ernotionol Journol of Periodor.

tic5 ond ReBiorotive Dentistry- 2/1982

 23

The Subepithelial Connective Irregularities In gingivol height, al-

Tissue Graft veolar ridge height ond contour
A New Approach to the En- create casmetic problems for many
hancement of Anterior Cosmetics potients. In the past, these anotomic
defects have imposed limitations on
prosthetic restorations.

Two main types of tissue deformities

ore:
1. depressions in the residual al-
veolor ridge
Lawrence J. Cologn
D.M.D. 2, uneven gingival morgins
The former is subdivided into three
variotions:
a) depressions in the buccolingual
width of the residual alveolor ridge
(Figs, la and b]
b| loss of occlusogingival height in
the residual olveolor ridge (Fig, 2)
c) o cambinotion of a and b — o
loss of height and width of the resid-
uol olveolor ridge (Fig, 3)

These alveolor concovifies offen re-

sulf from a troumotic injury to a tooth
or the entire tooth olveolor complex,
extraction af o tooth with odvanced
periodontol disease or unsuccessful
endodontics, apicoectomies, impiont
failures and developmentol obnor-
malities.

Traditional methods of restoring al-

veolar depressed areas prosthetical-
ly were:
1. the fobricafian of excessively
long pontics (Fig. 4)
2. gingival acrylic sfents which
would mosk fhe apicol length of the
pontics ond thus reduce their un-
sightliness (Fig. 5)
3. the resforotion of an edenfulous
orea with o removable prosthesis,
rather fhan o fixed one, so as to ena-
1075 Central Avenue, Scarsdole, New
York 10583 ble the dentist to fabricóte o gingival-

"The Inlernotianol Jaurnol of Penodortics and Restarative Dentistry" 2/1982

 24

colored denture base which would

simulate the absorbed alveolar ridge
4. The creation of pontics with gin-
gival caloratian in the cervical third
to resemble the adjacent tissue

Limitatians of these oppraaches

were self-evident

The second type af anatomic de-

formity, uneven gingival margins, is a
special prablem when the patient
has a high lip line and requires full
coverage restoratians (Fig. 6). The
unevenness is often unsightly.
The solution to the latter problem has
aften been excisional reduction af
gingival tissue and marginal bone ta
fig ;• A to; of buccolingual width ot fhe residuoi olveoi 'cavity in the maxiilaiy
right tolero! in- or region. Note Ihe lack oi continuity m the lobiol orchitecFur,

Fig Sb A diogro'

-The Intemationoi Journol of Penodontics and Restorative Denditiy" 2/19B2

 25

even out this irregularity (crown

lengthening procedure). The gingivol
margins of uninvolved teeth ore thus
Fig. 2 An ocdusogingivol cancavity in the re-
brought to the opieol height of the ¡iduol olveolor ridge al the maiiltary tee central in-
toath with the most gingival reces- cisor. The root was sectioned Iront this tooth,
which wos previously pari al o cantinuaus interno!
sion. Opticolly, this creates an even wire ond acrylic splint. Nate the discrepancy be-
tween the gingivot heights of Ihe adpcent teeth
gingival line, but the objectionable witt^ thol of ihe residual apically displaced rnargin
appeoronce of long teeth is fre- af the residual ndge. The latter resulted tram bone
loss Irom odvonced periodontitis of the maxillory
quently unocceptable to many pa- left central inosor
tients. In addition, it obliges the den-
tist to remove healthy labial ottoch-
ment in this attempt to enhance the
esthetics.
The purpose of this poper is to dem-
onstróte a technique which has been
successfully employed to correct Fig. 3 Eitrodion sites ol the ma'ilhry left central
ond lotero! incisors^ which had advonced
either or both of these problems in periodontitis. A combinalian of both buccaiingual
one surgicol procedure. ond occlusoaingivai alveolar ridge absorption
15 present.

Fig. 4 Due to Ihe alveolar ridge depressian. the

maxillary lelt central and lotero! incisar panlics
are extended apically lo canlact the residuol
alvealar ridge

Fig 5 A gingivol acrylic stent is placed aver Ihe

apical portion al the pontics to creóle Ihe illusion
ol normo!-sizcd leeth.

Fig 6 Uneven gingivoi morgins around Ihe

central and lateral incisars and the cantnes.

"The International Joumal af Periadontics and Restorative Denlistry" 2/1982

 Procedure
Donor Site

The technique employs the use of a

connective tissue autograft, which is
obtained in one of two ways:

1, Harvesting of donor material in

cases of palatal periodontal pockets
which require elevation of on inter-
nally bevelled flap (Fig. 7o], The col-
lor of connective tissue comprising
the pocket wall and remaining on the
bone after reflection of the internally
bevelled flap is used as the donor
material ¡Fig, 7b), Epithelium, which
is part of the morginal gingiva and
pocket lining, is removed with a scol-
pel, tissue rongeurs or an electrosur-
Fig. 7a An inter. oily bevelled flap was per- FIQ 7b The collar ai gingival cannective tissue, gical tip. Connective tissue from any
tom>ed to ossist I eliminating penodontal pocket which wos port of the pocket woll, was remaved.
depth. This will become the connective tissue danor other source such as a distal wedge
material, tt is advisable to remove epithelium from
the connective tissue surfoce belare using It as on or linguol flap moy be used,
2. If no periodontal surgery for
pocket elimination is indicoted, a
horizontal incision is made 4—5 mm
apicol to the free gingival margin

periodontal packet elimina-

tion is nat indicated, two
horizantal incisions ore
piaced in the palote to tocili-
tate the removol ola con-
nective tissue groft. Nate the
locotion ol the incisians at a
sole distance kam the tree
gingival margin to avoid re-
cessian in the approximating

"The irlernationol Journal ot Pcnodont.cs and Reslorahve Dentislry" 2/1982

 27

and an internally bevelled flap is

elevated, leaving a layer of connec-
tive tissue on the bone. A second
parallel incision is then mode 1—2
mm more coronal from the original
ane and at least one mm from the
free gingival morgin (this will prevent
recession ot the donor site). This lat-
ter incision is bevelled apicolly
towards the bone (Fig. 8].

Fig. 9 Diagram illustrating

The connective tissue lying over the
live tissue groll.
bone and beneath the first flap is
carefully peeled away and removed.
This will become the donor material
(Fig. 9]. The only portion of the bone
which is covered with connective tis-
sue is the bevelled coronal margin
(Fig. 10a]. This will furnish a con-
nective tissue base to receive the
margin of the original flap (Fig. 10b).
The danor material moy contain
adipose tissue. This is always re-
moved when performing a free gin- Fig. lOa Clinical photo-
gival graft, but Is acceptable for the groph ihawing the cannec-
tive tissue arafl remaved
purpose of ridge enhancement. fram Ihe palotal surface at
Ihe alveolar bone. Note thai
the coronal edge ol the
donor site is bevelled, which
will facilitate flap coaptalion
and healing. This will avoid
passible bane denudation
during heaiing.

Fig. lOb Flap is sutured lo

pa!ate. Note thai the bevel-
led portian received the mor-
gin of the flap preventing
bane exposure

"Ttie Internotionoi Journoi of Periodontics and Reslorative Denlistiv" 2/1982

 28

Recipient Site
The recipienf sife is prepared fo re-
ceive the donor moteriol, which has
been stored in moistened gauze (Fig.
11], The procedures for ridge oug-
mentotion ond correction of gingivol
recession ore bosicolly the some. The
portial fhickness flap is elevafed fo
the muccabuccal fald in the recipienf
area requiring augmentation. In
most coses, o horizontal incision is
Fig. II The conns•clive tissue mode over the crest of the edentu-
stört7din a nmisten ed piece
olg. ciuze lous alveolor ridge connecting two
vertical incisions. This design will
facilitate elevation ond mability of
the flop with subsequent coverage of
the donor moteriol
The flap is incised leaving connective
tissue covering the alveolar bone
(Figs. 12 and 13]. This will provide a
double source of vascular supply fo
the donor connective tissue, i.e.,
from fhe undersurfoce of the flop and
fhe connective fissue on the olveolar
bone.

The connective fissue groft is slid be-

Fig. ¡2 At Ihs recipient sits, neoth the recipient flop ond placed
o portioi Ihickness flap is ele-
vated U5ing Iwa verticat ond into the desired position necessory to
one horizontof incisions. Con-
nective tÍ5sue IS leu intention-
ougment the alveolar ridge (Fig. 14).
oily on the olvsolar bone In many instances, the connective
tissue may require trimming ar layer-
ing in order to obtoin the desired re-
sulf. This can be accomplished with
o scalpel, scissors or electrosurgicaI
tip.
In cases requiring on increase in
occlusogingival height, the horizon-
tal incision of the recipient buccol
flap is mode on the palatol portion of
the residual alveolar ridge. This will
offer more coveroge of fhe connec-
tive fissue implant. In pofients with
severe olveolar height loss, no ot-
tempt is made to cover all parts of
the connective tissue graft. The
Fig. 13 Diogrommolii: re- uncovered connective fissue lying
presentation ol the envelope
flop.
over fhe alveolar cresf will survive

"Tlie Internotional Journal af Periodontics ond liestarotive Denlistry"

 29

because it receives vascular naurish-

ment from twa sources identified pre-
viously. As a result, there is minimal
tissue slough and toss of volume.
The connective tissue graft is sutured
to the connective tissue overlying the
alveolar bone with absorboble su-
ture material. The sutures will help ta
immabilize the graft in the praper
orientation. The overlying buccal flap
Fig. M Diagram showing
is then sutured aver the connective innective tissue donor mate-
tissue implant with either absorbable rial in ploce between buccal
flap ond residual alveolar
or silk sutures (Fig. 15]. The danor
flap is also caapted over the bone
and sutured in place. If a void is
present between the flap and bone,
as in the case of a patient nat requir-
ing periodontal surgery for pockef
elimination, gelfoom can be placed
under the flap. This will reduce the
possibility of pastoperative bleeding.
Because both the donor and recip-
ient sites can be caapted almasf
completely, healing occurs mostly by
primary intention at the wound
edges. Periodantal dressing af the
recipient site is aptional and omitted
on the donor site. Fig i5 Diagram af sutured
ffap covering the underlying
Restorative ly, fhe pontic of the provi- the continuity of the residual
sional acrylic restoration must be
seated on the abutment teeth without
causing impingement on the grafted
site. This usually requires reshaping
and gingival trimming of the pantic.
Overbuilding the edentulaus ridge is
recommended by the authors at the
time of the original augmentation
procedure. This will help to create in-
terproximal papillae postoperatively.
Papillae are created by inducing
slight pressure af the pontic into the
newly augmented ridge appraxi-
mately six to eight weeks postopera-
tively. Occasionally, strategically
placed sutures aver fhe recipient flap
will also create interproximal papil- Fig. 1Ó Sutures aie placed
lae (Fig, 16). in o position to create infer-
proi'mal papillae.

-Tfie Inrernational Journal of Periodonlics ond Restoroiive Dentisrry^' 2/1982

 30

The ougmentation can be perfarmed contoured by the gingivoplosty

Reference
numerous times in the same areo if technique.
necessary ta obtoin the desired re- It should be understood by both pa- Longer, B., Ond Cabgno, L.
sult. In addition, layering af donor Subepitfieliol Groft lo Correct Ridge Con-
tient ond dentist that the subepithelial cavities. J. Prosthetic Denl., ^1-1.363, 1980.
connective tissue can also be ac- graft, which is ploced on denuded
camplished ot the recipient site to root surfaces, is not a true attoch-
obtain a desired result without fear of ment to the root but a curtain of tis-
tissue slough. sue which is purely cosmetic (Fig.
19). A high level of plaque control
must be fallowed in order to maintain
Gingival Recession tissue health. It has been the experi-
The procedure recommended far the ence of the authars that these areos
carrection of gingival recession is seem to mointain their integrity and
similar to thot described far the ridge tissue health with no more mainte-
augmentation, with o few excep- nance routine than is corried out
tions. The donor tissue is taken as carefully in other areas of the denti-
described in the augmentation pro- tian. In addition, the palatal graft is
cedure, but na attempt is made to re- resilient and thick enough so that it
move the epithelium from the donar does not readily recede or change its
tissue. The epithelium will be placed marginal position. The same is true
externol to the recipient flap. At the for the augmented ridge.
recipient site, o partial thickness dis-
section is made on the radicular sur-
face of the involved tooth or teeth. Summary
This will leave connective tissue over
A technique has been discussed
the recipient tooth (Fig. 17). Agoin,
which can be used to correct uneven
two vertical incisions ore usually
gingival margins and edentulous al-
necessary to mobilize the flop.
veolar ridge depressions. The step-
The cannective tissue graft is ploced
by-step procedure and cases illus-
beneath the recipient buccal flap so
trating the technique have been pre-
thot port of the donor connective
sented, see Cose Reparts I - IV on
tissue and epithelium covers the re-
pages 32 and 33.
ceded labial radieulor surface to
level even with, or slightly coronal to,
the free gingival margins of the adja-
cent teeth (Fig. 18).
The recipient flap is coapted over
most of the graft and sutured in ploce
in a monner which will immobilize the
underlying graft. Agoin, the inci-
dence of sloughing of the graft is re-
duced even though part of the groft
is external to the "connective tissue
sondwich" which provides moxJmum
vascularity. Occasionally, small ir- Acknowledgement
regulorities, which may occur sub- The authors wish to thonk Mrs. Lou-
sequent to healing, can be re- reen Langer for the diagrammatic il-
lustrotions.

"The Inlernatianal Journol ol Feriodonlia and Restarative Dentislry" 2/1982

 31

ffg. ' 7 Diagram af a partió! thickness flop Irom

the maxillary left central incisor to the moxillary
left first bicuspid Nate the presence olconnedive
tissue, which has been intenlionolly left over the
radicular surfaces ond residvol olveolor ridge

Fig. 18 The connective tissue graft has been

ploced undemeoth the buccot flop at o height
'en with the free gingival margin of the moxiliary
right centrol inosor Datted lines denote the
omount al connective tissue placed on the
denuded root surface.

Fio 19 Nate that the healed partian af the

connedive tissue graft on the maxillary leH central
incisor is even with the adjacent free gingival
morgin af the maxillary nght central masar.

"7tie Interralionol Journol ot Psriodortics and Restorative Dentislry" 2/1982

32

Case Report I

rig. 2ija Fre-opcrotive ¡.linicatphotagraph af Fig. 20b Radiagroph af the patient in 20a. Nate Fig. 20c The pravisianal restoratian piaced trom
potieni with advanced periodantitis present Ihe advanced degree afbone loss present around ihe maxiHary riqhl cuspid ta the maxiliar^ !eft cus-
around the maxiilar/ !eft central and lateral in- Ihe maxitlor/ left centrai and iateral incisors, it wos pid. Nale the ovccalinguai and ocdusogingivai
anticipated thot extraction of these leeth would concavity in the oreo al the eftrocted maatlary left
central and iotera! incisars.

Case Reporl II

Fig. 20d One year postoperative view of Ihe Fig 21a A pre-operolive photogroph ol a pro- Fig
g 21b Repair
p ai balh the concavityy m the al-
permanent fixed partial prosthesis in place sub- visional restoration repiadnq the moiillory left lot- veator riage and the élimination al the ialgam
sequent to the augmentation procedure. 7he re- eral incisar. Note Ihe huccolinguol ond occluso- toUoo.
gingiva! cancavity in the residua! olvealor ndge
gingival margins. necessitating the need far opicat extension of the
pontic. An amaigam tattaa resulting from a
previous apicoedomy is yisiUe.

Case Repart III

Fig. 22b Residual a!v.

Fig. 21 fhe exfraction of both i
marked ocdu.

"The Intemolionai Joumoi of Periodontics and Restarotive Dentistiy" 2/1982

 33

Rg. 22c Provisionol rsslorotion in pioce supply. Fig 22d Hsaled ougmsnisd civsalor ridge wilh Fig. 22s isrativs visw of the fixed pros.
ing Ihe moiillory central incisors. Note ihe opicoi ths crsation of an incisai papilla. Figurs 16 ittus- Ihssis. Il < seen ihol the height ol the csnirol
height o ' ths pontics, which were necessory to r pontic in hormony with the odiacsnt
contoct the residuol alveolar ridge. by property placed sutures.

Case Report IV

Fig. 2Jo Prf-operoii'/e phoiiiijiisiJl' ol Ir.c sast- Fig 23b The provisional restorolion is in phœ Fig 23c The subepilheliol groft procedure hos
ing fixed prosthesis showing gingivol rscsssina befare corrsction of the gingival ond olveolor bssn employed to corrsci both gingivoi rscession
over the moiitlary left incisor ond first bicuspid In ridge discrsponcies. The margins af the moxiltory and the concovity in the residuol olveolor ridge.
oddition. o concovity is present in Ihe aiveolor lefícenlrol incisor ond first bicuspid ore inten- Note the coronol plocemsnt of the connective tis-
tionally oliawsd to remain caronoi to the free sue qroft on the maxillory left centrol incisor and
gingivol margin. They ore placed opproximateiy first bicuspid
at me some height os Ihol oí the odfocenl tree
gingivol margins.

Fig. 23s One yeor postoperotive lobiol view of

Ihe completed fixed partial prosthesis in place.
Fig. 23d One month posloperotivs hsoling wiih Both the gingivol tissue on the labial of ths maxil-
lory left central incisor ond first bicuspid and Ihol Fig. 231 Loterol view of Ihs same palif
olmost totol corrsction of the gingival recession
ond oiveolor dsprsssian. ot Ihe olvsolar ridge hove nat recedsd continuity oí gingivol ond alvsalor

"The international Jaurnal of Periodortics and Restorative Dentistry" 2/1982