Live case study
graft of connective tissue. However, in some cases, where there is a shortage of keratinised tissue, we can take what is known as a composite graft, where there is part full thickness with epithelium and part connective tissue. There are two standard donor
sites, one being the maxillary tuber- osity and the other being the palate, with the tuberosity producing a more fibrous stable type of tissue and the palate giving us a fattier type of graft. In NC’s case, we decided on the palate as the donor site of choice as described by Bert Langer in ı980. The images show the stages of the
procedure. We begin with a crestal split thickness incision extending towards the palate, then a wedge of connective tissue is lifted from the palatal side and brought buccally, a technique called the ‘buccal roll’ and was first described by Abrams in ı980. While this helps increase the thickness of the tissue, it is seldom sufficient on its own and is a neat technique that when used in conjunction with a separate graft – as will be described – can usually make the vital difference. To complete the preparation of
the recipient site I then prepare a sub-epithelial pocket by a mixture of blunt and sharp dissection (Figures 3 and 4). A horizontal full thickness inci-
sion is then made in the palate, in this case extending from the distal of the first molar to the mesial of the first premolar, using a micro-
surgical blade #67 (Figures 5 and 6). From this horizontal incision the graft is harvested using vertical and horizontal incisions beneath the mucosa. This technique, if carefully carried out will usually result in no need for sutures, thus speeding up healing and reducing discomfort to a minimum. Care must be taken to avoid the greater palatine artery that runs near the vault of the palate just lateral to the midline. Once harvested, the graft must be
kept moist and I use sterile gauze soaked with sterile saline (Figure 7). The graft is oriented in the most advantageous way and placed into the sub-epithelial pocket of the recipient site, and held in posi- tion with two horizontal mattress sutures using 7’0 Vicryl Rapide (Ethicon) sutures (Figures 8 and 9). The crestal incision was then
closed with 6’0 interrupted sutures, again Vicryl-Rapide (Ethicon), (Figure ı0) and the provisional bridge re-bonded after the pontics had been re-contoured with composite so that pseudo-papillae could be shaped. Figures ıı and ı2 show the healing
at one week and figures ı3 and ı4, at three weeks. A total healing time of six to eight weeks is required before the next stage can be carried out, this being the uncovering of the implants, known as second stage surgery. This will be described in the next issue. Interestingly enough, the palatal
donor site will completely regen- erate, using the principles of form
“In some cases in the aesthetic zone, the shrinkage is such that further bulking of the tissue is
indicated” Stephen Jacobs
REFERENCES
Langer B, Calagna L: The subepithelial connective tissue graft. J Prosthet Dent 1980; 44:363-367
Abrams L: Augmentation of the deformed residual edentulous ridge for fixed prosthesis. Compen Contin Educ Dent 1980; 1:205-214
Scharf D, Tarnow D: Modified roll technique for localised alveolar ridge augmentation. Int J Periodont Rest Dent 1992; 12:415-425
following function, within three months and more could theoreti- cally be harvested, this rarely being the case... not that many patients would allow you! Post-operative advice centres
around the use of analgesia and mouthwashes (0.2 per cent chlo- rhexidene), however most patients report virtually no discomfort. Post operative haemorrhage from the palatal wound is not uncommon and if the patient is wearing a denture then this can help prevent this eventuality, or even a clear acrylic ‘suck-down’ stent. In summary, I find this procedure
an invaluable adjunct to enhancing the soft tissue profile in highly aesthetic cases, and can even be used to improve the appearance under conventional bridge pontics.
Fig 5
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Fig 13
Fig 14 Scottish Dental magazine 39
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