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Periodontal Plastic & Esthetic Surgery: A
Procedures to Increase the Width of
Attached Gingiva
Chapter 63
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Three specific mucogingival Problem areas
(width of attached gingiva, depth of vestibule, aberrant
frenum)
Different techniques to increase the width of attached
gingiva
Depth of vestibule
Frenectomy & frenotomy
Criteria for technique selection
Lecture Outline
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Periodontal Plastic Surgery
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Historical Background:
Originally proposed by Miller in 1993
Utilized by the World Workshop in Clinical Periodontics
(1996) instead of mucogingival surgery
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Definition:
Surgical procedures of the mucogingival therapy that
are performed to correct or eliminate anatomic,
developmental, or traumatic deformities of the gingiva or
alveolar mucosa
Periodontal Plastic Surgery
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Objectives:
A- Problems associated with inadequate attached
gingiva
B- Problems associated with a shallow vestibule
C- Problems associated with an aberrant frenum
D- Esthetic surgical therapy
E- Tissue engineering
Periodontal Plastic Surgery
Periodontal Plastic Surgery
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Objectives:
A- To increase the width of attached gingiva in order to
1) Enhance plaque removal around the gingival margin
2) Improve esthetics.
3) Reduce inflammation around restored teeth
4) Gingival margin binds better around teeth & implants
with attached gingiva.
Periodontal Plastic Surgery
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Objectives:
B- To increase the vestibular depth for
1) Proper plaque control
2) Retention of removable prostheses
Periodontal Plastic Surgery
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Objectives:
C- To remove the frenum/muscle attachment in order to
1) Improve plaque control
2) Eliminate its pulling action on the gingival margin.
Widening the Attached gingiva
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Free or pedicle grafts placed either
a) apical to the gingival recession:
1- enhance the oral hygiene
b) coronal to the gingival recession
1- enhance the oral hygiene
2- correct the esthetic.
c) apical and coronal to the recession
1- for pre-prosthetic reasons
Grafting apical to Recession
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1) Free gingival autograft
2) Free connective tissue autograft
3) Apically positioned flap
Free Gingival Autograft
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Free Connective Tissue Autograft
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Free Connective Tissue Autograft
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Free Connective Tissue Autograft
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Apically Displaced Flap
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Techniques to Deepen Vestibule
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Free gingival or connective tissue autogenous graft, but it must be
placed over a nonmobile recipient site that is covered by
immobile periosteal tissue.
In case of a lack of periosteal connective tissue, the donor tissue
may be placed over bone.
Aberrant Frenum
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Frenum:
A fold of mucous membrane with enclosed muscle fibers, that
attaches the lips and cheeks to the alveolar mucosa, gingiva &
underlying periosteum.
It is a problem:
if the attachment is too close to the marginal gingiva.
Origin:
1- Genetic condition
2- Gingival recession reaching the frenum.
Aberrant Frenum
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Clinical effects:
1- Pulling of the gingival margin away from the tooth resulting to
plaque accumulation & improper brushing (most often in the
mandibular anterior areas)
2- Esthetic problem in a patient with a high lip line if the aberrant
frenumis located between the maxillary central incisors.
Common sites:
1- Facial surface between the maxillary & mandibular central
incisors
2- Canine & premolar areas
3- less often on the mandibular lingual surface
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Techniques to Remove the Frenum
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1) Frenectomy:
Definition: Complete removal of the frenum, including its attachment
to underlying bone.
Indication:
Correction of the abnormal diastema between the maxillary central
incisors.
2) Frenotomy
Definition: Relocation of the frenumin a more apical position.
Techniques to Remove the Frenum
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Frenectomy & frenotomy are most often accomplished as separate
surgical procedures but can be performed in conjunction with other
periodontal surgeries like a free gingival graft to deepen the
vestibule in the mandibular anterior area.
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Criteria for Technique Selection
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1- Surgical site free of inflammation
This allows for meticulous, precise incisions and proper flap reflection.
2- Adequate blood supply
Apical grafting provides better blood supply than coronal grafting, since the
recipient site is entirely periosteal tissue. Therefore, if esthetics is not a factor,
apical grafting may be more predictable.
3- Anatomy of recipient site
Apical grafting needs enough vestibular depth to provide space for the graft.
Free (gingival /connective tissue) grafts can be used to deepen the vestibule &
widen the attached gingiva.
Lateral/ coronal pedicle flaps and tunnel procedures require vestibular depth
to be present before the surgery.
Criteria for Technique Selection
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4- Anatomy of the donor site
Pedicle grafts necessitate the presence of adjacent donor sites with adequate
gingival thickness and width. Palatal tissue thickness is also necessary for the
connective tissue autograft.
5- Stability of the graft to the recipient site
A stable environment is necessary for good blood supply. It is achieved with
sutures to stabilize the graft firmly against the recipient site. The least amount of
sutures and maximum stability should be achieved.
6- Minimal trauma to the surgical site
Poor incisions, flap perforations, tears, or traumatic & excessive placement of
sutures cause unnecessary tissue trauma & can lead to tissue necrosis.
Use of sharp blades, smaller-diameter needles & resorbable monofilament
sutures are important in achieving atraumatic surgery.
Summary
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