J Periodontal Implant Sci.  2020 Feb;50(1):2-13. 10.5051/jpis.2020.50.1.2.

Evaluation of 2 techniques of epithelial removal in subepithelial connective tissue graft surgery: a comparative histological study

• Marques de Mattos P
• Papalexiou V
• Tramontina VA
• Kim SH
• Luczyszyn
• Bettega PV
• Batista Rodrigues Johann AC

• KMID: 2470826
• DOI: http://doi.org/10.5051/jpis.2020.50.1.2

Abstract

PURPOSE
Subepithelial connective tissue grafts (SCTGs) are commonly performed for the treatment of gingival recession due to their high predictability. This study evaluated and histologically compared connective tissue grafts in terms of the presence of epithelial remnants and composition of the tissue types that were present (epithelium, lamina propria, and submucosa).
METHODS
Ten patients underwent epithelium removal using 2 different techniques: the use of a blade (group B) and through abrasion (group A). Twenty samples were collected and each tissue type was analyzed histologically in terms of its area, thickness, and proportion of the total area of the graft.
RESULTS
In 4 samples (40%) from group B (n=10) and 2 samples (20%) from group A (n=10), the presence of an epithelial remnant was observed, but the difference between the groups was not statistically significant (P>0.05). Likewise, no statistically significant differences were observed between the groups regarding the area, mean thickness, or proportion of the total area for any of the tissue types (P>0.05).
CONCLUSIONS
Histologically, SCTGs did not show statistically significant differences in terms of their tissue composition depending on whether they were separated from the epithelial tissue by abrasion or by using a blade.

Keyword

Connective tissue; Epithelium; Gingival recession

MeSH Terms

Connective Tissue*
Epithelium
Gingival Recession
Humans
Mucous Membrane
Transplants*

Figure

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  Figure 1 (A) Use of a millimeter periodontal probe to determine the dimensions of the tissue in the donor area. (B) Flap containing epithelial tissue, connective tissue, and submucosal tissue being removed from the donor area. Care was taken to maintain a uniform thickness of the graft and to keep the periosteum as intact as possible. (C) Use of a No. 11 blade to separate the epithelial tissue from the connective tissue.

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  Figure 2 (A) Diamond bur used in the abrasion procedure. The flat structure aids in the removal of the epithelial tissue. (B) Removal of the epithelial tissue using a high-speed diamond-tip drill and abundant irrigation.

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  Figure 3 (A) SCTG removed. (B) SCTG, measuring 10 mm in length and 3 mm in width, with the 14 standardized measurements to be used in the histological analysis. SCTG: subepithelial connective tissue graft.

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  Figure 4 Schematic drawing showing the portion of the graft with the standardized measurements for use in the histological analysis. The section was obtained along the long axis of the graft with the region of choice facing the teeth of the patient. To identify the edge to be used for histology, a small incision (*) was performed on the opposite edge.

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  Figure 5 Histological image of a sample from group A analyzed in the Image Pro Plus 4.5 program, where tools were used to make measurements of the studied variables (3% of a ×20 lens).

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  Figure 6 (A) Histological section of a sample from group B where no epithelial remnant was present (hematoxylin and eosin staining; 3% of a ×20 lens). (B) Histological section of a sample from group B where an epithelial remnant was present (*) (hematoxylin and eosin staining; 3% of a ×20 lens).

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  Figure 7 (A) Histological section of a sample from group A where no epithelial remnant was present (hematoxylin and eosin staining; 3% of a ×20 lens). (B) Histological section of a sample from group A an epithelial remnant was present (*) (hematoxylin and eosin staining; 3% of a ×20 lens).

Reference

1. Miller PD. Regenerative and reconstrutive periodontal plastic surgery. Dent Clin North Am. 1988; 32:287–306.

2. Bosco AF, Bosco JM. An alternative technique to the harvesting of a connective tissue graft from a thin palate: enhanced wound healing. Int J Periodontics Restorative Dent. 2007; 27:133–139.

3. Lafzi A, Faramarzi M, Shirmohammadi A, Behrozian A, Kashefimehr A, Khashabi E. Subepithelial connective tissue graft with and without the use of plasma rich in growth factors for treating root exposure. J Periodontal Implant Sci. 2012; 42:196–203.

4. Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol. 1985; 56:715–720.

5. Bruno JF. Connective tissue graft technique assuring wide root coverage. Int J Periodontics Restorative Dent. 1994; 14:126–137.

6. Raetzke PB. Covering localized areas of root exposure employing the “envelope” technique. J Periodontol. 1985; 56:397–402.

7. Harris RJ. The connective tissue and partial thickness double pedicle graft: a predictable method of obtaining root coverage. J Periodontol. 1992; 63:477–486.

8. Rasperini G, Silvestri M, Schenk RK, Nevins ML. Clinical and histologic evaluation of human gingival recession treated with a subepithelial connective tissue graft and enamel matrix derivative (Emdogain): a case report. Int J Periodontics Restorative Dent. 2000; 20:269–275.

9. Zucchelli G. Cirurgia estética mucogengival. São Paulo: Quintessence;2012.

10. Song JE, Um YJ, Kim CS, Choi SH, Cho KS, Kim CK, et al. Thickness of posterior palatal masticatory mucosa: the use of computerized tomography. J Periodontol. 2008; 79:406–412.

11. Cho KH, Yu SK, Lee MH, Lee DS, Kim HJ. Histological assessment of the palatal mucosa and greater palatine artery with reference to subepithelial connective tissue grafting. Anat Cell Biol. 2013; 46:171–176.

12. Reiser GM, Bruno JF, Mahan PE, Larkin LH. The subepithelial connective tissue graft palatal donor site: anatomic considerations for surgeons. Int J Periodontics Restorative Dent. 1996; 16:130–137.

13. Pontes AE, Pontes CC, Souza SL, Novaes AB Jr, Grisi MF, Taba M Jr. Evaluation of the efficacy of the acellular dermal matrix allograft with partial thickness flap in the elimination of gingival melanin pigmentation. A comparative clinical study with 12 months of follow-up. J Esthet Restor Dent. 2006; 18:135–143.

14. Farnoosh AA. Treatment of gingival pigmentation and discoloration for esthetic purposes. Int J Periodontics Restorative Dent. 1990; 10:312–319.

15. Perlmutter S, Tal H. Repigmentation of the gingiva following surgical injury. J Periodontol. 1986; 57:48–50.

16. Harris RJ. Histologic evaluation of connective tissue grafts in humans. Int J Periodontics Restorative Dent. 2003; 23:575–583.

17. Ouhayoun JP, Khattab R, Serfaty R, Feghaly-Assaly M, Sawaf MH. Chemically separated connective tissue grafts: clinical application and histological evaluation. J Periodontol. 1993; 64:734–738.

18. Harris RJ. Successful root coverage: a human histologic evaluation of a case. Int J Periodontics Restorative Dent. 1999; 19:439–447.

19. Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U. The interproximal clinical attachment level to classify gingival recessions and predict root coverage outcomes: an explorative and reliability study. J Clin Periodontol. 2011; 38:661–666.

20. Jepsen S, Caton JG, Albandar JM, Bissada NF, Bouchard P, Cortellini P, et al. Periodontal manifestations of systemic diseases and developmental and acquired conditions: consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions. J Clin Periodontol. 2018; 45:Suppl 20. S219–S229.

21. Deliberador TM, Santos FR, Bosco AF, Furlaneto FA, Messora MR, Giovanini AF, et al. Simultaneous application of combination of three surgical techniques for treatment of gingival recession: a case report. Bull Tokyo Dent Coll. 2010; 51:201–205.

22. Deliberador TM, Bosco AF, Martins TM, Nagata MJ. Treatment of gingival recessions associated to cervical abrasion lesions with subepithelial connective tissue graft: a case report. Eur J Dent. 2009; 3:318–323.

23. Kim SH, Grein RL, Tramontina VA. Use of bismuth subgallate as a hemostatic agent in periodontal surgery. JBC J Bras Clin Odontol Integr. 1997; 1:31–34.

24. Fletcher P, Saito H, Tarnow D, Brown M. Cyst in alveolar mucosa adjacent to a dental implant following connective tissue grafting for ridge augmentation. Clin Adv Periodontics. 2011; 1:34–39.

25. de Castro LA, Vêncio EF, Mendonça EF. Epithelial inclusion cyst after free gingival graft: a case report. Int J Periodontics Restorative Dent. 2007; 27:465–469.

26. Wei PC, Geivelis M. A gingival cul-de-sac following a root coverage procedure with a subepithelial connective tissue submerged graft. J Periodontol. 2003; 74:1376–1380.

27. Vastardis S, Yukna RA. Gingival/soft tissue abscess following subepithelial connective tissue graft for root coverage: report of three cases. J Periodontol. 2003; 74:1676–1681.

28. Wennström JL. Mucogingival therapy. Ann Periodontol. 1996; 1:671–701.

29. Kim HJ, Chang H, Kim S, Seol YJ, Kim HI. Periodontal biotype modification using a volume-stable collagen matrix and autogenous subepithelial connective tissue graft for the treatment of gingival recession: a case series. J Periodontal Implant Sci. 2018; 48:395–404.

30. Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles of successful grafting. Periodontics. 1968; 6:121–129.