Author :
DR. ESHITA D PATEL (M.D.S),
Post graduation from K.M.SHAH DENTAL COLLEGE

Abstract:

Gingival recession is the exposure of root surfaces due to apical migration of the gingival tissue margins. The principal objectives of treating   gingival recession are to achieve better esthetics and reduce hypersensitivity. Various soft tissue augmentation techniques such as coronally advanced flap, free mucosal graft, subepithelial connective tissue graft, guided tissue regeneration, laterally positioned flaps etc are used for treating the same. The gingival phenotype and other local factors play important role in the results obtained by these treatments. This case reports show the stable results obtained using subepithelial connective tissue graft technique.

Introduction:

Gingival recession can be defined as the displacement of gingival margin apical to cementoenamel junction. The causes range from periodontal disease, improper brushing technique, frenal pull, bone dehiscence, improper restoration and tooth malposition. One of the main assumptions of periodontal plastic surgery is to guarantee aesthetics of the red complex. This can be gained with the application of recession coverage and gingival augmentation. A variety of surgical methods used for recession coverage enables to choose the most efficient method which in turns allows gaining the best therapeutic and aesthetic effect depending on the operated area condition. 1

It is essential to carry out root coverage surgery whenever concerns such as aesthetics, sensitivity, susceptibility to root caries, pulpal symptoms due to exposure of root, food lodgment and plaque deposition exist. Currently accepted procedures for root coverage include coronally advanced flap, free mucosal graft, subepithelial connective tissue graft, guided tissue regeneration, laterally positioned flaps and acellular dermal matrix. Successful coverage of unpleasing exposed roots for esthetics as well as functional reasons has been the objective of various mucogingival problems.

When adequate gingiva exists, repositioning it over the denuded root surface provides the most esthetic result; but adequate gingiva does not always exist in adjacent locations. For this reason, grafting of gingiva from a remote location is often required to augment the area with autogenous free gingival grafts or connective tissue grafts harvested from the palate. In 1963 Bjorn pioneered the free gingival graft (FGG), one of the first soft tissue techniques, in Europe.2 However, the FGG is highly unpredictable, tends to produce unacceptable gingival color matches and can heal with a “keloid” appearance. In 1956 Grupe and Warren introduced the lateral pedicle flap  (LPF). 3 Cohen and Ross proposed the double papilla flap in 1968. 4

These techniques are unsuitable if sufficient adjacent keratinized tissues do not exist. In 1965 Harvey popularized the combination of a FGG, followed by a coronally positioned flap (CPF).5 However, this entails additional surgery, patient treatment time, expense and have limited applications, working best for narrow defects only. In an attempt to reduce the morbidity associated with a donor site and produce true periodontal regeneration, Tinti and Vincenzi were the first to apply the principles of guided tissue regeneration (GTR) to root coverage.6

GTR is highly technique sensitive, time consuming and the long-term stability of GTR is still a question.

The advent of the subepithelial connective tissue graft (SCTG), as described by Langer and Langer with modification by others, predictably increased root coverage of Miller Class I and II recessions to more than 90%.7,8

The SCTG combines a connective tissue graft (CTG) with an overlying pedicle flap that provides the added blood supply needed to maintain the graft. Root coverage gained with SCTG was reported to be stable over long term. Therefore SCTG procedures have commonly served as the ‘gold standard’ to evaluate the safety and results of other root coverage procedures. Taking into consideration of advantages of SCTG over other procedures, this case report describes the results of root coverage using SCTG procedure using Langer’s technique.

Case presentation:

A 24 year old male patient reported to Department of Periodontics, K M Shah dental college and Hospital with the complaint of sensitivity and inability to brush properly in relation to lower anterior teeth. On examination there was Miller’s Class III recession in relation to 41 and 31. 9  The distance from CEJ to marginal gingiva was 5 mm and 3 mm respectively. Probing depths were 2mm and width of recession 3mm in both 41 and 31.Gingiva was inflammed with rolled out margins. Frenal attachment was high in relation to 31 and 41 (Figure-1). Fremitus test was positive. Subepithelial connective tissue graft using Langer’s technique was planned.

Root planning was performed in 31 and 41, the root convexity reduced and the region of 41 and 31 was anesthetized. Root biomodification was done with tetracycline. It was applied with a cotton pellet on each tooth for 3 minutes. The area was later flushed with saline.10.

Two horizontal incisions were made at the level of CEJ in the   interdental papillae adjacent to the area to be grafted. The incisions were at right angles to the gingival surface creating a butt joint. A sulcular incision through each recession area was given followed by two vertically diverging incisions on distal aspect of 42 and 32 beyond the mucogingival junction so as to relax the flap sufficiently to allow placement of the connective tissue graft. To maintain the vascularity, the flap was kept broad at the base (Figure-2)

Using sharp dissection of the scalpel blade, a split thickness flap was elevated to the level of the apical end of the vertical incisions. A tin foil template was prepared for checking the dimensions of the graft required to be harvested. Foil was placed at the recipient site and adjusted for the required dimensions. The foil was then placed on the already anesthesized donar site to mark the outlines of the incisions (Figure-3). Trap door technique with one horizontal and two vertical incisions was used to harvest connective tissue from the palate. 11 (Figure-4) Horizontal incision was at a distance of 4mm from the gingival margins of 24, 25 and 26 region. Initial horizontal incision was bone touching, through which periosteal elevator was passed to obtain the connective tissue. The graft obtained was 15mm in length and 5mm in width with the thickness of about 1.5mm. (Figure-5)

The graft was placed over the recipient site and secured with sling sutures coronally and interrupted sutures laterally using 5-0 vicryl resorbable sutures (Figure-6). Pressure was applied on the graft for 5 mins for close adaptation. Overlying flap was coronally repositioned over the graft and sutured with interrupted sutures. Periodontal dressing was used to protect the graft. Analgesics were prescribed for five days. Patient was advised to abstain from brushing at the surgical site for 4 weeks. Use of 0.2% chlorhexidine mouthrinse was prescribed for 4 weeks. The patient was enrolled in maintenance regimen with monthly recall sessions until three months post surgery. Each session included reinforcement of oral hygiene instructions and supra gingival plaque removal.

RESULTS

Gingival recession is treated to reduce root sensitivity and increase width of gingiva. Parameters such as recession depth, recession width, probing depth and clinical attachment level were recorded pre-operatively, 1 month and 3 months after the surgical procedure. Figure 7 shows the 3 months postoperative results.

Table 1 shows the pre-operative and post-operative measurements of recession depth.

Treatment type	Pre-treatment		Post-treatment at 3 months		Root coverage
Subepithelial connective tissue graft	41	4mm	41	2.5mm	41	1.5mm
	31	3mm	31	1mm	31	2mm

Table 2 shows pre operative and postoperative measurements of recession width

Treatment type	Pre-treatment		Post-treatment at 3 months		Root coverage
Subepithelial connective tissue graft	41	3mm	41	3mm	41	0mm
	31	3mm	31	2mm	31	1mm

Table 3 shows changes in probing depth

Treatment type	Pre-treatment		Post-treatment at 3 months		Changes
Subepithelial connective tissue graft	41	1mm	41	1mm	41	0mm
	31	1mm	31	1mm	31	0mm

Table 4 shows percentage of root coverage in terms of recession depth after 3 months

Site	% of root coverage
41	62.5%
31	66%

After 3 months, the zone of attached gingiva was increased and the high frenal attachment was relocated.

CONCLUSION:

The treatment of gingival recession can be accomplished with a variety of different procedures. The evolution of periodontal plastic surgical techniques has allowed the clinician to meet the demands of today’s dental patient. The majority of studies concluded they provide comparable results, however, SCTG has statistically been shown to be slightly superior to GTR. A large variety of mucogingival grafting procedures for coverage of exposed roots exists. These procedures are quite predictable and produce satisfactory solutions to the problems presented by gingival recessions. Selection of the appropriate procedure and precise and meticulous surgical technique will provide successful and highly predictable results in the treatment of gingival recessions. Gingival biotype is an important factor in the treatment of gingival recession.12 The present case highlights the significance of using subepithelial connective tissue graft to achieve more stable and long-lasting results.

References:

1. Tolga Fikret Tözüm. A Promising Periodontal Procedure for the Treatment ofAdjacent Gingival Recession Defects., J Can Dent Assoc 2003; 69(3):155–9

2. Bjorn H. Free transplantation of gingival propria. Sven Tandlak Tidskr 1963; 22: 684.

3. Grupe HE, Warren, RF. Repair of gingival defects by a sliding flap operation. J Periodontol 1956;27: 92-95

4. Cohen DW, Ross SE. The double papillae repositioned flap in periodontal therapy. J Periodontol 1968;39:65-70.

5. Harvey P. Management of advanced periodontitis. Part I Preliminary report of a method of surgical reconstruction. N.Z. Dent. J., 61:180, 1965

6. Tinti C, Vincenzi GP. The treatment of gingival recession with “guided tissue regeneration” procedures by means of Gore-Tex membranes. Quintessence Int 1990;6: 465-468.

7. Cordioli G, Mortarino C, Chierico A, et. al. Comparison of 2 techniques of subepithelial connective tissue graft in the treatment of gingival recessions. J Periodontol. 2001 Nov;72(11):1470-6

8. Hirsch A, Attal U, Chai E, et. al. Root coverage and pocket reduction as combined surgical procedures. J Periodontol. 2001 Nov;72(11):1572-9.

9. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent.
1985;5(2):8-13.

10. Bhavya Shetty, Ashwini Dinesh, Hema Seshan. Comparitive effects of tetracyclines and citric acid on dentin root surface of periodontally involved human teeth: A scanning electron microscope study. Journal of Indian Society of Periodontology - Vol 12, Issue 1,  2008

11. Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinized gingiva. J Clin Periodontol. 1974;1(4):185-96.

12. Harpreet Singh Grover, Anil Yadav, Priya Yadav, and Prashant Nanda
Optimizing Gingival Biotype Using Subepithelial Connective Tissue Graft: A Case Report and One-Year Followup. Case Reports in Dentistry.Volume 2011 (2011):1-3

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