Periodontal esthetic surgeries

Esthetics is the prime focus of today’s dental care. Along with the functionally efficient occlusion, patients frequently ask for an esthetic smile. Esthetic dentistry is not just limited to color matching composite or porcelain restorations, but it refers to the overall presentation of the orofacial complex. Color and contour of gingiva, as well as its adaptation around the teeth, play a very important role in the overall esthetic appearance of the face.

Historically, Friedman (1957) 1 used the term “mucogingival surgery” to describe the surgical procedures for the correction of relationships between gingiva and oral mucous membrane with reference to three specific problems: those associated with attached gingiva, shallow vestibules, and frenum interfering with the marginal gingiva. With the advancements in the surgical procedures, more and more non-pocket surgical procedures which primarily focused on the esthetics of soft tissue adaptation around the teeth were introduced. In 1993, Miller proposed the term “periodontal plastic surgery” to describe these surgical procedures. In 1996, the world workshop on periodontics 2 renamed the “mucogingival surgery” as “periodontal plastic surgery” and this broad term included following procedures,

  • 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.

In the present discussion, we shall discuss in detail, mainly the treatment procedures for corrections of soft tissue defects in relation to the tooth and the edentulous ridge. Other procedures such as bone augmentation procedures, reconstruction of the papilla and esthetic surgical correction around implants have been discussed elsewhere.


Periodontal plastic surgery procedures are performed to prevent or correct anatomical, developmental, traumatic or plaque disease-induced defects of the gingiva, alveolar mucosa, and bone [American Academy of Periodontology (AAP) 1996] 2.

Basic principles of facial esthetics

Facial symmetry is dependent on standard esthetic principles that involve proper alignment, symmetry, and proportion of face. The most important components of the face that play a key role in smile designing are the interpupillary line and Lips. The interpupillary line should be perpendicular to the midline of the face and parallel to the occlusal plane. Lips are important from the esthetic point of view as they make the boundaries of smile. Maxillary incisal edge position is the most important determinant in smile creation because once set, it serves as a reference point to decide the proper tooth proportion and gingival levels. Esthetically acceptable color and contour of gingiva around the teeth is also an important component of overall esthetics. Zenith points are the most………………….


Problems associated with an inadequate width of attached gingiva

Attached gingiva is a part of keratinized gingiva which does not include marginal gingiva which is also a part of keratinized gingiva. The keratinized gingiva includes both free and attached gingiva and extends from the gingival margin to the mucogingival junction. The width of the keratinized gingiva may vary from 1-9 mm 4.

Lang and Loe (1972) 4 strongly suggested that……….


Along with the width of attached gingiva, the thickness of gingiva is also important. A thin gingiva is more likely to recede due to inflammation and faulty brushing technique than an adequately thick gingiva. Gosalind et al. (1977) 10 reported that the average thickness of attached gingiva is 1.25 mm. The methods of determining the width of attached gingiva have been discussed in the chapter 39, “Art of history taking in periodontology”.

According to Friedman et al. (1992) 11, the ‘‘inadequate’’ zone of gingiva would be one, which facilitates subgingival plaque formation because of improper pocket closure resulting from the movability of the marginal tissue. Generally, the attached gingiva is considered insufficient if stretching of the lips or cheeks results in the movement of the free gingival margin.

The important reasons for the inadequate width of attached gingiva include,

  • Deep pockets reaching the level of the mucogingival
  • Due to vigorous brushing in areas with thin gingiva.
  • Abnormal frenal attachment which exaggerates the pull on gingival margin.
  • Some individuals have an insufficient width of the attached gingiva by birth, resulting in the muscles pull on the gingiva, causing recession.

Various surgical procedures have been advocated which are aimed at increasing the width of attached gingiva. The advantages of increasing the width of attached gingiva include,

  • Efficient plaque removal around gingival margin,
  • Reduced marginal inflammation around restored teeth, and
  • Improved esthetics.

It must be remembered that if inadequate attached gingiva is present in young children, surgery is not an immediate choice of treatment. During growth and development, due to dimensional changes in the attached gingiva, it may spontaneously improve, if adequate oral hygiene is maintained. So, mucogingival surgery should be postponed until possible spontaneous improvement has been allowed to take place 12, 13.

Problems associated with a shallow vestibule

The vestibular depth is measured from the gingival margin to the bottom of the vestibule. A shallow vestibule jeopardizes the maintenance of proper oral hygiene, thus facilitating plaque accumulation and initiation of gingival inflammation.  If the inadequate vestibular depth is accompanied with minimum or no attached gingiva, the maintenance of oral hygiene is further compromised. On the other hand, if minimum attached gingiva is present with adequate vestibular depth, a surgical intervention may not be required if the patient is able to maintain a good oral hygiene.

Another requirement of adequate vestibular depth is in case of removable appliances. A shallow vestibule may cause dislodgement of the removable partial denture or complete denture. So, surgical procedures to increase the vestibular depth may be beneficial in these cases.

Problems associated with aberrant frenum

The frenal pull on the gingival margin may interfere with plaque removal and tension on this frenum may tend to open the sulcus. A high frenum and muscle attachment produces pull on the marginal gingiva which can be seen by pulling the lip outwards and upwards (for upper lip) / downwards (for lower lip). If the marginal gingiva moves with this maneuver, it indicates muscle pull which requires a surgical correction.

Indications of periodontal plastic surgery

  • To establish an adequate zone of attached gingiva to facilitate proper oral hygiene maintenance and prevent further recession.
  • Before coronal positioning of a graft and/or……………………..


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Gingival recession

Gingival recession is defined as an apical displacement of gingival margins to the cementoenamel junction (CEJ), which results in root exposure 14. The recession may occur due to the apical displacement of the marginal gingiva or due to the formation of a true periodontal pocket. There are multiple factors which are responsible for the gingival recession. These are,

Bone anatomy:

The presence of adequate amount of bone around the teeth is required for normal soft tissue adaptation around the teeth. Gingival recession significantly increases in root surfaces which are not covered with bone (dehiscence) 15.

Tooth position:

Tooth eruption and its position affect the amount of gingiva which surrounds the teeth. A buccally erupted tooth tends to show significantly more recession as compared to a normally positioned tooth 14.

Orthodontic movements:

The orthodontic movement of teeth may increase the probability of recession. Tooth movement in a position which will compromise its periodontal support predisposes to the development of recession 16.

Improper tooth brushing technique:

One of the most common reasons for recession is improper tooth brushing technique 17-19. It has also been shown that recessions are related to the use of hard toothbrushes 18.

High frenum attachment:

High frenum attachment is attributed to the local gingival recession.


Several studies have shown that  is an important factor in gingival recession 20, 21.

Active periodontal disease:

The active periodontal disease results in connective tissue attachment loss and periodontal pocket formation or gingival recession 22.


Several studies have demonstrated marginal recession is greater in smokers than non-smokers 23-26.

Classifications of gingival recession

Coverage of denuded root surface is one of the primary goals of periodontal plastic surgery. It was important to classify gingival recession on the basis of its clinical presentation and also on the basis of its probable clinical outcome after treatment. Sullivan and Atkins published the first classification of gingival recession, according to its amenability of being covered using mucogingival surgical procedures. The basis of their gingival recession classification was according to the depth and width of the recession defect. Four categories to describe defects were: deep wide, shallow wide, deep narrow and shallow narrow 27. Miller presented an expanded classification, which is probably most widely used today (Figure 70.1). Miller’s classification system is as follows 27, 28:

Class I:

Marginal tissue recession not extending to the mucogingival junction. No loss of interdental bone or soft tissue. Complete root coverage can be anticipated.

Class II:

Marginal recession extending to or beyond the mucogingival junction. No loss of interdental bone or soft tissue. Complete root coverage can be anticipated.

Class III:

Marginal tissue recession extending to or beyond the mucogingival junction. Loss of bone or soft tissue, apical to the CEJ, but coronal to the level of the recession defect. Partial root coverage can be anticipated.

Class IV:

Marginal tissue recession extending to or beyond the mucogingival junction. Loss of bone or soft tissue apical to the level of the recession defect. No root coverage can be anticipated.

Figure 70.1Diagrammatic representation of Miller’s Class I, II, III and IV recession

Miller's recession classification

Procedures for increasing width of attached gingiva

Free gingival autografts are widely used for increasing the width of attached gingiva and also for the root coverage in areas with recession. This procedure can be done apical to the area of recession to increase the width of attached gingiva, for root coverage or to treat both of these problems at the same time. In procedures where the gingival augmentation is done apical to the area of recession, no attempt is made to cover the denuded root surface. By doing these procedures, our main motive is to increase the width of attached gingiva. In the procedures which are done coronal to the area of recession, our main motive is to cover the denuded root surface due to gingival and bone recession. In the combined procedure the graft is placed in such a way that it covers the recession and also increases the width of attached gingiva. This procedure is usually done in case of localized mild to moderate recession.

Free gingival autografts

The free gingival autograft is one of the most common techniques used for gingival augmentation apical to the area of recession. This technique accomplishes the following objectives: enhances plaque removal around the gingival margin, reduces gingival inflammation and improves esthetics. This procedure results in an increased width of attached gingiva which helps in stopping the progressive gingival recession. It must be remembered that this procedure can also be used for root coverage when placed coronal to gingival recession.

History of free gingival graft:

The free gingival graft was first described by Bjorn in 1963, and Sullivan and Atkins in 1968 29. The procedure was initially described to increase the width of attached gingiva and to extend the vestibular depth. Later on, the procedure was used to attempt coverage of exposed root surfaces. This is a versatile procedure and can also be used over an extraction socket or osseous graft 29, 30.


Free gingival grafts are used for,

  • Increasing the amount of keratinized tissue (specifically, attached gingiva).
  • Increasing the vestibular depth.
  • Increasing the volume of gingival tissues in edentulous spaces (preprosthetic procedures).
  • Covering roots in areas of gingival recession.


The contraindications of a free gingival graft are as follows:

  • Lack of donor tissue thickness.
  • Medical considerations (uncontrolled diabetes, hypertension, bleeding disorders, anti-coagulant therapy, etc.).
  • When the mesiodistal width of the denuded root is significantly larger than the interproximal periosteal blood supply, so that the graft would not receive an adequate blood supply.
  • An unacceptable color mismatch between the grafted site and adjacent gingiva.

Surgical procedure:

The free gingival autogenous grafts involve two surgical sites, with the recession defect being the primary recipient site and the secondary donor site which is usually the maxillary palatal tissue (Figure 70.2 a-j). The recipient site is a firm connective tissue bed which receives the graft. While preparing the recipient bed, the periosteum is left covering the bone. The incisions to prepare the recipient bed are extended to approximately twice the desired width of the attached gingiva, allowing for 50% contraction of the graft when healing is complete. According to Egli et al. (1975) 31……………………………


The rugae area should be avoided for harvesting the graft as it results in a poor aesthetic appearance after healing and is difficult to eliminate even with surgical intervention 34. After controlling the bleeding, the donor site can be left as such for healing or periodontal dressing can be placed using an acrylic stent to cover the donor site.

One disadvantage of the free gingival graft is that it retains the color of the donor tissue. The grafted tissue can be clearly seen if the color of the recipient site and grafted tissue are different. This procedure is not recommended in areas with high esthetic concern 35.

The surgical procedure for free gingival graft is as follows,

Preparation of the recipient site:

  • After administration of the local anesthetic agent, a sound anesthesia is achieved, which is followed by a thorough root planning of the exposed root surfaces using curettes.
  • A horizontal incision is then made using a #15c blade at the level of CEJ extending from the line angle of adjacent teeth on either side of the recession deep into the papilla, creating a well-defined butt joint margin.
  • Vertical incisions are then made along the disto-proximal line angles of the adjacent teeth extending beyond the mucogingival junction and into the alveolar mucosa.
  • The overlying keratinized epithelial tissue is then excised with the help of a sharp blade and care should be taken not to leave any tissue tags.
  • A template is then prepared using aluminium foil on the recipient site to harvest the graft of the desired size from the palate.

Preparation of the donor site:

  • After placing the template on the palate, an incision is given with a #15c blade to demarcate the tissue which has to be harvested.
  • With the help of a tissue forceps, the graft is gradually separated with the blade till it is free from all sides. The graft is then raised keeping an even thickness of 1.5 mm. Care should be taken to ensure a uniform thickness of the graft.
  • The graft obtained is then inspected for any glandular or fatty tissue remnants.
  • Hemorrhage at the donor site is controlled using a pressure pack of moist
  • A pre-fabricated acrylic Hawley’s retainer is then given to the patient for the protection of the wound which the patient has to wear for a period of 2 weeks.

Suturing of the graft:

  • The recipient site is inspected and is cleaned of any excess clot or tissue tags.
  • The graft is then sutured at the…………………………


Free Gingival Graft

Healing following free gingival graft:

Healing following free gingival graft has been well studied. In most of the cases, sloughing of epithelium occurs, but the survival of underlying connective tissue determines the fate of the graft. Oliver et al. (1968) 36 and Nobuto et al. (1988) 37 studied healing following free gingival graft in monkeys and divided the healing process into three phases,

  1. The initial phase (from 0-3 days),
  2. Revascularization phase (from 2-11 days), and
  3. Tissue maturation phase (from 11-42 days).

The initial phase (from 0-3 days):

As soon as the graft is placed and stabilized over the recipient bed, a thin layer of exudate occupies the space in between the graft and the recipient bed. During these initial days, the graft obtains its nutrients from this exudate. This avascular “plasmatic circulation” is essential for……………………


Revascularization phase (from 2–11 days):

During this period, revascularization of the graft takes place. Anastomosis of the blood vessels in the recipient bed and the graft is established initially, re-establishing the blood supply of the graft. As the healing progresses, the proliferation of the blood vessels takes place, resulting in a dense network of blood vessels in the graft. The fibrous union of the graft with the underlying connective tissue starts from the second day and progresses for several days 38. With this union, the grafted tissue becomes completely integrated with the recipient bed.

Tissue maturation phase (from 11-42 days):

During this period, the number of blood vessels gradually reduces in the grafted tissue and at approximately 14 days, the vascularization of the grafted tissue appears to be normal. There is a gradual proliferation of the epithelium which keratinizes and virtually becomes indistinguishable from the surrounding epithelium.

Root coverage

The recession is a common finding and many times it causes compromised esthetics. Root coverage is one of the most important components of periodontal plastic surgeries. In the literature, three types of periodontal plastic surgery procedures have been described to treat recession defects. These include free grafts, pedicle flaps, and guided tissue regeneration 39. Free gingival grafts can be used for recession coverage as described in the previous section. Let us discuss now the pedicle flaps.

Classification of treatment modalities for root coverage

Currently, numerous surgical techniques are proposed for root coverage. These procedures are as follows 40:

I) Pedicle soft tissue grafts,

  • Rotational flaps:
    • Laterally positioned flap,
    • Double papilla flap
  • Advanced flaps:
    • Coronally positioned flap,
    • Semilunar flap

II) Free soft tissue grafts,

  • Non-submerged graft:
    • One stage [free gingival graft]
    • Two stage [free gingival graft + coronally positioned flap]
  • Submerged grafts:
    • Connective tissue graft + laterally positioned flap
    • Connective tissue graft + double papilla flap
    • Connective tissue graft + coronally positioned flap
    • Envelope technique.

III) Additive treatments,

  • Root surface modification agents.
  • Enamel matrix proteins.
  • Guided tissue regeneration:
    • Nonresorbable membrane barriers
    • Resorbable membrane barriers

Pedicle soft tissue grafts

Rotational flaps:

Laterally positioned flap:

A lateral pedicle graft involves repositioning the donor tissue from an area adjacent to the recession defect to cover the exposed root surface. Grupe and Warren (1956) 41 in 1956 first described it as the ‘‘lateral sliding flap’’. The procedure was then improved and named: the laterally positioned flap 42, 43. Hattler (1967) 44 later on, used split thickness flap repositioned in a similar way to cover multiple exposed root surfaces.

Variations in incision design as described by Grupe and Warren have been described with other names such as the ‘‘rotation flap’’ 45, ‘‘oblique rotational flap’’ 46 and the ‘‘transpositioned flap’’ 47. When the lateral movement is both mesial and distal to the defect (by including both mesial and distal interdental papillae), the rotational flap is called a double papilla flap 48.


  • It is a simple procedure.
  • Predictable for narrow areas of root exposure.
  • Avoids recession at the donor site.


  • Cannot be used for the root coverage in case of multiple tooth recession.
  • Cannot be done in the case of narrow interdental papilla.
  • Cannot be done if the thickness of gingival is less.
  • Does not give good results in areas with wide areas of recession.

Clinical procedure for laterally repositioned pedicle flap:

As already stated, in this procedure donor tissue adjacent to the recession is used to cover the recession (Figure 70.3 a-g). Following is the clinical procedure for the same,

Figure 70.3 Laterally repositioned pedicle flap

Laterally displaced flap

Preparation of the recipient site:

The recipient site is prepared by making a reverse bevel incision along the soft tissue margin of the defect. After removal of the epithelium, the underlying connective tissue is exposed to allow the adequate union and healing of the repositioned flap. Similarly, the surface epithelium adjacent to the recession defect on the side opposite to where the donor tissue will be taken is also removed to expose the underlying connective tissue. This area of de-epithelialisation is extended approximately 3 mm laterally and apically to the gingival margins. This provides a recipient bed for the repositioned tissue. After this, the root surface is thoroughly curetted to achieve a smooth surface.

Re-positioning of the pedicle flap:

The tissue adjacent to the recession from where the pedicle flap has to be raised is then prepared. A pedicle flap twice the width of the recession defect is then raised. The pedicle flap is raised by placing an oblique incision away from the recession defect leaving a few millimeters of keratinized gingival tissue around the adjacent tooth at the donor site. A second oblique incision is made from where the first incision ends and is carried apically beyond the alveolar lining mucosa. A split thickness flap is then…………………………………


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The operated area is then protected by placing a periodontal dressing, but it is not mandatory. A newer material, Barricaid TM (Dentsply International Inc. Milford, DE, USA) which is light cured can be used because it does not displace the repositioned flap and also has a favorable esthetic appearance. The recipient site heals by primary intention and the donor site heals by secondary intention.

The periodontal dressing and sutures are removed after 10-14 days and the patient is instructed to avoid mechanical tooth cleaning for further 2 weeks. Antimicrobial mouthwash such as chlorhexidine is prescribed to the patient for twice daily rinses.

Variations in incision design for lateral pedicle flap:

One of the most important disadvantages of the laterally positioned pedicle flap with originally described incisions is the exposed harvesting site extending up to the marginal gingiva. As it heals by secondary intention, renewed recession may occur at the harvested area. These limitations have been confirmed by Grupe (1966) 42 and later by Zuccheli (2004) 49.

Another problem with the original incision design was tension at the base of the flap when the flap is laterally displaced. This can be avoided by giving a “cut-back” incision which relieves the tension. Figure 70.4 (a-d) describes originally described incisions by Grupe and Warren (1956) 41, modified incision to protect the marginal gingiva described by Grupe (1966) 42, the cut back incision as described by Corn (1964) 50 and modified incision to protect marginal gingiva as described by Zuccheli (2004) 49.

Figure 70. 4 The variations of incision design for lateral pedicle grafts procedure

Variation in incision design


Variation in incision design for lateral pedicle


Variation in incision design for lateral pedicle flap


Lateral pedicle flap incision design


Double papilla flap:          

As already stated, Cohen and Ross in 1968 48, described the double papilla repositioned flap using the interproximal papillae to cover recessions and correct gingival defects in areas of insufficient gingiva not suitable for a lateral sliding flap. This procedure can be used for root coverage when soft tissue from one side of the area of recession is not sufficient to cover the recession. The width of the recession is initially measured to ensure that the interdental papillae mesial and distal to the recession have sufficient tissue to allow full coverage of the exposed root surface.


  • When the interproximal papillae adjacent to the mucogingival problem are sufficiently wide.
  • When the attached keratinized gingiva on an approximating tooth is insufficient to allow for a laterally positioned flap.
  • When periodontal pockets are not present.


  • The risk of loss of alveolar bone is minimized because the interdental bone is more resistant to loss than is radicular bone.
  • The papillae usually have thicker gingiva with greater width of attached gingiva as compared to the radicular surface of teeth.
  • The clinical predictability of this procedure is fairly good.


  • The primary disadvantage of this procedure is that it is a technique sensitive procedure where two interdental papillae are joined together to act as a single flap.

Clinical procedure:

Following clinical steps are followed while doing double papilla laterally repositioned pedicle flap (Figure 70.5 a-h),

  • Following administration of local anesthesia, two horizontal incisions are made on both sides, parallel to the CEJ of the tooth to be treated with a #15c
  • With a reverse bevel incision, the epithelial lining of the gingival margins around the recession is removed exposing the underlying connective tissue.
  • The root surface is then thoroughly scaled with the help of curettes.
  • Vertical incisions are then made…………………………


The most common problem associated with double papilla design is that the sutures to join two flaps are placed on the avascular surface of the root, because of which this area may become dehiscent.

Figure 70.5 The double papilla flap

Double papilla pedicle flap

Healing following soft tissue pedicle graft:

The healing following the lateral pedicle graft has been studied well. In areas other than the root surface, healing of the repositioned flap is similar as after flap surgery. There is a proliferation of the new connective tissue and blood vessels. The fibrous union then matures with due course of time. Wilderman and Wentz (1965) 51 studied healing of soft tissue over denuded root surface in a dog model. They divided the healing process into following four stages,

  1. The adaptation stage (from 0-4 days)
  2. The proliferation stage (from 4-21 days)
  3. The attachment stage (from 21-28 days)
  4. The maturation stage (from 28 days-6 months)

The adaptation stage (from 0-4 days):

Initially after the repositioning of the flap, a thin fibrin layer occupies the space between the flap and the root surface. During the initial few days of healing, epithelium from the transplanted tissue proliferates and attaches to the tooth surface at its coronal portion.

The proliferation stage (from 4-21 days):

As the healing continues, the fibrin layer between the repositioned flap and the root surface is then invaded by the proliferation of the connective tissue from the inner surface of the flap. It must be noted that the healing on root surface is different from the healing in other areas because connective tissue proliferation on root surface is only from the inner surface of the flap, unlike other areas where the connective tissue proliferates from both the inner surface of the flap and the recipient bed.  6-10 days postoperatively, …………………………


The attachment stage (from 21-28 days):

This stage is characterized by the insertion of newly formed collagen fibers into the newly formed cementum on the root surface.

The maturation stage (from 28 days-6 months):

During the last stage of healing, there is continuous formation and maturation of the collagen fibers. The collagen fibers formed can be seen inserting the cementum deposited on the apical portion of the recession. This union of the flap and the root surface allows a stable structural relation between the two.

Advanced flaps

Coronally positioned flap:

In this procedure, a partial thickness flap is created apical to the area of recession and is then repositioned coronally to cover the root. Bernimoulin et al. (1975) 52 first reported the coronally positioned graft, succeeding grafting with a free gingival autograft. It was described as a two-stage procedure wherein the first stage a free gingival graft was placed apical to the margins of the recession to be treated and in the second stage (after a few months), the graft was coronally positioned over the denuded root surfaces. Techniques involving coronal positioning of the flaps have been previously described by Mutschelknauss (1968) 53 and by Restrepo (1973) 54. Bjorn (1971) 55 described a technique by means of which the width of attached gingiva was increased and repositioned after one month.

Maynard (1977) 56 outlined the following requirements as criteria for the success, when using coronally positioned flaps:

  • The presence of shallow crevicular depths on proximal surfaces.
  • Normal interproximal bone heights.
  • Tissue height within 1 mm of the CEJ of adjacent teeth.
  • Six-week healing of the free gingival graft prior to coronal positioning.
  • Reduction in root prominence.
  • Adequate release of the flap during the second-stage surgery to prevent retraction during healing.

Coronally advanced flap can be done in one stage or two stage procedure. One stage procedure is done to cover shallow recession defects (Figure 70.6 a-f). A two-stage procedure is done when the recession is more and there is insufficient soft tissue apical to the recession to provide recession coverage. In two-stage procedure, the first procedure involves a free gingival graft, connective tissue graft or guided tissue regeneration procedure to increase the thickness and amount of keratinized tissue. After approximately three months of healing the tissue can be coronally repositioned as a second stage surgery. If the gingiva apical to the recession is of thick biotype and there is adequate keratinized tissue (minimum 3 mm) then the tissue can be coronally repositioned by a one-stage technique.

Figure 70.6 The coronally displaced flap (Courtesy: Dr. Dilesh Bagadia)

Coronally displaced flap

Clinical procedure:

  • After performing extraoral asepsis with an anti-microbial solution, intraoral asepsis is performed with 0.12% chlorhexidine solution.
  • A profound anesthesia is achieved using a local anesthetic agent.
  • Two vertical incisions are made starting from the adjacent teeth on both the sides which extend beyond the mucogingival junction.
  • The internal bevel incision is then made from the gingival margin to the bottom of the pocket to eliminate the diseased pocket wall.
  • The flap is then raised using sharp dissection.
  • The root surface of the tooth is thoroughly instrumented with manual scalers to achieve a flat root surface.
  • The flap is now sutured coronal to its original position. Interrupted sutures are placed to stabilize the flap at its place.
  • The area is then covered with a periodontal pack (not mandatory), which is removed along with the sutures after 1 week to 10 days.

As already stated, the main disadvantage of this procedure is that the results are often not favorable if the insufficient width of attached gingiva is present. In these cases, the two-stage procedure is adopted where the free gingival graft is done initially to increase the width of attached gingiva and then the coronally displaced flap is done.

Semilunar flap:

The semilunar coronally displaced flap was described by Tarnow in 1986 57. The technique involved a semilunar incision made parallel to the free gingival margin of the facial tissue, and coronally positioning this tissue over the denuded root. The main advantages of the procedure were: no requirement of sutures, no tension on the flap, no shortening of the vestibule, and no interference with the existing papillae.

Clinical procedure:

  • The patient is prepared for the surgery by giving plaque control instructions, scaling and root planning is done two weeks prior to the surgery to minimize the inflammation. There should be minimal pocket depth on the buccal aspect of the tooth prior to the surgery.
  • Root planing is done on the exposed root surface.
  • A semilunar incision is made following the………………………………..


The main advantage of this procedure is that it is easy to do and it is a quite predictable procedure for root coverage in mild to moderate recession areas where sufficient gingival tissue is available.

Free soft tissue grafts

Non-submerged graft:

The non-submerged grafts include free gingival graft procedure which has already been discussed in preveious sections.

Submerged grafts:

Sub-epithelial connective tissue graft:

The sub-epithelial connective tissue graft was introduced by Langer and Langer in 1985 58. Later on, the technique was modified by Nelson in 1987 59. The main objective of the technique was to provide soft tissue coverage to individual and multiple root sites. The technique aimed at covering deep and wide recession areas where often desirable results were not achieved.


  • Root coverage where a gingival color match is esthetically important.
  • Similar coverage for multiple root exposures.
  • For the avoidance of “keloid” formation.
  • Recession adjacent to an edentulous area which also requires ridge augmentation.

Clinical procedure:

The clinical procedure for the connective tissue graft procedure includes the following steps (Figure 70.7 a-j),

Preparation of the recipient site:

  • After the patient has been prepared for the surgery, the recipient bed is prepared for the connective tissue graft procedure.
  • A partial thickness flap is then raised with two vertical incisions placed at a distance of at least one papilla mesial and distal to the area of recession. The flap is raised beyond the mucogingival junction so that it is mobile.
  • The root surface is then meticulously planed. Root surface bio-modification agents such as tetracycline, citric acid, etc. may be applied on the root surface.

Harvesting of connective tissue graft:

  • The area on the hard palate, from where the connective tissue graft has to be harvested is anesthetized using a local anesthetic agent.
  • The available thickness of the mucosa is estimated by the use of the tip of the syringe.
  • The connective tissue graft is harvested from the plate using a “trap door” approach. The desired graft length is measured which should be…………………………


Placement of the harvested tissue on the recipient site and suturing:

  • The harvested graft is immediately placed on the denuded root surface. The graft is then sutured with fine, resorbable sutures to the periosteum.
  • The graft is then covered with the partial thickness flap on the outer surface. It is made sure that at least one-half to two-thirds of the graft is covered by the flap as it is essential for graft survival.
  • The area is then covered with a foil and periodontal pack.
  • After 7-10 days, dressing and sutures are removed.

The main advantage of this procedure is desirable esthetics and minimum post-operative discomfort to the patient as the donor site heals by primary intention.

Figure 70.7 The sub-epithelial  connective tissue  graft

Connective tissue graft

Connective tissue graft using “envelope” technique:

The connective tissue graft can also be placed using this technique. Following is the clinical procedure for envelop technique,

  • An internal bevel incision is placed along the gingival margin to eliminate the sulcular epithelium.
  • Now, an envelope is prepared around this incision in the gingiva both in apical and lateral direction, extending 3-5 mm. In the apical direction, the preparation should extend beyond the mucogingival junction so that placement of the connective tissue graft is facilitated.
  • A connective tissue graft is harvested from the palate by “trap door” technique in the same way as described previously in the sub-epithelial connective tissue graft.
  • The harvested graft is now placed in the prepared envelope in such a way that the recession is completely covered.
  • Sutures are placed to secure the graft in its position. As already stated, the flap should cover at least one-half to two-thirds of the graft. The flap can be coronally positioned and sutured to achieve this minimum coverage.
  • With the help of a moist gauze, pressure is applied for 5 minutes to adapt the graft closely to the root surface and covering soft tissue.
  • The area is then covered with the help of periodontal dressing.

Pouch and tunnel technique:

The survival of the graft depends on its stability and presence of abundant blood supply. Root coverage is especially difficult to achieve in areas with multiple recession. Zabalegui et al. 60 treated multiple gingival recessions by creating a tunnel under the areas of gingival recession to receive the connective tissue graft, thus avoiding dissecting the intermediate papilla and improving blood supply to the flap.

The main aim of pouch and tunnel technique is to minimize the incisions and maximize the blood supply to the graft. In this technique, the sub-epithelial donor connective tissue is placed into the pouches beneath the papillary tunnel which allows intimate contact of the donor tissue to the recipient site, thus ensuring an abundant blood supply to the graft. Following is the description of the clinical technique for pouch and tunnel procedure (Figure 70.8 a-h),

  • After preparing the patient for the surgery, local anesthesia is administered to achieve profound anesthesia.
  • With the help of # 15C or 12D blade, a sulcular incision is made around teeth adjacent to the recession. The incision separates the junctional epithelium and connective tissue attachment from the root surface.
  • With the help of small curette,………………………………………………….


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One major advantage of this procedure is the establishment of thicker gingival margins after healing. The thicker gingival margin is more stable to allow for the possibility of “creeping reattachment” of the gingival margin.

Figure 70.8 The pouch and tunnel technique for recession coverage

Pouch and tunnel technique

Additive treatment

Using barrier membrane (GTR):

The goal of guided tissue regeneration-based root coverage is to repair gingival recession via new attachment formation. The new connective tissue attachment is accompanied by the regeneration of new cementum and bone. Piniprato et al. (1995) 61 showed more gain of keratinized gingiva in GTR if a longer healing period was allowed and the results obtained were constant and comparable to other techniques. The clinical procedure for root coverage using guided tissue regeneration is as follows,

  • After achieving profound anesthesia, the denuded root surface is thoroughly scaled.
  • A full thickness trapezoidal flap is prepared by giving a horizontal crevicular incision extending from the mid-facial surfaces of the adjacent teeth.
  • Subsequently, vertical incisions are placed from the mid-facial surfaces of the adjacent teeth extending them apically.
  • The full thickness flap is elevated 3-4 mm apical to the crest of osseous dehiscence; partial thickness flap was prepared thereafter.
  • The surgical site is degranulated.
  • The GTR membrane is bent in a tent-like fashion with a suture and placed over the denuded root surface.
  • A sling suture is used to stabilize the membrane against the root surface.
  • The flap is displaced coronally until the flap covers the membrane completely, so as to avoid the exposure of the membrane and sutured using a sling suture.
  • Interrupted sutures are placed to stabilize the flap in coronally advanced position.
  • The area is protected with periodontal dressing which is removed after 7-10 days.

Various studies on recession defect coverage have utilized the principles of GTR and employed either bioabsorbable 62-81 (Figure 70.6) or non-resorbable 82-90 membranes. Bioabsorbable membrane studies show mean defect coverage ranging from 45% to 94% with a mean of 72% for all the studies. Whereas, for non-resorbable membranes, studies show mean defect coverage ranging from 45% to 91% with a mean of 73%  for all studies 91. The root coverage procedure with the barrier membrane placement is a technique sensitive procedure. The barrier membrane should adequately cover the defect and the coronally advanced flap should cover the membrane completely to achieve best results.

Know more…………Periosteal pedicle graft procedure:

This is a recent root coverage technique in which the periosteal layer is used to cover the recession defect. Periosteum is a highly vascular connective tissue sheath covering the external surface of all the bones (except the sites of articulation and muscle attachment) 92. It is mainly composed of two layers, the outer fibrous layer made up of collagenous fibers and fibroblasts and the inner layer is made up of an osteogenic layer of osteogenic cells and osteoblasts.

In this technique, after achieving profound anesthesia, an intrasulcular incision is given with the help of #15c blade on the buccal aspect of the involved tooth. Two horizontal incisions are then made in the gingiva at the level of the CEJ of the adjacent teeth. Vertical incisions are then made extending beyond the mucogingival junction, creating a trapezoidal flap. A full thickness flap is raised 3-4 mm apical to the osseous crest. The flap is then pulled buccally, and an incision is made in the periosteum to create a partial thickness flap which is then extended apically beyond the mucogingival junction. Periosteum is then separated from the underlying bone at the apical end and is lifted slowly in a coronal direction. The periosteum is not separated completely from the underlying bone, leaving it attached at its coronal most end. This periosteal layer is then inverted over its coronal attachment to cover the recession. The periosteal pedicle graft is then sutured with a synthetic 5-0 bioabsorbable suture. The flap is coronally positioned and sutured using a sling suture technique with a non-resorbable suture. Interrupted sutures are then placed to stabilize the flap. The area is then protected with periodontal dressing.


Factors influencing the degree of root coverage

The outcome of a root coverage procedure depends on  many factors which can be divided into three categories: the patient-related factors, the recession site related factors and the technique-related factors.

Patient-related factors:

Patient’s oral hygiene status is an important factor which influences the outcome of a root coverage procedure.  Poor oral hygiene adversely affects the outcome of a root coverage procedure 93. Faulty tooth brushing is one of the most common causes of gingival recession. The patient must be educated about the correct brushing technique because an inappropriate brushing technique may lead to the undesirable outcome of the surgical procedure. Smokers have less favorable results of the root coverage procedures as compared to non-smokers 90.

Recession site-related factors:

The class of recession (Miller’s classification) is the most significant factor determining the outcome of the root coverage procedure. The interdental area serves as a major source of nutrition for the grafted tissue. According to Miller’s classification system, full root coverage can be achieved in Class-I and Class-II recession cases because interdental tissue which serves as a source of blood supply, is present. In the case of Class-III and Class-IV recession only partial root coverage can be achieved due to lack of interdental tissue.

The dimensions of the recession also have a direct relation to the outcome of the surgical therapy. Wide and deep recession have a less favorable outcome as compared to narrow and shallow recession. In a study done by Wennstrom et al. (1996) 94, a coronally advanced flap was used with connective tissue graft placement. It was observed that complete root coverage was observed in only 50% of the defects with an initial depth of ≥5 mm as compared to 96% in shallower defects.

Technique-related factors:

The most important technique-related factor determining the success of the root coverage procedure is the thickness of the graft. If an inadequate thickness of the graft is taken, the results of the surgical therapy are adversely compromised. A systemic review, which included 15 studies, analyzed the thickness of the tissue flap and root coverage. It was found that for complete root coverage a critical thickness of free gingival graft  was 1 mm 95. For the free gingival grafting procedure, the graft thickness of 2 mm has been recommended 96.

Also, the final positioning of the flap margin plays an important role in root coverage.  It was demonstrated in one study that for complete root coverage in the treatment of Miller’s Class I recessions with a coronally advanced flap procedure, the flap margin has to be positioned at least 2 mm coronal to the CEJ 97.

Tension in the flap in coronally advanced flap also negatively affects the outcome of the procedure. Pini Prato et al. (2000) 98 in one study investigated effects of……………………………….


Deepening of shallow vestibule

Adequate vestibular depth is required for oral hygiene maintenance and for retention of prosthetic appliances. After the removal of natural teeth, remodeling of alveolar processes results in the reduction in the height and width of residual ridges. With resorption of alveolar process, adjacent muscles are found to attach at or near the crest of residual ridges. Due to continued bone resorption, the residual gingiva becomes diminished and labiobuccal vestibule and lingual sulcus become shallow. Vestibuloplasty is a surgical procedure whereby oral vestibule is deepened by changing soft tissue attachments. Various procedures have been described to increase the depth of the vestibule to provide an immobile soft tissue covering for the residual ridge. These procedures include,

Labial vestibuloplasty:

  • Kazanjian’s technique.
  • Godwin’s technique.
  • Lip Switch technique.
  • Clark’s Technique.
  • Obwegeser’s technique

Lingual vestibuloplasty:

  • Trauner’s technique.
  • Caldwell’s technique.

Labial vestibuloplasty:

Kazanjian’s technique:

This technique involves elevation of the pedicle flap from the alveolar ridge which is then sutured to the depth of the vestibule. The inner portion of the lip is allowed to heal by secondary epithelialization. Following are the surgical steps followed during this surgical procedure,

  • The area to be operated is anesthetized using local anesthesia bilaterally.
  • A transverse horizontal incision is made in the lower lip between the opposite premolar area.
  • A large flap of labial and vestibular mucosa is reflected.
  • Supraperiosteal dissection of the mental muscle is done.
  • The vestibule is deepened.
  • The pedicled flap is then sutured to the periosteum at the depth of the sulcus.
  • The open wound on the inner surface of the lip heals by secondary intention.

The major disadvantage of Kazanjian technique is scar contraction on the labial side of the vestibule with the loss of vestibular depth 99.

Godwin’s technique:

This technique deepens the mandibular vestibule like the Kazanjian’s technique where a flap of labial mucosa is elevated, but the vestibule is deepened by means of subperiosteal stripping, instead of supraperiosteal dissection.

Lip Switch technique:

It is also known as ‘Transpositional flap vestibuloplasty’ or ‘Edlan vestibuloplasty’.  It is a variation of the Kazanjian’s technique. The clinical procedure for this technique is as follows,

  • In this technique, the mucosal flap is created in the same way as suggested in the Kazanjian’s technique.
  • After reflection of the mucosal flap till the alveolar crest, the periosteum is incised high on the alveolar ridge.
  • Now, the flap contains the periosteum, connective tissue, and muscle. The flap is then transported outwardly and sutured to the margin of the raw wound in the lip.
  • The mucosal flap is turned downward against the bare bone and sutured to the periosteum deep in the vestibule.
  • As a result, the vestibule is now lined on the osseous side by mucosa and on the labial side by periosteum.
  • The new epithelium grows on the periosteal surface within 2-3 weeks.

The procedure can be combined with a surgical splint. In a denture wearing patient, his denture can serve as a retention splint if it is relined with tissue conditioner to adapt it properly to the vestibular depth. Major disadvantages of the procedure include scar contraction and relapse, which occurs in approximately 50% of the cases.

Clark’s technique:

Clark’s vestibuloplasty technique uses mucosa pedicled from the lip. The clinical procedure for this technique is as follows (Figure 70.9 a-f),

  • After achieving profound anesthesia, an incision is made on the alveolar ridge and supra-periosteal dissection is made to the desired depth.
  • The mucosa of the lip is undermined to the vermilion border.
  • Along the labial surface of the alveolar bone, supra-periosteal dissection is done till the desired vestibular depth.
  • Edge of the mobilized flap is pushed into new vestibular depth area and held in position by sutures.
  • As the alveolar bone is covered by the periosteal layer, it heals quickly by the formation of granulation tissue.

The success rate of this method is better than the Kazanjian technique.

Figure 70.9 Clark’s vestibular deepening procedure

Vestibular deepening

Obwegeser’s technique:

This procedure is similar to Clark’s technique except for the alveolar bone with its periosteal attachment is covered with a split-thickness skin graft which is held in position by sutures or stent constructed preoperatively. In place of skin graft, mucosal graft has also been placed. The main advantages of this technique are,

  • Faster healing as the bone is covered with the graft.
  • Less patient discomfort post-operatively.
  • Less bone loss and scarring.

Lingual vestibuloplasty:

Trauner’s technique:

The attachment of the mylohyoid and genioglossal muscles in the floor of the mandible to the denture-bearing area /the alveolar process, present similar problems on the lingual aspect of the mandible as on the buccal surface. This procedure is used to increase the depth of the floor of mouth in the mylohyoid region. The brief description of the clinical procedure is as follows,

  • After administering local anesthesia, an incision is placed over the lingual side of alveolar ridge bilaterally in the posterior region.
  • Supraperiosteal dissection is done to identify mylohyoid muscle.
  • Mylohyoid muscle is separated from the bony attachment.
  • Lingual nerve is avoided.
  • Fixation of mylohyoid muscle is established in a new place at desired depth on the lingual
  • Sutures are passed extraorally over the skin.

Caldwell’s Technique:

This technique involves placement of the incision at the lingual side of the ridge from second molar to second molar on the opposite site. Entire lingual mucoperiosteum is reflected. Mylohyoid ridge and genial tubercles are reduced. The mylohyoid and genioglossus muscles are pushed inferiorly. Sutures are passed through skin extraorally at the inferior border of the mandible.

Techniques for correction of aberrant frenum

One of the common causes of persistent midline diastema is the presence of aberrant frenal attachment. A frenum is an anatomic structure formed by a fold of mucous membrane and connective tissue, sometimes muscle fibers. A normal frenum attaches apical to the free gingival margin, so as not to exert a pull on the zone of attached gingiva and usually terminating at the mucogingival junction. However, its level may vary from the height of the vestibule to the crest of the alveolar ridge and even to the incisal papilla area in the anterior maxilla.

The maxillary labial frenum is………………………………………


The clinical diagnosis of abnormal frenal attachment is made by pulling the lip outwards and outwards in maxillary arch and outwards and downwards in the mandibular arch. If while doing so, the movement of the papillary tip or its blanching (which is produced due to ischemia in the region) is seen, the frenal attachment can be considered as abnormal. Frenum is also characterized as pathogenic when it is unusually wide or when there is no apparent zone of the attached gingiva along the midline.


Mirko et al. (1974) 102 classified labial frenal attachments into following.

  1. Mucosal – when the frenal fibers are attached up to the mucogingival junction.
  2. Gingival – when the fibers are inserted within the attached gingiva.
  3. Papillary – when the fibers are extending into the interdental papilla.
  4. Papilla penetrating – when the frenal fibers cross the alveolar process and extend up to the palatine papilla.

Frenum may also be classified depending on its morphology as:

  • Long and thin.
  • Short and broad.

Indications for abnormal frenal correction:

According to Olivi et al. (2010) 103 the clinical indications for frenum removal include:

  • Anomalous frenum associated with inflamed gingiva (resulting from poor oral hygiene).
  • Anomalous frenum associated with gingival recession.
  • Maxillary frenum associated with diastema after the complete eruption of permanent canines.
  • Abnormal and/or anomalous maxillary frenum (Class III or IV), resulting in the presence of a diastema during mixed dentition.
  • Anomalous mandibular frenum with high insertion, causing the onset of gingival recession.

Treatment for abnormal frenal correction:

Broadly, there are two surgical procedures to correct abnormal frenal attachment: frenectomy and frenotomy. Frenectomy is the complete removal of the frenum, including its attachment to the underlying bone. It may be required for the correction of abnormal diastema between maxillary central incisors. Frenotomy is the incision and relocation of the frenal attachment 104.

Surgical techniques to correct aberrant frenal attachment:

Various surgical approaches have been used to correct aberrant frenal attachment include: scalpel techniques, electrosurgery and lasers. The conventional technique involves excision of the frenum by using a scalpel. Since it was first proposed, a number of modifications of this technique like Miller’s technique, V-Y plasty and Z-plasty have been developed. Electrocautery has been used widely for this purpose and recent introduction is that of lasers. Following is the list of procedures used for the surgical correction of aberrant frenal attachment,

  • Conventional (Classical) frenectomy
  • Miller’s technique
  • V-Y Plasty
  • Z Plasty
  • Frenectomy using electrocautery
  • Frenectomy using lasers

Conventional (Classical) frenectomy:

The conventional/classical technique for frenectomy was introduced by Archer (1961) 105 and Kruger (1964) 105. This technique was introduced for the correction of midline diastema due to aberrant frenal attachment. The muscle fibers of orbicularis oris which were supposedly connecting with the palatine papilla were removed with this technique. A brief description of the surgical technique of this procedure is as follows (Figure 70. ),

  • The area is anesthetized with a local infiltration.
  • The frenum is engaged with the help of a hemostat.
  • An incision is placed on the upper and the under surface of the hemostat until the hemostat is free.
  • Blunt dissection is done on the bone surface to relieve fibrous attachment.
  • The edges of the wound are then sutured by using 4-0 black silk with interrupted sutures.
  • The area is covered with a periodontal dressing which is removed after one week.

Figure 70.10 The conventional frenectomy procedure


Miller’s Technique:

IProposed by PD Miller in 1985 106, this technique is used for the correction of post-orthodontic diastema cases. It has been seen that presence of high frenal attachment results in post orthodontic diastema formation. Ideally, the procedure should be done 6 weeks before the orthodontic appliances are removed. It provides adequate time for healing and the orthodontic appliance also helps in retaining periodontal dressing. Following is a brief description of the procedure,

  • The area is anesthetized with a local infiltration.
  • With the help of #15c blade, the frenulum is carefully excised and labial alveolar bone is exposed in the midline.
  • The attachment of the frenum with interdental papilla is excised with a horizontal incision.
  • Now, a laterally positioned pedicle graft (split thickness) is obtained from the neighboring tissue and is sutured across the midline.
  • The periodontal dressing is placed over the operated area which is then removed after one week.

The advantage of this technique is less postoperative discomfort to the patient and good esthetic results.

V-Y Plasty:

This is a modification of conventional frenectomy technique. The scar formation is reduced with this technique. Following is the brief description of the surgical technique of V-Y plasty,

  • The area is …………………………………………


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The main advantage of this frenectomy technique over the V-Y plasty technique is minimal scar tissue formation. The method requires a skilled operator as it is tedious to perform. Following is a brief description of the procedure,

  • Local anesthetic infiltrations are given around the frenum and palatally.
  • With the help of a #15c blade, a vertical incision is made at the center of the frenum. The incision is made at the most inferior part of the frenum in an upwards direction.
  • The incisions are then made to create the ‘Z-shape’ triangular flap. To create the ‘Z-shape’ triangular flap, an incision is made in the labial mucosa, starting from the top of the frenum and then extending outwards perpendicular to the primary incision. This incision is 1-2 cm in length. Another identical triangular flap is raised on the contralateral side but at the base of the vertical incision which gives the incision a ‘ Z – shape’.
  • The flaps are then rotated and repositioned to achieve closure.
  • Interrupted sutures are placed to achieve a close approximation of the flap.

Frenectomy using Electrosurgery:

The electrosurgery has an advantage of minimal bleeding and no need for sutures following the procedure. This procedure is recommended in cases of patients with bleeding disorders where excessive bleeding is suspected. The healing following this procedure takes place by secondary intention, as the wound edges were not approximated with sutures. Following is the description of the clinical procedure,

  • The area is anesthetized by administrating local anesthesia.
  • The frenum is held with the hemostat till the full depth of the vestibule.
  • The frenum is excised using a loop electrode tip.
  • Excessive desiccation of the tissue should be avoided because it results in delayed healing and more post-operative patient discomfort.
  • The area is then covered with the periodontal pack which is removed after one week.

Frenectomy using LASER:

LASER (Light Amplification by Stimulated Emission of Radiation) is based on spontaneous and stimulated emission of radiation which was first described by Albert Einstein. Since their introduction, LASERs have been used extensively in the medical and dental fields. A detailed description of LASER has been given in chapter 54, “Application of lasers in periodontal treatment”. Briefly, the clinical procedure for frenectomy using LASER is as follows,

  • The local anesthesia may or may not be administered before the procedure as the procedure is almost painless.
  • The frenum is stretched to visualize its extent.
  • The laser is applied in a contact mode with a focused beam for excision of the tissue.
  • The ablated tissue is continuously mopped using a wet gauze piece.
  • The tissue is lased until all the underlying muscle fibers are dissected.
  • There is no requirement of placing sutures and periodontal dressing.

The main advantages of using LASER are,

  • It is a painless procedure; hence there is no need of administering local anesthesia. As a result, there is less patient apprehension.
  • Bloodless operative field, thus better visibility.
  • There is no need of periodontal dressing, therefore no patient discomfort as a result of irritation from the dressing.
  • Less time consuming.
  • Better healing and less scarring.

Papilla reconstruction

Interdental papilla is the portion of the gingiva, which occupies the space between two adjacent teeth. It is very important from an esthetic point of view because its absence can lead to cosmetic deformities in the esthetic zone. Also, it may result in phonetic difficulty and food impaction 107. The absence or loss of the interdental papilla in the esthetic zone results in the formation of so-called “black hole”, which poses a great challenge for dental treatment.

The anatomy of interdental papilla:

Interdental papillae are the extensions of gingiva filling the spaces between neighboring teeth. It is formed by dense connective tissue covered by oral epithelium and may be influenced by the height of the alveolar bone, the distance between the teeth and interdental contact point 108. Because the tooth mass bordering the interdental papilla is less in the anterior teeth, the interdental papilla is narrow and has a pyramidal shape with its tip just below the contact point. In posterior teeth, due to the presence of larger tooth mass, it is wider and with a ridge-shaped concave area called as “col” 109.

In the anterior teeth, the location of contact points varies. For example, the contact point between two central incisors is located at the incisal third of the labial aspect. The contact point between central and lateral incisor is located in the middle and the contact point between the lateral incisor and canine is located at the cervical third. In other words, we can say that the interdental papilla between two central incisors is filled with more space than the other teeth in the anterior region.

Factors determining the presence or absence of interdental papilla:

There are multiple factors which determine the presence or absence of interdental papilla. These factors include, changes in tooth alignment during orthodontic treatment, loss of periodontal ligament resulting in recession, loss of alveolar bone height in relation to the interproximal contact, angulation of the roots and presence of crowns. Active periodontal inflammatory diseases are associated with the loss of interdental papilla/papillae. Periodontal pockets with probing depth greater than 3 mm will lead to an increase in plaque retention, inflammation, and recession. As the resorption of alveolar crest progresses, the distance between the contact point and the alveolar bone crest increases, resulting in loss of interdental papilla.

Following is the detailed description of the factors influencing the presence of papilla,

Underlying osseous architecture:

The shape and form of the interdental papilla depend on………………………………………….


Distance between the root surfaces:

The distance between the root surfaces also influences the presence of papilla. In a study, Tal (1984) 110 analyzed the interproximal distance of roots and the prevalence of infrabony defects. It was concluded that when the distance between roots was ≥ 3.1 mm, two separate infrabony defects were noted. In other words, we can say that a minimum of 3 mm interdental distance may be needed in maintaining papillae.

Periodontal biotype:

There are two morphological forms of interdental papilla and the osseous architecture, the thin and thick periodontal biotype 111. In general, thick biotype is better than thin biotype for the presence of interdental papilla. Thin biotype has thin and fragile periodontium which is more susceptible to recession. Thick biotype is fibrotic and resilient, making it resistant to surgical procedures with a tendency for pocket formation and recession. The interdental gingival tissue possesses biological tissue memory, due which under favorable conditions the interdental papilla attains its original shape and form. The thick biotype is more conducive for the rebound of gingival tissue than thin biotype.

Periodontal bioforms:

The periodontal bioforms denote the basic gingival scallop morphologies. Three types of gingival scallop morphologies have been described:……………………………………….


Contact points:

The contact points of maxillary anterior teeth and their distance from the crest of interproximal bone plays an important role in the form and the shape of interdental papilla. In a landmark study, Tarnow et al. (1992) 107 described “the 5 mm rule”. This rule states that when the distance from the contact point to the interproximal osseous crest is 5 mm or less, there is complete fill of the gingival embrasures with an interdental papilla. For every 1 mm above 5 mm, the chance of complete fill is progressively reduced by 50%. For square-shaped teeth with wide contact points, the chances of “black triangles” are minimal as compared to triangular teeth having narrow, more incisally positioned contact points.

Crown morphology:

The shape of the crown is an important factor which determines the shape and form of the interdental papilla. There are three basic crown forms: circular, square and triangular. The square crown shape yields better interproximal papilla maintenance due to wider contact and smaller interproximal distance from the osseous crest to the contact point. The triangular crown form results in a pronounced gingival scallop and thin underlying crestal bone, which predisposes for interdental papilla recession 111 (Figure 70.11).

Figure 70.11 Etiology pyramid of the  gingival black space

Etiology pyramid of the  gingival black space

Classification of the interdental papilla loss:

Nordland and Tarnow (1998) 114 classified the interdental papilla loss based on three anatomical points: the interdental contact point, the most coronal point of the enamel-cementum junction on the interproximal surface and the most apical point of the enamel-cementum junction on the labial surface.


The interdental papilla occupies the entire embrasure space apical to the interdental contact point/area.

Class I:

The tip of the interdental papilla is located between the interdental contact point and the level of the CEJ on the proximal surface of the tooth.

Class II:

The tip of the interdental papilla is located at or apical to the level of the CEJ on the proximal surface of the tooth, but coronal to the level of the CEJ mid-buccally.

Class III:

The tip of the interdental papilla is located at or apical to the level of the CEJ mid-buccally.

Jemt (1997) 115 described an index to clinically evaluate the degree of recession and regeneration of papillae adjacent to single implant restorations through a clinical and photographic examination. The assessment was measured from a reference line through the highest gingival curvatures of the crown restoration on the buccal side and the adjacent permanent tooth.

Score 0:

No papilla is present, and there is no indication of a curvature of the soft tissue contour adjacent to the single-implant restoration.

Score 1:

Less than half of the height of the papilla is present. A convex curvature of the soft tissue contour adjacent to the single-implant crown and the adjacent tooth is observed.

Score 2:

At least half of the height of the papilla is present, but not all the way up to the contact point between the teeth. The papilla is not completely in harmony with the adjacent papilla between the permanent teeth.

Score 3:

The papilla fills up the entire proximal space and is in good harmony with the adjacent papilla. There is an optimal soft tissue contour. Acceptable soft tissue contour is in harmony with adjacent teeth.

Score 4:

The papilla is hyperplastic and covers too much of the single-implant restoration and/or the adjacent tooth. The soft tissue contour is more or less irregular.

Correction of receded interdental papilla:

Various surgical and non-surgical techniques have been introduced with the sole intention of either reconstruction or regeneration of the lost papilla either by modifying the interproximal space or by surgical reconstruction of the lost soft tissues between the teeth. The nonsurgical approaches  (orthodontic,  prosthetic and restorative procedures)  modify the  interproximal space,  thereby inducing modifications  to the  soft tissues. Most of the surgical procedures have emphasized gingival grafting (free grafting, ruga grafting, etc.). But, the lack of blood supply for the donor tissue in a small, restricted recipient site has been one of the limiting factors for success. Numerous papers have discussed the challenges in diagnosing, treatment planning, and correcting deficiencies in esthetic clinical results after papilla reconstruction in the esthetic zone, in tooth-tooth, tooth-implant, and implant-implant situations 116-124. Newer techniques have emphasized on improved blood supply for the survival of the grafted tissue.

Surgical procedures to correct deficient or lost interdental papilla:

Several periodontal surgical techniques have been proposed to recreate the missing papillae 116, 125-134. Case reports and various non-surgical and surgical techniques in the literature regarding papilla reconstruction have demonstrated various success rates. However, the predictability of these procedures has not been documented and no data are available in the literature providing information on the long-term stability of surgically regained interdental papillae. In the following discussion, we shall discuss a few techniques which have been proposed for papilla reconstruction,

Beagle (1992) 135, described a surgical technique in which………………………….


Han and Takei (1996) 132, described a technique, the “semilunar coronally repositioned papilla” where they used free connective tissue graft to increase the soft tissue dimensions for papilla reconstruction. In this technique, they placed the semilunar incision in the alveolar mucosa facial to the interdental papilla. The intrasulcular incision was placed on the mesial and the distal surfaces of the teeth adjacent to the papilla to be reconstructed and the interdental tissue is freed from the tooth surface to facilitate its coronal positioning. A connective tissue graft is harvested from the palate and is introduced in the pouch that was created with the semilunar incision. The connective tissue graft supporting the coronally position interdental papilla is now sutured.

Azzi et al. (1998) 116 introduced an envelope technique, where…………………………………………..


Ridge augmentation

Localized alveolar ridge defects are commonly seen in partially edentulous patients impairing the prosthetic rehabilitation of the damaged ridge causing esthetic, phonetic and oral hygiene complications. These defects are due to osseous and soft tissue deficiency resulting from traumatic tooth extraction, advanced periodontal diseases, developmental defects, external trauma and tumors.  Seibert (1983) 136 classified the alveolar ridge defects as follows:

Class I:

Loss of tissue volume in buccolingual direction, with normal conditions of height in apical-coronal dimension

Class II:

Tissue loss in apical-coronal direction, with no change in volume in the buccolingual dimension

Class III:

Decreased volume both in buccolingual and apical-coronal dimensions.

Class I deformities are infrequent and not esthetically challenging, and the surgical augmentation of ridge width is not common. Meanwhile, treatments of Class II and III ridge deformities present more difficulties because of the need to replace a high volume of tissue.

In 1985, Allen et al. 137 classified the alveolar ridge defects according to  the depth of the deformity in relation to the adjacent alveolar bone level, as:

Mild: depth less than 3 mm

Moderate: ranging from 3-6 mm

Severe: more than 6 mm

Various grafting procedures have been developed for the reconstruction of deformed edentulous ridges. Soft tissue autografts, such as subepithelial connective tissue grafts 138, onlay grafts 139 and hard tissue grafts (e.g., guided bone regeneration) 140 can be used to augment residual ridges. In the present discussion, we shall discuss only the soft tissue ridge augmentation techniques.

Classification of soft tissue ridge augmentation techniques:

Pedicle graft procedure:

  • Roll flap procedure

Free graft procedures:

  • Pouch graft procedure
  • Interpositional graft procedure
  • Onlay graft procedure.

Roll flap procedure:

This technique is used for the soft tissue ridge augmentation in small to moderate Class I ridge defect usually associated with single or few teeth. In this technique de-epithelized connective tissue pedicle graft is prepared which is subsequently rolled back and placed in the sub-epithelial pouch. The connective tissue placed in the sub-epithelial pouch increase the soft tissue thickness and normal convexity of the ridge is achieved.

Clinical procedure:
After achieving profound anesthesia, a rectangular pedicle flap is created on the palatal aspect of the defect. The dimensions of the flap created should match the augmentation required. It must be noted that in the case where two or three pontic space is treated, two or three separate pedicles are raised. With the help of a sharp blade, the epithelium over the palatal flap is removed. The maximum amount of connective tissue should be preserved. A pouch is now created in the supra-periosteal connective tissue on the labial aspect. The palatal pedicle graft which was de-epithelized is now rolled back and placed in the buccal pouch. Sutures are placed to secure the rolled flap in its position. The de-epithelized raw area heals by secondary intention.

Pouch graft procedures:

This technique is used in moderate to large ridge defects. In this procedure, sub-epithelial pouch is created in the area of the ridge defect in which free connective tissue graft is placed, thus increasing the overall soft tissue dimensions bucco-coronally.

Clinical procedure:

After administration of local anesthesia, the initial incision is made. The position of the incision can be varied according to the…………………………


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Interpositional graft procedure:

In this procedure, the soft tissue graft is inter-positioned and not completely submerged. The procedure is indicated in Class I and small to moderate Class II defects. In this procedure, there is no need to remove the epithelium from the harvested graft because the epithelial portion of the soft tissue graft is sutured with the neighboring epithelium.

Clinical procedure:

A split thickness or envelope flap is created with releasing incisions on the buccal aspect of the defect. The provisional bridge is placed to estimate the dimensions of the graft to be harvested. After the dimensions of the graft to be harvested have been measured, a suitable site on the palate or the maxillary tuberosity is selected. Using “trap door” technique, connective tissue graft of suitable dimensions is harvested.

The harvested graft is placed at the recipient site. If only the thickness of the defect site has to be increased, the epithelium of the graft is flushed with the surrounding epithelium. But, if thickness, as well as the height of the defect site, has to be increased, the graft is sutured above the level of the surrounding tissue. The swelling due to inflammation helps in sculpturing the contour of the ridge below the provisional bridge. Eventually, after healing a smooth surface of the epithelium is achieved.

Onlay grafting procedure:

This procedure is used to increase the apico-coronal dimensions of the ridge. The procedure includes placement of a free gingival graft over a de-epithelial surface from which it receives its nutrition. This technique is indicated in case of Class II and Class III ridge defects. If the desired thickness of soft tissue is not obtained after post-operative healing, the procedure can be repeated after 2 months.

Clinical procedure:

Preparation of the recipient site:

With the help of a #15c blade, the epithelium is removed from the recipient bed. The margins of the recipient bed may be prepared with either butt joint or a beveled margin. Care must be taken to preserve as much of the lamina propria as possible. After de-epithelizing the recipient site, vertical incisions are made across the recipient bed at a distance of approximately 1 mm. The prepared recipient bed is covered with a moist gauge.

Harvesting the soft tissue graft:

The dimensions of the recipient bed are measured and an aluminum foil template is prepared. As a rule, the graft should be a few millimeters wider and longer than the dimensions of the recipient site. In this procedure, ……………………………………………………..


Stabilization of the graft tissue at recipient site:

The harvested soft tissue graft is now trimmed according to the shape of the recipient site. As already stated, vertical parallel incisions are made at the recipient site which helps in providing nutrition to the grafted tissue. The graft is stabilized in its position by placing interrupted sutures.

Healing following onlay soft tissue grafting procedure:

During initial few days, inflammation is present at the recipient site which slowly subsides with due course of time. The epithelium over the graft sloughs within a few days after placement. Within 4-7 days following the surgery, the revascularization of the graft is initiated. The healing process continues for many months thereafter, but the graft attains the normal appearance approximately after 3 months. The donor site is populated by granulation tissue and the complete pre-surgical contour of the palate is achieved by 3 months.

Combined overlay and interpositional grafting procedure:

This procedure is done in Class III ridge defects where more thickness of the tissue is required. A soft tissue graft is harvested from the palate with an extended portion of the connective tissue. This extended portion of connective tissue acts as an inter-positional graft and the remaining portion acts as an overlay graft.

Esthetic crown lengthening

The appearance of the gingival tissues surrounding the teeth plays an important role in the esthetics of the anterior maxillary region of the mouth. The lip line of the upper lip and its relation to the cervical margins of the maxillary anterior teeth is an important determinant of an esthetic smile. Depending on the relationship of the upper lip to the cervical margin of the maxillary central incisors 141, a smile is one of three types: high lip line, low lip line, and medium lip line. Most of the esthetic related problems are usually associated with the high lip line. A medium lip line results in most acceptable esthetics whereas a low lip line rarely results in esthetic problems. A high lip line causes excessive display of the gingiva which results clinically results in “gummy smile”. Usually a gingival exposure of more than 3 mm, apical to the gingival margin of upper teeth, results in this unwanted “gummy smile” appearance 142. The location of the gingival margins of maxillary central incisors, lateral incisors and canines is also important from an esthetic point of view. Allen (1988) 143 suggested following criteria to describe ideal relationships of gingival margins in upper anterior teeth,

  1. The gingival margins of the central incisors are symmetric and are either even with or 1 mm apical to the margins of the lateral incisors.
  2. The gingival margins of the canines should be 1 mm apical to the level of the lateral incisors.
  3. A line drawn horizontally at the level of the canine gingival margins should be parallel to the inter-pupillary
  4. The smile should expose a minimal amount of gingiva apical to the centrals and canines and should be in harmony with the smile line.
  5. The lateral incisors should be exposed 1.5 mm less than the length of the centrals.

The problem of gummy smile may also arise due to the incomplete passive eruption of some or all of the maxillary anterior teeth. The average crown lengths of maxillary anterior teeth are 11, 9, and 10.5 mm for upper centrals, laterals, and canines, respectively.

The biological width

The biological width is an important anatomical feature while doing a restorative procedure. Biologic width is the term applied to the dimensional width of the dentogingival junction (epithelial attachment and underlying connective tissue). It was first described by Sicher 144. Gargiulo et al. (1961) 145 described the dimensions and the relationship of the dentogingival junction in human. Their findings were,


Based on these dimensions, several authors have suggested that 3 mm of supracrestal tooth structure be obtained during surgical crown lengthening 146, 147.More details regarding this are available in the chapter 76 “Prosthodontic- periodontic-restorative interrelationship”.

Treatment planning:

As already stated, in an esthetic smile a line drawn horizontally at the level of the canine gingival margins is parallel to the inter-pupillary line. So, initially, a line parallel to the inter-pupillary line is drawn at anticipated levels of gingival margins of canines and central incisors. This line is placed at a distance of no more than 12 mm from the incisal edge of the central incisors, and no more than 11 mm from the cusp tips of the canines 143. In the case of attrition of incisal edges, the loss of crown length needs to be compensated when estimating the level of the CEJ 148.

After estimation of the…………………..


After the desired crown length is determined and osseous levels are identified the surgical treatment is planned. As a general rule, if the crest of alveolar bone is less than 3 mm away from the anticipated gingival margin, then bone resection is necessary, which requires a full thickness flap to be raised. Otherwise, gingivectomy or flap surgery without bone removal can be done.

Classification of esthetic crown lengthening procedures:

Gingival reduction only (bone removal not required)

  • Gingival flap surgery.

Mucoperiosteal flap with ostectomy (bone removal required)

One-stage procedures, which require one of the following:

  • Flap elevation, ostectomy, apical positioning of the flap.
  • Internal bevel gingivectomy, flap elevation, ostectomy, flap suturing.

Two-stage procedure, which requires:

  • Flap elevation, ostectomy, flap suturing at its original position.
  • Gingivectomy, 4 to 6 weeks later.

Gingival reduction only (bone removal not required):

This procedure is rarely done because in most of the cases osseous reduction is required. The technique involves simple gingivectomy or gingival flap surgery without osseous reduction. Gingivectomy is performed with the help of specially designed knives such as Kirkland knife and Orban knife, making a beveled incision which is about 45 degrees towards the long axis of the tooth in an apico-coronal direction. The procedure can also be performed with the help of #15c blade or with the help of diode lasers.

Full thickness flap without bone removal is used when minimal apical positioning of the gingival margin is required. Advantages of this procedure are preservation of the interdental papilla and if after flap elevation, it is found that the bone level is not distant enough from the new gingival margin, osseous resection can be performed.

Mucoperiosteal flap with ostectomy (bone removal required):

One-stage procedures:

When crown lengthening requires bone removal, the desired gingival margin position can be achieved by a one stage or two stage procedure. There are two types of one stage procedure: one which involves apical positioning of the flap and the other which involves gingivectomy. The apically positioned flap technique is useful if the amount of keratinized gingiva is limited. With this procedure, most of the keratinized gingiva is preserved and a healthy band of attached and free gingiva remains after the surgery. In cases where sufficient amount of keratinized gingiva is present, the procedure which involves gingivectomy can be performed. It must be made sure that an adequate amount of keratinized tissue remains after the removal of a collar of free marginal gingiva.

One stage procedure with apically positioned flap:

In this procedure, the mucoperiosteal flap is raised to achieve access to the facial alveolar bone. Bone removal is performed after flap reflection making sure that there is approximately 3 mm distance between the final gingival margin and alveolar bone crest. Osseous recontouring is done keeping in mind the contour of the gingival margins. The height of alveolar contour should be at the midline of the lateral incisors and slightly distal to the centrals and canines 143, 149, 150. The flap is then positioned apically at or near the crest of bone 151, 152. The disadvantage of this procedure is that healing is prolonged and it may take months for the sulcus to reform. The position of the final gingival margin is also unknown because swelling or shrinkage of the gingival margin may be there which varies from patient to patient.

One stage procedure with internal bevel gingivectomy:

This procedure is done where after gingivectomy sufficient amount of keratinized gingiva is left. The procedure is initiated with internal bevel gingivectomy placing the margins of gingival tissue at their final anticipated position regardless of their relationship to the underlying alveolar bone. After removal of the tissue, a sulcular incision is made in the new sulcus and a full thickness mucoperiosteal flap is raised. The underlying bone is exposed and osseous recontouring is done making sure that approximately 3 mm of distance remains between the new gingival margin and alveolar bone crest. If restorative procedures are not planned, removal of 2 mm of bone from the CEJ is recommended to expose the maximum amount of clinical crown without causing a recession. The main disadvantage of this procedure is that the results of the therapy are not always predictable. Despite adhering to the biological principles, the healing may not yield desired results.

Two-stage esthetic crown lengthening procedure:

As discussed above, in one stage procedures the healing is not always predictable. To overcome this problem the two stage crown lengthening procedure can be done. In this procedure, the stage one therapy involves flap reflection and osseous reduction. The flap is then sutured back at its original position. After 4 to 6 weeks post-operatively, second procedure is done, which involves internal bevel gingivectomy to achieve the desired crown length.

During the first step,……………………………..


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The second procedure is done 4 to 6 weeks after healing which involves internal bevel gingivectomy. The alveolar crest is sounded and the distance from the gingival margin till the bone crest is determined. This number minus 3 mm is the amount of the gingiva that can be removed with no change in the free gingival margin. The excess of the gingiva is removed, exposing the maximum clinical crown. The main advantage of this procedure is its more predictable results as compared to the single-stage crown lengthening procedure.

Esthetic corrections around dental implants:

The success of implant therapy not only depends on the fixture osseointegration and adequate function but also on the esthetics of the rehabilitated area. Achieving appropriate esthetics around implant-supported restorations is an important challenge to the restorative dentist. Because of the circular shape of the implant and its smaller diameter as compared to the natural tooth, it becomes difficult to construct an implant supported artificial crown which imitates the natural tooth crown when emerging from the gingiva.

In natural teeth, the emergence profile angle is relatively straighter, which in most cases cannot be replicated in implant supported crown. Various clinical procedures have been described to achieve appropriate esthetic results with implant-supported restorations in the esthetic zone.

Etiology of esthetic implant failure:

Let us first try to understand various etiological factors that result in esthetic implant failure. These factors can be broadly divided into two categories: anatomical factors and iatrogenic factors.

Anatomical factors:

Alveolar bone:

The status of the alveolar bone in which the implant is placed plays a significantly important role in esthetics specifically in the maxillary anterior area. The ridge anatomy and the soft tissue contour are heavily influenced by the anatomy of underlying bone. A ridge deficiency may result in deficient tissue volume around the neck of the implant where the tooth emerges from the gingiva. Various surgical techniques including the hard tissue regeneration and the soft tissue ridge augmentation procedures have been described to eliminate ridge deficiencies.

The contour of the interdental bone is also very important from an esthetic point of view. As discussed in esthetic crown lengthening, the distance from the interdental alveolar bone crest and the contact point should not be more than 5 mm otherwise interdental papilla may not be able to fill the inter-dental space resulting in “black triangle”.

Biological width:

Another important anatomical factor is biological width. Studies have shown that………………


Gingival biotype:

Depending on the thickness of the soft tissue, the gingival biotype may be thick or thin described as “thin biotype” or “thick biotype”. Thin biotype has highly scalloped gingiva as compared to the thick biotype which has blunted contour of the interdental papillae 113, 159. Establishing an acceptable esthetic implant restoration in thin gingival biotype is relatively more difficult as compared to the thick biotype.

Iatrogenic factors:

Implant position and orientation:

The position of the implant, as well as its angulation and orientation, is a key to an esthetic treatment outcome regardless of the implant system used. An implant placed too buccally or too palatally compromises its esthetic outcome. The mesiodistal orientation of the implant is also important. Minimum of 1-1.5 mm of bone is required around all the surfaces of the fixture. An incorrect mesiodistal placement of the implant may compromise its interdental tissue architecture.

Clinical procedures for esthetic correction around implants:

The esthetic corrections around dental implants include many procedures which are more or less similar to the esthetic corrections around natural teeth. The procedures may involve soft tissue augmentation or hard tissue augmentation or a combination of both. The soft tissue grafting procedures include roll technique, pouch technique, interpositional graft, onlay graft and combination grafts. The hard tissue augmentation procedures include the application of bone grafts to fill the defects around implants.


In this chapter, we discussed the etiology, diagnosis, classification, prognosis and surgical treatment of various mucogingival problems. There are various factors which govern the success of a periodontal esthetic surgery, most important of which are the correct diagnosis and gentle manipulation of the soft tissue during the surgery. The autogenous grafts harvested from the palatal area still remain the gold standard for free-gingival grafting procedures because none of the available allograft materials can be considered as a true substitute for autogenous tissue grafts. Further research is required to improve the techniques used in periodontal esthetic procedures as well as to reduce patient morbidity associated with the procedure.

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References available in the hard copy of the website

Periobasics: A textbook of periodontics and implantology

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