PERIODONTAL

PLASTIC AND
AESTHETIC
SURGERY
Assoc. Prof.
SİBEL KAYAALTI YÜKSEK
PERIODONTAL • The term Mucogingival Surgery was
PLASTIC AND defined by Friedman.
AESTHETIC
SURGERY • It includes surgical procedures applied
to correct the relationship between
gingiva and oral mucosa. These
surgical procedures are applied
specifically in 3 regions:
1) attached gingiva
2) shallow vestibule
3) frenulum affecting free gingiva
PERIODONTAL • At the 1996 World Periodontology
PLASTIC AND Workshop
AESTHETIC (World Workshop in Clinical Periodontics)
SURGERY the term mucogingival surgery has been
replaced by the term “Periodontal Plastic
Surgery”.

• The term Periodontal Plastic Surgery

was first proposed by Miller in 1993.
 Periodontal plastic surgery is a surgical
procedure applied to correct or eliminate
anatomical, developmental or traumatic
PERIODONTAL deformities in the gingival and alveolar
PLASTIC mucosa.
SURGERY
Mucogingival therapy; is a broader term,
including non-surgical procedures (such as
papillary reconstruction with orthodontic or
restorative treatment).

Periodontal plastic surgery includes only the

surgical procedures of mucogingival
treatment.
 The scope of Periodontal Plastic Surgery
has also been expanded.
PERIODONTAL
PLASTIC AND • Periodontal-prosthetic corrections
AESTHETIC • Crown lengthening
SURGERY • Ridge augmentation
• Aesthetic surgery corrections
• Coverage of the denuded root surface
• Papillary reconstruction
• Esthetic surgical correction around
implants
• Exposure of unerupted teeth for
orthodontic treatment
PERIODONTAL
PLASTIC In periodontal plastic surgery, 5 topics are emphasized;

SURGERY 1) Problems with attached gingiva

2) Problems associated with shallow vestibule depth

3) Problems with frenulum

4) Perioodntal plastic surgery

5) Tissue engineering
 Attached Gingiva: It is the distance from the base of
the gingival sulcus (end of the free gingiva) to the

Problems mucogingival junction.

Associated The greater width of the attached gingiva facilitates

oral hygiene. The minimum attached gingival width

with required for this purpose could not be determined.

It is known that hygiene is provided even if there is
no attached gingiva in individuals who perform

Attached atraumatic and careful oral care.

Gingiva In individuals who do not provide optimal oral

hygiene, the width of the attached gingiva and the
depth of the vestibule gain importance. Adequate
vestibule depth ensures comfortable placement of
the brush and no brushing of the mucosa.
It has been found in various studies that plaque accumulation is
less in regions with more attached gingiva width than in regions
where there is little or no attached gingival width.

The ultimate goal of mucogingival surgical procedures is the

creation or widening of attached gingiva around teeth and
implants.
Widening the attached gingiva accomplishes
the following four objectives:

1.Enhances plaque removal around the

gingival margin.

2.Improves esthetics.

3.Reduces inflammation around restored

teeth.

4.Gingival margin binds better around teeth

and implants with attached gingiva.
 Another objective of periodontal plastic surgery is
the creation of vestibular depth when it is lacking.
Oral hygiene practices become difficult with
minimal vestibular depth.
Problems
Associated With the recession of the gingiva, the depth of the
vestibule decreases.

with
Shallow The distance from the gingival margin to the
bottom of the vestibule forms the vestibule depth.

Vestibule
The sulcular brushing technique involves placing
the toothbrush at the gingival margin, which may
not be possible with reduced vestibule depth.
In case of minimum attached gingiva + adequate
vestibule depth; Surgery may not be required if
atraumatic and appropriate brushing can be performed.

Minimum attached gingival with no vestibule depth;

mucogingival correction may be necessary.

Adequate vestibule depth is also required for the

placement of removable partial dentures.
Problems Associated
with Aberrant Frenum
Periodontal plastic surgery also includes muscle attachments and frenulum
corrections.

If adequate keratinized, attached gingiva is present coronal to the frenum, it may

not be necessary to remove the frenum.

The frenulum extending to the gingival margin may inhibit removal of dental
biofilm and tension on the frenulum may tend to open the sulcus, in which case
surgical removal is indicated.
 Esthetic Surgical
Therapy
Gingival recession in the facial region creates an aesthetic problem by
disrupting the gingival symmetry.

The presence of interdental papilla is aesthetically important, in the presence

of papillary loss "black hole" are formed. Papillary reconstruction is one of the
most difficult procedures.

Moreover; Excessive exposure of the gums during the «gummy smile» smile is
also an important aesthetic problem. Crown lengthening can be applied.
Tissue Engineering
In order to eliminate the donor site problem,
tissue engineering materials that can be used for
this purpose are being studied.

In recent years, the aim in periodontal plastic

surgery is; using minimally invasive methods.
Abnormal frenulum
a.Gingival recession due to gingival inflammation
b. Gingival recessions
FACTORS AFFECTING THE
RESULT OF THE SURGERY

v Irregularity in the Tooth Sequence:

The position of the gingival margin, the width of the attached gingiva,
the height and thickness of the alveolar bone are affected by the
alignment of the teeth.

v Mucogingival Junction
 Irregularity in the Tooth Sequence:

• Abnormal tooth alignment is a major cause of gingival problems, may

require surgical correction, and is also an important factor in
determining the outcome of treatment.

• In overturned or labially rotated teeth, the labial alveolar bone is

positioned thinner and more apically than the adjacent teeth,
resulting in recession of the gingiva and exposing the root surface.

• Root surface covered with thin bone is a disadvantage for plastic

surgery. Even a half-thickness flap carries a risk of bone resorption.
Techniques to Increase
Attached Gingiva
• Gingival augmentation apical to the area of recession.
A graft, either 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 (root

coverage).
A graft (either pedicle or free) is placed covering the denuded
root surface.
 Gingival augmentation apical
to the area of recession

v Free gingival autograft

v Free connective tissue autograft
v Apical positioned flap
Gingival augmentation apical to the area of
recession
Free gingival autograft;

• Free gingival grafts are used to increase the

amount of attached gingiva.

• It was described by Björn in 1963 and has been

studied in detail until today.
 a. Before the procedure
b. Prepared recipient site
c. Donor palate
Free gingival graft
d. FGG
e. FGG placed in the recipient site
(FGG)
f. 6 months after the procedure
 • 1 stage; Preparing the receiving area:
Free gingival • The purpose of this stage is to prepare the
connective tissue bed where the graft will

autograft be placed.

classical • In the recipient area, a half-thickness

horizontal incision is made along the
mucogingival junction with a #15 scalpel.
technique: The horizontal incision is extended
mesially and distally from the same
border. The periosteum should cover the
bone.

• A thin bed of connective tissue is prepared

by removing elastic fibers and muscle
fibers.
 • 2nd stage; Receiving the graft:
Free gingival • Half thickness graft is used in the classical technique.

autograft
It contains epithelium and thin connective tissue.

• An incision is made with a scalpel no. 15. The graft is

classical
separated from the underlying connective tissue at
the desired thickness.

technique:
• The graft is held from the raised edge with tissue
forceps and separated from the tissue with a half-
thickness incision.

• A 1-1.5 mm thick epithelial and thin connective

tissue graft is prepared.

• After the graft is obtained, periodontal paste can be

placed on the donor area.
• It is important that the graft should have
appropriate thickness for its viability. It should
be thin enough to allow fluid diffusion in the
area where it is placed. If the graft is too thin,
necrosis may occur and the recipient site may
suffer this necrosis. If it is too thick, it will
jeopardize the nutrition and new circulation of
the graft. There is also the possibility of injury
to the major palatal arteries with thick grafts.
A deep wound can be created in the area
taken.

• The ideal thickness of the graft should be

between 1-1.5mm.

• After the graft is taken, the rough tissues and

fat tissues are removed with a scalpel or
scissors and the thickness of the graft is
adjusted.
3rd stage; Graft immobilization and transfer:

• Bleeding control is provided in the recipient

area. Clot residues are removed. The thick
clot prevents the vascularization of the graft.

• The positioning and adaptation of the graft

must be firmly ensured in the recipient area.
There should be no space in between graft
and recipient area. The lateral edges of the
graft are sutured to the periosteum to secure
its position.

• The graft is positioned with pressure and

fixed with a suture. The graft should be
immobilized. Any movement interferes with
healing. Excessive tension should be avoided
as the underlying tissues may distort the
graft.
Free gingival After approximately two days, the
epithelial part is discarded and the
autograft free gingival graft (FGG) becomes
classical similar to a necrotic appearance.

technique: The nutrition of the graft is primarily

Healing of the from the clot-plasma coming from
the periosteum.
graft;
After one week, the graft healing is
largely completed and is covered
with a thin epithelial layer. Complete
keratinization occurs after about 4
weeks.
There are also variations of this
process:
1. The accordion technique,
2. The Strip technique,
3. Combination of Epithelial-
Connective Tissue strip technique

• In order to prevent the donor site

problem, Acellular Dermal Matrix
(Alloderm) can also be used for the
same purpose as the free gingival
graft. It is obtained from human
skin tissue.
 Gingival • better nutrition,
augmentation at • primary closure of the grafted area:
the Apical Gingival (donor area can be sutured back in
primary closure)
Recession:
• high aesthetic success as a result of
Free connective good compatibility of the graft with
tissue autograft; the surrounding tissues in the
recipient area
• It is frequently used because of the
advantages of being applied in large
area
Connective tissue graft to increase the width of the attached gingiva
 The 3rd method (Apically
Displaced Flap) that can be applied
to increase the keratinized tissue
in the apical to recession.
Gingival
Augmentation
Apical to It can be applied as half thickness
Recession or full thickness.
Apically
Displaced Flap
It is applied to increase the
thickness of the keratinized
gingiva.
Gingival augmentation
coronal to the recession
(root coverage)

Understanding the
different stages and
conditions of gingival
recession is necessary for
predictable root coverage
 Gingival Recession

• Exposure of the root surface by apical

displacement of the gingival margin from the
enamel-cementum junction.

• 1996, “the location of marginal tissue apical

to the cemento-enamel junction”
 Gingival
recession:
Localized gingival
recession:

It affects a single tooth

or a group of teeth.

Generalized gingival
recession:

It affects all teeth.

 Etiology of Gingival Recessions
• Less alveolar bone thickness
• Presence of dehiscence and fenestration in alveolar
Anatomical Factors: bone
• Abnormal tooth position within the dental arch
• Morphological changes in tooth roots
• High frenulum and muscle attachments

Physical Factors : • Dehiscence formation in labial and lingual alveolar

bone with orthodontic tooth movement

• Improper brushing and flossing

• Inflammatory periodontal disease due to dental
plaque
• Direct trauma associated with malocclusion
Pathological Factors : • Subgingival overflow fillings and faulty prosthetic
restorations that cause supracrestal connective
tissue attachment violation
• Chemical trauma
• Harmful chronic habits such as nail, finger, toothpick
and pencil sucking
• Perioral or intraoral piercing use
 Sullivan-Atkins, 1968

• Shallow-Narrow
• Shallow-Wide
• Deep-Narrow
• Deep-Wide
Classification of
Gingival Mlinek et al., 1973

Recessions • Shallow-Narrow: Gingival recession < 3mm

(Horizontal-vertical direction)
• Deep-Wide: Gingival recession > 3mm
(Horizontal-vertical direction)
Classification of
Gingival
Recessions

Miller
classification,
1985

Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics

Rest Dent 1985; 5: 8-13.
 Gingival
recession:
• Miller Classification:

• Class I: Gingival recession does not extend

to the mucogingival junction. There is no
bone or soft tissue loss in the interdental
area. This type of recession can be wide or
narrow.
 Gingival
recession:
Miller Classification:

Class II: Gingival recession has reached

or passed the mucogingival junction.
There is no bone or soft tissue loss in the
interdental region. These types of
recessions can be wide or narrow.
 Gingival
recession:
Miller Classification:

Class III: Gingival recession has

extended or passed the mucogingival
junction. There is bone and soft
tissue loss in the interdental area or
malposition of the tooth.
 Gingival
recession:
Miller Classification:

Class IV: Gingival recession has reached

or passed the mucogingival junction.
There is severe bone and soft tissue loss
in the interdental region or severe
malposition of the tooth.
 • RT1 (recession type) Gingival recession: Recessions
without loss of interproximal attachment

Classification of • RT2 Gingival recession: Recessions with loss of

interproximal attachment
Gingival Interproximal attachment loss: equal to or less than
the buccal attachment loss level
Recessions
• RT3 Gingival recession: Recessions with loss of
Cairo interproximal attachment
Interproximal attachment loss: greater than the
classification, buccal attachment loss level

2011
• Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U.
The interproximal clinical attach- ment level to classify
gingival recessions and predict root coverage
outcomes: an explo- rative and reliability study. J Clin
Periodontol 2011;38:661-6.
Atraumatic brushing technique
Quitting smoking
Recommendations for quitting traumatic habits
Orthodontic treatment plan (if there is a possibility of dehiscence, reviewing the soft tissue
in the area
and grafting before inappropriate orthodontic treatment)
Partial denture design and restorations (good support of prosthetics, supragingival restorations
much as possible, regular checking)
Treatment of periodontal disease
 Indications for Root Coverage
Treatment with Surgical
Techniques

• Aesthetic complaints

• Hypersensitivity
complaints

• Keratinized tissue
augmentation

• Root caries and abrasions

• Incompatibility at the
gingival margin
• The surgical treatment of
gingival recessions is
performed with different
perionatal plastic surgery.
Miller gingival
recession
classification
 Partial root
the prognosis of
coverage can be
classes I and II: are
achieved in Class
good to excellent,
III.

Class IV has a very

poor prognosis.
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
Coronally positioned flap; includes semilunar
pedicle (Tarnow)

4. Subepithelial connective tissue graft

(Langer)
5. Guided tissue regeneration (GTR)
6. Pouch and tunnel technique