Mucogingival Defects and Gingival Grafting

Gingival Grafting

When are periodontal mucogingival procedures indicated? This is an area of confusion among many dentists and hygienists. This issue will address those concerns and describe the many techniques which are available.Grafting is now a very predictable procedure.

Indications for Surgery

The decision to treat an area is usually made based upon only three factors:
1. Reestablishment esthetic architecture.
2. Restoration of a fuctional "attachment."
3. Elimination of hypersensitivity. [top]

Without a doubt, patients are most concerned with esthetics and sensitivity and it is these patients who often seek care on their own. These forms of recession are usually self inflicted, having been caused by tooth brush abrasion However, an extemely high number of patients require functional repair and are unaware of this important necessity. Examples of some of these indications for augmentation include:

1. Any site that measures less than 2mm of attached gingiva represents a potential site requiring a graft (see "assessment" below).

2. Sites that demontrate "progressive recession" which has been documented, regardless of patient age. Any site that demonstrates recession is also demonstrating bone loss.

3. Young patients which demonstrate 1mm or less of attached gingiva, especially where a restoration is planned or when orthodontic treatment is anticipated. Approximately 12% of all mandibular central incisors will demonstrate 1mm or less attached gingiva when they erupt and half of those suffer recession within the first six months. [top]

4. Class V- Buccal or full coverage restorations with subgingival margins or any RPD "I-bar" abutment; either existing or pre-prosthetically. While a few studies suggest having at least 5mm of keratinized gingiva for these restorations most studies state that 3mm of gingiva must be "attached."

5. Any orthodontic patient- Orthodontic and Mucogingival problems are related, but not by cause and effect. Any tooth that erupts in a prominent facial version usually will have erupted beyond the zone where attached gingiva is abundant. Therefore, these teeth typically demonstate "inadequate" or "minimal" attachments.[top]

Assessment of Mucogingival Status- Follow these simple steps:

1. Determine the amount of keratinized gingiva (KG) by measuring the distance of the coronal gingival margin to the mucogingival junction (MGJ). The MGJ is easily demonstrated by holding the measurement zone of your probe horizontally over the mucosa and moving the mucosa in a coronal direction. A fold will occur at the MGJ

2. Subtract the pocket depth at the mid facial of the tooth from the width of KG and this determines the width of "attached gingiva."

3. If the reult is zero or a negative number, the site is a mucogingival defect and should be treated. [top]

Augmentation Techniques- Many different techniques are available to augment the gingiva and the method depends upon the goal of treatment.

Root Coverage Grafts- these are similar to the case on the front page and are indicated for cosmetic improvement and for coverage of sensitive roots.

The subepithelial connective tissue graft provides the best esthetic result as it has superior color and contour blending. Additionally, it provides greater degrees of root coverage since it has an additional source for angiogenesis. Very simply, a wedge of palatal connective tissue with an epithelial collar is inserted below the exisiting epitheluim of the recipient site.

Laterally positioned flaps are often used when there is adequate available donor tissue on the next adjacent tooth and where the risk of increased recession on the donor tooth can be properly managed.

Guided tissue regeneration membranes are being studied for this indication, however we have found that the resultant augmented tissues lack the character and qualities of normal attached gingiva.

Free Gingival Grafts - These grafts employ the placement of palatal mucosa as donor material into the pre-prepared recipient site. The graft is stabilized with sutures and both the donor and the recipient sites are usually covered with a periodontal dressing. [top]

Apical Augmentation Grafts- these are very simply indicated to widen the width of attached gingiva. They are typically employed when root coverage is not a necessary treatment outcome. Usually the free gingival graft is used for this procedure. It is highly predictable and the results are dimensionally very stable. Alloplastic grafts such as Alloderm (decellularized human dermal tissue) or Human freeze dried skin are also occaisionally used for the patient who refuses the palatal donor site, however, these are somewhat less stable dimensionally.

All restorative procedures should wait until after the augmentation has healed sufficiently. Most studies suggest a period ranging from minimally one month to preferably three months. All Class V resin restorations chemically alter the root surface and render them biologically incompatible. Significant root planing must be completed to remove these compounds. Root coverage can then be predictably obtained. [top]