Types of grafts

a. Connective tissue graft

In dentistry, the subepithelial connective tissue graft (SECT) is an oral and maxillofacial surgical procedure and it is generally used to obtain root coverage following gingival recession.

There are various ways in which to carry out this procedure, all share a common sequence of steps:

1. Prepare the recipient site of tissue exhibiting recession by incising the gingiva.
2. Obtain the SECT from the donor site.
3. Secure the SECT at the recipient site.
4. Suture the incised gingival tissue at both the donor and recipient sites.

The donor site might be sutured closed either before or after securing the donor tissue to the recipient site.

The subepithelial connective tissue graft (SECT graft) is a sort of hybrid procedure that combines the pedicle flap with the free gingival graft and enjoy the benefits of both. Pedicle flaps alone, such as the coronally advanced flap, frequently suffer from retraction and muscle pull.

Surgical Procedure :

For preparation of recipient bed after obtaining adequate anesthesia, two vertically divergent incisions extending beyond the mucogingival junction (MGJ) were made on the buccal aspect of the involved tooth. The sulcular incision was then placed up to the end of vertical incisions.

Care was taken to see that the papilla was intact.

Figure 1 , 2, 3

The flap was extended well beyond the mucogingival junction.

A fresh tetracycline solution (100mg/ml) was prepared and applied to the root surface for each surgery for 4 min.

The root surface was then extensively rinsed with saline solution.

For graft harvesting from donor site a measurement of the approximate length and width of the graft required was taken and obtained from the palate. After its removal from the palate, the wound was closed.

After the required amount of connective tissue graft (CTG) was harvest, the tissue and prepared root surfaces were coated with PRP to allow the growth factors impregnate the CTG and root surfaces.

Then CTG with PRP was secured in position to cover the defect 3mm apically over the adjacent alveolar crest and 1 mm coronal to the CEJ and then sutured with 5-0 vicryl sutures.

Then the overlying flap was positioned over the CTG with very little tension using sling, suspensory sutures into the mesial and distal papillae, covering as much of the CTG as possible.

Periodontal dressing coe-pak were placed on recipient and donor sites. Postoperative antibiotics, analgesics and mouthwash were prescribed.

Postoperative instructions were given and were recalled after 9 days for suture removal.

Recall appointments were made after 1-month, 3 months, 6 months and 1-year post surgery. Patients were advised for chlorhexidine mouth rinse twice daily for another 3 weeks.

b. Free gingival graft (FGG)

A Free gingival graft is a dental procedure where a small layer of tissue is removed from the palate of the patient’s mouth and then relocated to the site of gum recession. It is sutured (stitched) into place and will serve to protect the exposed root as living tissue.

The difference between a connective tissue graft and free gingival graft is that the former is the better option when there is an esthetic problem or tooth sensivity.

A connective tissue graft will add new tissue that covers the exposed roots of the teeth. One the other hand, a FGG is often performed when you want to increase or stablish the presence of firm, protective gum tissue around a tooth.

Both procedures have been performed by us in Amirad Family Dentistry for many years and have had great outcomes.

• BENEFITS :

-Preventing further gum recession and ensuring the health of the teeth.
-Creating a protective barrier of strong, healthy gum tissue
-Reducing the risk of gum recession due to a thin gingival biotype
-Reducing tooth loss
-Establishing a healthy, wide bond or keratinized attached gingiva
-Helping to eliminate the frenum pull

• Indications :

– To increase keratinized tissue around teeth, implants or crown
– To increase keratinized tissue under removable prostheses
– To increase vestibular depth
– To augment the thickness of attached gingiva
– To repair gingival recession
– To prevent the progression of gingival recession (e.g. during ortho treatment)

• Advantages :

o High degree of predictability
o Simplicity
o Ability to treat multiple teeth at the same time
o As the first step in a two-stage procedure for attending root coverage
o As a single step for attaining root coverage
o Can be performed when keratinized gingiva adjacent to the involved area is insufficient

• Disadvantages :

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

Surgical Procedure :

After scaling and root planning and pocket probe until the patient achieved plaque score of 20% or below and eliminate trauma from occlusion if detected, surgical procedure will be started:

Step 1 : preparing the recipient site

The recipient site was prepared by horizontal papillary incisions made at right angle to the papilla at the level of CEJ. Two vertical incisions were made from the cut gingival margin to the alveolar mucosa.

A split thickness flap was separated without disturbing the periosteum at the recipient site. An aluminum foil template of the recipient site was made. (Figure 5)

Step 2 : Harvesting the free gingival graft from palate

Template of the recipient site made was placed over the donor site, and a partial thickness FGG was harvested from the palate. (Figure 6)
The graft consisted of epithelium and a thin layer of underlying connective tissue. Proper thickness between 1.0 and 1.5 mm is an important factor for survival of the graft.

Step 3 : preparation and placement of fibrin fibronectin sealing system (Tissucol/ Tisseel) on the root surface

After the required amount of FGG was harvested, a 2-3 ml film of FFSS (Tissucol) was placed over the root surface and the surrounding bone margins and let it set in place. (Fig 7

Step 4 : Placement of free gingival graft on the recipient bed coated
with Tissucol

The harvested FGG from the palate was then placed at the recipient site and sutured at the lateral borders and to the underlying periosteum (Fig 9). The graft was firmly held in place using digital pressure for 5 min and coe-pak was placed at the donor site and over the recipient site. Periodontal dressing was applied over the surgical area for 10 days.

Step 5 : Postoperative care

The patient was advised not to brush the treated site for 4 weeks. 0.12% chlorhexidine mouth rinse was prescribed twice a day for 4 weeks. Antibiotics and analgesics were administered as needed. Sutures were removed 10 days after surgery. Patient was examined weekly for the 1st month and then once a month for the next 3 months. Patient was recalled at 3 months intervals for oral hygiene instructions and supra gingival scaling until the end of the study period. The case follow up for a period of 1 year (Fig 10 and 11).

c. Pedicle graft

Gingival recession is defined as the apical displacement of the gingival margin from the Cemento-Enamel junction (CEJ). The patient’s main complaint often relates to poor aesthetics and occasionally it is related to sensitivity.

There are some of the surgical options available to correct localized recession defects.

Periodontal plastic surgery describes any surgical procedures involving the mucogingival tissues. It includes surgery which attempts to increase the width of keratinized tissue around a tooth and cover any exposed root surface associated with a recession defect. The main indications for surgical intervention to correct recession defects include the need to improve localized soft tissue aesthetics, reduce hyper sensitivity, improve plaque control and prevent further progression of recession defect.

There are three main types of periodontal plastic surgery procedures described in the literature to treat recession defects.

These include pedicle flaps, free gingival grafts, and guided tissue regeneration.

A pedicle graft involves repositioning donor tissue from an area adjacent to the recession defect to cover the exposed root surface. It avoids the need of a second surgical site and has the advantage of retaining its own blood supply from the base of the flap which remains attached to the donor site. This helps nourish the graft and facilitates vascular union with the recipient site.

The pedicle flap was first described as a laterally repositioned full thickness flap.

Here the donor tissue is taken from one side of the recession defect and repositioned over the exposed root surface. This was later modified with the use of a split thickness flap repositioned in a similar way to cover multiple exposed root surfaces. Soon after, described the double-papilla repositioned flap for use in areas where there was insufficient keratinized gingival tissue on any one side of the recession defect to reposition and cover the exposed root surface. Here the papillae are taken from both sides of the recession defect and repositioned over the exposed root surface. This procedure limits itself to single tooth recession defects. The double-papilla flap can also be performed either as a full thickness flap or a split thickness flap depending on the thickness of the gingival tissues.

There are many types of pedicle grafts:

a- Laterally repositioned pedicle flap

clinical technique (Figs. 1a-g)
Before raising the donor tissue, the width of the recession defect should be measured to gauge what size pedicle flap is required. To allow adequate union and healing of the repositioned flap a cuff of epithelialized tissue around the margins of the recession defect is cut away to expose the underlying connective tissue. Similarly, the surface epithelium adjacent to the recession defect on the side opposite to where the donor tissue will be taken is also removed to expose the underlying connective tissue. (Fig. 1a –b)

A pedicle flap twice the width of the recession defect is then raised by making an oblique incision away from the recession defect leaving a few millimeters of keratinized gingival tissue around the adjacent tooth at the donor site. A second oblique distal relieving incision is made towards the apical region from where the first incision terminated and extended beyond the mucogingival junction into the alveolar lining mucosa.

A split thickness pedicle flap is then raised and rotated over the exposed root surface and the connective tissue previously exposed on the opposite site (Fig. 1c).

The graft tissue should be free from any tension; if not the relieving incision should be extended further apical.

Once repositioned the pedicle flap is sutured down with fine interrupted sutures (Fig. 1d) and pressure applied for a few minutes to minimize the clot underneath the pedicle flap. This is important to ensure good union between donor and recipient tissues and to ensure good vascularization of the grafted tissue. A periodontal dressing can be placed if necessary but is not mandatory. The donor site is left to heal by secondary intention.

If the flap is left under tension, or there is excessive movement and poor stabilization or if the flap is too narrow for the recession defect, then there is a higher chance of failure of the procedure. (Fig. 1e- g) Show an example of a Miller’s class III recession defect on the lower left first molar treated with a laterally repositioned pedicle flap. At one week post- surgery there has been significant coverage of the exposed mesial root surface.

Grafting of a Miller’s class III defect of this size is highly unlikely to provide full coverage of the recession defect; however, significant improvement can be made with partial coverage of the root surface and an increased amount of keratinized tissue around the gingival margin as shown in this case.

A second surgical procedure with a coronally repositioned flap can be under taken to try and cover the remaining exposed root surface if necessary.

b. Double Papilla Rotational Flap

Clinical technique (Fig. 2a-b).

The width of the recession defect should be measured initially to ensure there is sufficient width of tissue available from the two adjacent papillae to allow full coverage of the exposed root surface. A cuff of epithelialized tissue is removed from around the recession defect to expose the underlying connective tissue (Fig. 2a).

Split thickness flaps of the papillae either side of the recession defect with vertical reliving incisions on the distal line angle of the tooth in front and mesial line angle of the tooth behind should be raised. The relieving incisions are extended beyond the mucogingival line and taken down to bone at this point to help release tension in the flap. The two papillae are repositioned and placed over the exposed root surface and sutured together with fine interrupted sutures along the midline of the exposed root surface (Fig. 2b).

A sling suture is placed around the tooth to hold the grafted tissue in its position and prevent it from sliding apically.

Gentle pressure is applied for a few minutes to minimize the clot that forms under the pedicle graft and a periodontal dressing can be placed if necessary. The exposed connective tissue at the donor site can be left to heal by secondary intention.
Inadequate suturing and inadequate stabilization can result in separation of the two pedicle flaps resulting in failure of the procedure.

c. Coronally Repositioned Flap

Clinical Technique (Fig. 3a-f)

The procedure can be performed either as a one stage technique to cover shallow recession defects or a two stage technique which is combined with a free gingival graft, connective tissue graft or with guided tissue regeneration procedures.

If the gingival tissue apical to the recession defect has thin gingival biotype or there is insufficient keratinized tissue, a free gingival graft or a connective tissue graft can be carried out first to increase the thickness and amount of keratinized tissue. After approximately three months of healing the tissue can be coronally repositioned as a second stage surgery.

If the gingival biotype is thick and there is adequate keratinized tissue (minimum 3 mm) then the tissue can be coronally repositioned as a one-stage technique.

In order to carry out this procedure it is essential to ensure there are shallow crevicular depths on inter proximal surfaces and no inter proximal bone loss.

The amount of coronal advancement required is determined by measuring the height of the recession defect. The same length is then measured from tip of the papilla towards the apex and horizontal incisions are placed through the tissue for a split thickness flap. Vertical relieving incisions are placed at the distal line angle of one tooth anteriorly and mesial line angle of one tooth posterior to the tooth with the recession defect (Fig. 3a).

A split thickness flap of even thickness is raised and extended beyond the mucogingival margin. The periosteum is released to allow freedom of movement of the flap. The most coronal part of the papilla which remains intact is de-epithelialized before coronal advancement of the flap (Fig. 3b).

The flap is then sutured in place approximately 0.5 mm to 1mm coronal to the CEJ with interrupted sutures in the papilla regions and along the reliving incisions (Fig. 3c).

Gentle pressure is applied for a few minutes and if necessary a periodontal dressing can be placed. Excessive tension in the coronally advanced flap can result in failure or a reduced amount of root coverage.

(Fig. 3d-f) show an example of a recession defect at lateral incisor treated initially with a connective tissue graft to increase the thickness of the gingival tissues around the recession defect followed by a second surgical procedure with a coronally repositioned pedicle flap to cover the recession defect.

The tooth has also had some minor enameloplasty to decrease the length and some composite bonding to improve the overall shape of the tooth.

If you have severe gum disease known as periodontitis. You may have lost some of the bone that holds your teeth in palace. Your dentist may suggest a bone graft. Bone grafts can help grow new bone to replace the bone destroyed by periodontitis.

During periodontal surgery the dentist may need to place a bone graft to help regenerate lost tooth supporting bone. During the procedure the dentist folds back part of the gum and cleans out any infected gum tissue, bacteria covered calculus and rough tooth surfaces that can make gum disease worse. Then bone graft material is placed, which works with the body to help build new bone. Bone graft can repair damage from gum disease and may boost the chances of keeping your teeth.

When tooth lose has already occurred, a metal post can be inserted into the jaw bone to act as an artificial tooth root. This requires strong and ample bone to form a stable base. If there is not enough bone is present, a bone graft is needed before you can get an implant. In bone grafting, a piece of bone is removed from another part of your jaw or your body, such as your hip, and transplanted to your jawbone. Frequently, commercially available artificial bone is also used. It will take several months for the transplanted bone to be ready for a dental implant. New bone growth will eventually replace the graft material. Sometimes you may need only minor bone grafting which can be done at the same time as the implant placement surgery.

-Classification of bone grafts based on material groups:

-Autograft: a bone graft using your own bone, usually sourced from the hip bone or back of the jaw.
-Allograft: a bone graft using bone sourced from a human donor.
-Xenograft: a bone graft using bone from an animal, usually a cow.
-Alloplast: a bone graft using synthetic material containing calcium, phosphorous and hydroxyl apatite.

Ask your dentist at Amirad Family Dentistry to explain the advantages and disadvantages of the different materials and grafting procedures.

Based on the pattern of bone loss around teeth as a result of gum disease, regeneration of some or all of the lost bone can be accomplished by bone grafting. A variety of materials and techniques have been developed to simulate growth in the remaining bone. This process is often performed in conjunction with flap and osseous surgery.

Guided bone regeneration (GBR) and guided tissue regeneration (GTR) are dental surgical procedures that use barrier membranes to direct the growth of new bone and gingival tissue at sites with insufficient volumes or dimensions of bone or gingiva for proper function, esthetics or prosthetic restoration.

GBR typically refers to ridge augmentation or bone regenerative procedures.

GTR typically refers to regeneration of periodontal attachment.

GBR is similar to GTR, but is focused on development of hard tissues in addition to the soft tissue of the periodontal attachment.

At present, GBR is predominantly applied in the oral cavity to support new hard tissue growth on an alveolar ridge to allow stable placement of dental implants.

Four stages are used to successfully regenerate bone and other tissues, abbreviated with the acronym PASS:

1. Primary closure of the wound to promote undisturbed and uninterrupted healing.
2. Angiogenesis to provide necessary blood supply.
3. Space creation and maintenance to facilitate space for bone in-growth.
4. Stability of the wound to induce blood clot formation and allow uneventful healing

In the GBR technique, different material are used for regeneration of bone.
These substances can come from our own bodies (Auto graft) or from another human (allograft) or animal body (xenograft) or from synthetic materials (Alloplast) which is then packed into the bony defect and covered by Resorbable or Non-Resorbable barriers (membrane).

For higher predictability, Non-Resorbable barriers are recommended.

Currently there are two types of barrier membranes available:

• Resorbable
• None-Resorbable

The main types of Non-Resorbable barrier membranes are e-PTFE, d-PTFE, Titanium mesh and Titanium- reinforced PTFE.

There are many different types of Resorbable barrier, but the main ones are synthetic polymers and natural biomaterials.

Synthetic polymers are such as polylactic acid bilayer.
Natural biomaterials are such as the collagen-derived membranes which can be obtained from bovine or porcine or dermis.

Success depends on osteoblasts being present at the site. There must be a sufficient blood supply, graft must be stabilized during healing and soft tissue must not be under tension.

Indications :

-Fenestration and Dehiscence
-building up bone around implants placed in tooth sockets after tooth extraction
-Socket preservation for future implantation of false teeth or prosthetics.
-Sinus Lift Elevation prior to implant placement
-filling of bone after removing that root of a tooth, cystectomy or the removal of impacted teeth
-repairing bone defects surrounding dental implant caused by peri-implantitis
-cystic cavity
-vertical and horizontal augmentation of the upper and lower jaws

Contraindication :

-Smokers
-Inadequate self-performed oral hygiene
-Many sits of defect
-Unable to achieve wound closure due to insufficient soft tissues
-Systemic disease e.g. diabetics

The objective of this technique is similar to that of bone grafting.

During the procedure, a biocompatible membrane is placed to isolate the area of bone damage around the tooth, creating an environment for new bone to form.
This procedure is often performed in conjunction with flap and osseous surgery.

This techniques, done in conjunction with flap and osseous surgery, uses an implantable protein material that stimulates new attachment between the tooth and the surrounding bone.