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OX 62-1 Classification of Cervical Enamel Projections Grade I: The enamel projection extends from the cementoenamel junction of the

tooth toward the furcation entrance. Grade II: The enamel projection approaches the entrance to the furcation. It does not enter the furcation, and therefore no horizontal component is present. Grade III: The enamel projection extends horizontally into the furcation.
From Masters DH, Hoskins SW: J Periodontol 35:49, 1964.

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that a grade III furcation exists (see Figure 62-6, C). Properly exposed and angled radiographs of early Class III furcations display the defect as a radiolucent area in the crotch of the tooth (see Chapter 31).

Grade IV
In grade IV furcations, the interdental bone is destroyed, and the soft tissues have receded apically so that the furcation opening is clinically visible. A tunnel therefore exists between the roots of such an affected tooth. Thus the periodontal probe passes readily from one aspect of the tooth to another (see Figure 62-6, D).

Other Classification Indices


Hamp et al17 modified a three-stage classification system by attaching a millimeter measurement to separate the extent of horizontal involvement. Easley and Drennan10 and Tarnow and Fletcher37 have described classification systems that consider both horizontal and vertical attachment loss in classifying the extent of furcation involvement. The Tarnow and Fletcher article utilizes a subclassification that measures the probeable vertical depth from the roof of the furca apically. The subclasses being proposed are: A, B, and C. A indicates a probeable vertical depth of 1 to 3 mm, B indicates 4 to 6 mm, and C indicates 7 or more mm of probeable depth from the roof of the furca apically. Furcations would thus be classified as IA, IB, and IC; IIA, IIB, and IIC; and IIIA, IIIB, and IIIC. Consideration of defect configuration and the vertical component of the defect provides additional information that is useful in planning therapy. Glickman14 classified furcation involvement into four grades (Figure 62-6).

Grade I
A grade I furcation involvement is the incipient or early stage of furcation involvement (see Figure 62-6, A). The pocket is suprabony and primarily affects the soft tissues. Early bone loss may have occurred with an increase in probing depth, but radiographic changes are not usually found.

Grade II
A grade II furcation can affect one or more of the furcations of the same tooth. The furcation lesion is essentially a cul-de-sac (see Figure 62-6, B) with a definite horizontal component. If multiple defects are present, they do not communicate with each other because a portion of the alveolar bone remains attached to the tooth. The extent of the horizontal probing of the furcation determines whether the defect is early or advanced. Vertical bone loss may be present and represents a therapeutic complication. Radiographs may or may not depict the furcation involvement, particularly with maxillary molars because of the radiographic overlap of the roots. In some views, however, the presence of furcation arrows indicates possible furcation involvement (see Chapter 31).

Grade III
In grade III furcations, the bone is not attached to the dome of the furcation. In early grade III involvement, the opening may be filled

with soft tissue and may not be visible. The clinician may not even be able to pass a periodontal probe completely through the furcation because of interference with the bifurcational ridges or facial/ lingual bony margins. However, if the clinician adds the buccal and lingual probing dimensions and obtains a cumulative probing measurement that is equal to or greater than the buccal/lingual dimension of the tooth at the furcation orifice, the clinician must conclude
Figure 62-6 Glickmans classification of furcation involvement. A, Grade I furcation involvement. Although a space is visible at the entrance to the furcation, no horizontal component of the furcation is evident on probing. B, Grade II furcation in a dried skull. Note both the horizontal and the vertical component of this cul-de-sac. C, Grade III furcations on maxillary molars. Probing confirms that the buccal furcation connects with the distal furcation of both these molars, yet the furcation is filled with soft tissue. D, Grade IV furcation. The soft tissues have receded sufficiently to allow direct vision into the furcation of this maxillary molar.

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For more information on furcation therapy, please visit the companion website at www. expertconsult.com.

CHAPTER 62 Furcation: Involvement and Treatment 593

NONSURGICAL THERAPY Oral Hygiene Procedures


Furcal management is difficult at best. Therapeutic modalities for the treatment and maintenance of furcations have long been a dilemma amongst periodontists and restorative dentists. Nonsurgical therapy is a very effective way of producing a satisfactory stable result. Ideal results with furcations are impossible to obtain. Once furcation breakdown has begun, there is always a somewhat compromised result clinically. Both surgical and nonsurgical therapies have been shown to work effectively over time. Nonsurgical therapy, a combination of oral hygiene instruction and scaling and root planing, has provided excellent results in some patients. The earlier the furcation is detected and treated the more likely a good longterm result can be obtained. Nonetheless, even advanced furcation lesions can have successful long-term treatment.34 Several oral hygiene procedures have been utilized over time. All include access to the furcation. Obtaining access to the furcation requires a combination of the awareness of the furcation by the patient and an oral hygiene tool that facilitates that access. Many tools, including rubber tips; periodontal aids; toothbrushes, both specific and general; and other aids have been used over time for access to the patient (Figure 62-8).

Scaling and Root Planing


Nonsurgical maintenance by the clinician has also improved over time as instrumentation has improved. In recent decades, instruments beyond simple curettes have been used to instrument the furcation. The frustration of instrumentation of the furcation was illustrated beautifully by Bower in 1979 in his articles5,6 illustrating that only 58% of furcations could be entered by typically utilizing curettes (see Chapter 33). Subsequent to this time, other instrumentation has evolved, including DeMarco curettes, diamond files, Quetin furcation curettes, and mini Five Gracey Curettes. See Chapter 45 for a detailed discussion on this subject. Svrdstrm and Wennstrm34 illustrated that in the long term, furcations could be maintained over a 10-year period in patients utilizing nonaggressive techniques and who were participants in consistent maintenance. Other studies have also illustrated that maintenance therapy has been useful for patients to facilitate furcation cleanliness. Chemotherapy has proven disappointing. Ribeiro et al32 found that nonsurgical therapy can effectively treat Class II furcation involvements, but using povidone-iodine did not provide

additional benefits to subgingival instrumentation. The area most critical in furcation management is maintaining a relatively plaque-free status to the furcation. Attaining access is a problem in this regard, but with the previously mentioned instruments and an effective nonsurgical approach, much can be accom-

A B
Figure 62-8 A, The utilization of a Perio-Aid into the furcation for plaque removal. B, Proxy brush is used for plaque removal into the furcation lesion. (Courtesy Karen DeYoung, RDH, and Janet Shigekawa, RDH.)

SCIENCE TRANSFER
mented. This will generally provide excellent treatment outcomes but when a furcation has advanced bone loss and is a grade III or grade IV classification, the prognosis may not be good and so clinicians need to consider extraction and regenerative surgical treatment of the socket followed in 4 to 6 months by implant replacement of the tooth. This use of predictable implant treatment has reduced the utilization of the root resective and hemisection approaches. Furcations can be classified into grade I, grade II, grade III, and grade IV categories with increasing severity and increasing poor prognosis associated with the higher number of the category. Nonsurgical therapy may be applicable to some grade I furcations, but clinicians must closely monitor all furcation defects as progression of bone loss makes treatment more complex and less predictable; so early surgical intervention with flap and osseous surgery or flaps with regenerative materials should be impleplished. The most critical component of multirooted tooth maintenance is always the successful reduction or elimination of plaque retention areas from the furcation area; meticulous oral hygiene by the patient and an effective nonsurgical therapy can play a major role in attaining this goal.21,33

PROGNOSIS
For many years the presence of significant furcation involvement meant a hopeless long-term prognosis for the tooth. Clinical research, however, has indicated that furcation problems are not as severe a complication as originally suspected if one can prevent the development of caries in the furcation. Relatively simple

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be (1) thorough diagnosis, (2) selection of patients with good oral hygiene, (3) excellence in nonsurgical therapy, and (4) careful surgical and restorative management.
References can be found on the companion website at www.expertconsult.com.

periodontal therapy is sufficient to maintain these teeth in function for long periods.21,33 Other investigators have defined the reasons for clinical failure of root-resected or hemisected teeth.2,25 Their data indicate that recurrent periodontal disease is not a major cause of the failure of these teeth. Investigations of root-resected or hemisected teeth have shown that such teeth can function successfully for long periods.2,8,25 The keys to long-term success appear to

CHAPTER 63
Periodontal Plastic and Esthetic Surgery

Henry H. Takei, E. Todd Scheyer, Robert R. Azzi, Edward P. Allen, and Thomas J. Han
CHAPTER OUTLINE TERMINOLOGY
The term mucogingival surgery was initially introduced in the literature by Friedman38 to describe surgical procedures for the correction of relationships between the gingiva and the oral mucous membrane with reference to three specific problem areas: attached gingiva, shallow vestibules, and a frenum interfering with the marginal gingiva. With the advancement of periodontal surgical techniques, the scope of nonpocket surgical procedures has increased, now encompassing a multitude of areas that were not addressed in the past. Recognizing this, the 1996 World Workshop in Clinical Periodontics renamed mucogingival surgery as periodontal plastic surgery,3 a term originally proposed by Miller in 1993 and broadened to include the following areas2,3: Periodontal-prosthetic corrections Crown lengthening Ridge augmentation Esthetic surgical corrections Coverage of the denuded root surface Reconstruction of papillae Esthetic surgical correction around implants Surgical exposure of unerupted teeth for orthodontics Periodontal plastic surgery is defined as the surgical procedures performed to correct or eliminate anatomic, developmental, or traumatic deformities of the gingiva or alveolar mucosa.2,3 Mucogingival therapy is a broader term that includes nonsurgical procedures such as papilla reconstruction by means of orthodontic or restorative therapy. Periodontal plastic surgery includes only the surgical procedures of mucogingival therapy. This chapter discusses the periodontal plastic surgical techniques included in the traditional definition of mucogingival surgery: (1) widening of attached gingiva (2) deepening of shallow vestibules, and (3) resection of the aberrant frena. In addition, esthetic surgical therapy around the natural dentition and tissue engineering (biologic mediator) are included in this chapter. Other aspects of periodontal plastic surgery, such as periodontal-prosthetic surgery, esthetic surgery around implants, and surgical exposure of TERMINOLOGY OBJECTIVES Problems Associated with Attached Gingiva Problems Associated with Shallow Vestibule Problems Associated with Aberrant Frenum Esthetic Surgical Therapy Tissue Engineering ETIOLOGY OF MARGINAL TISSUE RECESSION FACTORS THAT AFFECT SURGICAL OUTCOME Irregularity of Teeth Mucogingival Line (Junction) TECHNIQUES TO INCREASE ATTACHED GINGIVA (online only) Gingival Augmentation Apical to Recession Gingival Augmentation Coronal to Recession (Root Coverage) TECHNIQUES TO DEEPEN THE VESTIBULE (online only) TECHNIQUES TO REMOVE THE FRENUM (online only) Frenectomy and Frenotomy Procedure TECHNIQUES TO IMPROVE ESTHETICS (online only) Root Coverage

Papilla Reconstruction Excessive Gingival Display TISSUE ENGINEERING Passive Engineering Active Engineering CRITERIA FOR SELECTION OF TECHNIQUES Surgical Site Free of Plaque, Calculus, and Inflammation Adequate Blood Supply Anatomy of the Recipient and Donor Sites Stability of the Grafted Tissue to the Recipient Site Minimal Trauma to the Surgical Site CONCLUSION

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Refer to the companion website at www.expertconsult.com for additional content and supplements to this chapter. Some figures may be out of numeric order in this printed chapter.

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gingival margin apically, thus reducing vestibular depth, which is measured from the gingival margin to the bottom of the vestibule. As indicated previously, with minimal vestibular depth, proper hygiene procedures are jeopardized. The sulcular brushing technique requires the placement of the toothbrush at the gingival margin, which may not be possible with reduced vestibular depth. Minimal attached gingiva with adequate vestibular depth may not require surgical correction if proper atraumatic hygiene is practiced with a soft brush. Minimal amounts of keratinized attached gingiva with no vestibular depth benefit from mucogingival correction. Adequate vestibular depth is also necessary for the proper placement of removable prostheses.

Problems Associated with Aberrant Frenum


Still another important objective of periodontal plastic surgery is to correct frenal or muscle attachments that may extend coronal to the mucogingival junction. If adequate keratinized, attached gingiva is present coronal to the frenum, it may not be necessary to remove the frenum. A frenum that encroaches on the margin of the gingiva may interfere with plaque removal, and the tension on the frenum may tend to open the sulcus. In such cases, surgical removal of the frenum is indicated.

Esthetic Surgical Therapy


As indicated earlier, the recession of the facial, gingival margin will alter the proper gingival symmetry and result in an esthetic problem. The presence of the interdental papilla is also important to satisfy the esthetic goals of the patient. A missing papilla creates a space which many address as a black hole. The regeneration of the lost or reduced papilla is one of the most difficult goals in esthetic periodontal plastic surgery. Another area of concern is the patient who presents an excessive amount of gingiva in the visible area. This condition is often addressed as a gummy smile and may be corrected surgically by crown lengthening. The correction of these anatomic defects has become an important part of periodontal plastic surgery.

Tissue Engineering
The future of periodontal plastic surgery will encompass the use of tissue-engineered products at the recipient site to reduce the donor site morbidity. Currently, there are numerous studies, both clinically and in the laboratories, to allow the clinician to utilize this minimally invasive approach to periodontal plastic surgery.

ETIOLOGY OF MARGINAL TISSUE RECESSION


The most common cause of gingival recession and the loss of

attached gingiva is abrasive and traumatic toothbrushing habits. The bone and soft tissue anatomy of the buccal, radicular surface of the dentition is usually thin, especially around the anterior area. Teeth positioned buccally may have a even thinner bone and gingiva. In many instances, such areas may have a complete absence of bone beneath the thin overlying gingival tissue. Such defect in the bone is called a dehiscence. This anatomic status combined with external trauma from overzealous brushing can lead to the loss of gingival tissue. Recession of the gingival tissue and bone exposes the cemental surface of the root, which results in abrasion and ditching of the cemental surface apical to the cementoenamel junction (CEJ). The cementum is softer than enamel and will be destroyed before the enamel surface of the crown. teeth for orthodontic therapy, are covered in Chapters 50, 65, and 74.

OBJECTIVES
The five objectives of periodontal plastic surgery addressed in this chapter are as follows: 1. Problems associated with attached gingiva 2. Problems associated with a shallow vestibule 3. Problems associated with an aberrant frenum 4. Esthetic surgical therapy 5. Tissue engineering

Problems Associated with Attached Gingiva


The ultimate goal of mucogingival surgical procedures is the creation or widening of attached gingiva around teeth and implants.3 The width of the attached gingiva varies in different individuals and on different teeth of the same individual (see Chapter 2). Attached gingiva is not synonymous with keratinized gingiva because the latter also includes the free gingival margin. The width of the attached gingiva is determined by subtracting the depth of the sulcus or pocket from the distance between the crest of the gingival margin and the mucogingival junction. The original rationale for mucogingival surgery was predicated on the assumption that a minimal width of attached gingiva was required to maintain optimal gingival health. However, several studies have challenged the view that a wide, attached gingiva is more protective against the accumulation of plaque than a narrow or a nonexistent zone. No minimum width of attached gingiva has been established as a standard necessary for gingival health. People who practice good, atraumatic oral hygiene may maintain excellent gingival health with almost no attached gingiva. However, those individuals whose oral hygiene practices are less than optimal can be helped by the presence of keratinized gingiva and vestibular depth. Vestibular depth provides space for easier placement of the toothbrush and prevents brushing on mucosal tissue. To improve esthetics, the objective is the coverage of the denuded root surface. The maxillary anterior area, especially the facial aspect of the canine, often presents extensive gingival recession. In such cases, the covering of the denuded root surface not only widens the zone of attached gingiva but also creates a improved esthetic result. This recession and the resultant denuded root surface have a special esthetic concerns for individuals with a high smile line. A wider zone of attached gingiva is also needed around teeth that serve as abutments for fixed or removable partial dentures, as well as in the ridge areas bearing a denture. Teeth with subgingival restorations and narrow zones of keratinized gingiva have higher gingival inflammation scores than teeth with similar restorations and wide zones of attached gingiva.90,91 Therefore, in such cases, techniques for widening the attached gingiva are considered preprosthetic periodontal surgical procedures. Chapter 65 discusses this subject in detail.

Widening the attached gingiva accomplishes the following four objectives: 1. Enhances plaque removal around the gingival margin. 2. Improves esthetics. 3. Reduces inflammation around restored teeth. 4. Gingival margin binds better around teeth and implants with attached gingiva.

Problems Associated with Shallow Vestibule


Another objective of periodontal plastic surgery is the creation of vestibular depth when it is lacking. Gingival recession displaces the

CHAPTER 63 Periodontal Plastic and Esthetic Surgery 597

FACTORS THAT AFFECT SURGICAL OUTCOME Irregularity of Teeth


Abnormal tooth alignment is an important cause of gingival deformities that require corrective surgery and also an important factor in determining the outcome of treatment. The location of the gingival margin, width of the attached gingiva, and alveolar bone height and thickness are all affected by tooth alignment. On teeth that are tilted or rotated labially, the labial bony plate is thinner and located farther apically than on the adjacent teeth; therefore the gingiva is recessed so that the root is exposed.106 On the lingual surface of such teeth, the gingiva is bulbous, and the bone margins are closer to the CEJ. The level of gingival attachment on root surfaces and the width of the attached gingiva after mucogingival surgery are affected as much by tooth alignment as by variations in treatment procedures. Another cause for gingival recession is periodontal disease and chronic marginal inflammation. The loss of attachment caused by the inflammation is followed by the loss of bone and gingiva. Advanced periodontal involvement in areas of minimal attached gingiva results in the base of the pocket extending close to, or apical to, the mucogingival junction. Periodontal therapy of these areas also results in gingival recession caused by the loss of gingiva and bone. Frenal and muscle attachments that encroach on the marginal gingiva can distend the gingival sulcus, which creates an environment for plaque accumulation. This condition increases the rate periodontal recession and will contribute to the recurrence of the recession even after treatment (Figure 63-1). These problems are more common on facial surfaces, but may also occur on the lingual surface.11 Orthodontic tooth movement through a thin buccal osseous plate may lead to a dehiscence beneath a thin gingiva. This also can lead to the recession of the gingiva45,106 (Figure 63-2).
Figure 63-1 High frenum attachments. A, Frenum between maxillary central incisors. B, Frenum attached to facial surface of maxillary lateral incisors. C, Frenum attached to facial surface of mandibular incisor. D, Frenum attached to facial surface of an incisor.

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Figure 63-2 A, Gingival recession and extreme inflammation around a lower central incisor. B, Advanced recession of mesial root of a first lower molar.

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Passive Engineering
1. Therapies based on guided tissue replacement (GTR) based therapies; barrier membranes 2. Biologically based acellular dermal matrix (ADM)

Active Engineering
1. Enamel matrix derivative (EMD) 2. Growth factors: Recombinant human platelet-derived growth

factor-BB (rhPDGF-BB) beta-tricalcium phosphate (TCP) collagen wound dressing 3. Cell therapy Autologous fibroblast: Isolagen Bilayered cell therapy (BLCT): Celltx Human fibroblast-derived dermal substitute (HFDDS): Dermagraft GTR (see Chapter 61) and ADM are both considered passive cell manipulation in which the cells themselves are not biologic mediators. The active portion will be discussed in this section. In 2003, McGuire and Nunn62,63 published results of a single-center randomized controlled clinical trial comparing a coronally advanced flap with enamel matrix derivative (EMD) to subepithelial connective tissue graft (SECTG). The results showed no statistical difference in the percentage of root coverage between test and control. It was concluded that within the limitations of this single-center trial that EMD with a coronally advanced flap is a valid alternative to the subepithelial connective tissue.62,63 Currently, the rhPDGF-BB has been studied and marketed under the brand name GEM21S. Recently, McGuire and Scheyer published a case series using this growth factor rhPDGF, -TCP, and a collagen wound dressing to obtain root coverage comparable to SECTG, which led to a controlled clinical trial. This randomized controlled clinical trial used the growth factormediated procedure to obtain clinical and histologic evidence of root coverage and regeneration when compared to the SECTG was published.68,69 These studies provided proof of principle that in four of four human histology block sections, true periodontal regeneration (alveolar bone, periodontal ligament, and new cementum) was possible with rhPDGF -TCP a collagen wound dressing (see Supplement B Figure 63-13). Histologic evidence of root coverage verifies that this tissue engineering method offers true periodontal regeneration, which is not expected with the SECTG. The reconstruction of the open interproximal space remains one of the greatest challenges in esthetic periodontal therapy. In a landmark study by McGuire and Scheyer,66 autologous fibroblasts were injected into the interdental papilla in a method to atraumatically augment the deficient gingival papilla. Although this method has not been thoroughly validated, treatment outcomes reduced open interproximal spaces and improved esthetics in the maxillary anterior region (Figure 63-24). No long-term evidence exists for tissue stability with this method, but this pilot study shows promise for an innovative study design for a tissue engineering application in dentistry. In 2008, McGuire and Scheyer67 published a pilot study comparing a tissue-engineered BLCT (Apligraf, Organogenesis, Inc, Canton, MA) to an free gingival graft (FGG) with promising enough results to warrant a multicentered controlled clinical trial. From the pilot study, there is evidence of de novo formation of attached and keratinized gingiva with the placement of a live cell therapy device without donor site surgery. In this randomized, controlled clinical trial, the test material was capable of generating up to 2.72 mm of keratinized gingiva, and in more than 75% of the subjects, greater than 2 mm of keratinized tissue was developed after a 6-month follow-up visit. This pilot study supports further

TISSUE ENGINEERING
Tissue engineering and the use of biologic mediators in periodontal plastic surgery has become a reality in recent years as the result of research and the demand for noninvasive surgical procedures by both the patients and clinicians. Current periodontal plastic surgery is based on the use of the palatal site for donor tissue (subepithelial connective tissue graft), which entails a second surgical wound.

Many patients are fearful of this donor wound and resist the surgery needed to correct a mucogingival problem. For these patients who desire to avoid the palatal donor site, morbidity associated with the subepithelial connective tissue graft (SECTG), and free gingival graft (FGG), tissue engineering methods are a excellent alternative. Periodontal therapy has been involved with tissue engineering for decades, beginning with GTR, a form of passive tissue engineering that excluded certain cell types and created an engineered wound left to heal with the appropriate cell types (see Chapter 61). The following is a brief summary of the materials that have been used for procedures based on tissue engineering and is divided into passive and active categories to recognize the role the cells play in tissue engineering.
For more information on numerous surgical techniques to increase attached gingiva, please visit the companion website at www.expertconsult.com. For more information on alternative donor tissue and supplements to this chapter, please visit the companion website at www.expertconsult.com. For more information on techniques to deepen the vestibule and frenum is, please visit the companion website at www.expertconsult.com.

Orthodontic correction is indicated when mucogingival surgery is performed on malposed teeth in an attempt to widen the attached gingiva or to restore the gingiva over denuded roots. If orthodontic treatment is not feasible, the prominent tooth should be reduced to within the borders of the alveolar bone, with special care taken to avoid pulp injury. Roots covered with thin bony plates present a hazard in mucogingival surgery. Even the most protective type of flap, a partialthickness flap, creates the risk of bone resorption on the periosteal surface.48 Resorption in amounts that ordinarily are not significant may cause loss of bone height when the bone plate is thin or tapered at the crest.

Mucogingival Line (Junction)


Normally, the mucogingival line in the incisor and canine areas is located approximately 3 mm apical to the crest of the alveolar bone on the radicular surfaces and 5 mm interdentally.92 In periodontal disease and on malposed disease free teeth, the bone margin is located farther apically and may extend beyond the mucogingival line. The distance between the mucogingival line and the CEJ before and after periodontal surgery is not necessarily constant. After inflammation is eliminated, the tissue tends to contract and draw the mucogingival line in the direction of the crown.31

CHAPTER 63 Periodontal Plastic and Esthetic Surgery 599


For more information on tissue-engineering, see Chapter 63 Supplement B on the companion website at www.expertconsult.com.

In the quest for new technologies to reduce trauma during surgery, further research is needed to investigate treatment methods such as ADM and biologic factors, as well as materials that could carry growth factors to the surgical site and maintain their action. At some point, recombinant growth factors could eliminate both the need for donor sites and the use of exogenous materials inserted into the human body. Future research should focus on obtaining additional evidence when using growth factors and live-cell technology during periodontal therapy to eliminate donor site morbidity.

CRITERIA FOR SELECTION OF TECHNIQUES


Different techniques are presented for solving mucogingival problems outlined in this chapter. The proper selection of the numerous techniques must be based on the predictability of success, which in turn is based on the criteria described next.

Criteria for selection of mucogingival techniques are as follows: 1. Surgical site free of plaque, calculus, and inflammation. 2. Adequate blood supply to the donor tissue. 3. Anatomy of the recipient and donor sites. 4. Stability of the grafted tissue to the recipient site. 5. Minimal trauma to the surgical site.

Surgical Site Free of Plaque, Calculus, and Inflammation


Periodontal plastic surgical procedures should be undertaken in a plaque-free and inflammation-free environment to enable the clinician to manage gingival tissue that is firm. Meticulous, precise incisions and flap reflection cannot be achieved when the tissue is inflamed and edematous. Thorough scaling and root planing, as well as meticulous plaque removal by the patient, must be accomplished before any surgical procedure.
Figure 63-24 A, Preoperative view of open interproximal space. B, Four months after three injections into the papilla with the patients own expanded and concentrated fibroblast. Note the improved papillary form. Also note green horizontal lines used for image analysis. (From McGuire MK, Scheyer ET: A randomized double blind placebo-controlled study to determine the safety and efficacy of cultured and expanded autologous fibroblast injection for the treatment of interdental papillary insufficiency associated with the papilla priming procedure J Periodont 78: 4-17, 2007).

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research of the BLCT to produce de novo keratinized gingiva without the use of a traditional autograft. More data are being analyzed that will allow for the commercial use of this material. In 2005, McGuire and Nunn64 published a pilot study evaluating the safety and efficacy of a living tissue-engineered HFDDS (Dermagraft, Advanced Tissue Science, La Jolla, CA) compared to a gingival autograft. Although the autograft produced a greater band of keratinized tissue, the test group represented the first attempt to use an off-the-shelf tissue-engineered material capable of generating attached and keratinized gingival.105

Adequate Blood Supply


To obtain the maximum amount of blood supply to the donor tissue, gingival augmentation apical to the area of recession provides a better blood supply than coronal augmentation, since the recipient site is entirely periosteal tissue. Root coverage procedures present a portion of the recipient site (denuded root surface) without blood supply. Therefore, if esthetics is not a factor, gingival augmentation apical to the recession may be more predictable. A pedicle-displaced flap has a better blood supply than a free graft, with the base of the flap intact. In root coverage, therefore, 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 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.

Anatomy of the Recipient and Donor Sites


The presence or absence of vestibular depth is an important anatomic criterion at the recipient site for gingival augmentation. If gingival augmentation is indicated apical to the area of recession, there must be adequate vestibular depth apical to the recessed gingival margin to provide space for either a free or a pedicle graft. If a vestibule is necessary, only a free graft can accomplish this objective apical to the recession.

Mucogingival techniques, such as free gingival grafts and free connective tissue grafts, can be used to create vestibular depth and widen the zone of attached gingiva. Other techniques require vestibular depth to be present before the surgery, including pedicle grafts (lateral and coronal), subepithelial connective tissue graft (Langer), and pouch and tunnel procedures. The availability of donor tissue is another anatomic factor that must be considered. 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 required at the recipient site for techniques using split-thickness, sandwich-type flap or the pouch and tunnel techniques.

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. The least amount of sutures and maximum stability should be achieved.

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Minimal Trauma to the Surgical Site


As with all surgical procedures, periodontal plastic surgery is based on the meticulous, delicate, and precise management of the oral tissues. Unnecessary tissue trauma caused by poor incisions, flap perforations, tears, or traumatic and excessive placement of sutures can lead to tissue necrosis. The selection of proper instruments, needles, and sutures is mandatory to minimize tissue trauma; sharp contoured blades (see Figure 63-17 online), smaller-diameter needles, and resorbable monofilament sutures all are important factors in achieving atraumatic surgery.

CONCLUSION
New techniques are constantly being developed and are slowly being incorporated into periodontal practice. The practitioner should be aware that, at times, new methods are published without adequate clinical research to ensure the predictability of the results and the extent to which the techniques may benefit the patient. Critical analysis of newly presented techniques should guide our constant evolution toward better clinical methods.

SCIENCE TRANSFER
Surgical techniques used solely to increase the width and thickness of the keratinized tissue are among the most predictable periodontal procedures. Periodontal plastic surgical procedures for root coverage have less predictability because of the absence of a foundation for blood supply over the root surface. The literature shows that the most predictable root coverage procedure is the use of connective tissue grafts in combination with split-thickness flaps. In cases where it is not possible to obtain a connective tissue graft because of the thinness of the palatal tissue, alternative procedures include coronally displaced flaps with membranes or Emdogain. In cases requiring root coverage where the gingival recession is 2 mm or less, a semilunar pedicle flap can be used. Cigarette smoking is a contraindication for root coverage techniques because the compromised gingival blood supply results in many failures. As defined in this chapter, perioplastic surgery refers to soft tissue relationships and manipulations. In all these procedures, blood supply is the most significant concern and must be the underlying issue for all decisions regarding the individual surgical procedure. A major complicating factor is the avascular root surface, and many modifications to existing techniques are used to overcome this. Diffusion of

fluids is short term and of limited benefit as tissue size increases. Thus the formation of a circulation through anastomosis and angiogenesis is crucial to the survival of these therapeutic procedures. The formation of vascularity is based on growth molecules, such as vascular endothelial growth factor (VEGF), and cellular migration, proliferation, and differentiation. As tissue-engineering techniques improve, the success and predictability of mucogingival surgery should dramatically increase. Undoubtedly, however, all advancements will have adequate circulation and blood supply as their basis.
References and Suggested Readings can be found on the companion website at www.expertconsult.com.