Gum graft – Gingival graft

Gum grafts are a set of surgical techniques responding to different indications. The general principle is to take a small portion of gum from the palate to graft it to the gum to be reinforced. The main indication is the gum reinforcement on a tooth where it is loosening, but it can also be to cover a bare root or thicken the gum around an implant. Gingiva grafting is never done without prior treatment:

• Long cone radio assessment.
• Surfacing.
• Brushing advice and periodontal reassessment assessment is essential before any gum graft.

Because the gum graft only treats the consequences of loosening, it is imperative to treat the upstream causes, often linked to the bacteria in the tartar and brushing habits.

GUM GRAFT: INDICATIONS

The most common indications for gum grafting are periodontal recession, keratinized tissue augmentation, and second-stage implant surgery.

 

Periodontal recession is a retraction of the gums with multiple causes and affects the 4 periodontal tissues. Its surgical correction by gum grafting depends on the type of periodontal recession. The classifications of periodontal recessions make it possible to give a prognosis of root coverage by the graft. The current classification includes three classes of recessions; it was proposed by an Italian periodontist named Cairo in 2011. Its principle is based on the fact that the gum is a thin mucous membrane stretched over bone: in other words, there where there is no bone, it is impossible to stick gum. Thus, thanks to an evaluation of the presence of the bone and the gum, the classification of Cairo makes it possible to give a prognosis of recovery of the denuded root. 

1. Class 1 corresponds to denudation of the root without any bone loss, i.e., the prognosis for covering the root by the graft is good.
2. Class 2 corresponds to root denudation with less bone loss than gum loss, complete root coverage will be impossible, but partial coverage can be obtained.
3. Class 3 corresponds to denudation of the root with a bone loss greater than the loss of gums; no root recovery will be possible.

Thus, not all periodontal recessions will be able to benefit from a gum graft with root coverage, and a meticulous evaluation of the treatment possibilities must be carried out beforehand. For more information on periodontal recession, its causes, and the four tissues that make up the periodontium, see a periodontal recession.

Creating or increasing keratinized tissue is often the primary goal of a gum graft. Keratinized tissue is a characteristic of the gum's superficial layer, making it more resistant. An example of particularly keratinized skin is the sole (for a more precise description of keratinized tissue, see the periodontal recession section). When this tissue is lacking, for genetic reasons (thin gums) or acquired (trauma, for example), the gums are much more fragile and unstable. However, the tissue of the palate is much keratinized, and grafting it to a site that is not will make it much more resistant. In other words, gum grafting aims to strengthen fragile gums and thus make them more stable in the long term. The two objectives, root coverage and increase of keratinized tissue can be sought thanks to the same graft. 

The second stage of implant surgery is the ideal time to graft resistant gingiva around the implant, thus limiting the risk of peri-implantitis. For more information, see the implant surgery and peri-implantitis sections.

SURGICAL TECHNIQUES

 Many surgical techniques for gum grafts have been developed since the 1950s. The most common graft today is the buried connective tissue graft.

 The buried connective tissue graft is an exclusively connective tissue graft that is buried under the gums of the recipient site. From the thinnest to the thickest layer, the gingiva comprises epithelium, connective tissue, periosteum, and bone. Connective tissue is one of the body's most widespread tissues; it is made of collagen and gives thickness to tissues. The connective tissue graft, therefore, uses only the second layer of the palate and does not use the most superficial. Therefore, the buried connective tissue graft has two major advantages: thickening of the gum, increased resistance, and aesthetic result because the graft is buried under a tissue with the same appearance as the recipient site.

The conjunctival epithelial graft is a graft of connective tissue and epithelium. That is to say, we take the two layers of the palate, including the most superficial layer. It is an older technique, but it still retains an unequaled advantage: it is the technique that makes it possible to increase the most keratinized tissue and, therefore, strengthen the existing gum tissue as much as possible on the recipient site. However, it has a drawback: its final appearance is often less aesthetic because the gum removed from the palate is paler pink than the gum from the recipient site, usually a brighter pink. It will therefore be indicated on sectors that are not visible when smiling (lower or posterior sectors).

Finally, when good-quality gingiva is near the graft site, it is sometimes possible to move this tissue without removing it from the palate. This is particularly the case in the release of canines included in orthodontics (see the periodontics and orthodontics section) and the implant treatment plan (see the implant surgeries section). These displaced flaps can be coupled with buried connective tissue grafts.

GUM GRAFT: OPERATIVE FOLLOW-UPS AND RESULTS

 

Gum grafts are now surgical techniques for which 9 out of 10 patients only take paracetamol. Numerous studies have shown that postoperative pain is low. However, the intervention area is very fragile for 10 to 15 days. We can compare the gum graft to a bone fracture: in the context of a bone fracture, the plaster guarantees the immobility essential for the two fragments to heal together. It is the same for a gum graft, even if the healing time of the gums is ten times faster than that of the bone. It is impossible to put a cast in the mouth, so the patient’s daily precautions for food and brushing his teeth are essential; for more details, see the postoperative advice sheet.

 The results are very dependent on the initial situation. We cannot graft all situations. We can sometimes obtain a perfect root covering with an aesthetic integration making the free gingival graft invisible. Still, we can also obtain visible grafts that do not completely cover the tooth: the periodontist will be able to give a prognosis thanks to the numerous studies made on the subject and will be able to advise the patient according to the clinical situation.