Gingival Graft – Dental Minute with Steven T. Cutbirth, DDS

Gingival Graft – Dental Minute with Steven T. Cutbirth, DDS

Let’s discuss gingival grafting with periderm. Dr danny melker has been a speaker at my teaching center in Dallas when that was going on several times, and he is a he is the guy for using periderm and gingival grafting, and he taught us this technique.

So, we’ve got basically no attached gingiva right here, and then we’ve grafted with periderm. Here this is an article in the library of by p d miller, classifying general recession.

This is a class one, marginal tissue recession which does not extend to the muco gingival junction, meaning it’s only in the non-keratinized unattached gingiva see here’s the muco gingival junction right here. This is attached gingiva.

This is unattached, so a class one means it does not extend to the keratinized attached gingiva, there’s no periodontal bone loss in the interdental area, so you can expect a hundred percent coverage of this of the tooth up to the level of bone in the interdental Area.

A class two marginal tissue recession which extends to or beyond the mu congenital junction, see here’s the attached gingiva and this extends to or past that there’s no periodontal loss in the interdental area, meaning the bone levels are symmetrical between all these teeth.

So, you can expect coverage remembers, you’ve got bone up to here, so you can expect the surface of the tooth to be completely covered class.

Three, the marginal tissue recession which extends to or beyond the muco gingival junction there’s bone or soft tissue loss in the inner dental area in these areas or mouth positioning of the teeth.

Preventing 100 roof cover root coverage. So, you, in those cases all you’re going to get, is some attached gingiva you’re not going to get root coverage up to the ideal position, and this is so good to know.

This article is one of the most important articles in dentistry because you know what to tell the patient to expect. Sometimes I tell the patient.

I expect to get coverage, so aesthetically the root is covered other times. I tell them we’re not going to get root coverage, we’re just going to get attached gingiva, or we’re going to get keratinized gingiva.

So, what? What is the benefit of that? Well, the attached ginger, the keratinized genuine, is like a hard rubber band around the tooth to prevent bacteria from getting down the root of the tooth.

If you’ve only got non-keratinized unattached gingiva, this flimsy stuff around the tooth, then bacteria can shoot down and calculus and plaque and all that can go down the root of the tooth, causing bone loss and eventually lose the tooth.

So, you want attached gingiva around the neck of the tooth, how much non-keratinized non-attached ginger was okay. Okay, i mean you want at least a couple of millimeters of attached, gingiva keratinized gingiva on the facial surface of a tooth. They have that hard rubber band to keep the bacteria and the calculus and the plaque from getting down the root of the tooth.

So, this class three you’re not even thinking about coverage you’re going to get some coverage, but if the bone level, if the interdental bone is down to here, you’re not going to cover up to here, you’ve got to have the interdental bone to get root coverage past.

The point of soft tissue past a point in class four marginal tissue recession which extends to or beyond the muco gingival junction, here’s, the muco gingival junction, severe bone or soft tissue loss in the interdental area and our mouth positioning of the teeth.

So, we’re not expecting any root coverage because we don’t have any bone. You’ve got to have bone to get root coverage. You have to have bone up to the level that you want the root coverage. You can’t just put soft tissue out here in space. If you had bone up to here, you could get root coverage up to here.

But if you, the bones down here, you’re not going to get any coronal placement of the soft tissue you’re just gonna you’re gonna get attached gingiva. If there is none there. So, this is very important to know before you start grafting sites, so the patient understands what they can expect to see.

So, this is how you determine where the attached gingiva is. You can’t move attached gingiva, you can only move unattached gingerbread, so see how this is folding.

There’s no attached gingiva around those teeth, see this folds all the way. This ends about right here. So, we’ve got a little bit around that tooth, but we don’t have any attached gingiva around the lower anterior teeth.

This patient had orthodontic treatment and I think the lower teeth were moved facially and sometimes that possibly could affect the attached gingiva. This tissue is very thin.

Very friable, so I’m going to make my incision with this 15 bard parker, really thin tissue, we’re doing this not for root coverage. This is that key point: we’re not doing it for root coverage, we’re doing it because there’s no attached gingiva, so we’re doing it to protect the roots of the teeth, to get that hard rubber band around the roots of the teeth.

So, the bacteria can’t go down the roots of the teeth. This number 12 bard parker, and you’re not removing the papilla you’re going to suture into the papilla. So, you can use you, don’t have to use a full thickness flap, it’s actually ideal.

If it’s a split, thickness flap, but if the tissue is this thin, that’s not an option because you can’t, it’s so thin. You can’t separate it into a split thickness, so you’re gonna reflect a full thickness flap. This will cut in to the papilla this way.

Leaving the papilla, but you’re going to remove the facial half, just be very careful. It’s like working with toilet paper, it’s so thin, so keep the no big movements, keep the periosteal elevator on the bone and just peel it away.

It’s hard to reflect this tissue, see it’s too thin for a split thickness. Flap just carry carefully reflect the flap. You don’t want to perforate the flap if you can help it, that compromises the result.

So, what we’re trying to do is just reflect the flap, so we can place the periderm under the flap, so you don’t want just a little barely reflected flap. You want to reflect fairly significant.

You know, down to about here because it’s important in the end that the periderm is covered by the flap. You want the peridone completely covered by the flap.

Now I’m using the larger end of the periodontal elevator just slowly reflecting that tissue, I’m not worried about getting all the tissue off the alveolar process. You can see the bone level is pretty good here.

Do we have good interdental bone, but we’re not trying to increase the height of the gingiva, we’re just wanting to add attached, gingiva and periderm histologically isn’t look like attached gingiva, but it acts like attached?

Ginger, there’s some histology you can read about and some articles. I’M going to show you here in a moment that talk about that, but this is how they want you to position it with this little cut in the upper land, hand upper left-hand corner, so the dermal side is facing out now some say it doesn’t really matter which way you place it.

But if you can place this side out the nice thing about periderm is it adapts to the teeth and to the bone once it’s wet, and you need to soak it a little while to read the directions, and you soak it Before you place it, and it adapts real nicely, it’s not like a stiff shirt or a start shirt, so you want it down in the bottom of the flap far enough that the flap doesn’t lift it up.

You have to reflect far enough that the flap will go over it easily and not be strained, I’m reflecting a little bit more. Then this is 5.0 proline.

You want a deep bite in the flap and many times. You’ll come through actually go through the peridone because you want to hold it tight against the teeth. So, you go through the flap here and then go through the periderm and then take the back end of your needle and push that through this interproximal area, when you suture go three wraps in the clockwise direction.

One wrap then pull that tight and if you do three it’ll stay, if you do two it’ll come it’ll loosen, so do three wraps in the clockwise direction: pull it snug, then one wrap counterclockwise, pull that snug and then one more wrap in the clockwise direction and pull that snook, and you’ve got a good tight knot.

If you do that, so we’re going deep into the tissue, and then we’re going through the periderm on the way through and then take you the back end of your needle and go through the interproximal area there.

I’M going through the periderm to lock it in and then come back with the back end of your back end of your needle. So, you can tie the knot on the facial side many times in surgery, suturing takes longer than the surgery itself.

So three one. So, there we have that this after a week of healing now, you have to remove this proline after one week of healing, if you let it seat, sit two weeks you’re going to have to anesthetize the patient because the tissue grows over the proline.

It’s not like gut suture that dissolves, so you’ve got to have them back in a week and remove the suture, or you’ll have to anesthetize it to remove it because the tissue will have grown over it.

This, after a week of healing this is after a year healing, and we’ve veneered the teeth. So, you can see you know if you move to try to move the tissue with the instrument.

You can’t move it past here. So, this general tissue is attached, whereas preoperative operatively, it was not. So, that’s the dental minute, these techniques work, and they work every time.

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