Mucogingival Surgery

PERIODONTAL PLASTIC SURGERY AND MUCOGINGIVAL SURGERY COVERING ALL AREAS

1. MUCOGINGIVAL
SURGERY
DR.VIDYA VISHNU
SENIOR LECTURER
MALABAR DENTAL COLLEGE AND RESEARCH CENTRE
1

2. INTRODUCTION
Thescopeofperiodontaltherapyhasgonefarbeyond
arrestingthediseaseandeliminatingthepockets.
Theperiodontistisnowanimportantmemberofthe
interdisciplinaryteam,whichaimsatoverall
maintenanceofthedentitioninastateofhealth,
functionandestheticharmony.
Increasingpatientawarenesshasresultedinabig
demandforrestorationandaugmentationofesthetics.
2

3. TERMINOLOGY
‘Mucogingivalsurgery’,introducedbyFriedmanin
1957,isusedtodescribesurgicalproceduresforthe
correctionofrelationshipsbetweenthegingiva,and
theoralmucousmembranewithreferencetothree
specificproblemareas:
attachedgingiva,shallowvestibule,andfrenum
interferingwithmarginalgingiva.(FriedmanN1957)
3

4. WorldWorksopinclinicalPeriodontics,1996
renamedmucogingivalsurgeryas‘Periodontal
PlasticSurgery’,atermproposedbyMiller,1993
whichwasdefinedas‘surgicalprocedures
performedtocorrectoreliminateanatomic,
developmental,ortraumaticdeformitiesofthe
gingivaoralveolarmucosa(WennstromJ.1996).
4

5. Mucogingivaltherapy–broadertermthatincludes
nonsurgicalproceduressuchaspapilla
reconstructionbymeansoforthodonticor
restorativetherapy.
Periodontalplasticsurgeryincludesonlythe
surgicalproceduresofmucogingivaltherapy.
5

6. MAIN OBJECTIVES
Correction of problems associated with
Attached
gingiva
Shallow
vestibule
Aberrant
frenum
6

7. INDICATIONS
Periodontal-prosthetic corrections
Gingival augmentation
Coverage of denuded root surface
crown lengthening
removal of aberrant frena
Socket preservation
Ridge augmentation
Reconstruction of papillae
Esthetic surgical correction around implants
Surgical exposure of unerupted teeth for orthodontics
7

8. ATTACHED GINGIVA
GINGIVAL
AUGMENTATION
8

9. NEED FOR ADEQUATE ATTACHED
GINGIVA
Adequatezoneofgingivaisneededto:
Protectperiodontiumfrominjurycausedbyfrictional
forcesencounteredduringmastication.
Dissipatepullongingivalmargincausedbymusclesof
adjacentmucosa.
Maintenanceofmarginaltissuehealth&preventionof
continuouslossofconnectivetissueattachment.
Deflectionoffood&preventionoffoodaccumulation.
9

10. Nabers(1954)&Ochsenbein(1960)-“adequatezoneof
A.Giscriticalformaintainenceofmarginaltissue
healthandpreventionofcontinuouslossofC.T
attachment.
Bowers(1963)–lessthan1mmofgingivamaybe
sufficienttomaintaingingivalhealth.
Lang&Loe(1972)-“alltoothwithlessthan2mmof
gingivaexhibitedpersistentsignsofclinical
inflammation.2mmofkeratinizedgingiva,withless
than1mmofattachedgingivaisadequatetomaintain
gingivalhealth.
10

11. TISSUEBARRIERCONCEPT:
◦GoldmanandCohen(1979)
◦TheypostulatedthatadensecollagenousbandofCT
retardsorobstructsthespreadofinflammationbetter
thandoestheloosefiberarrangementofthealveolar
mucosa.
◦Theyrecommendedincreasingthezoneof
keratinizedattachedgingivatoachieveanadequate
tissuebarrier.tissuetoachieveanadequatetissue
barrier(thicktissue).
11

12. AFreegingivalunit(FGU)supportedbyaloosely
attachedalveolarmucosaisnotmoresusceptibleto
inflammationthanaFGUissupportedbyawidezone
ofA.G–Wennstrom&Lindhe(1983)
Athinmarginaltissueinparticularintheabsenceof
underlyingalveolarbonewillbeatgreaterriskof
recession(Wennstrom1985)
12

13. StudiesbyMiyastoetalfailedtosupportthe
conceptofrequiredminimumdimensionofA.G.
In1980LindheandNymanconcludedthatgingival
healthcouldbemaintainedindependentofits
dimensions.
DeTrayandBernimoulinconcludedthatadequacy
ofattachedgingivacan’tbedeterminedby
measurementofitswidthalone.
13

14. PROBLEMS ASSOCIATED WITH
DECREASED WIDTH OF ATTACHED
GINGIVA
Difficultyinremovalofplaque&maintenanceof
oralhygiene.
Estheticproblemsduetorecession
Inflammationaroundrestoredteeth.
14

15. To increase width and thickness of gingiva
To establish proper vestibular depth
To prevent progressive soft tissue recession
To facilitate plaque control
INDICATIONS FOR GINGIVAL
AUGMENTATION
15

16. When to Augment ?
Augment
Soft tissue
Recession
No attached
gingiva
Intra Crevicular
Restorations
FrenalPull
Ortho Movement
in thin
Periodontium
Gingival
Inflammation
16

17. Theneedforgingivalaugmentationisusuallydecided
onthebasisofHALL’scriteria:
Teeththatareinvolved
Ageofthepatient
Patientsoralhygienepractice
Existing/potentialestheticproblems
Existenceofrecessionalready
Patientsdentalneeds
Previousdentaltreatment
17

18. Gingival augmentation apical to area of
recession.
•1-Vestibular/gingival extension procedures
•2-Free Gingival Autografts
•3-Free connective tissue autografts
•4-Apically positioned flap.
Gingival augmentation coronal to recession
(root coverage)
•Pedicle grafts
•Free grafts
18

19. Earliest: Vestibular Extension operations
Gingival augmentation procedures
Denudation
technique
Split flap/ periosteal
retention procedure
19

20. The“vestibularextensiontechnique,”originally
describedbyEdlanandMejchar,producedstatistically
significantwideningofattachednonkeratinizedtissue.
Thisincreaseinwidthinthemandibulararea
reportedlypersistedinpatientsobservedforupto5
years.Currently,thistechniqueisofhistoricinterest
only.
Thefenestrationoperation/periostealseparation
techniquewasdesignedtowidenthezoneofattached
gingivawithaminimumlossofboneheight
20

21. Itusesapartial-thicknessflap,exceptinarectangular
areaatthebaseoftheoperativefield,wherethe
periosteumisremoved,exposingthebone.Thisisthe
areaoffenestration.
Createsascarthatisfirmlyboundtothebone.
Itpreventssofttissueseparationfromtheboneand
postsurgicalnarrowingoftheattachedzone.
Resultsarenotpredictable;notwidelyperformedexcept
forsmallisolatedareas.
21

22. FGG
1. THE CLASSIC TECHNIQUE (Bjorn
1963)
2. VARIANT TECHNIQUE
•Accordion Technique (Rateitschak1985)
•Strip Technique (Han, Carranza Jr., and Takei, 1993)
•Combination epithelial connective tissue strip
technique
23

23. Historical Backround
24

24. INDICATIONS OF FGG
•Increase gingival width of AG
Recession coverage
•Deepen vestibule
•Ridge augmentation
25

25. THE CLASSIC TECHNIQUE
STEPS:
1.Prepare the recipient site
2.Obtain the graft from the donor site
3.Transfer & immobilize the graft
4.Protect the donor site
26

26. PREPARATIONOFRECIPIENTSITE
Purposeistoprepareafirmconnectivetissuebedto
receivethegraft.
Donebyincisingattheexistingmucogingivaljunction
witha#15bladetothedesireddepth,blendingthe
incisiononbothendswiththeexistingmucogingival
line.
Periosteumshouldbeleftcoveringthebone.
27

27. Anothertechniqueconsistsofoutliningtherecipientsite
withtwoverticalincisionsfromtheincisedgingival
marginintothealveolarmucosa.
Extendtheincisionstoapproximatelytwicethedesired
widthoftheattachedgingiva,allowingfor50%
contractionofthegraftwhenhealingiscomplete.
Theamountofcontractiondependsontheextenttowhich
therecipientsitepenetratesthemuscleattachments.
28

28. Thedeepertherecipientsite,thegreateristhe
tendencyforthemusclestoelevatethegraftand
reducethefinalwidthoftheattachedgingiva.
The#15bladeisusedtoincisealongthegingival
margintoseparateaflapconsistingofepitheliumand
underlyingconnectivetissuewithoutdisturbingthe
periosteum.
Extendtheflaptothedepthoftheverticalincisions.
Suturetheflapwheretheapicalportionofthefree
graftwillbelocated.
29

29. Analuminumfoiltemplateoftherecipientsitecanbe
madetobeusedasapatternforthegraft.
Graftscanalsobeplaceddirectlyonbonetissue-less
postoperativemobilityofthegraft,lessswelling,better
hemostasis,and1.5to2timeslessshrinkage.
However,thereisahealinglagperiodthatisobserved
forthefirst2weeks.
30

30. OBTAINING GRAFT FROM DONOR
SITE
Apartial-thicknessgraftisused.
Thepalateistheusualdonorsite.Thegraftshould
consistofepitheliumandathinlayerofunderlying
connectivetissue.
Placethetemplateoverthedonorsite,andmakea
shallowincisionarounditwitha#15blade.
31

31. Insertthebladetothedesiredthicknessatoneedgeof
thegraft.Elevatetheedgeandholditwithtissueforceps.
Continuetoseparatethegraftwiththeblade,liftingit
gentlyasseparationprogressestoprovidevisibility.
Placingsuturesatthemarginsofthegrafthelpscontrolit
duringseparationandtransferandsimplifiesplacement
andsuturingtotherecipientsite.
32

32. Properthicknessisimportantforsurvivalofthegraft.
Itshouldbethinenoughtopermitdiffusionoffluid
fromtherecipientsite,whichisessentialinthe
immediatepost-transplantperiod.
Agraftthatistoothinmaynecroseandexposethe
recipientsite.
Ifthegraftistoothick,itsperipherallayeris
jeopardizedbecauseoftheexcessivetissuethat
separatesitfromnewcirculationandnutrients.
33

33. Thickgraftsmayalsocreateadeeperwoundatthe
donorsite,withthepossibilityofinjuringmajorpalatal
arteries.
Theidealthicknessofagraftisbetween1.0and1.5
mm.
Afterthegraftisseparated,removetheloosetissuetags
fromtheundersurface.Thesubmucosaintheposterior
regionisthickandfattyandshouldbetrimmedsothatit
willnotinterferewithvascularization.
34

34. TRANSFER AND IMMOBILIZE THE
GRAFT
Removetheexcessclotasathickclotinterferes
withvascularizationofthegraft.
Positionthegraftandadaptitfirmlytotherecipient
site.Aspacebetweenthegraftandtheunderlying
tissue(deadspace)impairsvascularizationand
jeopardizesthegraft.
Suturethegraftatthelateralbordersandtothe
periosteumtosecureitinposition.
35

35. Thegraftmustbeimmobilized.Anymovement
interfereswithhealing.Avoidexcessivetension,which
candistortthegraftfromtheunderlyingsurface.
Everyprecautionshouldbetakentoavoidtraumato
thegraft.Tissueforcepsshouldbeuseddelicatelyand
aminimumnumberofsuturesusedtoavoid
unnecessarytissueperforation.
36

36. PROTECT THE DONOR SITE
Coverthedonorsitewithaperiodontalpackfor1week,
andrepeatifnecessary.
AmodifiedHawleyretainerisusefultocoverthepack
onthepalateandoveredentulousridges.
37

37. FGG
38

38. 39

39. VARIANT TECHNIQUES
ACCORDION TECHNIQUE
•DescribedbyRateitschak(1985)
•Attainsexpansionofthegraftbyalternateincisions
inoppositesidesofthegraft.
•Thistechniqueincreasesthedonorgrafttissueby
changingtheconfigurationofthetissue.
40

40. ACCORDION TECHNIQUE
41

41. STRIP TECHNIQUE
Hanetal
2or3Stripsofgingivaldonortissue,3-5mmwide
enoughtocovertheentirelengthoftherecipient
site.
Stripsareplacedsidebysidetoformonedonor
tissueandsuturedontorecipienttissue
42

42. STRIP TECHNIQUE
43

43. Greatershrinkageisexpectedinthegraft.
Rapidhealingofthedonorsite.
Theepithelialmigrationoftheclosewoundedges
(3to5mm)allowsrapidepithelializationofthe
openwound.
Thedonorsiteusuallydoesnotrequiresuturing
andhealsuneventfullyin1to2weeks
44

44. COMBINATION TECHNIQUE
Adeepstripgraftistakenfromthepalateandissplit
intobothanepithelial-connectivetissuestripanda
pureconnectivestrip.
Removeastripoftissuefromthepalateabout3to4
mmthick,placeitbetweentwowettongue
depressors,andsplititlongitudinallywithasharp#15
blade.Bothwillbeusedasfreegrafts.
45

45. Thesuperficialportionconsistsofepitheliumand
connectivetissue,andthedeeperportionconsists
onlyofconnectivetissue.
Thesedonortissuesareplacedontherecipientsiteas
inthestriptechnique.
ADVANTAGE:
Theminimaldonorsitewoundobtainedbytwodonor
tissuesfromonesite.
46

46. Healing of FGG
Successofthegraftdependsonsurvivalofthe
connectivetissue.Sloughingoftheepitheliumoccursin
mostcases,buttheextenttowhichtheconnectivetissue
withstandsthetransfertothenewlocationdetermines
thefateofthegraft.
Fibrousorganizationoftheinterfacebetweenthegraft
andtherecipientbedoccurswithin2toseveraldays.
Thegraftisinitiallymaintainedbyadiffusionoffluid
fromthehostbed,adjacentgingiva,andalveolar
mucosa.
47

47. Duringthefirstday,theconnectivetissuebecomes
edematousanddisorganizedandundergoesdegeneration
andlysisofsomeofitselements.Ashealingprogresses,the
edemaisresolved,anddegeneratedconnectivetissueis
replacedbynewgranulationtissue.
Revascularizationofthegraftstartsbythesecondorthird
day.Capillariesfromtherecipientbedproliferateintothe
grafttoformanetworkofnewcapillariesandanastomose
withpreexistingvessels.
48

48. Manyofthegraftvesselsdegenerateandarereplacedby
newones,andsomeoftheseparticipateinthenew
circulation.Thecentralsectionofthesurfaceisthelast
tovascularize,butthisiscompletebythetenthday.
Theepitheliumundergoesdegenerationandsloughing,
withcompletenecrosisoccurringinsomeareas.
Itisreplacedbynewepitheliumfromthebordersofthe
recipientsite.
Athinlayerofnewepitheliumispresentbythefourth
day,withretepegsdevelopingbytheseventhday.
49

49. Heterotopicallyplacedgraftsmaintaintheirstructure
(keratinizedepithelium),evenafterthegrafted
epitheliumhasbecomenecroticandhasbeenreplaced
byneighboringareasofnonkeratinizedepithelium,
whichsuggeststhatageneticpredeterminationofthe
specificcharacteroftheoralmucosaexiststhat
dependsonstimulioriginatingintheconnectivetissue.
Healingofagraftofintermediatethickness(0.75mm)
iscompleteby10.5weeks;thickergrafts(1.75mm)
mayrequire16weeksorlonger.
50

50. Initial phase plasmatic
circulation
0-3 days
Revascularisation
Phase 2-11 days
Tissue maturation
phase 11-42 days
Oliver 1968
51

51. Alternative Donor Tissue
Anothertechniquetominimizetheuseofthepalateas
adonorsiteistheuseofacellulardermalmatrix
(ADM)asasubstituteforpalataldonortissue.
ADMprovidesadvantagesoverpalatalconnective
tissueinthatitdoesnotrequireasecondsurgicalsiteto
obtaindonortissueandprovidesanunlimitedamount
oftissuetotreatmultipleteethinoneappointment.
52

52. Attemptswithlyophilizedduramater,andsclera
havenotbeensatisfactory.
Theuseofirradiatedfreegingivalallograftshowed
satisfactoryresults,butfurtherresearchisnecessary
beforeitcanbeconsideredforclinicaluse.
53

53. Originallydescribedby:Edel
BasedonthefactthattheCTcarriesthegenetic
messagefortheoverlyingepitheliumtobecome
keratinized.ThereforeonlyCTfromakeratinised
zonecanbeusedasagraft.
FREE CONNECTIVE TISSUE
AUTOGRAFTS
54

54. Advantages
Healingisbyfirstintention.
Thepatienthaslessdiscomfortpostoperativelyatthe
donorsite.
Improvedestheticscanbeachievedbecauseofabetter
colormatchofthegraftedtissuetotheadjacentareas.
55

55. Friedman(1962)
Eitherpartialthicknessorfullthicknessflap
Increasesthewidthofthekeratinizedgingivabut
cannotpredictablydeepenthevestibulewithattached
gingiva.
Adequatevestibulardepthmustbepresentbeforethe
surgerytoallowapicalpositioningoftheflap.
APICALLY DISPLACED FLAP
56

56. Theedgeoftheflapmaybelocatedinthreepositionsin
relationtothebone:
1.Slightlycoronaltothecrestofthebone-
Preservetheattachmentofsupracrestalfibers;mayalso
resultinthickgingivalmarginsandinterdentalpapillae
withdeepsulciandmaycreatetheriskofrecurrent
pockets.
2.Atthelevelofthecrest-
Resultsinasatisfactorygingivalcontour,providedthat
theflapisadequatelythinned.
57

57. 3.Twomillimetersshortofthecrest-
Thisproducesthemostdesirablegingivalcontourand
thesameposttreatmentlevelofgingivalattachmentas
obtainedbyplacingtheflapatthecrestofthebone.
Newtissuecoversthecrestofthebonetoproducea
firm,taperedgingivalmargin.
Placingtheflapshortofthecrestincreasestheriskofa
slightreductioninboneheight,buttheadvantageofa
well-formedgingivalmargincompensatesforthis.
58

58. Apically displaced flap
59

59. GINGIVAL AUGMENTATION
CORONAL TO RECESSION
(ROOT COVERAGE)
60

60. Basedonetiology-Classification
Associatedwithmechanicalfactors(toothbrushing
trauma)
Associatedwithlocalisedplaqueinduced
inflammatorylesions
Associatedwithgeneralisedformsofdestructive
periodontallesions
GINGIVAL RECESSION
61

61. 62

62. Regenerativeprocedures(withbarriermembraneor
applicationofenamelmatrixproteins).
63

63. Selectionofsurgicaltechniquedependsonseveral
factors:
Relatedtothedefect(thesizeandnumberofthe
recessiondefects,
thepresence/absence,quantity/qualityofkeratinized
tissueapicalandlateraltothedefect,
thewidthandheightoftheinterdentalsofttissue
(papillae),
thepresenceoffrenumormusclepull&
thedepthofthevestibule,
Relatedtothepatient
(ZucchelliG,DeSanctisM.2000).
64

64. Esthetic reasons
Hypersensitivity
Inconsistency/disharmony of gingival margin
Changing topography of marginal soft tissue in
order to facilitate plaque control.
INDICATIONS
65

65. ROTATIONAL FLAP PROCEDURES:
LATERALLY/ HORIZONTALLY DISPLACED
FLAP:
Introduced by Grupeand Warren (1956)
PEDICLE SOFT TISSUE GRAFT PROCEDURES
66

66. Indications
For covering isolated denuded roots
When there is sufficient width of adjacent interdental
papilla
Sufficient vestibular depth
Contraindications
Presence of deep interproximal pockets
Excessive root prominence
Deep or extensive root abrasion or erosion, Significant
loss of interproximal bone height
67

67. Step1:Preparetherecipientsite.Epitheliumisremoved
aroundthedenudedrootsurface.Therootsurfacewillbe
thoroughlyscaledandrootplaned
Step2:Preparetheflap.Theperiodontiumofthedonor
siteshouldhaveasatisfactorywidthofattachedgingiva
andminimallossofbone,withoutdehiscenceor
fenestration.Afull-thicknessorpartial-thicknessflapmay
beused,butthelatterispreferablebecauseitoffersthe
advantageofrapidhealingatthedonorsiteandreduces
theriskoflossoffacialboneheight.
68

68. Witha#15blade,makeaverticalincisionfromthe
gingivalmargintooutlineaflapadjacenttothe
recipientsite.Incisetotheperiosteum,andextendthe
incisionintotheoralmucosatothelevelofthebaseof
therecipientsite.
Theflapshouldbesufficientlywiderthantherecipient
sitetocovertherootandprovideabroadmarginfor
attachmenttotheconnectivetissueborderaroundthe
root.Theinterdentalpapillaatthedistalendofthe
flap,oramajorportionofit,shouldbeincludedto
securetheflapintheinterproximalspacebetweenthe
donorandtherecipientteeth.
69

69. Step3:Transfertheflap.Slidetheflaplaterallyonto
theadjacentroot,makingsurethatitliesflatandfirm
withoutexcesstensiononthebase.Fixtheflaptothe
adjacentgingivaandalveolarmucosawithinterrupted
sutures.Asuspensorysuturemaybemadearoundthe
involvedtoothtopreventtheflapfromslipping
apically.
Step4:Protecttheflapanddonorsite-periodontal
dressing
70

70. 71

71. Advantages:
Abilitytocoverisolateddenudedrootsthathave
adequatedonortissuelaterally
Goodvascularityofpedicleflap
Singlesurgicalsite
Disadvantage:
Limitedbyamountofadjacentkeratinized
gingiva
Possibilityofrecessionatdonorsite
Dehiscenceorfenestrationatdonorsite
Limitedtooneortwoteethwithgingival
recession
72

72. MODIFICATIONS
Staffileno1964:Partial-thicknessflap,insteadofa
full-thicknessflap,tocovertherootexposure.
Grupe1966:Submarginalincisionatthedonorsitein
ordertopreservethemarginalintegrityofthetooth
adjacenttotherecessiondefect.
73

73. Rubenetal.,1976:Mixed-thicknessflapthat
consistedofafull-thicknessflap,performedcloseto
therecessiondefectforcoveringtherootexposure,
&asplit-thicknessflapcreatedlaterallytothefull-
thicknessflap,forcoveringtheboneexposure
occurringatthedonorsiteofthefull-thicknessflap.
74

74. Zucchellietal.(2004)-coronaladvancementtothe
lateralmovementofthepedicleflap(‘laterallymoved
CAF’).
ThelaterallymovedCAFismainlyindicatedforthe
treatmentofdeepsingletypegingivalrecessiondefects
affectingalowerincisororthemesialrootoftheupper
firstmolar.
75

75. OBLIQUELY ROTATED FLAP
Thisisavariationofthelaterallypositionedflap
(Penneletal.1965).
Thepedicleisrotatedobliquely(90°)andsuturedto
theunderlyingconnectivetissuebed.
76

76. Indications
Whentheinterproximalpapillaadjacentto
mucogingivalproblemaresufficientlywide
Whentheattachedgingivaonanapproximatingtooth
isinsufficienttoallowforalateralpedicleflap
Whenperiodontalpocketsarenotpresent
DOUBLE PAPILLA FLAP
77

77. Advantages:
Riskoflossofalveolarboneisminimized
Thepapillausuallysupplyagreaterwidthofattached
gingivathanfromtheradicularsurfaceofasingle
tooth.
Clinicalpredictabilityisfairlygood
Disadvantages:
Techniquesensitive-havingtojointogether2flapsin
suchawaythattheyactasasingleunit
Primarilyusedforsingletoothcoverage
Healingofthekeratinisedgingivacanbeirregularand
hencegingivoplastymayberequired.
78

78. DOUBLE PAPILLA FLAP
79

79. CORONALLY ADVANCEDFLAP
InitiallydescribedbyNorberg(NorbergO.1926)and
subsequentlyreportedbyAllen&Miller(AllenEP,
MillerPDJr.1989).
Techniqueofchoiceforthetreatmentofisolated
gingivalrecession.
ADVANCED FLAP
80

80. Step1.Withtwoverticalincisions,delineatetheflap.
TheseincisionsshouldgobeyondtheMGJ.Makean
internalbevelincisionfromthegingivalmargintothe
bottomofthepockettoeliminatethediseasedpocket
wall.Elevateamucoperiostealflapusingcarefulsharp
dissection.
Step2.Scaleandplanetherootsurface.
Step3.Returntheflapandsutureitatalevelcoronalto
thepretreatmentposition.Covertheareawitha
periodontaldressing.
81

81. 1
CORONALLY DISPLACED FLAP
82

82. Advantages
Technically simple, well tolerated
Treatment of single or multiple areas of root exposure
No need for involvement of adjacent teeth
High degree of success
Good esthetics
Even if procedure does not work it does not increase
the existing problem
83

83. CONTRAINDICATIONS OFCAF:
absenceofkeratinizedtissueapicaltotherecession
defect,
thepresenceofagingivalcleft(‘Stillman’cleft)
extendingintothealveolarmucosa,
highfrenulumpullatthesoft-tissuemargin,
deeproot-structureloss,
buccallydislocatedrootand
averyshallowvestibulumdepth.
84

84. Modification by De SanctisM, ZucchelliG.2007
Trapezoidalflapdesignandasplit–full–split-thickness
flapelevationapproach.
Split-thicknesselevationatthelevelofthewide(3mm)
surgicalpapillaprovidedanchorageandbloodsupply
totheinterproximalareasmesialanddistaltotheroot
exposure;facilitatedthenutritionalexchanges
betweenthemandtheunderlyingde-epithelialized
anatomicalpapillaeandimprovedtheblending(in
termsofcolorandthickness)ofthesurgically
treatedareawithrespecttotheadjacentsofttissues.
85

85. Thefull-thicknesselevationofthesofttissueapicalto
therootexposureconferredmorethicknessandsome
periosteum,andthusbetteropportunitytoachieveroot
coveragetothatportionoftheflapresidingoverthe
exposedavascularrootsurface.
Themoreapicalsplit-thicknessflapelevationfacilitated
thecoronaldisplacementoftheflap.Althoughthe
techniqueincludedverticalreleasingincisions,thesedid
notresultinunestheticscars.
86

86. Modified Coronallyadvanced flap
87

87. Indication:
Areas where gingival recession is only 2-3 mm
Advantages:
No vestibular shortening as occurs with coronally
positioned flap
No esthetic compromise of interproximal papilla
No need for sutures
Disadvantages
Inability to treat large areas of gingival recession
The need for a free gingival graft if there is an
underlying dehiscence or fenestration.
SEMILUNAR CORONALLY REPOSITIONED
FLAP PROCEDURE [TARNOW]
88

88. Step1.Asemilunarincisionismadefollowingthe
curvatureoftherecededgingivalmarginandending
about2to3mmshortofthetipofthepapillae.This
locationisveryimportantbecausetheflapderivesits
bloodsupplyfromthepapillaryareas.Theincisionmay
needtoreachthealveolarmucosaiftheattached
gingivaisnarrow.
Step2.Performasplit-thicknessdissectioncoronally
fromtheincision,andconnectittoanintrasulcular
incision.
89

89. Step3.Thetissuewillcollapsecoronally,coveringthe
denudedroot;heldinitsnewpositionforafewminutes
withamoistgauze.Manycasesdonotrequireeither
suturesorperiodontaldressing.
Thistechniqueissimpleandpredictablyprovides2to3
mmofrootcoverage.
Indicatedwheretherecessionisnotextensive(3mm)
andthefacialgingivalbiotypeisthick.
Successfulforthemaxilla;Notrecommendedforthe
mandibulardentition.
90

90. 91

91. 92

92. Healing of pedicle grafts
Adaptation stage
(0 -4 days)
Proliferation
Stage (4-21 days)
Attachment stage
21-28 days
Maturation stage
2-3 months
Wilderman1965
93

93. EPITHELIALISED FREE SOFT TISSUE GRAFT
94

94. ADVANTAGES
Can be performed when keratinized gingiva
adjacent to involved area is insufficient.
Simplicity
Ability to treat multiple teeth at same time
DISADVANTAGES
Two operative sites
Compromised blood supply
Lack of predictability in root coverage
Greater discomfort
Poor hemostasis
Poor colour match
95

95. TWO-STAGE SURGICAL TECHNIQUE
FGGcanbeusedasthefirstsurgicalprocedureinthe
two-stagetechniquedescribedbyBernimoulinetal.in
1975.
Thisconsistsofafirststageofsurgery,inwhichafree
gingivalgraftisperformedtoincreasethekeratinized
tissueheightapicaltothegingivalrecession,anda
secondstageinwhichthegraftedtissueiscoronally
advancedtocovertheexposedrootsurface.
96

96. Thisprocedureisnotwellacceptedbythepatient
becauseofthetwosurgicalstages.
INDICATIONS:
thelackofkeratinizedtissueapicaland/orlateralto
therootexposure;gingivalcleftextendingbeyondthe
mucogingivalline;andthepresenceofashallow
vestibulumdepth.
97

97. 98

98. Advantages
Esthetics are favorable since donor is connective tissue.
Donor site heals fast with primary intention.
Less discomfort.
Disadvantage
High degree of technical skill required.
Indication
Where esthetics is of prime concern.
For covering multiple denuded roots.
In the absence of sufficient attached gingivain the adjacent
areas.
FREE CONNECTIVE TISSUE GRAFT
(Levine in 1991)
99

99. Step1:Divergentverticalincisions.Divergent
verticalincisionsaremadeatthelineanglesofthe
toothtobecovered,creatingapartial-thicknessflap
toatleast5mmapicaltotherecededarea.
Step2:Suturing.Suturetheapicalmucosalborderto
theperiosteumusingagutsuture.
Step3:Scalingandrootplaning.
100

100. Step4:Obtainthegraft.Fromthepalate,obtaina
connectivetissuegraft.Thedonorsiteissuturedafter
thegraftisremoved.
Step5:Transferthegraft.Transferthegrafttothe
recipientsite,andsutureittotheperiosteumwithagut
suture.Goodstabilityofthegraftmustbeattainedwith
adequatesutures.
Step6:Coverthegraft.Coverthegraftedsitewithdry
aluminumfoilandperiodontaldressing.
101

101. 102

102. •Trap-doorprocedures(EdelA.1974)andthe
•Envelopetechniqueswithsingle(LorenzanaE,2000)
ordouble(BrunoJ.1994)incisions.
•Theseprocedureshavethefollowingcommon
characteristics:aprimarysplit-thicknessaccessflap
elevation;thewithdrawalofconnectivetissuegraft;
andcompleteclosureofthepalatalwoundwiththe
accessflap.
103

103. TRAP DOOR TECHNIQUE
104

104. 105

105. SUBEPITHELIAL CONNECTIVE TISSUE
GRAFT (BILAMINAR TECHNIQUE)
ByLangerandLangerin1985.
Combinestheuseofapartialthicknessflapwiththe
placementofaconnectivetissuegraft.
Doublevascularization,fromboththeperiosteumand
thebuccalflap.
106

106. Thepredictabilityandsuperioraestheticsprovidedby
thistechniquemakeitthegoldstandardforroot
coverage.
Thebiologicalrationaleforthesetechniquesisto
providethegraftwithanincreasedbloodsupplyfrom
thecoveringflap.
Thiswillincreasethesurvivalofthegraftabovethe
avascularrootsurfaceandimprovetheesthetic
outcomebyhiding,partiallyorcompletely,thewhite-
scarappearanceofthegraftedtissue.
107

107. Indicatedforlargerandmultipledefectswithgood
vestibulardepthandgingivalthicknesstoallowa
split-thicknessflaptobeelevated.
Severalmodificationsrelatedtothetypeofgraft
(partiallyorcompletelyde-epithelialized)harvested
fromthepalateandtothedesign(envelopetypeor
withaverticalreleasingincision)ofthecoveringflap.
Thepartialthicknessflapmayormaynothave
verticalreleasingincisions(Langer&Langer1985;
Raetzke1985;Bruno1994).
108

108. Verticalreleasingincisionswillnoticeablyreducethe
bloodsupplyoftheflap.
Anenvelopeorapouchdesign,withoutthevertical
incisions,hasabetterlikelihoodforsuccessthandoesa
flapwithverticalreleasingincisions.
109

109. Procedure is basically a combination of a partial thickness
coronally positioned flap and a free c.t graft.
110

110. 111

111. ENVELOPE FLAP
112

112. ADVANTAGES
Esthetics
Predictability
One-step procedure
Minimal palatal trauma
Can treat multiple teeth
Increased graft vascularity
DISADVANTAGES
High degree of technical skill required
Complicated suturing
114

113. Aclassificationforincisiondesigns,relativetodonor
sitepreparation(palate)forsubepithelialconnective
tissuegrafting,wasproposedbyLiuetal.
TheLiuclassificationofincisiondesignhelpsthe
clinicianstodecideabouttheincisionsandalsohelps
toachievethemosteffectiveincision/flapdesignto
harvestthedonortissue.
115

114. 116
Cl 1is 1 incision,cl 2 is 2 incisions,cl3 is 3 incisions type A 1 horizontal
incision,type B is 2 horizontal

115. Pouch and Tunnel Technique (Coronally
Advanced Tunnel Technique)
Tominimizeincisionsandthereflectionofflapsandto
provideabundantbloodsupplytothedonortissue,the
placementofthesubepithelialdonorconnectivetissue
intopouchesbeneathpapillarytunnelsallowsfor
intimatecontactofdonortissuetotherecipientsite.
Estheticresultisexcellent.
Thetechniqueisespeciallyeffectivefortheanterior
maxillaryareainwhichvestibulardepthisadequate
andthereisgoodgingivalthickness.
117

116. POUCH & TUNNEL TECHNIQUE
118

117. 119

118. 120

119. Surgical Procedure
13 with gingival recession
Flap Reflected Following Incisions
121

120. 3m
m
Embossed
epithelium
Split thickness
Donor site after harvesting
122

121. Embossed epithelium
SECTG
Graft placed over the defect
123

122. REGENERATIVE PROCEDURES
BARRIER MEMBRANES
GTRwithresorbable&nonresorbablemembraneshas
beenusedforthetreatmentofgingivalrecessions.
Pini-Pratoetal.(1992)andTinti&Vincenzi(1994)
reportedtheuseofanePTFEmembranetotreatgingival
recessions.
Thisprocedurehasbeenshowntoofferapredictable
modalityforrootcoverage,especiallyindeep
recessions,resultingintheregenerationofnew
connectivetissueattachmentandbone.
124

123. INDICATIONS
• Moderate to severe gingival recessions
• Thin palate
• Patient reluctant to have a second surgery site
125

124. 127

125. Therootcoverageobtainedbypolytetraethylene
membranesorbioresorbablemembranesrangesfrom
54%to87%(withameanof74%).
However,theuseofthemembranetechniquealso
resultedinseveralproblemssuchasmembrane
exposure&contamination,technicaldifficultiesin
placingthebarrier&possibledamageofthenewly
formedtissueasaresultofmembraneremovalor
absorption.
128

126. MatterJ.1980showedthattheuseofabarrier
membrane,inconjunctionwithaCAF,doesnot
improvetheresultofCAFaloneintermsofcomplete
rootcoverageandrecessionreduction.
129

127. ENAMEL MATRIX DERIVATIVE
EMD,incombinationwithaCAF,wasintroducedto
treatgingivalrecessionwiththedoubleobjectiveof
enhancingrootcoverageresultsandinducing
periodontalregeneration(DelPizzoM,ZucchelliG,
2005).
EMD,inconjunctionwithaCAF,improvedthe
percentageofcompleterootcoverage,increased
keratinizedtissueheightandprovidedbetterreduction
ofrecession.
130

128. Histologicalstudiesarecontradictory,reportingeither
predominantattachmentconsistingofcollagenfibers
runningparalleltotherootsurfacewithoutnew
cementumorSharpey’sfibers&withnewbone&new
cementumformingonlyinthemostapicalportionof
rootsurface,orperiodontalregenerationwith
connectivetissueattachment,newbone&new
cementum(McGuireM,CochranD.2003).
131

129. Thetrueclinicalrationaletochoosethisapproachwith
respecttotheCAFaloneorothertechniquesisunclear;
thus,routineuseofEMDassociatedwithaCAFisnot
recommended.
Recommendedinsituationsinwhichawiderextension
ofnewattachmentformationbetweenthesofttissue&
therootsurfacecouldbeofclinicalrelevance.
132

130. Thismaybearesultofthesizeofrootexposure(a
verywideanddeeprecessiondefect),orthetooth
position(buccallydislocatedroot)oraconcomitant
bucco–lingualattachmentandbone.
133

131. SURGICAL TECHNIQUE
134

132. Patient related factors
Poor oral hygiene
Tooth brush trauma
Smoking
Site related factors
Interdental periodontal support:
Complete coverage in classIand II recessions
But loss of interdental tissue occurs as in class III and IV
recession, only partial coverage
Dimension of recession site
Less favourableoutcome in sites with a width of >3mm and
depth of >5mm
Factors influencing degree of root
coverage
136

133. Techniquerelatedfactors
Positivecorrelationnotedbetweenthicknessoftissue
flapandrecessionreduction.Forcompletecoveragea
criticalthresholdthicknessof1mmwasfoundfor
pediclegraftand1.5to2mmforfreegraft.Howevera
fullorsplitthicknessflapuseddoesnotdeterminethe
treatmentoutcome.
Eliminationofflaptensionisimportantforoutcomeof
coronallypositionedflap.
PositionofgingivalmarginrelativetoCEJ:In
coronallypositionedflapcompletecoveragewhen
positioned2mmcoronaltoCEJ.
137

134. SURGICAL EXPOSURE OF
IMPACTED TEETH
Themaxillarycuspidisthesecondmostfrequently
impactedtooth(2%)(Bass,1967)andismostoften
(2:1)impactedpalatally(Johnston,1969;Gensior
andStrauss,1974).
138

135. Thecuspidsaregenerallyoneofthelastteethtoerupt
intothearchandareadverselyaffectedby(Smukler
andcolleagues,1987):
1.Thelossofspace
2.Overretaineddeciduousteeth
3.Deflectionfaciallyorpalatallyoffthelateralincisor
139

136. Methods
The surgical techniques required are similar to those
used for basic periodontal surgery:
1. Gingivectomy: buccalexposures with adequate
keratinized gingiva only
2. Partial-thickness flap: labial or buccal
exposures
3. Full-thickness mucoperiostealflap: palatal
and lingual exposure
4. Osseous surgery: tooth exposure
140

137. Thethreemostsignificantadvanceshistoricallyfor
exposurewere
1.Palatalflapforexposure(Lappin,1951)
2.Directbondingbrackets(Gensiorand
Strauss,1974)
3.Softtissuemanagement(VanarsdallandCorn,
1977)
141

138. Thepalatalflapprovidedaccessandvisibility.
Directbondingreducedmorbiditybyminimizing
woundsizeandreducedtissueovergrowthand
additionalsurgeriesbyhavingthebracketplacedat
thetimeofexposure.
Softtissuemanagementmaintainedandpermitted
anincreaseinkeratinizedgingiva,eliminating
needlesssecondarysurgerytotreatmucogingival
problemsandpreventrecession.
142

139. DIAGNOSIS
Therearethreecommonlyusedmethodsfor
diagnosisofthepositionoftheimpactedcuspid:
1. PALPATION
2. RADIOGRAPHS
3. TRANSGINGIVAL PROBING (TGP)
143

140. PALPATION
Labialimpactionisoftenvisiblydiscernibleasa
bulgeonthelabialaspectorinthemucobuccalfold.
Digitalpalpationwillrevealalocalized,hard,well-
circumscribed,oval-shapedbodyjustbeneaththe
tissue.
144

141. Radiographs: The Buccal
Object Rule
Whentwodifferentradiographs(onestraightandone
angulatedmesiallyordistally)aretakenofapairof
objects,theimageofthebuccalonemoves,relative
totheimageofthelingualobject,inthesame
directionasthex-raybeamisdirected(Richards,
1980).
Clark(1910),inhisoriginalarticle,advocatedthree
radiographs(straight,mesial,distal)forafinal
determination
145

142. DiagrammaticrepresentationOfClark’srule.AandB,representthe
expectedmovementsoftheobjectswithangulation.Crepresents
straightradiography.
146

143. TransgingivalProbing
TGPwillprovideexactlocation.
TGPisconductedatthetimeofsurgeryafter
administrationoflocalanesthesiausinga30-gauge
needletoprobethearea.
A27-gaugeneedleissometimesrequiredifthe
impactionliesinabonycrypt(the30-gaugeneedleis
tooflexibleforosseouspenetration).
147

144. Theareaoftheimpactionisprobeduntiltheexact
positionofthetoothislocalized.Thisisdetermined
bythedifferenceintranslationoftheneedletipover
boneandoverenamel.
Whentheneedleisincontactwiththebone,itwill
stickandnotslide.
Whenincontactwiththeenamelofthetooth,itwill
slideorglideasifonasheetofglass.
148

145. Definitivelocalizationwillfacilitateflapdesign,
permittingaconservativesurgicalapproach.
TheTGPwillnotworkwhentheimpactedtoothis
coveredbyathickanddenselayerofbonethatthe
needlecannotpenetrate.
149

146. PROCEDURE: General Principles
Allproceduresusethefollowingcommonelements:
a.Localanesthesia
b.TGPfortoothlocalization
c.Theexposedtoothsurfaceiscleanedsufficiently
withsealersorrotaryinstrumenttopermitbracket
bonding.
d.Ultravioletlightorautopolymerizingbonding
agentsarerecommended
150

147. e.Bracketplacement
f.Wiretie-intoarchwire
g.4-0(or)5-0silkorchromicsutureswithaP-3
needle
h.Periodontaldressing
151

148. LABIAL POSITION
GINGIVECTOMY
nottheprocedureofchoiceandisusedonlyinlimited
situations.
Indications.
1.Impactionifpositionedabovethemucogingivalline
2.Awidezoneofkeratinizedgingivaexists
3.Excisionwillstillresultinaminimumof2to
3mmofkeratinizedgingivaapicaltotheCEJofthe
impactedtooth.
152

149. Contraindications.
1. Inadequate zone of keratinized gingiva
2. Access to the underlying bone is required
3. Tip of the impacted tooth is at or below the
mucogingivalline
Procedure.
1.WithaKirklandknifeorno.15scalpelblade,the
tissueoverthecrownisremoved.
2.Onlyasufficientamountoftissuetopermitbracket
placementisremoved.
153

150. APICALLY POSITION PARTIAL (SPLIT)
THICKNESSFLAP
Procedureofchoiceforsofttissuemanagement.
Indications.
1.Treatmentandpreventionofmucogingival
problems
2.Preciseflapstabilizationandpositioningare
required
3.Extensiveosseoussurgeryisnotrequired
Contraindication.
1.Aneedforextensiveosseoussurgery
154

151. Procedure
1.Asplit-thicknessflapisraisedbysharpdissections
usingano.15/15Cscalpelblade.
2.Theverticalreleasingincisionsarecarriedhighenough
intothevestibuletopermitapicalorlateralrepositioning
oftheflaps.
3.Theflapshouldbewideenoughtomaintainadequate
vascularity.
155

152. 4.Theflapisraisedtopermittheexposureofan
adequateamountoftoothstructuretopermitbracket
placement.
5.Theimpactedtoothiscleanedandscaledtopermit
bonding.
6.Anorthodonticbracketorbuttonisbondedto
position.
7.Theflapisapicallypositionedandstabilizedwith4-0
or5-0chromicgutinterruptedsutures
156

153. Buccal cuspid exposure. A, Initial view. B, Sharp dissection for partial-thickness pedicle flap
and preservation. C, Cuspid exposed. D, Residual tissue and/or bone is removed for
adequate exposure. E, Pedicle flap sutured apically with 4-0 or 5-0 chromic periosteal
sutures. F, Case completed.
157

154. PALATAL POSITION
Thecuspidisgenerallypositionedinoneofthe
followingpositions(KokichandMathews,1993).
1.Intra-alveolar—verticallywithintheedentulousarea
2.Horizontally
3.Apicaltothelateralandcentralincisors
158

155. Intra-alveolar position
Impactedcuspidmaybepresentvertically
positionedintra-alveolarlyintheedentulousarea.
Buccalorpalatalexposureisnotrecommendedfor
theseteethowingtotheexcessiveamountofbone
removalthatwouldberequired.
159

156. Procedure
1.Acrestalincisionisperformedoverthecrestofthe
edentulousridgewithano.15/15Cscalpelblade.
2.Amucoperiostealflapisreflectedwithaperiosteal
elevatorbuccallyandpalatally.
3.Theboneisexposedfor2to3mmbeyondtheosseous
crest.
4.Theflapsaretiedbacktoaidinexposureandbracket
placement.
160

157. 5.Thetoothisnowfullyexposedandthedentalsacis
enucleatedfromthebonycryptbysharpdissection
aidedbycurettes(Smuklerandcolleagues,1987).
6.Ostectomy,ifnecessary,iscarriedoutwithhigh-
speedrotaryinstrumentation,removingonlyenough
bonetoprovideforbracketplacement.
7.Afterbracketplacementandwiretie-in,theflapsare
suturedovertheedentulousarea.
161

158. Midridge exposure of an impacted cuspid. A, Initial occlusal view. B, Buccal
palatal flaps raised and area degranulated for exposure. C, Bracket placed
and area sutured. D, Bracket used for initial movement. E, Case near
completion.
162

159. PALATALPOSITION.
Mostcommonpositionandthemostdifficulttotreat.
1.Full-thicknessmucoperiostealflapfromthebicuspid
tomidline(Lappin,1951;KokichandMathews,1993)
2.Submarginalsemilunarortrapezoidalflap(Smukler
andcolleagues,1987)
163

160. PROCEDURE
A.FULL-THICKNESSMUCOPERIOSTEAL FLAP.
1.Intrasulcularorsubmarginalincisionsarecarriedout
withano.15orno.15Cscalpelbladefromthebicuspid
tothemidline.
2.Afull-thicknessflapisraisedtothepalatalvaultwith
aperiostealelevatorandtheflapisligatedtothe
opposingarchforretraction.
3.ContinueatC(post–flapreflectionandligation
procedures).
164

161. Palatal exposure of an impacted cuspid. Full
thickness mucoperiostealflap.
165

162. B.SEMILUNARORTRAPEZOIDAL FLAP.
1.Usingano.15cscalpelblade,asemilunarincision
ismadestartingmesiopalataltotheimpactedtooth
andfinishingdistopalatally.
Thiswillpermitelevationoftheflapwithunimpeded
accesstotheimpactedtoothandtoadjacentbone.
2.TheU-shapedincisionshouldpassthroughthe
edentulousareaifpossible.
166

163. 3.Theintactmarginalareasoftheadjacentteeth
shouldbeavoided.
4.Thescalpelbladeshouldbeangledtoobtainalong
bevel,whichwillfacilitateflapclosure.
5.Afull-thicknessmucoperiostealflapisreflected
withaperiostealelevator,whichisligatedtothe
opposingarchforretraction.
6.ContinueatC(postflapreflectionandligation
procedure)
167

164. C.POST–FLAPREFLECTIONANDLIGATION
PROCEDURES
1.Theroofofthebonycrypt,ifpresent,isgently
removedwithhandandrotaryinstrumentation.
2.Thedentalfollicleorsacisremovedbysharp
dissectionandhandcurettes.
3.Thewallsofthebonycryptareonlywidened
enoughtoprovideaccessforbracketplacement.
168

165. 4.Toothmobilityistestedwithaninstrument.
Ifthereisnomovement,anattemptismadetoluxate
andloosenitwithinthealveoluswithanelevator.
5.Thepositionofthetoothinthecryptisnoted.An
attempt(notalwayspossible)shouldbemadetoplace
thebracketinapositionthatwillfacilitatefavorable
orthodontictootheruption.
169

166. 6.Bracketorbuttonplacementisthemostdifficultpart
oftheprocedureowingtobleeding.
Bleedingcanbecontrolledby
a.Intraosseousinjectionoflocalanesthesiaof1:50,000
b.Packingtheareawithimpregnated(1:50,000)gauze
c.Sterilebonewaxburnishedintothebonycrypt
d.Propersuctiontechnique:Thetipispositionedwhere
thebleedingisemanatingfrom.
7.Thebracketbondistestedafterthewireisattached.
170

167. FLAP CLOSURE. FULL-THICKNESS
MUCOPERIOSTEAL FLAP(KOKICHANDMATHEWS,
1993).
1.Theflapisreturnedtoitsoriginalposition.
2.Theflapispalpatedtolocatethebracket.
3.Ano.15scalpelbladeisusedtofenestratetheflapfor
bracketexposure
4.Theflapissuturedwithacontinuousslingsuture
5.Thewireisnowattachedandtiedin
171

168. SEMILUNARFLAP.
1.Theflapisreplacedafterwireplacement
2.Ano.15scalpelblademaybeusedforbracket
exposurepriortofinalsuturing.
3.Theflapissutured
COMPLICATIONS
1. Loss of bracket—0 to 5%
2. Infection—none reported.
172

169. RIDGE AUGMENTATION
Hard tissue augmentation
•1. Vertical ridge augmentation
•2. Horizontal ridge augmentation
Soft tissue augmentation
173

170. RIDGE DEFECTS
Classification-Siebert 1983
174

171. SOFT TISSUE AUGMENTATION
1. Pedicle Graft Procedure
-Roll flap procedure
2. Free Graft Procedure
-OnlayEpithelialisedGraft
-Pouch Graft Procedure
-Inter positional onlayGraft
-Subepithelialconnective tissue graft
3. ALLOGRAFT-ADM
175

172. SOFT TISSUE AUGMENTATION
ROLL TECHNIQUE
DescribedbyAbrams&coworkers
Softtissueaugmentationproceduretocorrectaclass1
oranearlyclass2ridgedefect.
Involvesdissectingade-epithelializedpalatalflapand
creatingapedicletowardthevestibularaspect.
Thisconnectivetissuepedicleisthenrolledbelowthe
vestibularflapintheareaoftheridgethusgaining
volumeoftissuetothebuccalaspectofthedeficient
ridge.
176

173. Roll Flap (Abrams)
Removal of epithelium Elevation of pedicle
Pouch
created
Flap secured
To create a
Convex ridge
177

174. Advantage-
goodcolormatchofthesurroundingtissues
involvingasinglesurgicalsite.
Disadvantage–
Inabilitytotreatlargerdefectsbecauseofthelackof
donortissueavailability.
178

175. ONLAY EPITHELIALIZED GRAFTS/
FULL-THICKNESS SOFT TISSUE
GRAFTS
Meltzer(1979)publishedthefirstclinicalreporton
usingasofttissuegraftsolelytocorrectanesthetic
anteriorverticalridgedefect.
Full-thicknessfreegingivaloronlaygraftsusingthe
palateasthedonorsiteasdescribedbySeibertand
SeibertandSalama.
Thetuberosityordentulousridgeisthebestsourcefor
donortissue.Theprocedureislimitedbythe
availabilityofthick,graftabletissue.
179

176. Thesegraftsmaintaintheirepithelium;thegraftis
securedwithitsconnectivetissuebaseincontactwith
thedeepithelializedrecipientsite.
verticalslicesaremadeatrecipientsitetoenhancethe
bleedingsurface.Thisistopermitadequatediffusingof
thefull-thicknessgraft.
DISADVANTAGE:
Poorcolourblending
180

177. 181

178. POUCH PROCEDURE
Techniquefortreatingridgesthathadahorizontalloss
ofdimension.GarberandRosenberg(1981)
Usingaconnectivetissuegraftfromthetuberosityfor
subepithelialplacement,theprocedureprovidesboth
stabilizationofthegraftandridgeenhancement.
Thistechniquewasarefinementandanadvancementof
thosedevisedbyLanger(1980)andbyAbrams(1980).
182

179. Apartial-thicknessincisionismadewithano.15
scalpelbladeandextendedapicallyandlaterallyover
thedeformity.Bluntdissectionmaybeusedtoextend
thepouch.
Theconnectivetissuegraftissuturedusing4-0or5-0
silkorgut.Thesutureispassedfirstthroughthebase
ofthepouch.
Thisprovidesapicalstabilizationofthegraft.
183

180. POUCH PROCEDURE
184

181. SUBEPITHELIAL CONNECTIVE TISSUE
GRAFT FOR RIDGE AUGMENTATION
PlacingpalatalC.Tgraftbelowthemucogingivalflap
(LangerandCalagna1980;Garber&Rosenberg
1981)
Advantages
1.Versatility
2.Primaryclosure
3.Goodvascularity
4.Goodcolourmatch
5.Maybecombinedwithadjacentrootcoverage
procedures
6.Reducedtrauma
185

182. Disadvantages
1.Technicallydifficult
2.Possibleneedforsecondarymucogingivalsurgery
owingtoalteredcoronalpositionofthemucogingival
junction.
Indication
1.Forcorrectionofalltypesofridgedeformities
186

183. Procedure
1.Withano.15cscalpelblade,apartial-thickness
flapisbegunatthecrestorpalataltothecrestofthe
edentulousridge(onlyifaflapoverlapisdesired).
2.Theincisionsarecarriedmesiallyanddistallytothe
terminalendsoftheedentulousridge.
187

184. 3.Verticalincisionsarenowmadebuccallyand
palatally.Buccally,theyarecarriedfarenoughapically
beyondthemucogingivaljunctiontopermitfreedom
ofmovement.Palatally,theflapisreflectedjustfar
enoughtopermitplacementofthegraft.
4.Ahorizontalapicalreleasingincisionofthebuccal
flapmaybenecessaryforgreaterflapmobilityand
coronalpositioning.
188

185. 5.Theconnectivetissuegraftswithouttheepithelial
borders,aresuturedinplaceusingchromicgut
sutures.Oneormorepiecesmaybeuseddepending
onthedefect.
6.Thebuccalflapiscoronallypositionedandsutured
atthecrestoftheridgeoroverlappedpalatally.The
flapisalsosuturedlaterallyforenhancedstability.
189

186. SECTG
190

187. INTERPOSITIONAL ONLAY GRAFT
DevelopedbySiebertandLouis(1995,1996),for
treatmentoflargeClassIIIridgedefects.
Attemptstomaximizethebenefitsofonlay
epithelializedgraftsandSCTG.
Theepitheliumofthegraftisnotremovedfromthe
superficialborderoftheC.Tgraft;thegraftissecured
belowmucogingivalflap,leavingitsepithelium
exposed.
191

188. ADVANTAGES
1.Increasedrevascularizationoftheonlaygraft
2.Smallerpalatalwound
3.Lessmorbidity
4.Increasedabilitytocontroldirectionof
augmentation
a.Apicocoronal
b.Buccolingual
5.Noalterationinvestibulardepth
192

189. Procedure
Deepithelialization.
1.Witha15Cscalpelblade,theepitheliumoverthe
coronalaspectoftheridgeisremoved.
2.Verticalgroovesintheridgearesometimeadvocatedfor
increasedvascularizationoftheonlayportionofthegraft
(Siebert,1991).
Pouch.
1.Witha15Cscalpelblade,apartial-thicknesspouch
procedureisperformed.
193

190. 2.Unlikethebasicpouchprocedure,SiebertandLouis
(1995,1996)advocatetheuseofverticalreleasing
incisionattheterminalendsofthedeepithelialized
ridge.
Graft.
1.Theepithelializedandconnectivetissueportionsof
thegraftaredetermined.Thegraftisgenerally
trapezoidalinshape.
194

191. InterpositionalGraft.(Siebert,1992)isalmost
identicaltothepouchprocedureexceptthatathick
epithelializedconnectivetissuegraftor“wedge”is
positionedbetweenthefreeedgeofthepouchandthe
exposedportionoftheridge.Itisusedfortreatmentof
ClassIridgedefects.
Unlikethetruepouchprocedure,theepithelialsurface
ofthegraftisleftexposedandverticalincisionsmay
alsobeemployed.
195

192. 196

193. 197

194. TUNNEL TECHNIQUE
Atunneltechniquehasbeendescribedtoaugmentthe
ridgeunderanexistingponticbyaverticalincision
madeadjacenttothedeficientridgeandaconnective
tissuegraftplacedintothetunneltoaugmentthe
depression.
Tunnelispreparedoveranedentulousspace.
Thistechniqueisparticularlyusefulintryingto
augmentadeficientridgewhenafixedpartialdentureis
alreadyinplace.
198

195. HARD TISSUE AUGMENTATION
Bone grafting
Biomaterials
GBR
Alveolar distraction osteogenesis
199

196. AUTOGENOUS BONE GRAFT
◦Gold standardfor bone augmentation procedures
◦Block bone or particulate forms
Block bone -reduced osteogenicactivity & slow
revascularization than particulate bone
◦Extra-oral or Intra-oral donor-site
Intraoral harvested intramembraneousbone graft may
have minimal resorption, enhanced revascularization,
and better incorporation at the donor site
200

197. AdvantagesofAutogenousbonegraft
◦Osteogenicpotential
◦Blockgraftsthatmaintainformandshape
◦Abilitytocorrectanysizeorshapedeformity
◦Eliminationofthepossibilityforanimmunogenic
reaction
201

198. Disadvantages
◦2
nd
surgical intervention
◦Morbidity associated with the donor site
◦Unpredictable bone resorption
◦Longer recovery period
◦Difficulty in managing soft tissue coverage
◦Increased treatment time
◦Increased risks
202

199. Autogenousblock bone grafts
Widthdeficiency
◦Veneerorsaddlegraft
◦Mostpredictableandresistanttoresorption
Verticaldeficiency
◦Onlayorsaddlegraft
◦Difficulttogainandmaintain,highresorptionrate
Combineddeficiency
203

200. Donor Sites of AutogenousBone
Cortical Bone
◦Mandible, Cranium
Cancellous Bone
◦Mx. Tuberosity
◦Inner Cancellous part
Cortico-Cancellous Bone
◦Iliac bone
204

201. Intra-oral vsExtra-oral
Kusiak et al (1985)
◦Intramembranous bone grafts accelerate revascularization
and healing as compared to endochondral bone grafts
◦Cortical membranous grafts revascularize more rapidly
than endochondral bone graft with a thicker cancellous
part
Zins & Whittacker (1983), Philips & Rhan (1990)
◦Membranous bone (such as mandible) undergoes less
resorption than endochondral bone (such as iliac crest)
Intraoral harvested intramembraneous bone grafts
◦Minimal resorption
◦Enhanced revascularization
◦Better incorporation at the donor site
205

202. Critical Success Factors
Stability of grafting materials
Condition of recipient sites
No infections
Resistance to resorptions
Soft tissue coverage
206

203. IMPROVED TECHNIQUE
In1985,Allenandcolleaguesoutlinedanimproved
surgicaltechniqueforlocalizedridgeaugmentationthat
wassimilartothatpreviouslydescribedbyKaldahland
colleagues(1982)exceptthatthegraftmaterialwasa
hydroxyapatiteimplant.
Theuseofahydroxyapatiteimplantpermittedan
unlimiteddonorsource,withgreaterpredictabilityof
results.
Theuseofapartial-thicknesspalatalflapprevents
separationandopeningofthepouch.
207

204. Procedure
Twopartial-thicknessverticalparallelincisionsare
joinedbyahorizontalincision.Thepartial-thickness
flapwillextendtothecrestoftheridge.
Apartial-thicknessflapisraisedusingsharp
dissectiontothecrestoftheridge.
208

205. Atthecrestoftheridge,afull-thicknesspouchis
reflectedofftheboneandextendedfarenough
apicallyforcorrectionoftheridgedeformity.The
pouchisnowfilledwithanyofthehydroxypatiteor
allographicmaterials,nonresorbable.
Thepouchisclosed,andtheflapissutured.
Eveniftheflapisnottotallyapproximatedpalatally,it
willstillnotopenbecauseoftheadequateoverlapof
thetissuepalatally.
209

206. IMPROVED TECHNIQUE
210

207. GBR
WhileGTRisfortheregenerationofperiodontaltissue
ofnaturalteeth(rootcementum,periodontalmembrane,
alveolarbone),GBRisfortheregenerationof
supportingbone.
BecauseoflessmembraneexposureinGBR,thechance
ofinfectionisdecreasedmakingboneregeneration
highlypredictable.
ThisprinciplewasfirstintroducedbyHurleyand
colleaguesin1959forthetreatmentofexperimental
spinalfusion.
Nonabsorbableandabsorbablemembranes.
211

208. Nonabsorbablemembranes
Nonabsorbablemembranesareusuallymadeofa
porous,polytetrafluoroethylene(e-PTFE),or
nonporous(high-density)PTFE
Theporouse-PTFEmembranesshouldstay
submergedthroughoutthehealingphase,butthemost
commoncomplicationisexposureofthemembrane,
whichwilloftenleadtoinfectionandfailureofthe
technique.
Successoccurswhenthesofttissuecoveringthe
membraneremainsintactforaminimumof30days
andideallyfor6monthsorlongerasneededfor
maturingofthenewlyformedbone.
212

209. Ifthemembranecanmaintainasuitablespaceunder
themembrane,nobonegraftingmaterialsareneeded.
Titaniumreinforcementhelpswithshapingof
membranesandmaintainingspaceunderthe
membrane.However,bonegraftingmaterialscanalso
beusedunderthemembranetoensureproperspacefor
boneregeneration.
Nonporoushigh-densityPTFEmembranesdonothave
tobecoveredandcanremainexposedtoanoral
environmentuntilremovedat30daysorlater.
213

210. Absorbable membranes
Someresorbinafewdayswhereasotherstakemonths
toresorb.Thelongerthemembranestaysintactthe
longertimethebodyhastoregenerateboneunderthe
membrane.
Thelastbonetomineralizeisthebonelocateddirectly
underthemembrane,whichisfarthestawayfromthe
nativeboneandclosesttothesofttissue.
214

211. Whenabsorbablemembranesareexposedtotheoral
cavitytheydegrademuchfasterthantheywouldif
containedunderaflap.
Theabsorbablemembraneshavefewerpostoperative
complicationsthannon-absorbablemembranesanddo
notrequireasecondaryprocedureformembrane
removal;therefore,absorbablemembranesaremore
widelyused.
215

212. 216

213. 217

214. DISTRACTION OSTEOGENESIS
Thisinvolvedtheuseofamechanicaldevice(the
distractor)andtheformationofnewbonebetweenthe
bonesegmentsthatweregraduallyseparatedby
incrementaltraction(BirchandSamchukov2004).
Thistractiongeneratedtensionthatstimulatednewbone
formationparalleltothevectorofdistraction(Copeand
Samchukov2001,Samchukov1998).
Thistechniquehadtheaddedadvantageofdisplacing
andpreservingthesofttissuewiththemobilizedbony
segment.
218

215. Indications
•Combineddeficienciesinhardandsofttissuenot
allowingfordentalimplantplacement
•Verticalalveolarridgedeficiencyimpairingthe
placementofadentalimplantorfixedpartialdenture
Advantages (Chiapasco2004)
• Eliminates the need to harvest bone
• Less operating time
• Distraction histogenesis
219

216. Limitations
•Musthaveaminimumof6mmofresidualbone
height
•Musthaveadequatebonewidth(otherwiseblock
graftnecessarybeforedistraction)
•Thinresidualbonyarch,presentingtheriskof
fracture
•Patientsonbisphosphonates
•Irradiatedpatients(>40to60Gy)
•Malignancies
•Heavytobaccouse
220

217. Rose & Mealey
CHOICE OF TREATMENT
221

218. ESTHETIC SURGICAL CORRECTION
AROUND IMPLANTS
222

219. Theendresultofimplanttherapybecomeasuccess
onlywhenacloseresemblancewithwhatonceexisted
innatureisachieved,foritsabilitytoprovidethe
propermasticatoryfunctionwhiledisappearingin
betweentheremainingnaturalteeth.
Itisimperativetosurroundthecrownwithhealthy,
gingival-liketissue.
223

220. Encompassingthefixtureistissue,withitslower
cellularityandreducedvascularity,thatresembles
cicatritialtissueandrequiresspecialcarewhen
surgicallychallenged.
Thelackofpdlligament,withitsvesselsandcells,
mustbekeptinmindwhenapproachingtheperi-
implantmucosa.
224

221. Thequalityandquantityoftheperi-implanttissues
shouldbeimprovedeitherbeforeoratimplant
placement,duringthesubmergedhealing,oratthetime
ofsecond-stagesurgery(Nevins&Mellonig1998).
Inanattempttocoveranexposedimplant-abutment
complex,ortomaskthegrayishnessthattranspires
throughthinperi-implantmucosaltissue,surgical
approaches,suchasthevariouslydisplacedpedicle
flaps(coronally,laterally,doublepapilla,etc.)orfree
gingivalautografts,usuallyfallshort.
225

222. Insuchclinicalscenarios,andprovidedthattheangle
ofemergenceoftheimplant-abutment-crowncomplex
isnotexcessivelybuccal,acoronallyadvancedflap
augmentedbyasubepithelialconnectivetissuegraft
representsthemostpredictableprocedurebecauseofits
doublebloodsupply(Langer&Langer1985;Nelson
1987).
Inparticularlydifficultclinicalcases,removingthe
prostheticcomponentstoresubmergethefixturecanbe
usefultowidentherecipientvascularbedpalatallyfor
thesubepithelialconnectivetissuegraft.Thisfurther
increasesthepredictabilityofsuccess.
226

223. Clinical rationale for adequate attached
peri-implant soft tissues:
Provide “prosthetic –friendly” environment
Facilitate oral hygiene maintenance
Resist recession
Maintain predictable levels over time
Enhance esthetic blending
227

224. BIOLOGIC WIDTH
Clinically,0.5to1.0mmisthesafedistancein-between
restorativemarginandbaseofthecrevice.Violationsof
biologicwidthleadtopocketformation,softtissue
recessionandlossofalveolarbone.Biologicwidth
existsaroundnonsubmergedone-piecetitanium
implantsandthisisphysiologicallyformedandstable
structurewhichissimilartothatfoundonhuman
naturaldentition.
MaynardandWilsondivideddentogingivalunitas
superficialphysiologicdimension,Crevicular
physiologicdimensionandsubcrevicularphysiologic
dimension.
228

225. Submergedornonsubmergedapproach–which
providesestheticpredictability?
LiteraturesuggestsNonsubmergedapproachasithas
variousadvantagessuchas,
Itprovidessufficienttimeformaturesofttissue
integration
allowsforstabilizationofjunctionalepitheliumand
sulcusdepthdimensionsduringintegrationperiods
eliminatestheneedtodisruptmatureperi-implantsoft
tissues
improvesthelong–termpredictability
requiresfewersurgicalapproaches,thus,circulation
preservedinthatarea
lesstreatmenttimeandpatientdiscomfort,
229

226. improvedpatientacceptance
closestotheingressofbacterialcontaminants
maintainsordevelopspositivesofttissuearchitecture
atthesite
preventssofttissueshrinkage
providesopportunitytomonitorsofttissuevolume
andarchitectureandtoperformsofttissuerefinements
asneeded
Providesstableenvironmentfortherestorativedentist
andfinallyfacilitatesabutmentselection.
230

227. EVALUATIONOFESTHETICIMPLANTPATIENT
Smiledesignandsmileesthetics,facialanddental
symmetry,upperlipline,lowerlipline,incisalplane,
occlusalplane,toothproportionsandrelationships,
gingivalplaneandoutlineandfinallyperiodontal
biotypeshouldbeevaluatedbeforeimplantplacement
inordertoprovidethemthegoodesthetics.
231

228. SOFT TISSUE GRAFTING
Periodontal plastic surgery for the implant patient
includes
Augmentationof attached tissues surrounding
natural teeth and implant restorations
Root and implant abutment coverage
Correction of mucogingival defects around
implants
232

229. Edentulous ridge preservation following tooth
removal in preparation for prosthetic rehabilitation
with conventional or implant prosthesis
Managementofaberrantfrenula
Preservationofreconstructionofinterdentalor
inter-implantpapillae
Surgicalsofttissuesculptingprocedures
233

230. Goals of soft tissue grafting
Tocreateastableperi-implantsofttissue
environmentbyprovidinganadequatezoneof
attachedkeratinizedtissueswithintimateadaptation
toemergingimplantstructures
Inconspicuousreconstructionofnaturalsofttissue
architecturetoenabletheemergenceofharmonious
implantrestorations
234

231. Principles of soft tissue grafting
PREPARATION OFRECIPIENTSITE:Ensure
adequatevascularitytosupportthegraftandProvidea
meansforrigidimmobilizationofthegraft.Then
prepareuniformsurfaceforintimategraftadaptation
andobtainhemostasis.
MANAGEMENT OFDONORTISSUE:Harvestgraft
ofadequatesizetotakeadvantageofperipheral
circulation.Ensureauniformgraftsurfacefor
adaptationofrecipientsite.Ensureadequatethickness
toobtaindesiredvolumeaugmentationandforsurvival
overavascularsurfaces
235

232. VARIOUS TECHNIQUES OF SOFT
TISSUE GRAFTING:
MODIFIED ROLL TECHNIQUE
EPITHELIALIZED PALATAL GRAFT TECHNIQUE
FOR DENTAL IMPLANTS
236

233. SUBEPITHELIALCONNECTIVETISSUEGRAFT
TECHNIQUE:
Versatileapproachtoanteriorestheticenhancement
VASCULARIZED INTERPOSITIONAL
PERIOSTEALCONNECTIVE TISSUE(VIP-CT)
FLAP:
Itallowslargevolumesofttissueaugmentationat
estheticsiteswithasingleprocedure
ALLODERM (Acellulardermal matrix)
237

234. MODIFIED ROLL TECHNIQUE
ThefirstmodificationforAbramsrolltechniquewas
proposedbyScharfandTarnow1992,theyraisedand
preservedtheepitheliumoverthepalatalconnective
tissue(trapdoor).Theideawassmartlymodifiedby
Hüzeleretal.,2010,whobenefitedfromtheusually
discardedkeratinizedmucosaoverthecoveringscrewto
augmentthelabialsofttissues.
Insteadofusingthestandardcrestalincisionfor
uncoveringtheimplant,theoverlyingmucosacanbe
pedicledtothelabialmucosaandrolledbeneathitto
effectivelyenlargeitswidth.
238

235. Thistechniquecansparetheproblemofdonorsite
morbidity,post-surgicalbleedingandanatomical
limitationsthatmaylimitthepalatalharvesting.Italso
eliminatestheneedforsecondsurgicalsitewith
consequentpost-operativecomplicationsandpatient
discomfort.Moreover,itovercomesthecostproblems
ofacellulardermalmatrix.
Doneinconjunctionwithsecondstageforsubmerged
&simultaneouslywithonestagednon-submerged
implantplacement.
239

236. Themodifiedrollflap(MRF)isapedicleflapdesignedto
makeuseofthegingivaltissueoverlyingthecoveringscrew
toexpandthethicknessofthelabialsofttissueinsteadof
discardingitasinflaplesstechnique. 240

237. 241

238. MODIFIED ROLL TECHNIQUE
242

239. EPITHELIALIZED PALATAL GRAFT
TECHNIQUE FOR DENTAL IMPLANTS:
Predictable & versatile technique
INDICATION:
Absence of attached gingiva at edentulous implant
site-perform grafting 8-12 wksbefore implant
placement
Less than 3mm attached tissue & less than 10mm
height of mandible/ maxilla
243

240. Toincreasethezoneofattachedtissue,thicksplit-
thickness(0.75–1.25)graftpreferredandforroot
orabutmentcoverage,splitthicknessflap
approachingfull-thickessflap(1.25–1.75mm)
preferred.
244

241. ALLODERM
Alternative to harvesting autogenous epithelialized
palatal grafts.
245

242. VASCULARIZED INTERPOSITIONAL
PERIOSTEAL CONNECTIVE TISSUE
(VIP-CT) FLAP
Introducedasanalternativetoothertechniqueswhich
allowsthecliniciantoperformlargevolumesofttissue
augmentationatestheticsiteswithasingleprocedure.
ADVANTAGE-minimalpostsurgicalshrinkage,
minimallyinvasivedonorsitewound,allowsprimary
closureofdonorsite,maintainsanintactvascular
supply,providesexcellentestheticblendingatthe
recipientsiteandreducedtreatmenttime.
246

243. Recipientbedwaspreparedbygivingexaggerated
curvilinear-beveledincisionstartingatthevestibuleapical
totheinterdentalpapillaoftheteethadjacenttothesite
andcontinuedcoronallywithaslightcurveasitreached
therecipientsitefinallyterminatingonthepalatalaspect
oftheridgewithabbreviatedverticalreleasingincisions
madeonthepalateatthemesialanddistalaspectofthe
recipientsite.
Horizontalincisionwasthenmadeconnectingthevertical
incisions.Mucoperiostealflapwasperformedtoraisea
buccalflap.
247

244. Incisionatthedistalaspectoftherecipientsiteparallels
thegingivalmarginontheoralaspectoftheadjacent
tooth;thisisextendedhorizontallytothedistalaspectof
the2ndpremolarandfollowingapathapproximately2
mmapicaltofreegingivalmarginofcanineand
premolarteeth.
Sharpdissectionwasusedtocreatesplitthickness
palatalflapinthepremolararea.Thesubepithelial
dissectionwascarriedanteriorlytowardthedistalaspect
ofthecanine.
248

245. Averticalincisionwasthenmadeatthedistalaspectof
subepithelialdissection.Subepithelialconnectivetissue
layerwaselevatedbeginningfromsecondpremolararea
towardtheanteriorextentofthedissection.
Asecondincisionwastheninitiatedundertension
internallyattheapicalextentofthepreviousvertical
incisionandextendedhorizontallyanteriortothedistal
aspectofthecanine.
Tensionreleasingcutbackincisionswasextendedinto
thebaseofthepedicleflapforflaprotation.
249

246. Flapisrotatedintotherecipientsiteandrigidly
immobilizedwithsuturesplacedapicallyand
laterally.
Donorandrecipientsitesweresuturedtoobtain
primaryclosureandgentlepressurewasappliedwith
moistenedgauzefor10minutes
250

247. 251

248. Periodontalplasticsurgerybasicallyincludessofttissue
relationshipsandmanipulations.
Surgicaltechniquessolelytoincreasethewidthand
thicknessofthekeratinizedtissueareamongthemost
predictableperiodontalprocedures.
Periodontalplasticsurgicalproceduresforrootcoverage
havelesspredictabilitybecauseoftheabsenceofa
foundationforbloodsupplyovertherootsurface.
Howevermeticulous,preciseandcarefullyplanned
surgicalprocedurearefoundtobringaboutthebest
results.
CONCLUSION
252

249. Oneofthemostimportantinnovationsingingival
recessiontreatment,whichhasalreadystartedbut
needsfuturedevelopmentandimprovement,isthe
designofclinicaltrialswiththepatient’soutcome,
estheticsandmorbidityinparticular,asprimary
outcomemeasures.
Thisislikelytochangecurrentsuccessevaluation
criteriaandperhapsalsothedecisionalmatrixinthe
surgicalmanagementofgingivalrecession.
253

250. REFERENCES
Newman,Takei,Klokkevold,Carranza-Clinical
Periodontology.12
th
ed.Elsevierpublication;2015.
SergeDibart•MamdouhKarima.PracticalPeriodontal
PlasticSurgery.Blackwellpublication;2006.
EdwardSCohen.Atlasofcosmeticandreconstructive
periodontalsurgery.Thirdedition.2007.
JanLindhe,NiklausPLang,ThorkildKarring-
ClinicalPeriodontology&ImplantDentistry.
GiovanniZucchelli&IlhamMounssif.Periodontal
plasticsurgery.Periodontology2000,Vol.68,2015,
333–368.
254

251. Chiun-LinLiu,ArnoldS.Weisgold.ConnectiveTissue
Graft:AClassificationforIncisionDesignfromthePalatal
SiteandClinicalCaseReports.TheInternationalJournalof
Periodontics&RestorativeDentistry,Volume22,Number
4,2002.
AshishKumar,VishalSood,SujataSurendraMasamatti,M.
G.Triveni,D.S.Mehta,ManishKhatri,VipinAgarwal.
Modifiedsingleincisiontechniquetoharvestsubepithelial
connectivetissuegraft.JournalofIndianSocietyof
Periodontology,Vol17,Issue5,Sep-Oct2013.
RobertA.Levine,GuyHuynh-Ba,DrMedDent,DavidL.
Cochran.SoftTissueAugmentationProceduresfor
MucogingivalDefectsinEstheticSites.IntJOral
maxillofacImplants2014;29.
Paavai Ilango, ArulPari. Soft tissue esthetics around
implants -a review. Annals and Essences of Dentistry,
Vol. V Issue 4 Oct–Dec 2013.
255

252. THANKYOU
256