Clinical Practice Guidelines No.

2021-001: Plastic Periodontal Procedures and Surgeries/Recession

CLINICAL PRACTICE GUIDELINES

TITLE : Plastic Periodontal Procedures and
Surgeries/Recession
EFFECTIVE DATE : June 25, 2021
CPG NO. : 2021-080

1. STATEMENT OF PURPOSE
1.1 Plastic surgery is indicated to treat soft tissue deformities around teeth (lack of attached gingiva,
correction of high gingival display, reconstruction of papilla, etc.). For this paper will focus on gingival
recession treatment procedures.

2. REVISION HISTORY
Date Rev. Change
No.
14 April 2021 V.1.0 New

3. RELATED DOCUMENTS
3.1 NA

4. RELATED ACCREDITATION STANDARDS

4.1 NA

5. DEFINITIONS
5.1 Periodontal Plastic Surgery: surgical procedures performed to correct or eliminate anatomic,
developmental, or traumatic deformities of the gingival, alveolar mucosa or bone.

5.2 Mucogingival Junction (MGJ): is anatomical feature representing the demarcated line
between keratinized, immobile, and non-keratinized, mobile, soft tissue.

5.3 Alveolar mucosa: soft, thin mucosa membrane located below MGJ and continues to mouth vestibule.

5.4 Attached gingiva is firm, resilient, and tightly bound to the underlying periosteum of alveolar bone.
5.5 Cemento-Enamel Junction: area of enamel and cementum meet.
5.6 Denuded root (gingival recession): exposure of the root surface by apical migration of
gingival margin to cemento-enamel junction.

5.7 Root modification: chemical removal of smear layer.

5.8 Root planning: A procedure where the disease and softened cementum is removed and the root
surface is smooth.

5.9 Alloderm: Acellular Dermal Matrix derived from donated human skin.

5.10 Enamel matrix protein (Emdogain)

5.11 Free gingival graft: is soft tissue graft obtained from palate consisting of epithelial and part of
connective tissue layer.

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5.12 Sub epithelial connective tissue graft: is soft tissue graft obtained from palate consist of
connective tissue graft.
5.13 ASA (American Society of Anesthesiologists) Classification scores:
5.13.1 ASA I: Normal healthy patient.
5.13.2 ASA II: A patient with a mild systemic disease.
5.13.3 ASA III: A patient with sever systemic disease limiting activity but not incapacitating.
5.13.4 ASA IV: A patient with incapacitating diseases that is a constant threat to life.
5.14 Miller Gingival Classification:
5.14.1 Class I: Marginal tissue recession not extending to the mucogingival junction, without
interdental hard or soft tissue loss

5.14.2 Class II: Marginal tissue recession extending to or beyond the mucogingival junction, without
interdental hard or soft tissue loss.

5.14.3 Class III: Marginal tissue recession extends to or beyond the mucogingival junction, with
interdental loss of hard and/or soft tissue or malpositioning of the tooth facially.

5.14.4 Class IV: Marginal tissue recession extends to or beyond to the mucogingival junction. There
is sever bone and soft tissue loss interdentally or sever tooth malposition.

5.15 Cairo gingival recession classification:

5.15.1 Recession Type 1 (RT1): Gingival recession with no loss of interproximal attachment.
Interproximal CEJ was clinically not detectable at both mesial and distal aspects of the tooth.
5.15.2 Recession Type 2 (RT2): Gingival recession associated with loss of interproximal
attachment. The amount of interproximal attachment loss (measured from the interproximal CEJ
to the depth of the interproximal pocket) was less than or equal to the buccal attachment loss
(measured from the buccal CEJ to the depth of the buccal pocket).
5.15.3 Recession Type 3 (RT3): Gingival recession associated with loss of interproximal
attachment. The amount of interproximal attachment loss (measured from the interproximal CEJ
to the depth of the pocket) was higher than the buccal attachment loss (measured from the
buccal CEJ to the depth of the buccal pocket).
6. POLICIES
6.1 Periodontal plastic procedures must only be performed by someone who is privileged to do so by the
SCHS Credentialing and Privileging Committee decision.
6.2 Plastic surgery utilized to cover the expose by soft graft to enhance health status and aesthetic
appearance of the gingiva.
6.3 Modifications based on patient’s ASA Score:
6.3.1 ASA I: no modification.
6.3.2 ASA II: communication with the patient’s physician as appropriate.
6.3.3 ASA III: Evaluate necessity of the procedure to patient’s whose medical condition is stable as

per their physician.

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6.3.4 ASA IV: is contraindicated for this procedure.

7. PROCEDURES
7.1 Free gingival autograft
FFG technique utilized to increase the zone of attached gingival in addition to cover expose root.
7.1.1 Prepare the recipient site:
7.1.1.1 Administration proper local anesthesia based on medical status of the patient.
7.1.1.2 Root plaining on exposed root to smoothen the surface.
7.1.1.3 Modification of root surface by citric acid for 5 minutes to remove smear layer. The
effect of citric acid on root coverage outcome still controversial subject, however;
numerous clinicians practice uses this technique.
7.1.1.4 Make horizontal sulcular incision extended to interdental papilla (mesially and distally)
at the level of CEJ.
7.1.1.5 Make two vertical incisions with bevel at proximal line angel of adjacent teeth.
7.1.1.6 Separate a flap consisting of epithelium and underlying connective tissue without
disturbing the periosteum. Dissect the flap by blunted instrument or back of 15-blade
to have intact periosteum recipient bed for the soft tissue graft.
7.1.1.7 Excised the retracted tissue.
7.1.1.8 A template of the recipient site can be made to be used as pattern for procuring the
graft from the palate.
7.1.1.9 Cover the area with wet gauze.

7.1.2 Obtain the graft from the donor site (Palate):

7.1.2.1 Administration proper local anesthesia based on medical status of the patient where
soft tissue graft will be obtained.
7.1.2.2 Place template over the donor site and make shallow incision around it with #15-blade
at all borders of the template. Insert the blade to the desired thickness into borders.
7.1.2.3 Elevate the edge and hold it with tissue forceps.
7.1.2.4 Continue to separate the graft with #15 blade, lifting it gently as separation progress.
7.1.2.5 The ideal thickness of a graft is between 1.0 and 1.5 mm.
7.1.2.6 Remove the loose tissue tags form undersurface.
7.1.2.7 Trimmed the flap at posterior region to remove thick and fatty layer.

7.1.3 Transfer and immobilize the graft:

7.1.3.1 Position the graft and adapt it firmly to the recipient site to eliminate dead space.
7.1.3.2 Suture the graft at lateral borders and to the periosteum to secureit in position. Graft
must be immobilized.
7.1.3.3 Avoid trauma to the graft by minimized number of sutures should be used to avoid
unnecessary tissue perforation.
7.1.4 Protect the donor site (Palate):
7.1.4.1 Apply pressure on donor site to control bleeding.
7.1.4.2 Several product can be used to cover donor site (such as: gelform, oxycel, surgical
absorbable hemostate, collaPlug or collaTape) and immobilized it by suture.
7.1.4.3 Periodontal dressing to cover donor site is other option can be used to comfort the
patient.
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7.2 Sub epithelial connective tissue graft (Pouch and Tunnel technique)
The connective tissue graft is preformed to cover denuded root especially where aesthetic area is
concerned.
7.2.1 Preparation recipient site:
7.2.1.1 Administration proper local anesthesia based on medical status of the patient.
7.2.1.2 Composite material is placed (temporarily) at the contact points to prevent collapse of
the suspended sutures into the interproximal spaces before surgery.
7.2.1.3 Root planning for the exposed root surface.
7.2.1.4 Initial sulcular incisions are made using #15 c or micro-blades to create the recipient
pouches and tunnels.
7.2.1.5 On the buccal aspect, an intrasulcular incision is made around the necks of the teeth.
The incisions is extended to the adjacent tooth mesially and distally usinga #15 c
blade.
7.2.1.6 Muscle fibers and any remaining collagen fibers on the inner aspect of the flap, which
prevent the buccal gingival form being moved coronally, are incised.
7.2.1.7 The papillae are kept intact and undermined to maintain their integrity and carefully
released from the underlying bone, which allows coronal position of the papillae.
7.2.1.8 An envelope, full thickness pouch and tunnel are created and extended apically
beyond the mucogingival line by blunt dissection for insertion of the free connective
tissue graft through the intrasucular incision.
7.2.1.9 The size of pouch, which includes the area of the denuded root surface, is measured
so that and equivalent size donor connective tissue can be procured from the palate.
7.2.2 Preparation of donor site:
7.2.2.1 Administration proper local anesthesia based on medical status of the patient.
7.2.2.2 Donor site is created to obtain a connective tissue graft of adequate size and shape
to place at the recipient site. The donor connective tissue is contoured to fit into the
recipient pouch and tunnel.
7.2.3 Immobilize the connective tissue graft.
7.2.3.1 A mattress sutures placed at one end the graft helps to guide the graft through the
sulcus and beneath each interdental papilla. The border of the tissue is gently pushed
into the pouch and tunnel using tissue forceps and packing instrument. The graft
pushed from the adjacent tooth on side of the surgical area to the adjacent tooth on
the other side.
7.2.3.2 A mattress suture placed on one end of the graft helps to maintain the graft in
position while the buccal tissue covers the connective tissue graft. This connective
tissue graft is anchored to the inner aspect of the buccal flap in the interdental papilla
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7.2.3.3 A vertical mattress suture is used to hold the connective tissue in position beneath
the gingiva. The connective tissue is completely submerged beneath the buccal flap
and the papillae.
7.2.3.4 The entire gingivopapillary complex (buccal gingiva with underlying connective tissue
graft and papillae) is coronally positioned using a horizontal mattress anchored at the
incisal edge of the contact area. The contact areas are splinted preoperatively to
close the interdental contact using a composite material to prevent the suture from
sliding apically interdentally.
7.2.3.5 Other holding sutures can be placed through the overlying gingival tissue and donor
tissue to the underlying periosteum to secure and stabilized the donor tissue and the
overlying in a coronal position.

7.3 Acellular Dermal Matrix (Alloderm): Alloderm method is beneficial to cover exposed root and
lower patient morbidity by preventing second surgery site (donor site).
7.3.3 Alternate papilla tunnel (ATP) method:
7.3.3.1 Administration proper local anesthesia based on medical status of the patient.
7.3.3.2 Incision is made in a papilla adjacent to a tooth recession and the adjacent papilla
is tunneled.
7.3.3.3 Next papilla is incised, and the following papilla is tunneled.
7.3.3.4 Intrasulcularincision are made facial to each tooth and interproximally at each
tunneled papilla.
7.3.3.5 Papilla in the anatomic midline is always tunneled to reduce tension and retraction
of the recipient pouch.
7.3.3.6 Depithelizedincised papilla to adapt surgical papilla on a vascular bed when advance
the flap coronally.
7.3.3.7 Initial dissection is performed and extended apically past MGJ and laterally under the
facial aspect of the tunneled papillae.
7.3.3.8 Tunneled papillae are lifted from the interdental crest by blunt reflection.
7.3.3.9 After blunt reflection, sharp dissection is used to deepen and mobilize the recipient
pouch.
7.3.3.10 The length of graft needed is measured and trimmed so that graft will extend 3 mm
past the last tooth with recession at each end of the prepared site.
7.3.3.11 The vertical dimension of the graft should be 6 to 8 mm.
7.3.3.12 Graft should be hydrated according to manufacturer instruction.
7.3.3.13 Allograft placed into the surgical pouch, with basement membrane surface facing
outward and secured with 6-0 sling sutures.

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7.3.3.14 The graft should be well adapted to the root surface, extending to but not coronal to
the CEJ and apical to gingival margin, but should not be over the papillary recipient
beds.
7.3.3.15 The pouch then coronally advanced completely cover the allograft and secured with
6- 0 or 7-0 sling sutures.
7.3.4 Papilla Retention Pouch (PRP, all papillae are tunneled)
7.3.5 Administration proper local anesthesia based on medical status of the patient.
7.3.5.1 Intramuscular incisions are made facial and proximal to all teeth to be treated plus an
additional tooth at each end.
7.3.5.2 Full thickness elevation of the margin extending apically past the MGJ and laterally
under the facial aspect of the papillae.
7.3.5.3 The pouch extended apically and mobilized by sharp dissection, and papillae
lifted from the interdental crest as in the APT.
7.3.5.4 The graft rehydrated, measured, and trimmed.
7.3.5.5 Placement of the allograft within the pouch over exposed roots.
7.3.5.6 Stabilized the graft and flap with a continuous subgingival, double back sling sutures.
Starting anterior end with needle of a 6-0 suture.
7.4 Single root recession without interdental attachment loss at moderately deep maxillary recessions
located in anterior and premolar teeth, recommended surgical procedure is coronally advance flap
with connective tissue graft or Emdogain (2).
7.5 Multiple roots recession without interdental attachment loss, scientific evidence cannot support
one technique over another. On the other hand, single surgical approach to treat multiple gingival
recession is possible (2).
7.6 Complete root coverage may be possible at recession with minimal inter-dental attachment loss,
but no recommendation can be made to support the selection of one technique over another.(2).

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8 APPENDICES
8.2 Periodontal Plastic Surgery Instruments
Instruments

1 Micro-scissors

2 Micro-forceps

Micro-Needleholder-
3
Straight

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Micro-Needle holder-
4
Curved

5 Micro-scalpel handle

Suture forceps with eye

6
tips

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7 Papilla elevator

8 Straight Tunneling knifes

Curved micro-Tunnelling
9
knifes

11

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10 Curved Tunnelling knifes

11
UNC-15 Periodontal Probe

9 REFERENCES
9.2 Clinical periodontology, Newman and Carranza’s, 13th edition, 2019.
9.3 Clinical efficacy of periodontal plastic surgery procedures: Consensus Report of Group 2 pf the
10th European workshop on Periodontology, Maurizio S. Tonetti, J ClinPeriodontol, 2014.
9.4 Periodontal Plastic Surgery, G. zucchelli, Periodontol 2000, 2015.
9.5 ASA Physical Status Classification System, American Society of Anesthesiologists, October 2019
https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system
accessed 10/08/2020

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PREPARED BY:

DR. BAHER FELEMBAN

Consultant in Periodontics and implant Dentistry Assistant Professor
Department of Periodontology,
Basic and Clinical Science,
Umm Alqura collage of Dentistry Date of Signature

REVIEW OF REGULATORY DOCUMENTS DEPT.:

REVIEWED BY:

PROF. FATIN ARAB AWARTANI

Position
Department
Date of Signature

APPROVED BY:

(signature)

DR. ADNAN AL MAGHLOUTH

Consultant
Head of the Publication Committee
Date of Signature

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