Dentaltown January 2022 - 54

Noncarious cervical lesions
Noncarious cervical lesions present a
similar challenge to what was described
previously with Class V buccal restorations.
The CEJ is no longer visible and we need
to estimate where it was to determine how
much soft tissue coverage can be achieved.
The decision about whether to place a
restoration depends on the location of the
defect. If the defect is nearly all below the
level of the CEJ and primarily composed
of root surface, no restoration is needed;
a tissue graft can fill that void and cover
the defect.
If the defect extends above the level
of the CEJ in the area of the enamel, then
the restorative dentist may want to place a
restoration to re-create the CEJ. Whether
this is done before or after grafting is a
decision that needs to be agreed upon by
the restorative dentist and the periodontist.
But it is important to keep in mind that
the maximum root coverage achievable is
at the level of the CEJ if the interproximal
attachment is intact. If there is interproximal
attachment loss, the amount of root coverage
that is achievable decreases.
Free gingival graft case
Another common clinical situation that
arises is the presence of localized recession
associated with a frenum attachment and
minimal or no attached keratinized gingiva
(Fig. 12). You may see these frequently in
your practice on the buccal surfaces of
mandibular central incisors. A free gingival
graft is an excellent treatment technique to
address all the clinical concerns at once.
Free gingival grafts (Figs. 13-15) are
able to obtain some root coverage (albeit
less predictably than connective tissue
grafts6
), increase the amount of attached
keratinized gingiva and relieve frenum
attachments. While the aesthetics of a
healed free gingival graft are less desirable
than those of a connective tissue graft, the
gingiva of mandibular central incisors is
rarely fully displayed by patients.
54 JANUARY 2022 // dentaltown.com
Fig. 13: Recipient bed preparation. Creation
of a butt joint with the papillae and extending
3 mm laterally and apically from the exposed
root surfaces.
Fig. 12: Preoperative photo of #24 and #25.
Note the localized 3 mm recession, 1 mm of
keratinized gingiva and a frenum attachment.
Fig. 14: Graft stabilized in place with 6-0
polypropylene sutures. These are monofilament
and nonresorbable.
Fig. 15: 18-month follow-up. Nearly complete
root coverage, thick band of attached keratinized
gingiva, elimination of frenum pull.
Criteria for successful soft
tissue grafting procedures
* Surgical site free of plaque
and calculus.
* Adequate blood supply.
* Anatomy of the recipient
and donor sites.
* Stability of the grafted tissue
to the recipient site.
* Minimal trauma to the surgical site.
Conclusion
The use of autogenous tissue grafts
in periodontal surgery is supported by
significant evidence.7
A free gingival graft
remains an excellent choice for increasing
soft-tissue thickness and keratinized gingiva
around both teeth and dental implants. A
connective tissue graft provides the greatest
predictability for achieving root coverage as
well as higher aesthetic results. Establishing
which technique is appropriate for a particular
clinical situation is of great importance before
any periodontal soft-tissue graft surgery. n
References
1. Naber, JM. Free gingival grafts. Periodontics. 1966;4:243245.
2.
Langer
B, Calagna LJ. The subepithelial connective tissue
graft. A new approach to the enhancement of anterior cosmetics.
Int J Periodontics Restorative Dent. 1982;2:22-33.
3. Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U. The
interproximal clinical attachment level to classify gingival
recessions and predict root coverage outcomes: an explorative
and reliability study. J Clin Periodontol. 2011;38(7):661666.
4.
Cairo, Francesco and Giovanpaolo Pini-Prato. " A technique
to identify and reconstruct the cementoenamel junction level
using combined periodontal and restorative treatment of
gingival recession. A prospective clinical study. " Int J Periodontics
Restorative Dent 30 6 (2010): 573-81.
5.
Dragoo MR. " Resion-ionomer and hybrid-ionomer cements:
Part II, human clinical and histologic wound healing
responses in specific periodontal lesions. " Int J Periodontics
Restorative Dent 1997; 17:75-87.
6.
Jahnke PV, Sandifer JB, Gher ME, Gray JL, Richardson AC.
Thick free gingival and connective tissue autografts for root
coverage. J Periodontol 1993;64:315-322.
7. Zucchelli G, Tavelli L, McGuire MK, et al. Autogenous
soft tissue grafting for periodontal and peri-implant plastic
surgical reconstruction. J Periodontol. 2020;91(1):9-16.
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