Bill Klaproth (host): This is OMS Voices, an AAOMS podcast. I'm Bill Klaproth. And with me is Dr. Paul Ciuci, who is here to discuss soft-tissue grafting for dental implants. Dr. Ciuci, thank you for being here today.

Paul Ciuci: Thank you for having me, Bill.

Bill Klaproth (host): Yeah, I am very interested to talk about this. So, let's jump right in. What is a soft-tissue graft?

Paul Ciuci: Well, let's take a little step back. A graft is just when we move tissue from one area to another. And for oral surgeons, it's inside the mouth or in the head and neck structures. So, you can do a graft of hard tissue, which would be a bone graft. You could do a graft of gum tissue. That's what we're talking about today around dental implants. You could do grafting of muscle, anything like that. So, that's what oral surgeons do.

Bill Klaproth (host): So, we've heard of skin grafts before, but many people might not think of the mouth and soft-tissue grafting. Why is a soft-tissue graft needed?

Paul Ciuci: So when it comes to dental implants, the most important thing for a dental implant is the foundation. The foundation is the bone in the soft tissue. And over time, some of that bone can go away from infections. Some of that gum tissue can go away from infections and prior surgeries. And when you come see the oral surgeon for your dental implant, no matter what tooth it is, they're going to look at the tooth that's there or the space that's there. They're going to first evaluate how much gum tissue you have, because that's going to really keep your dental implant healthy. And then, they're going to see how much bone tissue you have and whether you need to rebuild that foundation with bone grafting, soft-tissue grafting, and then your dental implant.

Bill Klaproth (host): Okay. So, why would soft tissue be inadequate? Why would someone need this?

Paul Ciuci: Yeah. Typically, there are many factors that can cause soft tissue to go away, the health of the patient. One of the most common things that you’re probably aware of is toothbrushing and oral hygiene. So, periodontal disease, gum disease, brushing too hard, previous infections, all of these things can cause the gum tissue to go away. Even things you might not think of, like orthodontics, if a tooth is not in the right position, if it's too far forward or too far back, it can cause the gum tissue to go away.

Bill Klaproth (host): That's really interesting. I never thought of forceful brushing as a reason someone would destroy their gums to the point where they would need a soft-tissue graft. That's kind of crazy.

Paul Ciuci: Some people hold their toothbrush rock hard. And they go in, they go at it, and that's why they always say buy a soft-bristled brush and they try to teach you those things when you go see the dentist.

Bill Klaproth (host): Okay. Let me ask you this. Are you recommending a soft-bristled brush?

Paul Ciuci: Absolutely. Yes.

Bill Klaproth (host): Okay. Because I tend to go for the medium.

Paul Ciuci: And you hold it like a pencil, like literally two fingers. You don't have to hold it in a–

Bill Klaproth (host): You don't have to get in there and–

Paul Ciuci: You don't need the death grip on your toothbrush, Bill.

Bill Klaproth (host): So, I'm picturing the gum and the soft tissue, where do you get other soft tissue from to graft?

Paul Ciuci: Yeah. Exactly. It's like you just don't go to the vending machine for that. I would say one of the most common sites is we try to use the patient's own tissue. So, we look for an area that has healthy gum tissue. It could be right next to the site that we're doing an implant. It could be from the roof of the mouth. There's usually a lot of nice soft tissue up there. It could be behind the last tooth in the mouth. There's some soft tissue up there. And then, sometimes you actually can get basically synthetic soft tissues. They actually make collagens that you can transplant in there. So, there are a lot of different places and a lot of different reasons you would choose one over the other. And it's kind of up to your surgeon to figure out which is the best for you.

Bill Klaproth (host): Right. There's not a soft-tissue vending machine in your office, Dr. Ciuci? No?

Paul Ciuci: There's isn't. It would be nice, but no, there isn't. And unfortunately, sometimes when patients hear, you know, soft-tissue grafting, they're like, you know, just want my dental implant. But unless you have enough bone and you have enough soft tissue, your implant might not be successful. So, we want to set you up for success. That's why we do that evaluation and we see, if you need hard tissue, we add bone. If you need soft tissue, we do the bone graft so that you can have an implant. And then with your soft-bristled brush, you can keep it clean for the rest of your life.

Bill Klaproth (host): Right. Well, you said earlier, the foundation that you have to have is bone and soft tissue. So when someone asks, "Why do I need this?" Well, you have to have that strong foundation, bone and soft tissues. So, that's why it's so important.

Paul Ciuci: Exactly. Unfortunately, patients usually go online prior to coming in to see an oral surgeon, or they see things on TV or the radio where you can get all of this done in one day. And you can have your tooth out, you can have an implant done, you could put a tooth on top and walk out whole. And the stars really have to align for that to happen. Patients lose their teeth. Teeth just don't all of a sudden go bad. It happens over time. And over that time, patients tend to lose bone, they tend to lose their gum tissue. And so, it really is a process and it does take some patience.

Bill Klaproth (host): When you describe it, certainly it doesn't sound like, "Yeah. Come in in an hour. We'll have you ready." So, you talked about taking soft-tissue grafts from nearby gum tissue. The roof of the mouth. How do you do this? How is a soft-tissue graft performed?

Paul Ciuci: So, I think for all of our patients, the number one thing is that we don't want anything to hurt.

Bill Klaproth (host): Thank you.

Paul Ciuci: Yes, exactly. None of these procedures should be painful. The majority of them are relatively quick. They could be a half an hour to a 45-minute procedure. They can all be done with local anesthesia and good Novocain. And a lot of time, nothing's going to hurt. If patients are anxious, oral surgeons are happy to provide light sedation, something to take away their anxiety. But the majority of the time patients basically can get numbed up, have a 30 to 45-minute procedure. And they actually do very well with it. At the end of the procedure, patients come in and they're like, "That wasn't so bad. I was expecting a whole lot worse."

Bill Klaproth (host): So basically, are you, for lack of a better term, cutting healthy skin out and putting it where you want the diseased or damaged skin or, should I say, soft tissue to be?

Paul Ciuci: That's precisely it. So at the area where we're lacking soft tissue, we would get that area numb. And then, we would actually kind of prepare that site. You can't just take it and stick it on there. It doesn't work that way. So, we have to prepare the site for the graft and make sure that that site is healthy. Sometimes you have to actually prepare the tooth in that area or the space in that area to accept the graft. And then, you go to the roof of the mouth or another area, or like I said, you can use kind of things from a tissue bank or other donors that you can use other type of materials. And once the site is ready, the recipient site, then we go to the donor site, so that site has to be numbed up. And then, we can take all of the tissue, not all of the tissue, but a part of the tissue of the hard palate that can go there or other areas or the synthetic things, we place it at the recipient site. And then, we need a lot of stitches, not a lot of stitches, but enough to keep that graft in place. Then, the soft-bristled brush comes in again. You have to keep the area clean and allow that new grafted gum tissue to become new, healthy gum tissue in the area of your implant.

Bill Klaproth (host): So, where you take the healthy, soft tissue, the donor tissue, if you will, does that area then need to be stitched up sometimes?

Paul Ciuci: Sometimes it does. There are different types of grafts. There can be what's called a full thickness graft, and that would actually leave an area that's kind of raw on the roof of the mouth and patients don't like that so much. Sometimes you can just open up a little soft-tissue window in the roof of the mouth and you take the undersurface or a split-thickness graft.

Bill Klaproth (host): Then, you kind of close it back up like a flap almost.

Paul Ciuci: Exactly. That's exactly right. So then, you close that flat back up. That tends to be a little less painful for the patient because the area's not open and raw. If you're not using tissue from the same patient, then you don't have a second grafted site. You have the recipient site, but you don't have a donor site. So, that's a nice way to go. But sometimes the best tissue is the patient's tissue. And so, your surgeon is the expert in that, and they're going to figure out, "Okay, how much tissue do we need? Where can we get it from? And what's the best option for you?"

Bill Klaproth (host): Right. Absolutely. So then, what is the healing time for a soft-tissue graft procedure?

Paul Ciuci: So, there’s two types of healing, right? So, the first is patients always want to know, how long is this going to be painful? How long is this going to be swollen? Things like that. So, there’s the acute or the healing time that’s right after the procedure. “Am I going to need to take time off from work from this?” And usually, the initial healing phase is just a couple of days. So, we’re talking, you know, it might be three or four days where the donor site and the recipi”nt site is sore. Most of the time, patients take what they would take for a headache. They might take some Advil, some Tylenol. They can ice that area. Keep it cold. They'll have a little swelling. We wouldn't expect bleeding. The mouth is full of bacteria. So, there's always a chance for infection and the oral surgeon will prescribe either antibiotics or maybe an antibiotic mouth rinse to keep that area clean.

Then, you have the longer term recovery. So now, you have to allow that gum tissue, that grafted gum tissue to really become a part of you, and that's going to take on the order of weeks. But the patient's not going to be in pain for weeks or months. But it's going to take time for what say the graft is going to mature and it's going to become good, attached gum tissue in the area of your future dental implant.

Bill Klaproth (host): And that's exactly what you're looking for, that strong foundation again.

Paul Ciuci: Exactly. It all comes down to we have to figure out where your new tooth is going to be. And then, we work backwards and we say, "Okay, your new tooth has to be here. Do we have enough gum tissue in that area?" No. Then, we'd need a soft-tissue graft. Do we have enough bone in that area? Yes or no. Then, we might need a hard-tissue or a bone graft in order to get you the implant, because the implant has to be in the right spot. Your tooth has to be in the right spot. If it's not in the right spot, then it's not going to look right. It's not going to work right and you're not going to be happy with your result. And unfortunately, to get that result, it takes time.

Bill Klaproth (host): Right. So that soft tissue then just becomes part of your body in that spot and then regular, good oral hygiene, soft-bristled toothbrush, you're pretty much good to go then. You're okay then.

Paul Ciuci: That's if all the other factors have been taken care of. So if you don't brush properly, if you don't – God forbid, you'd never start smoking. So if all the other factors which caused the soft tissue or the gum tissue to go away have been taken care of, then with your new grafted tissue and good hygiene, then yes, that soft tissue should last you.

Bill Klaproth (host): Yeah. Well, this has been fascinating. Dr. Ciuci, thank you so much. Anything else you want to add about soft-tissue grafting for dental implants?

Paul Ciuci: I think the oral surgeon is the expert and they want you to have a successful long-term result. So when you see them, they're going to tell you exactly what they can do and exactly what you need to get that result. So, I don't want patients to be disappointed when all they want is the tooth, that's what the patient's focused on. And when the oral surgeon says, "Oh, you need some bone grafting or you need some soft-tissue grafting." If that's what you need to get that successful long-term result, you know, trust your oral surgeon and they're going to get you exactly what you need to have that successful implant.

Bill Klaproth (host): Absolutely. Well, oral and maxillofacial surgeons treat patients with soft-tissue defects around teeth, dental implants and other oral sites utilizing a variety of surgical procedures. Make sure you contact an OMS to discuss soft-tissue grafting to improve your overall health. Dr. Ciuci, thank you so much for being here. We appreciate it.

Paul Ciuci: Thank you, Bill. Thank you for having me.

Bill Klaproth (host): You bet. And for more information and the full podcast library, please visit MyOMS.org. And if you found this podcast interesting, please share it on your social media. And don't forget to subscribe. Thanks for listening.