Question regarding connective tissue graft

In Jan I had 3 connective tissue grafts done on my bottom teeth to cover a partically exposed root and to add more tissue to this area prior to putting braces on my bottom teeth. The procedure was realtively painless and both the donor site and the grafted areas healed very quickly - I was amazed. Two of the three grafts look awesome !!! The graft on tooth 25 however did not heal quite as nicely - the frenum (which was cut loose during the intial procedure but not removed) healed along with the graft on this tooth and pulled the graft down so that the final result was not much better than before the graft. Neither the periodontist or myself were happy with the result. So, my periodontist performed a frenectomy last Tuesday and attempted to stitch the graft on this tooth back into the desired position. The "bandage" that was placed over this area feel off on Sunday and it became apparent to me from looking at the area that it is going to be necessary to apply another graft, there is no/or very, very little gum tissue covering the root of this tooth at this point (its even lower now that it ever was before). Since some planing was done on this tooth during the grafting process and I think again during the frenectomy, the tooth is ultra sensitive :icon10: -even breathing in causes it to "tingle" (much like when you chip a tooth). I went back to the periodontist yesterday and he agreed that another graft does indeed need to be added to this area. He applied some floride directly to the tooth to ease some of the sensitivity, he indicated that this should last about 30 days. He cannot apply a new graft in this area until the frenectomy has had time to heal (4-6 weeks). We are leaving for a Disney vacation/cruise at the end of March so I will have the new graft performed the day after we return from vacation in April.

My concern is that we are scheduled to dive at the Living Seas in Epcot while at Disney... is this root being exposed and sensitive going to be an issue? The dive will be realtively shallow (around 25-27 ft - I think). I asked the periodontist and he said it should not be a problem that he could do the graft and he would be comfortable saying I could dive after about a week of healing. While I trust his opinion, I thought it best to seek additional input from someone with "dive medicine" experience. I was gonna call DAN but thought I'd ask here first since I recalled seeing post from the "toothdoc" on this board.

Thanks for any input/insight you can provide!

cindy0519:

In Jan I had 3 connective tissue grafts done on my bottom teeth to cover a partically exposed root and to add more tissue to this area prior to putting braces on my bottom teeth. The procedure was realtively painless and both the donor site and the grafted areas healed very quickly - I was amazed. Two of the three grafts look awesome !!! The graft on tooth 25 however did not heal quite as nicely - the frenum (which was cut loose during the intial procedure but not removed) healed along with the graft on this tooth and pulled the graft down so that the final result was not much better than before the graft. Neither the periodontist or myself were happy with the result. So, my periodontist performed a frenectomy last Tuesday and attempted to stitch the graft on this tooth back into the desired position. The "bandage" that was placed over this area feel off on Sunday and it became apparent to me from looking at the area that it is going to be necessary to apply another graft, there is no/or very, very little gum tissue covering the root of this tooth at this point (its even lower now that it ever was before). Since some planing was done on this tooth during the grafting process and I think again during the frenectomy, the tooth is ultra sensitive :icon10: -even breathing in causes it to "tingle" (much like when you chip a tooth). I went back to the periodontist yesterday and he agreed that another graft does indeed need to be added to this area. He applied some floride directly to the tooth to ease some of the sensitivity, he indicated that this should last about 30 days. He cannot apply a new graft in this area until the frenectomy has had time to heal (4-6 weeks). We are leaving for a Disney vacation/cruise at the end of March so I will have the new graft performed the day after we return from vacation in April.

My concern is that we are scheduled to dive at the Living Seas in Epcot while at Disney... is this root being exposed and sensitive going to be an issue? The dive will be realtively shallow (around 25-27 ft - I think). I asked the periodontist and he said it should not be a problem that he could do the graft and he would be comfortable saying I could dive after about a week of healing. While I trust his opinion, I thought it best to seek additional input from someone with "dive medicine" experience. I was gonna call DAN but thought I'd ask here first since I recalled seeing post from the "toothdoc" on this board.

Thanks for any input/insight you can provide!

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Hi Cindi, TOOTHDOC HERE!!!! To save the day!!!

What your periodontist has told you sounds about right. Once you have some initial healing of the graft site, you should be fine to dive.

On the subject of sensitivity, you might want to put a regulator in your mouth and breath out of a tank to see how the cold air actually feels in your mouth. You also want to make sure that the mouthpiece is not rubbing either the donor or recipient sites to avoid both pain and additional trauma to the graft site that could compromise the result.

You might want to start using Sensodyne or Crest Sensitive toothpaste exclusively to help reduce your sensitivity. You can even wipe some additional toothpaste on the sensitive tooth following brushing and leave it in place 5 minutes or more. If you happen to have a tooth whitening tray, put the Sensodyne in the tray and leave in place a while. Also, avoid any toothpaste that says, "Tartar Control" or "Whitening" as they both may cause or increase sensitivity.

It that doesn't work, your general or restorative dentist may be able to apply a thin layer of bonding resin to the exposed root surface to reduce sensitivity. Do do this to the root before you graft surgery...only if needed after some healing has occurred.

If your tooth persists in being sensitive after a reasonable healing period, be aware that although it is uncommon, the tooth that was planed and grafted, could also become devitalized...the nerve can die. So pulp testing or vitality testing may become necessary.

Hope this helps. Let me know if you have more questions.

Now I have to go and save a....wisdom tooth. TOOTHDOC away!!!!!

Regards,

Laurence Stein, DDS

Laurence Stein DDS:

TOOTHDOC HERE!!!! To save the day!!!

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:yelclap: :yelclap: Hip Hip Horray for tooth doc! :yelclap: :yelclap:

Seriously, thanks for sharing your wisdom and insight! Put a regulator in my mouth to see how the air effects the tooth is a great idea and one I would not have thought of. I did try the mouthpiece (I have a SeaCure) and it is no problem, but the air is indeed what may be the issue. The grafts sights have heal wonderfully and if I didn't have this issue with #25 you would never know the grafts were done. No lumps, bumps or discolored tissue to be found anywhere in my mouth :jump013:! Some of the pics on the internet look plain awful.. was really worried about having that uneven lumpy look.

The periodontist did mention put Sensodyne on the tooth and just leaving it and said that if the floride doesn't seem to be helping any longer he would gladly apply more. I have been however using a "complete" toothpaste for both tartar and whitening. Will stop tonight and buy the Sensodyne and another toothpaste that is not whitening or tartar control.

Hopefully this tooth is just sensitive because it is "exposed" and once it is covered with the new graft it will be happy again. My regular dentist has discussed putting a thin layer of bonding on this tooth prior to the graft if the graft did not cover the entire root area, however my periodontist does not think this will be necessary as he believe we can achieve full root coverage....just needed to get the freneum out of the way!!

Thanks again for your guidance on this! Definately don't want to go through all this with my mouth and then goof it up!!!!

For others reading this thread....a connective tissue graft is a way of creating new gum tissue around teeth.

Typically, in the past, a graft technique called a free gingival graft was used. The donor site was from the palate and the recipient site was around the neck of teeth that had gum recession that was compromising the health and support of the tooth. A rectangular "block" of palatal gum tissue (epithelium and underlying connective tissue) was "harvested" and that block was sutured to a prepared bed around the teeth needing more gums. The donor site was simply allowed to "granulate in"...there was an open wound that had to heal over. There might have been some sort of "dressing' sutured over the wound but basically it was a big ulcer that had to close naturally. The recipient site had this block of skin over the roots of the teeth. It was generally rectangular, thicker than the surrounding gums and usually a different color pink. The graft worked well but it could take a long time until the contours appeared more normal. The color may never equal the surounding gum.

Now, it is common to do a connective tissue graft. Again the donor site is the palate but the difference is that a single incision line is made and then a sliver of the connective tissue from under the epithelium is dissected out. This wound is sutured closed and it heals more quickly and with less discomfort. There is no ulcer. The recipient site is prepared differently. An envelope is created in the gum and the strip of connective tissue is slipped into it and allowed to heal. Initially, connective tissue covers the recession areas but as healing progresses, epithelial cells from the adjacent gum tissue migrate over the connective tissue bed. The result is a thinner, more natural contour and a gum color that is the same as the surrounding gum.

There are advantages and disadvantages to each technique and there are situations where one is better than the other. There are also other types of gum grafting available such as a pedicle graft. Your dentist will advise what is best for you.

On to Tartar Control and Whitening toothpastes. The concept sounds great...but...there are problems. First, despite what manufacturers say, the experience of most dentist is that both toothpastes may cause sensitivity, especially to cold. Tartar control seems worse.

Next, Tartar Control is used to create a softer deposit of SUBGINGIVAL calculus (tartar). This is easier for the hygienist to remove and usually less uncomfortable for the patient....but....there is still tartar. You're teeth are not actually cleaner...it's just softer dirt that must still be removed by the hygienist. This toothpaste does NOTHING to reduce dental plaque and dental plaque is the live bacteria that cause all the problems. TARTAR DOES NOT IN ITSELF CAUSE GUM DISEASE. It acts as an anchor for additional plaque...so if you get the plaque off the tartar, your mouth will be relatively healthier.

Whitening toothpastes don't really work! They may be more abrasive to remove surface stain better than traditional toothpastes but they do not whiten or bleach teeth with cliniclal significance. If you want your teeth whiter, you must bleach them...and bleaching can also produce some temporary sensitivity. Whitening toothpastes are usually more expensive because you think you are buying a cosmetic aid. It is not worth it, IMHO.

So why are we using Tartar Control or Whitening toothpastes? I donno!

A brand name, regular formulation fluoride toothpaste with a soft brush is what I recommend...and floss. No mouthwashes except fluoride rinses if applicable.

Cindy, glad you had a good outcome. One last thing. You should be aware that there are not hard and fast dental guidlines with respect to scuba diving. We simply have to use our heads and if a procedure is not ready for the real world then we wait.

Laurence Stein, DDS

Laurence Stein DDS:

You should be aware that there are not hard and fast dental guidlines with respect to scuba diving. We simply have to use our heads and if a procedure is not ready for the real world then we wait.

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I agree with this statement 110%. I think this is true of not only our dental health but our health in general. I know personally I sometimes push my body harder than I should when it is recovering and sometime I should just step back and take a deep breath and rethink my situation before proceeding. There will always be another day to dive or whatever else I might be doing.

My connective tissue grafts were performed by the periodontist perparing the lower gum areas that required grafting (3 places in my case) for the donor tissue. This included in my case releasing the freneum, making the necessary insisions into the gum itself, and planing the tooth surface where each graft(s) were to be placed. The donor site was on the left side of my mouth just about my teeth on the very edge of my palate and was relatively small. An envelope was cut in this area and the tissue removed and the flap of the envelope was stitched closed- thus no big uclering area is left exposed in the palet as in with the free gingival graft. The donor tissue was then "woven" (like a basket) into place on the site to be grafted. A few stiches were also placed on the grafts themselves and a small amount of dental "super glue" was also used on one of the grafts. The entire procedure took about 2 hours and was done using septocaine. I was sent home with a 10 day antibotic perscription, another perscription for a pain (which I only used the night of the surgery) and a a mouth rinse containing chlorhexidine to rinse with twice a day and told no sonic care toothbrush for 3 months ..as the vibration may cause the graft to move or not heal correctly. After about 10 days all the stitches were gone and both the donor and the recipient sites were hard to detect at all. All in all it was a relatively easy procedure to endure. My mouth looked more than a bit "frankenstien like" for awhile but now you would never know. I am truly very pleased with the results!

In your message above you state that there are advantages and disadvantages to all of the grafting procedures. I can't recall hearing an disadvantages to the connective tissue grafts...can you tell me what they are?

The information you posted about toothpaste is VERY good. THANKS for the insight and helping to educate us all!!

cindy0519:

I can't recall hearing an disadvantages to the connective tissue grafts...can you tell me what they are?

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The advantages and disadvantages have more to do with where to use the appropriate technique. For instance, if you needed a large volume of gingival tissue, you might want to use the free gingival graft. If you wanted to "plump" up the shape of the gum before a restorative procedure, you might want to use a connective tissue graft buried under the epithelium...you cannot place epithelium under the gum without potential problems.

In other situations either technique can be used successfully.

Laurence Stein, DDS

Laurence Stein DDS:

The advantages and disadvantages have more to do with where to use the appropriate technique. For instance, if you needed a large volume of gingival tissue, you might want to use the free gingival graft. If you wanted to "plump" up the shape of the gum before a restorative procedure, you might want to use a connective tissue graft buried under the epithelium...you cannot place epithelium under the gum without potential problems.

In other situations either technique can be used successfully.

Laurence Stein, DDS

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The only disadvantages to the connective tissue graft I recall being mentioned was the fact that there would be two surgery sites. Glade to hear that the advantages/disadvantages have more to do wiht where to use the appropriate technique than with something I should "watch" for to happen as time passes or things progress.

Again, thanks for you time - I truly appreciate you sharing your insight and knowledge!!