D88 – Séance SFPIO // Biological and clinical aspects in utilizing connective tissue graft in esthetic mucogingival surgery

Résumé :

One of the most important aspect in mucogingival surgery is the definition of the phenotype of the tissue to be treated; this aspect has been stressed by the joint consensus AAP/ EFP in 2017
The gingival phenotype, in fact, thick or thin, is an expression of the genotype that may be influenced by local factors, as tooth position, rotation etc. so the evaluation must be conducted for any single tooth.
The quality of a phenotype, thick or thin, is influencing both the treatment choices as well as the esthetic outcome of the surgery.

The most utilized surgical technique for the treatment of multiple recession is the MCAF plus CTG, this technique in a recent consensus was indicated as the one yielding the best results and providing the operator with the higher probability of obtaining a complete root coverage . On the other hand the use of a connective graft is a more invasive surgery and could cause more discomfort to the patient when compared to the coronally advanced flap per se.

It is now well documented that the addition of a connective tissue graft to the multiple coronal advanced flap, when in presence of a thin tissue, is beneficial in root coverage, but when in presence of a thick gingival phenotype, the adjunct of a connective graft, not only does not improve the amount of root coverage, but also it yields anesthetic result.
Therefore, it is mandatory, when in presence of multiple gingival recessions, to operate a correct evaluation to determine in which site the utilization of a connective tissue graft is needed.
To operate in other worlds with a selective use of the connective tissue graft, reducing patient discomfort and increasing the esthetic result.
Another factor very often related to the use of the connective tissue graft is , among the other results, the evidence that it is capable to increase the keratinized tissue height.
The explanation to these phenomenon according to many authors is related to the induction of the connective tissue on the epithelium of the overlying flap, that is the induction of the keratinization operate by dense connective tissue.
A recent work has demonstrated that the augment in keratinized tissue is due to the contraction of the overlying flap which leave exposed in part the graft that in turn become covered by keratinized epithelium.
From a clinical stand point, thus, this increase in keratinized tissue become an esthetic disadvantages , also described as keloid tissue.
In conclusion the connective tissue of the graft , has to be rewarded as a “phenotype modificator” and for this reason utilized only when indicated.