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Xenograft vs. autograft

Using a 3-D collagen matrix for vestibuloplasty

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No painful graft harvest and very good color and texture match surrounding tissue - these are major advantages when performing a vestibuloplasty with Geistlich Mucograft®. Now there is long-term data over five years.

Dr. Christian Schmitt | Germany

2 mm of keratinized mucosa around an implant seems to have a positive impact on peri-implant tissue health.1 The most common methods for widening of the keratinized mucosa are an apically positioned flap or a vestibuloplasty.2 A secondary granulation of the resultant wound surface is not ideal due to postoperative morbidity and wound contraction with a high tendency for muscular reattachment.2-4

Autologous grafts from the palate

Autologous soft tissue grafts from the palate – such as free mucosal grafts or connective tissue grafts – are the gold standards for covering a wound surface. They reduce postoperative contraction and improve the regenerative result.2,3,5,6 Furthermore, autologous grafts show reproducible clinical results in terms of treatment, integration, shrinkage and long-term stability (Fig. 1). However, disadvantages of autologous tissue grafting are:
• Necessity for palatal harvest with additional surgical risks,2–4
• Patients’ harvest site morbidity,6
• Limited availability of grafts,3,4
• Prolonged surgery time,2–4,6
• Poorly matched texture and color, when using free mucosal grafts.4,6

The Clinical tips: flap technique

The coronally advanced flap is preferred when dealing with thin mucosal tissue (thin biotype), since the preparation of a tunnel is likely to cause perforations or tearing of the gingiva. The coronally advanced flap is also recommended when a greater amount of coronal advancement is planned and if the scalloped nature of the free gingiva is absent – flatly contoured gingival zenith, such as in the lower anterior region.
The tunneling technique is ideal when working with a thick biotype, highly scalloped free gingiva and suitable keratinized tissue. The tunneling technique should also be considered if esthetics are critical and a mild to moderate coronal advancement is anticipated. One of the key factors for success is the proficiency of the periodontal surgeon.

Connective tissue graft vs. biomaterial

Connective tissue grafts help create keratinized gingiva, based on a study of tissue specificity by Karring and co-workers.3 In this epithelial differentiation study, Karring was able to demonstrate that free grafts harvested from the palate produced keratinized gingiva, whereas grafts transplanted from the non-keratinized alveolar mucosa produced alveolar mucosa.4

Advantages of connective tissue grafts include plasmatic circulation (capillary beds within the grafts) that help with high graft survival, outstanding color match after healing and dimensional stability. Disadvantages include patient morbidity, e.g. bleeding, delayed healing and pain, along with the secondary graft harvest sites. (Figs. 1, 2)

Accordingly, clinicians have been interested in developing a graft substitute. Such biomaterials not only avoid connective tissue graft harvest and associated morbidity but also provide unlimited supply with consistent quality. Working with such biomaterials, complete primary closure with a tension-free flap is recommended. Ideal biomaterials should act as scaffolding to promote ingrowth and regeneration by host cells, while remaining dimensionally stable. (Fig. 3)

Clinical tips: biomaterial

When the connective tissue graft is chosen as a graft material, its availability must be determined prior to the intervention using bone sounding. Reiser5 emphasized the importance of the anatomy of the donor area and classified the vault dimension as shallow, medium or high.
The collagen matrix Geistlich Mucograft® should be handled, trimmed, positioned and sutured before the biomaterial becomes wet. Therefore, it is beneficial to finish any necessary preparation of the biomaterial extra-orally in order to minimize intra-oral working time. In this way the volumetric dimension is not compromised.
The periodontal flap should be reflected without tension. A tension-free flap is critical for primary closure, and a passive flap will not compress the underlying Geistlich Mucograft® collagen matrix.

Minimally invasive approach

A meticulous periodontal surgeon is always investigating advances in periodontal plastic surgery. How can we improve surgical techniques in order to improve predictability and reduce complications? Can the surgical time be shortened or post-surgical wound healing be accelerated? Minimally invasive surgery can be the answer. Shanelec and colleagues first introduced periodontal surgery using a microscope, which provided clinical benefits over conventional treatment.6 Cortellini and co-workers studied a minimally invasive surgical approach to periodontal surgery.7 Atraumatic flaps, harvest graft substitute biomaterials, use of microscopes and loupes (without increasing surgery time due to unfamiliarity), teamwork, proper armamentarium, surgical skill and experience can all help with the minimally invasive approach in periodontal plastic surgery.

Clinical tips: minimum invasion

These are the key factors for a minimally invasive approach to periodontal plastic surgery:

  • Limited flap reflections
  • Use of SM67 or SM69 blades (Swann-Morton)
  • Use of 5–0 or 6–0 sutures
  • Introduction of microscopes or loupes
  • Use of specified instruments, such as tunneling instruments
  • Combination of tunneling techniques and biomaterials.

Dr. Christian Schmitt

Dr. Christian Schmitt | Germany

Clinic of Oral and Maxillofacial Surgery

University Clinic Erlangen-Nuremberg


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