Connective Tissue, (CT) Graft #27
Capt Alfred G. Khallouf AEGD-2 Senior Resident
Pt presentation at initial appt
Preparing the Recipient Site• Scaled/Root Planed site
to Remove all calculus and debris, FIRST before tissue reflection is begun. – Do Not want to remove
fibrous attachments
• Placed sulcular incisions and reflected tissue from M of #26 to D of #28.
• Must make sure the site is free of any debris
Preparing the Recipient Site
• Make sure to prepare the site by conditioning
• Treated area for 2 minutes with PrefGel (EDTA)
Reflecting Tissue
• Reflect the tissue beyond mucogingival junction in order to create space for the donor graft
Initial Incision
• Horizontal incision extending on palate from approximately mesial of canine to mesial of 1st Molar about 3mm from Crest of tissue
• 8mm x 8mm site chosen on Palatal Rugae
Split the Difference• Split the difference,
separate the superior & inferior layers of the connective tissue in order to protect the outermost surface of the palate.
• Extend the internal incision the length of the blade
Rotate the blade
• Rotate the blade handle toward the boney side in order to separate the 2 vertical parallel aspects of the donor tissue
• This leaves only the most medial part still intact
Final Separation
• Be Very Careful
• Carefully separate the last part of tissue still holding it in place
• Have lots of blades ready throughout procedure
Like Magic
• The donor tissue should come out intact with the Adson’s Forceps
• KEEP THE SUCTION
AWAY
Donor Tissue
• Place the donor tissue on a flat surface the will not roll up or shrink
Suture Palate• Placed Surgical
(resorbable hemodent) in place of donor area
• Suture the site for primary closure
• 4-0 chromic gut interrupted sutures placed
Stent
• Make sure the lab fabricates a clear palatal stent prior to the surgery
• This is mainly for protection of tissue and pt comfort
• Should lock into place via interproximals, no balls or clasps
Suture Flap
• Initial suture placed, goes through the facial aspect of the mesial flap
Suture Donor Tissue
• 1 Suture placed through the donor tissue
Suture back
• Place suture through lingual aspect of mesial flap
Donor Tissue Positioned
• Donor tissue is positioned in place at the recipient site where it is to be sutured into place
Secure
• Secure donor tissue into place, but do not tie too tightly
• You do not want to strangulate the tissue
Suture Distal Flap
• Suture the Distal flap from the facial, initially, and pass through the donor tissue
• NOT TOO TIGHT
Secure
• Secure the suture and tie down
• Placed vertical mattress suture to position Graft
Connect the flaps (but not against each other)
• Suture the 2 flaps to each other now
• Graft was sutured into place with total of 6 interrupted 4-0 Chromic Gut sutures
Coe Pack Dressing
Coe-Pak surgical dressing on recipient site, locked into interproximal spaces
1 Week Post-op
• Tissue is healing WNL
• Granulation WNL
1 Week Post-op
• Removed coe-pack dressing
• Lightly dabbed periphery with Peridex
• Did NOT remove sutures
2 Week Post-op
• Palatal Donor Site is healing well
2 Week Post-op- OH NO• Pt stated that he
had noticed on Saturday afternoon that the CT graft, placed 10 days ago, was no longer in place on the facial of #27.
2 Week Post-op
• He stated that it may have fallen out the previous night when he was spitting out the Peridex
• He denies any aggressive or vigorous spitting or swishing.
3 Week Post-op
• Palate is healing very well
3 Week Post-op
• Clinically, the superior ¾ of the graft has sloughed off.
Before & After
Keys to better success• Apical portion should have been higher
– I did not coronally position the tissue high enough
• Ideally, I should have done a Free Autogenous Graft first, before CT
• CT Harvest from anterior about 3mm to 1st Premolar
• Free Auto start at the Mid Palate – This Donor tissue will be larger
• Root Coverage- CT Graft is sufficient • Keratinized Tissue- Free Auto Tissue Graft is
preferred
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