1. Periodontal Plastic Surgery
Soft Tissue Grafting
Indications and Procedures

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

3. Common Questions (FAQ’s):
When is gingival grafting needed and when is it not?
Why do I need it? What happens if I don’t do it?
Does it hurt?
What is the recovery time?
Does it work? Does it have to be redone?
Does brushing too hard cause recession?
How much does it cost?

4. Definitions
Attached Gingiva – The portion of the gingiva that is firm, dense, stippled and tightly bound to the underlying periosteum, tooth, and bone.
Free Gingiva – That part of the gingiva that surrounds the tooth and is not directly attached to the tooth.

5. Definitions
Mucogingival Junction – the area of union of the gingiva and alveolar mucosa
Alveolar Mucosa – Loosely attached mucosa covering the basal part of the alveolar process and continuing into the vestibular fornix and the floor of the mouth

6. Definitions
Mucogingival Defect – a departure from the normal dimension and morphology of the relationship between the gingiva and the alveolar mucosa

7. Definitions
Free Gingival Graft (FGG) - A soft tissue graft that is completely detached from one site and transferred to a remote site. No connection with the donor site is maintained
Subepithelial Connective Tissue Graft (CTG) - A detached connective tissue graft that is placed beneath a partial thickness flap. This variation of the free gingival graft provides the tissue graft with a nutrient supply on two surfaces

8. History of Periodontal Plastic Surgery
1930’s – Frenectomies and vestibuloplasties
1948 – First Gingivoplasties
1956 – Grupe and Warren publish Laterally Positioned Flap
1963 – Bjorn publishes the Free Gingival Graft
1982 – P.D. Miller introduces the FGG for root coverage. Fernandez does first CT graft
1989 – AAP renames Mucogingival Surgery to Periodontal Plastic Surgery

9. Indications for Perio Plastic Surgery
Gingival Augmentation
Free Gingival Graft
Connective Tissue Graft
Root Coverage
Coronally positioned flap
Semilunar flap
Laterally positioned flap
Double papilla flap
Guided Tissue Regeneration using allograft

10. Grafting Decision Tree Leong and Wang. IJPRD 2011; 31 (3) 307 - 313

11. When is Grafting Needed?
How much keratinized gingivae 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 subgingival 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.

12. When is Grafting Needed?
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?

13. Free Gingival Autografts
Indications
To increase keratinized tissue around teeth, implants or crowns
To increase keratinized 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

14. Free Gingival Autografts
Classic “Gum Graft”
Will increase keratinized gingivae
Results in “Tire Patch” look

15. Free Gingival Graft
Pre-op
Pre-op
Courtesy of Barry R. Wohl, DDS

16. Free Gingival Graft
Donor Site
Recipient Site

17. Free Gingival Graft
Before
Long-term follow-up

18. Miller Classification of Recession
Class I. Recession that has not extended to MGJ. No bone loss
Class II. Recession to or beyond the MGJ. No bone loss
Class III. Recession to or beyond MGJ. Bone loss. Papilla recession
Class IV. Recession beyond MGJ. Bone loss to the base of recession defect

19. Causes and Predisposing Factors in Gingival Recession
Minimal attached gingiva/thin tissue biotype
Frenum pull / shallow vestibule
Tooth malposition
Precipitating Factors:
Inflammation related to plaque
Restorations adjacent to thin tissue
Occlusal Trauma including orthodontic treatment
Bone loss at an adjacent site

20. 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

21. Connective Tissue Grafts
Disadvantages
Two surgical sites
Technique sensitive
Bleeding from palate (potential)

22. Connective Tissue Grafts
Surgical technique
Root preparation
Thorough root planing of exposed root to remove cementum and affected dentin
Etch root surface with tetracycline (pH 2.0)
Exposes collagen tufts to promote fibroblast adhesion

23. Connective Tissue Graft
Surgical Technique
Incision design (tunnel technique)
Create “pouch” using full/split thickness incision between gingiva and bone/root
Maintain papilla for bilaminar blood supply
Extend incision to adjacent teeth
Undermine flap

24. Connective Tissue Graft
Surgical Technique
Donor site incision (Buser)
First palatal incision perpendicular to long axis of teeth

25. Connective Tissue Graft
Surgical Technique
Donor site incision (Buser)
Second palatal incision parallel to long axis of teeth

26. Connective Tissue Graft
Donor Site
Harvest Tissue
Suture Palate

27. Connective Tissue Graft
Surgical Technique
Recipient site
Insert graft into tunnel
Suture using interrupted and sling sutures

28. Connective Tissue Graft
Before
After

29. Connective Tissue Graft
Pre-op
Post-op

30. Connective Tissue Grafts
Miller Class IV with supra-eruption of central incisor
Only minimal root coverage was possible

31. Connective Tissue Grafts
Before
3 years post-op

32. When is a CTG not indicated?
All exposed dentin is gingival recession
Abfraction
Tissue at or near the CEJ

33. When is a CTG not Indicated?
Gingival hyperplasia adjacent to normal gingival contours

34. Brushing TOO Hard?

35. Does brushing cause recession?
Does brushing too hard causes gum recession? Not really….
Toothbrushing and Gingival Recession. Litonjua, LA, et al. Int Dent J (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

37. FEAR

38. 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-op bleeding, swelling or bruising
Of course, everyone’s pain threshold is different…

39. What is the Recovery Time?
Recovery times vary from individual to individual
Post-op instructions include:
Soft foods for a week
Avoid chewing in the donor or recipient sites if possible for the first week
Bleeding from the palate is possible for the first 24 hours and sometimes longer
Don’t brush the donor site for 1 week; the recipient site for 3 weeks. Chlorhexidine mouthwash in the meantime
Ibuprofen 800mg 3/day for 2 – 3 days

40. What is the Recovery Time?
Most patients report some soreness during the first week, but most do not take anything more than the Ibuprofen 800 mg
Some swelling of the recipient site is normal and occasionally some bruising
Sutures resorb in the palate in 2 – 3 days and in about 1 week in the recipient site
Most people resume normal activities either the next day or two days after
Smokers heal more slowly and results are less predictable

41. Conclusions
Mucogingival defects are very common across all age groups and both genders
Mucogingival defects can be either congenital or acquired with both predisposing and precipitating factors
Periodontal Plastic Surgery can be used to correct mucogingival defects via a variety of methods and techniques
Indications for Periodontal Plastic Surgery can vary depending on rate of progression or the impact of local factors

42. Thank You!
GINGIVAL RECESSION