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Newsletter Articles

Case Study 3 Subepithelial Connective Tissue Grafts

The autogenous free gingival soft-tissue graft has been used for many years by clinicians to widen the zone of attached gingiva and cover exposed roots. Problems with this procedure included unesthetic post-operative results, unpredictable root coverage, root sensitivity and post-operative pain and bleeding from the donor site. The emergence of the subepithelial connective tissue graft in the mid-eighties has allowed periodontists to perform predictable and esthetic root coverage procedures with fewer post-operative difficulties. This technique is more comfortable for our patients and has significantly impacted the field of periodontal esthetic plastic surgery. With it, we can repair the defects and deformities left by periodontal disease, trauma and congenital development to produce a more attractive, natural-looking smile.

The major difference between the subepithelial connective tissue autograft and other techniques is the preparation and positioning of the recipient bed and tissue grafts. A flap is elevated, with or without releasing incisions, at the graft site to gain access to the underlying connective tissue. The graft is then placed superficial to the periosteum and the outer flap sutured over it, providing the graft with a dual blood supply both from above and below.

The greatest advantage of the subepithelial connective tissue graft appears to be its high predictability for obtaining root coverage with good gingival color match and minimal likelihood of “keloid” (scarring) formation. In addition, the palatal donor site can be completely closed with sutures, minimizing post-operative bleeding and discomfort from the donor area. The “double blood supply” created is also advantageous. To obtain the proper thickness of the connective tissue graft and to stabilize the connective tissue under the flap requires great technical finesse.

The connective tissue autograft often eliminates many of the disadvantages of previous techniques for root coverage. In comparison studies, this technique has resulted in more predictable root coverage and higher incidence of complete coverage of root surfaces. Other advantages include a better color match of grafted tissues, an equivalent amount of attached gingiva, and less post-operative discomfort. It also appears that this technique is equally applicable to narrow and broad areas of recession.

Although the important functional role played by connective tissues in wound healing and repair has been recognized for decades, it is only recently that research into their structure, assembly and metabolism has been actively pursued. Subepithelial connective tissue grafts are a result of this research and provide periodontists with another very predictable technique for enhancing the functional and cosmetic results is situations where mucogingival defects exist. Shown below are some recent cases with typical results.