An Alternative Donor Site for an Epithelialized-Free Soft-Tissue Autograft

The amount of attached and keratinized tissue necessary to maintain periodontal health and prevent recession has been debated frequently.^1-8 In the presence of effective plaque control, some studies have demonstrated that sites with or without attached gingiva demonstrate little difference in gingival health.^2-7 Where plaque control is poor, sites without attached gingiva may be more prone to inflammatory changes and gingival recession than areas with attached gingiva and a greater zone of keratinized tissue.² Adolescents undergoing orthodontic tooth movement are at a disadvantage in maintaining good oral hygiene. Bands and arch wires increase the potential for plaque retention and limit the effectiveness of brushing and flossing. In addition, tooth movement in the presence of poor oral hygiene may result in an increased risk for recession.^9,10 In light of these challenges, mucogingival procedures aimed at increasing the width and thickness of attached gingiva may decrease susceptibility to further gingival recession in patients requiring orthodontic tooth movement.¹⁰

Reported indications for mucogingival procedures in children include: 1) marginal tissue comprised of alveolar mucosa with a frenum pull; 2) exposed root surfaces with minimal keratinized tissue and no attached tissue; 3) labial eruption of incisors into areas with minimal keratinized tissue; 4) tooth eruption into a rotated position with minimal keratinized tissue; 5) a thin periodontium where labial tooth movement is planned; 6) orthodontic movement that may cause root exposure; and 7) maxillary incisor overbite resulting in the stripping of palatal keratinized tissue.¹¹

Treatment options in such situations may include epithelialized-free soft-tissue autografts (eFSTA), connective tissue (CT) grafts, or allografts. Traditionally, eFSTAs have been used for augmenting zones of keratinized tissue with good predictability.^12,13 This procedure requires a second surgical site to harvest the graft and may result in compromised esthetics after healing. CT grafts have been successfully used to treat recession and also to slightly increase the zone of keratinized tissue even when covered by a flap.^14-17 CT grafts offer the advantage of an improved esthetic outcome but also require a second surgical site, and therefore may not be the treatment of choice when the primary treatment goal is increasing the width of keratinized tissue. Allografts offer the benefit of a single surgical site and improved esthetics but may not predictably increase the width of keratinized tissue.^18,19

Autogenous soft-tissue grafts are usually harvested from palatal mucosa; however, other possible donor sites include edentulous ridges, retromolar areas, and wide zones of gingiva. The following case report describes a procedure to increase the width of the mandibular anterior facial gingiva in an 11-year-old female prior to orthodontic tooth movement by using the operculum over an erupting mandibular second molar as an alternative harvest site.

A healthy 11-year-old girl was referred by her orthodontist to the periodontal department at Wilford Hall Medical Center (Lackland Air Force Base, Texas) for evaluation of minimal keratinized tissue around her mandibular anterior teeth. A clinical evaluation revealed a narrow band of keratinized tissue (no more than 1 mm) and a high frenum attachment on the facial aspect of teeth Nos. 24 and 25 with no gingival recession (Figure 1). Her oral hygiene was good, and periodontal probing depths were ≤ 2 mm at all sites. The orthodontic treatment plan called for labial movement of the mandibular anterior teeth.

The preoperative assessment of the area revealed that a soft-tissue autograft of 10 mm in length would be necessary to adequately augment the zone of keratinized tissue. Treatment options were presented to her parents with the suggestion of harvesting the autograft from the gingival operculum covering the erupting left mandibular second molar (Figure 2). Informed consent was then obtained from the parents.

Prior to surgery, the patient rinsed with 0.12% chlorhexidine for 60 seconds. Local anesthesia was obtained using xylocaine 2% with epinephrine 1:100,000. The recipient bed was prepared for a conventional eFSTA. An initial incision was made just coronal to the mucogingival junction on the distal aspect of tooth No. 23 to the midline of tooth No. 25 followed by a split-thickness dissection that apically displaced the remaining keratinized tissue, mucosa, and labial frenum (Figure 3). The recipient site was measured, and a 6-mm x 6-mm x 2.5-mm thick eFSTA was obtained from the keratinized operculum over the erupting left second mandibular molar (Figure 4). Using two tongue depressors and a 15C surgical blade (Figure 5 ), the graft was split into an approximately 11-mm x 6-mm x 1-mm thick combination graft, consisting of an epithelialized half and a connective tissue-only half (Figure 6). The graft was trimmed, positioned against the recipient site, and secured with 5-0 monocryl sutures (Figure 7). The patient's lower lip was manipulated to ensure the graft would be immobile with lip movement. Postoperative instructions included no brushing of the surgical site. The parents were given a prescription for a 0.12% chlorhexidine rinse, ½-oz twice daily for 2 weeks, and 400 mg ibuprofen every 6 hours as needed for her pain. Follow-up appointments were scheduled at 2, 3, and 5 weeks, with a final evaluation at 8 months.

At the 2-week follow-up visit, the patient reported minimal postoperative discomfort following the procedure. The recipient site appeared to be healing well with pinkish-red donor tissue, suggesting revascularization of the autograft. Sutures were removed after the site was carefully debrided with 0.12% chlorhexidine on a cotton-tip applicator. Healing was uneventful at the donor site. The patient was advised to continue chlorhexidine rinses with no brushing or flossing at the surgical site. At 3 weeks, healing continued without complications. The oral hygiene instructions provided at this appointment were to gently apply chlorhexidine with an extra-soft toothbrush and a coronal rolling stroke. By 5 weeks, excellent healing and color match were noted. The patient was allowed to return to gentle brushing with toothpaste. The referring provider was informed that orthodontic therapy in the mandibular arch could begin. At 8 months, the patient was undergoing active orthodontic treatment. A gain of 3 mm in keratinized tissue height, as well as increased tissue thickness and apical displacement of the frenum attachment, was observed (Figure 8). The patient was unwilling to return to the authors' practice for additional follow-ups; however, the referring orthodontist reported that this augmented zone of keratinized tissue remained stable for the treatment duration.

Where possible, there are several advantages to using the gingival operculum from an erupting molar as an autograft. Avoiding the palate as a donor site minimizes both surgical trauma and postoperative pain and circumvents the risk of incising the greater palatine artery, especially in younger patients with shallow palatal vaults. Using the operculum as an autograft also allows more rapid healing at the donor site because the tissue covering the crown of the erupting tooth does not need to be restored. Because gingival tissue has a better color match when compared to eFSTAs from the palate, the esthetic outcome may also be improved. Operculum tissue is gingival tissue, so it is the same composition as other eFSTAs or CT grafts. As such, the authors would expect it to be as predictable in the long term as any other gingival graft; however, this has never been reported in the literature. Removing the operculum does not interfere with eruption and may improve the patient's ability to clean around the erupting tooth. The chief disadvantage to this technique is that the volume of graft tissue obtained may be limited. In this case, splitting the graft into epithelial and connective tissue halves was required to create a graft large enough to cover the recipient site. The use of CT grafts exposed in this manner to augment the zone of keratinized tissue is a common clinical procedure, which was first described by Edel.¹⁴ He reported significantly increased widths of keratinized tissue and a normal histologic appearance, using this technique. Had the recipient site been larger, a different surgical option would have been required.

An operculum autograft and a frenectomy were used to increase the width and thickness of keratinized tissue in an 11-year-old patient expected to undergo facial repositioning of her mandibular anterior teeth. The advantages of this procedure are ease of harvest, improved esthetic outcome, and avoidance of the palate as a source for donor tissue in a child.

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2. Miyasato M, Crigger M, Egelberg J. Gingival condition in areas of minimal and appreciable width of keratinized gingiva. J Clin Periodontol. 1977;4(3):200-209.

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12. Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles of successful grafting. Periodontics. 1968;6(3):121-129.

13. Sullivan HC, Atkins JH. Free autogenous gingival grafts. 3. Utilization of grafts in the treatment of gingival recession. Periodontics. 1968;6(4):152-160.

14. Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinised tissue. J Clin Periodontol. 1974;1(4):185-196.

15. Raetzke PB. Covering localized areas of root exposure employing the "envelope" technique. J Periodontol. 1985;56(7):397-402.

16. Borghetti A, Louise F. Controlled clinical evaluation of the subpedicle connective tissue graft for the coverage of gingival recession. J Periodontol. 1994;65(12):1107-1112.

17. Paolantonio M, di Murro C, Cattabriga A, Cattabriga M. Subpedicle connective tissue graft versus free gingival graft in the coverage of exposed root surfaces. A 5-year clinical study. J Clin Periodontol. 1997;24(1):51-56.

18. Harris RJ. Clinical evaluation of 3 techniques to augment keratinized tissue without root coverage. J Periodontol. 2001;72(7):932-938

19. Harris RJ. 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. Int J Periodontics Restorative Dent. 2000;20(1):51-59.

Jody S. Harrison, DDS, MS
USAF Periodontics Residency
Wilford Hall Medical Center
Lackland Air Force Base, Texas

Michael J. Conlan, DDS, MS
USAF Periodontics Residency
Wilford Hall Medical Center
Lackland Air Force Base, Texas

David E. Deas, DMD, MS
USAF Periodontics Residency
Wilford Hall Medical Center
Lackland Air Force Base, Texas