Trie International Journal of Penodontics & Restarative Dentistry
127
Connective Tissue Graft Technique
Assuring Wide Root Coverage
John F. Bruno. DDS, MS'
Gingival recession related ta periodontal disease or developmental problems can result in root sensitivity, roof caries, and estheficatiy unacceptable rppt exposures. Consequently, root restorations are pertomed that
aften complicate, rather than resolve, the problems created by exposed
roofs. This article presents a predictable pracedure for root coverage on
areas af wide denudation in the maxilla and the mandible. (Int J Periodont
Rest Dent ]994;14:127-137.)
'Correspondence to: John F. Bruno, DDS. MS. 6120 Brandon
Avenue, Springfield, Virginia 22150.
In recent years, ottempts to
treat gingival recession began
with the loterai siiding flap,
introduced by Grupe and
Warren.' While it was a novel
approoch, it had limited success for covering wide rcot
denudations. Nabcrs^ went on
to describe a free gingivai graft
technique to increase the zone
ot keratinized gingiva. Sullivan
and Atkins^ then ciossified
recession, indicating that the
free gingivoi graft procedure
wos predictable for root coverage in areas of shaiiow-narrow
and deep-narrovi/ recession.
This ciassificotion was an important benchmark for what
developed loter.
For yeors, ottempts to
caver dreds of deep, wide gingival recession were met with
frustration. Miller,'^ in 1985, ciossified marginal tissue recession
by combining the four Sullivan
and Atkins^ classifications into
his first two classifications and
then adding o third and fourth
ciassification. He indicated that
the presehce of interdental
Volume líl.Number2, 1994
128
Fig I nie initiol horizontal right-angle
incision is mode into the oopilloe with a
12B surgical blade.
Fig 2 The initial incision is made at or
corono! to the CEJ af the tooth with the
exposed toot surface.
Fig 3 Sharp dissection is accomplished with a-^15 surgical blade to create a partiai-thickness flap.
bone ioss, soft tissue ioss, or
extruded teeth make it impossibie to place o tree gingivai
gratt at the cementoenamel
junction (CEJ), making it impossible to obtoin compiete root
coverage. In a series ot
articles^' on the free soft tissue
graft, Miiier demonstroted successful root coveroge tor his
Closs i (shailow-norrow ond
shaliow-wide) ond Ciass li
(deep-narrow and deep-wide)
recessions.
Prior fo Miller's ciassificafion
poper,"^ Langer ond Coiogno,^
in 1980, presented o poper on
o subepifheiiai connecfive tissue groft fechnique to correct
ridge concovities. This was toliowed by the benchmork
Langer ond Longer' articie, in
1985, describing a subepitheiioi
connective tissue groft technique tor root coverage. They
indicated that their technique
hod, "the advantage ot a closer color blend of the graft with
the adjocent tissue ovoiding
the 'keioid' heoling present
with free gingivol grafts."' in o
1987 article, Neison'° described
a modificafion of the Longer
ond Longer technique.' which
he caiied, "a biiominar reconstructive procedure."
The purpose of this articie is
to present some significant
modifications of the originai
Langerand Langer technique.'
joint is provided. The epithelium
of the papulae is left undisturbed. A portial-thickness fiap
is creafed by sharp dissection
(Fig 3). The dissection is corefuliy oocompiished to prevent
perforation of the flap. The
mesiodistal length of the incision IS extended to provide
easy access to the denuded
root becouse vertical incisions
are not used. The incision is
extended apioaiiy, weil beyond the mucogingival junction into the mucobuccoi fold
(Fig 4). The exposed root is
meticuiously pioned with
curets. At times, it may be
desirable to use finishing burs
as weii. Foilowing root planing,
the root is freafed with tetracycline. A measurement of the
approximate width necessory
tor the gratt is obtained with
the use of a periodontal probe
(Fig 5).
Method and materiais
Recipient site
The initiol horizonto! right-angle
incision (Figs ) ond 2), is made
into the adjacent interdentol
papillae at or siightiy coronai to
the CEJ of the tooth with an
exposed root surtoce. A butt-
The International Journal at Peiiodontics à Restorative Dentistry
129
Fig 4 The incision is extended apicaily
into the muoobuccal foid. wsll beyond
thie mucogingivai junction.
Fig 5 A periodontol probe is used to
obtoin the approximate width ot the
donor tissue that will be required for the
recipient site. Note the extent ot the
hidden recession that is reveoled.
Volume 14, Number 2, 1994
130
Fig ó The first incision at the donor site
on the palate is made appraximately 2
to 3 mm apical to the gingival margins
of the teeth.
First mctsion:
Perpendicular
to long axis
of tooth
Donor Site
The first incision on the palate is
made perpendicular to the
long axis of the teeth, approximately 2 to 3 mm apical to the
gingivai margin of the maxillary
teeth (Fig ó). The mesiodistai
length of the incision is determined by the length of the
graft that is necessary for the
recipieht site. The second incision is made parallel to the
long axis of the teeth, 1 to 2
mm apical ta the first incision,
depending on the thickness of
the graft that is required (Fig 7).
The incision is carried fdr
enough opicaliy fo provide a
sufficient height of connective
tissue to cover the denuded
root and the adjacent periosteum of the recipient site. A
small periosteal elevator is used
to raise a fuii-thickness periostedl connective tissue graft
(Figs 8 and 9). The donor tissue
is removed from the paiate as
atraumaticaily as possible,
using oniy the periosteal elevator. The tissue is not removed
with tissue pliers, a hemostat, or
The International Journol of Penodohtics & Restorative Dentistry
any other instrument that could
compress or injure the donor
tissue. Utilizing 4-0 siik suture
materiai with a FS-2 needie, a
crossed horizontal suspension
suture is used to approximate
the wound on the palate (Fig
10). When the donor tissue is
extraorai, the 1- to 2-mm band
of epithelium at the coronal
aspect of the tissue may be
removed, but it is usuaily retained. At that time, the width
and uniform thickness of the
gratt can be modified vi/ith a
surgicai blade.
131
Fig 7 The second incision at the donor
site is maae I to 2 mm apicol to the first
incision. The more apical the incision.
the thicker the danor tissue v^itl be.
Second incision:
Parallel to
long axis
of tooth
Fig 8 A small periasteai elevator is
used to roise o full-thickness connective-tissue flap.
Full
periostea!
elevation
Volume 14, Number 2, 1994
132
Fig 9 Note ttie convergence oí ttie
incisions at their mesial and distal borders.
Fig ¡0 Ihe palatal wound is approximated with a crossed horizontal suspension suture.
Fig 11 The donar connective tissue is
stabilized with Interrupted sutures. In this
case, a I-mm band ol epithelium is
retained at the corana! margin at the
gran.
Fig 12 The overlying partiol-thickness
flap is replaced with Interrupted sutures
inta the papillae.
Fig 13a Preoperative view
Fig 13b
view.
Recipient Site
periodontai dressing is placed
over the recipient site; however, the donor site is ieft uncovered.
The dressing and sutures
are removed 7 days postoperativeiy. At that time, the
patient is prescribed a chlorhexidine rinse and instructed to
cleanse the graft site with o
cotton swob soturated with
chiorhexidine.
Figure 13o demonstrotes the
recipient site precperatively; Fig
13b shows the orea 2 months
postaperatively.
Discussion
The donor connective tissue is
secured in position with interrupted sutures utiiizing 6-0
monofilament pliabilized nylon
with a (PC-3) ccnventionoi cutting needle (Fig 11). Then the
overlying partial-thickness fiop
is replaced over the donor tissue using interrupted sutures
into the mesiol and distal papiliae, covering as much ot the
donor tissue as possibie (Fig 12).
No attempt is made to cover
the donor tissue completely. A
The Internotional Journal of Periodontics S Restorotive Dentistry
Two-month
postoperative
it is imperative that the initiai
horizontoi right-angle incision
be made at the CEJ or siightly
coronal to the CEJ. This horizontoi incision must be made an
adequate distance mesially
and distally to provide for easy
access, because vertical incisions are not utiiized. Vertical
incisions are not m a d e , to
avoid compromising the biood
suppiy of the overlying tissue''
ond to prevent cicatricioi lines.
It con be postulated thot verti-
133
cal incisions greotiy reduce
blood circulation ot the groft
site. The lack of vertical incisions also decreases the
potient's discomfort during the
healing process and promotes
more rapid healing. The blood
supply for the donor tissue must
be obtoined ioteroiiy and apicolly, because trequentiy the
overlying tissue does not completely cover the connective
tissue graft. The retention ot the
vascuiar periosteum on the
donor tissue may provide
increased circuiation to the
gratt. The incompiete coverage of the conneotive tissue
by the overlying tissue ot the
recipient site apparentiy is not
critical as to the amount ot root
coverage that is obtained (see
Figs 14c and 14d). Otten a
thick graft is required to cover
a wide d e n u d e d orea to
decrease the possibiiity ot the
donor tissue undergoing complete necrosis. When a thick
graft is utilized, a gingivoplasty
may be necessary tor esthetics
or psychoiogicol requirements
of the potient.
Avoiding the use of verticai
incisions ot the paiatol donor
site increases the ditticuity ot
the procedure and does not
opporently improve the cliniool
resuits. Nevertheless, it does
minimize the postoperotive
sequela at the donor site ond
promotes more rapid heaiing;
theretore, it is recommended.
The use ot o conventionol
cutting plastic surgery needle
PC-3. ollows suturing into very
smoli papilioe. Using o larger,
less shorp needle mocerotes
small papiiiae ond mokes suturing impossibie. The sutures ore
removed 7 days postoperativeiy. Whiie the removal of the
Ó-0 sufure materioi beneath the
overlying flap requires a delicate technique, it is not significontiy ditticult with the use of
surgical mognitication. The
outhor believes the use of ot
least surgical magnitication
and a fiberoptic heodlight is
essential to goin optimol results
trom this procedure ond most,
if nof all, of fhe periodontal surgicai procedures presently
being rendered.
The keratinized epitheiium
thot results from o subepitheiial
connecting tissue grott appears to demonstrate the findings ot Karing et al,'^ that the
specificity of the gingival
epifheiium is determined by the
underiying connective tissue.
This procedure, when
employed in the manner
described above, uniformly
covers oreos of wide root
denudation (Figs 14a to 17b),
Some ot the benefits of the
prooedure are that oreos of
root abrosion and sensitivity
con be eliminoted (Figs 15 and
17o to 18d); failing ond estheticaily unacceptabie root
restorations can be removed
and subepitheiial conneotive
tissue grafts can be used to
cover the previously restored
oreas (Fig 1ó); muitipie oreas of
recession can be eliminoted
(Fig 17); and root coverage
con be accompiished prior fo
restorotive procedures (Fig 18).
Volume 14. Number 2. t994
134
Fig Ma ffecession on a mandibular left canine. Previousiy, o
free soft tissue graft had been ottempted by the referring
dentist
Fig 14c The donor tissue ond the overlying flap sutured In
pioce Note the omount of donor connective tissue not covered by the overiying fiap.
The International Journai of Periodontics & Restorative Dentistry
Fig 14b The omount ot hidden recession disclosed.
Fig J4d
amount
amount
ing fiap
The areo 16 months postoperatively. Nate the
ot root coverage obtained, notwithstanding the
of donar tissue that was net covered by the overlyaf fhe surgical procedure.
135
Fig I5o (left) Areas af wide recession
and abrasion.
Fig ¡Sb (rigtit) Raot coverage
obtained 4 manttis pastoperafively.
Fig láa Qeft) A maxillary leff canine
wifh recession and a oamposite raat
restoration.
Fig 16b (right) 7"ne canine 4 monlfis
posfaperativeiy. The graff has covered
the racf fallowing the removai of fhe
composite restoration
Fig 17a (left) Extensive raot exposure
on the maxillary leff canine and premolars
fig 17b (rignt) Raot caverage
abtained 2.5 years posfcperafively
Volume Id, Number 2. 1994
136
Figs 18a and 16b Root exposure of the right and left canines ond premoiors in fhe same patient. Note tetracydine
Figs JBc and 18d Root coverage obtoined
I year postoperativeiy,
The International Journal of Periodontics & Restorative Dentistry
foilowing the placement
of porcelain
staining
laminates.
137
Conclusion
Gingival recession related to
periadontal disease or deveiopmental problems can resuit
in root sensitivity, root caries,
and estheticdiiy unacceptable
root exposures. Consequently,
root restorations ore frequently
performed. These restorations
often complicate, rather than
resolve, the problems created
by exposed roots.
Prior to the efforts of Longer
and
Langer,^
Nelson,'°
Miiier,"-' '3 and ethers, root coverage was not addressed adequately in periodontai therapy.
Minimai consideration wos
given to providing the patient
with improved esthetics.
Recentiy, significant regenerotive techniques have been
developed whereby the needs
of the patient can be better
met. Miller" has detined the
term periodontal pidstic
surgery as "surgical procedures
performed to correct or eiiminate anatomic, developmental, or traumatic deformities of
the gingiva or alveoiar
mucosa." Root coverage is a
majar component of "periodontal plastic surgery."
The poradigm exists that
periodontai therapy frequently
disfigures a patient by exposing
root surfaces, resuiting in a cosmetically unacceptable smileline. Concomitant with root
exposure are the occurrence
of sensitivity and caries. This
paradigm and the perception
that periodohta! therapy is
directed solely at disease controi, with little concern for
esthetics, is fallacious.
This article demonstrates a
prediotoble procedure for root
coveroge on aredS ot wide
denudotion in the moxiiia and
the mandibie. This procedure
addresses the esthetic needs
ond requirements of the
potient OS well as those of the
dentist. The procedure is
indicative of the advances
that are being made in regenerative periodontal therapy.
Acknowledgment
Dr Gary Reiser was the inspiration for
ttiis article His guidance and contribution to the preparation ot this monuscript was indispensable. My sincerest
appreciotion goes to him.
References
1. Grupe HE. Warren RF. Repair of gingival defects by o sliding flop operation J Periodontol 1956.27:92-99
ó Miiier PD, Jr. Root coverage using a
free sott tissue autograft foiiowing
citric acid application, il. Treotment
of the carious root, int J Periodont
Rest Dent 1983:3:38-57.
7. Milier PD, Jr. Root coverage using
the free soft tissue outogroft following citric ocid applicotion. Port iil A
successful and predictoble procedure in oreas of deep-wide recession int J Periodont Rest Dent
1985;5:15-37.
B. Longer B, Caiogno L. Subepitheliai
graff fc correct ridge concovities. J
Prosthet Dent 1980.44:363-367.
9 Langer B. Langer L. Subepitheiiol
connective tissue graff technique
for root ccveroge. J Periodonfol
1985:56 715-720
10. Neisori S The subpedicie connective tissue graft: A bilaminor reconstructive procedure for the coveroge of denuded root surfaces. J
Periodontoi 1937;5B:95-!02
11 Fedi P. Periodontic Syilabus.
Phiiodelphio: Lea & Febiger.
1985 90
12. Korring t. Long NP, Loe H Role of
gingivol connective tissue in determining epitheiiol differentiation. J
Periodont Res 1974.10:1-11.
13. Milier PD, Jr. Regenerative and
reconstructive periodontoi plastic
surgery. Dent Clin Norfh Am
1988:32(2)287-306.
2. Nabors J. Free gingival grafts.
Periodont 19óó:il 243-245.
3 Sullivan HC, Atkins JH. Free autogenous gingival grafts. III. Utilization of
grofts in the tieotment o¡ gingival
recession. Periodont 1908 0:152-160.
4 Miller PD, J<. A classification ot marginoi tissue recession Int J Periodont
Rest Dent 1965:5-9
5. Milier PD. Jr. Root coverage using o
free soft tissue autograft foiiowing
citric ocid application I. Technique.
int J Periodont Rest Dent 1982.2:
65-70.
Volume ld,Number2. 1994