Periodontal Plastic Surgery

1. Good Afternoon
IVth Year
Good Afternoon
IVth Year

2. Periodontal Plastic Surgery
Presented By :
Dr. Abhishek Gaur
BDS, MDS, (Ph.D)
Department of Periodontics
R. R. Dental College & Hospital
Umarda, Udaipur (RAJ.)

4. Miller (1993)
Periodontal plastic surgery, treatment
of problems associated with the
amount of gingiva and recession type
defects to also include correction of
ridge form and soft tissue esthetics.
Miller (1993)
Periodontal plastic surgery, treatment
of problems associated with the
amount of gingiva and recession type
defects to also include correction of
ridge form and soft tissue esthetics.

5. PERIODONTAL PLASTIC
SURGERY
(WORKSHOP 1996 )
•Gingival augmentation
•Root coverage
•Correction of mucosal defects at implants
•Crown lengthening
•Gingivectomy
•Removal of aberrant frenulum
•Prevention of ridge collapse associated with tooth
extractions.
•Augmentation of the edentulous ridge
PERIODONTAL PLASTIC
SURGERY
(WORKSHOP 1996 )
•Gingival augmentation
•Root coverage
•Correction of mucosal defects at implants
•Crown lengthening
•Gingivectomy
•Removal of aberrant frenulum
•Prevention of ridge collapse associated with tooth
extractions.
•Augmentation of the edentulous ridge

6. Objectives
1.To understand some of the different types of grafts used
in Periodontal Plastic Surgery (Mucogingival Surgery)
2.To understand the indications for the different types of
mucogingival surgeries.
3.To show some examples of one of the most common
grafting procedures, the FGG and CTG.
4.To understand when a condition would not benefit from
Mucogingival Surgery
ObjectivesObjectives
1.To understand some of the different types of grafts used
in Periodontal Plastic Surgery (Mucogingival Surgery)
2.To understand the indications for the different types of
mucogingival surgeries.
3.To show some examples of one of the most common
grafting procedures, the FGG and CTG.
4.To understand when a condition would not benefit from
Mucogingival Surgery

7. Indications
• Gingival Augmentation
• Free Gingival Graft
• Connective Tissue Graft
• Root Coverage
• Coronally positioned flap
• Semilunar flap
• Laterally positioned flap
• Double papilla flap
• Free Gingival Graft
• Connective Tissue Graft
• Guided Tissue Regeneration using allograft
IndicationsIndications
• Gingival Augmentation
• Free Gingival Graft
• Connective Tissue Graft
• Root Coverage
• Coronally positioned flap
• Semilunar flap
• Laterally positioned flap
• Double papilla flap
• Free Gingival Graft
• Connective Tissue Graft
• Guided Tissue Regeneration using allograft

8. When is Grafting Needed ?
How much keratinised gingiva is needed ?
• Bowers 1963 – felt that gingival health could be maintained with a
narrow zoned of KG (<1mm) but some was required for healing.
• Lang & Loe 1968 – suggested 2mm.
• Maynard and Wilson 1979 – 5mm of KG with 3mm attached
when sub-gingival restorations are planned.
• Kennedy 1985 – over a 6 year period, patients with inconsistent
OH saw recession with thin tissue.
Bottom Line : some attached gingiva is necessary for health, but
patients with good OH can maintain thin AG.
When is Grafting Needed ?When is Grafting Needed ?
How much keratinised gingiva is needed ?
• Bowers 1963 – felt that gingival health could be maintained with a
narrow zoned of KG (<1mm) but some was required for healing.
• Lang & Loe 1968 – suggested 2mm.
• Maynard and Wilson 1979 – 5mm of KG with 3mm attached
when sub-gingival restorations are planned.
• Kennedy 1985 – over a 6 year period, patients with inconsistent
OH saw recession with thin tissue.
Bottom Line : some attached gingiva is necessary for health, but
patients with good OH can maintain thin AG.

9. •Is the recession progressing ?
•Is the tooth treatment planned for orthodontic care or
prosthetic treatment ?
•Is there root sensitivity ?
•Is there difficulty cleaning the root surface by the
patient ?
•Is there an esthetic concern ?
When is Grafting Needed ?When is Grafting Needed ?When is Grafting Needed ?

10. Free Gingival Auto-Grafts
Indications
• To increase keratinised tissue around teeth, implants or crowns.
• To increase keratinised tissue under removable prostheses.
• To increase vestibular depth.
Disadvantages
• Difficult to achieve root coverage.
• High esthetic demand.
• Large, uncomfortable donor site.
• Graft site, slow uncomfortable healing.
Free Gingival Auto-GraftsFree Gingival Auto-Grafts

11. •Classic “Gum Graft”
•Will increase keratinised gingiva
•Results in “Tire Patch” look.
•Classic “Gum Graft”
•Will increase keratinised gingiva
•Results in “Tire Patch” look.

15. Connective Tissue
Graft
Advantages
• Very predictable for root
coverage
• Smaller donor site (than FGG)
• Smaller recipient site (than FGG)
• Less soreness overall (than FGG)
• Uses patient’s own tissue
• Excellent esthetics
• Can cover multiple, large
recessions even on teeth with a
previous restorations
Disadvantages
• Two surgical sites
• Technique sensitive
• Bleeding from palate (potential)
Connective Tissue
Graft
Advantages
• Very predictable for root
coverage
• Smaller donor site (than FGG)
• Smaller recipient site (than FGG)
• Less soreness overall (than FGG)
• Uses patient’s own tissue
• Excellent esthetics
• Can cover multiple, large
recessions even on teeth with a
previous restorations
Disadvantages
• Two surgical sites
• Technique sensitive
• Bleeding from palate (potential)

16. ProcedureProcedureProcedure

30. CTG ? Not-Indicated ?
•All exposed dentin is gingival recession.
•Abfraction.
•Tissue at or near the CEJ.
•Gingival hyperplasia adjacent to normal gingival
contours.
CTG ? Not-Indicated ?
•All exposed dentin is gingival recession.
•Abfraction.
•Tissue at or near the CEJ.
•Gingival hyperplasia adjacent to normal gingival
contours.

31. Does Tooth-brushing
‘too hard’
causes
gum recession ?
Does Tooth-brushing
‘too hard’
causes
gum recession ?

33. Not really….
•Tooth-brushing and gingival recession. Litonjua, LA, et al. Int
Dent J 2003 53(2) a literature review showed no direct
relationship between toothbrushing and gingival recession.
•Trauma from toothbrushing may contribute to recession in
a minor way, but other more important factors should be
treated first.
•Abrasion of the hard surfaces of the teeth are likely caused
by abrasives in the toothpaste.
Not really….
•Tooth-brushing and gingival recession. Litonjua, LA, et al. Int
Dent J 2003 53(2) a literature review showed no direct
relationship between toothbrushing and gingival recession.
•Trauma from toothbrushing may contribute to recession in
a minor way, but other more important factors should be
treated first.
•Abrasion of the hard surfaces of the teeth are likely caused
by abrasives in the toothpaste.

36. Does It Hurt ???
• The common perception is that Connective Tissue
Grafting is VERY PAINFUL!!
• This is often the patient’s perception.
• This perception is usually the result of hearsay from
friends and relatives.
• The origins probably go back to the days of the Free
Gingival Grafts.
Does It Hurt ???
• The common perception is that Connective Tissue
Grafting is VERY PAINFUL!!
• This is often the patient’s perception.
• This perception is usually the result of hearsay from
friends and relatives.
• The origins probably go back to the days of the Free
Gingival Grafts.

37. Reality
•In 20 years of performing CT grafts, very few patients ever
complain about significant pain afterwards.
•Most are pleasantly surprised at how little pain they had.
•Very little post-opp. bleeding, swelling or bruising.
Of course, everyone’s pain threshold is different…
Does It Hurt ???Does It Hurt ???
Reality
•In 20 years of performing CT grafts, very few patients ever
complain about significant pain afterwards.
•Most are pleasantly surprised at how little pain they had.
•Very little post-opp. bleeding, swelling or bruising.
Of course, everyone’s pain threshold is different…