Periodontal Plastic SurgerySoft Tissue Grafting

Indications and ProceduresRobert C. Cain, DDS

First Mondays CE ClubNovember 4, 2013

Objectives

To understand some of the different types of grafts used in Periodontal Plastic Surgery (Mucogingival Surgery)To understand the indications for the different types of mucogingival surgeriesTo show some examples of one of the most common grafting procedures, the FGG and CTG.To understand when a condition would not benefit from Mucogingival Surgery

Common Questions (FAQ’s):

When is gingival grafting needed and when is it not?Why do I need it? What happens if I don’t do it?Does it hurt?What is the recovery time?Does it work? Does it have to be redone?Does brushing too hard cause recession?How much does it cost?

DefinitionsAttached Gingiva – The portion of the gingiva that is firm, dense, stippled and tightly bound to the underlying periosteum, tooth, and bone.Free Gingiva – That part of the gingiva that surrounds the tooth and is not directly attached to the tooth.

DefinitionsMucogingival Junction – the area of union of the gingiva and alveolar mucosaAlveolar Mucosa – Loosely attached mucosa covering the basal part of the alveolar process and continuing into the vestibular fornix and the floor of the mouth

Definitions

Mucogingival Defect – a departure from the normal dimension and morphology of the relationship between the gingiva and the alveolar mucosa

Definitions

Free Gingival Graft (FGG) - A soft tissue graft that is completely detached from one site and transferred to a remote site. No connection with the donor site is maintainedSubepithelial Connective Tissue Graft (CTG) - A detached connective tissue graft that is placed beneath a partial thickness flap. This variation of the free gingival graft provides the tissue graft with a nutrient supply on two surfaces

History of Periodontal Plastic Surgery1930’s – Frenectomies and vestibuloplasties1948 – First Gingivoplasties1956 – Grupe and Warren publish Laterally Positioned Flap1963 – Bjorn publishes the Free Gingival Graft1982 – P.D. Miller introduces the FGG for root coverage. Fernandez does first CT graft1989 – AAP renames Mucogingival Surgery to Periodontal Plastic Surgery

Indications for Perio Plastic SurgeryGingival Augmentation

Free Gingival GraftConnective Tissue Graft

Root CoverageCoronally positioned flapSemilunar flapLaterally positioned flapDouble papilla flapFree Gingival GraftConnective Tissue GraftGuided Tissue Regeneration using allograft

Grafting Decision TreeLeong and Wang. IJPRD 2011; 31 (3) 307 - 313

When is Grafting Needed?How much keratinized gingivae is needed?

Bowers 1963 – felt that gingival health could be maintained with a narrow zoned of KG (<1mm) but some was required for healingLang & Loe 1968 – suggested 2mmMaynard and Wilson 1979 – 5mm of KG with 3mm attached when subgingival restorations are plannedKennedy 1985 – over a 6 year period, patients with inconsistent OH saw recession with thin tissue

Bottom Line: some attached gingiva is necessary for health, but patients with good OH can maintain thin AG.

When is Grafting Needed?

Is the recession progressing?Is the tooth treatment planned for orthodontic care or prosthetic treatment?Is there root sensitivity?Is there difficulty cleaning the root surface by the patient?Is there an esthetic concern?

Free Gingival AutograftsIndications• To increase keratinized tissue around teeth,

implants or crowns• To increase keratinized tissue under removable

prostheses• To increase vestibular depth

Disadvantages• Difficult to achieve root coverage• High esthetic demand• Large, uncomfortable donor site• Graft site, slow uncomfortable healing

Free Gingival AutograftsClassic “Gum Graft”Will increase keratinized gingivaeResults in “Tire Patch” look

Free Gingival Graft

Pre-op Pre-op

Courtesy of Barry R. Wohl, DDS

Free Gingival Graft

Recipient Site

Donor Site

Courtesy of Barry R. Wohl, DDS

Free Gingival GraftBefore Long-term follow-up

Courtesy of Barry R. Wohl, DDS

Receding Gums

Miller Classification of RecessionClass I. Recession that has not extended to MGJ. No bone lossClass II. Recession to or beyond the MGJ. No bone lossClass III. Recession to or beyond MGJ. Bone loss. Papilla recessionClass IV. Recession beyond MGJ. Bone loss to the base of recession defect

Causes and Predisposing Factors in Gingival Recession

Predisposing Factors:Minimal attached gingiva/thin tissue biotypeFrenum pull / shallow vestibuleTooth malposition

Precipitating Factors:Inflammation related to plaqueRestorations adjacent to thin tissueOcclusal Trauma including orthodontic treatmentBone loss at an adjacent site

Connective Tissue Graft

AdvantagesVery predictable for root coverageSmaller donor site (than FGG)Smaller recipient site (than FGG)Less soreness overall (than FGG)Uses patient’s own tissueExcellent estheticsCan cover multiple, large recessions even on teeth with a previous restorations

Connective Tissue Grafts

DisadvantagesTwo surgical sitesTechnique sensitiveBleeding from palate (potential)

Connective Tissue GraftsSurgical technique

Root preparationThorough root planing of exposed root to remove cementum and affected dentinEtch root surface with tetracycline (pH 2.0)Exposes collagen tufts to promote fibroblast adhesion

Connective Tissue GraftSurgical Technique

Incision design (tunnel technique)Create “pouch” using full/split thickness incision between gingiva and bone/rootMaintain papilla for bilaminar blood supplyExtend incision to adjacent teethUndermine flap

Connective Tissue GraftSurgical Technique

Donor site incision (Buser)First palatal incision perpendicular to long axis of teeth

Connective Tissue GraftSurgical Technique

Donor site incision (Buser) Second palatal incision parallel to long axis of teeth

Connective Tissue Graft

Donor SiteHarvest TissueSuture Palate

Connective Tissue Graft

Surgical TechniqueRecipient site

Insert graft into tunnelSuture using interrupted and sling sutures

Connective Tissue GraftBefore

After

Connective Tissue GraftPre-op Occlusal Trauma

Post-op

Connective Tissue Grafts

Miller Class IV with supra-eruption of central incisorOnly minimal root coverage was possible

Connective Tissue Grafts

Before 3 years post-op

When is a CTG not indicated?All exposed dentin is gingival recessionAbfractionTissue at or near the CEJ

When is a CTG not indicated?Gingival hyperplasia adjacent to normal gingival contours

Brushing TOO Hard?

Does brushing cause recession?

Does brushing too hard causes gum recession? Not really….

Toothbrushing and Gingival Recession. Litonjua, LA, et al. Int Dent J 2003 53(2) a literature review showed no direct relationship between toothbrushing and gingival recessionTrauma from toothbrushing may contribute to recession in a minor way, but other more important factors should be treated firstAbrasion of the hard surfaces of the teeth are likely caused by abrasives in the toothpaste

Does it HURT?

The common perception is that Connective Tissue Grafting is VERY PAINFUL!!

This is often the patient’s perceptionThis perception is usually the result of hearsay from friends and relativesThe origins probably go back to the days of the Free Gingival Grafts

FEAR

Does it HURT?

RealityIn 20 years of performing CT grafts, very few patients ever complain about significant pain afterwardsMost are pleasantly surprised at how little pain they hadVery little post-op bleeding, swelling or bruisingOf course, everyone’s pain threshold is different…

What is the Recovery Time?

Recovery times vary from individual to individualPost-op instructions include:

Soft foods for a weekAvoid chewing in the donor or recipient sites if possible for the first weekBleeding from the palate is possible for the first 24 hours and sometimes longerDon’t brush the donor site for 1 week; the recipient site for 3 weeks. Chlorhexidine mouthwash in the meantimeIbuprofen 800mg 3/day for 2 – 3 days

What is the Recovery Time?

Most patients report some soreness during the first week, but most do not take anything more than the Ibuprofen 800 mgSome swelling of the recipient site is normal and occasionally some bruisingSutures resorb in the palate in 2 – 3 days and in about 1 week in the recipient siteMost people resume normal activities either the next day or two days afterSmokers heal more slowly and results are less predictable

Conclusions

Mucogingival defects are very common across all age groups and both gendersMucogingival defects can be either congenital or acquired with both predisposing and precipitating factorsPeriodontal Plastic Surgery can be used to correct mucogingival defects via a variety of methods and techniquesIndications for Periodontal Plastic Surgery can vary depending on rate of progression or the impact of local factors

Thank You!

Questions?