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Operculum from Erupting Third Molar: An Alternative Donor Site for an

Epithelialised-Free Soft-Tissue Autograft Case Report

Article  in  Journal of Nepalese Society of Periodontology and Oral Implantology · February 2020

DOI: 10.3126/jnspoi.v3i2.30888

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Case Report J Nepal Soc Perio Oral Implantol. 2019;3(6):75-7

Operculum from Erupting Third Molar: An Alternative Donor Site for

an Epithelialised-Free Soft-Tissue Autograft

Dr. Harish Kumar Shah,1 Dr. Sajeev Shrestha,1 Dr. Shivalal Sharma,1 Dr. Pujan Acharya1
1
Department of Periodontology and Oral Implantology, College of Dental Surgery,
BP Koirala Institute of Health Sciences, Dharan, Nepal.

ABSTRACT
Gingival augmentation technique is used to increase the thickness of attached gingiva and arresting the progress of recession. Autogenous
epithelialised free gingival graft obtained from palate is a well-established periodontal plastic procedure for root coverage and increasing
the width of attached gingiva. This case report shows augmentation of attached gingiva from operculum of erupting third molar as
an alternative donor site in marginal tissue recession not extending beyond the mucogingival junction with soft and hard tissue loss
interdentally of 31 and 41 in a 20-year-old female.

Keywords: Attached gingiva; epithelialised free gingival graft; operculum.

INTRODUCTION test positive with marginal tissue recession not extending

beyond the mucogingival junction (MGJ) with a soft tissue
Attached gingiva aids in increasing resistance to external
loss interdentally of 31 and 41 and erupting 48 covered
injury and contributing to stabilisation of gingival margin.1
with the operculum. Radiographic examination revealed
Increasing attached gingiva should be strongly considered
loss of interdental bone of 31 and 41 (Figure 1a).
where patient's plaque control is compromised and
connective tissue graft are common surgical procedures Miller’ classification has become very popular and widely
used for augmenting zone of attached gingiva predictably. 2 used.7 Recently, some criticisms to this classification were
Problems related to attached gingiva and aesthetics can be reported as the difficult differential diagnosis among
managed effectively with proper treatment plan and correct different groups.5 The cases, which have inter-proximal bone
surgical technique.3 Use of operculum of erupting third loss and the marginal tissue recession that does not extend
molar to augment attached gingiva is predictable. However,
4 to MGJ cannot be classified either in Class I because of inter-
adequate evidence is not present. Objective of this case proximal bone or in Class III because the gingival margin
was to evaluate operculum as an alternative donor site to does not extend to MGJ.5,8 Mucogingival deformities and
augment attached gingiva. conditions around teeth-gingival recession (Recession Type
2 proposed by Cairo et al.) with aberrant frenum diagnosis
CASE REPORT
was made.5,6 After diagnosis, the patient was informed
A 20-year-old female reported to Department of about the importance of attached gingiva to prevent further
Periodontology and Oral Implantology, College of Dental
Surgery, BP Koirala Institute of Health Sciences with a chief
complaint of receding lower front gums for 6 months.
Medical history was non-contributory. Clinical examination
revealed an aberrant lower labial frenum with tension

Correspondence:
Dr. Harish Kumar Shah Figure 1a: Gingival recession. Figure 1b: Operculum of 48.
Department of Periodontology and Oral Implantology, College of
Dental Surgery, BP Koirala Institute of Health Sciences, Dharan,
Nepal.
email: [email protected]

Citation
Shah HK, Shrestha S, Sharma S, Acharya P. Operculum
from Erupting Third Molar: An Alternative Donor Site for an
Epithelialised-Free-Soft-Tissue Autograft. J Nepal Soc Perio Oral
Implantol. 2019;3(6):75-7. Figure 1c: IOPAR.

Journal of Nepalese Society of Periodontology and Oral Implantology :Vol. 3, No. 2, Issue 6, Jul-Dec, 2019 75
Shah et al. : Operculum from Erupting Third Molar: An Alternative Donor Site for an Epithelialised-Free Soft-Tissue Autograft

Figure 2a: Recipient site. Figure 2b: Operculum detachment. Figure 2c: After operculectomy.

recession. The patient was counselled regarding various Donor tissue was obtained from erupting 48 by giving
treatment options among which she preferred to go for incision 2 mm apical from occlusal surface of 38, starting
simultaneous frenectomy and augmentation of attached from the mid-buccal aspect, distal and ending at mesio-
gingiva of 31 and 41 with soft tissue graft obtained from lingual aspect of 38 and graft was detached from mesio-
operculum. buccal side with 15 number Bard-Parker blade from the inside
of sulcus until it was detached completely from it (Figure 2b,
Treatment began with non-surgical phase. After scaling
2c). Approximately 8 mm x 14 mm size of soft tissue graft
and root planing, the patient was advised to maintain
was obtained (Figure 3a). After obtaining soft tissue graft
meticulous plaque control. Six weeks after phase I therapy,
the inner sulcular layer was de-epithelialised. The trimmed
as plaque control was good, the surgical phase was initiated.
graft was transferred to a prepared bed such that connective
The treatment plan to perform frenotomy along with
tissue surface faced the prepared bed and secured against
augmentation of attached gingiva with a free soft tissue
recipient side by placing interrupted, horizontal matrix
autograft from operculum was made.
and vertical matrix sling suture (Figure 3b). The patient's
Written informed consent was taken after explaining the
lower lip was moved in all possible directions to ensure
nature of procedure. Proper extraoral asepsis with 2%
the graft stability against lip movement. The recipient bed
povidone-iodine was followed by intraoral preprocedural
was covered by Coe-Pak (Figure 3c). The patient was given
0.2% chlorhexidine rinses and then adequate local
analgesics (Ibuprofen 400 mg every 8 hours for 3 days and
anaesthesia was administered. Relocation of frenum was
0.2% chlorhexidine gluconate rinse every 12 hours for 14
done with frenotomy by giving the incision deep in the
days. Postoperative written instructions were given. Sutures
vestibule. Recipient bed was prepared by performing
were removed on seventh day after the site was carefully
horizontal incisions in the interdental papilla in relation
debrided with 0.2% chlorhexidine rinses.
to 32, 31, 41 and 42. Vertical incisions were made along
Healing was uneventful at the donor site as well as recipient
the mesial proximal line angle of 32 to mesial proximal
site. The patient was instructed to continue chlorhexidine
line angle of 42 beyond the mucogingival junction and
rinses with no brushing or flossing at the surgical site
de-epithelialisation was done to place donor tissue against
for further one week. After three weeks, the patient was
it (Figure 2a).

Figure 3a: Graft. Figure 3b: After suturing. Figure 3c: After Coe-Pak.

76 Journal of Nepalese Society of Periodontology and Oral Implantology :Vol. 3, No. 2, Issue 6, Jul-Dec, 2019
 Shah et al. : Operculum from Erupting Third Molar: An Alternative Donor Site for an Epithelialised-Free Soft-Tissue Autograft

Figure 4a: Healing after six months at 48 and recipient site of 31 and 41.

advised to brush gently with a soft toothbrush by using a augment attached gingiva is predictable.4 However, so
rolling stroke coronally. By six months, excellent healing far, the adequate evidence is not present for the use of
and colour match was noted (Figure 4a and 4b). The gain operculum to augment attached gingiva to prevent the
in keratinised tissue height, as well as increased tissue gingival recession.
thickness and apical displacement of the frenum attachment
The advantages to using the gingival operculum from an
was observed. The patient was completely satisfied with the
erupting molar as an autograft are: it avoids the palate as
result obtained.
a donor site; it decreases postoperative morbidity related

DISCUSSION to surgical trauma; and risk of incising greater palatine

artery in case of shallow palatal vaults.4 It also allows for
Attached gingiva is a part of keratinised gingiva which
more rapid healing at the donor site, as the tissue covering
aids in periodontium in increasing resistance to external
the erupting tooth does not need to be recovered. It has a
injury and thus contributing in the stabilisation of gingival
better colour match and aesthetic improvement than palatal
margin against frictional forces and also aids in dissipating
highly keratinised mucosa as it is gingival tissue. The other
physiological forces exerted by the muscular fibers of the
advantages of this technique are ease of harvest and exposure
alveolar mucosa on the gingival tissues.1 Increasing attached
of erupting third molar for oral hygiene maintenance. The
gingiva should be strongly considered in cases where the
patient was happy with this treatment as augmentation
patient's plaque control is compromised and connective
of attached gingiva and exposure of third molar for oral
tissue graft are the most common surgical procedures used
hygiene maintenance was done simultaneously. It may act
for augmenting the zone of attached gingiva effectively
as one of the predictable options where possible to use
and predictably.2 The problems related to attached gingiva
operculum from erupting third molar for augmentation of
and aesthetic concern can be managed effectively if
gingiva and root coverage.
proper treatment plan and correct surgical technique are
executed.3 The use of operculum of erupting third molar Conflict of Interest: None.

as an alternative harvesting site in younger patients to

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J Nepal Soc Perio Oral Implantol. 2017;1(2):81-3.
4. Harrison JS, Conlan MJ, Deas DE. An Alternative Donor Site for an Epithelialized-Free Soft-Tissue Autograft. Compend Contin Educ
Dent. 2011 Mar;32(2): e29-31.
5. Cairo F, Nieri M, Cincinelli S, Mervelt J, Pagliaro U. The interproximal clinical attachment level to classify gingival recessions and predict
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7. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent. 1985;5(2):8-13.
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Journal of Nepalese Society of Periodontology and Oral Implantology :Vol. 3, No. 2, Issue 6, Jul-Dec, 2019 77
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