MUCOGINGIVAL: The portion of the oral mucosa that covers the alveolar process including the gingiva (keratinized

tissue) and the adjacent alveolar mucosa. SURGERY: I. That branch of medical science concerned with the treatment of diseases or injuries by means of manual or operative methods. 2. The procedures performed by a surgeon. 3. The performance or procedures of an operation.
[Glossary of Periodontology Terms. American Academy of Periodontology. 4th ed. Chicago; 2001. p. 44.]

M. DEFORMITY: A departure from the normal dimension and morphology of, and/or interrelationship between gingiva and alveolar mucosa; the abnormality may be associated with a deformity of the underlying alveolar bone.
M. JUNC TION: The junction of the gingiva and the alveolar mucosa. . M. THERAPY: Correction of defects in morphology, position, and/or amount of soft tissue and underlying bone. [Glossary of Periodontology Terms. American Academy of Periodontology. 4th ed. Chicago; 2001. p. 44.]

INDICATIONS FOR MUCOGINGIVAL PROCEDURES

 Historically, mucogingival surgery was used to increase the amount of attached gingiva. A certain amount of attached gingiva was considered necessary to maintain gingival health and prevent gingival recession.
Although establishing an adequate width of keratinized tissue has been emphasized, the thickness of this tissue is at least equally important in preventing soft tissue recession in the presence of bacterial plaque.

 Other indications for mucogingival procedures include

Elimination of frenum and muscle attachments, Increasing vestibular depth, Coverage of gingival clefts, Modification of edentulous ridges prior to prosthetics, Establishing a zone of attached gingiva prior to coronally positioning a graft, and for restorative considerations, particularly if subgingival margins are contemplated in areas of thin tissue (Nery and Davies, 1977).

THERAPEUTIC GOALS

 Mucogingival therapy is defined as non-surgical and/or surgical correction of defects in morphology, position, and/or amount of soft tissue and underlying bone. The goals of mucogingival therapy are to help maintain the dentition or its replacements in health with good function and esthetics, and may include restoring anatomic form and function. A further goal is to reduce the risk of progressive recession. This may be accomplished with a variety of procedures including root coverage, gingival augmentation, pocket reduction, and ridge reconstruction, as well as control of etiologic factors. Several mucogingival conditions may occur concurrently, necessitating the consideration of combining or sequencing surgical techniques.

TREATMENT CONSIDERATIONS

1. In order to monitor changes of mucogingival conditions, baseline findings should be recorded 2. Depending on the mucogingival conditions, the following treatments may be indicated: A. Control of inflammation through plaque control, scaling and root planing, and/or antimicrobial agents; B. Gingival augmentation therapy; C. Root coverage; D. Extraction site grafts to prevent ridge collapse; F. Frenectomy; I. Surgical procedures to reduce probing depths; etc.

3. Vestibular depth alteration. Treatment options for altering vestibular depth may include gingival augmentation and/or vestibuloplasty.
4. Ridge augmentation. Ridge defects that may need correction prior to prosthetic rehabilitation can be treated by a variety of tissue grafting techniques and/or guided tissue regeneration. The selection of surgical procedures may depend on the configuration of the defect, availability of donor tissue, and esthetic considerations of the patient.

Labial Frenectomy

 Frena, which are triangle-shaped folds found in the maxillary and mandibular alveolar mucosa, are located between the central incisors and canine premolar area. Frena may be long and thin, or short and broad. Labial frenum attachments have been described as mucosal, gingival, papillary, and papilla penetrating (Placek et al. 1974).
Insertion points of the frena may become a problem when the gingival margin is involved (Corn 1964)

Aberrant frena can be treated by frenectomy or frenotomy procedures.

INDICATIONS

Eliminate tension on the gingival margin (frenum-pull concomitant with or without gingival recession) Facilitate orthodontic treatment Facilitate home care

Preprosthetic Ridge Augmentation

In 1983, Seibert classified the different types of alveolar ridge defects that a clinician may encounter while planning a prosthetic rehabilitation. His classification described the following three clinical situations: Class I alveolar ridge defects have a horizontal loss of tissue with normal ridge height. Class II alveolar ridge defects have a vertical loss of tissue with normal ridge width. Class III alveolar ridge defects have a combination of class I and class II resulting in loss of normal height and width.

INDICATIONS
The indications of alveolar ridge defects occur when the loss of substance compromises the positive outcome of a prosthetic restoration. This is particularly true in the aesthetic zone, and most of the time is caused by periodontal disease, careless tooth extraction, chronic infection, implant failure, congenital diseases, trauma, or neoplasm. The loss of gingiva or bone can be detrimental to the successful placement of an implant or a fixed partial denture.

 This loss of substance can be avoided by socket preservation or immediate implant placement, or treated with soft and hard tissue grafting. When planning treatment for corrective surgery, it is important to inform the patient that a single procedure may not repair the defect, so a second, or sometimes even a third, procedure is sometimes warranted. A Seibert class I defect is easier to treat than a class II, which, in turn, is easier to treat than a class III. A class III defect will require

SOFT TISSUE GRAFT

GINGIVAL RECESSION & ESTHETIC ROOT COVERAGE

INTRODUCTION
Recession is defined as the exposure of the root surface by an apical shift in the position of the gingiva.

It implies the loss of periodontal connective tissue fibres along with the root cementum and alveolar bone.

 Recession of the gingival margin results in impaired esthetics and sometimes hypersensitivity.
The treatment of gingival recessions aims at covering the exposed root surface and arresting the progression of tissue loss.

Various mucogingival procedures have been used successfully resulting in root coverage.

To understand recession , one must distinguish between the actual and the apparent position of gingiva Actual position is the level of the epithelial attachment on the tooth. Apparent position is the level of the crest of the gingival margin. The severity of recession is determined by the actual position of the gingival, not its apparent position

TYPES:
Visible: Clinically observable. Hidden: Covered by gingiva and can be measured only by inserting a probe to the level of epithelial attachment

ETIOLOGIC FACTORS
1. Age: Increases with age. Incidence-8% in children, to 100% after the age of 50 years. 2. Development / Anatomical Factors Dehiscence and Fenestration. Abnormal tooth position in the arch. Aberrant path of eruption of the tooth. Individual tooth space. Improper root morphology. High frenum attachment.

3. Pathological Factors : Inflammatory periodontal disease. Uneven atrophy of marginal gingiva. Friction from soft tissues (gingival abalation) 4. Local factors Plaque and calculus. Overhanging margins or restorations. Tooth brushing injuries / vigorous brushing.

5. Deleterious habits: Smoking Placing finger nails, pencils, hair pins. 6. Others : Trauma from bands, arch wires, crowns, clasps and denture bars. Intra Oral and extra oral piercing. Direct trauma on localized area of mouth due to accidental blow.

CLINICAL SIGNIFICANCE Susceptible to caries. Abrasion or Erosion of the cementum. Hypersensitivity Hyperemia of the pulp. Interproximal recession causes oral hygiene problems and results in plaque accumulation.

CLASSIFICATION
Several classifications of denuded roots have been proposed. Sullivan and Atkins (1968) Type 1: Shallow-Narrow Type 2: Shallow-Wide Type 3: Deep-Narrow

Type 4: Deep-Wide.

Bengui et al (1983)

Classified recession according to the cover prognosis U type- Poor prognosis V type- Fair prognosis I type- Good prognosis

Miller(1985)
Class I - Marginal tissue recession that does not extend to the mucogingival junction. There is no loss of bone or soft tissue in the interdental area. This type of recession can be narrow or wide.

Class II - Marginal tissue recession that extends to or beyond the mucogingival junction. There is no loss of bone or soft tissue in the interdental area. This type of recession can be subclassified into wide and narrow.

Class III - Marginal tissue recession that extends to or beyond the mucogingival junction; in addition, there is bone and/or soft tissue loss interdentally or there is malpositioning of the tooth.

Class IV - Marginal tissue recession that extends to or beyond the mucogingival junction with severe bone and soft tissue loss interdentally and/or severe tooth malposition.

TECHNIQUES The following is a list of techniques used for root coverage: Free gingival autograft Free connective tissue autograft Pedicle autografts Pedicle Rotational flap flap rotated or displaced laterally. Laterally positioned flap Transpositional flap Double papilla flap Advanced flap flap placed without rotation or lateral migration Coronally positioned flap Subepithelial connective tissue graft (Langer), or Alloderm. Guided tissue regeneration Pouch and tunnel technique

CRITERIA FOR SELECTION OF TECHNIQUES

1.Surgical site free of plaque, calculus, and inflammation, to enable the clinician to manage gingival tissue that is firm.

2. Adequate blood supply:

Root coverage procedures present a portion of the recipient site

(denuded root surface) without blood supply.

A pedicle-displaced flap has a better blood supply than a free

graft, with the base of the flap intact.

Therefore, in root coverage, if the anatomy is favorable, the pedicle flap or any of its variants may be the best procedure.

 The subepithelial connective tissue graft (Langer) and the Pouch and Tunnel techniques use a split flap with the

connective tissue sandwiched in between the flap.

This flap design maximizes the blood supply to the donor tissue. If large areas require root coverage, these sandwich-type recipient sites provide the best flap design for blood supply

3. Anatomy of the recipient and donor sites:.

Pedicle displacement of tissue necessitates the presence of an adjacent donor site that presents gingival thickness and

width.

Palatal tissue thickness is also necessary for the connective

tissue donor autograft.

Gingival thickness is also required at the recipient site for techniques using split thickness, sandwich-type flap, or the pouch and tunnel techniques.

4. Stability of the grafted tissue to the recipient site : Good communication of the blood vessels from the grafted donor tissue to the recipient site requires a stable environment. This necessitates sutures that stabilize the donor tissue firmly against the recipient site.

5. Minimal trauma to the surgical site :

Unnecessary tissue trauma due to poor incisions, flap perforation, tears, traumatic and excessive placement of sutures can lead to tissue necrosis. The selection of proper instruments, needles, and sutures are mandatory to minimize tissue trauma.

FREE GINGIVAL AUTOGRAFT.

Bjorn in 1963, and Sullivan & Atkins in 1968, were the first to describe the free gingival autograft.
Later it was used to attempt coverage of exposed root surfaces (Sullivan & Atkins 1968; Holbrook & Ochsenbein 1983; Miller 1985).

Indications:
All cases where root coverage is necessary except where a graft of sufficient thickness (1.5 - 2.0 mm) cannot be harvested (palatal tissue).

However, in area of extensive gingival recession, there is the problem of blood supply to the graft. In such cases, connective tissue grafts are suitable.

Disadvantages :

Poorest ability to provide blood supply to the graft. Deep and large wound is exposed on the palatal mucosa (donor tissue), difficulty achieving hemostasis and patient pain and discomfort due to slow healing ( healing by secondary intention). Scarring occurs with wound healing, therefore, esthetic results may be inferior to other methods. Surgery is required in two areas

Connective Tissue Grafts

First described in the literature in 1985 (Langer & Langer 1985; Raetzke 1985) as a predictable means for root coverage, a subepithelial connective tissue graft combines the use of a partial thickness flap with the placement of a connective tissue graft. This enables the graft to benefit from a double vascularization, from both the periosteum and the buccal flap.
In addition, the connective tissue carries the genetic message for the overlying epithelium to be keratinized (Edel 1974). Therefore, only connective tissue from a keratinized mucosa should be used as a graft. The partial thickness flap may or may not have vertical releasing incisions (Langer & Langer 1985; Raetzke 1985; Bruno 1994).

Root Coverage Using Connective Tissue Grafts

Advantages 1. High predictability. 2. The graft receives abundant blood supply from both the inside of the flap and the periosteum-connective tissue.
3. Wound closed at palatal donor site after harvest of connective tissue graft. Therefore, hemostasis is easy and healing is rapid. There is also less discomfort and pain during healing.

4. The graft fits the surrounding tissue on the recipient site, therefore, results are esthetically pleasing.
5. Applicable for gingival recession on multiple teeth.

Disadvantages
1. Technically demanding. 2. Because a thick graft is used, the grafted tissue is thick. Gingivoplasty may be necessary postoperatively to obtain better morphology.

Indications Root coverage necessary in the gingival recession area.

Contraindications Inadequate thickness of donor tissue. The necessary thickness of the connective tissue graft for root coverage is 1.5-2.0 mm, and the thickness of the palatal flap should be 1.5-2.0 mm after graft harvest to prevent necrosis. Therefore, at least 3-mm thickness is necessary in the palatal soft tissue of the donor site.

Pedicle Autograft
Advantages
One surgical area (no donor site). Blood supply of the pedicle flap covering the root surface is preserved. Postoperative color is in harmony with the surrounding tissue.

Disadvantages
Applicable for relatively minor gingival recession (narrow and shallow) or for recession limited to one tooth. The success rate is not high.

Pedicle gingival grafts are classified according to the direction of flap migration.

Rotational flap flap rotated or displaced laterally Laterally positioned flap Transpositional flap Double papilla flap Advanced flap flap placed without rotation or lateral migration Coronally positioned flap

Laterally Positioned flaps

Laterally positioned flaps have been widely used since Grupe and Warren (1956) introduced this method for the treatment of localized gingival recession.

In this procedure, the adjacent keratinized gingiva is positioned laterally, and the exposed root surface in the localized gingival recession is covered. Guinard and Caffesse reported an average of 1mm postoperative gingival recession on the adjacent donor site.

Indications
Sufficient width, length, and thickness of keratinized tissue exist adjacent to the area of gingival recession. Coverage of the exposed root is limited to one to two teeth. This method is most suitable for root coverage in gingival recession with narrow mesiodistal dimension ( eg. Mandibular anterior area).

Contraindications
Insufficient width and thickness of keratinized tissue in the adjacent donor site.

Extremely thin bone in the donor site or an osseous defect such as a dehiscence or fenestration.
Gingival recession area extremely protrusive. Deep periodontal pocket and remarkable loss of interdental alveolar bone in the adjacent area. Narrow oral vestibule. Multiple teeth involved.

Step 1: Make incision on gingival margin around exposed roots. Remove resected soft tissue. Root planing. Step 2: A full/ partial thickness flap may be reflected. Make vertical incision from GM to outline a flap adjacent to recipient site.the flap should be wider than the recepient site.

Step 3: Separate flap consisting epithelium and a thin layer of connective tissue. Step 4: Slide the flap laterally onto the adjacent root.

Transpositional flaps
Bahat et al (1990) modified oblique rotated flap introduced by Pennel et al (1965). This is called the transpositional flap. Advantages Predictability in areas of narrow root exposure Possible to avoid gingival recession at the donor site. Disadvantages Sufficient length and width of the interdental papilla adjacent to the gingival recession area necessary. Not suitable for multiple tooth root coverage.

Double Papilla Flaps

Cohen and Ross (1968) introduced the method in
which bilateral interdental papilla is used as donor tissue for localized root coverage. In this technique, there is less chance of flap necrosis and suture is easy because interdental papilla is thicker and wider than labial gingiva on the root surface.

Indication
Sufficient width and length of the interdental papilla on both sides of the area gingival recession.

Advantages The amount of donor tissue is small because interdental papilla adjacent to the gingival recession area is displaced. Therefore, less tension to the pedicle flap. Interdental bone is exposed if a full-thickness pedicle flap including interdental papilla is used, there is little damage to the alveolar bone because interdental alveolar bone is thick. Disadvantages : Technically demanding. Limited application. The technique is generally used for multiple interdental papilla grafting.

 Bernimoulin et al. (1975) first reported the coronally positioned graft succeeding grafting with a free gingival autograft The purpose of the coronally displaced flap operation is to create a split-thickness flap in the area apical to the denuded root and position it coronally to cover the root. Two techniques are available for this purpose.

Semilunar coronally positioned flap to cover denuded root (Tarnow 1986)

Advantage: Simple. High success in maxilla.2mm to 3mm of gingival recession can be covered. Can be performed on several adjoining teeth.

A semilunar incision is made following the GM, 2-3 mm short of tip of papilla.

Perform split thickness dissection coronally and connect to intra sulcular incision.

Tissue will collapse, covering denuded teeth. Held in new position with moist gause. No need to suture

Guided tissue Regeneration technique for root coverage.

Pini-Prato and collegues have described a technique based on the principle of guided tissue regeneration. Theoretically, guided tissue regeneration (GTR) should result in reconstruction of the attachment apparatus, along with coverage of the denuded root surface. Indications : Single teeth with wide deep, localized recession 5 mm in width or depth or wider and deeper For areas of root sensitivity where oral hygiene is impaired. For the repair of recession associated with failing or unaesthetic class restorations.

Advantages :
Does not require a secondary donor surgical site, reducing post operative discomfort. The new tissue blends evenly with the adjacent tissue providing aesthetic result.

Disadvantages:
Multiple defects cannot be treated at the same surgical session. Root coverage is limited by the height of the interproximal bone.

Disadvantages of GTR over Mucongingival Surgery:

More demanding surgical technique. Additional cost Less predictability in cases of high frenal attachment and shallow vestibule

Acellular Dermal Matrix Graft (AlloDerm)

 Acellular dermal matrix allograft, originally intended to cover burn wounds (Wainwright 1995), has been introduced as a less invasive alternative to soft tissue grafting (Silverstein & Callan 1997). This allograft is a freeze-dried, cell-free, dermal matrix comprised of a structurally integrated basement-membrane complex and extracellular matrix in which collagen bundles and elastic fibers are the main components (Wei et al. 2000).

 INDICATIONS
Soft tissue augmentation Multiple adjacent gingival recessions Lack of graftable palatal tissue Patient reluctant to have a second surgical site Correction of gingival/mucosal amalgam tattoos

Pouch and Tunnel technique.

Advantage: Minimize incisions. Provide abundant blood supply to the donor site. Pouch allows intimate contact of donor tissue to the recipient bed. Esthetic improvement. Good results with maxillary anterior with sufficient vestibular depth.

CONCLUSION
There are numerous techniques designed to obtain root coverage. Some are more predictable than others and provide aa more esthetically pleasing result. No single technique is best suited for every situation and every clinician. Each situation presents circumstances that favour one technique or other.

REFERENCES :
Practical Periodontal Plastic Surgery: Serge Dibart Mamdouh Karima Color atlas of periodontology:Wolf&Hassel Atlas of Cosmetic and reconstructive periodontal surgery - 2n edition - Edward S.Cohen. Periodontal therapy - Clinical approaches and evidences of success -Vol 1 - Nevins and Mellonig. Clinical periodontology and implant dentistry 4&5 edition - Jan Lindhe. Carranza's Clinical periodontology 9th , 10th edition Atlas of periodontal surgery- Sato. Perio 2000; Vol 27, 2001. Perio 2000; 11; 49-57. Int. J. Periodontics Restn. Dent. 1991; 11: 472-479. J.P. 1993; 64: 387-391. J.P. 1992; 63: 919-928. Quint Int. 1990; 6: 465 - 468. J.P. 1992; 63: 54-60 J.P. 66; 14-22. JCP 1997,24:529-33. JCP 1998,69: 1271 -1277. JP 1996; 67 621-626. J.P. 1998p;69:975-981. J.P. 1999; 70: 1118-1124. J.P; 1997; 68: 770-778. Perio 2000; Vol 19,1998.

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