Mucogingival Surgery
(Mucogingival
problems and
Management)
BY Dr Arshad Jamal Sayed
Preventive Dentistry
(Periodontology)
• Define Muco-gingival Surgery
• Enumerate mucogingival problems and its
surgical management.
• Explain Various Types of mucogingival
surgical procedures.
• Step by step technique of most common muco-
gingival surgical procedures and Healing
after surgery
What is Muco-gingival junction?
Mucogingival junction remains
the same throughout life. Any
changes occur in the coronal
portion of the attached
gingiva.
The alveolar mucosa
It covers the alveolar process basally and it is loosely
attached to the periosteum
It is markedly redder than the attached gingiva and
covered by non keratinized epithelium.
Attached gingiva:
Stippled, dense
tissue that is
continues with the
marginal gingiva .
• Firmly bound to the underlying periosteum.
– Extends from the base of the sulcus to the mucogingival
junction.
– The width of the attached gingiva represents an important
clinical parameter.
Mucogingival problems arise from
1- Chronic periodontitis (pockets extending
beyond MGJ)
2- Frenal pull
3- Gingival recession
4- Gingival enlargement
Muco-gingival conditions:
Mucoginigival Therapy:
• Definition:
– Mucoginigival surgery: Periodontal
surgical procedures used to correct
defects in the morphology, position,
and/or amount of gingiva (AAP
Glossary).
Mucogingival problems:
I- Chronic periodontitis AND Recession
extending beyond MGJ
Management of Pockets beyond MGJ
Apically
Positioned Flap:
Pocket eradication .
Preserving or increasing the zone of attached gingiva.
Apically Positioned flap
• Indications:
• 1. Deep pockets extending to or beyond MGJ
• 2. Inadequate width of attached gingiva
• 3. Shallow vestibule
• Contra-indications:
• 1. Gingival Recession
• 2. Cases Requiring Regenerative therapy
Apically Positioned flap
• Disadvantages Post-op:
• Recession
• Sensitivity
• Root caries
• Displeasing Aesthetics
2- FRENAL PULL MANAGEMENT
• Frenal pull is exerted
by a frenum muscle
attachment that is
inserted into an
unhealthy gingival
margin.
• It may interfere with
the effective plaque
control.
Frenal pull
• It may pull on the wall of the pocket and therefore
aggravate the pocket (this may be detected by
observing blanching of the gingival margin after
gentle pulling on the lip or cheek).
• Thorough scaling and root planing and good oral
hygeine measures may keep the situation stable for
several years. However, if gingival inflammation
persists and there is evidence that the lesion is
progressing, surgical corrective treatment may be
indicated.
Frenum pull types
Mucosal frenal Gingival frenal
attachment attachment
Frenum pull types
Papillary frenal Papilla penetrating
attachment frenal attachment
Diagnosis & Management of High
Frenum
Tests for frenal attachment:
1. Tension Test.
2. Blanch Test.
• Thorough scaling and root planing and good
oral hygeine measures may keep the situation
stable for several years. However, if gingival
inflammation persists and there is evidence that
the lesion is progressing, surgical corrective
treatment may be indicated.
Treatment of frenum pull
This may be treated by either a frenectomy or
frenotomy
Frenectomy : Refers to the complete removal of frenum, including
its attachment to the underlying bone.
It is required in the correction of abnormal diastema between
maxillary central incisors (Friedman 1957).
Frenotomy: Is the incision of the frenum.
It is usually done to relocate the frenal attachment so as to create
a zone of attached gingiva between the gingival margin and the
frenum.
Surgical Technique
Excision of the frenum will leave a rhomboid shaped wound and-
the mucosal edges are approximated with sutures. Swabs are
placed firmly over the wound to control bleeding and a periodontal
dressing is applied. Sutures are removed after 1week
Post-operative
Frenectomy
GINGIVAL RECESSION AND MANAGEMENT
• Localized gingival recession
It may affect single or multiple teeth, it may be
:caused by
An underlying local bony dehiscence with-1
associated tooth brushing trauma
Direct gingival trauma from the occlusion such as-2
.deep over bite (angle’s class 2 division II occlusion)
Orthodontic tooth movement through a thin buccal-3
.osseous plate
Causes of gingival recession
1. Prominent Roots of the Teeth
2. Muscle Attachments
3. Associated with Orthodontic Treatment
4. Trauma (physical damage) to the Gums e.g. tooth brushing, appliances
Miller classification of Gingival
recession:
Class 1: marginal tissue recession not extend to
mucogingival junction + no bone or soft tissue
loss in the interdental area
Class 2: marginal recession extend to or beyond the
mucogingival junction +no bone or soft tissue loss
in the interdental area
Class 3: marginal recession that extend to or beyond
the mucogingival junction+ bone &S.T loss
interdentally or malpositioning of teeth
Class 4: marginal recession that extends to or beyond
mucogingival junction + severe bone & s.t loss
interdentally &/or severe malposition of teeth
Prognosis:
Class1 &Class2 :
excellent prognosis
Class3 : only
partial coverage can
be expected
Class4 : very poor
prognosis
Treatment of gingival recession:
Localized & generalized recession may be
managed conservatively or surgically.
The main complications of gingival recession are:
1-Esthetics.
2-Root dentine sensitivity.
3-Abrasion, erosion.
4-Root caries.
Treatment
There are two approaches to treatment of recession :
1-Accept and maintain: Conservative technique with oral
hygiene.
2-Repair and eliminate recession if recession is
unacceptable to the patients.
Techniques for treatment of
recession
:Pedicle grafts -1
A-Lateral repositioned flap
B-Double papilla flap
C-Coronal repositioned flap
Free grafts -2
A-Full thickness free graft
B-Connective tissue free graft
Other regenerative techniques -3
A-GTR with non resorbable membranes
.B-GTR with resorbable membranes
Pedicle grafts for gingival recession
A-Laterally sliding flap
It is an effective
procedure for treating
an isolated area of
gingival recession where
a suitable adjacent
donor site of keratinized
tissue is present
Laterally sliding flap
• Advantages:
1- One surgical site
2- Good vascularity of the pedicle flap
3- Ability to cover a denuded root surface
• Disadvantages:
1- Limited by the amount of adjacent keratinized attached
gingiva
2- Possibility of recession at the donor site
3- Dehiscence or fenestration at donor site
4- limited to one or two teeth
Laterally sliding flap
• Contraindications:
1- Presence of deep interproximal pockets
2- Excessive root prominence
3- Deep or extensive root abrasion or erosion
4- Significant loss of interproximal bone
height
Surgical procedure
Coronally positioned flap for
Recession
It can be used alone or in combination with other •
procedures to treat localized recession. This procedure alone
cannot increase the zone of keratinized gingiva.
However it can be combined with procedures to fulfill this
function. It may be combined with free gingival grafts for
.this purpose
Coronally positioned flap
Management of inadequate width of
attached gingiva, Gingival Recession and
Shallow vestibule
with
Gingival grafts
• These may be:- 1. Free Gingival Grafts
• 2. Sub-epithelial Connective Tissue Grafts
commonly obtained from the palate as a donor site donor site
1-Full thickness epithelial graft
A procedure in which the graft is
placed directly over the denuded
root surface for treatment of
recession or increasing the zone of
attached gingiva
Free gingival graft for inadequate
attached gingiva
Free gingival graft for Recession
2- Subepithelial Connective tissue
graft
Donor tissue from the palate
Other regenerative techniques
GTR with non resorbable-1
.membranes
.GTR with resorbable membranes-2
Guided tissue regeneration (GTR)
GTR
1.Clinical periodontology and implant dentistry: Jan lindhe ,Thorkild
karring, Niklaus peter lang. 4th ed. 2003.
2.Carranza s clinical periodontology :Michael G Newman, Fermin A
Carranza, Henry Taky.12th ed.2010
3.Periodontics, Medicine, Surgery and Implants: Robert Genco, Brian
Mealy, Louis Rose.2004
