The Subepithelial Connective Tissue Graft
Periodontists are dentists who specialize in treating periodontal disease. This includes treating the side effects of gum disease such as receding gums. There are various procedures which the periodontist can use to help repair and restore the function and appearance of damage gums. The marginal recession of gum tissue does not usually result in tooth loss, however, it can cause increased sensitivity, increase the patient’s risk for cavities, and can also impact the patient’s smile. There are surgical periodontal procedures which can be used that offer predictable and effective outcomes. The below article will discuss issues associated with root coverage, gingival recession, and the subepithelial connective tissue technique.
Mucogingival surgery was introduced as a term in periodontal literature around the 1950s. In clinical terms, mucogingival surgery is a surgical procedure for preserving gingiva, removing aberrant frenulum and muscle attachments, and used to increase the depth of the vestibule. Modern dentistry defines the term as periodontal surgical procedures which correct defects in the morphology, position, and amount of gingiva which surrounds the teeth. Some suggest the term periodontal plastic surgery may be more appropriate as mucogingival surgery includes both the treatment of the gingivae, but also includes the correction of the soft tissue aesthetics and the ridge form.
The gingivae is made up of dense connective tissue which is covered by keratinized epithelium. It extends from the gingival margin to the mucogingival junction. The gingivae is divided into two parts, the free segment and the attached segment. The free segment is the portion of the gingivae which corresponds to the probing depth. The attached segment is measured clinically by subtracting the probing depth from the entire gingival tissue’s width.
The following procedures are often used to manipulate and modify the gingival tissues:
- Rotational flaps
- Coronally positioned flap
- Pedicle soft tissue graft with the use of a membrane
- Free soft tissue grafts such as epithelialized free gingival grafts and subepithelial connective tissue grafts
The subepithelial connective tissue graft is one of the most widely-used plastic surgery procedures. The procedure is incredibly popular because it is predictable it its ability to successfully cover the roots. This procedure was introduced in 1985 by Langer and Langer. Over the past few years, the procedure has been refined and perfected. The subepithelial connective tissue graft is considered to be major improvement compared to the free gingival graft because it results in more predictable root coverage, is less invasive, has fewer complications, and achieves an improved aesthetic outcome with an excellent color match of the tissue.
The Miller 5 classification system is considered to be the most accepted system as it effectively predicts the success in achieving root coverage. Below is a summary of the classification system:
Class 1: Marginal tissue recession that does not extend to the mucogingival junction. The patient does not have periodontal loss in the interdental area.
Class 2: Marginal tissue recession extending to or beyond the mucogingival junction. The patient has no periodontal loss in the interdental area.
Class 3: Marginal tissue recession, which extends to or beyond the mucogingival junction. Bone or soft tissue loss is present in the interdental area and the teeth may not be positioned correctly.
Class 4: Marginal tissue recession extending to or beyond the mucogingival junction. The bone or soft tissue loss is in the interdental area and there is severe malpositioning of the teeth.
In Class 1 and Class 2 cases, a skillful operator can achieve full root coverage. Partial root coverage can often be achieved in Class 3 cases. And very minimal or no root coverage is typically achieved in Class 4 cases.