Re: Periodontists please help: Gingival Graft Procedure Questions

MrBCID wrote:
Hello to all who read this,

This is my first post on this group, and I want to thank those of you
that can help me out in advance :-)

I am 22 years old and a non-smoker, and have questions on a procedure
that my dentist has told me I need. I apparently need a graft to treat
teeth # 20 through #28. I know that a picture can only tell you so
much, but hopefully I can get an idea of what I should do about my
recession, in other words what would you do if you were my periodontist
and what should I ask my periodontist before having the surgery... Here
is a picture of my teeth. <p><a
href="http://members.aol.com/mp1984/dental";>
http://members.aol.com/mp1984/dental</a></p>

I have consulted with three periodontists and this is what each one has
said:

Periodontist # 1 - grade II - mucogingival involvement for teeth #'s
20, 21, 22, 23, 24, 25, 26, 27, 28. No attached keratinized tissue.
High frenum attachment. Probing depths were 2-3 mm. Bone levels
generally within normal limits. Correction by means of subepithelial
connective tissue graft. (He mentioned using alloderm; is that what
subepithelial connective tissue graft means?)

Periodontist #2 - Does not want to use alloderm like Periodontist #1
and wants to do only teeth 23, 24, 25, 26. and worry about the rest at
a later time... Wants to use my own tissue for these.

Periodontist #3 - This periodontist contact was via E-mail with the
attached picture above... He says he does not like to use alloderm
because he does not like the long term results (being that I am 22). He
mentioned that the bone on the front surface of these teeth is very
thin and has also receeded and that this is a permanent change.
(Doesn't this contradict Periodontist #1 that says bone levels normal?)
He also mentions that it is important to get rather large amounts of
thicker connective tissue in order to have tissue that will hold up
without further problems.

Now concerns of mine are:

Does the delicate mucosa need to be brought up over the grafted tissue
to allow it to heal?

Alloderm vs. my own tissue?

Should I have a free gingival graft procedure done on top of the
existing tissue and then later moving it up and covering more of the
roots? Possible complications of this?

How often do patients have this procedure done on 8 teeth?

Possible causes of this? I had braces from 96'-99' but my gums were
fine after they were removed... other causes? Will it happen again
after the surgery?

What can be done to help get ATTACHMENT of the tissue to the root
surface, (I have heard of "biological material" used as part of the
surgery) since I would like this to be a long lasting change that will
function normally.

Do I need to ask about bone grafting/splinting? What is this?

I really appreciate any information you can give me as to how
complicated of a procedure I need, what I should ask, etc. What I
thought was a simple surgery now has become a whole research project
for me, is it safe to say I have at least 3 problems to fix? 1) Gum
recession, 2) no tough, thicker, non-movable gingival tissue, 3) soft
mucosal tissue has quickly receeded and possible thinning bones?

Hope the picture helps, and again thank you very much in advance.

Michael


I am answering as a general dentist, not a periodontist. Is that the way your teeth normally come together in the front, or are you sticking your lower jaw out for visibility?
I am going to take for granted that the periodontists' pocket readings are accurate. The concern here is that the gums will rapidly recede without the protection of keratinized tissue. From your high-quality photo (thanks!) I can confirm that you have little or no attached gingiva in this area. However, you only have minor gingival recession visible, particularly over the two lateral incisors (#23 and 25).
The problem with subepithelial grafts is that (if I remember my histology correctly) the tissue overlying the bone (the periosteum) determines the level of keratinization of the overlying mucosa. You have a large area there with NO attached tissue. I don't see how this can be corrected without grafting of some kind. I don't know how commonly Alloderm is used--(I'm not aware that my periodontists use it) but it is likely the alternative is a free gingival graft. I understand a periodontist's concern about having to harvest that amount of tissue from your palate to cover such a wide area--hence the appeal of an exogenous graft material. I have no idea what problems periodontist #3 has seen long-term.
I did not see your gums right after your orthodontic treatment, so I can't say for certain that there hasn't been significant recession, only that the gumline is at a fairly normal level on these teeth. It is in fact very likely that there is no bone over the facial surface of these teeth--there is seldom much in any case, and it is possible that your orthodontic treatment may have compromised this, rather than any periodontal condition per se. In any case, when evaluating bone we look at the x-rays, which will show the level of bone in between the teeth; this no doubt appears normal, but it is difficult at best to assess bone on the facial surface of these teeth except during surgery.
My take (based on this photo) is that this procedure would be largely preventive in nature--we don't KNOW that you will suffer severe recession here. I HAVE seen it in this situation, but I have also NOT seen it in very similar situations over a period of many years, so don't feel you have to rush into this. I think if you ARE going to do this, have any periodontist explain the downside of using grafting materials, because not having to use tissue from the roof of your mouth is IMO a big plus, well-worth paying for. You do NOT need bone grafting to cover the roots (but you may need a membrane to allow proper healing of the graft and gum.

Good luck,
Steve
.

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