MUCOGINGIVAL SURGERIES

INTRODUCTION
Mucogingival
surgical
techniques
are
designed
to provide a functionally adequate zone of keratinized
attached gingiva.(Friedman, 1962).
Pocket elimination or creation of proper physiologic form
Complex capable of withstanding the stresses of
mastication
Tooth brushing
Trauma from foreign objects
Tooth preparation associated with a crown and bridge
Subgingival restorations, orthodontics, inflammation,
and
frenulum pull.

 Miller included procedures such as the correction of

ridge deformities, exposure of unerupted teeth for
orthodontic treatment and crown lengthening

DEFINITION
The definition proposed by Friedman included surgery
designed to preserve attached gingiva, to remove frena or
muscle attachment and to increase the depth of the
vestibule , correct or eliminate anatomic, developmental or
traumatic deformities of the gingiva or alveolar mucosa

History of Periodontal Plastic Surgery

!1930s Frenectomies performed as well as
deepening of the mucobuccal fold !1948 Goldman
performed the first gingivoplasty !1956 Warren &
Grupe showcase the Laterally Positioned Flap !1962
Friedman introduces the Apically Positioned Flap and
the internal beveled incision !1963 Bjorn introduces
the Free Gingival Graft !1982 P.D. Miller introduces
the FGG for root coverage Fernandez first to do CTG
Pini Prato performs first GTR procedure !1989 AAP
renames Mucogingival Surgery to Periodontal Plastic
Surgery

 Allen considered the treatment of gingival pigmentation

and discoloration and the correction of flat marginal
contours, gummy smile and gingival asymmetry also
pertinent to mucogingival surgery.

American Academy of Periodontology has replaced the

term mucogingival surgery with the more general
term soft tissue plastic surgery to describe surgical
procedures designed to correct defects in the
morphology, position or amount of gingiva surrounding
the teeth.

 No standard width of keratinized attached

gingiva has been established. In people with good
oral hygiene, 1 mm or less may be sufficient for
health (Lange and Loe, 1972; Miyasato and colleagues, 1977; Hangorsky and
Bissada, 1980; de Trey and Bernimoulin, 1980; Dorfman and colleagues, 1980,
1982). Kirch and colleagues (1986), Wennstrm (1987),
Salkin and colleagues (1987) showed that even a movable marginal tissue of
alveolar mucosa can be kept stable over a
long period of time. Yet it may be necessary to
increase this zone of healthy tissue if it is to be
subjected to the trauma of prosthetic treatment
(Maynard and Wilson, 1979; Ericsson and Lindhe, 1984), orthodontic restoration
(Maynard and
Ochsenbein, 1975; Coatoam and colleagues,
1981), or frenulum pull (Gottsegen, 1954; Corn,
1964a; Gorman, 1967) or in instances of rapidly
progressing recession (Baker and Seymour, 1976;
de Trey and Bernimoulin, 1980)

TISSUE BARRIER CONCEPT

Goldman and Cohen (1979) outlined a TISSUE

BARRIER concept for mucogingival surgery. They
postulated that a dense collagenous band of
connective tissue retards or obstructs the spread of
inflammation better than does the loose fiber
arrangement of the alveolar mucosa.
They recommended increasing the zone of
keratinized attached tissue to achieve an adequate
tissue barrier (thick tissue), thus limiting recession
as a result of inflammation.

 colleagues (1973), Baker and Seymour (1976),

Rubin (1979), and Lindhe and Nyman (1980).
In contrast to these findings, teeth possessing
the least attached tissue (cuspids and bicuspids)
are the least involved periodontally, whereas the
incidence of disease is greatest on the lingual and
palatal surfaces, where the amount of keratinized
tissue is greatest (Waerhaug, 1971). Furthermore,
Wennstrm and colleagues (1981, 1982),
Wennstrm and Lindhe (1983), and Kure and
colleagues (1985)showed that a free gingival unit
supported by a loosely attached alveolar mucosa
is not more susceptible to inflammation than a
free gingival unit th

INDICATIONS
These procedures, therefore, should be used only where
specifically indicated or where inflammation cannot be
controlled.
Wennstrm (1985) stated: A thin marginal tissue, in
particular in the absence of underlying alveolar bone, will be
at greater risk of recession since the plaque-induced
inflammatory lesion may occupy
and cause destruction of the entire connective tissue portion
of the gingiva.

 Hall (1977) noted several critical factors to be

considered other than the mere lack of an adequate
zone of attached gingiva:
1. Patient age
2. Level of oral hygiene
3. Teeth involved
4. Potential or existing esthetic problems
5. Existing recession with esthetic or sensitivity
problems
6. The patients dental needs
7. Previous dental treatmen

General Considerations
Principles
1. Existing keratinized gingiva should always be
maintained.
2. Exposing bone to increase the zone of keratinized
gingiva is contraindicated (Wilderman, 1964).
3. When an adequate zone of attached keratinized
gingiva exists, vestibular depth is not
a factor (Bohannan, 1963a).

Objectives
To create an adequate zone of attached keratinized gingiva
To eliminate pockets that extend beyond the mucogingival
line
To eliminate muscle and frenulum pull
To deepen the vestibule
To cover denuded root surfaces for esthetics
or hypersensitivity
To overcome the anatomic factors of tooth
position, thin alveolar housing, and large
prominent roots, which promote dehiscence
and/or fenestration formation with gingival
accession

To minimize recession during orthodontic movement

To overcome the trauma of prosthetic restorative
dentistry requiring subgingival placement
To stabilize and maintain a healthy mucogingival
complex
To correct areas of progressive gingival recession
To correct ridge deformities and undercuts

Classification of Procedures
The surgical methods available for correction of mucogingival
problems are as follows:
1. Periodontal flapspositioned and repositioned
a. Full thickness (mucoperiosteal; modified, apically positioned)
b. Flap curettage
c. Partial thickness (apically positioned)
d. Curtain procedure
2. Free soft tissue autografts
a. Grafting for root coverage
b. Connective tissue pedicle graft
c. Ridge augmentation for esthetics

3. Subepithelial connective tissue graft

4. Laterally positioned pedicle flaps (partial
and full thickness)
a. Edentulous ridge modification
b. Oblique rotated pedicle flap
c. Periosteally stimulated pedicle flap
d. Partial-full-thickness pedicle flap
e. Submarginal incisions
f. Coronally positioned flap

5. Double-papillae laterally positioned flap

a. Horizontal lateral sliding papillary flap
b. Rotated or transpositional rotated flap
6. Frenulectomy and frenulotomy