Gingival Graft Failure!
Graft failures are relatively common and can often be stressful for both the clinicians and patients. This case describes what graft failures look like and how to manage them...
Clinicians always share their successes and pictures of cases with impressive results. Unfortunately that is not a reflection of real-world clinical practice. In the real world we get failures a lot more frequently than we like. It is important for us to understand how to manage failures and learn from them.
This particular patient attended with miller grade 3 gingival recession on the lower anterior teeth. She didn't like the appearance of her gums and struggled to keep them clean. The biotype was very thin and delicate and made it sore for her to brush in the area. This resulted in a vicious cycle of "inflammation - sensitivity -inability to brush - worsening of inflammation/sensitivity - worsening of the recession".
After a frank discussion with the patient we explained that some of her concerns can be resolved with surgical treatment but not all. Due to class 3 Miller recession (where interproximal tissue height is decreased) it would not be possible to regain full root coverage of the teeth. However we may be able to improve the thickness of these tissues to make them more resilient.
Outcomes agreed with the patient:
Minimal improvement in gingival recession
Increase in thickness of gingival tissues
The patient understood that by increasing the thickness of ginigval tissues it will make them more resilient. This means that the likelihood of inflammation and further recession will be decreased. It will also mean that she will be able to maintain the area better.
Choice of Surgical Procedure
The gold standard in gingival augmentation is regarded as connective tissue grafting. The benefit of this technique is that it is less destructive to the palatal donor site and tends to have higher success rates. The higher success rates are due to the fact that connective tissue grafts are provided with a dual blood supply (one from the underlying periosteum, and one from the overlying flap) at the recipient site due to the use of a bilaminar technique.
Unfortunately in this case the biotype was so thin that a spit thickness flap to allow placement of a connective tissue graft would not have been possible. As a result it was chosen to undertake a Free Gingival Graft to augment the area.
The first step in augmentation involves preparing the recipient bed. This in effect is a de-epithelialisation of the gingival tissues at the desired site. The bed must be large enough to ensure that there is adequate blood supply for the graft. This means that ideally we would like about 70% of the graft bed to be made up of vascular tissue and the other 30% composed of avascular tooth tissue. If the root surfaces area is large then the margins of the bed preparation need to be extended to incorporate more vascular tissue.
A suitable sized free gingival graft was then taken from the palate and sutured in place at the recipient bed. A combination of simple interrupted sutures and "cross-mattress-sling" sutures going from the periosteum apical to the graft and around the incisors. The stability of the graft is paramount. The plasmatic circulation brings a flow of nutrients to the graft from the underlying tissues. If this gets disrupted then the nutrient supply to the graft becomes lost and as a result the graft dies.
The usual advice at this stage for the patient is to completely leave the graft alone... this means no looking or touching the graft... it even means smiling or speaking gently so as to prevent your lips from rubbing too vigorously against it.
Unfortunately for this patient the graft didn't survive. The tissue became ischemic then necrotic. A week after the surgery the graft became completely free from the underlying tissues and fell out.
These failures rarely cause pain however do cause psychological distress to the patient. It was important to reassure the patient at this stage that such failures can occur.
Fortunately they are rarely complete failures and some keratinised tissue cells remain. In the picture to the right a small thickening of the marginal tissue can be seen indicative of a partial success. As we see later, this amount of keratinisation is sufficient for a robust gingival margin.
Repeating the Surgery
Following 2-3 months of healing a second procedure was performed to coronally advance the soft tissues. This time around another graft was not required as the gingival tissues were already thickened following the partial success of the previous graft.
A 3-sided coronally advanced flap was performed. The patient was again reminded that due to the recession being grade 3 Miller it will not provide full coverage.
The final healing led to a satisfactory result where some improvement in the recession was achieved as well as having thicker more robust soft tissue. Having thick tissues is the secret to long term success in root coverage procedures and that is why periodontists pay so much attention to soft tissue grafting.
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