The proper selection of the numerous techniques must be based on the predictability of success that, in turn, is based on the following criteria discussed in this chapter.
Periodontal plastic surgical procedures should be performed in a plaque-free and inflammation-free environment to enable firm gingival tissue management. When the tissue is inflamed and edematous, precise incision lines and flap reflection cannot be achieved. The patient’s teeth must undergo careful and thorough scaling, root planning, and meticulous plaque control before any surgical procedure.
Short-term clinical studies show that the connective tissue graft results in superior root coverage compared with the epithelialized free soft tissue graft. In addition, the color match of the grafted area to the adjacent gingiva is aesthetically more favorable with the connective tissue graft than with an epithelialized free graft.
Maximum blood supply to the donor tissue is essential. Gingival augmentation apical to the area of recession benefits from a better blood supply than does coronal augmentation, because the recipient bed is entirely vascular (periosteum). Root-coverage procedures are a challenge because a portion of the bed is avascular (the portion of the root to be covered). Therefore, if aesthetics is not a factor, gingival augmentation apical to the recession may have a more predictable outcome.
A pedicle-displaced flap has a better blood supply than a free graft (since the base of the flap is intact in the former). Therefore, in root coverage, if the anatomy is favorable, the use of a pedicle flap or any of its variants may be the best procedure.
The pouch and tunnel techniques use a split flap for a subepithelial connective tissue graft, with the connective tissue sandwiched in between the flap. This flap design maximizes the blood supply to the donor tissue. If large areas require root coverage, these sandwich-type recipient sites provide the best flap design for blood supply.
The anatomy of the recipient and donor sites is an important consideration in selecting the proper technique. The presence or absence of vestibular depth is an essential anatomical criterion at the recipient site for gingival augmentation. If gingival augmentation is indicated apical to the area of recession, there must be adequate vestibular depth apical to the recessed gingival margin to provide space for either a free or pedicle graft.
Only a free graft can accomplish vestibular depth apical to the recession. Use mucogingival techniques, such as free gingival grafts and free connective tissue grafts, to create vestibular depth and widen the zone of attached gingiva. Other techniques require the presence of the vestibule before the surgery. These procedures include pedicle grafts (lateral and coronal), subepithelial con/>