A novel approach to Free Tissue Connective Graft for Root Coverage.
– An Interview with John Chao: Part 1
Today, we have Dr. John Chao on his Pinhole Technique, a non invasive treatment for receding gingival tissue. His Pinhole Surgical Technique (PST) allows you to perform a gingival lift for root coverage without scalpels, sutures or grafts, an alternative to grafting tissue from the roof of the mouth. This is a welcome, groundbreaking discovery of major importance in the field of periodontics.
In this interview you’ll learn:
● Revolutionary Gum Lift Technique
● Differences between traditional grafting vs Pinhole
● Long Term Results of PST
● How to regenerate crestal bone
With a traditional Periodontal Free Gingival Graft technique, a partial thickness flap is made around the mucogingival defect to maintain vascularity to receive the graft. Gingival tissue is then harvested from the palate and placed over the mucogingival defect area. It is a surgically invasive procedure which is very Time Intensive and Technique Sensitive.
Can you describe the Pinhole Technique vs the traditional method for treating gingival recession along the gumline?
The most respected, traditional gold standard for root coverage is the Sub-epithelial Connective Tissue Graft (SCTG). It’s a two step procedure where the clinician removes a sliver of tissue from the donor site which is the palate. Then this piece of tissue is transplanted to the area of recession, which is prepared by making vertical or horizontal incisions. These incisions then allow a split thickness flap to be made. The donor graft is placed under this flap, which is advanced coronally and all sutured together.
This traditional method has good long term results.
For the clinician it takes high level of time and dedication to become skillful at it. SCTG is usually done by board trained periodontist and some highly skilled GP’s.
However, morbidity is a major problem as it’s recognized by literature and patients. Morbidity such as pain, swelling, bleeding and nerve damage usually occurs, especially around the donor site.
There has always been research to find other method that does not produce as much morbidity.
Pinhole technique comes to the forefront to solve these morbidity issues. I invented this to eliminate the need of donor grafts. PST only requires a tiny pinhole above the mucogingival junction, in the mucosa. Through this pinhole, instruments are used to elevate a full thickness flap from underneath the mucosa. The flap is then moved coronally or incisally to where it needs to go for root coverage to the CEJ. Then the flap is stabilized with tiny collagen strips (1-10mm long). These strips are inserted underneath the flap for stabilization.
Are there significant differences in healing time and postoperative pain?
Morbidity or postoperative pain is almost non existent with PST. Pain pills are OTC for only 1-2 days. No bleeding, very mild swelling if at all. The pinhole is healed the very next day. No downtime for the patient.
With our classes, after the live surgery the patients come back the next day for docs to examine postoperative healing. The docs question patients on symptoms and can verify how they are healing in the mouth. They are always amazed at how nice the results are the next day, 24 hours after the surgical procedure.
How long have you been practicing this technique and what are the long term results showing?
I have been practicing grafting for many many years. It took many years to achieve and reach the exact protocol for how PST is today. This technique was finalized in 2006. So the cases for PST go back 10 years. I formally introduced the patented instruments and started collecting data from 2006.
With those cases, we published a study consisting of 43 patients with 121 sites, studied over a span of 33 months. Avg case length was 18 months. Some cases were considered long term since 24 months is definition of long term. With the long term subjects, of the 121 sites, the class 1 & 2 cases, show that the papilla have not receded away from the contact point. The success rate for full mouth coverage is at 80%. So this is as good as all the other methods that have been published. It is very comparable to the success rate of the SCTG which is from 70-90% success. So PST is in the middle of the very best techniques, but without the morbidity, the pain, swelling, and bleeding that comes with the SCTG.
Of those 43 cases we did, 30 of them are still around for us to measure their long term results. We are compiling statistics with the same original cases. The exciting 10 year long term results are almost ready for publication from a well respected post grad perio program (eastern University).
The degree of success long term is very favorable. At our seminars we bring long term patients who have had this procedure 5-10 years ago. We have our docs examine their before photos and the patients in class. They are able to question the patients on how they felt during and after the procedure. To verify the minimal pain, bleeding, and swelling.
Relapse wise, we don’t have 100% perfect coverage, but we do get over 90% coverage at the root.
With traditional grafting, you can only treat 1-2 sites. How does the Pinhole Technique compare?
Very commonly it’s done full arch, at least. Because you get the best release that way. It’s difficult to do by quad. If you have recession on the anteriors, you can’t just stop in the middle leaving recession between #8 and 9. We like to do full arch and full mouth. This is another advantage of PST since we are not limited by the number of teeth we can work on. Full arch can be done in about 1-1.5 hours.
The subepithelial connective tissue grafting (SCTG) at the most can only get coverage for 3-4 teeth at a time. It would take at least 3-4 separate surgeries to finish one full arch.
The problem with that is, after you send the patient home from the first SCTG procedure, it will be difficult to get the patient back the second and third time since they don’t want to go through all the pain and suffering afterwards. This doesn’t mean every time this procedure is done, they will have tremendous amount of pain afterwards, but typically there usually is pain associated with it. I would hesitate in referring patients to periodontists for the grafting procedure, because most likely when they come back, they would not be very happy.
So do your Patients love it? Has there been any dramatic moments with the before and after?
There is no question. They love it. There is a tremendous difference.
One of the docs that took the first classes we offered on PST was a periodontist. He says he’s been doing only PST for the last 3 years after taking the class. No more grafting he says. Before doing PST he never got hugs. Now he gets hugs everyday from patients.
Overwhelming results show that patients don’t experience pain. It doesn’t matter who does it. Pain is just not a factor. It’s a very comfortable procedure.
It’s amazing to the patients that there is no pain, and amazing to the patients that it looks so good afterwards. No sutures, no perio dressings. The tissue moves down and it looks good immediately.
A life changing emotional moment for a patient after PST was done.
Do pocket depths increase after you do the PST?
Great question. I get asked that a lot.
We were able to show to the satisfaction of the editors and chief of the international Journal of Periodontics and Restorative Dentistry, that pseudo pockets are not formed.
When we move the tissue from a 6mm recession to where it sits at the CEJ, when you probe the sulcus, it will be 1-2mm. (We help save the patient’s Pockets, financially as well, since they do not need multiple grafting surgeries. )
In fact, the study was able to show that the average pocket depth was 1.2mm. The sulcus actually becomes shallower. No psuedo pocket depth. There is true attachment and we show case after case that the tissue keratinizes. You won’t be able to tell the difference when you pull the gums up to a veneer or any other gingival tissue in the mouth.
In addition, we are currently doing cone beam studies looking at before after cases of PST 3-4 years later.
The results show bone growth by the radiologist report. This will be published soon as well.
So the crestal bone actually grows?
Yes it does. The eastern university is requesting permission to do histological studies from the institutional review board which controls the ethics of doing experiments on live patients. The head of the Perio department there at the university is getting permission through the IRB in about 3-4 months. So we are moving on all fronts with coming up with proof that this is a valid long term technique.
End of the Interview Part 1 – Continue to Part 2
Dr. John Chao Bio
Dr. John Chao is the inventor and patent holder of the Pinhole Surgical Technique. He currently teaches this scalpel-free, suture-free technique for correcting gum recession to Dentists from North America and from around the world. This method has been featured on over 240 TV stations, numerous blogs and newspapers. It is estimated that viewers reached by TV stations number about 25 million. Dentists trained in the Pinhole Surgical Technique are in great demand in the US and around the world.
Dr. John Chao graduated from the USC School of Dentistry and currently practices general dentistry in Alhambra. He received professional degrees from both USC School of Dentistry and Southwestern University School of Law. Dr. Chao has served as a reviewer for the Journal of Periodontology and he also teaches ethics at the USC School of Dentistry. Dr. Chao also holds the following professional titles: Master of the Academy of General Dentistry, Fellow for the Institute for Advanced Laser Dentistry, and Member of the Academy of Microscope Enhanced Dentistry. In 2012, Dr. Chao was recognized as the teacher of the year at the USC School of Dentistry for outstanding service over 10 years.
In his spare time he enjoys Lecturing and presenting at many dental societies and study clubs, attending and Hosting TV talk shows, and being a columnist. He also has a Doctor of Divinity, in Theological Seminary.