Background of periodontal plastic surgery, indications and techniques for soft tissue grafting.

1. Soft Tissue Grafting
Indications and Procedures
Robert C. Cain, DDS
First Mondays CE Club
November 4, 2013

2. 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 surgeries
To 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

3. 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?

4. Attached 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.

5. Mucogingival Junction – the area of union of the
gingiva and alveolar mucosa
Alveolar Mucosa – Loosely attached mucosa
covering the basal part of the alveolar process
and continuing into the vestibular fornix and the
floor of the mouth

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

7. 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 maintained
Subepithelial 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

8. 1930’s – Frenectomies and vestibuloplasties
1948 – First Gingivoplasties
1956 – Grupe and Warren publish Laterally
Positioned Flap
1963 – Bjorn publishes the Free Gingival Graft
1982 – P.D. Miller introduces the FGG for root
coverage. Fernandez does first CT graft
1989 – AAP renames Mucogingival Surgery to
Periodontal Plastic Surgery

9. Gingival Augmentation
Free Gingival Graft
Connective Tissue Graft
Root Coverage
Coronally positioned flap
Semilunar flap
Laterally positioned flap
Double papilla flap
Free Gingival Graft
Connective Tissue Graft
Guided Tissue Regeneration using allograft

11. 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 healing
Lang & Loe 1968 – suggested 2mm
Maynard and Wilson 1979 – 5mm of KG with 3mm
attached when subgingival restorations are planned
Kennedy 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.

12. 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?

13. Indications
• 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

14. Classic “Gum Graft”
Will increase keratinized gingivae
Results in “Tire Patch” look

15. Pre-op
Pre-op
Courtesy of Barry R. Wohl, DDS

16. Donor Site
Recipient Site
Courtesy of Barry R. Wohl, DDS

17. Before
Long-term follow-up
Courtesy of Barry R. Wohl, DDS

19. Class I. Recession that has
not extended to MGJ. No
bone loss
Class II. Recession to or
beyond the MGJ. No bone
loss
Class III. Recession to or
beyond MGJ. Bone loss.
Papilla recession
Class IV. Recession beyond
MGJ. Bone loss to the base
of recession defect

20. Predisposing Factors:
Minimal attached gingiva/thin tissue biotype
Frenum pull / shallow vestibule
Tooth malposition
Precipitating Factors:
Inflammation related to plaque
Restorations adjacent to thin tissue
Occlusal Trauma including orthodontic treatment
Bone loss at an adjacent site

21. Advantages
Very predictable for root coverage
Smaller donor site (than FGG)
Smaller recipient site (than FGG)
Less soreness overall (than FGG)
Uses patient’s own tissue
Excellent esthetics
Can cover multiple, large recessions even on teeth
with a previous restorations

22. Disadvantages
Two surgical sites
Technique sensitive
Bleeding from palate (potential)

23. Surgical technique
Root preparation
Thorough root planing of exposed root to remove
cementum and affected dentin
Etch root surface with tetracycline (pH 2.0)
Exposes collagen tufts to promote fibroblast adhesion

24. Surgical Technique
Incision design (tunnel technique)
Create “pouch” using full/split thickness incision between
gingiva and bone/root
Maintain papilla for bilaminar blood supply
Extend incision to adjacent teeth
Undermine flap

25. Surgical Technique
Donor site incision (Buser)
First palatal incision perpendicular to long axis of teeth

26. Surgical Technique
Donor site incision (Buser)
Second palatal incision parallel to long axis of teeth

27. Donor Site
Harvest Tissue
Suture Palate

28. Surgical Technique
Recipient site
Insert graft into tunnel
Suture using interrupted and sling sutures

29. Before
After

30. Pre-op
Occlusal Trauma
Post-op

31. Miller Class IV with supra-eruption of central
incisor
Only minimal root coverage was possible

32. Before
3 years post-op

33. All exposed dentin is gingival recession
Abfraction
Tissue at or near the CEJ

34. Gingival hyperplasia
adjacent to normal
gingival contours

36. 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 recession
Trauma from toothbrushing may contribute to recession in a
minor way, but other more important factors should be
treated first
Abrasion of the hard surfaces of the teeth are likely caused
by abrasives in the toothpaste

38. The common perception is that Connective
Tissue Grafting is VERY PAINFUL!!
This is often the patient’s perception
This perception is usually the result of
hearsay from friends and relatives
The origins probably go back to the days of
the Free Gingival Grafts

40. Reality
In 20 years of performing CT grafts, very few
patients ever complain about significant pain
afterwards
Most are pleasantly surprised at how little pain
they had
Very little post-op bleeding, swelling or bruising
Of course, everyone’s pain threshold is different…

41. Recovery times vary from individual to
individual
Post-op instructions include:
Soft foods for a week
Avoid chewing in the donor or recipient sites if
possible for the first week
Bleeding from the palate is possible for the first 24
hours and sometimes longer
Don’t brush the donor site for 1 week; the recipient
site for 3 weeks. Chlorhexidine mouthwash in the
meantime
Ibuprofen 800mg 3/day for 2 – 3 days

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

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