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MUCOGINGIVAL SURGERIESINTRODUCTIONMucogingival surgical techniques are designedto provide a functionally adequate zone of keratinized attached gingiva.(Friedman, 1962).

Pocket elimination or creation of proper physiologic formComplex capable of withstanding the stresses of masticationTooth brushingTrauma from foreign objectsTooth preparation associated with a crown and bridgeSubgingival restorations, orthodontics, inflammation, andfrenulum pull.

Miller included procedures such as the correction of ridge deformities, exposure of unerupted teeth for orthodontic treatment and crown lengthening

DEFINITIONThe definition proposed by Friedman included surgery designed to preserve attached gingiva, to remove frena or muscle attachment and to increase the depth of the vestibule , correct or eliminate anatomic, developmental or traumatic deformities of the gingiva or alveolar mucosa

History of Periodontal Plastic Surgery !1930s Frenectomies performed as well as deepening of the mucobuccal fold !1948 Goldman performed the first gingivoplasty !1956 Warren & Grupe showcase the Laterally Positioned Flap !1962 Friedman introduces the Apically Positioned Flap and the internal beveled incision !1963 Bjorn introduces the Free Gingival Graft !1982 P.D. Miller introduces the FGG for root coverage Fernandez first to do CTG Pini Prato performs first GTR procedure !1989 AAP renames Mucogingival Surgery to Periodontal Plastic SurgeryAllen considered the treatment of gingival pigmentation and discoloration and the correction of flat marginal contours, gummy smile and gingival asymmetry also pertinent to mucogingival surgery.

American Academy of Periodontology has replaced the term mucogingival surgery with the more general term soft tissue plastic surgery to describe surgical procedures designed to correct defects in the morphology, position or amount of gingiva surrounding the teeth.

No standard width of keratinized attachedgingiva has been established. In people with goodoral hygiene, 1 mm or less may be sufficient forhealth (Lange and Loe, 1972; Miyasato and colleagues, 1977; Hangorsky and Bissada, 1980; de Trey and Bernimoulin, 1980; Dorfman and colleagues, 1980, 1982). Kirch and colleagues (1986), Wennstrm (1987), Salkin and colleagues (1987) showed that even a movable marginal tissue of alveolar mucosa can be kept stable over along period of time. Yet it may be necessary toincrease this zone of healthy tissue if it is to besubjected to the trauma of prosthetic treatment(Maynard and Wilson, 1979; Ericsson and Lindhe, 1984), orthodontic restoration (Maynard andOchsenbein, 1975; Coatoam and colleagues,1981), or frenulum pull (Gottsegen, 1954; Corn,1964a; Gorman, 1967) or in instances of rapidlyprogressing recession (Baker and Seymour, 1976;de Trey and Bernimoulin, 1980)

TISSUE BARRIER CONCEPT

Goldman and Cohen (1979) outlined a TISSUE BARRIER concept for mucogingival surgery. They postulated that a dense collagenous band of connective tissue retards or obstructs the spread of inflammation better than does the loose fiber arrangement of the alveolar mucosa.

They recommended increasing the zone of keratinized attached tissue to achieve an adequate tissue barrier (thick tissue), thus limiting recession as a result of inflammation. colleagues (1973), Baker and Seymour (1976),Rubin (1979), and Lindhe and Nyman (1980).In contrast to these findings, teeth possessingthe least attached tissue (cuspids and bicuspids)are the least involved periodontally, whereas theincidence of disease is greatest on the lingual andpalatal surfaces, where the amount of keratinizedtissue is greatest (Waerhaug, 1971). Furthermore,Wennstrm and colleagues (1981, 1982),Wennstrm and Lindhe (1983), and Kure andcolleagues (1985)showed that a free gingival unitsupported by a loosely attached alveolar mucosais not more susceptible to inflammation than afree gingival unit th

INDICATIONSThese procedures, therefore, should be used only where specifically indicated or where inflammation cannot be controlled. Wennstrm (1985) stated: A thin marginal tissue, in particular in the absence of underlying alveolar bone, will be at greater risk of recession since the plaque-induced inflammatory lesion may occupyand cause destruction of the entire connective tissue portion of the gingiva.

Hall (1977) noted several critical factors to be considered other than the mere lack of an adequate zone of attached gingiva:1. Patient age2. Level of oral hygiene3. Teeth involved4. Potential or existing esthetic problems5. Existing recession with esthetic or sensitivityproblems6. The patients dental needs7. Previous dental treatmenGeneral ConsiderationsPrinciples1. Existing keratinized gingiva should always bemaintained.2. Exposing bone to increase the zone of keratinized gingiva is contraindicated (Wilderman, 1964).3. When an adequate zone of attached keratinized gingiva exists, vestibular depth is nota factor (Bohannan, 1963a).

ObjectivesTo create an adequate zone of attached keratinized gingivaTo eliminate pockets that extend beyond the mucogingival line To eliminate muscle and frenulum pullTo deepen the vestibule To cover denuded root surfaces for estheticsor hypersensitivityTo overcome the anatomic factors of toothposition, thin alveolar housing, and largeprominent roots, which promote dehiscenceand/or fenestration formation with gingivalaccession

To minimize recession during orthodontic movement To overcome the trauma of prosthetic restorative dentistry requiring subgingival placementTo stabilize and maintain a healthy mucogingival complexTo correct areas of progressive gingival recessionTo correct ridge deformities and undercuts

Classification of Procedures The surgical methods available for correction of mucogingival problems are as follows:1. Periodontal flapspositioned and repositioneda. Full thickness (mucoperiosteal; modified, apically positioned)b. Flap curettagec. Partial thickness (apically positioned)d. Curtain procedure

2. Free soft tissue autograftsa. Grafting for root coverageb. Connective tissue pedicle graftc. Ridge augmentation for esthetics

3. Subepithelial connective tissue graft

4. Laterally positioned pedicle flaps (partial and full thickness)a. Edentulous ridge modificationb. Oblique rotated pedicle flapc. Periosteally stimulated pedicle flapd. Partial-full-thickness pedicle flape. Submarginal incisionsf. Coronally positioned flap

5. Double-papillae laterally positioned flap

a. Horizontal lateral sliding papillary flapb. Rotated or transpositional rotated flap

6. Frenulectomy and frenulotomy