40 INSIDE DENTISTRY OCTOBER 2006 CONTINUING THIS CE LESSON IS MADE POSSIBLE THROUGH AN EDUCATIONAL GRANT FROM Achieving Predictable Connective Tissue Root Coverage Gregori M. Kurtzman, DDS, Lee H. Silverstein, DDS, MS, David Kurtzman, DDS, and Peter C. Shatz, DDS ABSTRACT Gingival recession creates esthetic issues. These issues may be corrected from a restorative perspective by the placement of composite resin or ceramic over the exposed root. But this approach often results in a gingival-incisal length that does not blend esthetically with the adjacent teeth. Often accompanying the gingival recession is a decrease in the band of attached gingiva. The wider the band of attached gingiva, the more stable the long-term result. Therefore, surgical correction of the recession also requires the addition of connective tissue to increase the width of the attached gingiva. Root coverage is dependent on the height of the adjacent papilla. The coronal apex of the papilla will dictate where the gingival margin can be placed. Patients who have lost interdental papilla may be poor candidates for predictable root coverage. Additionally, the recession may be confined to the attached gingiva or may extend beyond the mucogingival junction. 1 In general, Miller class I and II defects in which the interdental tissue has been maintained may allow complete root coverage. When interdental tissue has been lost (Miller class III and IV defects), achieving complete root coverage may not be possible. METHODS AND MATERIALS Preoperative It is recommended that preoperative administration of a broad-spectrum antibiotic should be initiated beginning the day before surgery and continued for 5 to 7 days postsurgery. Additionally, if not contraindicated by the patient s medical history, administration of a nonsteroidal anti-inflammatory drug (NSAID) should be administered 1 hour Gregori M. Kurtzman, DDS Private Practice Silver Spring, Maryland David Kurtzman, DDS General Private Practice Hospital-Based Practice Treating Special Needs Patients Marietta, Georgia before surgery. The NSAID will help depress prostaglandin synthesis elicited during the surgery and help mediate postoperative discomfort and associated swelling. Table 1 lists the materials and instruments needed to complete the surgical procedure. SURGICAL PHASE Connective Tissue Connective tissue needs to be harvested from the patient to help augment the missing soft tissue at the surgical site or a tissue bank allograft needs to be procured before surgery. When connective tissue will be harvested, the donor tissue is taken from the patient s palate. The initial incision should be made perpendicular to the long axis of the molars 5 mm from the gingival margin to ensure that the tissue coronal to the incision is over bone and adequate blood supply is maintained to the gingival marginal tissue. This incision should be made to the bone beginning at the mesial of the first molar (to avoid the greater palatine vessels) and may be extended to the mesial Lee H. Silverstein, DDS, MS Associate Clinical Professor of Periodontics Medical College of Georgia Augusta, Georgia Private Practice, Marietta, Georgia Peter C. Shatz, DDS Assistant Clinical Professor of Periodontics Medical College of Georgia Augusta, Georgia Private Practice, Marietta, Georgia of the canine. A second incision is made 2 mm to 3 mm apical to the initial incision and should contact the bone approximately 10 mm to 15 mm apically toward the midpalatal suture creating a partial thickness incision. 2 Care should be taken to avoid vasculature running anteriorly from the greater palatine foramen toward the canine area. These vessels run in a groove typically found midway between the midpalatal suture and the crestal bone. Vertical releasing incisions should be avoided on the palate to prevent excision of these vessels. A periosteal elevator should be introduced into the first incision and the connective tissue elevated to remove the tissue between the epithelium and palatal bone. The wedge of tissue is removed by grasping the band of epithelial tissue and teasing out the attached connective tissue. Wet gauze should be placed over the donor site and firm pressure exerted for 5 minutes to prevent hematoma formation under the epithelial tissue. The incision should then be closed with resorbable sutures in a crisscross-style horizontal mattress suture. 3 Patient comfort may be increased by use of Table 1: Materials and Instruments Needed Alloderm (adequate size for defect) Sterile saline (2) Sterile 50 ml stainless steel containers (2) 250 mg capsules of tetracycline Triple antibiotic ointment Sterile 2 x 2 gauze sponges Needle holder Suture scissors Addison forceps Periosteal elevator Periodontal hoe (3) 15C scalpel blades Scalpel handle 4-0 PGA sutures (3/8 circle reverse cutting needle) 5-0 PGA sutures (1/2 circle reverse cutting needle) LEARNING OBJECTIVES After reading this article, the reader should be able to: Identify the factors that contribute to the use of an acellular dermal allograft. Describe how acellular dermal allograft may be used in place of connective tissue derived from the patient s palate. Discuss why a Burrow s triangle would be used during preparation of the graft site. a vacuform stent worn for the first 2 weeks after harvesting of the palatal graft. 4 After harvesting of the palatal connective tissue, a scalpel is used to remove any adipose tissue and adjust the thickness of the graft. The tissue should be placed in gauze soaked in physiologic saline while preparing the recipient site. ACELLULAR DERMAL ALLOGRAFT If an acellular dermal allograft is to be used in place of connective tissue derived from the patient s palate, reconstitution of the tissue will be necessary. The piece of allograft should be removed from its sterile packaging and placed into a sterile dish containing 50 ml of sterile saline and allowed to soak for 5 minutes. The allograft should then be transferred to a second sterile dish with 50 ml of fresh sterile saline for 5 minutes. At the completion of the second soak, the allograft should be transferred to a separate sterile dish containing 250 mg of tetracycline dissolved into 50 ml of sterile saline and allowed to soak for a minimum of 15 minutes before surgical placement. Several pieces of 2 x 2 gauze should be soaked in a solution of 250 mg of tetracycline and 50 ml of sterile saline in a separate container to be used at the completion of the surgery. The benefit of using acellular dermal tissue compared to a bioresorbable bovine collagen membrane is the acellular graft contains the blood vessel channels that were present before harvesting the tissue. This permits the recipient site to use the allograft as a scaffold, connecting existing vessels to these open channels and establishing vascularization more rapidly then could be achieved with bovine collagen membranes. PALATAL DONOR TISSUE VS ACELLULAR DERMAL ALLOGRAFT There are pros and cons to both palatal donor tissue and acellular dermal allograft Log on now to www.insidedentistryce.com to take the FREE CE quiz!
42 INSIDE DENTISTRY OCTOBER 2006 Figure 1 Incisions illustrated with Burrow s triangles located apical to the mucogingival junction. Figure 2 While grasping the tissue at the center of the Burrow s triangle, a scalpel is used to excise it. Figure 3 While grasping the flap margin with an Addison forceps, a scalpel is used to create a partial thickness flap. Figure 4 At the mucogingival junction, an incision is made to the underlying bone. for connective tissue. Patient-derived connective tissue has no additional cost added to the procedure, but there is a higher morbidity then when an acellular graft is chosen. Patient comfort after the procedure is also a factor because graft acquisition from the palate can result in discomfort during the healing phase. By contrast, although there is a higher cost involved with an acellular graft, patient comfort after surgery is higher because no surgery is performed on the hard palate. Additionally, the amount of tissue required is not influenced by what is available on the patient. With regard to the rate of healing, palatal donor tissue will heal quicker then allograft. 5 However, studies published comparing the two sources of connective tissue have not found any clinical differences when used in dental applications. 6,7 These results mimick what has been seen dermatologically. 8 There is one caution that should be considered when considering allograft. Because the graft is processed with tetracycline, the use of this material should be avoided in patients with a known sensitivity to tetracycline drugs. In these patients, use of palatal tissue may be a more prudent option. Preparation of the Graft Site Surface bacterial levels intraorally can be reduced by having the patient rinse with an approved rinse such as chlorhexidine, Listerine (Pfizer, Inc, Morris Plains, NJ), Chloraseptic (Prestige Brands, Inc, Irvington, NY), or such rinse for another 30 seconds before the initiation of surgery. A local anesthetic should be administered mesially and distally of the intended surgical site. A sulcular incision is then started one tooth distal to the tooth/teeth to be treated. The incision is continued to the opposing side one tooth from the site requiring treatment. The papilla should be spared and left attached to the lingual soft tissue to help eliminate soft tissue loss interproximally. Vertical releasing incisions are next made bilaterally and carried beyond the mucogingival junction, ending in Burrow s triangles (Figure 1). A Burrow s triangle is used to relieve tension at the most apical extent of a vertical releasing incision to improve flap mobility and achieve tension-free closure. 9 The Burrow s triangle is then grasped by a tissue forceps and a split thickness dissection with a 15C blade is accomplished to remove this tissue (Figure 2). 10
INSIDE DENTISTRY OCTOBER 2006 43 Figure 5 A periosteal elevator is used to create a full thickness elevation apical to the mucogingival junction. Figure 6 A hand instrument is used to plane the exposed root surface. Figure 7 The keratinized collar on the adjacent teeth is denuded and the periosteum at the flap base is scoured with a scalpel. Figure 8 The connective tissue is sutured over the recipient bed. Using a 15C scalpel blade and holding the flap margins with tissue forceps, a split thickness flap is reflected past the mucogingival junction (Figure 3). Coronal to the Burrow s triangles using a new 15C blade, an incision should be carried across the apical extent of the split thickness bed down to the underlying bone (Figure 4). Using a periosteal elevator, a full thickness flap should be reflected from the horizontal incision to a level approximately 5 mm to 10 mm apical to the Burrow s triangles (Figure 5). Undermining of the tissue bilaterally will aid in flap placement and closure. Using hand instrumentation, the tooth is scaled and root planed, performing odontoplasty as needed, to reduce root surface convexity (Figure 6). The key is to plane the extruding root surface so that it lies within the buccal plate of bone and does not protrude buccally. Care should be taken not to excessively plane because this may encroach on the root canal system leading to the need for additional intervention. 11 Using a new 15C blade, and holding the flap with tissue forceps, the periosteum should be scored, taking care not to perforate the flap (Figure 7). This incision will help mobilize the flap, allowing it to be stretched to a more coronal position with no tension in the flap. If acelluar connective tissue is used, place the rehydrated piece of acellular dermal allograft on the site to allow blood to contact the material, making sure to touch both sides to the recipient bed. The side that retains the coloration from the blood (red side) should be placed over the recipient bed facing away from the roots. This technique places the white side (basement membrane side) toward the root surface to be grafted. The connective tissue is placed over the root exposure and secured with 5-0 polyglycolic acid (PGA) sutures (Figure 8). 12 The apical boarder of the graft is not sutured so that apical tension is not placed upon the graft during function as healing occurs. 13 The flap should be coronally positioned over the graft and secured with 4-0 PGA (3/8 circle reverse cutting needle) (Figure 9). Using a sling suturing technique, the coronal flap margin is fixated to the lingual soft tissue. 14,15 Releasing incisions and Burrow s triangles are secured with 5-0 PGA (1/2 circle reverse cutting needle). Interrupted sutures are then used to secure the lateral graft borders. It is not critical that all of the graft PULPDENT Photos Courtesy of Dr Christopher Ramsey it should be this easy Order through your dental dealer. Technical Information (800) 343-4342 pulpdent@pulpdent.com www.pulpdent.com (Circle 47 on Reader Service Card) TM EMBRACE WetBond TM it is Self-Adhesive Self-Etching Moisture Tolerant Low Film Thickness: 12 microns Medium and Low Viscosity Automix Syringes Resin Cement All Surface, One-Step Cementation Wet-Bonding Dual Cure Fluoride Releasing Radiopaque 7 gm or 3.5 gm Automix Syringes PULPDENT Corporation 80 Oakland Street Watertown, MA 02471-0780 USA Tel: (617) 926-6666 / Fax: (617) 926-6262
44 INSIDE DENTISTRY OCTOBER 2006 Figure 9 The flap is repositioned and sutured in place. Figure 10 Pressure is applied to wet gauze placed over the site for 5 minutes. Figure 11 A periodontal dressing is placed to protect the surgical site. is covered, and having some portion of the graft exposed at the gingival margin will not affect healing. Wet gauze should be placed over the graft site and finger pressure exerted for 5 minutes to prevent hematoma formation under the flap and graft (Figure 10). This will also allow the fibrin in the site to act as a tissue glue temporarily tacking the tissues together. Triple antibiotic ointment should be applied over the site and a periodontal dressing mixed and placed to protect the surgical site during the first few days after the procedure (Figure 11). Postoperative Care The patient should be instructed to avoid brushing the area for the first 3 weeks after surgery. Rinsing with an overthe-counter antiseptic mouthwash will help maintain hygiene. Warm salt water rinses may also be used. Granular or crunchy foods should be avoided during this time because particles may migrate Figure 12 Moderate gingival recession present on the maxillary left cuspid and first premolar. Figure 13 Recession repair on the maxillary cuspid and premolar shown 6 weeks postsurgery. Figure 15 Correction of the attached gingiva and repair of the recession shown 8 weeks postsurgery. Figure 14 Gingival recession on the first and second maxillary premolars with a thin band of attached gingiva. (Circle 48 on Reader Service Card)
INSIDE DENTISTRY OCTOBER 2006 45 under the flap margins and irritate the site. The periodontal dressing can be removed after 7 days. The sutures should be allowed to resorb on their own or be left in place for 21 days. Early suture removal may result in apical positioning of the gingival margin, compromising the desired results. CASE EXAMPLES Case One This patient presented with moderate gingival recession and minimal existing attached keratinized tissue (Figure 12). The patient s chief complaint was discomfort when brushing. A subepithelial connective tissue allograft was placed to create a zone of attached connective tissue and achieve considerable coverage of the previously exposed root surfaces (Figure 13). subepithelial connective tissue graft and acellular dermal matrix graft for the treatment of gingival recession. J Periodontol. 2001; 72(11):1477-1484. 8. Li TG, Shorr N, Goldberg RA. Comparison of the efficacy of hard palate grafts with acellular human dermis grafts in lower eyelid surgery. Plast Reconstr Surg. 2005;116(3):873-878. 9. Silverstein LH. Practical procedures: connective tissue grafting using alloderm. Pract Proced Aesthet Dent. 2004;16(10):1-4. 10. Silverstein LH, Shatz PC. Instrumentation for modern day implant surgery. Pract Proced Aesthet Dent. 2005;9. 11. Silverstein LH. Anatomic principles for gingival recontouring. Pract Proced Aesthet Dent. 2003;15(10):13. 12. Silverstein LH. Suturing principles. Applied techniques for predictable suture placement. Part I. Pract Proced Aesthet Dent. 2002;14(3):229-231. 13. Silverstein LH. Essential principles of dental suturing for the implant surgeon. Dent Implantol Update. 2005;16(1):1-7. 14. Silverstein LH, Kurtzman GM. A review of dental suturing for optimal soft-tissue management. Compend Contin Educ Dent. 2005; 26(3):163-170. 15. Kurtzman GM, Silverstein LH, Shatz PC, et al. Suturing for surgical success. Dent Today. 2005;24(10):96-102. 16. Aichelmann-Reidy ME, Yukna RA, Evans GH, et al. Clinical evaluation of acellular allograft dermis for the treatment of human gingival recession. J Periodontol. 2001; 72(8):998-1005. Case Two The patient presented with gingival recession and a complaint of cold sensitivity in the maxillary first and second bicuspid teeth (Figure 14). Minimal attached gingiva was noted. A connective tissue graft was placed to widen the band of attached gingiva and eliminate the cold sensitivity present presurgically (Figure 15). CONCLUSION Achieving root coverage in treating gingival recession has become a more predictable treatment modality. Case selection is important. Surgical intervention has been shown to yield a more predictable long-term result with more complete coverage when treatment is initiated before complete loss of the attached gingiva at the tooth demonstrating recession. The acellular dermal graft has has shown identical long-term results as previously reported with palatal connective tissue grafts. These results suggest that acellular dermal grafts may be a useful substitute for autogenous connective tissue grafts in root coverage procedures. 16 REFERENCES 1. Rose L. Surgical therapies for the treatment of gingival recession. Inside Dentistry. 2006; 2(4):66-70. 2. Sato N. Periodontal Suturing, A Clinical Atlas. Chicago: Quintessence Publishing Co; 2000: 134-135. 3. Silverstein LH. Dental Principles of Suturing. Mahwah, NJ: Montage Publishing; 2000. 4. Wolf HF, Rateitschak-Pluss EM, Rateitschak KH. Color Atlas of Dental Medicine. Periodontology. New York: Thieme Medical Publishers; 1989:298. 5. Tal H, Moses O, Zohar R, et al. Root coverage of advanced gingival recession: a comparative study between acellular dermal matrix allograft and subepithelial connective tissue grafts. J Periodontol. 2002;73(12):1405-1411. 6. Santos A, Goumenos G, Pascual A. Management of gingival recession by the use of a acellular dermal graft material: a 12-case series. J Periodontal. 2005;76(11):1982-1990. 7. Novaes AB Jr, Grisi DC, Molina GO, et al. Comparative 6-month clinical study of a (Circle 49 on Reader Service Card)
INSIDE DENTISTRY OCTOBER 2006 THIS CE LESSON IS MADE POSSIBLE THROUGH AN EDUCATIONAL GRANT FROM GlaxoSmithKline, MAKERS OF SENSODYNE, SUPER POLIGRIP, POLIDENT, AND OASIS. CONTINUING QUIZ Log on to www.insidedentistryce.com to take this FREE CE quiz. Achieving Predictable Connective Tissue Root Coverage Gregori M. Kurtzman, DDS, Lee H.Silverstein, DDS, MS, David Kurtzman, DDS, and Peter C. Shatz, DDS Tufts University School of Dental Medicine provides 2 hours of FREE Continuing Education credit for this article for those who wish to document their continuing education efforts. To participate in this CE lesson, please log on to www.insidedentistryce.com, where you may further review this lesson and test online. Log on now, take the CE quiz and, upon successful completion, print your certificate immediately! It s that easy! For more information, please call 877-4-AEGIS-1. 1. Root coverage is dependent on the: a. height of the adjacent papilla. b. thickness of the tissue after graft placement. c. width of the defect. d. height of the defect. 2. Administration of an NSAID before surgery will: a. help attain root coverage. b. help mediate postoperative discomfort and associated swelling. c. reduce the chance of postoperative infection. d. heighten the band of attached gingiva. 3. Patient-derived connective tissue has: a. no additional cost added to the procedure. b. a higher morbidity then an acellular graft. c. resulted in patient discomfort during the healing phase. 4. What factors contribute to the use of an acellular dermal allograft? a. A higher cost is involved with an acellular graft b. Patient comfort after surgery is higher because no surgery is performed on the hard palate c. The amount of tissue required is not influenced by what is available on the patient 5. A Burrow s triangle is used to: a. relieve tension at the most apical extent of a vertical releasing incision. b. relieve tension at the gingival margin. c. reduce scar formation. 6. When planing the root, it is important to: a. reduce root surface convexity. b. extrude root surface so that it lies within the buccal plate of bone. c. not excessively plane because this may encroach on the root canal system. 7. Scoring the periosteum will: a. allow an increase in hemostasis. b. allow it to be stretched to a more coronal position with no tension in the flap. c. thin the overlaying flap. d. improve postoperative pain management. 8. Which side of the allograft should be placed toward the root surface to be grafted? a. The white side b. The pink side c. The black side d. The red side 9. During the first 3 weeks after surgery, the patient should: a. maintain the area with a toothbrush. b. avoid brushing the area with a toothbrush. c. use a peroxide rinse. d. eat granular food. 10. The resorbable sutures should be left in place for how long? a. 7 days b. 10 days c. 14 days d. 21 days Tufts University School of Dental Medicine is an ADA CERP and ACDE recognized provider. Association for Continuing Dental Education (Circle 50 on Reader Service Card)