classic Technique
Free Connective Tissue Autograft
• The free connective tissue technique was described by Levine in
1991.
Pedicle Autograft
Laterally Displaced Pedicle Flap

• The displaced pedicle flap technique, originally

described by Grupe and Warren in 1956, was the
standard technique for many years and is still
indicated in some cases.
• The laterally (horizontally) positioned flap can
be used to cover the isolated, denuded root
surfaces that have adequate donor tissue
adjacent to the recipient site.
• The vestibular depth must exist to laterally move
the pedicle.
Variant Techniques
Accomplishments of a Pedicle Autograft

• Coverage of the exposed root surface with the sliding-flap

technique has been successful in 60% of cases in one study and 61%
to 72% in another. Histologic studies in animals have reported
coverage in 50% of cases.
• In the donor site, there is uneventful repair and restoration of
gingival health, with some loss of radicular bone (0.5 mm) and
recession (1.5 mm) reported when full-thickness flaps are used as
the donor tissue.
Coronally Displaced Flap

• The purpose of the coronally displaced flap procedure is to create

a split-thickness flap in the area apical to the denuded root
surface. The flap is coronally positioned to cover the root. Two
techniques are available for this purpose. The technique is
essentially a coronally positioned pedicle flap.
First Technique
Variations of the First Technique
Second Technique
• Tarnow described the semilunar, coronally repositioned flap to
cover isolated denuded root surfaces.
Subepithelial Connective Tissue Graft

• The subepithelial connective tissue graft (i.e., Langer procedure)

is indicated for larger and multiple defects with good vestibular
depth and gingival thickness to allow a split-thickness flap to be
elevated.
• Adjacent to the denuded root surface, the donor connective tissue
is sandwiched between the split flaps.
• This technique was described by Langer and Langer in 1985.
• A variant of the subepithelial connective tissue graft, called a
subpedicle (bilaminar) connective tissue graft, was described by
Nelson in 1987.
• This technique uses a pedicle over the connective tissue that
covers the denuded root surface.
• The blood supply is increased over the donor tissue, and the
gingival margin is thickened for better marginal stability.
Guided Tissue Regeneration Technique for
Root Coverage

• Pini-Prato and coworkers described a technique based on the

principle of guided tissue regeneration (GTR).
• Theoretically, GTR should result in reconstruction of the
attachment apparatus, along with coverage of the denuded root
surface.
• Tinti and Vincenzi used titanium-reinforced
membranes to create space beneath the membrane.
Resorbable membranes have also been used to
achieve root coverage. The inability to create space
between the resorbable membrane and the denuded
root may present a problem, even though a second
surgery is not needed.
• Clinical studies comparing this technique with the
coronally displaced flap have shown that the GTR
technique is better when the recession is greater
than 4.98 mm apicocoronally. Histologically, one
case reported 3.66 mm of new connective tissue
attachment associated with 2.48 mm of new
cementum and 1.84 mm of bone growth.
Pouch and Tunnel Technique

• The pouch and tunnel technique is also referred to as the coronally

advanced tunnel technique.
• To minimize incisions and the reflection of flaps and to provide
abundant blood supply to the donor tissue, placement of the
subepithelial donor connective tissue into pouches beneath papillary
tunnels allows intimate contact of donor tissue with the recipient
site.
• Positioning of the graft in the pouch and through the tunnel and
coronal placement of the recessed gingival margins completely
covers the donor tissue. The aesthetic result is excellent. The
technique is especially effective for the anterior maxillary area in
which vestibular depth is adequate and there is good gingival
thickness.
• An advantage of this technique is thickening of the gingival margin
after healing. The thicker gingival margin is stable, allowing for
the possibility of creeping reattachment of the margin. The use of
small, contoured blades enables the surgeon to incise and split the
gingival tissues to create the recipient pouches and tunnels.
Techniques to Deepen the Vestibule
• Adequate vestibular depth is important for oral hygiene and retention of
prosthetic appliances.
• Numerous surgical techniques have been proposed to accomplish
deepening of the vestibule.
• The classic clinical studies in the early 1960s by Bohannan indicated that
deepening of the vestibule by non–free-graft procedures were not
successful when evaluated years later.
• Predictable deepening of the vestibule can be accomplished only by the
use of free autogenous graft techniques and their variants.
• The recipient site must be covered by immobile periosteal tissue. If there
is a lack of periosteal connective tissue, donor tissue may be placed over
the bone.
• The donor tissue can be free gingival or connective tissue, but it must be
placed over a nonmobile recipient site.
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 or gingiva and underlying
periosteum.
• A frenum becomes a problem if the attachment is too close to the marginal gingiva.
• This anatomic situation can be a genetic condition or the result of recession of the
gingival margin reaching the area of the frenum.
• Tension on the frenum can pull the gingival margin away from the tooth. This
condition can be conducive to biofilm accumulation and inhibit proper placement of
the toothbrush at the gingival margin.
• These hygiene problems are most often encountered in the anterior mandibular
areas.
• The maxillary anterior vestibule is deep, and the frenum is usually located in the
midline between the two central incisors.
• The aberrant frenum located between the maxillary central incisors may cause an
aesthetic problem in a patient with a high lip line.
Frenectomy and Frenotomy
• Frenectomy and frenotomy can be performed in conjunction with
other periodontal treatment procedures, such as a free gingival
graft procedure to deepen the vestibule in the mandibular anterior
area. If the aberrant frenum is the only problem, the surgical
procedure is accomplished separately. Frenal problems occur most
often on the facial surface between the maxillary and mandibular
central incisors and in the canine and premolar areas. They occur
less often on the lingual surface of the mandible.
Procedure
Techniques to Improve Aesthetics
• The maxillary anterior area in a patient with a high lip line may cause
concerns about the aesthetic appearance of gingival tissues.
• This area is called the aesthetic zone, and it requires special
consideration in restorative, periodontal, and implant therapy.
• The symmetry of the facial gingival margin from canine to canine is
altered with recession of the gingival margin, loss of the interdental
papilla, or an excessive amount of gingival tissue creating a gummy smile.
• Therapy to correct these gingival conditions is discussed under the topics
of root coverage, papilla reconstruction, and correction of excessive
gingival display.
Root Coverage
Papilla Reconstruction

• Loss of the interdental papilla is a major aesthetic problem for

many patients. It is often referred to as the black triangle or hole.
• Reconstruction of the lost or reduced interdental papilla is the
most difficult and unpredictable problem in aesthetic periodontal
therapy. Interdental papilla is gingival tissue supported and
created by two adjacent teeth in contact and the underlying bone
beneath this tissue.
• The loss of bone as the result of periodontal disease or the loss of
the contact alters the support of the interdental tissue, which can
lead to the loss or reduced height of the papilla.
• Tarnow, in his study of this area, stated the 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.
• The predictable reconstruction of the papilla is determined by
augmentation of the gingival tissue, the presence or absence of
the underlying bone, and contact of the two adjacent teeth.
• Orthodontics and restorative therapy also play important roles in
the loss and reconstruction of the papilla because they can
determine the location of the contact position in the dentition.
• We have also learned from experience that 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, both of which have minimal contact due to their
size.
• Bone grafting or free gingival grafting of interdental areas to
reconstruct the papilla is not a predictable procedure.
• There have been numerous case reports of different techniques to
augment gingival tissue into the interdental area.
• All techniques must be based on the principle of adequate blood
supply to the donor tissue.
• Of the many gingival grafting procedures used in periodontal
therapy, the technique that offers the best blood supply to the
donor tissue is the pedicle graft because it maintains a connection
between the donor tissue and the origin of the graft.
• The pouch and tunnel surgical procedure also creates the ideal
blood supply for the recipient site to accept the donor tissue.
• Han and colleagues reported a technique using a semilunar pedicle
graft and pouch to gain papillary height, but without bone support
this technique was only able to reduce the interdental space.
• Azzi and coworkers reported successful results in numerous cases
using different surgical techniques to regain the lost papilla.
• All of these cases employed different grafting techniques using
connective tissue and bone and a surgical flap design that applied
the principle of the pouch and tunnel to maximize the blood
supply to the grafted tissue.
1) semilunar pedicle design,
2) connective tissue and bone grafting into the interdental area, and
3) use of restorative dentistry to place the apical portion of the contact
closer to the crestal bone.
• The future of papilla reconstruction will involve techniques
developed by tissue engineering using biologic mediators.
• In a study reported by McGuire and Scheyer, autologous fibroblasts
were injected into the interdental papilla to atraumatically
augment the deficient interdental papilla.
• The exciting field of tissue engineering will allow the clinician to
use minimally invasive procedures to reconstruct lost papillae.
Therapy to Correct Excessive Gingival
Display
• Excessive gingival display (i.e., gummy smile) is an aesthetic
concern for many patients. This appearance may be caused by a
skeletal problem called vertical maxillary excess, by dentoalveolar
extrusion, or by incomplete exposure of the anatomic crown,
often referred to as altered passive eruption. It can be associated
with a short upper lip or excessive lip translation. A combination
of causative factors can require more than one treatment option.
• In patients with excessive gingival display, the primary aesthetic
feature may also be excessive appearance of the teeth.
• If the cause of the gummy appearance is incomplete exposure of the
anatomic crown, the teeth will appear short and unattractive.
• This appearance is often noticed in adolescent patients during
orthodontic treatment.
• If there is a need for aesthetic crown lengthening before orthodontic
therapy, there will still be a need after orthodontic therapy, which
may be 5 years later. Although patients may complain about the
gummy exposure, the real aesthetic issue is the altered tooth form.
• Surgical crown lengthening addresses both concerns, but its focus
should be on the exposure of a properly proportioned tooth.
• Ideally, the width-to-length ratio of a maxillary central incisor
clinical crown should fall between 0.78 and 0.85. A central incisor
with a width of 8.5 mm should have a length between 10 and 11
mm.
• The length of the maxillary canine is equal to or slightly less than
the central incisor, and its gingival margin should be aligned with
the central incisor gingival margin.
• The gingival margin of the lateral incisor is usually about 1.0 mm
coronal to the margins of the adjacent teeth, although in patients
with a high lip line, it is usually more pleasing to have the lateral
incisor gingival margin equal to that of the central incisors and
canines.
Surgical Techniques
Osseous Surgery
Tissue Engineering

• Tissue engineering and the use of biologic mediators in periodontal

plastic surgery have become a reality as the result of research and
the demand for noninvasive surgical procedures by patients and
clinicians.
• Current periodontal plastic surgery is based on the use of the
palatal site for donor tissue (i.e., subepithelial connective tissue
graft [SECTG]), which entails a second surgical wound.
• Many patients are fearful of this donor wound and resist the
surgery needed to correct a mucogingival problem.
• For those who desire to avoid the palatal donor site, morbidity
associated with the SECTG and free gingival graft (FGG), tissue-
engineering methods provide an excellent alternative.
• Periodontal therapy has involved tissue engineering for decades,
beginning with GTR, which is a form of passive tissue engineering
that excluded certain cell types and created an engineered wound
left to heal with the appropriate cell types.
• The passive and active categories recognize the roles cells play in tissue
engineering. Passive engineering involves the following treatments and
materials:
1. Therapies based on GTR-based therapies; barrier membranes
2. Biologically based acellular dermal matrix (ADM)
• Active engineering involves the following treatments and materials:
1. Enamel matrix derivative (EMD)
2. Growth factors: recombinant human platelet-derived growth factor-BB
(rhPDGF-BB) plus beta-tricalcium phosphate (β-TCP) plus collagen wound
dressing
3. Cell therapy
• Autologous fibroblast: Isolagen
• Bilayered cell therapy (BLCT): Celltx
• In 2003, McGuire and Nunn published results of a single-center,
randomized, controlled clinical trial comparing a coronally
advanced flap using EMD with SECTG.
• The results showed no statistical difference in the percentage of
root coverage between the test group and controls.
• It was concluded that within the limitations of the single-center
trial, EMD with a coronally advanced flap was a valid alternative to
the subepithelial connective tissue.
• In 2006, McGuire and Scheyer published a case series using a growth factor–
mediated procedure, including rhPDGF, β-TCP, and a collagen wound dressing, to
obtain root coverage comparable to that of SECTG, which led to a randomized,
controlled clinical trial.
• The clinical trial used the growth factor–mediated procedure to obtain clinical
and histologic evidence of root coverage and regeneration compared with SECTG.
• These studies provided proof of principle that in four of four human histology
block sections, true periodontal regeneration (i.e., alveolar bone, periodontal
ligament, and new cementum) was possible with rhPDGF plus β-TCP plus a
collagen wound dressing.
• Histologic evidence of root coverage verifies that this tissue-engineering method
offers true periodontal regeneration, which is not expected with SECTG.
• Reconstruction of the open interproximal space remains one of the
greatest challenges in aesthetic periodontal therapy.
• In a landmark study by McGuire and Scheyer in 2007, autologous
fibroblasts were injected into the interdental papilla using a method to
atraumatically augment the deficient gingival papilla.
• Although this method has not been thoroughly validated, treatment
outcomes reduced open interproximal spaces and improved aesthetics in
the maxillary arch.
• No long-term evidence exists for tissue stability with this method, but
the pilot study showed promise for an innovative study design for a
tissue-engineering application in dentistry.
• For example, the technology allows for the concept of banking
autologous fibroblasts for future clinical use or research.
• In 2008, McGuire and Scheyer published a pilot study comparing a tissue-
engineered bilayered cell therapy (BLCT) (Apligraf, Organogenesis,
Canton, MA) to FGG with promising enough results to warrant a
multicenter, controlled clinical trial.
• From the pilot study, there is evidence of de novo formation of attached
and keratinized gingiva with the placement of a live cell therapy device
without donor site surgery. In this randomized, controlled clinical trial,
the test material was capable of generating up to 2.72 mm of
keratinized gingiva, and in more than 75% of the subjects, more than 2
mm of keratinized tissue was developed after a 6-month follow-up visit.
• This pilot study supports further research of the BLCT to produce de
novo keratinized gingiva without the use of a traditional autograft. More
data are being analyzed to allow then commercial use of this material.
• In 2005, McGuire and Nunn published a pilot study evaluating the
safety and efficacy of a living tissue-engineered human fibroblast–
derived dermal substitute (HFDDS) (Dermagraft, Advanced Tissue
Science, La Jolla, CA) compared with a gingival autograft.
• Although the autograft produced a larger band of keratinized
tissue, the test group represented the first attempt to use an off-
the-shelf tissue-engineered material capable of generating
attached and keratinized gingiva.
Criteria for Selection of Techniques
• Numerous techniques are used for solving the mucogingival
problems outlined in this chapter. Proper selection of a technique
must be based on the predictability of success, which is based on
specific criteria.
• The following criteria are used for selection of mucogingival
techniques:
1. Surgical site free of biofilm, 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
Surgical Site Free of Biofilm, Calculus, and
Inflammation

• Periodontal plastic surgical procedures should be undertaken in a

biofilm-free and inflammation-free environment to enable the
clinician to manage gingival tissue that is firm.
• Meticulous, precise incisions and flap reflection cannot be
achieved when tissue is inflamed and edematous.
• Thorough scaling and root planing and meticulous biofilm removal
by the patient must be accomplished before any surgical
procedure.
Adequate Blood Supply

• To obtain the maximal amount of blood supply to the donor tissue, gingival
augmentation apical to the area of recession provides a better blood supply
than coronal augmentation because the recipient site is entirely periosteal
tissue.
• Root coverage procedures involve a portion of the recipient site (i.e.,
denuded root surface) without blood supply. If aesthetics is not a factor,
gingival augmentation apical to the recession may be more predictable. A
pedicle-displaced flap has a better blood supply than a free graft, with the
base of the flap intact. If the anatomy is favorable, the pedicle flap or any of
its variants may be the best procedure for root coverage.
• The Langer subepithelial connective tissue graft (SECTG) procedure and the
pouch and tunnel techniques use a split flap with the connective tissue
sandwiched between the flaps. This flap design maximizes the blood supply
to the donor tissue. If large areas require root coverage, these sandwich-
type recipient sites provide the best flap design for blood supply.
Anatomy of the Recipient and Donor Sites
• The presence or absence of vestibular depth is an important anatomic
criterion at the recipient site for gingival augmentation. If gingival
augmentation is indicated apical to the area of recession, there must be
adequate vestibular depth apical to the recessed gingival margin to provide
space for a free or pedicle graft. If a vestibule is necessary, only a free graft
can accomplish this objective apical to the recession.
• Mucogingival techniques, such as free gingival grafts and free connective
tissue grafts, can be used to create vestibular depth and widen the zone of
attached gingiva. Other techniques require vestibular depth to exist before
the surgery, including pedicle grafts (i.e., lateral and coronal), the Langer
SECTG, and pouch and tunnel procedures.
• Availability of donor tissue is another anatomic factor that must be
considered. Pedicle displacement of tissue necessitates an adjacent donor site
that has gingival thickness and width. Palatal tissue thickness is also necessary
for the connective tissue donor autograft. Gingival thickness is required at the
recipient site for techniques using a split-thickness, sandwich-type flap or the
Stability of the Grafted Tissue to the
Recipient Site

• Good communication of the blood vessels from the grafted donor

tissue to the recipient site requires a stable environment. This
necessitates sutures that stabilize the donor tissue firmly against
the recipient site. The least amount of sutures and maximal
stability should be achieved.
Minimal Trauma to the Surgical Site

• As with all surgical procedures, periodontal plastic surgery is

based on the meticulous, delicate, and precise management of
oral tissues. Unnecessary tissue trauma caused by poor incisions,
flap perforations, tears, or traumatic and excessive placement of
sutures can lead to tissue necrosis. The proper selection of
instruments, needles, and sutures is mandatory to minimize tissue
trauma. Sharp contoured blades, smaller-diameter needles, and
resorbable monofilament sutures are important factors in
achieving atraumatic surgery.
Conclusions
• 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. A major complicating factor is
the avascular root surface, and many modifications to existing techniques
are used to overcome this. Diffusion of fluids is short term and of limited
benefit as tissue size increases. The formation of a circulation through
anastomosis and angiogenesis is crucial to the survival of these therapeutic
procedures.
• Formation of vascularity is based on growth molecules, such as vascular
endothelial growth factor (VEGF), and on cellular migration, proliferation,
and differentiation. As tissue-engineering techniques improve, the success
and predictability of mucogingival surgery should dramatically increase.
However, all advancements must have adequate circulation and blood
supply as their basis.
“ Your true success in life begins only when
you make the commitment to become
excellent at what you do.

Brian Tracy
”
Good Luck