CTG - DOUBLE PAPILLA

The desire for cosmetic dentistry has certainly increased the demand for root
coverage surgical procedures. A growing number of patients are requesting and
expecting root coverage as it has been reported by many clinicians and researchers
to be an obtainable goal.
Several authors have demonstrated that single multiple root coverage can be
accomplished utilizing a thick free gingival graft. The major weakness of this
procedure is a potential color discrepancy between the graft and the surrounding
tissue, described as a "keloid - like" appearance. Various pedicle flaps have the
possibility of creating esthetically satisfactory results, but their major weaknesses
include the limited situations in which they can be employed and their low degree
of predictability.
Langer and Langer reported on the use of a connective tissue graft placed beneath
a partial thickness flap using two vertical releasing incisions. In 1987, Nelson
reported on the use of a bilaminar procedure in which full thickness laterally
positioned pedicle grafts or double papilla pedicles are positioned over the free
connective tissue graft. A very high percentage, 91%, of the exposed root surface
was covered utilizing this bilaminar procedure. Recently, Harris described a
bilaminar technique as a predictable method of obtaining root coverage. 30 defects
were treated with a free connective tissue graft placed beneath a partial thickness
double pedicle graft. Root coverage of 100% was obtained in 24 of 30 defects, or
80% of the time, with a net root coverage of 3.5mm or 97%.

The "double blood supply" created in this and other bilaminar mucogingival
procedures could be a great advantage when seeking root coverage for deep wide
gingival recessions.

INDICATIONS
1) Total coverage in cases of isolated severe recession
2) Good color and form blending in site esthetic needs
3) To increase the gingival thickness
4) A deep vestibule

DISADVANTAGES
1) Two operative sites
2) Technical finesse is required to obtain the proper thickness and minimal
bulkiness.
SURGICAL TECHNIQUE
It is our clinical opinion that this surgical mucogingival technique is particularly
indicated on isolated defects it is now taken into consideration in the following step
by step surgical procedure.

Preparing the recipient site

1) Local anesthesia
2) The exposed root surface is thoroughly planed with curettes and rotary
instruments to remove all accretions, to smooth the root surface and to flatten the
root in areas of root prominence
3) Tetracycline solution with small cotton aledgets is applied and "burnished" into
the root surface for 5 minutes. The tooth surface is rinsed with a stream of water
for 30 seconds.
4) A V-shaped incision is made with a n 15 blade far enough apically into the
mucosa to remove a soft tissue wedge over the exposed root. The surgical blade is
used to create an internal beveled surface on one side and an external beveled
surface on the other side to permit an overlap of two connective tissue surfaces over
each other to favor the healing process.
5) Horizontal incisions are made mesial and distal to the defect, a few mm coronal
to the exposed CEJ toward the adjoining tooth. This incision is ended or
terminated 1mm away from the gingival margin of the adjacent tooth, mesially and
distally. As much of the interdental papilla is retained as possible without affecting
the adjacent teeth. A sulcular incision connects the horizontal incisions.
6) Two vertical incisions are made perpendicular to the horizontal incision, starting
at the termination point of the horizontal incision to the base of the vestibule and
extending generously into the alveolar mucosa.
7) Partial thickness pedicle flaps are then reflected by sharp dissection as close to
the periosteum as possible.
8) The reflection of the mesial and distal pedicle flaps is carried to allow
repositioning of the pedicles to the cementoenamel junction of the affected tooth.
9) Two "cutback" releasing incisions at the most apical point of the two vertical
incisions are recommended for tension release
10) Any remaining pocket lining and tissue tags are removed with curettes. The
root is reinspected to assure that all roughness has been removed
11) The pedicles are then sutured together with interrupted sutures.

Harvesting the donor tissue

The premolar area of the palate is the best and most common source of donor tissue
due to the widest gingival zone with the least amount of submucosa. The goal is to
stay away from the margin of the gingiva and the palatal arteries. Three methods
are used to obtain the connective tissue graft:
 a) A classical "Trap donor" approach;
b) Palatal "L" incision, and
c) a more recent one, the "Linear incision technique (for a more detailed
description see donor site-flap design).
In these methods, after obtaining local anesthesia, the palatal donor area is sounded
with a periodontal probe to be certain that a 3mm soft tissue thickness is present.

"Trap-door" approach
1) Adequate local anesthesia
2) An incision is made in the palate perpendicular to the maximally premolars. The
mesial-distal dimension is extended to result in a tissue graft adequate to cover the
recipient site.
3) Two perpendicular incisions, at the most mesial and distal end of this horizontal
incision, are made to establish the correct width of the graft.
4) A partial thickness flap is reflected to expose the underlying connective tissue
5) Sounding with a periodontal probe is used to plan the thickness of the "trap-
door" flap, so the underlying connective tissue will be approximately 2mm thick.
6) The graft is removed by incising and connecting the medial, mesial and distal
edges between the two parallel incisions.
7) A CTGO-CHISEL or a n7 Kramer-Nevins periodontal knife with a tissue plyer
are utilized to completely remove the graft from the palatal area.
8) The primary flap is then returned to its original position and sutured to obtain
primary closure with few interrupted sutures.
9) Pressure is then applied, with a wet gauze, to the donor site for 5 minutes to
obtain hemostasis
10) If an epithelial border of the graft is present, it is then removed and discarded.

Graft and pedicles stabilizations

1) In all three methods, the connective tissue graft is inspected and trimmed of
adipose, glandular and excessive tissue using a new n15 scalpel blade
2) The C.T. graft is sutured with a 5-0 absorbable sling suture over the original
defect
3) An additional periosteal suture may sometimes be necessary to mould the graft
to the tooth surface. In this horizontal circumferential periosteal suture the needle
enters and exits the periosteum for one tooth width apical to the graft and labial to
the recipient tooth. The suture is then passed over the graft through the
interproximal embrasure, around the lingual-cervical of the tooth, back labially
through the adjacent interproximal once and over the graft once more where it is
tied to its tail
4) Firm pressure is applied to the graft tissue with a wet gauze for 30 seconds.
5) Next, the previously sutured pedicle flaps are then sutured with a non-resorbable
sling suture over the C.T. graft and the original defect.
6) Every effort is made to avoid suturing together the two gingival tissues
7) The lateral borders of the pedicle flaps are sutured with mesial and distal
horizontal periosteal sutures (Cornicks's suture). This basting stitch creates an
intimate contact between the alveolar mucosa of the pedicle flaps with the
underlying C.T. graft avoiding any "dead-space" at the base of these pedicles.
8) A noneugenol periodontal dressing is placed over the recipient area for 7 to 10
days postoperatively; the patient is provided antibiotic coverage for six days and
should be prescribed an analgesic for discomfort. Chlorhexideine rinse twice a day
is prescribed for 3 weeks following surgery. Seven to 10 days after surgery, the
dressing and sutures are removed and the teeth are polished. The dressing may be
repeated for another week if healing is not satisfactory. Home care instructions are
given specifying the use of cotton swabs with fluoride toothpaste until healing has
progressed sufficiently to permit gentle brushing and flossing.

REFERENCES
1) Hall W.B.: Gingival augmentation/mucogingival surgery in proceedings of the
world workshop in clinical Periodontics. July 23-27, 1989 Chicago: American
Academy of Periodontology 1989:VIII-VII 21
2) Langer L., Langer B.: Root coverage procedures in Wilson Jr. T.G. and
Kornman K.S.: Fundamentals of Periodontics, Quintessence Publish. Co. 1996;
Chapter 26:506-510
3) Corn H. and Marks M.H.: Gingival grafting for deep-wide recession. A status
report. Par I. Rational, case selection and root preparation. Compend. Cont. Educ.
Dent. 1983, 4:53
4) Corn H. and Marks M.H.: Gingival grafting for deep-wide recession - a status
report. Part II. Surgical Problems. Compend Con. Educ. Dent.: 1983;4:167
5) Holbrook T. and Oschenbein C.: Complete coverage of the denuded root surface
with one-stage gingival graft. Periodont, Rest. Dent. 1983;3 (3):8-27
6) Miller P.D. Jr.: Root coverage using a free soft tissue autograft following citric
acid application. Part I. technique. Int. J. Periodont. Rest. Dent., 1982, 2;65-70
7) Miller P.D. Jr.: Root coverage using the free soft tissue autograft following citric
acid application. Part II. Treatment of the carious root. Int. J. Periodontol. and
Rest. Dent. 1983, 3:38-51
8) Borghetti A. and Gardella J.P. Thick gingival autograft for the coverage of
gingival recession: A Clinical evaluation. Int. J. Periodont. Rest. Dent. 1990;10:216-
229
9) Jahnke P.V., Sandifer J.B., Gher M.E. et al.: Thick free gingival and connective
tissue autografts for root coverage. J. Periodontol 1993;64:315-322.
10) Langer B., Langer L.: Suberpithelial connective tissue graft technique for root
coverage. J. Periodontol 1985; 60:715-720.
11) Nelson S.W. The subpedicle connective tissue graft. A bilaminar reconstructive
procedure for the coverage of denuded root surfaces. J. Periodontol 1987;58:95-
102.
12) Harris R.J.: The connective tissue and partial thickness double pedicle graft: a
predictable method of obtaining root coverage. J. Periodontol 1992;63:477-486.