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Wednesday, October 22, 2014
There are several reasons you may consider gum graft surgery. Common questions about this procedure include:
Based on current dental practice with available data, there are three indications for gum graft surgery:
Root Exposure Related Problems- The patient cannot brush the exposed root surface; the dentist detects a lot of plaque and calculus on the root; or, there is the beginning of root decay. Gum graft surgery can be performed to cover and protect the root surface.
Hypersensitivity - The patient complains about tooth hypersensitivity due to an exposed root surface. Covering the root surface may minimize these sensations.
Appearance - The patient is not happy with the way the tooth looks. Thus, the root surface is covered for aesthetic reasons.
In addition, for certain cases, soft tissue grafting is recommended prior to fixed type of restorations, such as crowns and implants, to protect supporting teeth. The amount of coverage depends on the shape of the root and the type of soft tissue defect, which is also related to the amount and type of underlying bone loss. Sometimes it is known from the beginning that it would be impossible to cover all of the exposed surfaces. And sometimes multiple surgeries may be done to move the newly created soft tissue toward a crown.
During gum grafting surgery, a periodontist will commonly take connective tissue from the roof of the mouth (palate) and suture it to the affected gumline. This allows more tissue to grow and close the exposed root surface (gum recession). After removing the tissue to be transplanted, the affected area on the palate is sutured and/or packed for healing.
There are three ways to perform soft tissue grafting:
Using connective tissue only – The roof of the mouth is covered with a layer of tissue. There is the surface tissue, which you can touch with your tongue, and there is connective tissue, which is the layer of tissue that is between the surface tissue and bone. With this procedure, a periodontist will make an incision and remove the tissue that is under the surface, thereby leaving a much smaller wound on the surface of the roof of the mouth. The procedure is similar to opening a sandwich and removing connective tissue from inside the sandwich. The benefit of this procedure is that although it requires sutures at the roof of the mouth, it is less painful since the wound where the tissue was removed is closed during healing.
Using surface and connective tissue – This procedure requires removal of both the surface and connective tissue from the roof of the mouth. You may still have sutures placed at the roof of the mouth to hold the edges of the wound together. However, the procedure leaves the wound exposed, and it is generally more painful and tends to bleed more.Thus, periodontists generally use the first procedure (connective tissue only) if there is enough thickness at the donor site. When there is not have enough thickness, the second procedure (surface and connective tissue) is used.
Using a biomaterial (AlloDermâ) - When there is a very limited amount of donor tissue, a periodontist may elect to use a biomaterial. This treatment is dependent upon having enough soft tissue at the recipient site to hold the material.
Given the right indication and right surgical technique, gum graft surgery works very well most of the time. Factors that help to predict success of the procedure are the type of defect that needs treatment and the amount of stress put on the graft after surgery.
The type of defect is important for graft survival. Narrow defects with intact tissue between the teeth (interdental areas)have a greater chance of success since the root surface does not have any blood supply and adjacent tissue will help the graft tissue to survive. Complete root coverage is the predictable outcome when this type of defect is present. The success rate of root coverage decreases with increasing interdental bone loss.
Anything that will cause the grafted tissue to move during healing, such as muscle pulls from inside the lip, will affect the healing. That is why periodontists generally show the site to the patient right after surgery and ask him/her not to look at it again during the first week. They know that every time the patient pulls his/her lip to look at it, there is a big chance that the graft will move.
During the healing, soft tissue shrinks a little and edema (swelling) goes down. Soft tissue binds the underlying root surface and neighboring bone surface and starts to mature. The most important aspect of this healing is the formation of new vessels that will bring the blood supply into newly grafted soft tissue (angiogenesis). Again, wound stability is very important for the newly-forming blood supply (vascularization).
Soft tissue healing generally takes 4-8 weeks to return to normal. Healing time also depends on how much tissue (thickness and area) was taken from the roof of the mouth and whether you had any bone exposure after the procedure. If you had bone exposure at the donor site, the healing may take longer. Also, if you developed bleeding into the tissue which accumulated there and caused swelling (hematoma together with hemorrhage), this may delay the wound healing.
Yes, the hole will close up. This is just a matter of time. The pain that is experienced has to do with underlying connective tissue being exposed to the oral cavity and getting irritated by rubbing of the tongue and food.
14 days after surgery, the superficial layer of the skin of the donor site will become thicker. The donor site will start feeling much better once this happens. Usually, it takes between 6 to 8 weeks after the surgery for the depression in the tissue to fill up completely.
Take pain medications prescribed by your dentist consistently according to the indications of the bottle. If they are over-the-counter, follow the directions on the label. Most of the pain medications also have an anti-inflammatory effect. Thus, they generally help with the healing process by not just controlling pain, but also controlling edema and inflammation.
Connective tissue grafts have a very high success rate. Generally tissue reforms, and we do not need to do anything extra.
Severe swelling/loosening sutures - The survival of the graft tissue (generally obtained from the roof of the mouth) purely depends on the blood supply that comes from surrounding bone (since there are no blood vessels on tooth surfaces). The stability of the grafted tissue is very important for the newly forming and migrating vessels.
During healing, sometimes due to severe swelling and/or loosening of the sutures, the graft may move and surgery will not be successful. In such cases, it is necessary to wait until the maturation of the surrounding tissues is complete and try again. This does not happen very often. However, every case is different and some of the surgical sites are harder to deal with, depending on the severity of the exposure and what is left from soft and hard tissue support.
Tissue sloughing from upper arch - A relatively, not infrequent, "normal" complication occurs where the tissue sloughs. It has to do with the size of the graft that was taken. Every individual's healing pattern is different, and the same is true for the pain threshold.
However, one suggested approach is to fabricate a plastic vacuum form of your upper arch. This is a clear, thin plastic that snaps press-fit onto your teeth and is trimmed to make sure that the palate is covered in its entirety. Thus, it will provide pressure to the donor site after the surgery and avoid irritation from food and the tongue. If a series of grafting surgeries is expected, this is a good option and would certainly have a positive effect.
Infection - Similar to any type of surgical procedure, infection will delay wound healing. This is especially true for oral wounds that are exposed to continuous bacterial challenge. A prescription for antibacterial/ antiseptic mouth rinses is generally given to control bacterial load for the first 10 days of healing.
Uneven healing - Following complete wound healing, if there is an obvious problem with symmetry, it may be necessary to go back and do what is called "gingivoplasty". This is a simple procedure performed to thin the extra soft tissue.
Treatment outcome is generally evaluated 4-6 weeks after soft tissue grafting. You need to wait up to 8 weeks or so for tissue maturation and to determine how much tissue has “taken”. If the graft tissue was thick to start with, the superficial layer will slough off but the deep parts will survive. (The most outside portion of the graft would not survive due to lack of blood supply. It becomes necrotic-white and comes out.) What is left should be reddish in color and will survive. White/pink color may change based on tissue thickness.
Your periodontist will need to re-evaluate the area and determine how much of it has taken. Sometimes it may be necessary to do a second surgery (gingival flap surgery) to bring what has “taken” more towards the root surface (coronally).
Pay attention and very carefully follow all the post-operative instructions given to you by your periodontist.
If you are having trouble with the packing on the roof of your mouth, or experiencing pain, go see your periodontist as soon as you can for a post-operative check. Ask if you could take stronger (prescription) pain medications to help with the pain.
If you develop continuous bleeding that does not stop with pressure application, call for an emergency post-operative control appointment.
This article is a NetWellness exclusive.
Last Reviewed: Sep 05, 2008
Binnaz Leblebicioglu, DDS, MS, PhD
Associate Professor of Periodontology
College of Dentistry
The Ohio State University
Jose I Arauz-Dutari, DMD
Formerly, Assistant Professor of Periodontics
School of Dental Medicine
Case Western Reserve University