Minimally Invasive Soft Tissue Grafting










Minimally Invasive Periodontal Therapy: Clinical Techniques and Visualization Technology, First Edition.
Edited by Stephen K. Harrel and Thomas G. Wilson Jr.
© 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.
Companion Website: www.wiley.com/go/harrel/minimallyinvasive
143
9
Soft tissue grafting is indicated for augmenting sites with deficient-attached gingiva
and for covering exposed roots. Surgical grafting techniques have evolved over the
past 50 years to a minimally invasive method with refinements in recipient site
preparation and the use of allograft donor tissue rather than harvesting tissue from
the palate. A distinct advantage when allografts are used is that multiple teeth can
be treated in one visit without concern for the amount of palatal tissue available.
Regarding recipient site preparation, there has been a progression from open-site
preparations to flaps with vertical incisions, to envelope flaps without vertical inci-
sions, to tunnels with only sulcular incisions. There has also been a progression from
completely exposed grafts to grafts partially covered by the recipient site flap, to
grafts completely covered by coronally positioning the recipient site flap. Increased
predictability of root coverage and greater patient comfort paralleled each of these
advancements in recipient site design. This chapter will trace the evolution of soft
tissue grafting procedures from the free gingival graft (FGG) to the current minimally
invasive tunneling technique. The tunneling technique will be described in detail.
Indications for soft tissue grafting
Soft tissue grafting is indicated for augmenting the zone of attached gingiva around
teeth and for covering exposed root surfaces. Attached gingiva is that portion of the
gingiva that extends coronally from the mucogingival junction (MGJ) to the base of
Minimally Invasive Soft
TissueGrafting
Edward P. Allen and Lewis C. Cummings

144 Minimally Invasive Periodontal Therapy
the gingival sulcus. It is comprised of dense collagenous connective tissue that is
firmly bound down to the tooth and alveolar bone and provides a protective
barrier that is resistant to the physical trauma from normal masticatory function
and personal oral hygiene procedures.
A certain amount of attached gingiva is often necessary to maintain health,
function, and comfort. The precise amount of attached gingiva needed varies among
individuals and physical demands at the site. For example, sites where restorative
margins will be placed at the gingival margin and sites where orthodontic or surgical
procedures are planned might require augmentation of the attached gingiva due
tothe added stress of these procedures on the marginal tissue.
The vertical dimension of attached gingiva, commonly called the “width” of
attached gingiva, is determined by measuring the depth of the gingival sulcus
with a periodontal probe and subtracting this dimension from the vertical
measure ment of keratinized tissue extending from the MGJ to the mid-facial
gingival crest. The thickness of the attached gingiva is also important, but its
dimension is typically estimated rather than measured. In sites where there is a
deficiency of attached gingiva, inflammation may be persistent, gingival reces-
sion may ensue, and the patient may experience discomfort [1]. Sites deemed to
have insufficient dimensions of attached gingiva might benefit from grafting
for augmentation of the gingival dimensions.
Coverage of exposed roots is another indication for soft tissue grafting, and
procedures are now available to both cover roots and augment the zone of
attached gingiva at the same time when indicated. Exposed roots present sev-
eral patient-based problems including esthetics, root sensitivity, and increased
susceptibility to cervical lesions. Complete root coverage with increased
dimensions of gingiva can routinely be achieved in sites where there is no loss
of interdental soft tissue or bone, thus restoring esthetics, function, and com-
fort [2]. In sites with loss of interdental tissues, partial root coverage can be
achieved along with augmentation of gingival dimensions to resist progres-
sion of recession.
Early soft tissue grafting techniques termed free gingival grafts (FGGs) were
successful in gaining an increased amount of gingiva, popularly called “gain of
keratinized tissue,” but required a palatal donor site consisting of both connective
tissue and epithelium and were less successful for covering exposed roots. The
subepithelial connective tissue graft (CTG) procedure solved the problem of root
coverage and used a more comfortable internal harvest method for palatal donor
tissue procurement.
The original recipient site preparation method for an FGG required creation of
a vascular bed by reflecting and discarding a supraperiosteal tissue flap over the
area to be grafted, while a CTG retained the reflected flap and used it to partially
cover the graft. Current trends in soft tissue grafting are directed toward more
minimally invasive approaches by eliminating vertical incisions and using alter-
natives to palatal donor tissue, both of which allow a more comfortable post
operation course for the patient. The use of the tunneling technique and allograft
tissue lead this trend.

MI Soft Tissue Grafting 145
Evolution of soft tissue grafting
The FGG, first described in the early 1960s [3,4], provided a means of gaining
a zone of attached gingiva in sites demonstrating a gingival deficiency. This
procedure was introduced during a time when the gingivectomy was a popular
method for eliminating periodontal pockets, and excision of gingiva often resulted
in a loss of an adequate protective zone of dense marginal gingiva. It was thought
at the time that new gingiva would develop as a response to vigorous tooth
brushing. In fact, minimal new marginal keratinized tissue would usually form,
being derived from the periodontal ligament. The undesirable consequences of
the gingivectomy were recognized and gave rise to flap procedures that preserve
existing gingiva. The FGG became a widely used procedure to treat sites with
surgically created deficiencies as well as to augment naturally deficient sites.
The FGG requires creation of an open vascular recipient bed and harvesting
of a superficial layer of palatal donor tissue approximately 1.0–2.0 mm thick.
Both epithelium and connective tissue are harvested. The donor tissue is sutured
over the recipient bed, while the palatal donor site is left to heal by secondary
intention. The palatal donor site is a source of discomfort and concern for the
patient.
While the FGG remains the “gold standard” for gain of keratinized tissue, it
was not initially a predictable procedure for coverage of deep, wide root exposure
[5]. A modified FGG technique for root coverage was presented in the early 1980s
[6,7]. At about the same time, the CTG method was introduced [8,9]. The harvest-
ing of the CT graft from the palate results in an outer flap of epithelium and
connective tissue that can be closed primarily, thus reducing discomfort and
accelerating healing of the donor site. The CTG method has other advantages
over the FGG for root coverage including greater predictability and improved
esthetics. The flap created at the recipient site is retained and secured over the graft,
thus providing an enhanced blood supply and improving survival of the graft over
the avascular root surface. The CTG procedure is now considered to be the “gold
standard” for root coverage.
Another popular root coverage technique is the coronally advanced flap (CAF),
originally described in the modern era in the mid-1970s [10,11]. The CAF procedure
coronally advances existing marginal gingiva to cover exposed roots without the
placement of any graft. The advantages of this method include the lack of need for
palatal donor tissue and enhanced esthetics. A significant limitation of the CAF
isthe need for adequate dimensions of gingiva apical to the exposed root surface.
It is generally considered necessary to have at least 3.0 mm of gingiva vertically
with a thickness of 0.8–1.0 mm to predictably cover roots [12–14].
Originally, the CAF used vertical releasing incisions. In 2000, a novel envelope
flap technique with unique papillary incisions and no vertical releasing incisions
was introduced [15]. This envelope flap technique has been shown to result in
greater probability of complete root coverage, a better postoperative course, and
better esthetics compared with a CAF with vertical incisions in the treatment of
recession involving multiple adjacent teeth [16].

146 Minimally Invasive Periodontal Therapy
The CAF is used to cover CTGs where the marginal gingival dimensions are
inadequate for CAF alone. As the CTG method has evolved, variations in
management of the overlying tissue have been introduced. In the method origi-
nally presented by Langer and Langer, vertical incisions were used to facilitate
coronal advancement of the overlying flap to partially cover the CTG [9]. Raetzke
used a pouch recipient site preparation with no surface incisions but made no
attempt to advance the margin coronally to cover the graft over the exposed root
surface [8]. This pouch technique was limited to localized recession defects and
was more successful in treating shallow recession sites than deep sites. More
recently, tunnel procedures have been described for coverage of CTGs [17–20].
The tunnel technique
Currently, root coverage grafting can be accomplished with a minimally invasive
tunnel technique using an allograft rather than palatal donor tissue [21,22] (Figure
9.1). Allografts have been shown to result in predictable root coverage and an
increase in marginal gingival thickness equivalent to the CTG while reducing the
morbidity associated with harvesting of palatal donor tissue [23–27]. A recent
long-term randomized clinical trial found stability of root coverage with allo-
grafts to be equivalent to that seen with palatal CTG [28]. A distinct advantage
when allografts are used is that multiple teeth can be treated in one visit without
concern for the amount of palatal tissue available.
There are two separate elements to this minimally invasive soft tissue grafting
technique:(i) the refined recipient site preparation and (ii) the elimination of the
palatal donor site.
Recipient site preparation
The recipient site can be prepared without the need for surface incisions in
treatment of most teeth with root exposure. Rather than surface incisions, intra-
sulcular incisions are made to release the soft tissue attachment to the cervical
area of the tooth, and internal supraperiosteal sharp dissection to mobilize
thepouch. The intrasulcular incisions extend from the base of the sulcus to the
alveolar crest, a distance of approximately 2.0 mm comprised of the epithelial
and connective tissue attachments to the root. This soft tissue attachment is often
called the “biologic width,” and it may extend more than the usual 2.0 mm where
there is a longer connective tissue attachment due to the presence of a bony dehis-
cence [29]. Through this intrasulcular incision, there is access for dissection of the
recipient vascular bed. The dissection extends both apically and laterally both to
prepare the recipient vascular bed and to mobilize the pouch sufficiently to allow
passive coronal advancement to completely cover the graft. It is necessary to
extend the dissection laterally under the papillae adjacent to the treated tooth
and additionally to include one tooth on either side of the tooth or teeth with

Figure 9.1 (a) Multiple tooth recession and root abrasion in the maxillary arch. (b) A tunnel
site preparation has been completed. (c) The allograft on the surface before placement within
the pouch. (d) The allograft and pouch were advanced together and secured at the
cementoenamel junction with a 6-0 polypropylene continuous sling suture. An additional sling
suture was placed around the canine for stabilization. (e) Thick marginal tissue with complete
root coverage at 1 year post surgery. The patient elected not to restore the minor cervical enamel
defects. (f) Maintenance of root coverage at 2 years post surgery. (g) Esthetically unappealing
pretreatment appearance. (h) Improved esthetics at 8 months post surgery.
(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)

148 Minimally Invasive Periodontal Therapy
recession. This tunneling under the papillae and lateral extension of the pouch
facilitate the passive coronal advancement of the pouch, thus eliminating the
need for vertical releasing incisions as well as papillary incisions.
This type of site preparation is ideally suited for treating root exposure in
the maxillary arch where the anatomic environment is typically favorable
(Figure 9.2). There are few anatomical obstacles to interfere with the dissection
process and the quality of the marginal tissue is usually better than that in the
mandibular arch.
Adequate interdental embrasure space is necessary to maintain intact
papillae in the tunneling process. Sites with close root approximation are sub-
ject to separation of the papillae due to a weak connection between the facial
and palatal papillae. This problem is more commonly seen in the mandibular
anterior region. In the mandibular arch, caution must be exercised when dis-
secting near the mental foramen located apical to the second premolar. There
are no significant vital structures encountered when dissecting facial to the
maxillary teeth.
A shallow vestibule, aberrant frenal attachments, thin tissue, bony undercuts,
and an irregular alveolar bony topography represent problems to be managed
when performing the tunnel technique. While all of these problems can be over-
come, advanced surgical experience is required for successful outcomes, and
treatment of sites with these conditions may be best left to periodontists who
routinely treat such sites.
Figure 9.2 (a) Generalized recession in the maxillary arch with moderately deep cervical
defects. (b) Allograft in tunnel over 7 teeth sutured with a 6-0 polypropylene continuous sling
suture. An additional sling suture was placed around the left lateral incisor to stabilize the
papillae. (c) Complete root coverage and thickened marginal tissue immediately following
suture removal at 3 months post surgery. (d) Complete root coverage with a pleasing appearance
of the gingiva that shows no evidence of surgical intervention at 2 years post surgery.
(a)
(b)
(c)
(d)

You're Reading a Preview

Become a DentistryKey membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Was this article helpful?

Minimally Invasive Periodontal Therapy: Clinical Techniques and Visualization Technology, First Edition. Edited by Stephen K. Harrel and Thomas G. Wilson Jr. © 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.Companion Website: www.wiley.com/go/harrel/minimallyinvasive1439Soft tissue grafting is indicated for augmenting sites with deficient-attached gingiva and for covering exposed roots. Surgical grafting techniques have evolved over the past 50 years to a minimally invasive method with refinements in recipient site preparation and the use of allograft donor tissue rather than harvesting tissue from the palate. A distinct advantage when allografts are used is that multiple teeth can be treated in one visit without concern for the amount of palatal tissue available. Regarding recipient site preparation, there has been a progression from open-site preparations to flaps with vertical incisions, to envelope flaps without vertical inci-sions, to tunnels with only sulcular incisions. There has also been a progression from completely exposed grafts to grafts partially covered by the recipient site flap, to grafts completely covered by coronally positioning the recipient site flap. Increased predictability of root coverage and greater patient comfort paralleled each of these advancements in recipient site design. This chapter will trace the evolution of soft tissue grafting procedures from the free gingival graft (FGG) to the current minimally invasive tunneling technique. The tunneling technique will be described in detail.Indications for soft tissue graftingSoft tissue grafting is indicated for augmenting the zone of attached gingiva around teeth and for covering exposed root surfaces. Attached gingiva is that portion of the gingiva that extends coronally from the mucogingival junction (MGJ) to the base of Minimally Invasive Soft TissueGraftingEdward P. Allen and Lewis C. Cummings 144 Minimally Invasive Periodontal Therapythe gingival sulcus. It is comprised of dense collagenous connective tissue that is firmly bound down to the tooth and alveolar bone and provides a protective barrier that is resistant to the physical trauma from normal masticatory function and personal oral hygiene procedures.A certain amount of attached gingiva is often necessary to maintain health, function, and comfort. The precise amount of attached gingiva needed varies among individuals and physical demands at the site. For example, sites where restorative margins will be placed at the gingival margin and sites where orthodontic or surgical procedures are planned might require augmentation of the attached gingiva due tothe added stress of these procedures on the marginal tissue.The vertical dimension of attached gingiva, commonly called the “width” of attached gingiva, is determined by measuring the depth of the gingival sulcus with a periodontal probe and subtracting this dimension from the vertical measure ment of keratinized tissue extending from the MGJ to the mid-facial gingival crest. The thickness of the attached gingiva is also important, but its dimension is typically estimated rather than measured. In sites where there is a deficiency of attached gingiva, inflammation may be persistent, gingival reces-sion may ensue, and the patient may experience discomfort [1]. Sites deemed to have insufficient dimensions of attached gingiva might benefit from grafting for augmentation of the gingival dimensions.Coverage of exposed roots is another indication for soft tissue grafting, and procedures are now available to both cover roots and augment the zone of attached gingiva at the same time when indicated. Exposed roots present sev-eral patient-based problems including esthetics, root sensitivity, and increased susceptibility to cervical lesions. Complete root coverage with increased dimensions of gingiva can routinely be achieved in sites where there is no loss of interdental soft tissue or bone, thus restoring esthetics, function, and com-fort [2]. In sites with loss of interdental tissues, partial root coverage can be achieved along with augmentation of gingival dimensions to resist progres-sion of recession.Early soft tissue grafting techniques termed free gingival grafts (FGGs) were successful in gaining an increased amount of gingiva, popularly called “gain of keratinized tissue,” but required a palatal donor site consisting of both connective tissue and epithelium and were less successful for covering exposed roots. The subepithelial connective tissue graft (CTG) procedure solved the problem of root coverage and used a more comfortable internal harvest method for palatal donor tissue procurement.The original recipient site preparation method for an FGG required creation of a vascular bed by reflecting and discarding a supraperiosteal tissue flap over the area to be grafted, while a CTG retained the reflected flap and used it to partially cover the graft. Current trends in soft tissue grafting are directed toward more minimally invasive approaches by eliminating vertical incisions and using alter-natives to palatal donor tissue, both of which allow a more comfortable post operation course for the patient. The use of the tunneling technique and allograft tissue lead this trend. MI Soft Tissue Grafting 145Evolution of soft tissue graftingThe FGG, first described in the early 1960s [3,4], provided a means of gaining a zone of attached gingiva in sites demonstrating a gingival deficiency. This procedure was introduced during a time when the gingivectomy was a popular method for eliminating periodontal pockets, and excision of gingiva often resulted in a loss of an adequate protective zone of dense marginal gingiva. It was thought at the time that new gingiva would develop as a response to vigorous tooth brushing. In fact, minimal new marginal keratinized tissue would usually form, being derived from the periodontal ligament. The undesirable consequences of the gingivectomy were recognized and gave rise to flap procedures that preserve existing gingiva. The FGG became a widely used procedure to treat sites with surgically created deficiencies as well as to augment naturally deficient sites.The FGG requires creation of an open vascular recipient bed and harvesting of a superficial layer of palatal donor tissue approximately 1.0–2.0 mm thick. Both epithelium and connective tissue are harvested. The donor tissue is sutured over the recipient bed, while the palatal donor site is left to heal by secondary intention. The palatal donor site is a source of discomfort and concern for the patient.While the FGG remains the “gold standard” for gain of keratinized tissue, it was not initially a predictable procedure for coverage of deep, wide root exposure [5]. A modified FGG technique for root coverage was presented in the early 1980s [6,7]. At about the same time, the CTG method was introduced [8,9]. The harvest-ing of the CT graft from the palate results in an outer flap of epithelium and connective tissue that can be closed primarily, thus reducing discomfort and accelerating healing of the donor site. The CTG method has other advantages over the FGG for root coverage including greater predictability and improved esthetics. The flap created at the recipient site is retained and secured over the graft, thus providing an enhanced blood supply and improving survival of the graft over the avascular root surface. The CTG procedure is now considered to be the “gold standard” for root coverage.Another popular root coverage technique is the coronally advanced flap (CAF), originally described in the modern era in the mid-1970s [10,11]. The CAF procedure coronally advances existing marginal gingiva to cover exposed roots without the placement of any graft. The advantages of this method include the lack of need for palatal donor tissue and enhanced esthetics. A significant limitation of the CAF isthe need for adequate dimensions of gingiva apical to the exposed root surface. It is generally considered necessary to have at least 3.0 mm of gingiva vertically with a thickness of 0.8–1.0 mm to predictably cover roots [12–14].Originally, the CAF used vertical releasing incisions. In 2000, a novel envelope flap technique with unique papillary incisions and no vertical releasing incisions was introduced [15]. This envelope flap technique has been shown to result in greater probability of complete root coverage, a better postoperative course, and better esthetics compared with a CAF with vertical incisions in the treatment of recession involving multiple adjacent teeth [16]. 146 Minimally Invasive Periodontal TherapyThe CAF is used to cover CTGs where the marginal gingival dimensions are inadequate for CAF alone. As the CTG method has evolved, variations in management of the overlying tissue have been introduced. In the method origi-nally presented by Langer and Langer, vertical incisions were used to facilitate coronal advancement of the overlying flap to partially cover the CTG [9]. Raetzke used a pouch recipient site preparation with no surface incisions but made no attempt to advance the margin coronally to cover the graft over the exposed root surface [8]. This pouch technique was limited to localized recession defects and was more successful in treating shallow recession sites than deep sites. More recently, tunnel procedures have been described for coverage of CTGs [17–20].The tunnel techniqueCurrently, root coverage grafting can be accomplished with a minimally invasive tunnel technique using an allograft rather than palatal donor tissue [21,22] (Figure 9.1). Allografts have been shown to result in predictable root coverage and an increase in marginal gingival thickness equivalent to the CTG while reducing the morbidity associated with harvesting of palatal donor tissue [23–27]. A recent long-term randomized clinical trial found stability of root coverage with allo-grafts to be equivalent to that seen with palatal CTG [28]. A distinct advantage when allografts are used is that multiple teeth can be treated in one visit without concern for the amount of palatal tissue available.There are two separate elements to this minimally invasive soft tissue grafting technique:(i) the refined recipient site preparation and (ii) the elimination of the palatal donor site.Recipient site preparationThe recipient site can be prepared without the need for surface incisions in treatment of most teeth with root exposure. Rather than surface incisions, intra-sulcular incisions are made to release the soft tissue attachment to the cervical area of the tooth, and internal supraperiosteal sharp dissection to mobilize thepouch. The intrasulcular incisions extend from the base of the sulcus to the alveolar crest, a distance of approximately 2.0 mm comprised of the epithelial and connective tissue attachments to the root. This soft tissue attachment is often called the “biologic width,” and it may extend more than the usual 2.0 mm where there is a longer connective tissue attachment due to the presence of a bony dehis-cence [29]. Through this intrasulcular incision, there is access for dissection of the recipient vascular bed. The dissection extends both apically and laterally both to prepare the recipient vascular bed and to mobilize the pouch sufficiently to allow passive coronal advancement to completely cover the graft. It is necessary to extend the dissection laterally under the papillae adjacent to the treated tooth and additionally to include one tooth on either side of the tooth or teeth with Figure 9.1 (a) Multiple tooth recession and root abrasion in the maxillary arch. (b) A tunnel site preparation has been completed. (c) The allograft on the surface before placement within the pouch. (d) The allograft and pouch were advanced together and secured at the cementoenamel junction with a 6-0 polypropylene continuous sling suture. An additional sling suture was placed around the canine for stabilization. (e) Thick marginal tissue with complete root coverage at 1 year post surgery. The patient elected not to restore the minor cervical enamel defects. (f) Maintenance of root coverage at 2 years post surgery. (g) Esthetically unappealing pretreatment appearance. (h) Improved esthetics at 8 months post surgery.(a)(b)(c)(d)(e)(f)(g)(h) 148 Minimally Invasive Periodontal Therapyrecession. This tunneling under the papillae and lateral extension of the pouch facilitate the passive coronal advancement of the pouch, thus eliminating the need for vertical releasing incisions as well as papillary incisions.This type of site preparation is ideally suited for treating root exposure in the maxillary arch where the anatomic environment is typically favorable (Figure 9.2). There are few anatomical obstacles to interfere with the dissection process and the quality of the marginal tissue is usually better than that in the mandibular arch.Adequate interdental embrasure space is necessary to maintain intact papillae in the tunneling process. Sites with close root approximation are sub-ject to separation of the papillae due to a weak connection between the facial and palatal papillae. This problem is more commonly seen in the mandibular anterior region. In the mandibular arch, caution must be exercised when dis-secting near the mental foramen located apical to the second premolar. There are no significant vital structures encountered when dissecting facial to the maxillary teeth.A shallow vestibule, aberrant frenal attachments, thin tissue, bony undercuts, and an irregular alveolar bony topography represent problems to be managed when performing the tunnel technique. While all of these problems can be over-come, advanced surgical experience is required for successful outcomes, and treatment of sites with these conditions may be best left to periodontists who routinely treat such sites.Figure 9.2 (a) Generalized recession in the maxillary arch with moderately deep cervical defects. (b) Allograft in tunnel over 7 teeth sutured with a 6-0 polypropylene continuous sling suture. An additional sling suture was placed around the left lateral incisor to stabilize the papillae. (c) Complete root coverage and thickened marginal tissue immediately following suture removal at 3 months post surgery. (d) Complete root coverage with a pleasing appearance of the gingiva that shows no evidence of surgical intervention at 2 years post surgery.(a)(b)(c)(d) MI Soft Tissue Grafting 149Indications for papillary incisionsThe tunneling technique can be used to augment sites without recession but with minimal attached gingiva, that may be subject to developing recession. These sites include teeth that will have orthodontic treatment or restorations placed at the gingival margin. In sites with very thin tissue and no root exposure, the intrasulcular site preparation method is difficult, especially in the mandib-ular anterior region where the root width, and thus the sulcular width, is small. In these sites, a papillary releasing incision provides the greater access needed for dissection and graft placement (Figure 9.3). Papillary incisions should be limited to the papilla between the canine and lateral incisor when treating the mandib-ular anterior region. This will provide access to tunnel under the remaining papillae that will act to prevent apical retraction of the pouch and contribute to wound stability. By retaining all three papillae in the midline, the stress of muscle pull in the midline is distributed to three papillae and the likelihood of a single weak papilla tearing is reduced.Figure 9.3 (a) Pre-orthodontic 12-year-old female with a shallow vestibule, absence of attached gingiva facial to her mandibular incisors, and thin attached gingiva facial to her lateralincisors. This site will be treated by augmentation grafting to gain a zone of dense connective tissue anddeepen the vestibule. (b) A tunnel recipient site was prepared facial to allfour incisors withbilateral papillary incisions between the canines and lateral incisors and an allograft was inserted through the right papillary opening. (c) The allograft was passed through the tunnel untilreaching the left papillary opening. (d) The coronal border of the allograft was aligned level with the cementoenamel junction in preparation for suturing.(a)(b)(c)(d) 150 Minimally Invasive Periodontal TherapyThe advantages of eliminating vertical incisions in the tunnel recipient site preparation technique include greater degree of root coverage, better postopera-tive course, and better esthetics [16]. The tunnel technique was also found to result in a better postoperative course compared withan envelope flap without vertical incisions but with papillary incisions [30]. The disadvantages of the tunnel technique include the greater technical difficulty, especially in presence of the limitations described earlier. Most of the difficulty is overcome with surgical experience and the judicious use of papillary incisions where needed.(g)(h)(e)12345(f)Figure 9.3 (Continued) (e) A continuous sling suture was initiated at the left open papilla by penetrating both the papilla and graft (1), passing through thedistal embrasure and around the lingual aspect of the lateral incisor before returning tothefacial through the mesial embrasure. The needle is then passed under the papilla before engaging the pouch and graft at the distal root line angle of the central incisor (2) and passing through the distal embrasure, around the lingual aspect, and back through the mesial embrasure to the facial. The needle is passed under the papilla before engaging the pouch and graft at the mesial root line angle of the right central incisor (3) and passing through the embrasure, around the lingual back to the facial, and under the papilla before engaging the pouch and graft at the mesial root line angle of the right lateral incisor (4). After passing through the mesial embrasure, around the lingual andback to the facial through the distal embrasure, the pouch and graft areengaged at the distal of the lateral incisor. The needle is then passed through the distal embrasure, around the lingual and back to the facial through the mesial embrasure. The needle is passed under the papilla (5)prior to engaging the pouch at the distal of the central incisor. (f) The continuous sling suturing sequence is continued until reaching the starting point where the suture is tied (1). (g)At 2 weeks post surgery, there is minimal edema and erythema, and the suture has disappeared into the tissue leaving only the knot exposed. There is a gain of vestibular depth and an augmentation ofthe marginal tissue with a dense, bound-down connective tissue beneath the mucosal surface. (h) At 30 months post surgery and near the completion of orthodontic therapy, the soft tissue has remained stable. MI Soft Tissue Grafting 151Allograft donor tissueThe second major feature of minimally invasive soft tissue grafting is the elimination of the palatal donor site. The tunnel technique provides a mini-mally invasive site preparation method suitable for either autologous or allo-geneic donor tissue and may be used without a donor as a coronally advanced pouch in Miller Class l recession sites with adequate dimensions of attached gingiva [12,13]. The substitution of an allograft in place of a palatal donor provides additional advantages in soft tissue grafting. The most obvious advantage is the reduction of postoperative morbidity, potential side effects, and inconvenience for the patient associated with palatal donor surgery [31,32]. Even though the discomfort associated with palatal harvesting is greatly reduced in the CTG technique, some patients postpone or decline the needed soft tissue grafting procedure because of a perception of potential postopera-tive pain. Discussing with the patient that no palatal tissue will be used helps to allay much of their apprehension. The use ofallograft donor tissue pro-vides an unlimited amount of tissue for treatment of multiple teeth and sites in one surgical appointment. The palate provides a finite amount of donor tissue that varies among patients and limits the amount of soft tissue grafting that can be accomplished. This donor tissue limitation factors into treatment planning and reduces treatment to those teeth with greatest need or may require multiple surgical appointments, either of which are compromises. The use of an allograft also reduces surgical time associated with harvesting the palate. Autologous tissue may be selected for treatment of single tooth recession sites requiring minimal palatal harvesting or for sites where graft survival is compromised and the forgiving nature of autologous donor tissue is advantageous.The most common allograft used today is an acellular dermal matrix (ADM). Of all the ADM options available today, the authors prefer AlloDerm®. Introduced in 1994 for treatment of burn patients, AlloDerm was subsequently used for addi-tional general surgical applications as well as intra-oral soft tissue grafting proce-dures [33]. Since its introduction, numerous studies of AlloDerm use have been published in both the medical and the dental literature. The dental studies include RCTs, systematic reviews, and meta-analyses [23–28,31,34–38]. No other ADM has such an extensive body of scientific study and long-term history of safety and successful outcomes.When compared to CTG, AlloDerm has been shown to result in equivalent root coverage, increase in tissue thickness, and gain of keratinized tissue [24–27,36]. Other ADM graft materials have recently become available, but they do not have the long-term positive outcomes studies of AlloDerm.Typically, gain of keratinized tissue is minimal with a submerged grafting technique whether an allograft or a CTG is used [25–27,31]. Because of this, gain of keratinized tissue is probably not the best parameter of success for sub-merged grafts (Figures9.4 and 9.5). While gain of keratinized tissue is useful for assess inggraft success for surface grafts such as a free gingival graft, the amount Figure 9.4 (a) Generalized recession in the mandibular anterior region with cervical notching of the left first premolar. (b) Allograft on the surface before placement in the pouch. (c) Allograft within the pouch coronally advanced with a single 6-0 polypropylene continuous sling suture. (d) Nearly complete root coverage and thickened bound-down connective tissue at 1 year post surgery.(a)(b)(c) (d)Figure 9.5 (a) Mandibular incisor with 4 mm recession, absence of attached gingival, and painful, irritated marginal tissue. The gingiva facial to the other incisors is thin. (b) Using the tunnel technique, an allograft is placed facial to all four incisors and secured with a single 6–0 polypropylene continuous sling suture. (c) At 2 weeks post surgery, the coronal border of the allograft is visible at the right central incisor. (d) At 1 year post surgery, there is complete root coverage. The thin mucosal surface belies the presence of the thick layer of dense connective tissue beneath the surface.(a)(b)(c)(d) MI Soft Tissue Grafting 153of keratinized tissue on the surface is not reflective of the gain of functional, dense collagenous connective tissue with submerged grafts. The small gain of keratinized tissue following a submerged grafting technique is reflective of initial graft exposure and secondary retraction of the overlying tissue exposing a small portion of the graft, and it is not an indicator of graft success.Surgical procedureIntrasulcular site preparationThe key feature of the tunnel technique is the elimination of traditional surface incisions and flap reflection. The recipient site is prepared by entry through the sulcus to create a pouch facial to the tooth or teeth to be treated. If multiple adjacent teeth are treated, tunneling under the papillae connects the pouches created facial to each tooth. An allograft is trimmed to size and placed within the pouch, and the graft and pouch are coronally advanced to completely cover the exposed root.The site preparation begins with an intrasulcular incision made from the base of the sulcus to the alveolar crest using an End-Cutting Intrasulcular Knife (Hu-Friedy, Chicago, IL) (Figure 9.6b). This incision should extend hori-zontally from the mesiolingual line angle to the distolingual line angle of each tooth to be treated as well as one additional tooth mesial and distal to these teeth. This initial incision provides access for subperiosteal blunt reflection with an Allen Microsurgical Elevator (Hu-Friedy, Chicago, IL) (Figure 9.6c). The blunt reflection should extend laterally under the facial aspect of the papillae and apically approximately 3.0 mm past the MGJ and any bony under-cuts. The papillae are elevated from the interdental crest with a Younger-Good 7/8 curette (Figure 9.6d).Root preparationRoot preparation is performed with curettes and/or an ultrasonic instrument with a safe-sided diamond tip (Varios 750, Brasseler USA, Savannah, GA) after mobilization of the marginal tissue to allow removal of shallow restorations, elimination of angular portions of cervical lesion, and creation of a uniform root surface without damaging the soft tissue (Figure 9.6e). EDTA is applied to the root surface to remove the smear layer. The next step is apical extension and mobilization of the pouch by sharp dissection using a Modified Orban Knife (Hu-Friedy, Chicago, IL) (Figure 9.6f and g). This instrument will allow dissec-tion that is immediately supraperiosteal to ensure passive advancement of the pouch to the CEJ and to create the required space for the graft while maintaining an immobile alveolar recipient bed. Figure 9.6 MIS technique. (a) A 3-mm root exposure with minimal marginal gingiva. (b) An incision is placed within the sulcus to detach the soft tissue from the root surface from the base of the sulcus to the alveolar crest. This incision extends from the mesiopalatal line angle around the facial aspect to the distopalatal line angle. (c) A microsurgical periosteal elevator is used to prepare a full thickness pouch under the mesial and distal papillae and facial to the root. This subperiosteal dissection extends apical to the mucogingival junction and past any bony undercuts. (d) Each papilla is elevated from the interdental alveolar crest by using a curette as a curved periosteal elevator. (e)After mobilization of the marginal tissue, the root is planed to remove any microbial deposits, sharp angles, and surface irregularities. (f) The pouch is extended apically and laterally by sharp dissection immediately supraperiosteally to allow passive coronal advancement of the pouch margin. (a)(b)(c)(d)(e)(f) (g)(h)(i)(j)(k)(l)Figure 9.6 (Continued) (g) The pouch is extended apically and laterally by sharp dissection immediately supraperiosteally to allow passive coronal advancement of the pouch margin. (h)The allograft istrimmed to extend completely under the papillae adjacent to the exposed root. A suture may be used to aid in positioning the graft after insertion. (i) The allograft is inserted inthe pouch overthe root. (j) The allograft is aligned with the pouch margin and advanced together to the cementoenamel junction with a 6-0 polypropylene sling suture. (k) Complete root coverage witha thickened margin and gain of keratinized tissue is seen at 3 months post surgery. (l)Complete root coverage maintained at 2 years post surgery. 156 Minimally Invasive Periodontal TherapyAllograft placementThe allograft is reconstituted according to the tissue bank instructions and trimmed to the proper dimensions to extend horizontally completely under the papillae mesial and distal to the treated teeth and vertically 6–8 mm (Figure9.6 h). The allograft is then soaked in a platelet-rich plasma preparation for enrich-ment with growth factors. The graft is inserted into the pouch through the largest sulcular opening with a Younger-Good 7/8 curette and/or by using a suture to aid insertion and positioning within the pouch (Figure 9.6i). The graft is aligned level with the gingival margins of the pouch so that both the graft and pouch may be advanced simultaneously with either a series of interrupted sling sutures or a single subpapillary continuous sling suture (Figure 9.6j) [39]. The continuous sling suture has the advantage of a single knot that is less irri-tating to the tissue and for the patient than multiple knots. A small diameter monofilament, nonresorbable 6-0 polypropylene suture with aC-17 needle (Hu-Friedy, Chicago, IL) isused to reduce tissue irritation and provide a longer period of stabilization.SuturingThe continuous sling suture engages the pouch and graft at the distal aspect of each tooth progressing from the posterior toward the anterior, and then engages the pouch and graft at the mesial aspect when returning to the posterior starting point (Figure 9.3).Beginning at the posterior-most tooth, the needle is placed through the pouch margin and allograft at a point 3.0 mm apical to the pouch margin at the distal root line angle using a microsurgical Castroviejo Needle Holder (Hu-Friedy, Chicago, IL). The microsurgical Allen Elevator (Hu-Friedy) is used at the pouch margin to help maintain the graft within the pouch. The needle is recaptured with microsurgical Dressing Forceps (Hu-Friedy) and passed through the distal embrasure space, captured lingually, passed around the lingual and back to the facial side through the mesial embrasure.The needle is then passed under the papilla from the mesial aspect of the initial tooth to the distal aspect of the adjacent tooth. The pouch margin and graft are penetrated at the distal root line angle of the second tooth 3.0 mm apical to the pouch margin. The needle is passed back through the distal embrasure, around the tooth lingually, and then passed back to the facial side through the mesial embrasure. The needle is next passed under the papilla facially from thedistal to mesial aspect, and the process continues until the last tooth to be treated is reached.After the needle is passed around the lingual aspect of the final tooth and back through the mesial embrasure to the facial side, the pouch margin and graft are penetrated at the mesial root line angle 3.0 mm apical to the pouch margin. The needle is passed back through the mesial embrasure to the lingual MI Soft Tissue Grafting 157side, around the tooth, and through the distal embrasure to the facial side. After passing under the papilla, the needle penetrates the pouch margin and the graft at the mesial root line angle of the next tooth, passes through the mesial embra-sure, around the lingual side of the tooth, and back to the facial side through thedistal embrasure. The process continues by passing under the papillae to engage the mesial root line angles of all treated teeth and finally returning to the distofacial aspect of theposterior-most tooth (starting point), to tie the suture. The surgical site is then inspected for adaptation and stability. An additional interrupted suture may be necessary on occasion for enhancement of adaptation or stabilization.The continuous sling suture may be removed easily after swelling has subsided. Based on clinical observation, it is recommended that the suture be retained for up to 2 months to allow time for graft integration and marginal stability.Postoperative careThe most significant postsurgical side effects are swelling and infection. Uneventful healing is facilitated by measures taken to minimize swelling. During the first 24hours after surgery, the patient should remain inactive at home, apply ice to theface opposite the grafted site during the waking hours, have cold liquids for meals, and avoid toothbrushing. After 24 hours, the patient may return to routine nonstrenuous activities and begin eating soft foods, but should avoid mastication, tooth brushing at the surgical site, and exercise for 2 weeks. A broad-spectrum antibiotic such as Amoxicillin for 10days post surgery and the use of an antimicrobial mouthrinse are recom-mended to prevent infection. A glucocorticoid such as prednisone is beneficial in reducing swelling, especially when treating multiple teeth in the mandib-ular arch. Pain from this procedure is usually of short duration and is managed with the usual medications.Advantages of MI soft tissue graftingThe advantages of this minimally invasive grafting technique include(i) no sur-face incisions, thus no scarring; (ii) use of an allograft, which eliminates need for a palatal donor site; (iii) reduced patient discomfort; (iv) greater acceptance of treatment; and (v) ideal esthetics.Palatal grafts are also very effective for predictable root coverage; however, they are subject to enlarging, thereby negatively impacting the esthetic out-come. Graft enlargement may be desirable in some alveolar ridge or papilla augmentation procedures, thus palatal connective tissue may be a better choice for these applications. In sites where the graft cannot be completely covered, palatal tissue will survive better than an allograft. Otherwise, an allograft is the better choice. 158 Minimally Invasive Periodontal TherapyApplication of the tunnel concept for ridge augmentationThe tunneling technique, primarily used to treat patients with gingival reces-sion on the facial root surfaces can also be used to treat alveolar ridge defects with rotated autogenous palatal connective tissue grafts. The rotated palatal pedicle graft technique described by Sclar as the Vascularized Interpositional Periosteal-Connective Tissue Graft (VIP-CT) is moderately invasive in the approach to both graft harvest and graft placement [40]. By applying the tunneling principles, the original technique has been modified to a less inva-sive grafting method to treat soft tissue defects at dental implant sites in theesthetic zone. The less invasive nature of this procedure as compared with-the original VIP-CT reduces postoperative complications while enhancing the overall esthetic outcome.The original VIP-CT grafting technique had two significant postoperative complications: (i) palatal sloughing at the donor site and (ii) incision line opening at the recipient site. By applying principles of minimally invasive surgery that include remote incisions and tunneling, both of these initial complications have been greatly reduced.The traditional VIP-CT graft utilized a palatal incision for graft harvest located several millimeters away from the free gingival margin. Due to the sloping posi-tion of the incision away from a fixed structure, primary closure after graft harvest is often difficult. A lack of primary closure may result in delayed healing and increased patient discomfort. It has been the author’s experience that beginning the palatal dissection with sulcular incisions and creation of a full-thickness palatal envelope flap provides better access to the underlying connective tissues for harvesting (Figure 9.7). Not only is the surgeon’s ability to dissect free periosteum and connective tissue layers improved, but the envelope flap design allows for precise re-approximation of the flap margins to the original incision point when harvest is complete. Securing the flap margin to theadjacent teeth with sling sutures is adequate for incision line closing. Since the flap has been designed as a full-thickness flap with primary closure, postop-erative opening is dramatically reduced. In addition, improved visibility of the harvest site facilitates maintenance of uniform thickness of the harvested tissue. This better control reduces the likelihood of overthinning the palatal tissues or perforating the epithelial layer; two common causes of postoperative palatal discomfort and sloughing.In addition, the original technique consisted of reflection of a facial flap to pre-pare the recipient site. This preparation included vertical incisions on the mesial and distal of the defect to facilitate surgical access. These vertical incisions increase the risk of postoperative graft exposure. In the modified version, the recipient site is prepared by creating a pouch through remote sulcular incisions without any vertical incisions. To maintain the integrity of the papilla on the mesial and distal of the surgical site, which is often an implant with delicate papilla, tunneling under the papilla and lifting them, rather than incising through them, is performed. MI Soft Tissue Grafting 159Tunneling under papillary areas and the edentulous ridge areas provides enhanced maintenance of blood supply in the surgical area. Using microsurgical instruments facilitates recipient site preparation and placement of the graft. Wound closure is accomplished with 6-0 or 7-0 sutures.This minimally invasive technique works well for augmenting soft tissue at implant sites, especially where the ridge deficiency has a vertical compo-nent and is associated with proximal recession involving the adjacent teeth (Figure 9.8). It is especially beneficial for anterior implant sites where esthet-ics is often compromised due to loss of soft tissue. Indications include Figure 9.7 (a) Pediculated palatal connective tissue graft harvested from full flap approach. forrotation through tunnel over the coronal and facial aspects of the implant. (b) Rotation ofgraft before inserting through tunnel over the coronal and facial aspects of the implant. (c)Graft secured in pouch with interrupted 6–0 polypropylene sutures. (d) Primary closure ofpalatal donor site with(a)(b)(c)(d) 160 Minimally Invasive Periodontal TherapyFigure 9.8 (a) (i) An alveolar ridge defect associated with facial and proximal recession ontheadjacent lateral incisor in a 17-year-old female following removal of an ankylosed tooth.The site has previously been treated by bone grafting and free connective tissue grafting on separate occasions. (ii) Recession and ridge defect from the lateral aspect. (b) (i) The site wasretreated with a pediculated connective tissue graft from the right palate, rotated and inserted in a tunnel created under the soft tissue over the ridge crest and facial to the lateral incisor. Papillary incisions were made distal to the right lateral incisor and left central and lateralincisors to facilitate creation of the tunnel. No vertical releasing incisions were made. Thesite was closed and stabilized with 6–0 polypropylene sutures. (ii) Ridge augmentation androot coverage from the lateral aspect. (c) (i and ii) Complete root coverage and ridge augmentation at 1 month post surgery. (d) (i and ii) Stability of outcome at 2 months post surgery.(a)(b)(c)(d)(e)(f) MI Soft Tissue Grafting 161augmentation of soft tissue deficiencies at edentulous sites, augmentation during immediate implant placement, and augmentation of soft tissue defi-ciencies at existing implant sitesSummarySoft tissue grafting techniques have advanced from effective but invasive methods requiring vertical releasing incisions and palatal donor tissue to current minimally invasive tunnel recipient site preparation and the use of allografts rather than palatal donor tissue. No surface incisions are required as the access for recipient site preparation is through the sulcus. This refinement in technique using microsurgical instruments and nonirritating 6-0 and 7-0 monofilament suture has resulted in a more comfortable and less intimidating procedure and postsurgical period for the patient while enhancing the esthetics of the outcome and allowing the treatment of multiple teeth in a single surgical appointment.References1. Lang, N.P. & Löe, H. (1972) The relationship between the width of keratinized gingiva and gingival health. Journal of Periodontology, 45, 623.2. Miller, P.D. (1985) A classification of marginal tissue recession. The International Journal of Periodontics & Restorative Dentistry, 5(2), 8–13.3. Björn, H. (1963) Free transplantation of gingiva propria. SverigesTandlakarforbrinds Tidning, 22, 684–689.4. King, K. & Pennel, B.M. (1964) Evaluation of attempts to increase the width of attached gingiva. Presented to the Philadelphia Society of Periodontology, April1964.5. Sullivan, H.C. & Atkins, J.H. (1968) Free autogenous gingival grafts. I. Principles of successful grafting. Periodontics, 6, 121–129.6. Miller, P.D. (1982). Root coverage using the free soft tissue autograft following citric acid application. Part I. Technique. The International Journal of Periodontics & Restorative Dentistry, 2, 64–70.(g)(h)Figure 9.8 (Continued) 162 Minimally Invasive Periodontal Therapy7. Miller, P.D. (1985). Root coverage using the free soft tissue autograft following citric acid application. Part III. A successful and predictable procedure in areas of deep-wide recession. The International Journal of Periodontics & Restorative Dentistry, 5, 14–37.8. Raetzke, P.B. (1985) Covering localized areas of root exposure employing the “envelope” technique. Journal of Periodontology, 56, 397–402.9. Langer, B. & Langer, L. (1985) Subepithelial connective tissue graft technique for root coverage. Journal of Periodontology, 56, 715–720.10. Restrepo, O.J. (1973) Coronally repositioned flap: Report of four cases. Journal of Periodontology, 44, 564.11. Bernimoulin, J.P., Luscher, B.&Muhlemann, H.R. (1975) Coronally repositioned flap. Clinical evaluation after one year. Journal of Clinical Periodontology, 2, 1–13.12. Allen, E.P.&Miller, P.D. (1989) Coronal positioning of existing gingiva: Short-term results in the treatment of shallow marginal tissue recession. Journal of Clinical Periodontology, 60, 316–319.13. Baldi, C., Pini-Prato, G., Pagliaro, U. et al.(1999) Coronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage? A 19-case series. Journal of Periodontology, 70, 1077–1084.14. Huang, L.-H., Neiva, R.E.F. & Wang, H-L. (2005) Factors affecting the outcomes of coronally advanced flap root coverage procedure. Journal of Periodontology, 76, 1729–1734.15. Zucchelli, G.&De Sanctis, M. (2000) Treatment of multiple recession type defects in patients with aesthetic demands. Journal of Periodontology, 71, 1506–1514.16. Zuccheli, G., Mele, M., Mazzotti, C., Marzadori, M., Montebugnoli, L. & De Sanctis, M. (2009) Coronally advanced flap with and without vertical releasing incisions for the treatment of multiple gingival recessions: A comparative controlled randomized clinical trial. Journal of Periodontology, 80, 1083–1094.17. Allen, A.L. (1994) Use of the supraperiosteal envelope in soft tissue grafting for root coverage. I. Rationale and technique. The International Journal of Periodontics & Restorative Dentistry, 14, 216–227.18. Azzi, R. & Etienne, D. (1998) Recouvrementradiculaireet reconstruction papillaire par greffon con-jonctifenfoui sous un lambeauvestibulairetunnellisé et tractécoro-nairement. Journal of Parodontal Implant Orale, 17, 71–77.19. Blanes, R.J. & Allen, E.P. (1999) The bilateral pedicle flap-tunnel technique: A new approach to cover connective tissue grafts. The International Journal of Periodontics & Restorative Dentistry, 19, 471–479.20. Allen, E.P. (2004) Multiple tooth recession: Papilla retention pouch procedure. In: E.P. Allen (ed), Contemporary Oral Plastic Surgery Procedural Manual, pp. 9–16. Center for Advanced Dental Education, Dallas, TX.21. Allen, E.P. & Cummings, L.C. (2005) Esthetics and regeneration: Acellular dermal matrix (AlloDerm). In: H. Yoshie & Y. Miyamoto (eds),Technique and Science of Regeneration, pp. 124–131. Quintessence, Tokyo, Japan.22. Allen, E.P. (2006) AlloDerm: An effective alternative to palatal donor tissue for treatment of gingival recession. Dentistry Today, 25, 48, 50–52.23. Harris, R.J. (2000) A comparative study of root coverage obtained with an acellular dermal matrix versus a connective tissue graft: Results of 107 recession defects in 50 consecutively treated patients. The International Journal of Periodontics & Restorative Dentistry, 20, 51–59. MI Soft Tissue Grafting 16324. Aichelmann-Reidy, M.E., Yukna, R.A., Evans, G.H., Nasr, H.F. & Mayer, E.T. (2001) Clinical evaluation of acellular allograft dermis for the treatment of human gingival recession. Journal of Periodontology, 72, 998–1005.25. Novaes, A.B. Jr., Grisi, D.C., Molina, G.O., Souza, S.L., Taba, M. Jr.&Grisi, M.F. (2001) Comparative 6-month clinical study of a subepithelial connective tissue graft and acellular dermal matrix graft for the treatment of gingival recession. Journal of Periodontology, 72, 1477–1484.26. Oates, T.W., Robinson, M. & Gunsolley, J.C. (2003) Surgical therapies for treatment of gingival recession. A systematic review. Annals of Periodontology, 8, 303–320.27. Gapski, R., Satheesh, K. & Wang, H.-L. (2005) Acellular dermal matrix for mucogin-gival surgery: A meta-analysis. Journal of Periodontology, 76, 1814–1822.28. Moslemi, N., Zazi, M.M., Haghighati, F., Morovati, S.P. & Jamali, R. (2011) Acellular dermal matrix allograft versus subepithelial connective tissue graft in treatment of gingival recessions: A 5-year randomized clinical study. Journal of Clinical Periodontology, 38, 1122–1129.29. Gargiulo, A.W., Wentz, F.M. & Orban, B. (1961) Dimensions and relations of the dento-gingival junction in humans. Journal of Periodontology, 32, 261–267.30. Papageorgakopoulos, G., Greenwell, H., Hill, M., Vidal, R. & Scheetz, J.P. (2008) Root coverage using an acellular dermal matrix and comparing a coronally posi-tioned tunnel to a coronally positioned flap approach. Journal of Periodontology, 79, 1022–1030.31. Cummings, L.C., Kaldahl, W.B. & Allen, E.P. (2005) Histologic evaluation of autoge-nous connective tissue and acellular dermal matrix grafts in humans. Journal of Periodontology, 76, 178–186.32. Griffin, T.J., Cheung, W.S., Zavras, A.I. & Damoulis, P.D. (2006) Postoperative com-plications following gingival augmentation procedures. Journal of Periodontology, 77, 2070–2079.33. Livesey, S.A., Herndon, D.N., Hollyoak, M.A., Atkinson, Y.H. & Nag, A. (1995) Transplanted acellular allograft dermal matrix. Potential as a template for the recon-struction of viable dermis. Transplantation,60, 1–9.34. Chambrone, L., Sukekava, F., Araujo, M.G., Pustiglioni, F.E., Chambrone, L.A. & Lima, L.A. (2010) Root-coverage procedures for the treatment of localized reces-sion-type defects: A Cochrane systematic review. Journal of Periodontology, 81, 452–478.35. Henderson, R.D., Greenwell, H., Drisko C. et al.(2001) Predictable multiple site root coverage using an acellular dermal matrix allograft. Journal of Periodontology, 72, 571–582.36. Paolantonio, M., Dolci, M., Esposito, P. et al.(2002) Subpedicleacellular dermal matrix graft and autogenous connective tissue graft in the treatment of gingival recessions: A comparative 1-year clinical study. Journal of Periodontology, 73, 1299–1307.37. Tal, H., Moses, O., Zohar, R., Meir, H. & Nemcovsky, C. (2002) Root coverage of advanced gingival recession: A comparative study between acellular dermal matrix allograft and subepithelial connective tissue grafts. Journal of Periodontology, 73, 1405–1411.38. Woodyard, J.G., Greenwell, H., Hill, M. et al.(2004) The clinical effect of acellular dermal matrix on gingival thickness and root coverage compared to coronally posi-tioned flap alone. Journal of Periodontology, 75, 44–56. 164 Minimally Invasive Periodontal Therapy39. Allen, E.P. (2010) Subpapillary continuous sling suturing method for soft tissue grafting with the tunneling technique. The International Journal of Periodontics & Restorative Dentistry, 30, 479–485.40. Sclar, A.G. (2003) The vascularized interpositional periosteal-connective tissue (VIP-CT) flap. In: A.G. Sclar (ed), Soft Tissue and Esthetic Considerations in Implant Therapy, pp. 163–188. Quintessence, Chicago, IL.

Related Articles

Leave A Comment?