3 traditional approaches to harvest a CT Graft form the palate:

 

1. Trap door

2. "L" Technique

3. Envelope/ Single incision

 

 

Area of premolars - anterior palate, it has a lot of fat and glandular tissue, called submucosa

 

 

MOLAR AREA IS BETTER

 

Only 1-1.2mm of thickness is needed. As you need only this thickness, you will not reach the submucosa, almost no bleeding, almost no pain, it's like an abrasion.

 

If you need thicker graft you don't go deeper! 

What you have to do is extend the length of the graft.

 

HARVESTING

horizontal incision

vertical incisions

the mesial vertical incision is used to calibrate the thickness of the graft being harvested

 

GRAFT

You have to remove not only the keratinized part but also the basal layer, this means removing 0.2mm of thickness.

Make a perpendicular incision to make sure you remove the epithelium facing the teeth.

 

Horizontal mattress sling suture

(13'03'')

It's done to close the recipient site, after placing a collagen substitute. 

You start distally on the palate, below the horizontal apical incision.

 

Desepithelialization of the harvested graft. Sharp perpendicular incision to remove the most coronal remaining epithelium (0,5mm at the most, not more).

 

The desepithelialized free gingival graft provides stability to the CAF, it doesn't cover the root. The root is covered by the CAF.

 

What are the clinical situations where you need to stabilize the CAF?

1. When there is not enough amount of keratinized tissue, apically to the recession, less than 2mm in height and less than 1mm in thickness.

2. When there is something so near the recession's margin, as a frenum, to impair the stability of the CAF. You never need to remove the frenum externally. If you have a basal big height of keratinized attached gingiva prognosis will be better.

3. Whenever you have one of two opposing situations: either a very deep root abrasion or a very prominent root.

 

A deep incision to release the flap is in fact not needed. The superficial incision is key to an effective release: it separates the submucosa from the alveolar mucosa.

 

Prepare split thickness surgical papillae. 

(23'01'')

It's important to preserve the epithelium and keratinized tissue of the surgical papillae.

After that you start the full thickness elevation of the flap.

The deep incision must be extended the minimum possible in order to just detach the submucosal tissue from the periosteal layer.

What will allow for the flap release will be the apical superficial incision detaching the alveolar mucosa from the submucosal tissue, use a new knife to do this.

THIS STEP, THE SUPERFICIAL RELEASING INCISION IS ESSENTIAL TO THE SUCCESS OF THIS PROCEDURE.

 

 

Desepithelialize both anatomical papillae.

The stability of the graft is due to the fact that the anatomical papillae serve as a good anchorage to the surgical advanced papilla, something you can not do with any tunnel approach.

 

Planing the root

EDTA gel 2 minutes, 24%, to remove the smear layer.

 

DIMENSIONS OF THE HARVESTED GRAFT

5mm in height and 10mm in length (mesiodistal dimension).

 

 

DONOR SITE CLOSURE

Criss-cross sling suture around the corresponding tooth. Close the knot  apical and  distal.

 

FGGraft fixation: Important to use a very small needle.

The graft must never cover the anatomical papillae.

First stitch from the graft to the base of the anatomical papilla. Same procedure is done on both mesial and distal anatomical papillae.

You stretch the flap till the surgical papilla covers the anatomical and, in that position you suture the mucosa to the periosteum at the base of the flap, you enter the flap and you exit on the alveolar mucosa of the adjacent tooth. You can stich it twice at each of the flap's bases.

 

Sling suture

(34'32'')

To suture the surgical papillae above the anatomical ones. One shot you perforate surgical, anatomic and palatal papillae, you go around the back of the tooth, you pass under the distal contact point without perforating any tissue, and only them you will again in one shot perforate the surgical, anatomic and palatal distal papillae. You go again around the back of the tooth, pass under the mesial contact point (no tissue perforation) and you close the knot at the buccal. Complete vertical releasing incisions' closure with simple stiches. 

 

Remove sutures only after 2 weeks.