Root Coverage - a Case Series in the Treatment of Isolated Gingival Recession Defects.

INTRODUCTION

Gingival recession associated with root surface exposure is a complex phenomenon that may present numerous therapeutic challenges to the clinician. Recession may be accompanied by root caries or cervical abrasion which may cause the patients esthetic or root sensitivity concerns.¹

A variety of periodontal procedures have the potential to correct gingival recession by increasing the width of attached gingiva and also attain partial or complete root coverage. Today, gingival reconstruction has become a routine part of periodontal practice. The success of these root coverage procedures depends upon several factors and ideal selection of cases.

CONDITIONS NECESSARY FOR SUCCESSFUL ROOT COVERAGE

1) Sufficient interdental papilla and interdental bone dimensions

2) Sufficient blood supply to donor tissue

3) Root surface to be covered with thick donor tissue

4) Close adaptation of donor tissue with the recipient site

5) No severe decay or abrasion of the tooth2

6) Thick gingival biotype (≥0.8mm)3

OVERVIEW OF VARIOUS TECHNIQUES FOR ROOT COVERAGE

Several techniques have been proposed for the treatment of isolated gingival recession defects. The main treatment goals are to achieve recession reduction and increasing keratinized tissue width. Some of the pedicle soft tissue grafts like lateral pedicle graft⁴, double papilla flap⁵ and oblique rotational flap⁶ and advanced flaps like coronally advanced flap⁷ and semilunar flap8have shown successful root coverage.Non submerged free soft tissue autografts either one stage (free gingival graft) or two stage (free gingival graft plus coronally advanced flap) has shown 48.1% of mean root coverage⁹. Connective tissue grafts predictably achieved 90% or greater root coverage most of the time. It has been clearly established as a highly effective means of achieving root coverage.¹⁰

Coronally advanced flap combined with additive treatments like non resorbable barier¹¹, resorbable barrier¹², enamel matrix derivative¹³, platelet rich plasma¹⁴, acellular dermal matrix¹⁵, growth factors¹⁶, tissue engineering¹⁷ and low intensity laser therapy18 have also shown predictable root coverage. In this paper we intend to discuss three predictable and simple techniques of achieving root coverage.

LATERALLY POSITIONED PEDICLE GRAFT (LPPG)

This technique was first introduced by Grupe and Warren in 1956.⁴This technique cannot be performed without sufficient attached gingiva lateral to the recession site. A shallow vestibule may also jeopardize the outcome. Although LPPG provides an ideal colour match, it is often inadequate for the treatment of multiple recessions.

The indications of LPPG are to cover isolated, denuded roots that have adequate donor tissue laterally and vestibular depth. The contraindications are diseased periodontium, excessive root prominences, deep caries, extensive root abrasion and significant loss of interproximal bone height.

CASE REPORT-1

A 27 year male patient, with isolated Miller’s class II gingival recession in 33 reported to the Department of Periodontology, Krishnadevaraya college of dental sciences desiring esthetic improvement. Intra oral examination revealed the presence of 7 mm of gingival recession with mild labial root prominence. The recipient site was prepared over which the lateral donor split thickness flap was displaced and sutured. Post-operative instructions were given. Complete root coverage was seen that was maintained for 2 years.

FREE GINGIVAL GRAFT (FGG):

FGG was introduced by Bjorn in 1963¹⁹ to increase the width of attached gingiva. FGG is indicated when the palatal tissue facilitates a graft of sufficient thickness (1.5-2.0 mm) and preferred in mandibular anterior teeth and premolars (because of colour mismatch). The disadvantages of FGG are necrosis of the graft with poor recipient site preparation , open palatal wound, scarring occurs with wound healing and graft stability.

CASE REPORT-2

A male patient aged 33 reported with Miller’s class III isolated gingival recession defect in 41. A split thickness flap was prepared in the recipient site and the papillae of 41 were also deepithelialized to facilitate the reception of the graft. Graft was harvested from palatal gingiva adjacent to 24 and 25. Graft was stabilized with sutures. Healing was uneventful. Successful root coverage was seen after 6 months.

CORONALLY ADVANCED FLAP (CAF) WITH SUBEPITHELIAL CONNECTIVE TISSUE GRAFT (SCTG):

Coronally advanced flap (CAF) was first described by Bernimoulin in 1975.⁷ Subepithelial connective tissue graft (SCTG) was first described by Edel in 1964.²⁰ CAF with SCTG has been the most successful technique forroot coverage.²¹The advantages of this technique arepossibility of multiple recession defect coverage, non-involvement of adjacent teeth, high success rate and even if this procedure does not work, it does not increase the existing problem.

CASE REPORT-3

A female patient aged 28 had multiple Miller’s class II recession defects from 12 to 15. Flap was coronally advanced by a full-split thickness flap. Subepithelial connective tissue graft was harvested from palate using trap-door technique. The graft was stabilized using simple interrupted sutures and the flap was coronally advanced and sutured with sling sutures without tension. Healing was uneventful. Complete root coverage was seen after 6 months.

DISCUSSION

The variability in the percentage of sites with complete and mean root coverage is probably associated with a set of factors such as the type of defect, amount and quality of adjacent gingival tissue and the inclusion criteria. Better results in terms of root coverage can be obtained when the recession defects are < 4mm. Smoking affects the results obtained by periodontal plastic surgery procedures.²² Root conditioning has not been found to have a significant clinical benefit in root coverage procedures.²³

Coronally advanced flap with subepithelial connective tissue graft has shown the highest success rate (95%) for gingival recession defects.¹⁰ Besides the primary objective of attaining root coverage, these procedures invariably increase keratinized tissue width, which in turn facilitates better plaque control.

The results obtained by these procedures as seen in the case reports are also stable for a long period of 2 years. In a long term RCT by Kuis et al (2013)²⁴ results obtained with CAF+ CTG were stable for 60 months.Rossberg et al in 2008 in their case series followed their patients for a longer period (6 to 22 yrs, mean 11 yrs) to find stable results.²⁵

CONCLUSION

Root coverage, on contrary to general opinion of the practitioners is not an unachievable feat. With proper selection of cases, ideal surgical procedures and motivation of patients to maintain good oral hygiene, successful root coverage is attainable with long term stability of results.

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