1. PERIODONTAL PLASTIC AND ESTHETIC SURGERY

2. Definition
Periodontal Plastic Surgery is defined as the procedures performed to correct the anatomical, developmental and traumatic deformities of gingiva and alveolar mucosa.

3. Terminology
Periodontal Plastic Surgery was previously termed as Muco-Gingival surgery
The term Periodontal Plastic Surgery was originally introduced by Miller in 1993.
AAP world workshop 1996 renamed Muco Gingival Surgery as Periodontal Plastic Surgery.

4. Objectives
To correct the problems associated with inadequate attached gingiva.
To correct the problems associated with shallow vestibule.
To correct the problems associated with high frenum attachment.

5. Indications of periodontal plastic surgery
Periodontal prosthetic surgery
Crown lengthening surgery
Ridge augmentation surgery
Esthetic surgical correction.
Coverage of denuded root surface
Reconstruction of papilla.
Esthetic surgical correction around implants

6. Rationale
Rationale of periodontal plastic surgery was previously predicated on the assumption that a minimum width of attached gingiva is essential to maintain optimum gingival health.

7. PROBLEMS ASSOCIATED WITH INADEQUATE WIDTH OF ATTACHED GINGIVA

8. Normal Gingiva

9. Gingival and periodontal structures

10. Problems Associated With Inadequate Width of Attached Gingiva
Difficulty in maintaining Optimum Gingival Health.
Improper plaque control.
Difficulty in maintaining Optimum Gingival Health around abutment teeth.
Inadequate keratinized tissue for placement of RPD.

11. Measurement of Width of Attached Gingiva
Width of attached gingiva can be measured by subtracting pocket depth from the distance between free gingival margin to the mucogingival junction.

12. Measurement of Width of Attached Gingiva and Keratinized Gingiva

13. Advantages of Creating Adequate Width of Attached Gingiva
Proper plaque removal.
Improved esthetics.
Reduces inflammation around restored teeth.

14. Techniques For Increasing Width of Attached Gingiva
Free gingival autograft,
Free connective tissue autograft,
Apically positioned flap,
Pedicle autograft,
Subepithelial connective tissue autograft.

15. Problems Associated With Shallow Vestibule
Improper plaque removal,
Difficulty in placement of removable prosthesis.

16. SHALLOW VESTIBULE
NORMAL VESTIBULAR DEPTH

17. Measurement of Vestibular Depth
Depth of vestibule is measured from gingival margin to the bottom of the vestibule.

18. Advantages of Creating Adequate Vestibular Depth
Proper plaque control.
Proper tooth brushing.
Proper placement of removable prosthesis.

19. TECHNIQUES VESTIBULAR DEEPENING (EDLAN- MEJCHAR’S)
FENESTRATION OPERATION
FREE SOFT TISSUE AUTOGRAFT

20. PROBLEMS ASSOCIATED WITH HIGH FRENUM
IMPROPER PLAQUE REMOVAL
TENSION ON THE FRENUM MAY TEND TO OPEN THE SULCUS

21. NORMAL FRENUM ATTACHMENT
HIGH FRENUM ATTACHMENT

22. EXAMINATION OF HIGH FRENUM
TENSION TEST IS PERFORMED BY PULLING THE LIPS : IN CASES OF HIGH FRENUM, THERE IS BLANCHING OF THE GINGIVA AND MOVEMENT OF GINGIVAL MARGIN ALONG WITH THE MOVEMENT OF CHEEKS AND THE LIPS

23. ADVANTAGES OF CORRECTING HIGH FRENUM ATTACHMENT
Proper plaque control.
Reduces inflammation of the gingiva around teeth.
Reduces progression of periodontal disease

24. TECHNIQUES
FRENOTOMY
FRENECTOMY

25. GINGIVAL RECESSION DEFINITION:
EXPOSURE OF THE TOOTH BY THE APICAL MIGRATION OF THE GINGIVA
EXPOSURE OF THE ROOT SURFACE BY AN APICAL SHIFT IN THE POSITION OF THE GINGIVA

26. GINGIVAL RECESSION IN RELATION TO MANDIBULAR CENTRAL INCISOR
NO GINGIVAL RECESSION

27. ETIOLOGY FAULTY TOOTH BRUSHING( GINGIVAL ABRASION)
TOOTH MALPOSITIONING.
FRICTION FROM SOFT TISSUE (GINGIVAL ABLATION)
GINGIVAL INFLAMMATION
HIGH FRENUM ATTACHMENT

28. Periodontal Plastic Surgery

29. Periodontal Plastic Surgery

30. CLASSIFICATION OF GINGIVAL RECESSION
SULLIVAN AND ATKIN’S
SHALLOW –NARROW
SHALLOW –WIDE
DEEP- NARROW
DEEP- WIDE

31. CLASSIFICATION OF GINGIVAL RECESSION

32. TECHNIQUES TO MANAGE GINGIVAL RECESSION
FREE GINGIVAL AUTOGRAFT
PEDICLE AUTOGRAFT
FREE CONNECTIVE TISSUE AUTOGRAFT
SUBEPITHELIAL CONNECTIVE TISSUE AUTOGRAFT
GUIDED TISSUE REGENERATION

33. MILLER’S CLASSIFICATION

34. Millers Class I Recession

35. Miller Class I Recession
 Marginal tissue recession which does
not extend to the mucogingival junction
 No periodontal bone loss in the
interdental area
 100% root coverage

36. Millers Class II Recession

37. Millers Class II Recession
 Marginal tissue recession which extends
to or beyond the mucogingival junction
 No periodontal loss in the interdental area
 100% root coverage

38. Millers Class III Recession

39. Millers Class III Recession
 Marginal tissue recession which extends
to or beyond the mucogingival junction
 Bone or soft tissue loss in the interdental area
or malpositioning of the teeth, preventing
100% root coverage
 Partial root coverage

40. Millers Class IV Recession

41. Millers Class IV Recession
 Marginal tissue recession which extends
to or beyond the mucogingival junction
 Severe bone or soft tissue loss in the
interdental area and/or malpositioning of teeth
 No root coverage

42. Root Coverage Using Free Autogenous Gingival Grafts
 Indications
 All cases where root coverage is necessary
except when a graft of sufficient thickness
( mm) cannot be harvested
 Contraindications
 Extensive gingival recession
 Esthetic cases

43. Root Coverage Using Free Autogenous Gingival Grafts
Disadvantages
 Poor ability to provide blood supply to the
graft for root coverage
 Exposed deep and large wound on the
palatal mucosa
 Inferior esthetic results due to scarring
 Surgery required in 2 areas

44. preoperative

45. Incisions

46. Epithelial Surface Removed

47. Donor Site

48. Free Gingiva Graft Harvested

49. Graft Placed at Recipient Site

50. Root Coverage & Increase In Attached Gingiva Postoperatively

51. Connective Tissue Grafts
 88% root coverage in areas of severe
gingival recession
 Greater amount of root coverage and rate
of complete coverage with the use of
connective tissue grafts as compared to
free gingival grafts

52. Root Coverage Using Connective Tissue Grafts
Advantages
 High predictability
 Graft receives abundant blood supply from 2
sources
 Wound closed at palatal donor site after
harvest of connective tissue graft
 Esthetically pleasing results
 Applicable for gingival recession on multiple
teeth

53. Root Coverage Using Connective Tissue Grafts
Disadvantages
 Technically demanding
 Gingivoplasty may be necessary
postoperatively

54. Multiple Rcessions

55. Recepient Site Incisions

56. Reflection of Flap

57. Donor Site

58. CT Graft Placed at Recipient Site

59. Flap placed over ct graft & sutured

60. Donor site flap sutured back

61. Postoperative root coverage