The use of gingivai autografts that contain submucosa in the

Penodontics

The use of gingivai autografts that contain submucosa in the repair ofmucogingival defects in maxillary molars: Case reportsCobi J, Landsberg* / Hyman Sinukler** / Haim Tal*

Many studies have shown thai deep and wide gingival recessions can be predictablycovered by free gingival aiitografls. Mosf of Ihe aiiiografis in these studies were per-formed on single-rooied leeih. This article presents a rationale for a new technique thatrepairs ihis type of defect in maxillary molar areas by means of thick masticatory mu-cosa autografts that intentionally include not only the lamina propria, but also portionsof the submucosa. In addition, a new suturing approach that allows adequate adapta-tion of the donor tissue to the recipient site and permits relocation of the graft is pro-posed. This new approach has been shown to be a significant advantage in the anatotni-eally problematic maxillary molar area. (Quintessence Int !993:24.693-700.)

Introduction

There is evidence that narrow, shallow areas of gin-gival recession can be repaired by gingival autograft-ing procedures.'"-' The concept that root surfaces ex-posed by deep and wide gingival recessions cannot bepredictably covered by gingival autografts'- has beensuccessfully challenged by the use of thick (1.5 to 2.0mm) autografts of masticatory mucosa.''^ In studiesin which thick masticatory mucosa autografts wereused, small amounts of submucosa containing fattyor glandular tissues were often included in the donortissue.^* Although the biologic mechanisms are notfully understood, it is apparent that the integrationof these grafts over deep and wide recessions is en-hanced. This finding is in contrast to the results ofSullivan and Atkins,' who claimed that the use ofthinner grafts (0.75 to 1.25 mm), which exclude thedeeper portions of the lamina propria and submucosa,increases the survival rates of gingival autografts.

Department of Perjodonlology, "Id Aviv University, Mauriceand Gabriela Goldsclileger School of Dental Medicine, RamalAviv, 69978 Tel Aviv, IsraelDepartment of Periodonlology and Oral Biology, Boston Uni-versity, Henry M, Goldman School ol Graduate Dentistry.Boston, Massachtisetts 02118.

Most of the grafts in the aforementioned studieswere performed on single-roo ted teeth. Therefore,there remains a paucity of information pertaining tothe grafting of wide and deep recessions in maxillarymolar areas. The purpose of this article is to presenta new technique that repairs this type of defect in themaxillary molar areas by using thick masticatory mu-cosa autografts that intentionally include not only thelamina propria but also portions of the submuco.sa.

Surgical technique

The surgical techniques used are based on those de-scribed by Miller'' in 1982 and Holbrook and Och-senbein^ in 1983. Briefiy, partial-thickness recipientsites are prepared and extended approximately 4 mmlateral and 3 to 5 mm apical to the surgically exposedrecession. Where possible, butt joints are made in theinterdental and recipient borders to accomodate thethick edge of the autograft."'-'

The autografts are obtained from the palate be-tween the first premolar and second molar. The di-mensions of each graft correspond to those of therecipient site. Tissue thickness varies between 2.5 to3.0 mm, always including some fatty and glandulartissue from the submucosa. Grafts are never trimmedor smoothed (Figs la and lb).

Root surfaces are thoroughly debrided and planeduntil they feel smooth and hard: this is accomplished

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Fig la The gingival autograft that contains submucosa iscomposed ot (EP) epithelium; ¡LP) lamina prapria; (SM)submucosa.

Fig 1b A typical 3-mm-thick gingival autograft containingsubmucosa, shoveling the lamina propria. the submucosa,and an unsmoothed undersurtace.

with both hand instruments and 12-fluted finishingburs. Although root surfaces are generally flattenedto some degree, this is not a primary intention of theroot-planing process.

Pîacement, fixation, and adaptation of grafts inmaxillary molar regions is difficult because of limitedaccess and visibility and because of anatomic imped-iments, such as the protuberance of the root of thezygoma, the loose nature of the periosteal bed, andthe pull of the buccinator muscle. To position thegraft with greater ease, a modification of the hori-zontal suture described by Holbrook and Ochsenbein'is used (Figs 2a to 2e). This modification, the hori-zontal sliding mattress suture, permits the graft toslide laterally or to be rotated to the exact positionrequired after it is sutured in place. Appropriate fix-ation may then be accomplished by using circumfer-ential sutures as described by Holbrook and Ochsen-bein.'

Both donor and recipient sites are protected withperiodontal dressings (Coe-Pak, Coe Laboratories)during the first postoperative week. Following sutureremoval on day 7, the donor sites are usually coveredagain for a second week.

Case reports

Ca.se Í

A 19-year-old man complained of pain in the areaover the mesial root of the maxillary right first molar.

E;<amination revealed gingival recession measuring4 mm. probing depth of 5 mm, and bleeding on prob-ing (Figs 3a to 3c). A free gingival autograft withsubmucosa included was chosen to treat both the gin-gival deformity and the periodontal problem (Fig 3d).Clinical examination 3 years postsurgery showed asolid band of attached gingiva and no pocketing orsigns of inflammation. Only minimal root coveragewas achieved^ (Fig 3e).

Case 2

This patient presented for treatment with markedrecession on the maxillary first molar and seeond pre-molar. The inflamed tissues bled easily on probing{Fig 4a), In spite of acceptable home care and regularprofessional cleanings, it was not possible to resolvethe marginal gingivitis associated with those teeth.This was probably due to the patient's inability toperform adequate brushing in this receded area withits inconsistent gingival margins and shallow buccalvestibule. The main treatment objectives were im-provement of the gingival contour to achieve a moreeasily maintainable gingival topography.* treatmentof the periodonta! pockets, deepening of the buccalvestibule, and augmentation of the gingiva. The pro-cedure chosen was the gingival aulograft with sub-mucosa (Figs 4b to 4e). The 3-year follow-up showedimproved gingival morphology and no signs of in-flammation (Fig 4f).

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Fig 2a The recipient site is extended approximately 4 mmlateral to and 3 to 5 mm apical to the surgically exposedrecession. (PB) periosteal bed; (AM) alveolar mucosa; (AG)attached gingiva.

Rg 2b The horizontal sliding mattress suture. The sutureneedle enters the graft at point A and traverses the adjacentperiosteum to exil at point S, It is then brought distally toenter the graft at point C and traverses the periosteumdistally to exit at point D. The suture is tied to its tail atpoint E.

Fig 2c After completion of the horizontal suturing, somerotation of the graft may result. This can be easily correctedby rerotaling the graft to the desired position (see Fig 2e),(AM) Alveoiar mucosa; (AG) attached gingiva.

Fig2d After completion of Ihe horizontal suturing, the graftmay be located laterally. This can be easily corrected bysliding the graft to Ihe desired position (see Fig 2e). (AM)Alveolar mucosa; f^lG^ttached gingiva.

Fig 2e Final fixation and adapfation are achieved by add-ing the circumferenlial suture, (AM) Alveolar mucosa; (AG)attached gingiva.

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Fig 3a Gingival recession over the mesial root of the max-illary first moiar. Note the toothbrusti injury in the recededgingiva.

Fig 3b A deep bleeding pocket is revealed on probing.

Fig 3c Removal ol pocket wall reveals denudation of theroot almost to its apex. Note remarkable root width andconvexity.

Fig 3d Graft sutLired into position with horizontal slidingmattress and circumferential sutures.

Fig 3e Tooth 3 years after healing. Note the improved gin-gival contours and augmentation.

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Fig 4a Persistent bleeding on probing 1 year after initia-tion ol nonsurgical periodontal therapy.

Fig 4b The recipient site illustrating butt-joint preparationin the papillae and mesial and distal borders. Note theincreased depth of the recession as it is completely ex-posed.

Fig 4c Graft held in position by the horizontal sliding mat-tress suture. Note the undesirable mesial deviation of graft.

Fig4d The graft has been relocated distaliy, but is stillpositioned too far coronaliy and therefore is a iittle off therecipient bed.

Fig 4e An accurate position of the graft is linally achievedwith the use of circumferential sutures.

Fig4f The 3-year postsurgical result reveals improvedgingival topography and no bleeding on probing.

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Fig 5a Gingival recession associated with the maxillaryfirst molar. The vestibule in the area is shallow.

Fig 5b Recipient site preparation showing increase indepth ot recessioh.

Fig 5c Site 2 years after surgery. There has been a dra-matic change in the shape of the lesion. Note the solid bandof gingiva and deeper vestibuie.

Fig 6 The fatty/glahdular submucosa is pliant and blendsihto the curved surface of the recipient site. ffP; epitheiium;fZ-P; lamina propria; Í'SM; submucosa; fPS; periosteal bed;(CSj circumferential suture.

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Case 3

A 22-year-old man had multiple recessions related toaggressive toothbrush abuse. Some teeth exhibited aV-shaped cleft that was extremely dilTicult to maintainplaque free. The shallow vestibule in the area of themaxillary first molar further interfered with appro-priate home care, resulting in perpetuation of gingivalinflammation and hidden recession on the buccal sur-face of that tooth^ (Figs 5a and 5b). Treatment ob-jectives included ehmination of the pockets, improve-ment of the gingival architecture, and deepening ofthe vestibule, all of which could be achieved by usinga gingival autograft that contained submucosa. A 2-year follow-up showed a dramatic change in the mor-phology of the original lesion, a deeper buccal vesti-bule, and a solid band of gingiva (Fig 5c).

Discussion

In their classic article on the use of free gingival au-tografts. Sullivan and Atkins' stated that "if the fat[contained in the submucosa of the anterior palate] isinadvertently included in the graft, it will act as abarrier both to diffusion and revascularization and,therefore, should be removed..." This unequivocalstatement has strongly enforced the belief that resid-ual fatty tissue should be completely removed fromall grafts.'•-•-•*•"' Thus, for many years only thin grafts(0.75 to 1.25 mm) were considered suitable for gin-gival augmentation and root coverage.'"'

Recent studies have shown that thicker grafts (1.5to 2.0 mm) produce more predictable root cover-age.̂ ""'" However, most clinicians still feel that thefatty tissue should be trimmed."*''" Grant'' foundthat in dogs "fatty tissue in the donor segments sur-vived transplantation and an adequate even abundantcirculation actually does exist in palatal adipose tis-sue." Seibert," discussing thick onlay grafts for ridgeaugmentation, also advocated the inclusion of the en-tire submucosal layer with its fatty content. The ra-tionale for this rather unique approach was the rec-ognition that the "submucosal zone of the palatalgraft is composed of loosely arranged connective tis-sue into which plasma from the recipient site maydiffuse readily, and capillary shoots can grow withgreater ease and rapidity than into the densely col-lagenized zone of the lamina propria." Seiberfs clin-ical observation led him to state firmly that total in-tegration of the grafted connective tissue may be con-

sidered predictable only when the fatty submucosallayer is included in the graft.

In the three cases presented, submocosa was Inten-tionally included on as much surface of the graft aspossible. Although the clinical objectives in the casespresented were different than those in Seibert's ridgeaugmentation study," there were some similar obser-vations;

1. The donor tissue was phable and easy to adapt andsuture to the recipient site.

2. The donor tissue survived well.

In the present cases, no attempt was made tosmooth the undersurface of the submucosa, becausethe fatty layer appears to act as a cushion that is pliantand tends to blend into irregular surfaces of the re-cipient site (Fig 6).

To overcome anatomic problems in the maxillarymolar area, it was necessary to use the horizontalsliding mattress suture. This suture not only allowsadequate adaptation of the donor tissue to the recip-ient site, but also permits relocation of the graft. Thecircumferential suture enables accurate vertical posi-tioning of the graft and ensures that the pliant graftis closely and accurately adapted to the recipient sur-face. No attempt is made to stretch the grafts as wasadvocated by Holbrook and Ochsenbein in 1983.'

O'Leary et al,''' in their study on the incidence ofrecession in young males, found that maxillary firstmolars are the most frequently affected teeth, Elliotand Bowers'-' reported in their study on human skullsthat maxillary left first molars are the most frequentlyinvolved with alveolar bony defects, such as dehis-cences and fenestrations. Although this theory is notproven, these lesions may be responsible, togetherwith plaque-induced inflammation and toothbrushabuse,'* for the type of patbosis treated in the casespresented. Early signs of clefting over the mesiobuccalroots of maxillary first molars should be treated con-servatively. Should these measures prove unsuccess-ful, gingival autografts that contain submocosa canbe used to improve the morphology and health of theperiodontium in areas associated with gingival reces-sion.

Acknowledgments

The authors thank Ms Rita Lazar lor edilorial assistance and prep-aralion of the manuscript.

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Periodontics

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13. Seibert JS. Reconstruction of deformed, partially edentulousridges, using full thickness onlay grafts. Part 1. Technique andwound healing. Compend Contin Educ Dent 1983;4:437-^53,

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