A few weeks ago while I was at my office in Barcelona performing an implant surgery with a connective tissue graft, I was thinking about how much I used to enjoy these kind of surgeries and how they stopped being so enjoyable the minute they became routine. I remember that day, I chose “The 80´s playlist” from my iPod. It was what I used to listen to bring some action during my not-so-large-days of work (yes, it’s amazing to hear from some of my pals how proud they are when they perform a full-arch immediate loading or a bilateral sinus lift surgery at 9pm. I congratulate them for that but it doesn’t suit my lifestyle anymore, although I might be poorer for refusing to perform block grafts after midnight).
While “Right between the eyes” was playing in the background (I know, sometimes I feel a little bit nostalgic about the eighties), something not so usual happened: I was just finishing harvesting a huge slice of connective tissue and the palatal artery just decided to be where it shouldn’t be (or maybe that was my first complaint – “anatomical aberration”, I said).
That was what I consider a shot “Right between the eyes”. First of all, I solved that bloody mess constraining the palatal artery with a ligature suture and then pressuring with a gauze for 15 minutes. Fortunately, it stopped bleeding and my patient didn´t even realize that something wrong happened. I finished the surgery without any other inconvenience (almost any inconvenience : my patient just couldn’t pay the bill. Not even some of it. It was almost summer and he really wanted to have more money to spend for his vacations. I don’t blame the chap, I would do the same).
After finishing the surgery, I thought that maybe If I create a few topics with some rules and concepts on a small piece of paper , I would help other colleagues to avoid these kind of complications and maybe help them enjoying plastic periodontal and implant surgery. So I decided to create this article in collaboration with Delia (yes, she´s another great Facebook friend; I love the way she works and her tenacity. She´s very friendly and one of the nicest persons I have ever met on social network).
So “Let´s get serious”:
We all know that performing soft tissue autografts have been a progressively trendy surgery for the past 20 years despite the fact that first articles about autografts in clinical periodontology where published more than 40 years ago (Haggerty 1966; Nabers 1966; Sullivan & Atkins 1968; Edel 1974). Our assumption is that the increasing “democratization” on the use of soft tissue autografts is correlated with the “democratization” of implant therapy as well.
But why we do use soft tissue grafts?
Two main goals are pursued:
- Increase the width of keratinized tissue
- Increase soft tissue volume
After several authors realized that the width of keratinized tissue around teeth was clinically overrated, the use of free gingival grafts (FGG) started to be an option to solve aesthetic defects like soft tissue recessions (Bernimoulin et al. 1975; Miller 1982), soft tissue ridge augmentation (Seibert 1983) and for something that is quite trending nowadays: Socket preservation in the aesthetic zone (Landsberg & Bichacho 1994).
We all know that FGG have two great limitations: volume augmentation and aesthetic result (sometimes the color and surface doesn’t blends in with the receptor site) and soon the advantages of using subepithelial connective tissue graft (SCTG) started to be evident in the literature (B. Langer & Calagna 1980; B. Langer & L. Langer 1985). Considering the advantages of the SCTG over the FGG we are going to focus this article on SCTG.
We also should know the role of inherent factors regarding genetic determination of gingival tissues and for that I recommend you the articles from Karring ((Karring et al. 1971; Karring et al. 1975) and also this lecture from Juan Alberto Fernandez on Oralsurgerytube which I strongly recommend you to subscribe.
The masticatory mucosa of the hard palate is composed of three histologic layers:
- The epithelium (300 µm thick, 0,3 mm this is really quite thin layer)
- Lamina Propia
Fig. 1- Layers that can be observed at the masticatory mucosa.
The thickness of the masticatory mucosa vary substantially from patient to patient and also depending the donor site it can be more thick in the tuberosity (4 mm) than in the palate (3 mm) (Muller et al. 2000). Another important finding by Gapsky is that the subepithelial connective tissue from the tuberosity is very dense, coarse and collagen-rich tissue with less fat and glandular tissue which all these may have some clinical interest (Gapski et al. 2006).
Another anatomical consideration that should always be respected is the great palatine artery (GPA). To keep it simple I`m going to use the reference from Monnet-Corti where the main branches of the GPA were +/- 12 mm distance from the gingival margin at the canine region +/- 14 mm at the second molar region (Monnet-Corti et al. 2006). Although this study has some inaccurate measurements (the gingival margin is not always a good reference) almost all the authors assumed that the GPA can be found at a distance of 76% of the global palatal height measuring from the cementoenamel junction of the first molar.