Lee H. Silverstein, DDS, MS/Michael D. Lefkove, DDS The Use of the Subepithelial Connective Tissue Graft to Enhance both the Aesthetics and Periodontal Contours Surrounding Dental Implants

Abstract-

he subepithelial connective tissue graft is a plastic surgery procedure that can be used to enhance the aesthetic and gingival contour of the around dental implants. This technique is described and illustrated to create a soft-tissue root prominence and mask the grey color penetrating the thin labial attached gingival tissues over dental implants.

Key words. Aesthetics, Connective Tissue.

Introduction The purpose of this aforementioned technique The subepithelial connective tissue graft was to provide coverage of individual and multiple procedure for root coverage was first mentioned in root surfaces. A specific goal of this technique was an article by Langer and Calagna (1982) and was to obtain root coverage in areas with deep, wide then described in detail by Langer and Langer recessions, such as those often encountered (1985). This surgical procedure was further clinically. The connective tissue grafting modified by Nelson [987). Actually, the present procedures can attain these goals because this technique as described by Nelson was an procedure combines the advantageous features of adaptation of the subepithelial connective tissue grafting surgical procedure used to modify deformed ridges, as originally reported by Seibert

Figure 2. Utilizing a palatal "trap door" design, we harvested a connective tissue graft from the . With Figure 1. Greyish color showing through thin facial this surgical procedure, primary coverage ofthe donor attached keratinized tissue over , Note: palate can be achieved, leading to a less traumatic heallng There is no root prominence evident. period for the patient.

Journal of Oral Implantology 135 Figure 3. Lifting of the palatal partial-thickness flap to Figure 5. Primary wound closure of the palate with 4-O gain access to a connective tissue wedge ofadequate chromic gut. Suturing the lateral borders to prevent length and thickness. hemorrhage and formation of hematoma is also recommended.

Figure 4. Connective tissue donor graft which was Figure 6. The harvested connective tissue graft being harvested from the palate. When graft is extra-oral, all sutured extra-orally with resorbable suture. adipose tissue is removed by dissection.

both the free soft-tissue autograft and the pedicle Case Report flap procedures. A 4O-year-old male presented to the office with a The utilization of the pedicle flap technique chief complaint of "grey-looking " where his offers the distinct advantage of a double blood dental implant was placed. This patient also said supply, thereby increasing the probability of graft that this region was concave, unlike the rest of the survival over the avascular dental implant. It also gums, which were convex in the area of the roots results in a more comfortable palatal wound, and (Fig. 1). A subepithelial connective tissue grafting it has improved aesthetics when compared with procedure was the treatment of choice in order to the traditional free gingival grafting procedure mask the greyish gingival color over the dental used presently in implant dentistry, as reported implant and concomitantly create a soft tissue by Miller (1988). convefty to mimic a root prominence. It is also advisable that use of this technique This gingival plastic surgery procedure was should be limited to non-smokers, since nicotine initiated by making intrasulcular incisions on the has been shown to compromise the available facial tissue from the line angles of the adjacent recipient blood supply, as reported by Cuff teeth to this implant in the region of tooth #9. A (re89). partial-thickness flap was reflected past the

136 Vol. XX/No. Two/1994 Figure 7. The donor graft being drawn under split- Figure 9. Complete coverage of the dental implant collar. thlckness facial flap but over dental implant uia vestibular Note the pink color due to newly grafted tissue end sling sutures. absence of the greyish color of the implant.

Figure 8. Facial pedlcle flap is elevated over the connective Figure 1O. Several weeks post-op, note the masking ofthe tissue graft and is stabilized with a resorbable sling suture. grey gingival color and the creation of a soft-tissue root As much ofthe graft as possible is covered, to take advan- prominence. tage ofthe increased blood supply by overlaying the flap.

. Care was taken not to perforate the flap so that the blood supply would not be compromised. A palatal "trap door" flap design (Fig. 2) was used to obtain the desired subepithelial connective tissue donor graft (Fig. 3). Note the large connective tissue donor graft which was harvested from the hard palate by means of this technique (Fig.4). Once the donor tissue was procured, the palatal flap was then replaced so that primary coverage of the palatal donor site could be obtained. This type of flap adaptation was also necessary to reduce the incidence of tissue sloughing, due to hematoma formation, with this (Fig. Figure ff. Dight weeks following surgery, the grafted type of harvesting procedure 5). recipient site blended completely with adjacent glngival The harvested connective tissue graft was tissues.

Journal of Oral Implantology 137 sutured (Fig. 6) and drawn under the split- References thickness flap over the dental implant uia the vestibular sling sutures (Fig. 7). T}re partial- thickness facial pedicle flap was subsequently Cuff MJA t1989). The presence of nicotine on root elevated over the connective tissue graft and surfaces of periodontally diseased teeth in secured in place with a sling suture (Fig. 8). In smokers. J Pertodontol 60:564-569. this case, an attempt was made to cover the Langer B, Calagna L (1982). The subepithelial entire graft, which would allow for the connective tissue graft. A new approach to the establishment of a better blood supply to the graft enhancement of anterior cosmetics. Int J and therefore enhance its chance of survival. Periodontol Rest Dent 2:22 -23. Langer B, Langer L (1985). The subepithelial Discussion connective tissue graft technique for root This procedure was successful at creating the coverage.J Periondontol 56:7 l5-7 20. desired soft-tissue root prominence (Fig. 9), and Miller PD (1988). Regenerative and reconstructive after several weeks of gingival maturation, the periodontal plastic surgery. Dent Clin North Am undesirable greyish gingival color was also 32:287-306. masked (Fig. lO). In addition, the grafted recipient Nelson S (1987). The subpedicle connective tissue site blended so completely that it would be graft. A bilaminar reconstructive procedure for difficult to distinguish the grafted tissue from the the coverage of denuded root surfaces. J adjacent tissues after eight weeks (Fig. I l). PeriodontoL58 :95- I 02. In this clinical report, the subepithelial Seibert J {l9BS). Reconstruction of deformed connective tissue grafting procedure provided a partially edentulous ridges using full thickness more pleasing aesthetic result as compared with onlay grafts. I: Technique and wound healing. the utilization of a traditional "keloid"-looking free Compend Cont Educ Dent 4:437. soft-tissue autograft. Generally, the former technique lends itself to an aesthetic blending of Dr. Srluerstein is tn priuate practice at 195O lVorth the marginal tissues with good coverage of the Park Place, Suite 4OO, Atlanta, GA 3O339. Dr. dental implant, along with creating the illusion of LeJkoue is in prtuate practice at 335O Cumberland a root prominence. Circle, Suite 775, Atlqnta, GA 30339.

138 Vol. XIK/No. Two/1994