People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023

Suture Less Gingival Augmentation Using Gingival

Unit Transfer – A Case Report

Ashok KP1, Aishwarya Banala1, Manikanta Kumar1, Anupama M1, Satyanarayana

Gajjarapu1

1Department of Periodontics, GSL Dental College & Hospital, Rajahmundry

ABSTRACT:

The use of root coverage procedures to treat gingival recession defects, a common periodontal

condition, is an important aspect of periodontal regenerative therapy. The synergistic

relationship between vascular configuration and involved tissues is the most important factor

in soft tissue graft success.

The present case reports the clinical effectiveness of Gingival Unit Graft (GUG) for the

management of Miller's class III gingival recession.Clinical parameters like Probing depth,

recession depth, keratinized tissue width and clinical attachment level were measured at

baseline and postoperative 6 months. Percentage of defect coverage was evaluated at

postoperative 6 months.

Healing was uneventful and 3mm root coverage was observed with 1mm residual recession

and increase in keratinized gingiva after 6 months follow up.

Free soft tissue autografts such as gingival unit transfers can be used along with bio-adhesives

such as cyanoacrylates for predictable results in the management of recession defects.

KEYWORDS: gingival recession, keratinized gingiva, free soft tissue autograft, cyanoacrylates

Address for correspondence : Dr Ashok KP, GSL Dental College & Hospital, Lakshmipuram, Rajahmundry-533296,

E-mail: drashokkp@gmail.com

Submitted: 06.01.2023, Accepted: 14.06.2023, Published: 26.06.2023

INTRODUCTION:

Gingival recession is defined as the oral

exposure of the root surface caused by a displacement

of the gingival margin apical to the cemento-enamel

junction, and it is frequently associated with dental

aesthetic deterioration. The use of root coverage

procedures to treat gingival recession defects, a

frequently reported periodontal condition, is an

essential consideration of periodontal regenerative

therapy. Many surgical procedures can be used to treat

recession defects, including free gingival grafts,

connective tissue grafts, acellular dermal matrix grafts,

various pedicle flaps, combinations of these pedicle

flaps and graft techniques, and guided tissue

regeneration. The literature review reveals varying

success rates and predictability with these surgical

procedures[1].

The synergistic relationship between vascular

configuration and involved tissues is the most

important factor in soft tissue graft success[2]. The

graft's vascular characteristics are most likely

important for rapid anastomosis of the recipient site's

capillaries with injured graft vessels[3]. Fine blood

vessels form a network in the gingival sulcus, and

capillaries have numerous anastomoses[4]. Because the

gingiva's vascular plexus is rich in horizontal

anastomoses that perfuse the marginal zone, marginal

and interdental gingival tissues could be used to

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How to cite this article:

Ashok KP, Banala A, Kumar M, Anupama M,

Gajjarapu S, Raval KK. Suture Less Gingival Augmentation Using

Gingival Unit Transfer – A Case Report. PJSR. 2023;16(1):60-65.

Case Report

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People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023

Ashok KP et al. Suture Less Gingival Augmentation

benefit from improved blood perfusion of the recipient

site, improving graft survival[5]. As a result, the supra-

crestal part of healthy gingiva that included marginal

and papillary tissues is thought to be the only soft tissue

with a free marginal portion naturally established to

survive and function over a vascular root surface[3].

Other research has found that healthy gingiva has

substantially different vascular patterns in the

marginal, attached, and interdental gingiva[6].

Site-specific donor tissue is presumed to have

improved potential for function and aesthetic

acceptance at recipient sites in soft tissue graft

procedures. Clinically, using a site-specific Gingival

unit graft placed on a traditionally prepared recipient

site results in predictable root coverage. Gingival Unit

Transfer (GUT) is a variation of Free Gingival Graft

(FGG) that includes marginal gingiva and papillae in

the traditional palatal tissue graft with a vascular

supply that matches the recipient site intimately[2].

Sutures have long been demonstrated to

provide appropriate wound closure while having a low

rate of dehiscence. However, their use in root coverage

has some drawbacks. The main disadvantage is that it

increases surgical time. It also traumatizes tissues,

affecting vascularization and increasing the risk of flap

tearing[7]. Furthermore, based on the material, it can

pinch and irritate patients or promote plaque

accumulation, enhancing susceptibility to infection[8].

Tissue adhesives, are biocompatible agents

that, when applied to skin or mucosa, demonstrate a

resistance to wound dehiscence via attractive forces

between the tissue and adhesive molecules, and are an

alternative to sutures. Because cyanoacrylates are

biocompatible, biodegradable, hemostatic, and have a

long half-life, they are an excellent adhesive agent for

the oral environment[9].

This adhesive was used as an adjunct to

intraoral/extraoral wound suture by Nevins et al.[10]

because it can be implemented faster, prevents

ischemia, and improves haemostasis. In general, a

longer operative time has been linked to increased

bacterial exposure, a greater amount of anaesthesia,

and a higher morbidity rate. In this study, using

cyanoacrylate tissue adhesive instead of suture

resulted in a significant decrease in operative time

(mean of 4.5 min) (mean of 8 min). According to

Stavropoulou et al.[11], the duration of treatment was 3-

fold shorter with cyanoacrylate than it does with

conventional suture.

The present case report describes utilization of

gingival unit graft for gingival augmentation and

stabilization of graft over recipient site using

cyanoacrylates.

Figure 1

Figure 2

Figure 1&2: Recession of 4mm with inadequate keratinized gingiva &

shallow vestibule.

CASE REPORT

A 24-year-old female patient came to the

department of periodontology with a complaint of

receding gums in the lower front tooth region &

inability to maintain oral hygiene. Patient has a history

of orthodontic treatment in her previous dental visit.

Patient gives no relevant medical & family history. On

intra-oral examination, mild supragingival calculus

was present. Gingiva exhibits soft & edematous with

rounded margins in relation to tooth #41. A 3.3 mm

wide & 4 mm deep Miller class III gingival recession

defect with inadequate keratinized gingiva was found

on mandibular right central incisor. The probing depth

was 1 mm and the CAL was 5 mm (Figure 1 & Figure

2). Patient also presented with mucogingival problems

like shallow vestibule and frenal pull in relation to

tooth #41. Patient was diagnosed as chronic

generalized gingivitis with localized periodontitis in

Ashok KP et al. Suture Less Gingival Augmentation

People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023

relation to tooth #41.Initially phase-1 therapy i.e., full

mouth scaling & root planing in relation to tooth #41

was done. After all the conﬁrmed inﬂammatory signs

were reduced after initial phase-1 therapy, Gingival

Unit Transfer was planned to reduce the recession & to

provide adequate zone of attached gingiva in relation to

tooth #41.

Presenting problems in this case report were a

3.3 mm wide & 4 mm deep Miller class III gingival

recession irt #41, inadequate attached gingiva (tension

test positive) which leads to progressing gingival

recession, inadequate depth of vestibule (inability to

maintain oral hygiene) &frenal pull.

Figure 3: Two divergent vertical bevelled incisions given at recipient site

Figure 4: Recipient site prepared using split thickness dissection showing

dehiscence.

METHODOLOGY:

After achieving adequate anesthesia, root

planing was done in the exposed portion of the root

surface and then irrigated with saline. The recipient

site was prepared by giving two vertical beveled

incisions that extended apically to adjacent teeth,

Figure 5

Figure 6

Figure 5&6: Gingival unit graft harvested from palatal aspect of #25

3 to 4 mm beyond the mucogingival line, and the

surfaces of interdental papillae were removed. The

incisions were divergent therefore the recipient site

was trapezoidal. At the mucogingival line, vertical

incisions were connected by a horizontal incision

(Figure 3). A partial thickness dissection was made

apical to the alveolar mucosa and care was taken to

r e l i eve t he f r enal a t t achment a l ong with

vestibuloplasty to increase the depth of vestibule. The

epithelial surfaces within these incisions were de-

epithelialized. After preparation of recipient site,

dehiscence was found in relation to tooth #41(Figure

4). The base of the recipient site was made 5 mm apical

to the apical part of the exposed portion of the root

surface. The Gingival unit graft was harvested from the

palatal aspect of #25 including the marginal gingival

tissue and the papillae (Figure 5 & Figure 6). The graft

was placed over the recipient site and gentle pressure

Ashok KP et al. Suture Less Gingival Augmentation

People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023

was applied for 2-3 minutes for achieving primary

ﬁbrin stabilization and for preventing formation of

dead space (Figure 7). Graft was stabilized using

cyanoacrylates (AMYCRYLATE -ISO AMYL 2

CYNOACRYLATE). The donor site (palatal aspect of

#25) was also covered with cyanoacrylate (Figure 8 &

Figure 9). The operated site was covered using non

eugenol periodontal dressing for protection which was

removed after 1 week. At the postsurgical care for

infection control, patient was advised to rinse twice

daily with 0.2% chlorhexidine mouth wash for 3 weeks

and asked to avoid brushing and hard chewing at the

surgical site. 2 weeks post-operatively, recipient site

showed complete healing with 5mm keratinized tissue

gain and 1mm residual recession in relation to tooth

#41(Figure 10). Patient was recalled at 3 months and at

6 months (Figure 11 & Figure12). The recession defect

coverage was stable. The colour match of the graft

with the adjoining tissues was acceptable aesthetically.

Figure 7: Graft placed at recipient site & stabilized using cyanoacrylates.

Figure 8: Donor site covered with cyanoacrylate.

Figure 9: Donor site covered with cyanoacrylate.

Figure-10:1mm residual recession with 5mm keratinized gingiva

&Increased depth of vestibule.

DISCUSSION:

Gingival unit transfer is a variation of the Free

gingival graft that includes marginal gingiva and

interdental papillae in the conventional palatal tissue

graft whose vascular supply matches integrally with

the recipient site, as described by Allen AL and Cohen

DW[ 1 2 ] . Gingiva has a distinct structure and

properties[13]. The gingival arterioles are oriented

apico-coronally. Capillaries form repetitive networks

in the marginal gingiva, and several small vessels form

loops that extend towards the marginal gingiva.

Furthermore, it has also been demonstrated that as

gingival vessels extend coronally, their size and

number decrease. Thus, in this modiﬁed technique, the

donor tissue's size, number of vessels, and vascular

conﬁguration would better match those of the recipient

Ashok KP et al. Suture Less Gingival Augmentation

People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023

Figure 11: 1mm residual recession with 5mm keratinized gingiva

&Increased depth of vestibule after 2 weeks.

during the microsurgical approach[16].

Tissue adhesives could help with some of

these issues. Tissue adhesives form a strong adherence

surface, allowing the graft to be stabilized without

perforating the ﬂap and ensuring a better blood supply.

Furthermore, they act as a barrier, securing the wound

edges and preventing infection or graft detachment,

attempting to make surgical techniques more

predictable[9]. It serves as a physical barrier over the

donor site, promoting faster wound healing and

increasing patient comfort.

As the cyanoacrylate is hard to control, it can

get under the graft. Care should be taken while grafting

larger areas with free soft tissue grafts, where there are

chances for dead space formation which are

considered as limitations of cyanoacrylates.

Jenabian et al.[14] used a split-mouth design to

treat 18 bilateral localised recessions (Miller Classes I

and II) in nine systemically healthy patients. Gingival

Unit Graft (GUG)produced higher aesthetic

satisfaction at 1, 3, and 6 months, as well as higher root

coverage at 1 month, according to the study.

Furthermore, 11% of GUGs had complete coverage at

6 months, as well as a higher healing index and

substantial reduction in recession width 3 months after

surgery; however, the reduction in vertical recession

depth (VRD) on this side was not statistically

signiﬁcant.

Kuru and Yildirim's[3] study, included 17

Figure 12: 6 months post-operative follow-up photograph.

site, providing a desirable aesthetic outcome and tissue

blend[14]. A successful surgery requires wound closure.

Inadequate suturing or postsurgical care by the patient

could result in complications such as graft loss[15].

A suture material with good capillary action

acts as a wick, delivering serum ﬂuid and bacteria,

making it susceptible to complications and surgical

failure. The angiographic analysis done immediately

just after surgical treatment revealed that the micro-

surgically operated sites had better vascularization

with a mean percentage of 8.9 ± 1.9% compared to a

macro-surgically treated sites with 8.0 ± 1.8%,

respectively. The observed difference provided

evidence that a minimally invasive technique may

result in less tissue trauma. It is possible that the

reduced tissue damage was caused by the sharper and

ﬁner surgical blades and ﬁner suture material used

patients who were randomly assigned to one of two

groups. The authors discovered that the GUG group

had greater vertical recession reduction, attachment,

and keratinized tissue gain than the second group.

Furthermore, the mean proportions of defect coverage

in the GUG group were 91.62% and 68.97% in the

FGG group (P˂0.05).

Sibel Kayaalti-Yuksek & Emre Yaprak[17]

compared the usefulness of GUG with connective

tissue graft using a randomized split mouth study to

verify the clinical parameters and patient scores in

gingival recessions. Sixteen patients with bilateral

defects were chosen. SCTG or GUG was performed in

thirty two defects. Clinical measurements, Recession

coverage and patient outcomes were measured at

baseline and at 1, 3 and 6 months. They concluded that

GUG can be a suitable method for treatment of

recession with inadequate Keratinized tissue width.

In a systematic review on comparison of

gingival unit transfer and free gingival graft done by

Chethana et al[18], the authors could not prove the

superiority of gingival unit transfer over Free Gingival

graft. But, GUT showed higher percentage of sites

with comprehensive root coverage than FGG.

Ashok KP et al. Suture Less Gingival Augmentation

People’s Journal of Scientific Research / Volume 16 / Issue 1 / Jan-June 2023

CONCLUSION:

For predictable results in the management of

recession defects, free soft tissue autografts such as

gingival unit transfers can be used in conjunction with

bio-adhesives such as cyanoacrylates. Although this

technique is simple and minimally invasive,

considerations such as proper plaque control, root

surface biocompatibility, careful surgical manipula-

tion, and tissue thickness have been shown to be

critical and may affect the grafting procedure's

outcome. Clinical trials are needed to demonstrate the

efﬁcacy of this technique in the treatment of class III

gingival recession.

Financial Support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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