Taylor Brewer

Tammy Maahs

Periodontology

3/13/2017

Connective Tissue Graft Observation

As my classmate, Charli, and I entered the office, the first thing that came to my mind

was how different and out of location the office felt. The inside was small and had a cabin feel,

but the reception and friendliness of the staff was exceptional upon arrival. We waited in the

waiting room for a few minutes before we were pulled back into the treatment area where we

were showed the prepped procedure by the assistant. There was one hallway with four treatment

chairs located directly off the front office. The dentists office, Dr. Morlock, was located at the

end of the hallway straight across from the break room. After a few moments of being there, Dr.

Morlock came out and greeted us before the procedure and proceeded to tell us to ask if we had

any questions throughout the next 3 hours.

The procedure we observed for the day was a connective tissue graft of tooth number 24

with a high amount of recession. The procedure took about 3 and half hours to complete from

patient greeting to post-op explanation. All patients treated here are given 800mg of Motrin

before the procedure begins for the pain and discomfort when the numbness from the anesthetic

wears off. Patient was brought back to area and seated by the assistant. She then did medical

history with the patient and provided the patient with Motrin. The procedure was explained and

the patient was asked for any questions or concern. There was none, so the procedure was started

shortly after.
 The assistant first took a maxillary impression for her retainer just in case there was an

issue of it fitting after the procedure; since connective tissue was going to be taken from that area

of her palate. She then took x-rays of the area and developed them with a traditional system

located across from the treatment room. The patients blood pressure was taken and vitals were

recorded through the poet plus 8100 on patients left index finger throughout the whole

procedure. The topical was placed as the assistant waited for doctor to proceed with the injection.

Both Dr. Morlock and his assistant wore gloves underneath their surgical gloves during the

surgery. Dr. Morlock next administered the anesthetic and informed a second assistant to prepare

the laser for laser curettage on the lower frenum. The anesthetic given was articaine 4% with

epinephrine 1:100,000. Two infiltrations were injected around tooth involved for maximum

anesthesia of the area. A palatal injection was also given on the patients right side. Both

injections administered to the patient consisted of to 2 full cartridges. The Periolase MVP-7TM

was the brand of the laser machine being used. Dr. Morlock first prepared and initiated the tip of

the laser before starting. After initiating, he begins the procedure by doing a vestibuloplasty and

cutting down the lower mandibular frenum that was too high and caused the recession of tooth

number 24. After laser curettage, incisions were made around the tooth sulcus with a dental knife

to free the tooth from the small connective tissue strands holding it in place. The recession was

then measured with the periodontal probe and was recorded as 9mm. The gingiva was then freed

open and the extra was scraped off where the graft was going to be placed and inserted. At this

point, the patient was feeling discomfort so Dr. Morlock administered another infiltration around

the tooth. After the injection, the exposed root surface and cementum was reported as healthy.

The assistant then prepared 125 mg cotton pellets soaked in tetracycline on the tray and

administered to the doctor with cotton pliers. Dr. Morlock instructed us that the tetracycline
helps remove toxins from the area and allows for better reattachment and regeneration of tissue.

Cotton pellets were then rubbed into the area of recession where the graft was going to be placed.

A sterile syringe was then used to rinse the tetracycline off the tooth surface. Next, doctor moved

to the palate and checked for anesthetic effectiveness with the periodontal probe. Patient was

thoroughly anesthetized in that area and felt no pain, so the procedure was started with a double-

bladed scalpel to make an incision on the palate. The incision made was measured to be 12mm

long down the patients palate. A pouch was created and then the connective tissue palate piece

was retained from the pouch. Doctor placed the 12x12mm palate piece into sterile water while he

prepared the suture. After suturing up the palate, the assistant tried the patients retainer in to see

if it would fit and provide efficient suction for stability and proper use. After observing the fit,

Morlock decided to make a new one due to it not being able to apply enough pressure to the

maxilla. The suture was then placed into the gum tissue prepared around tooth number 24, and

the palatal gingiva is placed and tucked into the sulcus area prepared earlier with the dental

knife. At this point, the patient was feeling pain again, so doctor administered an interpapillary

PDL directly on tooth number 24. Doctor then proceeded with the process of tucking and

suturing the connective tissue into place along the mandible. After completing, doctor dismissed

himself, asks for any questions and let the assistant complete the procedure.

The assistant then applied a periodontal dressing to the area involved with Baricaid. She

explained to us that the use of this material was due to it being easier to apply, it stays in place

for 2 weeks and aesthetically looks nicer than some of the other dressings. It was also addressed

that the sutures would be removed in 2 weeks at the follow up and evaluation of healing

appointment that was to be scheduled. The periodontal dressing was then light-cured into place

and patient was provided with a palatal covering as well and was instructed to keep that in place
for at least the next 3 days to allow for proper healing of her palate. Post operation instructions

were then given to the patient by the assistant. The patient was instructed to have proper rest time

for adequate healing of her tissue and to avoid any excessive excursion activities for the next 2-3

days. She was also told to avoid pulling down on her lower lip because the sutures could be

pulled that way. Applying heat to the area was encouraged, but no ice because it would restrict

the blood flow. The patient could be prescribed the narcotic Norco (hydro codon) which was

optional, or she could use 600mg of Ibuprofen for the next week for any pain that may occur

during healing. Her diet should consist of only soft foods for the first 24 hours and to avoid

crunchy items. After post operation instructions were explained, patient was asked if she had any

questions or concerns to call the office and they would assist her to the best of their ability.

The role of a periodontist is a dentist who specializes in the prevention, diagnosis, and

treatment of periodontal disease. They also specialize in the placement of dental implants and are

experts in treating oral inflammation. In these areas, the periodontist receives extensive training

in addition to dental school. Periodontists often treat more problematic periodontal cases, but

provide a wide range of treatments, such as scaling and root planning or root surface

debridement. Patients are usually referred to a periodontist when their inflammation and

periodontal disease is in the advanced and severe stages that are beyond what normal hygiene

therapy can provide for recovery of the tissue. Periodontal therapy can be attempted in a normal

dental office, but sometimes outcomes and opposite of what was expected and conditions worsen

which is when you would want to refer that patient to a periodontist.

My overall experience from observing this operation was very interesting. Ive never

seen a connective tissue graft before and it was fascinating to see how the process worked and to

see a palatal connective tissue graft. It was far from what I was expecting, but it helped give me a
better understanding about what happens in a periodontal office and what kind of surgeries can

be performed outside of a normal dental setting.