"The Internotionol Journal ot Peiiodontics ond Resloiotive Denliîtry" 3/I9&3

Complete Coverage Introduction

of the Denuded Root Surface
with a One-Stage Gingival Grah
Gingival recession and roat expo-
sure hove for many years created a
therapeutic problem for the clinicion.
The current variety of grafting proce-
dures largely has the abjective af
preventing further recession by in-
creasing tfie widtfi of keratinized gin-
giva, rather than the covering of the
Thomas Halbraok. D.D S. root surface. Most potients prefer
OiHard Ochsenbem, D.D.S.'
covering all of tfie expased root, par-
ticularly if anterior teeth are involved.
Even discounting the esthetic wishes
of tfie patient, it is common know-
ledge thot the exposed root surfoce
is associated frequently witfi hyper-
sensitivity and plaque retention, In-
flammotion of the gingiva can fallow
and the problem of raat caries can
arise. Furthermore, erosion is os-
sodated frequently with long-stand-
ing recession. One fiopes that few
tfierapists would object to a proce-
dure that would cover the denuded
root in en effort to recapture the orig-
inal morphology of the periodan-
tium. This article describes o proce-
dure for covering the denuded root
surface while increasing the width of
keratinized gingiva, using tfie au-
togenous gingival graft os o single
procedure,

Tfie literature reveols some early ef-

forts ta cover denuded roots, sucfi as
Norberg's publication in 1926,
Mare recently, Grupe and Warren^
in 1956, reported a method designed
to cover isolated areas of gingival
recession. They termed their proce-
dure "the lateral sliding flap," which
is known currently as the loterally
positioned flop. Since its inception,
there hove been a number of modifi-
cations, including the edentulous
' 8226 Douglas Avenue, Suite 648, Dallas, area pedicle graft,^ tfie oblique
Texos 75225

-The lrlernot,ond Journal of Penodontics ond Restorot.ve Dentistry" 3/1983

10
positioned pedicle groft," and the
double popilla graft,^
It is nat within our scope to review the
mony excellent publicotions dealing
with mucogingival procedures; much
is not germane to root coverage,
hlowever, various orticles have dealt
specifically with root exposure.
Laterally Positioned Flap
Smukler,'' Cuinard and Caffesse/
Smukler and Coidmon^ ond others
have reported the results of the later-
ally positioned flap in covering root
surfaces. If the therapist is selective,
the laterolly positioned flap can
sen/e as a useful procedure in partial
coverage of a denuded roat. The
mesiodistal width of the recession
should be narrow, and the interden-
tal gingiva and bone, both mesial
and distal to the defect, should ap-
proach the normal height. Further-
more, the od¡acent dañar site must
have an adequately thick buccal
plote of bone covered by gingiva
with a certain degree of thickness
and dimension. Thin, friable gingiva
over a thin sculptured alveolar pro-
cess is indeed a risky donor site. The
suspected presence of o dehiscence
or extremely thin bone in the donor
areo certainly limits the use of a full
thickness laterally positioned flap.
Utilization of a laterally positioned
flap also may be complicoted by the
presence of a shallaw vestibule -
that would negóte the procedure. It
"The Intemationol Jotrnol ot Penodontics Old Resloiotive Derlistry" 3/1983
seems that areas of gingival reces-
sion often occur ad¡acent to areas of
thin gingiva and bane or perhaps a
dehiscence. Therefore, the laterally
positioned flap has its limitations
arising from inadequate donor
areas, and one must be selective in
performing the procedure for root
coverage.
Double Papilla Graft
The double papillo groft, reported by
Cohen ond Ross,^ serves os o useful
procedure in covering localized root
exposure. The degree of success
seems to vory among clinicians, indi-
cating perhops thot the foilure rate
could be reduced if more precise
suturing techniques were used. In this
regard, Rubelmati^ has described
some excellent guidelines to follow
when performing the procedure.
Corono I ly Positioned Graft
The coronolly positioned graft, a
two-stage procedure, is currently
being used considerobly for covering
a denuded root, Bemimoulin^° has
refined the originol procedure and
has indicated that it is predictable in
partial coveroge of the exposed root.
Others, such as Maynarc/," Caffesse
and Cuinard,^^ Matter,^^ Teenen-
baum, Klewansky and Roth,^'' Liu
and Solt,^^ and Ototno ond Sims,^^
have done considerable work with
the coronolly positioned graft. These
reports and others indicate thot the the mesial, distal, and apical vascu- Dry Skull Observation
coronolly positioned groft is the most lor margins will maintain opproxi-
predictable method for covering a mately 1-2 mm of new keratinized Anatomical factors represent on im-
denuded root ond that 59-75% tissue over the apical partion of the portant aspect of all clinical
coverage may be anticipoted. deep wide recession." More re- periadantal pracedures. The obser-
cently, Mlinek, Stnukler onó Bûcher,^ vatian of normal gingiva, ond par-
Hawley and StaffettnoP Ward,'^' ticularly dry skull material, reveals
Free Autogenous Gingival Graft Llvitigsfon,^^ Guinard and Cof- some valuable information an the
The free autogenous gingival groft fesse,^^ and Coslel, Rosenberg and subject af gingival recession. The ar-
has gained a tremendous reception Tisot,"^^ hove published their own ob- chitectural types of gingiva and bone
from the periodontist and is no doubt servations of the autogenous groft (i.e. scalloped and flat) and their in-
the most frequently used method of and root coverage. Generally, the fluence on therapy has been previ-
grafting in general, awing to its free gingival graft seems to have little ausly discussed.^" Recessian with
simplicity, availability of donor tissue, application to root coverage, and its root exposure generally is seen an a
and wide application. Bjorn^^ ]s cred- limited success seems to be confined scolloped, thin periodontium and
ited with having been the first to use to areas of minimal recession. An seldom on a flat, thick type. Many
the free gingival groft procedure. opposite opinion was recently re- clinicians have abserved that scal-
Pennelf^ ond Nabers^'^ were the ported by Miller'^^ He opplied citric loped, sculptured gingiva and bone
early workers in this country, with the add to root surfaces prior to the ore susceptible to insult. Weîsgold^^
lotter describing the use of o gingival placement of grafts, and the results has stated that slight injury to the
groft that covered an area of gingi- were interesting and impressive. pronounced scalloped type of gin-
val recession. Sullivan ond Atkins^'^'^^ However, the statement issued at the giva during foath preparation can
published a series of articles more 1981 Nationol Institute of Dental Re- precipitate recession. If flaps have
than 10 years ago, explaining many search meeting on "The State of the been reflected on "ideal" normal
aspects of gingival grafts. Most of their Art^'" probably represents a com- gingiva, fenestratians and dehis-
remarks remain valid today, even mon attitude regarding the use of censes would be evident on many
after numerous studies by other com- grofts over denuded roofs. It was coses. Highly sculptured bony or-
petent researchers. It was their belief concluded that "only a narrow and chitecture is shown (Fig. la) with ex-
that the most difficult type of reces- shallow defect can be adequately tremely prominent roots ond taper-
sion ta treat was the deep, wide vo- covered by a free graft, since only ing tooth form. Fenestrations and de-
riety. This type of recession, they that size af lesion can provide hiscences offect most of the anterior
soid, was "too wide for two point adequate collateral circulation dur- teeth, so it seems evident that this
collaterol circulation to predictably ing initio! healing to assure the take type of onofomy would be os-
bridge the coronal avoscular orea. of the grafts." sociated with o highly sculptured gin-
Apicol circulation is too for away to givo. The root prominences of the
Old in maintaining the graft over the anterior teeth and the undulating ef-
coronal avascular area, therefore fect of the bony process are seen in
the tissue will necrose. The resulting Fig. 1 b. The concavities between the
three point collaterol circulation from prominent roots are particularly evi-

"Tfie Interratiorol Journol of Pe.iodonlics and Restorotive Deniistry" 3/1983

12

7. ¡a Maxillary anterior view oi o dryskvH with extreme sculpturing.

nesfroHons ond dehtscenses are obvious. This bany architecture is
jolly seen with a thin, sculptured, esthetic periodontium.

F>g. It Definite concavities are visible between the prominent roots.

Fig Jc Anterior view ota mandible with a pramir^ent relotiot^ship ot

the leefh to their bony support. Multiple fenestro'ions ond dehiscences
ore seen. Similor anotomical form would likely predispose o periodor}-
tium to severe gingivol recession.

'The internorionol Journal of Periodonhcsord Restorative Dentistry" 3/1933

 13

dent. Prominent roots also are seen

associoted with dehtscences and
fenestrations (Fig, Ic), This anatomi-
cal pattern might be associated with
a scalloped, thin, and possibly
fragile gingiva.
Anatomically, the most difficult de-
nuded root to cover with a one-stage
gingival graft is the maxillary canine.
Figure 2a is a maxillary conine with a
typical toath-to-bone relationship.
Since the canine is located at the
corner of the arch, there is o
mesiodistal curvature as the raot re-
lates to its mesial and distal bony
plate, A profile view of the same
tooth demonstrates considerable
apical curvature of the roat and
bane |Fig, 2bj, This is a comman re-
latianship in which the cuspid root Fig. 2a Dry skull view of a rr>oxtllary can"^ hg 2'D A profile view of the tooth in Figure 2Q.
ifJteraGntal concavity IS pronounced an the f^atïce the occluso-apical cufvature of the thin fa-
bends toward the palate. The aspect of the root. cial bane aver the roat prominsnce and the iT'esiol
fnterdental concavly. The pratnmerft cartrne *aot
mesiodistal and occluso-opical can- tnvalves a rnestoufstat COrtven'ly^ on occ'uso-opi-'
vexities compound the problem af cal canvexity. and olsa a rr^esiol and distol ¡nter-
dental carjcav'fy. Conventional coronai Sijtofir^g
adapting a groft to the area. In addi- will nat adapl a groft over a denuded raot under
such crcumstances.
tion to these problems, interdental
concavities are present mesial and
distal to the root prominence.
Routine caranal suturing of a graft in
o region with this anatomical topag-
raphy would allow the graft to buckle
ar floot freely at the apical portion.
The graft also would fail to adapt
over the interdental cancavities,
creating gross areas af "dead
space," The graft placed overo bare
raot will survive only if it is nourished
with plasmatic circulation for the first
2 days. The diffusion of fluids cannot
occur unless the graff is molded ar
adapted over this rather complex
surface topography.

"The Intemoliond Journal of Penodoniics and Resloraiive Denlistry" 3/1983

14
Clinical Examples
Shown fiere are several examples of
clinical cases of gingivol recession
which have been treated by a one-
stoge gingivol graft witfi tfie objec-
tive of total root coveroge. The oc-
tual amount of gingival recession in-
volving a tooth hinges on the pres-
ence or absence of a deepened sul-
cus or pocket associated with the
area. Therefore, Liu and Solf^ hove
clossified recession into twa types.
Visible recession is defined as the
clinically observable root measured
from the cementa-enamel junction to
the margin of the gingivo. Hidden
recession is the depth of the sulcus
or pocket as measured from the soft
tissue margin to the junctional
epithelium. The totol amaunt of re-
cession is the sum of the two types.
Dual lesions involving two mondibu-
lar centrol incisors are seen in on or-
thadantic potient (Fig, 3o). The pa-
'The III te m atonal Jourrol of Periodontics ond Restorotive Dentistry" 3/1983
tient was a 16 year-old girl, Bath she
and her mather had definite desires
to cover the root surfaces. The ar-
thodontist had o keen interest in the
progressive recession of the 2 in-
cisors ond the possibility of future
tooth loss. The right incisor hod 4 mm
of recession from the cemento-
enomel junction to the gingivol mar-
gin and the left incisar had 3 mm of
recession. Bath incisars had a sulcus
depth of opproximotely 2 mm. Fol-
lawing bed preparation, the amount
of exposed root surfoce increosed to
6 mm for the right incisor and 5 mm
for the left one. Because of the foct
that this case qualifies cs a deep and
wide recession, involving two teeth,
the possibilities for root coverage
were slim. The postoperative result is
seen in Figure 3b, with gingival mar-
gins ot or neor the cemento-enamel
junction (EJ¡. The sulcus depth is less
thon 1 mm cs measured with a
Michigan "0" probe.
 15

Fig. 3a A potient. with recession involving the

mandibular central incisors, shown öfter ar-
Ihodontic treatment Both incisors are praminent.
Definite inteidentol concavities are associated
with these two teeth. The gingiva is thin and
fragile.

Fig. 3b Postoperative result with gingivoi mar-

gins ot the cemento-enamel lunction. Sulcus depth
is less thon I mm. Look at the occlusa-apicol di-
mensian af the new zone of attached gingiva.

'The lolernolional Journol of Periodortics and Restorotive Dentiitry' 3/1983

16

A maxillary canine wos seen with 5

mm recessian of the root surfoce and
a width of 4.5 mm (Fig. 4a). By our
currenf standards, this represents a
deep, wide variety. The patient had
a high lip line and was concerned
with the gradual exposure of raot
surfoce. Root sensitivity had been an
ongoing problem despite various
methods of treatment. The sulcus
depth was 1.5 mm; following bed
preparation the total root exposure
was 6.5 mm. The root surfoce was
relatively flat, which was conductive
to success. In the 2-year postopera-
tive picture (Fig. 4b], the gingival
margin Is at or near the CEJ ond
there is a shallow sulcus,
A 15-year-old girl had recently cam-
pleted orthodontic therapy (Fig. 5a).
Her mother hod been a periodontal
patient for a number of years end
wos concerned about herdaughter's
recession in the canine-premolar re-
gion. The plaque index was 0 and
the sulcus depth was less thon 1 mm.
No treotment was given. One year
later, recession had increased
slightly on the first premolar, and a V-
shaped lesion with a small cleft was
present on the canine [Fig. 5b), Early
erosion was visible on both teeth. It
was believed that the farmation of
the cleft in the presence af very
thin, delicate gingiva would lead to
more extensive recession and root
exposure. A graft was performed to
cover the exposed roots and place o
much thicker gingiva in the area. The
graft was approximately 1.5 mm
thick at the time of surgery. Appear-
ance 28 months postoperative!y is
shown in Figure 5c. This typical case
illustrotes that excessive root expo-
sure can and does occur with alarm-
ing rapidity in certain young individu-
als.

'The International Jaurnal of Periodonlics and Restorolive Dentrstry" 3/1983

 17

Recipient and Donor Sites

The bed for the graft usually extends

approximately one tooth width on
each side of the recipient site. A stob
incision is made at the mucogingival
junction with a shorp pointed knue.
LoGronge curved scissors are in-
serted info the constricted incision
ond the mucosol portion of fhe bed
is prepared in on apical direction.
Periosteum is retained over the bone
The bed extends approximately 5
mm opicol to the gingival margin of
the denuded root. The orea should
be prepared with scissars, and not a
knife, to keep the bed clean and free
of connective tissue remnants. The
gingival portion is prepared by sharp
disection with o worn, shorp knife. 5û Poslorthodontic treatment ol o 15-ye Fig. 5b One year later, the premolar hos had a
jirl wilh early recession on a maxillary conn slight increase in recession and the cuspid now
The bed extends coronally on both first premolar has an early dell lormatlon. Early erosion involved
both teeth.
sides of the tooth to the level of the
desired root coverage and laterolly
just short of the adjacent tooth. All
sulcular epithelium that borders the
denuded root is removed. Care
should be taken tbot additional root
exposure is minimal. Root planing
Fig. 5c A 28-month postoperative result The qingival margin is ot the cementa- el¡uncllan The graft
produces a considerable reduction thickness was slightly excessive and exhibitis ¡his thickness m the photograph
af cementum thickness. Roat convex-
ity is somewhat diminished and thus,
in theory, minimizes the mesiodistal
dimension of the root surface. This
procedure con be done more ex-
peditiously with a properly designed
chisel or similar instrument thot will
produce a smaoth surfoce and plane
the borders of the denuded root pre-
cisely. Exfent of reduction of the root
prominence is empirical. The reci-
pienf site is irrigated and covered
with a saline-saturated gauze while
the donor tissue is being removed.

Jojrroi o( Periodontics ond Reîtorolive Dentistry" 3/1983

18
Fig ¿A Properly designed graft with
right angles ta the i^eratinKed surface.
'Tlie Internalioral Journol ol Penodortics and Restorotive Dentistry" 3/1983
A graft of praper size can be outlined
by various methods. The donor tissue
should cover the gingivol bed and
extend at least 3 mm apical to the
margin of the denuded root. The
graft shauld be uniformly thick, with
margins at right angles to the body
of the graft. These margins are never
beveled, it is important to have
adequate groft thickness becouse
this tissue later will represent the cer-
vical marginal gingiva, Praperly and
paoriy designed grafts are shown in
Figure 6, A graft with o beveled un-
dersurface cannot be adapted
adequately in the marginal orea and
also lacks connective tissue thickness
in the same area. Posterior palatal
gingiva is alsa nat suitable donar tis-
Fig. óB Improperly ( cuted graft with beveled sue. Following removal, the graft is
in graft thickness.
placed immediotely on a saline-satu-
rated gauze ond examined for any
adipose tissue and excessive thick-
ness. While bath of these problems
can be remedied with the aid af a
sharp blade or knife and scissors, it
is best to remove the groft in the de-
sired thickness. The graft should re-
moin covered with saline solution
until it is placed on the recipient site.
 19

Suturing

^ ~ \/ \ r ^
We prefer silk suture material with a
tapered otraumatic needle (Ethicon
5-0 N266H).* It is also beneficial to
have a proper needle holder such as
—N
G curved Costroviego instrument.'*
The initial suture is olways the hori-
zontal cantinucus suture and is
placed approximately midway
carono-apically across the graft.
First, the graft is tied at its distal mar- AG
gin to the underlying periosteum. The
suture is not cut, but is carried an- PB ^
teriorly across the graft with the
needle passing through the mesial
margin of the graft and exiting ot its
undersurface. It is helpful to use a
Corn suture plier for stabilizing the
graft so thot the suture can pass Fig 7 The harizantal continuous suture. The gralt is tied al its distal margin. The suture extends -.the
body ol the gralt, passes through the wesiaf balder al the grah and eats ¡ram its undersurface. A la .
through it. Slack is left in the portion remQj'ns in the suture extending across the graft. The suture then passes through the periosteal bed ap-
of the suture that extends across the proximately 2-3 mm mesial ta ihe border ol the graft. The gralt can now be stretched when the loop is tied
to the suture tail. a. Suture loop; b: suture tail; PB: periosteal bed; AC: attached gingiva; C: groft.
body of the graft. Next, it is important
that the needle enter the periosteum
at a sufficient distance from the me-
sial border of the groft sa that the
graft can be stretched adequotely,
ordinorily 2-3 mm. The suture end
that has exited from the periosteum is
tied to the loop formed by the slack
(Fig. 7). The horizontal suture should
be tested for tension with o curette or
similar instrument.

The only mention of "graft stretch-

ing" in periadontal literature is in a
repart by Sullivan ond Adkins, who
quote from two plastic surgery refer-
ences dating back to 1925 and
19^2.32,33 Stretching the graft may
counteract primary contraction and
make the graft more receptive fa re-

Johnson + Johnson Dental Products

Co., 20 Lake Dr., East Windsor, NJ
08520.
Hu-Friedy Compony, 3232 N, Rockwell,
Chicago, ILÓO618.

"The hternotiono! Journol of Periodontics and Reslorative Denlislry" 3/19B3

20
Fig 80 Graft sutured at its distoi morgin. Note
Ihe mesial morgm of the graft ond its rehtianship
to the periosteal bed
•The fnternotional Journol of Periodontics ond Restorotive Dentistry" 3/1983
Fig. 8b The graft is stretched ond tied ot Us
sial morgin os described in Figure 7.
vascularization by influencing the
collopsed blood vessels, A horizon-
tal suture can be tight, but it may or
may nat stretch the graft. Therefore,
a tight suture and a stretched graft
may nat be coexistent. Graft stretch-
ing is shown in Figure 8, The graft hos
been sutured to the bed at its distal
ospect ond is short of the mesial ex-
tension of the bed (Fig, 8o|, The graft
is stretched oppraximately 2 mm ond
tied on the mesial surface (Fig, 8b),
The purpose of the circumferential
suture is to adapt the graft to the un-
derlying marginal borders of the de-
nuded root so thot o dead space will
not develop in this criticol orea (Fig,
9). The suture is ploced through the
periosteum opical to the denuded
root and slightly below the inferior
border of the graft. If the suture goes
through the periosteum too for opt-
cally, the inferior border of the graft
may not be adopted. This is particu-
lorly true for the maxillary canine with
its pronounced coronal apical curva-
ture. The suture is carried around the
cervical region of the tooth and tied
to the apical portion with pasitive
tension [Fig, 9),
The adaptation of the graft with the
aid of a vertical suture will compress
and retain the graft in close proximity
to the periodontal ligament. Cellular
activity originating from the
periodontal ligament moy be an im-
portant foctor in the repoir ond survi-
vol of the graft. Recently Nyman,
Ltt^dhe, Karring and RylandeP' have
shown the tremendous potential of
the periodontal ligament to form new
cementum and investing fibers.
The next suture involves the adopta-
tion of the graft into the mesial and
distal interdentol concavities. This re-
quires two separate sutures (Fig, 10),
It is often difficult to insert the needle

through the periosteum in the depths
of the inferdentol concavity unless
the curvature of the needle is re-
duced. The curved Castroviego
needle holder olso will aid the clini-
cian in this endeavor. In many in-
stances, the circumferential and in-
terdental concavity sutures have
odapted the coronal marginal tissue
and there is no need for a coronal
suture; here, there are only two
needle punctures or holes in the
graft. FHowever, if the coronol mar-
gins of the graft are not adapted in
the interdental orea, a coronal suture
can be placed. As a final procedure,
one should examine the position and
tension of all sutures.
Application of Suturing Principles
A final clinical example demonstrates
the suturing procedures ad-
vocated in a difficult situotion. Figure
11 reveals recession of 3 mm on a
mandibular canine and 4 mm on a
first premolar. Notice the promi-
nence of these two teeth as they re-
late to the arch and the concommit-
ant undulated, washboard effect of
the existing gingiva. A two-stage
procedure with a coranally
pasitioned graft could have been at-
tempted, but the procedure is less
likely to succeed on the mandibulor
arch. Experience indicotes that the
graft is difficult to position coronally
at the cementoenamel junction on
mandibular onterior areas, ond thot
much of the graft may be lost in the
process. The bed was prepared as
shown (Fig. 1 la). Now 4 mm of ex-
posed root is present on the cuspid
and 5.5 mm exists on the first premo-
lar. The root surfaces have been
planed vigorously with a chisel. Fig-
ure l i b illustrates the sutured graft
and the variety of sutures used. This
case is typical of many in which the
suturing is designed at the time of
surgery to sotisfy the circumstances
dictated by the existing onotomy.
Coronal marginal sutures are evi-
dent on the mesial ond distal exten-
sions of the graft. A circumferential
suture is present on both canine and
premolar, with an interdental con-
covity suture on the mesiol of the
canine. A vertical suture has been in-
serted in the interdental concavity
between the twa teeth; it loops
around both teeth and is tied on the
buccal. The graft is placed coronally
at or neor the cementaenamel ¡unc-
tion. A four-month postoperative
view shows the gingival margin at
the level of the cementoenamel ¡unc-
tion (Fig. 11 c). The sulcus depth is no
more than 1 mm.
Considerations for Graft Adaptation
It is currently common practice to su-
ture grafts at their coronal border
and avoid suturing at their base. The
contention is that the centrol area of
the graft retains blood when apical
sutures are used. Furthermore, it is
believed that a dead space is likely
to result under these circumstances
and the groft may become necrotic
from lack of nutritional support. Still
other clinicians object to apical su-
tures thot oilow movement of the fa-
cial musculature to sever or damage
minute capillaries that have invaded
the graft from the adjocent tissue A
common approach today is to keep
suturing simple and minimal.
itvingslone}^ concerned with graft
adoptation, contoured the connec-
tive tissue aspect of the graft by
creoting concavities ta prevent dead
spaces. The concavities produced a
•The Internalranal Journal of PenodonHcs and Restoratii/e Deniislry" 3/1983
21
more favarable contact of graft to re-
cipient bed relatianship.
When a graft is sutured only at its
coronal border in a conventianol
manner for purposes of increasing
the width of attached gingiva, the
graft lies in close contact with the
prominent periasteal bed over the
raot (Fig. 12|. This factor may be the
prime reason for the survival of many
such grafts. When a graft is placed
over a denuded raot, obviously it will
be dependent on peripheral sources
far its survival. Suturing then be-
comes critical, as the graft must be
thoroughly odapted to the topog-
raphy of the recipient site ¡Fig. 12a).
When the coronally sutured graft is
placed far the purpose of increasing
the width of attached gingiva, it is the
convexities that supply the primary
nourishment for its survival. How-
ever, the concavities supply much of
the vitality for the gingival graft over
the denuded root.
After observing the anatomical to-
pography of a cansiderable number
of prepared beds and denuded raot
surfaces, one factar seems rather
obvious - dead spaces and
hematamas beneath grofts with cor-
anal sutures connot be eliminated by
finger pressure techniques in an at-
tempt to express pooled blood and
adapt the graft properly. While
methods of graft suturing for root
coverage may not need fo be identi-
cal with those advocated here, it
would seem that various methods of
graft adaptation that give adequate
cansideration to the anatomy of the
recipient site are necessary.
Graft Thickness
The thickness of a graft and its influ-
ence an clinical results has been a
22

Fig. 9 The circumlerential suture is inserted irlo the periasteal bed

slightly apical ta the inlerior margin of the groit. The suture entends
around the cervical area althe taoth and is tied lo Ihe tail. The sutures
can be seen compressing the graft al ths borders ollhe denuded raol
represented by the datted lines. CS Circurnlerential suture; HS. hori-
zontal suture: PB' periasteal bed: /^G: attached gingiva.

Diagram A shows a crass-section oía groll overo denudedraot

Sutures adapt the grah at the ¡unction ol the periosleal bed and the
denuded raat. DR: Denuded root; S: suture, G: gfoh.

Dioqram B. The circumlerential suture is inserted into Ihe periosteal

bed slightly apical ta the inlenar margin af the groft 7ïie suture extends
oround Ihe cen/ical area af Ihe taalh and is lied to the toil. The sutures
can be seen compressing the gralt at the borders at the denuded raat
represented by the datted lines. CS: Circumlerential suture: HS: hori-
zontal suture, PB: penosteal bed; AG: attached gingiva.

Fig 10 The interdental concavity sutures. The suture is inserted into

the depths af the interdental concavity periosteum, diagonolly
traverses the gralt, circles the loath and is tied lo Ihe suture toil. The
same procedure is repealed lor the other inlerdenial concavity. ICS:
Interdenfol concavity suture; PB: periostea! bed; AG- attached gin-
qiva

'The interrolionol Journoi of Peiiodontics ond Restoiotive Dentistry" 3/19S3

 23

Fig. ¡ la Recession involving the mandibular cuspid and firs' premoia Fig. I ¡b The penosteal bed hos been prepared ond Ihcrc n now -1 mm
with praminent roats and thm periodontium. Rolled gingival margins ar of exposed raot an the cuspid and 5.5 mm an the lirst premalar. Note the
evident with an undulated surface lapagtophy. mesiodistal dimension o ' (he raot at Ihe cementaenumel ¡unction af the
first premolar with its pronounced canvexity.

Fig. 1 Id Postoperative result. Girigival rrjargins at the cementaenamel

Fig lie A variety af sutures have been used to adapt the graft. Inad-
iunctian and the sulcus depth is I mm. Campare the coraijal position ol
dition to the horizantal, circumferential, interdental and coronal concavity
the sutured grail in Figure We with the postoperative result
sutures, there is a -vertide suture 'n the interdental concavity between the
twa mvatved teeth.

"The Interralional Jourrol of Periodontics and Restorative Dentistry" 3/1983

24

Fig. 12b Cross-section al a property sutured grohaver a denuded root

and the adjacent periasteal bed The circumferentiol suture adapts the
grail at the barders al the denuded raot and the periasteolbed, which in-
cludes the periadantal ligament. The interdental concavity sutures adapt
the graft inta their respective interdental concavities. ICS: Interdental con-
cavity suture; CS: circumiererlial suture,- DR: denuded roat; P: perias-

'The Inlernationol Journal ol Periodontics and Resloraliue Dentislry" 3/l?S3


topic of interest for some time. In this
regard, a recent and interesting pub-
lication by Mormann, Schaer, and
Firestone^^ reports findings with an-
giogropfiic studies ond graft thick-
ness. The current attitude about graft
thickness seems to be that the thin
graft has less contraction of its capil-
laries and will revascularize faster
than a thick graft. Furthermore, Gar-
giulo ond Arracha indicóte that the
thin graft is more receptive to the dif-
fusion of fluids during the critical
periad of the first 48 hours when the
graft is sustained primorily by the
exúdate of red blood cells, leuko-
cytes, and plasma cells,^* As o thin
groft is theoretically supposed to sur-
vive longer without circulation, it
would seem logicol to choose the
thin graft where circumstances for
survivol ore difficult.
Grafts of varying thicknesses hove
been placed over denuded roots by
a standardized method of suturing,
as described in this paper. It was
noted that grafts in the 0,5-0.75 mm
range have a high mortality rate.
While grofts of this thickness obvi-
ously survive very well when sutured
over a bed of periosteum-connective
tissue, they frequently sloughed
when placed over a denuded root.
Contrary to common belief, the
thicker graft of approximately 1,5
mm will survive very well, especiolly
if the bed is relatively flat. This thicker
graft is technicolly more difficult to
adapt to a surfoce which has consid-
erable occlusol-apical curvature, in-
terdental cancovities and marked
mesio-distal curvature of the root
surface. However, diligence and
finesse in the suturing technique de-
scribed will focilitate adequate
odaptotion to the periodontal liga-
ment and adjocent periosteal bed
Saehren, Allen, Outright and
Selbeti^^ have stated that palatal
epithelium ronges from 0.1 to 0.6 mm
in thickness. A graft approximating
1,5 mm thickness seems to have an
adequate dimension of lamina prop-
rio, ond has been found by the
authors to have the best survivol rote
over o denuded roat,
A gingivoi groft with a thickness in
the ronge of 1,5 mm creates a rela-
tively thick tissue over the root where
in many instances a thin gingiva had
previously existed. Clinical observa-
tion of grafts aver denuded roots in-
dicates that they survive fairly well
even after continual use of less than
ideal toothbrushes by the patient.
Graft potients and porticularly young
individuals, usually have additional
areas of thin gingiva over roots that
are candidotes for root exposure
ond may require periodic monitor-
ing. With this type of clinical patient
in mind it seems that groft potients as
well as others with thin, frioble gin-
giva should receive a brush with the
least abrasive bristle,* Clinical ob-
servations has indicoted thot 0.007
diameter nylon bristle is less abrasive
than the more commonly used 0,008
diameter bristle ossuming that both
have rounded polished ends.
Graft Shrinkage
Graft shrinkoge ossocioted with cur-
rent coronal suturing has been re-
ported to be OS common as 25-
50%,^^^' Close observation of
anatomical curvotures in certain
areas might reveal that the shrinkage
is related to poor adaptation of the
graft to the recipient site using the
coronol or "clothesline" suturing
technique. Tfiis is porticulorly true for
maxillary and mandibulor Conines,
'Tfie Internotioral Journal • ! Periodontics ond Restorotive Denlistry' 3/1983
25
as previously mentioned, owing to
their anatomical circumstances.
Another factor related to groft shrink-
oge is the beveled margin produced
by various instruments designed to
remove the graft. As discussed previ-
ously, a properly designed graft
should be uniform in thickness with its
margins at right ongles to the surface
epithelium.
Fatty Tissue and the Graft
Consideroble emphasis has been
placed on the importance of remov-
ing any fatty or glondular sub-
mucosal tissue from the graft, Sulli-
van and Atkins stated that if this fat is
inadvertently included in the palatol
graft, it will act as a borrier both to
difussion and vascularization and
therefore should be removed.^"^^ ^'
Recently, Corn and Marks expressed
support of this common belief. They
hove stated, "when the dissection
(sic, donor tissue) involves the
odipose and glandular zones, it is
necessary to dissect these tissues
away from the groft, leaving the
inner surface as smooth as possi-
ble.'"'^ A different point af view has
been recently expressed by Gront.'^
In uncompleted studies, he found
that fatty tissue in the donor seg-
ments survived tronsplontation.
Furthermore, he has noted an
odequate even abundant circulation
in palotal adipose tissue and expres-
sed that the maintenance of an inner
smooth surface and the creation of
desired thickness of the graft should
be the principle considerations.
' P.O.H, Toothbrush Comp.
26
Speculations on Graft Stretching
The plastic surgery literature indi-
cates that graft stretching is benefi-
cial to the groft as wos mentioned
previously.^^' '*'' Primary contraction
produces a collapse af the blood
vessels in the graft which delays vas-
cularization. The stretching of the
graft is said to counteract primary
contraction by praducing patent
blood vessels and thereby aid revas-
cularization. FHowever, while the
above may have certoin applications
to the successful management of
gingivoi grafts, it should also be re-
membered that difussian of fluids
and capillary penetration are im-
peded by a hematoma. The pre-
sence of blood in the blood vessels
of the graft and its subsequent clot-
ting may pose a similar problem far
difusston and revascularization.
Perhaps the stretching of the graft as
it is being removed from the palate
and also the stretching that takes
place with the initial horizontal suture
expells a clinically significant amount
of blood in the vessels. If this
hypothesis is correct, the blood ves-
sels would be more patent and per-
mit anastomosis with vascular buds
from the graft bed.
Evaluation of Results
Fifty documented examples
selected randomly from 200 clinical
cases. Patients included 29 females
and 6 males ranging in age from 10
to 60 years. Thirty-six teeth were in-
cisors, seven were canines, five were
premolars and two were molars.
Eleven recessions were less than 3
mm, 30 were 3-5 mm ond nine were
greater than 5 mm. Recessions less
thon 3 mm had 95.5% total root
coverage, recessions of 3-5 mm had
'The Irterroiionol Jourral ot Peiiodontics and Restorotive Dentistry" 3/1983
coverage of 80.6%, and the reces-
sions greofer than 5 mm had cover-
age of 76.6%. Six of the 50 reces-
sions covered less than 50%, 39 of
the 50 coses covered 80% or more,
and 22 recessions covered 100%. It
was also interesting to note that
seven of the nine recessions that
were greater than 5 mm had cover-
age of 90% or more. All produced o
zone of attached gingiva that ap-
peared clinically adequate in dimen-
sian.
Conclusion
Coverage of the denuded root using
the autogenous free gingivoi graft as
o single procedure hos been dem-
onstrated to be a successful and use-
ful technique for the clinician at-
tempting to recapture the original
morphology of the periodontium.
Observation of the anatomical find-
ings and proper adaptation of the
donar tissue to the recipient site will
reward the clinician for his efforts.
The procedure described here dem-
onstrates the extent to which surgi-
cally compromised tissue can survive
if certain criteria are satisfied. Obvi-
ously, some questions may be posed
about the relative importance and in-
terpretotion of fhe various parame-
ters. Success seems to be related to
a multiplicity of specific factors.
Realistically, the precise suturing pro-
were
cedures described are demanding,
and for that reason may not gain
general occeptance or usage.
A detailed histalogical evaluation of
the ottochment mechanism between
a graft and the denuded roots is not
available. The subject is being inves-
tigated at present. One may hope
that future studies will supply the
clinician with further insight into this
interesting clinical problem. n sion Treated by Coronally Reposifianed
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