Questions regarding mucogingival therapy abound at meetings I regularly attend.  These questions could be distilled to the following:

• When should soft tissue grafting be performed around teeth?

• When should soft tissue grafting be performed around implants?

• What advances are available to make this treatment simpler and less painful for patients?

The advent of gingival grafting in the ‘60’s and ‘70’s resulted in large pieces of soft tissue being stripped from the palate and placed on the buccal aspects of teeth which demonstrated minimal or no attached keratinized tissue, even in the absence of  soft tissue recession.  The theory was that all patients would benefit from such augmented bands of attached keratinized tissue.  We now know such an approach is not necessary.

Soft tissue grafting should be performed around teeth in the following situations:

• Active recession

• Sensitivity of exposed root surfaces

• Esthetic dissatisfaction

• Prior to initiation of orthodontic therapy in situations where the keratinized soft tissues are thin either apico occlusally or bucco lingually

• Prior to planned restorative therapy which would include gingival intrasulcular margins, when less than 3 millimeters of attached keratinized tissue is present.

Performance of gingival augmentation procedures in areas which demonstrate no attached keratinized tissue, no recessive lesions, and no plans for either restorative or orthodontic intervention, is unwarranted.  Such aggressive over treatment provides no benefits to the patient.

The role of keratinized tissue in the long term success of implant therapy has long been debated.  While there is no doubt that many implants have succeeded in the absence of keratinized peri implant soft tissues, there is no doubt that such a mucosal “cuff” around an implant is more susceptible to plaque, inflammation and peri implant bone breakdown.  The establishment of an appropriate keratinized soft tissue seal around implants helps lessen the incidence of periimplantitis and eventual loss of supporting bone.

Fortunately, the field of soft tissue grafting continues to evolve, offering patients alternatives which are highly predictable, much less invasive, and significantly more comfortable than older techniques.

The first advance of note was the use of connective tissue grafts harvested from the palate.  Rather than stripping the palate and leaving the patient with an open wound which is painful postoperatively, a palatal flap is reflected, a connective tissue graft is taken from beneath the flap, and the palatal flap is replaced.  The net result is would closure, healing by primary intention, and a more comfortable surgical donor site postoperatively.  However, while this approach does afford significant advantages for the patient, there are l two drawbacks to utilization of autogenous connective tissue grafts.  The first is the unpredictability of the precise dimension of the connective tissue graft which can be harvested at the time of surgical entry.  In addition, although the donor site is more comfortable than with conventional palatal stripping, there is still some patient discomfort at a second surgical site.

The advent of Dermis or Alloderm connected tissue grafts, harvested from organ donors, eliminates the need for a second surgical site.  This tissue is procured, processed and sanitized in a very safe manner, and affords a number of advantages when performing keratinized tissue augmentation, with or without root coverage.  The dimensions of the graft are known in advance, so that no “surprises” are encountered during therapy.  The graft is incorporated into and eventually replaced by the patient’s own connective tissue.  When utilized around teeth to attain root coverage, the dermis graft is soaked in Platelet Rich Factor prior to utilization.  As you know, Platelet Rich Factor (PRF)  is a technique by which we draw a small amount of the patient’s blood and spin it in a centrifuge machine.  We then separate out the growth factors into a “fibrin membrane”.  Application of these growth factors significantly enhances hard and soft tissue healing.  The exposed root surface is detoxified with Pref Gel prior to graft placement.

Dermis grafts also have many indications in regenerative and implant therapies.  When a tooth is removed which presents with a thin, highly scalloped biotype and compromised buccal soft tissues, placement of a dermis graft beneath a buccal flap at the time of implant placement and/or regeneration significantly improves esthetic treatment outcomes. Dermis grafts may also be placed at the time of implant insertion in areas of minor ridge atrophy, to help improve the patient’s esthetic profile.

I strongly believe that advances in our understanding of indications and contraindications for mucogingival therapy, and the utilization of newer materials and techniques including dermis and PRF, have dramatically altered both the patient experience and treatment outcomes of mucogingival therapy for the better.  It is imperative that we employ these techniques whenever possible to the advantage of the patient.

Sincerely,

Nicholas Toscano DDS