Connective Tissue Graft

Performed by Dr. Morlock

Charli Young
DH 271 Periodontology
Tammy Maahs
3/12/2017

Part 1: Observation
The day I went to observe at Dr. Morlocks office, he performed a connective
tissue graft above #24 on a 20 year old female patient. The entire staff was very
accommodating and willing to answer any questions we had regarding the procedure and
how the office is ran. I was thankful for the opportunity to get to observe in this specialty
office.
Before the patient arrived, the entire room was set up and ready for the procedure.
The only thing that had to be done was prep the patient. Everything to be used in the
procedure was sterilized previously, including the cotton rolls to use. The assistants
informed me that they never get in drawers with dirty gloves, even if using a pair of
cotton pliers to grab the item needed. They also informed me that Dr. Morlock has two
assistants available for every procedure; one to assist him directly, and the other to grab
anything the first assistant might need but isnt able to reach herself.
Once the patient arrived and before the procedure began, the assistants checked
with the patient to see if she had taken any pain medication before the procedure. Since
she hadnt, they gave her 800 mg of Motrin to help with pain for when the anesthetic
wore off. They then took a PA x-ray of the tooth to have the procedure performed on.
This office still uses traditional x-ray film. The patient had a retainer from orthodontics
that she was hoping to be able to use as a splint against the incision site to be made in her
palate, so one assistant took an impression of the palate to see if the ortho appliance
would cover the incision site like it needed to. Dr. Morlock made the decision that the
patients current retainer would not cover as much of the palate as it would need to, so the
impression was sent down the hall to the offices lab for a different splint to be made just
for this procedure. Next, the assistants took the patients blood pressure using an arm cuff
connected to a self-pumping machine and oxygen level using an O2 monitor on the
patients left index finger. The blood pressure was used as a base line to compare to the
blood pressure to be taken at the end of the appointment but the O2 monitor would stay
on for the whole appointment.
Topical for the injection was placed by the assistant to be directly assisting Dr.
Morlock. For the sake of confusion, I will refer to her as assistant #1, and the other one
assistant #2. After scrubbing their hands, Assistant #1 and Dr. Morlock wore normal
procedure gloves covered by sterile surgical gloves. Once their sterile gloves were on,
they didnt touch anything besides what was sterile in the operatory and the patient. A
sterile towel and gown was placed over the patient. Dr. Morlock gave infiltration
anesthesia through multiple injections around tooth #24, and injected straight into the
middle of the palate, dispensing one whole cartridge of Articaine 4% 1:100,000 into each
location.
 A Millennium PerioLase MVP-7 laser set at P=4.0 watts was used to perform a
vestibuloplasty to remove a high frenum. This was done in hopes to prevent the large
amount of recession on the facial of #24 from happening again. Once this was completed,
a scalpel was used to undermine the skin surrounding the frenum pull and to separate the
gingiva from the bone. A mini was used to scrape the root surface of tooth #24 down to
dentin to revascularize it, increasing chances for the graph to take. An area of 12 x 12
mm was prepped for the graft. The patient began to feel the site where the doctor was
working so he added 0.9 mL of Articaine 4% 1:100,000 to the site using an infiltration
technique. A solution of 125 mg/ml of Tetracycline was applied to the root surface with
cotton pellets allowing better reattachment of the graft. The Tetracycline was then rinsed
away with sterile saline.
Next, Dr. Morlock moved to the palate to retrieve the graft. He marked the palate
with a probe, and began the incision with a double-bladed scalpel. The graft was taken
from a site on the right half of the hard palate near teeth #3-6 about 10 x 10 mm in size.
The graft was placed in a small metal container filled with saline to keep it safe and dry
until it could be placed by #24. A strip of collagen was placed in the incision site of the
palate and the site was sutured shut.
Next, he began to suture the graft into place. He used a tool called a Woodson to
work the graft down into the pocket he made earlier above #24. It took a few minutes for
him to place it just how he wanted it at the site, but once it was in place, a suture was ran
around the site, holding the graft into place. A perio dressing called Barricade, a light
cured material, was then placed on the surgical site to protect it for the next two weeks.
The patient would return for a two-week reappointment, where this perio dressing would
be taken out and the sutures removed. The stent made by the lab at the beginning of the
appointment was pressed into place in the patients palate to protect that incision site for
the next two weeks also.
The patients blood pressure was checked again at the end of the procedure. She
was also provided with several post-op instructions, including: rest for the next couple of
days and avoid excessive exertion, dont touch or look at the incision sites, dont brush or
floss the incision sites, no smoking, rinse with warm salt water, take 600 mg of Ibuprofen
throughout the following day, maintain a regular diet but avoid nuts, chips and popcorn,
and bruising or swelling may occur but apply ice, not heat. The patient was supplied
these instructions in a written pamphlet to take home also.
To clean the room, the assistants threw away everything that was disposable and
sterilized all the reusable items. The counters, chair, and suctions were then soaked in
Birex and left to soak for ten minutes. If anything was bloody, it was wiped again with
CaviWipes. The air/water syringe and surgical hand-pieces were then set up again and
barriered with plastic sleeves. The total procedure took about an hour and a half. I was
not able to look at their charting system, so Im not sure what the notes looked like for
this patient.
A periodontists role is to perform procedures of the periodontium that is beyond
the scope of a general dentists practice. They generally send patients back to their
original dentist once the necessary procedure is performed. Procedures performed in a
periodontists office include root scaling therapy, periodontal flap surgery, gingivectomy,
gingivoplasty, osseous surgery, tissue grafts, regeneration surgery, crown lengthening,
extractions and implant placement.
Part 2: Reflection
I have never seen any kind of graft procedures before so this was extremely
interesting to me! Since Dr. Morlock is the only periodontist in our area, it was good for
me to get reassurance of his work and the care that is given to his patients so that if I end
up staying in the area to work, I will have confidence in sending patients to him. Overall,
I was slightly surprised the office didnt contain more up to date equipment, but he did an
excellent job with the procedure. I could tell he was good at what he does and everyone
was very cautious to keep anything near the surgical field sterile, which is important to
me.
http://www.lewistonperioandimplants.com/