Chapter 6
Subepithelial Connective Tissue Graft
HISTORY
First described in the literature in 1985 (Langer & Langer 1985; Raetzke 1985) as a predictable means for root coverage, a subepithelial connective tissue graft combines the use of a partial thickness flap with the placement of a connective tissue graft. This enables the graft to benefit from a double vascularization, from both the periosteum and the buccal flap.
In addition, the connective tissue carries the genetic message for the overlying epithelium to be keratinized (Edel 1974). Therefore, only connective tissue from a keratinized mucosa should be used as a graft. The partial thickness flap may or may not have vertical releasing incisions (Langer & Langer 1985; Raetzke 1985; Bruno 1994).
Vertical releasing incisions will noticeably reduce the blood supply of the flap. The gingiva is vascularized from the apical area, the interdental septum, and the periosteum. An envelope or a pouch design, without the vertical incisions, has a better likelihood for success than does a flap with vertical releasing incisions. The advantages of the technique are the maintenance of the blood supply to the flap, a close adaptation to the graft, and reduction in postoperative discomfort and scarring.
The predictability and superior aesthetics provided by this technique make it the gold standard for root coverage. Jahnke et al. (1993) reported a success rate fivefold greater for achieving 100% root coverage when using a connective tissue graft versus a thick free gingival graft.
INDICATIONS
- Root coverage in areas of gingival recession (mild, moderate, or severe)
- Gingival coverage of exposed implant abutment or metal collar.
- Increase in the width of attached gingiva
- Ridge augmentation (edentulous area)
ARMAMENTARIUM
This includes the basic surgical kit plus citric acid pH 1 (40%) or one capsule of tetracycline hydrochloride (HCl) 250 mg.
TECHNIQUE (ENVELOPE FLAP)
Preparation of the recipientsite
Rootcoverage
After anesthesia, thorough root planning of the recession by using a Gracey curette (Hu-Friedy, Chicago, IL, USA) or back-action chisel is recommended. This will remove the contaminated cementum and flatten the root surface, if necessary. Any concavity or convexity on the root surface should be eliminated or reduced at this stage by using hand or rotary instruments.
Immediately after root planning, saturated citric acid is burnished into the root surface for 5 min by using cotton pellets (Miller 1985). An alternative to citric acid is tetracycline HCl (50–100 mg/ml for 3–5 min). This will open the dentinal tubules (Polson 1984) and remove the smear layer that could act as a barrier to the connective tissue attachment from the root surface (Isik 2000).
Gingivalcoverage of an implantcollar
Clean the metal collar thoroughly by using a cotton pellet soaked with tetracycline HCl (100 mg/ml). There is no need to scale the exposed collar (Fig. 6.1)
Incisions and creation of the “pouch”
The technique is similar for root coverage or implant coverage.
Figure 6.1. The metal collar of the implant showing comprom/>
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