Free gingival grafts presentation

1. 1
Mucogingival Surgery
Dentistry 664
Module G: Free Gingival
Grafts

2. 2
Mucogingival Surgery
Procedures
• Free gingival graft
• Pedicle graft
• Connective tissue graft
• Coronally positioned flap
• Frenectomy

3. 3
Free Gingival Grafts:
Gingival soft tissue grafts that are
completely detached from one site
and transferred to a remote site
As previously noted, free gingival grafts are disconnected from their blood
supply when they are harvested from the donor site. For the first three days
after transplantation, their survival is totally dependent on the seepage of
nutrients from a carefully prepared graft bed. This suggests that free gingival
grafts are ill-suited for root-coverage procedures, because denuded root
surfaces are avascular and have no potential to provide nutrients to a free soft
tissue graft. In fact, the free gingival graft procedure has been modified for
covering roots. This module will explain how this works.

4. 4
Root Coverage with Free Gingival Grafts
Example 1: The patient pictured above has severe gingival recession over the
prominent root of a mandibular right canine. The patient is enrolled in a study
of the efficacy of free gingival grafts for root coverage. In this photo, a
reference stent and a compass are being used to obtain accurate gingival
recession measurements. Note that this relatively broad area of recession is
bordered mesially, distally and apically by intact soft tissue that could
potentially be used as a large graft bed.

5. 5
A common feature of root coverage graft procedures of all types is that the
existing marginal tissue must be removed before a soft tissue graft can be
placed. Note that the marginal tissue has been removed and the adjacent
interdental areas have been de-epithelialized to expose bleeding connective
tissue.

6. 6
The graft bed has been dramatically extended in the mesial, distal and apical
directions by split thickness dissection. The bed surface is connective tissue or
periosteum. Notice that the area of the graft bed is considerably larger than the
denuded root surface area. This provides a large area for nutrient exchange to
allow the center portion of the soft tissue graft to survive over an avascular
surface.

7. 7
This figure illustrates a cross sectional view of palatal mucosa. As shown
above, there are relatively few capillary channels in a thin graft, more in a
graft of intermediate thickness and even more in a thick graft. These capillary
channels provide a means for nutrients to move from one part of a soft tissue
graft to another. For example, these channels allow nutrients to move from the
peripheral areas of a graft to its center. This is crucial for the survival of a free
graft over an avascular root.

8. 8
A thick free soft tissue graft has been harvested from the posterior palate and
carefully sutured over the graft bed. Notice that the graft is placed slightly
coronal to the CEJ of the canine. Meticulous suturing maximizes adaptation of
the graft to the bed and enhances the passage of nutrients from bed to graft.
Capillary channels within the thick graft provide a means for nutrients to reach
the portion of the graft that overlies the root surface.

9. 9
At the post-operative appointment ten days later, there has been some loss of
tissue at the gingival margin, but substantially all of the graft survived. The
beefy red appearance is typical of the early post-operative course of this type
of graft.

10. 10
After 17 days, there is evidence of minor shrinkage of the graft. The red
pinpoints throughout the graft are accessory salivary glands that are normally
found in palatal mucosa. Note that a substantial amount of root surface has
been covered.
Although not shown in this series, root surface conditioning with citric acid or
tetracycline is frequently carried out in conjunction with root coverage grafts.
Animal studies suggest that this treatment exposes collagen fibrils and
removes the “smear layer”on the root surface. It also detoxifies the root
surface. Human studies are relatively few and are less supportive of the
benefits of root conditioning. Many periodontists condition the roots anyway,
since this treatment has little or no potential to do any harm.

11. 11
After six months, maturation of the graft has resulted in an increase in its
tensile strength. Epithelium appears more keratinized than before. The graft
blends in relatively well with the adjacent tissue, but would never be mistaken
for anything other than a graft. The thickness of the graft and pronounced
keratinization contribute the graft’s relatively pale appearance.
It is important to note that the graft attached to the root surface during healing.
This attachment and resultant shallow probing depth are compatible with
gingival health. A graft that merely covered the root without attaching to it
would be considered unsuccessful.

12. 12
Example 2: This patient has gingival recession and root exposure in the
central incisor areas. There has never been a wide zone of attached gingiva
over the lower central incisors and there is very little attached gingiva in
evidence at this appointment. The patient has a recent history of orthodontic
treatment to alleviate mandibular crowding. Facial movement of the incisors
was accompanied by thinning of the bone and soft tissue covering the facial
surface of the root. Over a period of nine months, the gingival margin
receded. Note the inflamed appearance of the marginal tissue. Fortunately,
there is much less root surface to cover in this patient than in the previous
example. The narrow and somewhat shallow configuration of the recession
enhances the success of root coverage by free soft tissue grafting.

13. 13
The graft bed was prepared by split thickness dissection of the mucosa mesial,
distal, apical and coronal to the recession defects. De-epithelialization of the
facial aspect of the interdental papillae is particularly important for graft
survival.

14. 14
A thick rectangular graft was obtained from the posterior palate, trimmed to fit
the bed and sutured to stabilize the graft so that contact with the graft bed was
maximized. As in the previous example, the graft was positioned slightly
coronal to the CEJ of the central incisors.

15. 15
At the ten day post-operative appointment, there has been some retraction of
the marginal tissue, but overall graft survival is excellent. It is essential that
the patient avoid traumatizing the graft during the first week or two of healing.

16. 16
After suture removal, the bulkiness of the soft tissue graft is evident. At this
early post-operative stage, the site exhibits unambiguous signs of
inflammation.

17. 17
After eight weeks of healing, inflammation has resolved and the site looks
healthy. Almost all of the denuded root surfaces were covered in this
procedure. The probing depths facial to the lower central incisors are shallow
and there is firm attachment of the soft tissue graft to the root. The palatal
donor site (not shown) healed by second intention.
The next two modules will present alternative techniques for root coverage.
They will use a different approach to providing nutrients to the soft tissue
graft.