GINGIVAL GRAFTS
Plan
INTRODUCTION
1. EPITHELIO-CONJUNCTIVE GRAFTS
1.1. Definition
1.2. Objectives
1.3. Indications
1.4. Contraindications
1.5. Technique
2. BURIED CONNECTIVITY GRAFTS
2.1. Principles and interests
2.2. Indications
2.3. Objectives
2.4. Sampling techniques
-Trap technique
-Bruno’s technique
-Parallel incision technique
2.5. Grafting techniques
-Langer technique (principle technique)
-Connective tissue technique with total coverage of the graft by the coronally positioned flap (GC + LPC)
-Bruno’s technique
-Envelope technique
-Tunneling technique
CONCLUSION
GINGIVAL GRAFTS
INTRODUCTION
Periodontal diseases are very complex multifactorial diseases in which different actors intervene. However, periodontitis always produces destruction of periodontal tissues. When this occurs in the areas concerned by aesthetics, aesthetics is at stake. The inevitable gingival recession associated with this destruction and surgical periodontal treatment is the main complaint of the patient in this area of the mouth.
1. EPITHELIO-CONJUNCTIVE GRAFTS
1.1. Definition
Free non-buried or epithelial-connective tissue gingival graft is the autogenous transplantation of fibromucosal tissue from a donor site to a recipient site.
1.2. Objectives:
Two main objectives can be sought:
– Increase in gingival height and thickness;
– Coverage of periodontal recessions in Miller classes I and II.
1.3. Indication:
The indication for surgery can only be made 4 to 6 weeks after the initial therapy in sectors without major aesthetic implications for:
- Increase in keratinized tissue
- Root coverage (treatment of single or multiple recessions)
- The arrangement of toothless ridges and increase in their volume;
- Peri-implant planning;
- The biological dressing: filling an alveolus after extraction;
- Complement to maxillofacial surgery: correction of cleft palates or after-effects of the operation;
- Association with laterally displaced flaps.
1.4. Contraindications:
Medical:
Aesthetic:
In the root coverage of the upper anterior teeth especially if it is a gummy smile;
Periodontal:
– In the presence of pockets or isolated recessions.
– When the gum adjacent to the recession is inflamed;
Technical:
– At the level of the 2nd mandibular molar, the external oblique line can constitute a nuisance
– At the level of the maxillary molar sectors, limited access and visibility and the presence of traction of the buccinator muscle;
– In the lingual regions of the mandibular incisors, stabilization and vascularization are precarious;
Specific contraindications for root coverage by gingival grafting:
-poor quality of donor tissue;
-Miller class 03 or 04 recessions;
-a mesio-distal diameter of the exposed root greater than the horizontal dimensions of the interproximal tissues.
GINGIVAL GRAFTS
1.5. Technique:
Consists of placing, at the level of the area to be treated, an epithelial-connective graft taken from:
The palace:
Last binoid papilla at the area of the palatine canal posteriorly.
Tuberosities:
The possibility of sampling depends on the presence or absence of the wisdom tooth.
The fibrous density of the tuberosity tissue is greater than that of the palatine corium.
Toothless crest:
Donor source for thin grafts.
The different operating times are:
- Preparing the receiving bed:
In order to allow the vascularization of the graft and avoid its necrosis during healing, the recipient bed must be wide (twice the size of the avascular area to be covered) and therefore extends on either side of the recession. The epithelial tissue is removed and a periosteal bed is prepared beyond the mucogingival junction line.
– Two horizontal incisions are made at the level of each papilla bordering the recession to a depth of 02 mm, they are continued by two vertical incisions exceeding the mucogingival line by 03 mm.
– The dissection of this mucous part in partial thickness ends with its section into a blade.
- Graft collection:
– A template is made to record the dimensions of the site to be treated
– In order to avoid papillary areas that are too tormented and areas at risk of bleeding, the sample is most often taken 02 or 03 mm from the palatal gingival edge of the two premolars and the 1st molar.
– the tissue taken is oversized by one third compared to the template, in order to compensate for the retraction of the graft linked to the contraction of the elastic fibers after collection. It must have a thickness of at least 1 mm in order to collect a strip of underlying connective tissue.
– the donor site is protected by sutures, and a surgical dressing or thermoformed gutter is placed
- Application and suturing of the graft to the recipient site:
It must be perfectly immobilized using lateral and periosteal sutures, in order to allow the formation of a fine and regular fibrin clot between the periosteal bed and the internal connective surface of the graft;
- Applying a surgical dressing.
GINGIVAL GRAFTS
.2. BURIED CONNECTIVITY GRAFTS
2.1. Principles and interests
Historically, the use of connective tissue grafts has been proposed to improve the aesthetic results of interventions compared to those obtained with epithelial-connective tissue grafts.
The principle of the connective tissue graft associated with the coronally positioned flap consists of placing a connective tissue graft in a “sub-epithelial” position.
- Indications:
- root coverage;
- gingival thickening on a natural prosthetic abutment;
- thickening of the peri-implant mucosa.
- Goals :
They are threefold: root coverage, increase in the height and thickness of the gum.
- Graft harvesting techniques:
The sample can be taken from the thickness of the palate or from the maxillary tuberosity. Different techniques have been described:
Trap technique, parallel incision technique, Bruno technique.
- Trap technique:
Consists of making an incision parallel to the line of the palatal necks of the premolar area and approximately 3mm. The length of this incision depends on the site to be treated. It is continued on either side by perpendicular incisions in the direction of the median raphe. The trapdoor is then dissected and lifted.
The connective tissue sample is taken at a thickness of approximately 1.5 mm (for root coverage)
- Bruno’s technique:
Consists of making a first incision in the palate perpendicular to the long axis of the tooth which goes up to the bone contact and is located approximately 2 to 3 mm from the gingival margin. A second incision begins between 1 and 2 mm from the previous one, depending on the desired thickness of the graft, and goes parallel to the long axis of the teeth up to the bone contact.
The mesiodistal extent of these incisions depends on the length of the site to be treated. The graft is harvested using a fine detacher.
The wound is closed with a suspensory suture. The graft is examined and the epithelial layer easily identified. The epithelium can be removed at this stage if the operator wishes, or preserved depending on its use.
- Parallel incision technique:
The harvest is done using the HARRIS double-blade scalpel. The two blades are inserted until they come into contact with the bone, then by moving in the MD direction a graft of constant thickness is prepared. Its detachment is more delicate than the harvest
It is necessary to change the instrument and take a 15 blade so as to join the two incision lines at the lateral ends.
Finally, in the apical part, the graft must be detached, with a blade or a detacher. The wound is easily closed with a suspensory suture or separated stitches.
All these protocols make it possible to obtain a connective tissue graft of sufficient thickness (at least 1.5 mm) and size to treat one or more recessions. However, it is advisable to carefully remove excess adipose tissue, as well as any epithelial part (in the context of the Bruno technique in particular).
The use of connective tissue grafts allows for tissue integration and aesthetically optimal healing, while allowing tissue thickening. Consequently, different authors have described techniques combining a surgical technique (such as a coronally or laterally displaced flap) and the use of a connective tissue graft.
GINGIVAL GRAFTS
2.2.5. Grafting techniques:
This is the original technique initially described by Langer in 1985, then a modification which consists of completely covering the graft and, finally, a variant described by Bruno in 1994.
- Langer technique (principle technique):
At the recipient site, the root surface to be covered is first prepared as in all other cases of recession treatment.
Then intrasulcular incisions around the recession are followed by horizontal incisions on either side of the enamel-cementum junction.
These horizontal incisions extend as far as possible but respect the attachment system of the neighboring teeth. The interproximal papillae remain intact.
Then, vertical or, better, oblique discharging incisions to determine a trapezoidal flap with a wide pedicled base, sink beyond the mucogingival line.
The flap is dissected in half thickness.
The graft is brought to the recipient site, tested and adapted.
The graft should extend apically beyond the 3 mm recession, thus increasing the chances of vascular supply.
The graft is then immobilized in the desired position by sutures to the underlying interproximal connective tissue and possibly to the periosteum with absorbable thread. But suturing the graft at this stage is not mandatory.
The flap is then replaced on the graft.
The part located on the root surface to be covered therefore remains exposed and epithelializes during healing.
- Connective tissue graft technique with total coverage of the graft by the coronally positioned flap (GC + LPC):
In this technique, the graft is completely buried under a coronally positioned flap.
The use of this technique is conditioned by the presence of keratinized tissue apically to the recession: only Miller classes I can be concerned.
The operative technique is that of a coronally positioned flap (preferably partial thickness, to provide a better vascularized bed for the transplanted connective tissue) associated with a connective tissue graft described previously.
In cases of contiguous recessions, the intrasulcular incision is extended to the two proximal teeth to facilitate flap elevation and avoid relieving incisions.
In case of a short vestibule, a horizontal incision in the apical region is made, based on the principle of the semilunar flap.
- Bruno’s technique:
In 1994, Bruno proposed some modifications to Langer’s original technique at the recipient site.
This is essentially to avoid discharging incisions to preserve maximum vascular supply.
This technique is similar to that of the envelope.
The only incision is horizontal, intrasulcular around the denudation and perpendicular to the soft tissue surface in the interdental spaces. It is located at the level of the cementoenamel junction. To facilitate dissection and provide access for graft placement, it is extended on both sides to the neighboring tooth
The split-thickness dissection then extends apically from the incision.
The graft is slipped into this kind of bag and its coronal edge is placed at the level of the enamel-cement junction. It is fixed with fine wire.
The flap is reapplied and immobilized with a non-absorbable suture.
- Envelope technique:
It was described by Raetzke in 1985.
Goals :
– Covering of root recessions,
– Increase in the height of keratinized tissue, tissue thickening.
· Indications:
It is intended to allow the recovery of single or multiple recessions, while seeking a significant aesthetic result due to the absence of discharge incisions.
· Technique:
– A partial thickness incision is made all around the recession to prepare a mucosal flap which, however, always remains attached at the level of the interdental gingival papillae. A real pocket then surrounds the recession. The vascularization of the envelope thus obtained is ensured by the papillae, as well as by the apical part.
– A connective graft is taken and then inserted into the envelope and covers all of the recessions.
– Digital pressure against the recession area helps promote primary bypass and avoid sutures.
- Tunneling technique:
It was described by Allen in 1994 and by Azzi and Etienne in 1994. The principle consists of creating a real tunnel in partial thickness bringing together in the same dissection several contiguous recessions.
Goals :
– Treatment of recessions and aesthetic integration even in Miller class III cases considered difficult to treat,
– Increase in the thickness and height of the gingival tissues.
Technique:
- Partial thickness dissection around the recessions which continues laterally to bring all the recessions together without harming the attachment of the papillae. To facilitate the progression of the 15C blade, it is essential to be able to very slightly lift the interdental papillae using a fine detacher or a periodontal probe, which allows the lateral and apical dissection to be controlled.
- The connective graft, freed from its epithelium and whose edges will have been previously beveled, is then inserted into the gingival tunnel in contact with the root surfaces on the supraperiosteal bed.
- To do this, a mattress-type suture at one end of the graft guides it under the interdental papillae.
- It is finally placed in the envelope at each mesial and distal end and sutured in this position with two simple periosteal stitches.
Benefits :
– This technique allows to maintain optimal vascularization of the surgical site due to the absence of releasing incisions and the preservation of the papillae.
– It is indicated in aesthetic sectors, in cases of multiple recessions as well as in preprosthetic surgery.
– It allows the reconstruction or conservation of interdental papillae.
– Tissue integration is good.
· Disadvantages:
The operating technique requires an experienced operator.
CONCLUSION
During the first consultation, the clinical examination allows to establish the need for mucogingival surgery. The choice of a technique is always made according to its simplicity and reproducibility for a given type of lesion. It should be noted that the experience of the practitioner is an important factor of success in this type of intervention.
GINGIVAL GRAFTS
Untreated cavities can damage the pulp.
Orthodontics aligns teeth and jaws.
Implants replace missing teeth permanently.
Dental floss removes debris between teeth.
A visit to the dentist every 6 months is recommended.
Fixed bridges replace one or more missing teeth.