 to define mucogingival problems.

 to list the treatment procedures available for

mucogingival problems.
 to illustrate the steps involved in lateral pedicle
flap, sub-epithelial connective tissue graft and
epithelial grafts.
 to discuss various soft tissue allografts and their
advantages over autogenous soft tissue grafts.
 to describe healing after muco-gingival surgery

Learning outcomes…..
 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. 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. Both the apical and
the coronal widening of attached gingiva enhance
oral hygiene procedures, but only the latter can
correct an esthetic problem.
 For preprosthetic purposes, the combination of
widening keratinized gingiva apical and coronal
to the recession would satisfy this objective.
 Widening of the keratinized attached gingiva
(apical or coronal to the area of recession) can
be accomplished by numerous techniques, such
as the free gingival autograft, free connective
tissue autograft, and lateral pedicle flap, which
can be used for either objective.
 The displaced pedicle flap technique, originally
described by Grupe and Warren in 1956.
 The laterally positioned flap can be used to cover
isolated, denuded root surfaces that have
adequate donor tissue laterally.
 The vestibular depth must also be present
 Prepare the recipient site. Epithelium is removed
around the denuded root surface. The exposed
connective tissue will be the recipient site for the
laterally displaced flap. The root surface will be
thoroughly scaled and root planed.

Lateral Pedical Flap Procedure

 Prepare the flap. The periodontium of the donor site should
have a satisfactory width of attached gingiva and minimal
loss of bone, without dehiscence or fenestration.
 A full-thickness or partial-thickness flap may be used, but
the latter is preferable because it offers the advantage of
rapid healing at the donor site and reduces the risk of loss
of facial bone height.
 With a #15 blade, make a vertical incision from the
gingival margin to outline a flap adjacent to the recipient
site. Incise to the periosteum, and extend the incision into
the oral mucosa to the level of the base of the recipient
site.

Lateral Pedicle graft procedure

 Transfer the flap. Slide the flap laterally onto the adjacent
root, making sure that it lies flat and firm without excess
tension on the base. Fix the flap to the adjacent gingiva
and alveolar mucosa with interrupted sutures.
 A suspensory suture may be made around the involved
tooth to prevent the flap from slipping apically.
 Step 4: Protect the flap and donor site. Cover the operative
field with aluminum foil and a soft periodontal dressing,
extending it interdentally and onto the lingual surface to
secure it.
 Remove the dressing and sutures after 1 week.

Lateral pedical graft procedure

 Prepare the recipient site. The purpose of
this step is to prepare a firm connective
tissue bed to receive the graft.
 Outline the recipient site with two vertical
incisions from the incised gingival margin
into the alveolar mucosa. Extend the
incisions to approximately twice the
desired width of the attached gingiva.

Free gingival graft-The Classic

Technique.
 The #15 blade is used to incise along the
gingival margin to separate a flap consisting of
epithelium and underlying connective tissue
without disturbing the periosteum.
 An aluminum foil template of the recipient site
can be made to be used as a pattern for the
graft.
 Obtain the graft from the donor site. The classic
or conventional free gingival graft technique
consists of transferring a piece of keratinized
gingiva approximately the size of the recipient
site.
Free gingival graft-The Classic
Technique.
 The graft should consist of epithelium and a thin
layer of underlying connective tissue. Place the
template over the donor site, and make a
shallow incision around it with a #15 blade.
Insert the blade to the desired thickness at one
edge of the graft.
 Elevate the edge and hold it with tissue forceps.
Continue to separate the graft with the blade,
lifting it gently a separation progresses to
provide visibility.
 Placing sutures at the margins of the graft helps
control it during separation and transfer and
simplifies placement and suturing to the recipient
site.
 Transfer and immobilize the graft. Position the graft
and adapt it firmly to the recipient site.
 A space between the graft and the underlying tissue
(dead space) impairs vascularization and jeopardizes
the graft. Suture the graft at the lateral borders and
to the periosteum to secure it in position.
 The graft must be immobilized. Any movement
interferes with healing. Avoid excessive tension,
which can distort the graft from the underlying
surface.
 Cover the donor site with a periodontal pack for 1
week, and repeat if necessary.

Free gingival graft-The Classic

Technique.
 The purpose of the coronally displaced flap procedure is to
create a split-thickness flap in the area apical to the
denuded root and position it coronally to cover the root.
 With two vertical incisions, delineate the flap. These
incisions should go beyond the mucogingival junction.
 Make an internal bevel incision from the gingival margin to
the bottom of the pocket to eliminate the diseased pocket
wall. Elevate a mucoperiosteal flap using careful sharp
dissection.
 Return the flap and suture it at a level coronal to the
pretreatment position. Cover the area with a periodontal
dressing, which is removed along with the sutures after 1
week. The periodontal dressing is replaced for an additional
week if it is necessary.
 This technique was described by Langer and
Langer in 1985.
 Step 1. Raise a partial-thickness flap with a
horizontal incision 2 mm away from the tip of the
papilla and two vertical incisions 1 to 2 mm away
from the gingival margin of the adjoining teeth.
These incisions should extend at least one tooth
wider mesiodistally than the area of gingiva
recession.
 Extend the flap to the mucobuccal fold.
 Thoroughly plane the root, reducing its
convexity.
 Obtain a connective tissue graft from the palate
by means of a horizontal incision 5 to 6 mm from
the gingival margin of molars and premolars. The
palatal wound is sutured in a primary closure.
 Place the connective tissue on the denuded
root(s).
 Suture it with resorbable sutures to the
periosteum.
 Coronally Advance the pedicle flap over the graft.