1. Subepithelial Connective Tissue Graft for Root Coverage

2. Brief history of the technique Etiology and indications for using a subepithelial connective graft (CTG) Advantages and limitations Millers classification and procedure predictability Materials, instruments and surgical technique Visit with patients who have undergone the procedure Live demonstration

3. Drs. Langer and Langer introduced the use of the subepithelial connective tissue graft for root coverage. Drs. Langer and Langer modified the free gingival graft onlay technique to a sandwich which provided blood flow from the underlying periosteum as well as from the overlying flap. This enhanced the blood flow to the graft and subsequently enhanced graft survival. Modifications were subsequently made to avoid vertical incisions in order to further enhance blood flow to the flap and to the graft.

4. ROOT COVERAGE Corrective or preventive (acts as a fiber barrier) Increased susceptibility to root caries Tooth hypersensitivity from exposed dentin Aesthetic concerns of exposed dentin and/or crown margins RIDGE AUGMENTATION

5. Type I No interdental bone loss Defect is coronal to the mucogingival junction (MGJ) Type II No interdental bone loss Defect extends to or beyond MGJ Highly predictable complete root coverage

6. Type III Interdental bone loss (mild to moderate) with accompanying loss of papillary height Defect at or apical to the MGJ Type IV Severe interdental bone loss with accompanying loss of papilla Defect at or apical to the MGJ Complete root coverage impossible

7. Highly predictable Highly successful due to enhanced blood supply Aesthetic Used on single or multiple sites Good healing potential for palate donor site

8. Technically demanding Anatomy may limit volume of available tissue-shallow palatal vault, greater palatine vessels, nasopalatine vessels Multiple sites may need multiple appointments due to tissue volume limitations Previous surgeries and scar tissue formation

9. Microsurgical Kit Mirror, probe, cotton pliers, suture pliers, Castroviejo suture forceps, scissors, microsurgery elevators, Orban knife, #15 & 15c blades and round handle, Harris knife, scalers, EDTA or tetracycline, saline, glass slab and gauze Gut 5-0, Polypropylene 6-0 and Vicryl 4-0 sutures Thorough oral hygiene work up Review procedure with patient Pre op meds Pre-surgical rinse Local anaesthetic (Citanest 4% plain, Lidocaine 2% 1:100,00/50,000) Prepare recipient site-floss, root plane and smear layer treatment, pouch/envelope flap preparation(blunt then sharp dissection) Harvest graft tissue from palate (premolar or retromolar) and close Place and secure graft (sling suture)

10. Ice area Review procedure Post-op Recommendations Ice on and off every 10 minutes Limited activity for 24 hours No brushing or manipulating area for 4-6 weeks Maintain good oral hygiene and take meds (antibiotic, anti-inflammatory, Peridex) Call patient Remove palatal sutures in 1 week and grafted site sutures in 2-3 weeks

11. QUESTIONS ?

12. Lisa: CTG lower anteriors lingual first surgery 2005, second surgery 2006 Robert: CTG #33 facial Oct. 2010 Armando: CTG #16 buccal one week ago Adrian: CTG #23 facial today Kathy: CTG #33 facial Feb. 2011