Clinical images courtesy Sam Shamardi. Background © Jakkapan Jabjainai |
Auger Clinical Collaborations 2

Clinical Collaboration: Connective tissue graft technique

April 21, 2021
Amber Auger, MPH, RDH, talks with a periodontist about the benefits and considerations of connective tissue graft, and what hygienists need to know to care for patients.
For this month’s clinical collaboration series, I went back into the operatory with Dr. Sam Shamardi. This case reviews a medical healthy patient in their early thirties. The patient presents with healthy bone levels, which provide the ability for full root coverage. The patient has a sensitivity to touch and cold, with no frenum pull contributing in the area.

Additionally, there is an early-stage recession in adjacent teeth, but the patient only wants to treat the canine. The patient lacks a foundation of keratinized tissue and admits to being an aggressive brusher; the extent of recession is 5 mm and is down to the mucogingival junction (MGJ). Due to the primary goal being root coverage, the technique of choice is connective tissue grafting.

Case overview

  • The patient was concerned regarding the aesthetics of tooth no 11
  • Chief concern: Lack of keratinized tissue, root exposure, mild sensitivity
  • Radiographic analysis: Bone levels WNL
  • Clinical analysis: Probing depths WNL, significant attachment loss, minimal keratinized tissue, sensitivity to touch, no mobility
  • Etiology: Plaque and bacteria, orthodontics, aggressive brushing
  • Goals of therapy: Root coverage
  • Procedure chosen: Connective tissue graft

Clinician Q&A

Amber Auger: Dr. Shamardi, why did you choose to provide a connective tissue graft for this case?

Dr. Sam Shamardi: Connective tissue grafting is a gold-standard technique for root coverage. Harvesting tissue from a donor site provides ideal tissue match, and studies show long-term stability to be superior to alternative methods such as membranes or alloderm. The donor site tissue completely regenerates and could have a new graft harvested after six weeks of healing.

Amber Auger: How does the healing differ in harvested tissue from the patient verus alloderm?

Dr. Sam Shamardi: Part of the benefit of using connective tissue opposed to alternative materials is that the graft does not need to be fully covered in order to heal; partial exposure can still result in excellent results as long as the majority (at least 2/3) of the graft is covered and receives blood supply. This provides further flexibility in comparison to alloderm, where even a slight amount of exposure at any point could result in failure.

Amber Auger: If the patient does not want to undergo surgery, what are alternative procedures to meet the patient’s chief concern?

Dr. Sam Shamardi: A Class V composite would work for the patient. If the patient has an aversion to the grafting with using their own tissue, a membrane or alloderm can be used.

Amber Auger: Tell us about the home-care limitations post-surgery.

Dr. Sam Shamardi:
  • No brushing/flossing of area 10-14 days
  • No eating hard/sticky foods
  • No heavy exercise for 48 hours afterward
  • Use Peridex and/or antibacterial rinses. Four ounces of warm water with 1 tsp of salt is another option
  • No straws/suction for 7-10 days
  • No pulling on the lip to evaluate the area for 10-14 days
  • Two-week follow-up to remove sutures; one month to general evaluation of healing
  • No probing/prophy of the area at gingival margin for a minimum of three months

The patient should ideally have a prophylaxis two to three weeks prior to the connective tissue graft procedure. This will allow for bacterial reduction, create the opportunity for hygiene instructions, and prevent the patient from discomfort while healing from the connective tissue grafting.

Amber Auger, MPH, RDH, is a practicing dental hygienist and clinical innovations implementation specialist. With 14 years of experience in the dental industry, Auger works with practices to provide customized protocols, to refocus on the patient experience, and to utilize systemic approaches to periodontal therapy. She is a regular contributor to RDH magazine, a featured author for DentistryIQ, and host of #AskAmberRDH. Auger also provides preventive services abroad yearly and is always willing to have dental professionals join her team. She can be reached at [email protected].