Connective Tissue, (CT) Graft #27

Capt Alfred G. Khallouf AEGD-2 Senior Resident

Pt presentation at initial appt

Preparing the Recipient Site• Scaled/Root Planed site

to Remove all calculus and debris, FIRST before tissue reflection is begun. – Do Not want to remove

fibrous attachments

• Placed sulcular incisions and reflected tissue from M of #26 to D of #28.

• Must make sure the site is free of any debris

Preparing the Recipient Site

• Make sure to prepare the site by conditioning

• Treated area for 2 minutes with PrefGel (EDTA)

Reflecting Tissue

• Reflect the tissue beyond mucogingival junction in order to create space for the donor graft

Initial Incision

• Horizontal incision extending on palate from approximately mesial of canine to mesial of 1st Molar about 3mm from Crest of tissue

• 8mm x 8mm site chosen on Palatal Rugae

Split the Difference• Split the difference,

separate the superior & inferior layers of the connective tissue in order to protect the outermost surface of the palate.

• Extend the internal incision the length of the blade

Rotate the blade

• Rotate the blade handle toward the boney side in order to separate the 2 vertical parallel aspects of the donor tissue

• This leaves only the most medial part still intact

Final Separation

• Be Very Careful

• Carefully separate the last part of tissue still holding it in place

• Have lots of blades ready throughout procedure

Like Magic

• The donor tissue should come out intact with the Adson’s Forceps

• KEEP THE SUCTION

AWAY

Donor Tissue

• Place the donor tissue on a flat surface the will not roll up or shrink

Suture Palate• Placed Surgical

(resorbable hemodent) in place of donor area

• Suture the site for primary closure

• 4-0 chromic gut interrupted sutures placed

Stent

• Make sure the lab fabricates a clear palatal stent prior to the surgery

• This is mainly for protection of tissue and pt comfort

• Should lock into place via interproximals, no balls or clasps

Suture Flap

• Initial suture placed, goes through the facial aspect of the mesial flap

Suture Donor Tissue

• 1 Suture placed through the donor tissue

Suture back

• Place suture through lingual aspect of mesial flap

Donor Tissue Positioned

• Donor tissue is positioned in place at the recipient site where it is to be sutured into place

Secure

• Secure donor tissue into place, but do not tie too tightly

• You do not want to strangulate the tissue

Suture Distal Flap

• Suture the Distal flap from the facial, initially, and pass through the donor tissue

• NOT TOO TIGHT

Secure

• Secure the suture and tie down

• Placed vertical mattress suture to position Graft

Connect the flaps (but not against each other)

• Suture the 2 flaps to each other now

• Graft was sutured into place with total of 6 interrupted 4-0 Chromic Gut sutures

Coe Pack Dressing

Coe-Pak surgical dressing on recipient site, locked into interproximal spaces

1 Week Post-op

• Tissue is healing WNL

• Granulation WNL

1 Week Post-op

• Removed coe-pack dressing

• Lightly dabbed periphery with Peridex

• Did NOT remove sutures

2 Week Post-op

• Palatal Donor Site is healing well

2 Week Post-op- OH NO• Pt stated that he

had noticed on Saturday afternoon that the CT graft, placed 10 days ago, was no longer in place on the facial of #27.

2 Week Post-op

• He stated that it may have fallen out the previous night when he was spitting out the Peridex

• He denies any aggressive or vigorous spitting or swishing.

3 Week Post-op

• Palate is healing very well

3 Week Post-op

• Clinically, the superior ¾ of the graft has sloughed off.

Before & After

Keys to better success• Apical portion should have been higher

– I did not coronally position the tissue high enough

• Ideally, I should have done a Free Autogenous Graft first, before CT

• CT Harvest from anterior about 3mm to 1st Premolar

• Free Auto start at the Mid Palate – This Donor tissue will be larger

• Root Coverage- CT Graft is sufficient • Keratinized Tissue- Free Auto Tissue Graft is

preferred

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