Soft Tissue Grafts - Gum Graft Surgery

Soft tissue or gum graft surgery is a dental procedure usually performed by a periodontist, a dental specialist who has advanced training in diagnosing and treating conditions that affect the gums and supporting bone. Gum graft surgery may be recommended for one tooth or several teeth in order to:

• Treat oral health problems caused by periodontal disease and gums recession.
• Cover exposed tooth roots to decrease the risk of tooth decay.
• Treat tooth sensitivity to hot and cold caused by exposed tooth roots.
• Prevent future oral health problems such as gum recession, tooth decay and sensitivity by reinforcing areas where the gums are very thin or weak.
• Prevent further gum recession and bone loss.
• Improve mouth aesthetics – Gums recession causes teeth to look longer than before or the gum line to appear uneven. The color difference between the tooth crown and the exposed root area may also make teeth to look unappealing.

Gum grafting may become necessary due to receded gums caused by:

• Periodontal disease – in the advanced stages of gum disease, gum infection causes periodontal pockets to deepen making gums to loose their attachment from the teeth surface and start to pull back exposing the teeth roots
• Aggressive brushing – vigorous brushing especially when using a hard toothbrush can cause gum recession and tooth enamel abrasion
• Bruxism (teeth clenching / teeth grinding) - Excessive biting forces can damage the connective tissue (periodontal ligament) that keeps the teeth attached to gums and bone causing the gums to recede and expose teeth roots
• Teeth malocclusion – crooked or misaligned teeth cause some of the teeth to sustain unevenly larger biting forces which leads to receding gums for similar reasons as in bruxism
• Aging

Although gum grafts are in most cases part of a periodontal disease treatment, they can also be used to improve the gumline symmetry as part of a cosmetic make-over.

Before the periodontist proceeds to the gum graft surgery, it is necessary that the causative factors of gum recession are already addressed and treated. This may involve a number of treatments or behavioral changes depending on the specific cause of receding gums from periodontal disease treatment to orthodontics or more. Otherwise gum recession will soon re-occur.

The gum graft procedure is performed by a periodontist under local anesthesia and it involves moving soft-tissue from another area of the mouth in order to cover the exposed tooth roots. There are three different types of soft-tissue grafts: free gingival grafts, connective-tissue grafts and pedicle grafts.

Free Gingival Graft

In a free gingival graft procedure, the periodontist cuts a small strip of soft tissue from the roof of the patient’s mouth (palate). The soft tissue graft, is then sutured to the existing gum tissue in the area of gum recession.

This type of gum graft procedure is often used for people who naturally have very thin gum tissue around their teeth and need to have them enforced. Freeze-dried human tissue from another donor may also be used for free gingival grafts to avoid the need of a second surgical site in the mouth or when large amount of gum graft is needed.

Connective Tissue Graft

In a connective-tissue graft, the gum graft is also taken from the roof of the mouth but in this case it is the sub-epithelial connective tissue that is used for the soft-tissue graft, and not the outer epithelial layer as in free gingival grafts. An incision is made in the roof of the mouth in a way that a flap is formed (also called a ‘trap door’). The underlying connective tissue is removed from the palate and sutured under the existing gum tissue next to the exposed root. The flap on the palate is put back and stitched into place. Connective tissue grafts is the most common type of gum graft surgery used for the treatment of exposed roots.

The ‘Pedicle’ Graft

In a ‘pedicle’ graft, also known as lateral graft, the gum graft is not taken from the palate but from the area immediately adjacent to the recessed gums. A flap of gum tissue from the adjacent area is partially cut away with the edge close to the recession site still attached. The flap (pedicle) is then rotated covering the exposed root and stitched into place.

Lateral gum graft is considered as more successful than other types of gum graft surgery because the blood supply is not interrupted. Some of the original blood vessels continue to feed the grafted section after surgery and help in healing. However there are two drawbacks:

• The pedicle graft is possible only when there is healthy and thick gum tissue in the immediate proximity of the gum recession area.
• The area from where the periodontist takes the gum graft is weakened having increased risk of gum recession in the future.

Whatever the type of graft, after the gum graft surgery the periodontist will usually place a periodontal dressing over the treated area to protect the graft for the first healing period.

Some discomfort, swelling or bruising is normal after a gum graft surgery. Free gingival and connective tissue grafts usually cause more discomfort than lateral grafts due to the second surgical site in the palate. The periodontist may prescribe some pain medication to help control after surgery discomfort.For the first days the graft may look whitish or yellowish as the exposed surface cells die and peel off. After a few days the graft will take a more natural reddish color as the blood supply is fully restored.

A follow-up appointment is scheduled 7-10 days after gum surgery for the periodontist to examine the progress of healing and remove any periodontal dressing, but the stitches are not usually removed until 2-3 weeks later. The gum graft will have significantly healed until then but full integration of the graft may take up to 6 months.

• In case of bleeding at the graft site, you can place a gauze on either side of the graft, but not over the graft. NEVER put pressure on the graft to stop bleeding or the graft could fail.
• Avoid pushing or rubbing your tongue over the surgical site or pulling the lips to examine it. Do not remove the periodontal dressing.
• Do not brush your teeth or rinse your mouth on the day after the surgery.
• Do not eat or drink anything hot for the first 1-2 days following surgery.
• Avoid any physical activities for the first 24 hours to help prevent bleeding
• Avoid chewing by eating only soft or liquid foods for the first week. You can then start to progressively return to your normal diet as long as you avoid chewing close to the grafted area.
• Do not brush over the gum graft for the first 30 days to provide enough time for healing and integration of the graft. After that period you can start brushing the graft area using a very soft toothbrush and avoiding vigorous movements.
• You may and should brush everywhere else in the rest of the mouth from the second day after the gum surgery. Your mouth must be kept as clean as possible to minimize the risk of an infection of the surgical site.
• An antimicrobial mouth rinse can help control dental plaque during the healing period. (mouth rinses containing chlorexidine should not be used for more than 10-14 days)
• An antibiotic may also be prescribed for a few days to help in infection control.

If the gum graftiing surgery is performed by an experienced periodontist and the patient follows the post-operative instructions, the procedure is successful in almost all cases. Complications such as the graft failing to integrate with the existing gum tissue are rare, especially if the lateral graft technique is followed. Infections of the graft area are also rare.

Problems related to the aesthetic appearance of the graft are a possible complication but it can be easily corrected. Any abnormalities usually disappear within some months. If the gum graft continues to look lumpy and bumpy, the periodontist can reshape the gum tissue and correct its appearance with a simple procedure called gingivoplasty.

Gum grafting is a periodontal procedure which is performed to treat the consequences of receded gums but also to prevent further gum recession and bone loss. Gum grafts can effectively treat root exposure and tooth sensitivity and improve the aesthetic appearance of teeth affected by gum recession.