Download Treatment of gingival recession in two surgical stages: Free gingival

soft tissue surgery
Treatment of gingival recession in
two surgical stages: Free gingival
graft and connective tissue grafting
Paulo Sergio gomes Henriques, ddS, MSc, Phd
n
Marcelo Pereira Nunes, ddS
this report describes a clinical case of severe miller Class ii gingival
recession treated by two stages of surgery that combined a free
gingival graft and connective tissue grafting. First, a free gingival
graft (Fgg) was performed to obtain an adequate keratinized
tissue level. three months later, a connective tissue graft (Ctg)
was performed to obtain root coverage. the results indicated that
r
oot coverage is an important
aim of periodontal therapy.
There is a growing demand
for this procedure in patients who
require an improvement in their
esthetic appearance.1
Gingival recession occurs when
the gingival margin is apical to the
CEJ; it results in exposed root surface and loss of both marginal tissue
and attachment. The most frequent
etiologic factors associated with
gingival recession are inflammatory periodontal disease, traumatic
toothbrushing, inadequate attached
gingival dimensions, and iatrogenic
factors.2 Indications for root recession coverage are root sensitivity,
root caries, difficulty in plaque
control, an increase in the level of
keratinized tissue, and undesirable
esthetic results.2 Periodontal surgery
to restore esthetics, comfort, and
function is one of the most common
surgeries in clinical practice.3
A variety of surgical techniques
have been developed to obtain root
coverage. However, it has been
determined that gingival recession
can be treated successfully, regardless of the technique utilized.4 Free
gingival grafting (FGG), connective
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November/December 2011
n
andre antonio Pelegrine, ddS, MSc, Phd
the Fgg allows for a gain in the keratinized tissue level and the
Ctg allows for root coverage with decreased recession level after
16 months. therefore, for this type of specific gingival recession,
the combination of Fgg and Ctg can be used.
received: July 2, 2010
accepted: september 28, 2010
tissue grafts (CTG), coronally
advanced flaps (CAF), and a combination of CTG, CAF, and guided
tissue regeneration (GTR) have
been introduced with a high degree
of predictability in Miller Class I
and II recession defects. A recent
systematic review of the literature
demonstrated that CTG, FGG, and
CAF were effective in reducing gingival recession, with concomitant
improvements in attachment level.2
Another systematic review demonstrated that the CTG procedure
optimizes results in root coverage
and width of keratinized tissue.5
The aim of this case report was
to evaluate the association of
FGG and CTG performed in two
different surgical stages to obtain
root coverage.
Case report
The patient was a 31-year-old
woman who was in good general
health and did not smoke. She was
taking no medications and had no
contraindications for periodontal
surgery. She had a history of
periodontal disease, orthodontic
therapy, and dental trauma in the
central incisors.
The clinical probing depth was
2.0 mm, the recession level was
8.0 mm, and the width of the
keratinized tissue was 0 mm (Table
1). Initial treatment consisted of
oral hygiene instruction, dental
adjustment, scaling with curettes,
and professional cleaning using
a rubber cup and a low-abrasive
polishing paste. Surgical treatment
of the recession defect was not
Table 1. Difference between baseline and 16-month measurements (in mm).
Fgg
Parameter
probing depth
CTg
Baseline
16 months
Baseline
16 months
2
2
2
2
gingival recession
8
4
4
0
Keratinized tissue
0
4
4
8
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Fig. 1. preoperative aspect of the
mandibular right central incisor.
Note the absence of keratinized
tissue.
Fig. 2. radiographic aspect showing the presence of interproximal
alveolar bone.
Fig. 5. Donor tissue was removed from the palatal area.
scheduled until the patient demonstrated an adequate standard of
plaque control.
An FGG was performed to gain
widened keratinized tissue. The
FGG, which was introduced by
Bjorn in 1963, is a highly predictable technique used to increase the
width of keratinized gingiva.6-8
After three months, an increase in
keratinized tissue was observed. For
this reason, a second surgical procedure was performed, involving a
CTG placed in an envelope recipient
bed. The CTG was removed from
Fig. 3. root planing with curettes.
Fig. 4. tetracycline being applied
to the denuded root surface.
Fig. 6. after preparation of the
recipient bed, an Fgg was placed
and sutured.
Fig. 7. one week after placement
of the Fgg.
the palate using the single-incision
palatal harvest technique referred to
by Lorenzana and Allen.9 The CTG
was placed and secured through
the envelope, covering the adjacent
exposed root (Fig. 1–14). The FGG
allows for a gain in the keratinized
tissue level, while the CTG allows
for root coverage with decreased
recession level (Table 1).
Discussion
The introduction of FGG to obtain
widened keratinized tissue and
root coverage was a substantial
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development in esthetic periodontal
surgery. Furthermore, using Miller’s
classification, knowledge of the
marginal tissue recession etiology,
risk factors, gingival biotypes, new
approaches in surgical techniques,
and the possible success of the root
coverage resulted in increased performance of these procedures.10
The results of this case report
support the theory that root
coverage with FGG and CTG
could produce an increase in root
coverage and keratinized tissue.
The defect in the current case was
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soft tissue surgery Treatment of gingival recession in two surgical stages
Fig. 8. one month after
placement of the Fgg.
Fig. 11. the connective tissue
with underlying periosteum was
carefully elevated and harvested
from the palate.
Fig. 9. three months after
the Fgg was placed, a Ctg
was performed. an envelope
technique was performed with a
microsurgical blade.
Fig. 12. immediately after positioning of the Ctg.
Fig. 13. Healing at one week after the Ctg.
classified as Miller Class II. Most
of the soft tissue grafting techniques described previously have
treated exposed root surfaces with
CTG and/or modified, coronally
advanced flap techniques.4,11
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Fig. 10. a partial thickness dissection was performed in the recipient bed.
November/December 2011
Fig. 14. Complete root coverage was
maintained at the 16-month follow-up.
In the current case, an FGG was
performed to increase keratinized
tissue, while a CTG procedure was
used to achieve root coverage. This
two-stage surgical treatment plan
involved deep recession in a thin,
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periodontal biotype and the total
absence of keratinized tissue around
the tooth. Initially, an FGG, such
as that described by Bjorn (1963),
was used to compensate for the
lack of keratinized tissue. Partial
root coverage was obtained with
the FGG but was considered
insufficient. To provide complete
root coverage, a second procedure,
involving an envelope technique
with CTG (considered the gold
standard), was necessary.12
In deep Miller Class II recession
defects, as shown in the current
case, abrupt movement of the flap
in a coronal position to ensure
major blood nutrition could cause
a change in the gingival line,
with undesirable vestibule loss.
Moreover, with the high level of
keratinized tissue obtained, the
tissue became thicker, facilitating
soft tissue management with a
subsequent surgery and reflecting a higher success of the root
coverage procedure.
It is important to note that both
treatments (FGG and CTG) proved
clinically successful with a high
percentage of root coverage and
keratinized tissue increase, and
that the quantity and quality of the
Published with permission by the Academy of General Dentistry.
© Copyright 2011 by the Academy of General Dentistry. All rights reserved.
keratinized tissue could contribute
to the long-term results of the root
coverage. The current case includes
issues of an absence of root sensitivity, patient oral hygiene compliance,
and periodontal health.
Summary
Based on this case report, deep
Miller Class II recession defects can
be treated successfully when FGG
is combined with CTG. However,
randomized clinical trials involving
patients with Miller Class II gingival
recession defects are needed to confirm these findings.
Author information
Dr. Henriques is Professor Chief,
Department of Periodontics, Sao
Leopoldo Mandic Dental Research
Institute, Campinas, SP, Brazil,
where Drs. Nunes and Pelegrine
also practice.
7.
References
1. Zabalegui i, sicilia a, Cambra J, gil J, sanz m.
treatment of multiple adjacent gingival recessions with the tunnel subepithelial connective
tissue graft: a clinical report. int J periodontics
restorative Dent 1999;19(2):199-206.
2. shin sH, Cueva ma, Kerns Dg, Hallmon WW,
rivera-Hidalgo F, Nunn me. a comparative study
of root coverage using acellular dermal matrix
with and without enamel matrix derivative. J
periodontol 2007;78(3):411-421.
3. al-Zahrani m, Bissada N. predictability of connective tissue grafts for root coverage: Clinical
perspectives and a review of the literature.
Quintessence int 2005;36(8):609-616.
4. de sanctis m, Zucchelli g. Coronally advanced
flap: a modified surgical approach for isolated
recession-type defects. three-year results. J Clin
periodontol 2007;34(3):262-268.
5. rocuzzo m, Bunino m, Needleman i, sanz m.
periodontal plastic surgery for treatment of
localized gingival recessions. a systematic
www.agd.org
6.
General Dentistry
8.
9.
10.
11.
12.
review. J Clin periodontol 2002;29 suppl 3:178194.
Bjorn H. Free transplantation of gingiva propria.
sven tandlak tidskr 1963;22:684.
miller pD Jr. root coverage using a free soft tissue autograft following citric acid application.
part i: technique. int J periodontics restorative
Dent 1982;2(1):65-70.
Holbrook t, ochsenbein C. Complete coverage
of denuded root surface with a one-stage gingival graft. int J periodontics restorative Dent
1983;3(3):8-27.
lorenzana er, allen ep. the single-incision palatal harvest technique: a strategy for esthetics
and patient comfort. int J periodontics restorative Dent 2000;20(3):297-305.
miller pD Jr. a classification of marginal tissue
recession. int J periodontics restorative Dent
1985;5(2):9-14.
langer B, langer l. subepithelial connective
tissue graft technique for root coverage. J periodontol 1985;56(12):715-720.
oates tW, robinson m, gunsolley JC. surgical
therapies for the treatment of gingival recession. a systematic review. ann periodontol
2003;8(1):303-320.
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