Dr.

Diana Mostafa Abo El Ola

 Periodontal plastic surgery
Is
the surgical procedures performed to correct or
eliminate anatomic, developmental, or traumatic
deformities of the gingiva or alveolar mucosa.
 Includes
• 1- Periodontal-prosthetic correction
• 2- Crown lengthening
Crown lengthening by flap
• 3- Ridge augmentation
• 4- Esthetic surgical correction
• 5-Coverage of denuded root surface
• 6-Reconstruction of papillae Surgical exposure for canine
• 7- Esthetic surgical correction around implant
• 8- Surgical exposure of unerupted teeth for orthodontics

Crown lengthening by gingivectomy

(gummy smile treatment )
Coverage of denuded root
 1-Treat problems associated with mucogingival conditions.

Attached Shallow Aberrant

gingiva vestibule frenum

2-Improve esthetics by esthetic surgery.

3-Tissue engineering (GTR , ADM .etc).

Narrow zone of attached gingiva Shallow vestibule Aberrant frenum

Objectives:
• Enhances plaque removal
• Improves esthetics
• Reduces inflammation around restored teeth
• Allows gingival margin to bind better around teeth and
implants with attached gingiva.

Before & after

Gingival augmentation apical
to the area of recession
Graft is placed on recipient bed
apical to recessed GM
(No coverage of root surface)
1- Free gingival autograft
2- Free connective tissue autograft
3- Apically positioned flap
Gingival augmentation
coronal to the recession
Graft placed to cover the
denuded root surface .
(root coverage)
1- FGG & Free CT autograft
2- Pedicle autografts
Laterally positioned pedicle F.
Coronally positioned flap
include Semilunar pedicle
3-Subepithelial connective tissue graft
4-GTR
5-Pouch and tunnel technique , Vista,
pinhole technique.
Gingival augmentation apical to recession

1- Free gingival autograft

2- Free connective tissue autograft
3- Apically positioned flap
 1. Free Gingival Autografts
Step 1: Prepare the recipient site
Prepare a firm connective tissue bed to receive the graft. The
recipient site can be prepared by incising at the existing
mucogingival junction with a ≠15 blade to the desired depth.

Step 2: Obtaining graft from the donor site: transferring a piece

of keratinized gingiva approximately the size of the recipient site
Palate is (a partial thickness graft usual site from which donor
tissue is removed the is used). The ideal thickness is 1 -1.5mm.

Step 3: Transfer and immobilize the graft: position the graft and
adapt it firmly to the recipient site.

Step4: Protect the donor site: with a periodontal pack for a week
Incision is done by # 15 blade at MGJ Blending incision on both sides(intacted periosteum)

Donor site: palatal strip(no suture) Placement of free gingival autograft

K.epitheluim+thin layer of underlying CT(1-1.5mm)
Use of free gingival graft from the palate to increase the
attached gingiva.
 Healing of the autograft
• Success of graft depends on survival of the CT .

• The 1st day graft becomes edematous & undergo

degeneration & necrosis in some areas.
• Revascularization of the graft starts after 2-3 days.
• Recipient bed Capillaries proliferate to graft and
form new capillaries
• Thin epithelial layer formed on 4th day

If too thin…………necrosis of graft & exposure of recipient site.

If too thick…………deeper wound in palate that may injury major palatal
arteries.
2-Free Connective tissue autograft

preoperative Divergent vertical incision, Split flap

Obtain CT graft from palate then suturing CT autograft

Transfer graft to recipient site +suturing postoperative

Advantages
1- Very predictable .
2- Smaller donor site (than FGG).
3- CT will carry the genetic message for overlaying epithelium to
become keratinized.
4- Donor site will heal by 1st intension.
5-Better esthetics and color (than FGG).
Disadvantages
1- Need 2 surgical sites.
2- Technique sensitivity.

Contraindications
1- All exposed dentin (no cementum).
2- Abfraction.
3- Tissue at or near CEJ.
4- Gingival hyperplasia.
 3-Apically positioned flap
• Adequate vestibule must be present to allow apical
displacement of the flap.

It Increases width of Keratinized gingiva

but not
increasing vestibule depth.
• An internal bevel incision is done< 1mm from crest of gingiva &
directed to crest of bone.
• Crevicular incisions and elevation of flap are done.
• Vertical incision is done extending beyond the mucogingival
junction.
• Full thickness flap is elevated by elevator.
• Split thickness flap is elevated using sharp dissection with blade.
• SRP and debridement if required.
• Place the flap apically and sling suture is done in case of full
thickness while direct loops is done in the partial thickness flap.
• A dry foil is placed over the flap before covering it with pack
The edge of the flap may be located in
3 positions in relation to the bone
Slightly coronal to the crest of the bone
• Preserve the attachment of supracrestal fibers.
• Give thick gingival margins.

At the level of the crest

• Satisfactory gingival contour .

2mm short of the crest

• Produce most desirable , firm tapered gingival margin.
 Modified apically repositioned flap

A horizontal beveled incision is done by blade 0.5mm coronal to MGJ

into attached gingiva.

Internal bevel incision Horizontal incision Sutured apically postoperative

 Gingival Augmentation Coronal to
Recession (Root Coverage)
• 1- FGG & Free CT autograft
• 2- Pedicle autografts
Laterally positioned flap- Double positioned flap
Coronally positioned flap includes Semilunar pedicle
• 3-Subepithelial connective tissue graft
• 4-GTR
• 5-Pouch and tunnel technique
• 6- Vista technique
• 7- Pin hole technique
• 8-Coronally positioned Flap
Marginal Tissue
Recession
Etiology

 Tooth brushing
trauma.
 Periodontal diseases
 Tooth malposition.
 Bone dehiscence.
 High muscle attachment and frenal pull.
 Orthodontic tooth movement through a thin buccal
osseous plate.
 Diagnosis & prognosis
• Class I & II : good-excellent

• Class III : Partial coverage

• Class V : Poor prognosis

1- FGG & 2- CTG
Which 1 is more esthetic??
FGG(more whitish in color)

CT autograft
More esthetic
2- Pedicle autografts
It is a soft tissue graft that is not completely detached from one site and
transferred to another.
According to direction of flap migration
Rotational flap
–Flap rotated or displaced laterally
Laterally positioned flap
Double papillae flap
Trans positional flap

Advanced flap
-Flap placed with out rotation or lateral migration
Coronally positioned flap
Semilunar flap
 Advantages
• One surgical site (no donor tissue) .
• It offers the best blood supply to the donor tissue because it
maintains a connection between the donor tissue and the
origin of the graft .
• Postoperative color is in harmony with surrounding tissue .
Lateral (horizontal )positioned flap

Donor site: adequate Slide flap laterally to adj. tooth without any tension postoperative
vestibule & AG
 Remember
The periodontium of the donor site should have
satisfactory width of attached gingiva & minimal
loss of bone without dehiscence or fenestration.

A partial thickness flap is preferable because it

offers the advantage of rapid healing at the donor
site and reduces risk of loss of facial bone height.
 Coronally positioned flap
The purpose →is to create a split thickness flap in the area apical to the denuded root
and position it coronally to cover the root.

Results are unfavorable because of insufficient keratinized gingiva apical the recession.
It needs keratinized gingiva ≥ 3mm.

Split thickness flap

Preoperative 2 diverging vertical incisions beyond MGJ Coronallly sutured

Split technique
Return flap coronal to the postion
2 diverging vertical incisions beyond MGJ
 Semilunar pedicle

Semilunar incision following the curvature of receded gingival margin

SRP should be done It may need to reach alveolar mucosa if attached gingiva is narrow.

Split thickness dissection coronally from

Flaps collapse covering recession
incision+ connect it to an intrasulsular
incision.
Pre-operative
Coronally advanced flap

Apical semilunar incision Post-operative

Intrasulular incision

Adv. Of coronally advanced flap:

• Simple and can be done for more than one tooth.
• One surgical site.
Indications:
• 2-3 mm recession.
• Thick gingival biotype.
• Maxillary teeth, y???because of the gravity direction.
3- Subepithelial connective tissue graft
• Indicated for larger & multiple defects.
• Take a CT from palate flap (donor site). Donor site
heals with 1ry intention + more esthetic results.
• The graft is sandwiched between the split flap.
SRP & Root conditioning should be done

Vertical incisions extend beyond MGJ(split thickness)

CT graft cover denuded root

Flap sutured over the graft Postoperative

Alternative donor site
• Acellular dermal matrix is a prepared biocompatible graft
that acts as a biologic regenerative matrix or scaffold for
the ingrowth of undifferentiated mesenchymal and
endothelial cells.

• Studies reported that → it is clinically effective and highly

predictable and compares favorably with subepithelial
connective tissue graft.

• Ability to cover an unlimited number of sites without the

need for a second surgical site → significant advantage.
4-Guided tissue regeneration(GTR)

Using resorbable membrane

-GTR is used to reconstruction of periodontium apparatus

along with coverage of denuded root.
-FGG & Subepithelial CT graft are much better.
5-Pouch & tunnel technique
(coronally advanced tunnel tech)
Advantages
• To decrease incisions & reflection.
• To provide good blood supply.
• Allow intimate contact of donor tissue to the recipient site (stability).
• Excellent esthetics.
• Thickening of gingiva.
Disadvantage
• Requires 2 surgical sites (if using autograft).
• Technique sensitive.
 Steps
• Vertical and Intrasulcular incision.
• Dissect the connective tissues beyond MGJ &
papilla are kept intact.
• Mattress suture placed at end of graft to guide
graft through sulcus.
• No dressing , only daily CHX+ antibiotics.

Intact papillae
6-Vista technique
(Vestibular Incision Subperiosteal Tunnel Access)
7- Pin hole technique
 Factors that affect Plastic surgery
outcome
1- Irregularities of teeth
-It affects location of gingival margin, width & alveolar bone
height and thickness.
-Malposed tooth with thin plate of bone→ results root
exposure.
2- MGJ
Anterior……3mm apical to radicular bone
5mm interdentally
In periodontal disease, bone margin may locate at or beyond
the MGJ.
Problems Associated with Shallow Vestibule:

 Gingival Recession reduces the vestibular

depth.
 Adequate vestibular depth is necessary for
proper brushing (OH) & retention of prostheses. Inadequate vestibule

It can be done by free autogenous autograft tech.

Using autograft to increase

depth of vestibule

Vestibule deepening surgery

 Ventriculoplasty techniques
1-Mucosal advancement vestibuloplasty
a)Closed submucosal vestibuloplasty
b)Open submucosal vestibuloplasty

2-Secondary epithelization(re-epithelialization vestibuloplasty)

a)Kazanjian’s technique
b)Clark’s technique

3-Grafting vestibuloplasty
 1-Mucosal advancement vestibuloplasty
Closed submucosal vestibuloplasty
• Vertical incision extends from MGJ to labial mucosa, then deepened to reach
periosteum.
• Blunt dissection and tunnels are done.
• A wedge shape strip of connective tissue remains between submucosal tunnel and
subperiosteal tunnel. Then, this wedged shaped tissue is excised.
• Stent is placed to retain the mucosa in the position. Then, removed after 1 week.

Open Submucosal Vestibuloplasty

• A horizontal incision through mucosa at the MGJ is done.
• Mucosa is dissected from submucosa towards the lip.
• Sutures are placed to fix the periosteum deep in the vestibule.
• The free margins of the flap are returned to their original position and
sutured.
 2- re-epithelialization vestibuloplasty
Kazanjian’s Technique
• Incision is made in labial mucosa.
• The labial and vestibular mucosa is reflected .
• Vestibule is deepened to the desired depth by supraperiosteal stripping.
• Mucosal flap is turned down from its attachment on alveolar ridge and placed
against periosteum. Then, sutured.
• The labial tissues is healed by secondary epithelization.
• A stent is placed for 1 week to maintain depth of the vestibule.

Lipswithch vestibuloplasty
• Labial incision is made and mucosal flap is raised from labial surface.
• Supraperiosteal dissection is done,Periosteum is incised on the crest of alveolar
ridge and sutured to the denuded labial submucosal surface.
• Mucosal flap is sutured over the denuded bone to inferior attachment of
periosteum.
• This is called transpositional flap because labial & periosteal flaps are
interchanged to line the opposing surface.
Clark’s technique
• Horizontal incision is done on alveolar ridge just buccal to crest of the
ridge .
• A supraperiosteal dissection is done, the lip mucosa is undermined
until the vermillion border.
• The free margin of the mucosal flap is sutured to depth of newly
created vestibule.
• The osseous side left with raw periosteal surface to granulate and
epithelialize secondarily.
• This technique has high liability of relapse as the lip musculature tot
alveolar bone shift towards the alveolar crest, obliterating the sulcus.
 3- Grafting vestibuloplasty

Clarks vestioplasty can be done followed by covering the raw

periosteal surface by soft tissue graft .
High frenum attachments
 Problems Associated with Aberrant
Frenum:
When the frenum invades on the GM

1-Interferes with plaque removal.

2-Its tension → open the gingival sulcus & pull GM away from tooth
→Cause esthetic problem

Rx: Surgical removal of the frenum(frenectomy/frenotomy).

Frenectomy → is the complete removal of the frenum,
including its attachment to the underlying bone
(required in the correction of abnormal diastema
between the maxillary central incisors).

Frenotomy→ is the relocation of frenum, usually in a

more apical position.
Superior & inferior margins are grasped by Excision of frenum from posterior surface of L.
curved mosquito hemostats hemostat until U. hemostat

Remove the hyperplastic tissues Undermining the mucosa from underlying tissues

Suturing in the middle of wound to facilitate

subsequent suturing
 Esthetic Surgical Therapy

-Root coverage
-Regeneration of lost or reduced papillae ,Black triangle
(black hole)
-Gummy smile (excessive gingival display)

Rx: Not predictable

 1- Root coverage surgery
• 1- FGG & Free CT autograft
• 2- Pedicle autografts
Laterally positioned and double positioned flap
Coronally positioned and Semilunar pedicle
• 3-Subepithelial connective tissue graft
• 4-GTR
• 5-Pouch and tunnel technique
• 6-Coronally positioned Flap
 2-Reconstruction of papilla

preoperative: loss of ID papillae + class IV CT graft +bone from tuberosity Coronally positioned flap
 3-Correction of gummy smile
Causes of gummy smile
1. -Vertical maxillary excess…(orthognathic
treatment)
2. -Dentoalveolar extrusion…(ortho. Rx)
3. -Incomplete exposure of the anatomic
crown “altered passive
eruption”…..(crown lengthening
surgery)
4. -Short upper lip or excessive lip
translation….(Botox or filler )
Crown Lengthening

Rx: Gingivectomy
Or
Osseous surgery
Crown lengthening with osseous reduction
• 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.

• Ex.Alloderm , biological mediators.

• Alloderm is sutured in a pouch with coronally
displaced flap
Use of enamel matrix derivates with
coronally displaced flap to treat
recession
3 mm recession was treated by human platelet derived
growth factor +beta tricalcium phosphate + collagen
wound dressing with coronally displaced flap (GTR).
 Criteria for selection of technique
1- Surgical site : free from plaque/calculus & no inflammation(should be firm).
2-Adequate blood supply
• Apical Gingival augmentation > coronal Gingival augmentation
• Pedicle graft(the best) >free autograft.
3- Anatomy of recipitent and donor site
• FGG & CTG →create vestibular depth +widening AG (Other techniques need
adequate vestibule).
• Donor site should be thick gingival biotype.
4- Stability of graft
5- Minimal trauma
• Poor incision, perforation, tearing or excessive suture→→cause tissue necrosis.
• Proper instruments selection+ Sharp blades+ smaller diameter needles+
resorbable monofilament sutures are needed.
This the meaning of Plastic Surgery