Subepithelial connective tissue graft

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Recipient site exhibits gingival recession on both premolars and first molar (molar recession is not an esthetic issue and will not be treated) Incisions prior to flap reflection Full thickness flap elevated Another viewpoint of the flapped recipient site SECT1.jpg
  1. Recipient site exhibits gingival recession on both premolars and first molar (molar recession is not an esthetic issue and will not be treated)
  2. Incisions prior to flap reflection
  3. Full thickness flap elevated
  4. Another viewpoint of the flapped recipient site

In dentistry, the subepithelial connective tissue graft (SECT graft, and sometimes referred to simply as a connective tissue (CT) graft) is an oral and maxillofacial surgical procedure first described by Alan Edel in 1974. [1] Currently, it is generally used to obtain root coverage following gingival recession, which was a later development by Burt Langer in the early 1980s. [2]

Contents

Terminology

Similar to the free gingival graft, the SECT graft can be described as a free autogenous graft.

The connective tissue is generally taken from the hard palate, although it may be taken from other sites as well, such as the maxillary tuberosity area. Because the connective tissue for the graft is transplanted without the superficial epithelium from the donor site, it is termed subepithelial.

History

As initially described by Edel, the treatment objective was to increase the zone of keratinized tissue. [1] Others, including Broome and Taggert [4] and Donn [5] also described the use of SECT grafts for increasing the zone of keratinized tissue.

Of the various ways of preparing the graft recipient site, Edel described using two vertical incisions, mesial and distal to the teeth at which the zone of keratinized tissue was intended to be widened. [1]

Ipsilateral palatal mucosa serving as the donor site The retrieved connective tissue, approximately 25 x 6 mm in dimension Connective tissue placed at recipient site Recipient site flap coronally advanced and sutured to entirely cover the graft Subepithelial graft.jpeg
  1. Ipsilateral palatal mucosa serving as the donor site
  2. The retrieved connective tissue, approximately 25 × 6 mm in dimension
  3. Connective tissue placed at recipient site
  4. Recipient site flap coronally advanced and sutured to entirely cover the graft

At the donor site, Edel described three methods for choosing and preparing the donor site to obtain connective tissue for the SECT graft:

  1. palatal partial thickness flap
  2. palatal full-partial thickness flap
  3. tuberosity partial thickness flap

Contrary to the donor site for a free gingival graft, the surgeon is able to achieve primary closure at the donor site for a SECT.

Langer later described the SECT as a method by which to augment concavities and irregularities of the alveolar ridge following traumatic extractions, advanced periodontitis or developmental defects. [3] Currently, though, such augmentation of hard tissue defects tends to be done with hard tissue replacements, namely bone graft materials.

However, it was only in 1985 that Langer proposed the SECT for root coverage following gingival recession. [6]

Advantages

The SECT graft is a sort of hybrid procedure that combines the pedicle flap with the free gingival graft and enjoys the benefits of both. Pedicle flaps alone, such as the coronally advanced flap, frequently suffer from retraction and muscle pull. [6]

Technique

Although there are various ways in which to carry out this procedure, all share a common sequence of steps:

  1. Prepare the recipient site of tissue exhibiting recession by incising the gingivae
  2. Obtain the SECT from the donor site
  3. Secure the SECT at the recipient site
  4. Suture the incised gingival tissue at both the donor and recipient sites

The donor site might be sutured closed either before or after securing the donor tissue to the recipient site

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Periodontology or periodontics is the specialty of dentistry that studies supporting structures of teeth, as well as diseases and conditions that affect them. The supporting tissues are known as the periodontium, which includes the gingiva (gums), alveolar bone, cementum, and the periodontal ligament. A periodontist is a dentist that specializes in the prevention, diagnosis and treatment of periodontal disease and in the placement of dental implants.

The vestibular lamina is responsible for the formation of the vestibule and arises from a group of cells called the primary epithelial band. This band is created at about 37 days of development in utero. The vestibular lamina forms shortly after the dental lamina and is positioned right in front of it. The vestibule is formed by the proliferation of the vestibular lamina into the ectomesenchyme. The vestibular lamina is usually contrasted with the dental lamina, which develops concurrently and is involved with developing teeth. Both the vestibular lamina and the dental lamina arise from a group of epithelial cells, called the primary epithelial band.

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Gingival recession

Gingival recession, also known as receding gums, is the exposure in the roots of the teeth caused by a loss of gum tissue and/or retraction of the gingival margin from the crown of the teeth. Gum recession is a common problem in adults over the age of 40, but it may also occur starting from the age of a teenager, or around the age of 10. It may exist with or without concomitant decrease in crown-to-root ratio.

Gingival sulcus Space between tooth and gums

The gingival sulcus is an area of potential space between a tooth and the surrounding gingival tissue and is lined by sulcular epithelium. The depth of the sulcus is bounded by two entities: apically by the gingival fibers of the connective tissue attachment and coronally by the free gingival margin. A healthy sulcular depth is three millimeters or less, which is readily self-cleansable with a properly used toothbrush or the supplemental use of other oral hygiene aids.

Crown lengthening

Crown lengthening is a surgical procedure performed by a dentist, or more frequently a specialist periodontist. There are a number of reasons for considering crown lengthening in a treatment plan. Commonly, the procedure is used to expose a greater amount of tooth structure for the purpose of subsequently restoring the tooth prosthetically. However, other indications include accessing subgingival caries, accessing perforations and to treat aesthetic disproportions such as a gummy smile. There are a number of procedures used to achieve an increase in crown length.

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Stippling (dentistry)

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Flap (surgery) Surgical procedure in which tissue is transferred with intact blood supply

Flap surgery is a technique in plastic and reconstructive surgery where any type of tissue is lifted from a donor site and moved to a recipient site with an intact blood supply. This is distinct from a graft, which does not have an intact blood supply and therefore relies on growth of new blood vessels. This is done to fill a defect such as a wound resulting from injury or surgery when the remaining tissue is unable to support a graft, or to rebuild more complex anatomic structures such as breast or jaw.

Clinical attachment loss (CAL) is the predominant clinical manifestation and determinant of periodontal disease.

Scalp reconstruction is a surgical procedure for people with scalp defects. Scalp defects may be partial or full thickness and can be congenital or acquired. Because not all layers of the scalp are elastic and the scalp has a convex shape, the use of primary closure is limited. Sometimes the easiest way of closing the wound may not be the ideal or best way. The choice for a reconstruction depends on multiple factors, such as the defect itself, the patient characteristics and surgeon preference.

Angularis nigra Small triangle-shaped gap which often occurs between the teeth, near the gums

Angularis nigra, Latin for 'black angle', also known as open gingival embrasures, and colloquially known as "black triangle", is the space or gap seen at the cervical embrasure, below the contact point of some teeth. The interdental papilla does not fully enclose the space, leading to an aperture between adjacent teeth. This gap has many causes including gingival recession, and gingival withdrawal post-orthodontic work. Interdental "black triangles" were rated as the third-most-disliked aesthetic problem below caries and crown margins. Treatment of angularis nigra often requires an interdisciplinary approach, involving periodontal, orthodontic and restorative treatment. Possible treatments to correct angularis nigra include addition of composite resin in the space, veneer placement, or gum graft. Angularis nigra is generally only treated based on the aesthetic preference of the patient.

Platelet-rich fibrin (PRF) or leukocyte- and platelet-rich fibrin (L-PRF) is a second-generation PRP where autologous platelets and leukocytes are present in a complex fibrin matrix to accelerate the healing of soft and hard tissue and is used as a tissue-engineering scaffold for endodontics. To obtain PRF, required quantity of blood is drawn quickly into test tubes without an anticoagulant and centrifuged immediately. Blood can be centrifuged using a tabletop centrifuge from 3-8 minutes for 1300 revolutions per minute. The resultant product consists of the following three layers; topmost layer consisting of platelet poor plasma, PRF clot in the middle, and red blood cells (RBC) at the bottom. PRF is available as a fibrin clot. PRF clot can be removed from the test tube using a sterile tweezer-like instrument. After lifting, the RBC layer attached to the PRF clot can be carefully removed using a sterilized scissor. Platelet activation in response to tissue damage occurs during the process of making PRF release several biologically active proteins including; platelet alpha granules, platelet‑derived growth factor (PGDF), transforming growth factors‑β (TGF‑β), vascular endothelial growth factor (VEGF), and epidermal growth factor. Actually, the platelets and leukocyte cytokines play important parts in role of this biomaterial, but the fibrin matrix supporting them is the most helpful in constituting the determining elements responsible for real therapeutic potential of PRF. Cytokines are immediately used and destroyed in a healing wound. The harmony between cytokines and their supporting fibrin matrix has much more importance than any other platelet derivatives.

Gingival grafting

Gingival grafting, also called gum grafting or periodontal plastic surgery, is a generic term for the performance of any of a number of periodontal surgical procedures in which the gum tissue is grafted. The aim may be to cover exposed root surfaces or merely to augment the band of keratinized tissue.

Periodontal surgery is a form of dental surgery that prevents or corrects anatomical, traumatic, developmental, or plaque-induced defects in the bone, gingiva, or alveolar mucosa. The objectives of this surgery include accessibility of instruments to root surface, elimination of inflammation, creation of an oral environment for plaque control, periodontal diseases control, oral hygiene maintenance, maintain proper embrasure space, address gingiva-alveolar mucosa problems, and esthetic improvement. The surgical procedures include crown lengthening, frenectomy, and mucogingival flap surgery.

References

  1. 1 2 3 Edel, Alan (1974). "Clinical evaluation of free connective tissue grafts used to increase the width of keratinized gingiva". Journal of Clinical Periodontology. 1 (4): 185–196. doi:10.1111/j.1600-051x.1974.tb01257.x. PMID   4533490.
  2. ↑ Wennstrom, JL; Pini Prato, GP (2003). "Mucogingival Therapy — Periodontal Plastic Surgery". In Lindhe, Jan; Karring, Thorkild; Lang, Niklaus P. (eds.). Clinical Periodontology and Implant Dentistry (4th ed.). Oxford: Blackwell Munksgaard. p.  607. ISBN   978-1-4051-0236-0.
  3. 1 2 Langer, B.; Calagna, L. (1980). "The subepithelial connective tissue graft". J Prosthet Dent. 44 (4): 363–367. doi:10.1016/0022-3913(80)90090-6. PMID   6931898.
  4. ↑ Broome, William C.; Taggert, Edward J. (October 1976). "Free autogenous connective tissue grafting: report of two cases". Journal of Periodontology. 47 (10): 580–585. doi:10.1902/jop.1976.47.10.580. PMID   29538889.
  5. ↑ Donn, Burt J. (May 1978). "The free connective tissue autograft: a clinical and histologic wound healing study in humans". Journal of Periodontology. 49 (5): 253–260. doi:10.1902/jop.1978.49.5.253. PMID   277676.
  6. 1 2 Langer, Burton; Langer, Laureen (December 1985). "The subepithelial connective tissue graft technique for root coverage". Journal of Periodontology. 56 (12): 715–720. doi:10.1902/jop.1985.56.12.715. PMID   3866056.
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