The use of paquette blade handle in harvesting free gingival graft from the palate – a report of three cases with its method of use, advantages and disadvantages.

INTRODUCTION

Autogenous Free Gingival Grafting (FGG) is a well-established periodontal plastic procedure to increase the width of keratinized gingiva and to stop progressive gingival recession. Bjorn,¹ and Sullivan and Atkins,² were the pioneers of FGG. Indications of FGG include increasing the vestibular depth, increasing the volume of gingival tissues in edentulous spaces (pre-prosthetic procedures), and root coverage procedures.

An important step in FGG is obtaining the graft from palate. Most commonly a scalpel is used, which, however, is slightly more time consuming and requires greater degree of learning curve and skill. These limitations have motivated the idea of developing alternative methods.

In this attempt, ivory matrix retainer No.8 was slightly modified to hold a razor blade and use it as a ‘3A’mucotome, which had the advantages of faster, simpler and easier graft procurement. It also allowed greater range of adjustment for the curvature of blade, initially with the main screw and later with the fingertip or pliers.³ However, it was difficult to get a fine grip due to the small handle, limiting the force application and increasing the difficulty in graft harvest.

An alternative method to harvest the graft is by using Paquette blade handle (PBH). It is an instrument designed by Dr. Omer E Paquette, which is an improved blade holding mechanism for use with the ‘Bowed Blade Concept’ pioneered by Uohara and Federbusch.4 Manufacturers of this product claim multiple advantages like Lesser time-consumption, ease and simplicity of graft harvest.

There are no reports till date as found in our literature search showing the usage and usefulness of PBH and hence, we intended to check the usefulness of this instrument in harvesting the graft from the palate.

This article reports the successful harvest of FGG using PBH which was used for the augmentation of keratinized gingiva. All the three-case described here were performed in the Department of Periodontics, Dayananda Sagar College of Dental Sciences, Bangalore. The patients were systemically and periodontally healthy, except for gingival recession mentioned in the following description. Pre-surgical therapy included scaling, root planing and plaque control instructions. Radiographic examination revealed no interdental bone loss. The graft was harvested using a PBH in all the cases. The outcome was satisfactory in terms of ease, speed and simplicity in graft harvest.

Case Reports

Case 1: A 25-year old female patient complained of sensitivity and longer appearing lower front tooth after orthodontic treatment. Intraoral examination revealed Miller’s class II recession of tooth #42, which was progressive (Figure-1). This tooth showed a 7mm deep and a 4mm wide recession with shallow vestibule and lack of keratinized gingiva. After patient’s consent was obtained, it was decided to treat the recession using FGG to achieve root coverage, increase the width of keratinized gingiva and simultaneously deepen the vestibule.

Case 2: A 27-year old male patient was referred from the Department of Orthodontics for the management of gingival recession and mobility associated with mandibular central incisors, after initiation of orthodontic therapy. Periodontal abnormalities included Miller’s class III gingival recession in relation to teeth #31 & 41. These teeth presented with gingival recession of about 4mm depth and 5mm width. Keratinized tissue was inadequate, labial frenum was attached at the tip of interdental papilla, and the vestibule was shallow.

Case 3: A 35 year-old male patient complained of long tooth in the lower front region of his mouth. The general periodontal health was good, except for Miller’s class II recession of tooth #43, which was transposed to the position of tooth #41.This tooth was supposed to be used as an abutment for replacing the adjacent missing tooth #42. It displayed a recession defect of about 8mm depth and 5mm width, keratinized gingiva was inadequate and the vestibule was shallow.

Procedure of using Paquette blade handle – Prior to, during, and after surgery: PBH has the following parts - Wedge, wedge recess, locknut and rear handle (Figure-2).

Preparing the blade: A standard double-edged stainless-steel safety razor blade was taken and cut into two halves length-wise by folding the blade in the middle portion inside the wrapper (Figure-3). The blade can also be cut using scissors with a smooth continuous pass to avoid nicks and barbs that could be caused by short chopping cuts (The full length of the blade can then be trimmed to a size of approximately 3mm width if needed, though not mandatory).The first technique of folding the blade inside the wrapper was found to be easier and simpler.

Insertion of blade: The threaded section of the rear handle was twisted in anti-clockwise direction to loosen the handle from locknut and was pushed towards the locknut to release the wedge from wedge recess (Figure-4). One of the free ends of the blade was inserted into one wedge recess as far as it would go and then the other end was bent as shown in the Figure-5, to be inserted into the other wedge recess till a secure grip was ensured. The blade and PBH portion adjacent to it was supported with fingers of one hand as shown in Figure-6, which would prevent accidental, forceful ejection of the blade from the wedge recess. Now, the other hand was used to tightly pull the threaded rear handle portion away from locknut and turned in clockwise direction to tighten the blade (Figure-6). The blade angle in relation to the handle can be adjusted to have different blade angulations based on various depths and angulation of the palate (Figure-7). Proper seating was checked by a slight pull with haemostat. After locking the blade in position, its contour was adjusted to desired shape, safely, using roundnose pliers, which was done at the back part of the blade to avoid damage to delicate cutting edges (Figure-8). The shape of the blade was adjusted based on the required width of the graft, which was obtained using a tin foil template. A normal oval shaped loop would result in a narrow graft width, whereas a blade bent into a trapezoid shaped would result in a wider graft (Figure-9). At this stage the knife was ready to use.

Removal of blade: After completing the procedure and discharging the patient, bladeremoval and instrument-cleaning was done. The blade and PBH portion adjacent to it was supported with fingers of one hand as shown in Figure-10, which would prevent accidental and/ or forceful ejection of the blade from the wedge recess. The threaded rear handle portion was twisted in an anti-clockwise direction to loosen it from the locknut (Figure-10) until its surface separated by around 2-3mm. Care was taken, not to create excessive separation as the blade would be ejected forcibly resulting in injury. The rear handle portion was pressed forward, towards the locknut, until a ‘click’ was heard, which indicated the wedge lock being disengaged. The blade was loose at this stage and ready to be removed. The used blade would be sharp and under tension and hence has to be removed carefully with haemostat or fingers. Following its use, the handle was dis-assembled, cleaned and autoclaved.

Surgical procedure

The surgical procedure for all three individuals was similar. After injecting local anaesthesia, the recipient site was prepared in the usual manner. A tin foil template of the recipient site was prepared and placed over the donor site in the palate.

Technique of using PBH to harvest FGG

The graft was obtained from palate using PBH. Shape of the blade loop was adjusted to oval or trapezoid based on the required width of the graft as measured from the tin foil template. The loop was adjusted to be oval for a narrower graft and trapezoid for a wider graft width.

The PBH was held in modified palm and thumb grasp with an extra-oral fulcrum. The angulation of the blade was adjusted at this stage to be between 0° and 30°for maximal adaptation, based on the depth of the palate. Once the blade was adapted well, the desired thickness of palatal tissue was engaged with the blade and PBH was moved in a shaving motion till the desired length of FGG was obtained (Figure-11). The harvested FGG was sutured to the recipient site (Figure-12) and periodontal dressing was placed. Post-op instructions were given and medication prescribed. The 2-weeks post-operative picture showed good healing in the donor site in palate (Figure-13). 6-months post-operative picture of the grafted area showed good root coverage and augmentation of the keratinized gingiva (Figure-14).

DISCUSSION

In the most commonly used classical method, a straight and stiff scalpel blade is used on the curved palate. Repeated incisions to release the graft from underlying connective tissue results in grafts with ragged undersurface, apart from longer time and greater degree of skill needed to harvest the graft.

These drawbacks were overcome by the use of a ‘3A’mucotome with advantages of faster graft procurement (within seconds), simplicity and greater range of adjustment for the curvature of blade.³ However, it might have few disadvantages like difficulty to get a fine grip due to the small handle, which interferes with the occlusal surface, limited force application due to smaller handle, increasing the difficulty in graft harvest. These problems were solved by the usage of PBH.

The advantages of PBH were similar to ‘3A’ mucotome, along with a better grip due to longer handle and thus a better generation of force. Also, the blade could be adjusted to various angulations depending on the depth and shape of the palate and also be moulded into different shapes to obtain required width and shape of the graft.

However, the following limitations were reported while using Paquette blade handle, by Agarwal et al.³

1. The curvature of the blade has limited range of adjustment, by finger pressure or by pliers. (In our experience we found that adequate practice can overcome this draw back).

2. For inserting the razor blade strip on the Paquette blade handle, the insertion points into the wedge recess for both ends of the blade are very close to each other. This creates a sharp curve (bend) and hence it becomes difficult to adjust the blade against comparatively shallow curvature of the palate, even after manipulation by finger/pliers. These are contrary to our findings as we did not have such difficulties in any of the three cases.

3. Accurate technique for use of this instrument is lacking in the literature. Hence there are multiple unanswered questions such as position of finger rest, angulation of blade and handle and method of mounting the blade on the handle etc.

This case report includes details of parts of PBH, position of finger rest; grasp used, angulation & shape of blade and also the method of blade insertion & removal. To the best of our knowledge, no such details are available in the literature till date.

However, few short-comings involved with the use of Paquette blade handle were noticed.They are:

1. The oval shaped loop of the blade on the Paquette blade handle, led to narrower grafts, which were considerably thicker in the middle part as compared to their edges. This created a saucer like wound in the palate, with the middle portion being deeper than the periphery. Due to this reason, all three cases encountered excessive bleeding as the palatal blood vessels were nicked in the deeper middle portion.

2. Another reason for excessive bleeding might be the saucer shaped palatal wound, which might not provide a favourable shape for clot retention compared to the wound created by scalpel blade harvest method.

3. The instrument is expensive and not commonly available on demand.

4. Requires a moderate degree of skill to learn inserting, removing and preparing the blade, which includes adjusting the blade shape and angulation.

CONCLUSION

This report shows that PBH is a useful instrument for harvesting FGG. This report describes in detail the method of using PBH and discusses about its advantages and dis-advantages concisely. Though the surgical procedure to procure the graft is simple and quick with this instrument, there are some disadvantages, which might deter its common usage. The advantages and disadvantages have to be weighed in randomized control trials before advocating its regular usage.