Jan Lindhe. Clinical Periodontology

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MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY •

Fig.

27-77. Pouch graft procedure.

(a) Pretreatment view of a Class I ridge deformity. (b) Placement of the free connec-

tive tissue graft in a tunnel prepared by split incision between the two vertical incisions. The graft is brought into

position by the use of a suture placed in one end of the free graft. (c) 4 months post-treatment showing restored fa-

cial dimension of the edentulous ridge.

Fig.

27-78.

Schematic illustrations

of the

interpositional graft proce

dure.

(

A) Cross-section of Class I ridge

defect. (B) A labial flap (par

tial

thickness dissection preferred)

used to create the pouch. (C) A

wedge-shaped graft is removed

from the palate. (D) The epithelial

surface of the graft is placed flush

with the surface of the tissue sur-

rounding the pouch and sutured

around its circumference.

Technique

(Fig. 27-76):

The pouch is prepared as de-

scribed above. The mesiodistal entrance incision for

the

edge of the pouch should be made with a long bevel and

must be started well to the palatal (lingual)

side of the

defect. After the pouch has been filled with graft, the

facial tissue will be stretched. The long bevel

of the entrance incision permits the palatal edge of the

flap to slide toward the facial surface without opening

gap at the incision line. Sometimes vertical releasing

incisions have to be made lateral to the border of the

defect.

A suitable donor site is selected in the palate, the

tuberosity area, or in an edentulous area and a free

636 • CHAPTER 27

Fig. 27-79. (a) Pretreatment view, Class III ridge defect. A 2-stage procedure will be used to augment the ridge. (b) A

pouch was prepared to receive an interpositional graft. Epithelium was removed from the borders of the recipient

site to permit some of the graft to be placed above the level of the surrounding tissue in order to gain apico-coronal

augmentation. (c) The wedge-shaped graft was 10 mm thick at its center. (d) The interpositional graft is both dis-

placing the labial surface of the pouch in the labial direction as well as gaining height to the ridge. (e) Two months

post-treatment. Additional augmentation is needed apicocoronally. (f) A second-stage onlay graft will be used to

create a papilla and fill the dark triangle between the pontics.

graft of connective tissue is excised by the use of a "trap-

door" approach. The graft is immediately trans

ferred to

the recipient site and properly positioned.

The palatal

entrance incision and the releasing inci

sions are closed

with sutures.

Interpositional graft procedure

Surgical concept:

Interpositional grafts are not com-

pletely submerged and covered in the manner that a

subepithelial connective tissue graft is placed (Fig. 27-

78) (Seibert 1991, 1993a,b). Therefore, there is no

need to remove the epithelium from the surface of the

donor tissue. If augmentation is required not only in the

buccolingual but also in the apicocoronal direc

tion, a

portion of the graft must be positioned above

the

surface of the tissue surrounding the recipient site

(Fig.

27-79). A certain amount of the grafted connective

tissue

will thus be exposed in the oral cavity.

Indications:

Interpositional graft procedures are used

correct Class I as well as small and moderate Class

defects.

MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY • 637

Fig. 27-79. (g) Two months after the first surgical procedure, the ridge was de-epithelialized and cuts were made

into the connective tissue prior to placing the second-stage onlay graft into position. (h) The onlay graft was su

tured into position. (i) The pontics were adjusted and brought into light contact with the graft. (j) Marked swelling

occurred within the graft at 14 days post-surgery. (k) Two months following the second surgical procedure, a

gingivoplasty was performed to deepen the pontic receptacle sites for the ovate pontics. (1) Post-treatment view 1

year after the final surgical procedure. Courtesy of Dr J. Seibert and Dr P. Malpeso, US.

Technique (Fig. 27-78):

An envelope flap, or a split

thickness flap with releasing incisions, is prepared at

the facial surface of the defect area. The provisional

bridge is placed in position to serve as a reference

when estimates are made regarding the amount of

tissue that has to be grafted to fill the defect. A peri-

odontal probe may be used to measure the length,

width and depth of the void of the pouch. A suitable

donor site is selected in the palate or the tuberosity

area, and a free graft of epithelium-connective tissue

excised.

The donor tissue is transferred to the recipient site

and placed in position. If gain in ridge height is not

intended, the epithelial surface for the graft is placed

flush with the surrounding epithelium. The graft is

sutured along its entire circumference to the tissues of

the recipient site. The provisional bridge is placed in

position and the pontics are trimmed and adjusted as

discussed above. No dressing is used to cover the

recipient site.

If gain in ridge height is also intended, a certain

portion of the graft has to be kept above the surface of

the surrounding tissue (Fig. 27-79d). Granulation tis-

sue formed during healing will eventually make the

638 • CHAPTER 27

Fig. 27-80.

Onlay graft procedure.

(a) Pretreatment view. The gingival tissues were distorted from previous attempts

esthetic reconstruction. The patient wished to have a papilla between the right maxillary lateral and central inci

sor

and a natural looking bridge. (b) The pontic area, including the papilla on the mesial of the right lateral incisor, was

de-epithelialized and a thick (5 mm) onlay graft was sutured into position. (c) The pontic was shortened at the time

of surgery to accommodate the thick graft. At 3 months post- surgery the graft had undergone maximum

shrinkage and gingivoplasty could now be done. (d) Incisal view at 3 months post-surgery. Note the "papilla" that

has

been created. The indentation in the ridge was naturally created by the tissue swelling against the pontic tooth.

(e)

Rotary diamond point gingivoplasty was done to reshape the bulky graft to normal contours, deepen the recep

tacle

site for the ovate pontic and level the gingival margins. (f) This view shows the esthetic harmony that was ob

tained

in the soft tissues and tooth form at 2 years post-treatment. Courtesy of Dr J. Seibert and Dr C. Williams, US.

Fig. 27-81a-h.

Onlay graft procedures

utilized to augment ridge and create papillae. (a) Pretreatment view. The left lat-

eral incisor was extracted after a traumatic injury. The patient detested the dark triangle on the mesial of the pontic,

the poor tooth form in the bridge and the irregular contours in her gingival tissue. (b-c) An onlay graft was used to

gain apicocoronal and buccolingual ridge augmentation as well as to develop papillae. Note how the graft was ex-

tended to the palatal side of the ridge to gain greater blood supply from a larger connective tissue base. (d-e) At 2

months post-surgery, a second-stage veneer graft was used to eliminate the surface irregularities on the surface of

the

gingiva and gain greater buccolingual augmentation. (f) At 4 months post second-stage surgery, gingivoplasty

was

done to prepare the area for an ovate form pontic. (g-h) One year post-treatment, esthetics have been restored for this

patient. Courtesy of Dr J. Seibert and Dr D. Garber, US.

MUCOGINGIVAL THERAPY - PERIODONTAL PLASTIC SURGERY •

Fig. 27-82. Basic anatomical-histo

logical zones of the palate. Note

the normal location of the greater

palatine foramen.

border between the graft and the adjacent tissue

smooth and properly epithelialized. The swelling,

which occurs postoperatively, will assist in sculpting

the contour of the ridge.

Onlay graft procedures

Surgical concept:

The onlay procedure was designed to

augment ridge defects in the apicocoronal plane, i.e.

to gain ridge height (Meltzer 1979, Seibert 1983). On-

lay grafts are epithelialized free grafts which, follow-

ing placement, receive their nutrition from the de-epi-

thelialized connective tissue of the recipient site. The

amount of apicocoronal augmentation that can be

obtained is related to the initial thickness of the graft,

the events of the wound healing process and the

amount of graft tissue that survives (Figs. 27-79, 27-80

and 27-81). If necessary, the grafting procedure can be

repeated at 2-month intervals to gradually increase

the ridge height.

Indications:

Onlay graft procedures are used in the

treatment of large Class II and III defects. They are not

suitable in areas where the blood supply at the recipi

ent site has been compromised by scar tissue forma-

tion from previous wound healing.

Technique (Fig. 27-79g-i):

An attempt must be made to

retain as much as possible the lamina propria of the

recipient site. The anesthetic solution should be placed

high in the vestibular fornix and in the palate, thus

keeping vasoconstriction in the recipient site to a mini

mum. A scalpel blade is used to remove the epithe-

lium. The scalpel is moved with short, saw-like

strokes across the recipient site at a level approxi-

mately 1 mm below the outer surface of the epithe-

lium. The least amount of connective tissue possible

should be excised. The margins of the recipient site can

be prepared with either a butt-joint or a beveled mar-

gin. The prepared recipient site should be covered

with a surgical gauze moistened with isotonic saline

while the donor tissue is dissected.

Selection of donor site:

Onlay graft procedures, as well

as frequently interpositional graft procedures, require

large amounts of donor tissue. The palatal vault re-

gion of premolars and first molars, midway between

the gingival margin and the midline raphae, is as a

general rule the only area in the maxilla that contains

the necessary volume of tissue required to augment

large size ridge defects. During the presurgical plan-

ning phase, the tissue of the palate should be probed

with a 30-gauge syringe needle to ensure that an

acceptable volume of tissue can be obtained at the time

of surgery.

The major palatine artery emerges from the poste-

rior palatine foramen located adjacent to the distal

surface of the maxillary second molar, midway be-

tween the gingival margin and the midline raphae (

Fig. 27-82). The artery passes in an anterior direction

close to the surface of the palatal bone. It is important

therefore that the second and third molar regions are

not used as donor sites for large volume grafts.

Planning in graft preparation: As

a rule the graft should

be made a few mm wider and longer than the dimen-

sions required at the recipient site. The dimensions of

the graft are outlined on the palate with the use of a

scalpel and light bleeding is provoked to define the

surface borders. In order to avoid interference with the

palatine artery, the borders of the graft must be

planned in such a way that its thinner portions are

located high in the palatal vault or in the first molar

area. The thicker portions should be harvested from

the premolar areas.

Dissection of donor tissue:

The base of the graft should

be V or U-shaped to match the shape of the defect in

the ridge. The different planes of incision prepared in

the palate must therefore converge towards an area

under the center or toward one edge of the donor site.

It is comparatively easy, with the use of a scalpel, to

dissect in an anteroposterior direction or from an area

high in the palate in a lateral direction towards the

teeth. It is, however, difficult to dissect in an anterior

640 • CHAPTER 27

MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY • 641

B C

Fig. 27-83. Diagram of the

combination onlay-interpositional graft procedure. (A)

Cross-section of a Class III ridge de

fect. (B) Epithelium is removed on the labial-crestal side of the ridge to prepare the recipient bed for the onlay seg

ment of the graft. (C) Partial-thickness dissection was then used to create a pouch for the interpositional section of

the graft. (D) The dissection for the graft is started at right angles to the surface of the palate. The scalpel blade

then angled to remove a long connective tissue segment for the graft. (E) Three-dimensional view of the onlay

sec

tion of the graft (including epithelium) and the connective tissue segment for buccolingual augmentation. (F)

Graft

sutured into position. Reprinted with permission,

International Journal of Periodontics and Restorative

Dentistry.

direction from the distal edge of the donor site. There

are a variety of blade holders available which permit

the scalpel blade to be positioned at different angles

to the holder and which enable the surgeon to cut with

a back-action. When the donor tissue has been re-

moved, it must at all times be stored in pieces of

surgical gauze moistened in isotonic saline.

Treatment of the donor site:

Since it is difficult to anchor

and maintain a periodontal dressing at the donor site

in the palatal vault, an acrylic stent should be fabri-

cated prior to surgery. The stent should be made with

wrought wire clasps on each side to add retention and

to aid the patient in removing and inserting the device.

The donor site must be inspected carefully for signs

of arterial bleeding. If any small-vessel bleeding is

observed, a circumferential suture must be placed

around the vessel distal to the bleeding point. Imme-

diately thereafter, the void at the donor site should be

packed with a suitable hemostatic agent and the edges

of the wound should be brought closer together with

sutures. The stent is then put into position.

Try-in and stabilization of graft:

The graft is transferred

with tissue forceps to the recipient site for a try-in. The

graft is trimmed to the proper shape and adjusted to

fit the connective tissue surface of the prepared ridge.

A series of parallel cuts may be made deep into the

exposed lamina propria of the recipient site to sever

large blood vessels (Fig. 27-79g) immediately before

suturing. A series of interrupted sutures is placed

along the borders of the graft. The dental assistant

should stabilize the onlay graft against the surface of

the recipient site, while the surgeon completes the

placement of sutures.

Wound healing in the recipient site:

Considerable post-

operative swelling often occurs during the first week

after pouch and onlay augmentation procedures. The

epithelium of the graft will slough to form a white film

on the surface of the graft. Patients should rinse two

to four times per day with an antimicrobial mouth-

wash during the first week after surgery and should

refrain from mechanical cleaning measures in the area

until a new epithelial covering has formed over the

graft, which will not occur until a functional capillary

circulation has been re-established in the graft (4-7

days after the surgery). The grafted tissue will assume

a normal color as the epithelium thickens via stratifi-

cation. Tissue form is usually stable after 3 months,

but further shrinkage may occur over a period of

several months. Final restorative measures should

therefore not be initiated until after 6 months.

Wound healing in the donor site:

Granulation tissue will

gradually fill the donor site. Initial healing is usually

complete within 3-4 weeks after the removal of a 4-5

mm thick graft. Patients should wear the surgical stent

642 • CHAPTER 27

Fig. 27-84. (a-b) The right maxillary lateral and central incisors were lost due to trauma. These views show the hori

zontal and vertical loss of ridge tissue 10 months after the extractions. (c) A partial-thickness path of incision was

extended labially and apically to create a pouch. The amount of space created within the pouch and the degree of

relaxation of the flap was then tested with a periosteal elevator. (d) The epithelialized section of the graft can be

seen in this view. (e) The premolar area, maxillary right side, was used as the donor area. The area of exposed con

nective tissue corresponds to the onlay section of the graft. The incisions were extended another 5-7 mm towards

the midline on a long bevel to obtain the interpositional segment of the graft. (f) The graft was tucked into the la-

bial pouch and sutured first along its palatal border. The labial flap was then sutured along the epithelial connec-

tive border of the graft. The residual labial socket defect in the flap created a soft tissue discontinuity defect along

the labial margin of the flap.

for about

2 weeks to protect the healing wound. The

palate returns to its presurgical contour after about

months.

Combined onlay – interpositional graft procedures

Class III ridge defects pose a major challenge to the

clinician since the ridge has to be augmented in both

vertical and horizontal dimensions. The combined

onlay-interpositional graft procedure (Figs. 27-83

and

27-84)

may successfully be used in such a situation

(

Seibert & Louis 1996). The combined graft procedure

may offer the following advantages:

• The submerged connective tissue section of the in-

terpositional graft aids in the revascularization of

MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY • 643

Fig. 27-84. (g) At 6 weeks postsurgery, it can be seen that further augmentation would be required to gain addi-

tional soft tissue in both the vertical and horizontal planes. A second-stage procedure was done at this time. (h) An

incision 1.5 mm in depth was utilized to de-epithelialize the crestal surface of the ridge. Note that the papillae were not

included within the surgical field. The mesial and distal borders of the onlay section of the recipient site were

then

extended apically to create vertical releasing incisions. The overall recipient site was to be trapezoidal in

shape. A

labial flap to create the pouch section of the recipient site was made using partial-thickness dissection. (i)

The left

maxillary premolar area was used as the donor site for the second-stage surgery. (j) This side view perspec-

tive

clearly shows the epithelialized onlay section of the graft and the de-epithelialized connective tissue section of

the

graft, as well as tissue thickness.

the onlay section of the graft, thereby gaining a

greater percentage of take of the overall graft

•

A smaller postoperative open wound in the palate

donor site

•

Faster healing in the palate donor site with less

patient discomfort

•

Greater latitude or ability to control the degree of

buccolingual and apicocoronal augmentation

within

a single procedure

•

Vestibular depth is not decreased and the mu-

cogingival junction is not moved coronally, thereby

eliminating the need for follow-up corrective proce-

dures.

Refinement of pontic contours and gingivoplasty soft

tissue sculpting procedures

It is desirable, when reconstructing defects within a

partially edentulous ridge, to moderately overcorrect

the ridge in the area of the deformity. This will com-

pensate for wound contraction and provide the neces-

sary bulk of tissue within the ridge to sculpt the ridge

to its final form. Gingivoplasty techniques using ro

tary

coarse diamond stones in an ultraspeed hand-

piece

with copious water spray are used to smooth out

incision lines and perfect the fit and shape of the

pontic teeth to the crest of the ridge (Figs. 27-80 and

27-84). Adjustments are made to shape the cervical

contour and emergence profile of the pontic teeth to

match that of the contralateral teeth. The tissue-con-

tacting surfaces of the pontic teeth are immediately

rebased with autopolymerizing resin and polished.

This final tissue sculpting procedure and reshaping of

the provisional prothesis is minor in nature but aids

greatly in defining the shape of the papillae and cre-

ating the illusion of the presence of a cuff of free

gingiva at the pontic /ridge interface.

644 • CHAPTER 27

Fig. 27-84. (k) The graft was sutured first along the fixed palatal border to gain initial stabilization. Then the connec

tive tissue

interpositional section was sutured along the lateral borders. The flap was then sutured over the interpo

sitional section of the

graft at the epithelialized edge of the onlay section of the graft and along the vertical inci

sions. (1) At 6 weeks postsurgery, the

provisional prosthesis was modified to bring the tissue surface of the pontics

into contact with the healing ridge. (m) At 2

months postsurgery, tooth form was further modified on the provi

sional prosthesis and gingivoplasty was done to sculpt the

tissues to final form and smooth out surface irregulari

ties. (n) The final ceramo-metal prosthesis was inserted 4 months later.

The life-like reconstruction of the soft tis

sues and dentition restored dentofacial esthetics for the patient. Courtesy of Dr J.

Seibert, Dr J. Louis & Dr D. Haz

zouri, US. Reprinted with permission from

International Journal of Periodontics and

Restorative Dentistry.

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