Characteristics of the

„healthy” attached
gingiva
• Colour
• Contour of the papillae
• Contour of the gingival
margin
• Outline translucency
• Texture
• Width of the gingiva
propria
• Depth of the vestibulum
BIOTYPE
 Periodontal biotypes

Narrow, thin, scalloped Thick, plain

Susceptible to recession Susceptible to cicatrization

Ohlson M, Lindhe J.
Periodontal characteristics in individuals with varying forms of the upper central incisors.
J Clin Periodontol 1991;18:78-82
Parodontális korrekciós

műtéti technikák
THE TYPES AND FORMS OF GINGIVAL RECESSION
ÍNYRECESSIO TÍPUSAI
6
ALVEOLAR BONE
Etiology of gingival recession
 Baseline measurements
Individual biotype has to be recorded first
• Gingival recession’s Depth - GRD
• Gingival recession’s Width - GRW
• Keratinized Gingival width - KG
• Papilla-Contactpoint’s distance - PC
• Probing depth - PD
KG
• Plaque index- PI
• Gingival index -GI
.
GRD . .
GRW PD

PC
 Classification

– Miller P.D. A classification of marginal tissue

recession Int. J. Periodontics Dent. 1985;5(2):8-13
 I. III.

II. IV.

MILLER’S CLASSIFICATION
Class I The recession does not affect the interdental papilla and
does not extend to the mucogingival junction .
Class II The recession does not affect the interdental papilla but
extends to the mucogingival junction
Class III The recession affects the interdental papilla
Class IV The recession seriously affects the interdental papilla.
 Miller classification of gingival recessions

Class 1 : Marginal tissue recession that 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 (group 1 and 2
Sullivan and Atkins classification).
Prognosis: good to excellent
 Miller classification of gingival recessions
Class 2: Marginal tissue recession that extends to or
beyond the mucogingival junction. There is no loss of bone
or soft tissue in the interdental area. This type of recession
can be subclassified into wide and narrow (corresponding to
group 3 and 4 Sullivan and Atkins classification).
Prognosis: good to excellent
 Miller classification of gingival recessions

Class 3: Marginal tissue recession that extends to or

beyond the mucogingival junction, in addition, there is bone
and/or soft tissue loss interdentally or malposition of the
tooth.
Prognosis: only partial coverage can be expected.
 Miller classification of gingival recessions

Class 4: Marginal tissue recession that extends to or

beyond the mucogingival junction with severe bone loss and
soft tissue loss interdentally and/or severe tooth malposition.

Prognosis: very poor with current techniques

Lang and Löe based on a study done on dental students
postulated that minimum 2 mm keratinized gingiva can
maintain gingival health even in adequate oral hygiene
According to Corn (1962) only a 3 mm band of attached
gingiva can guarantee the gingival and periodontal
healthy .

Lang and Löe. The Realtionship between the

Width of the Keratinizated Gingiva and the
Gingival Health. Journal of Periodontology 1972;
43; 623-627.
Wennström and Lindhe (1988) showed in their animal
study that thinner gingival margin associated with more
severe microscopic inflammatory reaction that the thick
well attached gingiva

.Wennström,J.L. and Lindhe, J. Plaque induced gingival

inflammation in the abscence of attached gingiva in
dogs. Journal of Clinical Periodontology 1983; 10:
266-276.
Dorfman and Kennedy (1980) based on their follow-up study
came to a conclusion that though free gingival grafting is a
successful and predictable surgical procedure it has no effect on
the periodontal state and prognosis of periodontal disease

Dorfman, H. S., Kennedy J.S. Longitudinal evaluation of free

autogenous gingiva grafts. Journal of Clinical Periodontology 1980; 7:
316-324.
The thin and narrow band of gingiva not necessarily
provides less protection to the underlying periodontium
that the thick and wide gingiva

Though the 3 mm wide attached gingiva clinically creates a

more favorable environment to the periodontium
The thin and narrow band of gingiva
not necessarily provides less
protection to the underlying
periodontium that the thick and wide
gingiva.
Though the 3 mm wide attached
gingiva clinically creates a more
favorable environment to the
periodontium
 Different therapeutical options for
root coverage localized defects
• Pedicle flaps
– Rotating flap
– Sliding flap

• Free connective tissue grafts

– epithelialized graft
– Subepithelial connective tissue graft

• GTR-techniques
– Resorbable and non-resorbable membranes

• Bioactive agents (in combination with different flaps)

– EMD
– ADM
– PRF
 Development of different surgical techniques
for mucogingival recessions
• Frenulotomy Hirschfeld 1939
• Guidelines for mucogingival surgery Friedmann 1957

Rotated and slided pedicle flaps

• Laterally repositioned flap

Grupe J. & Warren R. 1956
• Laterally repositioned partial thickness flap
Stafileno H. 1964
• Oblique rotated flap
Pennel BM Higgason JD, Towner JD, King Ko, Fritz BD, Salder JF. Oblique
rotated flap. J periodontol. 1965 jul-aug;36:305-9
• Laterally reposition flap with submarginal incision
Grupe HE. 1966 Modified technique for the sliding flap operation. J Periodontol.
1966 Nov-Dec;37(6):491-5.
• Double papillae repositioned flap
Cohen DW 1968
• Half-Moon shaped coronally repositioned flap
Tarnow DP. 1986
 Periodontal Plastic Surgery
/PPS/
• Augmentation of keratinized gingiva
• Coverage of denuded root surfaces
• Reconstruction of papillae
• Augmentation or correction of periimplant mucosa
• Crown lengthening
• Gingival preservation of teeth in ectopic position
• Removal of aberrant frenulum /Frenulectomy/
• Preservation of fresh extraction sites
• Hard and soft tissue augmentation of edentulous
ridges

Esthetic (Periodontal) Reconstructive surgery

 Development of different surgical techniques
for mucogingival recessions
• Frenulotomy Hirschfeld 1939
• Guidelines for mucogingival surgery Friedmann 1957

Rotated and slided pedicle flaps

• Laterally repositioned flap

Grupe J. & Warren R. 1956
• Laterally repositioned partial thickness flap
Stafileno H. 1964
• Oblique rotated flap
Pennel BM Higgason JD, Towner JD, King Ko, Fritz BD, Salder JF. Oblique
rotated flap. J periodontol. 1965 jul-aug;36:305-9
• Laterally reposition flap with submarginal incision
Grupe HE. 1966 Modified technique for the sliding flap operation. J Periodontol.
1966 Nov-Dec;37(6):491-5.
• Double papillae repositioned flap
Cohen DW 1968
• Half-Moon shaped coronally repositioned flap
Tarnow DP. 1986
FRENULECTOMIA
 Laterally repositioned flap

Grupe J. & Warren R. Repair of gingival defects by a sliding flap operation. J Periodontol
1956 27, 290-295
Stafileno H. Management of gingival recession and root exposure problems associated
with periodontal disease. Dental Clinics of North America 1964 March 111-120
 Laterally positioned flap
It was first described by Grupe and Warren (1956) the principle of the
surgical technique was to cover the denuded root surface with the laterally
sliding full thickness flap prepared from the attached gingiva of the distal
teeth
This technique was modified and improved by Staffelino (1964), and Pfeifer
& Heller (1971).
According to them only a partial thickness flap was prepared to facilitate
the postoperative healing and to avoid the postoperative bone resorption
and gingival recession at the donor site.
Laterally rotated flap
MILLER CLASS II
GINGIVAL
RECESSION AT
TOOTH # 14 WAS
COVERED BY A
PARTIAL
THICKNESS FLAP
PREPARED FROM
THE GINGIVAL OF
THE 2nd
PREMOLAR AND
1st MOLAR
EXTENDED LATERALLY
POSITIONED PEDICLE FLAP
LATERALLY POSTIONE FLAP COMBINED WITH FREE
AUTOGENOUS GINGIVAL GRAFT
LATERALLY POSTIONE FLAP COMBINED WITH FREE AUTOGENOUS
GINGIVAL GRAFT
 Double papilla flap procedure

Cohen DW, Ross SE. The double papillae repositioned flap in periodontal therapy. J
Periodontol. 1968 Mar;39(2):65-70.
 Half-Moon shaped coronally repositioned flap

Tarnow DP. Semilunar coronally repositioned flap. J Clin Periodontol. 1986

Mar;13(3):182-5.
Half-Moon shaped coronally repositioned flap
 Coronally advanced flap

Brustein DD. Cosmetics Periodontics- Coronally repositioned pedicle graft. Dent.Surv.

1970;46:22-25.
Allen EP,Miller PD. Coronal positioning of existing gingival.Short term result in the
treatment of shallow marginal tissue recession. J Periodontol 1989;60:316-319.
Coronally advanced flap
Coronally advanced flap
EPITHELIALIZED FREE GINGIVAL GRAFT
VESTIBULOPLASTY
WITH FREE
GINGIVAL GRAFT

1. free gingival
graft
2. minor salivary
glands
3. Arteria palati
4. Vena palati
5. Rugae palati
THE SURGICAL
TECHNIQUE OF
THE
EPITHELIALIZED
FREE GINGIVAL
GRAFTING
 FREE GINGIVAL GRAFTS

• Nabers J.M. Free gingival grafts.

Periodontics 1966;4: 243-245.
 PREOP

POSTOP
 PREOP

POSTOP
HEALING AFTER GRAFTING

• Initial phase (0-3. days)

• Revascularisation (2-11. days)
• Maturation (11-42.days)

– Oliver R. at al Microscopic evaluation of healing and revascularisation of free

gingival grafts.
J. of Periodont. Res. 1968;3: 84-95.
– Nobuto T. et al Microvascularisation of the free gingival autograft.
J. of Periodont Res. 1988;59: 639-646.
THE EPITHELIALIZED FREE GINGIVAL GRAFT IS ALWAYS WHITER
AND PALER THAN THE NEIGHBORING TISSUES
ORTHODONTIC TREATMENT DENTAL IMPLANT
FREE GINGIVAL GRAFT 25 YEARS AFTER
SURGERY
A SZABAD ÍNYLEBENY 25 ÉVVEL A MŰTÉT UTÁN
FREE GINGIVAL GRAFT
25 YEARS AFTER
SURGERY
MILLER II- III GINGIVAL EPTHELIALIZED FREE GINGIVAL
LAESION GRAFT FROM THE PALATE
DURING HEALING THE EPITHELIA TOTALLY DESQUAMATED BUT
LATER REEPITHELIALIZED FROM THE MARGINS
2001 NOVEMBER

2012 MÁJUS
MILLER II-III LAESION
2 YEARS CONTROL
CLINICALLY SUCCESSFUL BUT AESTHETICALLY
QUESTIONABLE RESULTS IN THE HIGHLY VASCULARIZED
RECIPIENT NEIGHBORHOOD
MARKED POSTOPERATIVE „CREAPING ATTACHMENT „ WITHIN TWO YEARS
1980 free gingival graft 2000 exostosis