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The Subpedicle Connective Tissue Graft

A Bilaminar Reconstructive Procedure for the Coverage of Denuded


Root Surfaces
Stephen W. Nelson
Accepted for publication 8 April 1986

A mucogingivai. grafting procedure has been developed to cover denuded root surfaces.
This procedure, the subpedicle connective tissue graft, is a bilaminar graft that is composed
of a free connective tissue graft and an overlying pedicle graft. By overlaying grafted free
connective tissue with a pedicle, the otherwise compromised section of free graft which
covers a denuded root surface is supplied by plasmatic circulation from capillaries in the
vascular portion of the pedicle allowing it to survive.
In this report 29 teeth were treated and monitored for as long as 42 months. In the group
with advanced recession of 7 to 10 mm, there was an average of 88% coverage. The
subpedicle graft created a healthy, functional, and esthetic result that appeared resistant tois
further breakdown. The subpedicle graft is indicated when a single surgical procedure
desired that will predictably cover denuded root surfaces when there is inadequate keratinized
gingiva available for a pedicle graft and where the prognosis is poor for root coverage with a
free gingival graft.

Considerable knowledge has been gained in the sur- sliding flap be modified in such a way that the
can
gical management of gingival recession since Grupe coronal half of the gingiva is undisturbed/ a free graft
and Warren1 described the lateral sliding flap. In spite can be used to enlarge the keratinized gingiva in the
°f advances and refinements in techniques of both donor area and then a month later a sliding flap per-
Pedicle and free grafting procedures, the treatment of formed,6 and a free graft can be placed over the donor
gingival recession and root exposure still presents a site to prevent recession there.7
therapeutic problem for the clinician. The current va- The double papilla pedicle graft, reported by Cohen
riety of grafting procedures has the main objective of and Ross,8 has been successfully used in specialized
Preventing further recession by increasing the width of circumstances to cover localized root exposure.
keratinized gingiva rather than coverage of the root Rubelman9 has described some guidelines to follow
surface. Most patients prefer covering all of the exposed when this procedure is performed. Hauler10 described
root, particularly if anterior teeth are involved. In ad- a multiple interdental papilla graft to increase the zone
dition to the esthetic concerns of a patient, exposed of keratinized gingiva. He repositioned a flap a distance
root surfaces frequently are associated with hypersen- of one-half of a tooth width so that the interdental
sitivity and plaque retention and are subject to further papillae were transposed to the radicular surfaces of the
breakdown if inflammation or thin tissue is present. affected teeth.
When there is an adequate amount of tissue and The possibility of attaining root coverage by placing
sufficient underlying bone at the donor site adjacent to free grafts in areas of gingival recession was first de-
the gingival defect, the prognosis for the lateral sliding scribed by Sullivan and Atkins." In cases of narrow
pap is good. The main disadvantage of this procedure denudation, the best results are obtained since collateral
's the risk of creating a gingival defect on the donor circulation is more likely to be sufficient. Positive re-
tooth. If the donor tooth has very thin bone prior to sults have been reported by several investigators.12"18
surgery, the final clinical result could be to trade reces- Although wide areas of recession can be stabilized by
sion on one tooth to another. The original procedure free grafts, the amount of root coverage that can be
has been modified in several ways: an edentulous site expected is much less dramatic. According to Sullivan
can be used as a donor area,21 the pedicle flap can be a and Atkins," when a graft is placed over recession,
split thickness instead of a full thickness flap,4 the some amount of "bridging" can be expected because a

95
J. Periodontol.
96 Nelson February, l?87

portion of the grafted tissue which is covering the root and athin or absent band of keratinized tissue. The
will survive by receiving circulation from the vascular patients included were informed of treatment options
portion of the recipient site. In addition to bridging, and they gave consent to subpedicle connective tissue
creeping attachment can result in a postoperative cor- grafting.
onal migration of the free gingival margin. Factors The outer layer of cementum and dentin of the
which favor creeping attachment are narrowness of the exposed planed with curettes to remove all
root was
recession, the presence of bone positioned more coro- deposits and smooth the root surface. Two vertical
nally interproximally than on the facial surface, absence incisions were made from the distal crest of the border-
of gross tooth malpositioning, and adequate plaque ing interdental papillas to the base of the vestibule.
control.19 Recent reports using the free gingival graft These incisions were horizontally connected on the
for root coverage have been favorable even in cases of proximal to a sulcular incision that was made on the
wide and deep recession. While differences in technique exposed root (Figs. 1-3). As much of the interdental
have been reported by Miller20 and Holbrook and Och- papilla was retained as possible without affecting the
senbein,21 extensive root planing that reduced root con- adjacent teeth. Full thickness mucogingival flaps were
vexity and prominence and the use of a thick graft that reflected to allow repositioning of the pedicles to the
measures between 1.5 mm21 and 2.0 mm20 has been cementoenamel junction of the affected tooth. Any
advocated. sulcular epithelium that remained on the borders of the
Harvey described a two-step operation to cover reces- denuded root surface was removed with curettes, and
sion which included a free gingival graft to establish a the root was reinspected to assure that all roughness
wider zone of keratinized gingiva.22 This was followed had been removed.
6 months later by a coronally positioned flap to cover A connective tissue graft was obtained from the
the root. Bernimoulin23 has refined the original proce- palate using a "trap door" approach. It was of adequate
dure and has reported that it results in predictable dimensions to cover the entire area of recession as well
partial coverage of the exposed root. The coronally as the donor pedicle sites. In obtaining the donor con-
positioned graft has been reported to result in root
coverage that varies between 59% and 75%.24"29 By
establishing a wider zone of attached gingiva with a free
gingival graft it was no longer necessary to involve
adjacent teeth and risk creating recession at the donor
site in the presence of a thin alveolar plate of bone.
Edel30 has shown that free connective tissue grafts
obtained from the palate and the saddle area of eden-
tulous ridges result in a significant increase in attached
gingiva and function similar to free gingival grafts to
cause the induction of keratinization.
Langer and Langer" have described a subepithelial
connective tissue graft consisting of placing a free con-
nective tissue graft placed underneath a split thickness
flap. The flap was then returned as near its original
position as possible and sutured. No attempt was made
to completely cover the connective tissue graft which
was exposed over the denuded root surfaces and the
coronal margin. He reported an increase of between 2
to 6 mm of root coverage.
This article describes a mucogingival grafting proce-
dure that has been developed to completely cover reces-
sion. The procedure, the subpedicle connective tissue Figure 1. . Incisions (I) are made to include as much of the inter-
graft, consists of a bilaminar reconstruction of the dental papilla as possible without affecting the adjacent teeth. Full
thickness flaps are reflected. B. Following root planing a connective
gingiva using both free and pedicle layers to preserve tissue graft (CTG) is sutured with resorbable sutures. The connective
graft viability over denuded root surfaces. tissue graft should cover the cementoenamel junction of the tooth as
well as the donor pedicle sites. C. The interdental pedicles (P) are
sutured together over the free connective tissue graft (CTG). They
MATERIALS AND METHODS should cover the avasallar part ofthefree connective tissue graft which
Fourteen healthy adolescent and adult patients with overlies the denuded root surface. D. A cross section of the subpedicle
connective tissue graft shows the free connective tissue graft (CTG)
an equal distribution between males and females and covering the denuded root as well as the donor pedicle sites. By
an age range from 12 to 52 years were selected for the suturing the pedicles (P) over the affected root, plasmalic circulation
study. All individuals presented with gingival recession will be supplied to the free connective tissue graft below.
Volume 58
Number 2 The Subpedicle Connective Tissue Graft 97

and nonkeratinized with slight


figure 2. A. Wide and deep recession is present on this canine that is in labioversion. The gingiva is thin B. A free connective tissue graft has
inflammation. The adjacent teeth have thin gingiva that would contraindícale a lateral sliding pedicle graft.
and are lying passively
been placed over the denuded root and interdental papilla pedicle donor sites. The interdental pedicles are sutured together
in place, the double pedicles cover the free connective tissue graft that overlies the denuded root
below the free graft. C. With the sling suture now
normal tissue color and appearance. The
surface. D. The 1-year postoperative result shows a thick and wide zone of keratinized gingiva with
sulcus depth is 1 mm.

nective tissue, an incision was made in the palate par- terrupted sutures. A sling suture was used to position
allel to the maxillary molars. Perpendicular incisions the pedicles directly over the free graft and denuded
were made to establish the correct width of the graft. A root surface to the height of the cementoenamel junc-
flap was reflected to expose the underlying connective tion (Fig. 1C).
tissue. Sounding with a periodontal probe was used to If two or more contiguous teeth were to be treated,
plan the thickness of the "trap door" flap so that the the procedure was the same except for changes in the
underlying tissue would be approximately 2 mm thick. pedicle graft. An interdental papilla pedicle graft was
The connective tissue graft was removed with a perios- performed to transpose mesially the interdental papillae
teal elevator. The primary flap was then returned to its one half of a tooth width to the radicular surfaces of
original position and sutured to obtain primary closure. the denuded teeth. Two vertical incisions were made
If a small artery was severed in the removal of the graft, that preserved all or most of the interdental papillae
additional local anesthetic with vasoconstrictor was mesial and distal to the teeth undergoing treatment.
infiltrated and external pressure applied for 5 minutes These incisions were connected horizontally to sulcular
to obtain hemostasis. incisions on the involved teeth (Fig. 4A). The entire
The connective tissue graft was then placed on the mesiodistal width of the papilla was preserved. Follow-
recipient bed at the level of the cementoenamel junc- ing reflection of a full thickness flap and placement of
tion and sutured with 5-0 plain resorbable sutures (Fig. the free connective tissue graft (Fig. 4B), the pedicle
1B). The pedicles were then sutured together with in- flaps were positioned as a double papilla pedicle graft
98 Nelson

Figure 3. . A deep isolated recession is present on this incisor. There is severe inflammation of the marginal tissue which at the apical border is
nonkeratinized. B. Following reflection offull thickness interdental papilla flaps and root planing, a free connective tissue graft is sutured into
place. C. The interdental papillas are sutured over the free connective tissue graft to the height of the cementoenamel junction. D. One year
following treatment the gingival margin is at the cementoenamel junction and the sulcus depth is 1 mm. Complete repair occurred in spite of
marginal inflammation on the adjacent teeth which have poorlyfittingfull coverage restorations.

on the most mesial tooth and as lateral sliding single recession of 4 to 6 mm, and slight recession of 3 mm
interdental papilla pedicle grafts on the remaining teeth. or less. Recession was measured from the cementoen-
The interdental papillae were sutured directly over that amel junction to the free gingival margin. A total of 29
part of the connective tissue graft that was covering the teeth were treated and monitored from 6 to as long as
denuded root surfaces (Fig. 4C). 42 months. Pocket depths were recorded prior and
One week following surgery, healing was evaluated following treatment. After treatment with the subpedi-
and if nonresorbable sutures had been used, they were cle connective tissue graft, the advanced group with 20
removed. Each patient was shown how to perform teeth had 66% to 100% coverage (Table 1). Fifty per
gentle sulcular brushing with a soft toothbrush on the cent of the advanced group had 100% coverage. The
involved teeth. At 3, 6, and 12 weeks following surgery, average coverage in the advanced group was 88%. The
a prophylaxis was performed with pumice on a ribbed moderate group had a range of 75% to 100% coverage.
cup, and the sulcular area was gently debrided with a The average coverage in this group in which three teeth
curette. Pocket depths were evaluated 12 weeks post- were treated was 92%. Sixty-seven per cent in the
operatively and at subsequent 3-month recall prophy- moderate group had 100% coverage. A total of six teeth
laxis visits. were treated with slight recession. There was 100%
coverage in this group.
In all three groups the subpedicle connective tissue
RESULTS
graft produced a zone of attached gingiva that was
The results of this study are divided into three com- clinically adequate without producing a pocket depth
ponents: advanced recession of 7 to 10 mm, moderate greater than 3 mm. In one case plaque control was
Volume 58
Number 2 The Subpedicle Connective Tissue Graft 99

Figure 4. . Incisions (I) arc placed to allow a double pedicle on the canine and a lateral sliding pedicle on
the bicuspids. The incision is suicidar
on the affected teeth to retain as much donor pedicle tissue as possible. B. Following reflection of the full thickness pedicle flap (P) and root
I'laning, a free connective tissue graft (CTG) is placed that will cover the denuded root surfacescovers to the cementoenamel junctions. C. Following
graft (CTG), lateral sliding pedicle the bicuspids and a double pedicle covers
suturing of the pedicle flap (P) over free
the connective tissue a
die canine.

Table 1 age procedures to improve plaque control in localized


Degree of Root Coverage Following Subpedicle Connective Tissue areas of recession, to reduce the chance of root caries,
Grafts to satisfy esthetic requirements of restorations, and to
_,
Classification
.,
No. cases
Average %
success
prevent further recession,12 particularly if prosthetic or
orthodontic treatment is planned. When the therapeu-
Slight (1-3 mm) 6 100% tic objective is the correction of recession, a procedure
92%
Moderate (4-6 mm) 3 should be selected that will most predictably result in
Advanced (7-10 mm) 20 88%
root coverage. In this report the subpedicle connective
Total 29 91% tissue graft has demonstrated its ability in a high per-
centage of cases to completely cover denuded root
surfaces.
inadequate during the first 2 months of healing, and When a free gingival graft is used for complete root
the tissue appeared inflamed and a 4-mm pocket tem- coverage, the results may not be entirely predictable
porarily developed on the treated root. Later this pocket unless the recession is shallow and narrow because the
shrank to less than 3 mm, and the repair was partial free gingival graft depends upon collateral circulation
rather than complete root coverage. from the lateral and apical parts of the recipient bed to
In certain cases a gain in tissue coverage of 1 to 2 prevent necrosis over the avascular root. There is some
rnm possibly similar to creeping attachment was ob- amount of bridging of the free gingival graft so that a
served. In these cases, during the first postoperative portion of grafted tissue will persist over the denuded
year, there was a coronal migration of the gingiva or a root, but coverage will not usually be as complete as
shallowing of the sulcus depth as the free gingival with the subpedicle connective tissue graft where graft
margin stayed stable. viability is also supported with an external pedicle flap.
The problem of graft necrosis over the denuded root
surface is reduced with the subpedicle connective tissue
DISCUSSION graft because the bilaminar section of the graft contains
In the prevention and correction of recession, a its own blood supply derived from the pedicle flap.
choice of four possibilities exists: no treatment at all; Although the lateral sliding flap will predictably cover
place a graft to prevent recession; stabilize an existing denuded root surfaces, the main risk in performing this
recession, or attempt the coverage of a denuded root. procedure is in compromising the marginal gingiva of
Patients with recession who complain of root sensitivity the donor tooth. This may create permanent bone loss
or esthetic concerns are candidates for root coverage. and gingival recession. When a single tooth is treated
In addition, the therapist may recommend root cover- with the subpedicle connective tissue graft, the double
J. Periodontol.
100 Nelson February, 1987

papilla pedicle can be designed so that the contiguous cles. The free connective tissue graft serves as a scaf-
teeth are not disturbed. When multiple teeth are to be folding for the reconstruction of the gingiva. Addition-
treated the subpedicle graft can combine a lateral sliding ally, the thickness of the free connective tissue graft
interdental papilla graft with a double papilla pedicle below the pedicles also provides a final result with a
graft. The specific surgical technique can be adapted to thicker dimension to the gingiva which may provide
satisfy the individual requirements of each situation to for greater resistance to future recession.
avoid the potential of creating recession on the contig- The esthetic result with the subpedicle connective
uous teeth. The subpedicle connective tissue graft does tissue graft is superior to free gingival grafts and repo-
not depend on transposing gingiva from the radicular sitioned free grafts because the final result assumes a
surfaces of adjacent teeth, so it is a preferable alternative more similar color match (Figs. 5 and 6). The subped-
to the lateral sliding flap when there is the potential of icle connective tissue graft is more similar in esthetic
creating recession on donor teeth. result to the lateral sliding flap because the pedicle
The double papilla flap has been used to cover de- tissue retains its original color and does not become as
nuded root surfaces when a sufficient amount of at- pale as free gingival grafts.
tached gingiva is not present on adjacent teeth. The There is a level of uncertainty with any mucogingival
most common failure of this procedure is the appear- procedure that attempts total root coverage. The long-
ance of a deep and narrow cleft at the middle surface term stability of root coverage with any flap procedure
of the root. The subpedicle connective tissue graft func- has not been documented other than by clinical obser-
tions to prevent clefting by providing a connective vations. Many clinicians are reluctant to recommend a
tissue base of adequate thickness underneath the pedi- two-stage procedure that will reposition a healed free

Figure 5. A. Gingival recession and root sensitivity occurred on the maxillary secondbicuspid and canine of this 45-year-old female during
orthodontic treatment. No After the reflection of a primary flap in the palate, the
suitable donor site is present for a lateral sliding pedicle. B.
connective tissue graft has been reflected as a secondaryflap. Following removal, the primary flap will be closed and sutured to obtain primary
healing. C. The subpedicle connective tissue graft has been sutured to the canine and bicuspid. The underlying free connective tissue graft is
covering the denuded root surfaces and donor pedicle sites. A double papilla pedicle covers the canine and a lateral sliding interdental papilla graft
covers the bicuspid. D. One year following the subpedicle connective tissue graft there is a wide and thick zone of keratinized tissue on both the
canine and second bicuspid. The suicidar depth on the canine is i mm in depth. The final tissue height corresponds closely to the placement of
the pedicles which were 2 mm short of the cementoenamel junction.
Volume 58
Number 2 The Subpedicle Connective Tissue Graft 101

connective tissue graft has been placed on


Figure 6. . Slight recession that clefts toward the mesial is present on the bicuspids. B. subpediclehave been placed over the mesial aspect of
A
the bicuspids. Following placement of the free connective tissue graft, the interdental papilla pedicles the canine includes epithelium and
the roots where the recession was deepest. The free connective tissue graft which covers the radicular surface of a wide band of gingiva which
the bicuspids have
functions as a classical free gingival graft. C. Eighteen months following surgical correction,
extends to the cementoenamcl junction. Suicidar depths are I mm.

objective and full coverage of the exposed root is not


graft due to the uncertainty of the final result. Any time
a single surgical procedure such as the subpedicle con- needed, then a simpler mucogingival procedure should
nective tissue graft can accomplish the same result as a be selected.
two-stage procedure, there should be greater patient Bilaminar grafting techniques have the potential to
be employed widely in the future and may ultimately
acceptance as well as willingness by clinicians to rec-
ommend the single procedure. Even if total root cov- provide the best kind of mucogingival grafts in cases of
erage is not accomplished, there will be the creation of advanced gingival recession where there is thin gingiva
a functionally adequate band of gingiva that will be
and radicular bone on the adjacent teeth. Although this
resistant further breakdown.
to procedure is more difficult and increases operating time
over less delicate operative procedures, the subpedicle
The subpedicle connective tissue graft is a delicate
operative procedure that requires careful technical at- connective tissue graft can, in a single procedure, pre-
tention. For success, the connective tissue graft should dictably cover denuded root surfaces when there is
be 1.5 to 2.0 mm in thickness, the interdental papillae inadequate keratinized gingiva available for a pedicle
should be retained as much as possible in the pedicle graft and where the prognosis is poor for root coverage
with a free gingival graft.
flap, the pedicles should be positioned correctly over
the avascular root to be covered, and adequate follow- REFERENCES
up care and plaque control instructions should
be given
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