Gingival Recession: Surgical Management Using Pedicle Grafts (PDF)

Gingival recession: part 2. IN BRIEF Gingival recession can be corrected using Surgical manag...

Gingival recession: part 2. IN BRIEF Gingival recession can be corrected using Surgical management using pedicle grafts but careful case selection PRACTICE is essential for complete root coverage. To ensure success of periodontal plastic pedicle grafts surgery several patient and tooth related factors need to be assessed before surgery. Pedicle grafts are not suitable in cases M. Patel,1 P. J. Nixon2 and M. F. W.-Y. Chan3 with thin gingival biotype and in areas where there is a lack of keratinised tissue. VERIFIABLE CPD PAPER This paper is the second in a three part series looking at the aetiology and management of gingival recession. Part one discussed the aetiology and non-surgical management and this part aims to discuss the use of pedicle soft tissue grafts in the treatment of gingival recession. This article also considers the factors affecting the outcome of surgical procedures used to treat localised recession defects. The third paper in this series will consider the use of free soft tissue grafts and guided tissue regeneration. INTRODUCTION Table 1 Miller’s classification of recession defects Gingival recession is defined as the api- cal displacement of the gingival margin from the Cemento-Enamel Junction (CEJ).1 Recession that does not extend to the mucogingival junc- The patient’s main complaint often relates Class I tion with no periodontal bone loss in the interdental areas to poor aesthetics and occasionally it is related to sensitivity. Part 1 in this series discussed the aetiology of gingival reces- sion and the non-surgical management. Recession that extends to or beyond the mucovingival This paper aims to introduce some of the Class II junction, with no interdental bone loss surgical options available to correct local- ised recession defects. PERIODONTAL PLASTIC SURGERY Recession that extends to or beyond the mucogingival Periodontal plastic surgery describes any Class III junction, with some periodontal attachment loss in the interdental area or malpositioning of the teeth surgical procedures involving the mucog- ingival tissues. It includes surgery which attempts to increase the width of kerati- nised tissue around a tooth and cover Recession that extends to or beyond the mucogingival any exposed root surface associated with Class IV junction, with severe bone and/or soft-tissue loss in the interdental area and/or severe malpositioning of the teeth a recession defect. The main indications for surgical intervention to correct reces- sion defects include the need to improve localised soft tissue aesthetics, reduce CLASSIFICATION OF as a result of surgical intervention and hypersensitivity, improve plaque con- GINGIVAL RECESSION therefore any periodontal plastic surgery trol and prevent further progression of Miller3 has classified gingival recession should be avoided. This is commonly seen recession defect.2 into four categories (Table 1). These cat- in patients who have developed recession egories can be used to assess the reces- due to chronic periodontal disease. sion defect present and predict the possible outcome of any periodontal plastic sur- FACTORS AFFECTING OUTCOME OF gery procedure which would aim to cover PERIODONTAL PLASTIC SURGERY Specialist Registrar in Restorative Dentistry, 1* Consultants in Restorative Dentistry, Department of 2,3 the recession defect and restore aesthet- There are several factors that can affect the Restorative Dentistry, Leeds Dental Institute, Clarendon Way, Leeds, LS2 9LU ics. Defects classified as Miller’s Class I outcome of any periodontal plastic sur- *Correspondence to: Dr Mital Patel and II can result in full coverage of the gery procedures. These are listed below and Email: [email protected] recession defect whereas class III would should be assessed and corrected where pos- Refereed Paper only provide partial coverage to the level sible before surgery as part of the pre-surgi- Accepted 21 July 2011 DOI: 10.1038/sj.bdj.2011.821 of the interdental bone. Class IV defects cal preparation or during surgery in order to © British Dental Journal 2011; 211: 315-319 are unlikely to provide any root coverage improve the overall success of the procedure: BRITISH DENTAL JOURNAL VOLUME 211 NO. 7 OCT 8 2011 315 © 2011 Macmillan Publishers Limited. All rights reserved. PRACTICE a) Condition of root surface - of keratinised tissue available adjacent to presence of calculus, caries, the recession defect should also be assessed contaminated cementum or when considering rotational or coronally restorations on root surface advanced pedicle graft.8 Any filling material or caries on the root surface should be removed before surgery e) Size of the recession defect and the root surface should be prepared and graft material by scaling to remove any residual calculus The graft material harvested from the donor and contaminated cementum. Removal of site should be large enough to cover the all endotoxins, bacteria and other antigens whole recession defect and extend beyond found in contaminated cementum is essen- it in order to get adequate blood supply Fig. 1a Diagram showing the outline of the initial incision through the surface epithelium tial to leave the root surface biologically from the soft tissue surrounding the reces- around the recession defect compatible with healthy periodontal tissues. sion defect. As the root surface does not Lindhe and Nyman4 and Lindhe et al.5 have contribute any blood supply to the graft highlighted that thorough debridement of material, recession defects which are nar- the root surface is essential for a success- row result in a better outcome than wide ful outcome of periodontal plastic surgery recession defects as the overlap between attempting to provide root coverage over a graft material and recipient soft tissue bed recession defect. Some authors have sug- will be greater. The graft should also be of gested the use of citric acid to treat the root an adequate thickness to prevent necrosis.2 surface before the surgical procedure. The The height of the recession defect is not aim of this treatment is to remove the smear as critical as the width of the defect but layer on the root surface to allow connec- will influence the choice of surgical proce- tive tissue attachment to the root surface.6,7 dure depending on the amount of attached Others have suggested the use of tetracycline gingival tissue available and the depth of Fig. 1b The surface epithelium is dissected away as shown to leave exposed connective hydrochloride to help promote the healing the vestibule.8 tissue (CT) on the mesial aspect which is now response post surgery however, clinical prepared to receive the graft tissue studies have failed to show any improve- f) Thickness of split thickness ments in outcome when using such agents.8 flaps raised The split thickness pedicle flaps raised b) Prominent frenal attachments for many of the periodontal plastic sur- Prominent frenal attachment can con- gery procedures play an important role in tribute to the cause of gingival recession. nourishing the grafted tissue. It is essential Before or as part of any periodontal plastic that this tissue has a certain amount of surgery it is worth considering carrying thickness to be robust enough to fulfil this out a frenectomy to relieve any tension on role. Evidence has shown that flaps with a the gingival tissues from a prominent fre- thickness of less than 1 mm can negatively num which may otherwise result in failure affect the outcome in terms of the amount of the surgical procedure. of root coverage achived.9 Fig. 1c The amount of tissue required is measured and a split thickness flap is raised on the distal aspect of the root surface. c) Depth of vestibule CONTRAINDICATIONS TO The tissue is laterally repositioned over the Patients with shallow vestibule depth should PERIODONTAL PLASTIC SURGERY recession defect and the exposed CT on mesial aspect of root not be considered for pedicle grafts as this a) Smoking can result in further decrease in vestibule depth. Alternative surgical procedures Any surgical procedure carried out on should be considered for these patients. smokers is likely to have a compromised healing response. Research has shown that d) Tissue type smoking can significantly impair the out- Patients with thin gingival biotype are likely come of surgical periodontal therapy when to have a poorer outcome than those with compared to non-smokers.10-13 Periodontal thick gingival biotype. When considering plastic surgery should therefore be avoided periodontal plastic surgery it is important in patients who smoke. to assess the periodontal tissues carefully to see if the gingival tissues require a surgi- b) Poor oral hygiene cal procedure such as a connective tissue Patients with inadequate oral hygiene and Fig. 1d The pedicle flap is sutured into graft that will thicken the tissue while also active periodontal disease should not be position and the exposed CT at the donor site is left to heal by secondary intention correcting the recession defect. The amount considered for periodontal plastic surgery. 316 BRITISH DENTAL JOURNAL VOLUME 211 NO. 7 OCT 8 2011 © 2011 Macmillan Publishers Limited. All rights reserved.  PRACTICE flaps and a subsequent article in the series incision away from the recession defect will discuss the use of free grafts and leaving a few millimetres of keratinised gin- guided tissue regeneration. gival tissue around the adjacent tooth at the donor site. A second oblique distal relieving PEDICLE FLAPS incision is made towards the apical region A pedicle graft involves repositioning from where the first incision terminated donor tissue from an area adjacent to and extended beyond the mucogingival the recession defect to cover the exposed junction into the alveolar lining mucosa. root surface. It avoids the need of a sec- A split thickness pedicle flap is then raised ond surgical site and has the advantage of and rotated over the exposed root sur- Fig. 1e Pre-op view of a Miller’s Class III retaining its own blood supply from the face and the connective tissue previously recession defect on the lower left first molar base of the flap which remains attached exposed on the opposite side (Fig. 1c). The to the donor site. This helps nourish the graft tissue should be free from any ten- graft and facilitates vascular union with sion; if not the relieving incision should be the recipient site. extended further apical. Once repositioned The pedicle flap was first described by the pedicle flap is sutured down with fine Grupe and Warren16 as a laterally reposi- interrupted sutures (Fig. 1d) and pressure tioned full thickness flap. Here the donor applied for a few minutes to minimise the tissue is taken from one side of the reces- clot underneath the pedicle flap. This is sion defect and repositioned over the important to ensure good union between exposed root surface. This was later modi- donor and recipient tissues and to ensure fied by Hattler17 with the use of a split good vascularisation of the grafted tissue. A thickness flap repositioned in a similar way periodontal dressing can be placed if neces- Fig. 1f Surgical site immediately post- surgery with a pedicle flap taken from the to cover multiple exposed root surfaces. sary but is not mandatory. The donor site is mesial aspect of LL7 and repositioned over Soon after, Cohen and Ross18 described the left to heal by secondary intention. the recession defect at LL6 double-papilla repositioned flap for use in If the flap is left under tension, or there is areas where there was insufficient kerati- excessive movement and poor stabilisation nised gingival tissue on any one side of or if the flap is too narrow for the reces- the recession defect to reposition and cover sion defect, then there is a higher chance of the exposed root surface. Here the papillae failure of the procedure. Figures 1e-g show are taken from both sides of the recession an example of a Miller’s Class III recession defect and repositioned over the exposed defect on the lower left first molar treated root surface. This procedure limits itself to with a laterally repositioned pedicle flap. single tooth recession defects. The double- At one week post-surgery there has been papilla flap can also be performed either significant coverage of the exposed mesial as a full thickness flap or a split thickness root surface. Grafting of a Miller’s Class III flap depending on the thickness of the defect of this size is highly unlikely to pro- Fig. 1g Clinical appearance one week gingival tissues.19 vide full coverage of the recession defect; post surgery however, significant improvement can be LATERALLY REPOSITIONED made with partial coverage of the root sur- SURGICAL TECHNIQUES FOR PEDICLE FLAP face and an increased amount of keratinised CORRECTING RECESSION DEFECTS Clinical technique (Figs 1a-g) tissue around the gingival margin as shown Periodontal plastic surgery is technique in this case. A second surgical procedure sensitive and involves delicate handling Before raising the donor tissue, the width with a coronally repositioned flap (discussed of the mucogingival tissues. Burkhardt and of the recession defect should be measured later) can be undertaken to try and cover the Lang14 concluded that the use of magni- to gauge what size pedicle flap is required. remaining exposed root surface if necessary. fication and microsurgical instruments to To allow adequate union and healing of handle the tissues resulted in improved the repositioned flap a cuff of epithelialised DOUBLE PAPILLA vascularisation of connective tissue grafts tissue around the margins of the recession ROTATIONAL FLAP and increased root coverage compared to defect is cut away to expose the underlying Clinical technique (Figs 2a-b) macrosurgical techniques. connective tissue. Similarly, the surface epi- There are three main types of periodon- thelium adjacent to the recession defect on The width of the recession defect should be tal plastic surgery procedures described the side opposite to where the donor tissue measured initially to ensure there is suffi- in the literature to treat recession defects. will be taken is also removed to expose the cient width of tissue available from the two These include pedicle flaps, free grafts, and underlying connective tissue (Fig. 1a-b). A adjacent papillae to allow full coverage of guided tissue regeneration.15 The rest of pedicle flap twice the width of the recession the exposed root surface. A cuff of epithe- this article will look at the use of pedicle defect is then raised by making an oblique lialised tissue is removed from around the BRITISH DENTAL JOURNAL VOLUME 211 NO. 7 OCT 8 2011 317 © 2011 Macmillan Publishers Limited. All rights reserved. PRACTICE recession defect to expose the underlying stage technique to cover shallow recession connective tissue (Fig. 2a). Split thickness defects21 or a two stage technique which is flaps of the papillae either side of the reces- combined with a free gingival graft, con- sion defect with vertical reliving incisions nective tissue graft or with guided tissue on the distal line angle of the tooth in front regeneration procedures. If the gingival and mesial line angle of the tooth behind tissue apical to the recession defect has should be raised. The relieving incisions are thin gingival biotype or there is insuf- extended beyond the mucogingival line and ficient keratinised tissue, a free gingival taken down to bone at this point to help graft or a connective tissue graft can be release tension in the flap. The two papil- carried out first to increase the thickness lae are repositioned and placed over the and amount of keratinised tissue. After exposed root surface and sutured together approximately three months of healing Fig. 2a Outline of the incisions made over with fine interrupted sutures along the mid- the tissue can be coronally repositioned the papilla either side of the recession defect line of the exposed root surface (Fig. 2b). A as a second stage surgery. If the gingi- to raise a split thickness pedicle flap sling suture is placed around the tooth to val biotype is thick and there is adequate hold the grafted tissue in its position and keratinised tissue (minimum 3 mm) then prevent it from sliding apically. Gentle pres- the tissue can be coronally repositioned sure is applied for a few minutes to mini- as a one-stage technique. In order to carry mise the clot that forms under the pedicle out this procedure it is essential to ensure graft and a periodontal dressing can be there are shallow crevicular depths on placed if necessary. The exposed connective interproximal surfaces and no interproxi- tissue at the donor site can be left to heal by mal bone loss.1 secondary intention. Inadequate suturing The amount of coronal advancement and inadequate stabalisation can result in required is determined by measuring the separation of the two pedicle flaps resulting height of the recession defect. The same in failure of the procedure. length is then measured from the tip of Fig. 2b The pedicle flaps are sutured together the papilla towards the apex and horizon- over the recession defect. CORONALLY REPOSITIONED FLAP tal incisions are placed through the tissue Clinical technique (Figs 3a-f) for a split thickness flap. Vertical relieving thickness flap of even thickness is raised incisions are placed at the distal line angle and extended beyond the mucogingival The coronally advanced flap was first of one tooth anteriorly and mesial line margin. The periosteum is released to allow described by Bernimoulin et al.20 The pro- angle of one tooth posterior to the tooth freedom of movement of the flap. The most cedure can be performed either as a one with the recession defect (Fig. 3a). A split coronal part of the papilla which remains Fig. 3a Diagram outlines the incisions made Fig. 3b The surface epithelium coronal to Fig. 3c Diagram shows the pedicle flap around the recession defect to raise a split the pedicle flap is removed to expose the coronally repositioned and sutured over the thickness pedicle flap underlying connective tissue. This prepares recession defect the site to receive the graft tissue Fig. 3f Post op clinical view of UL2 following grafting over recession defect, minor Fig. 3e Clinical picture demonstrating a enameloplasty to reduce length of tooth and Fig. 3d Pre-op clinical picture showing coronally advanced pedicle flap sutured in some minor addition of composite mesially to recession defect at UL2 position over the recession defect improve overall shape of the tooth 318 BRITISH DENTAL JOURNAL VOLUME 211 NO. 7 OCT 8 2011 © 2011 Macmillan Publishers Limited. All rights reserved.  PRACTICE intact is de-epithelialised before coronal in order to achieve 100% root coverage 10. Preber H, Bergstrom J. Effect of cigarette smoking on periodontal healing following surgical therapy. advancement of the flap (Fig. 3b). The flap with a coronally repositioned flap, the flap J Clin Periodontol 1990; 17: 324–328. is then sutured in place approximately should be over compensated by 2-2.5 mm 11. Trombelli L, Scabbia A. Healing response of gingival recession defects following guided tissue regenera- 0.5 mm to 1 mm coronal to the CEJ22 with and sutured tension free. However, this tion procedures in smokers and non-smokers. J Clin interrupted sutures in the papilla regions may be difficult in cases where there is a Periodontol 1997; 24: 529–533. 12. Martins A G, Andia D C, Sallum A W, Sallum E A, and along the reliving incisions (Fig. 3c). large recession defect and a shallow sul- Casati M Z, Nociti Júnior F H. Smoking may affect Gentle pressure is applied for a few min- cus depth. The coronally advanced flap is root coverage outcome: a prospective clinical study in humans. J Periodontol 2004; 75: 586–591. utes and if necessary a periodontal dress- often used together with a subepithelial 13. Chambrone L, Chambrone D, Pustiglioni F E, ing can be placed. Excessive tension in connective tissue graft and has proven Chambrone L A, Lima L A. The influence of tobacco smoking on the outcomes achieved by root-cov- the coronally advanced flap can result in to be the gold standard treatment in the erage procedures: a systematic review. J Am Dent failure or a reduced amount of root cov- treatment of recession defects.29 In Miller’s Assoc 2009; 140: 294–306. 14. Burkhardt R, Lang N P. Coverage of localized erage. Figures 3d-f show an example of Class I defects this combination has shown gingival recessions: comparison of micro- and a recession defect at UL2 treated initially to provide complete root coverage of the macrosurgical techniques. J Clin Periodontol 2005; 32: 287–293. with a connective tissue graft (see article recession defect.30 The use of connective 15. Chambrone L, Sukekava F, Araújo M G, Pustiglioni 3) to increase the thickness of the gin- tissue grafts is discussed further in the F E, Chambrone L A, Lima L A. Root coverage proce- dures for the treatment of localised recession-type gival tissues around the recession defect third article in this series. defects. Cochrane Database Syst Rev 2009; (2): followed by a second surgical procedure CD007161. with a coronally repositioned pedicle flap CONCLUSIONS 16. Grupe H E, Warren R F. Repair of gingival defects by a sliding flap operation. J Periodontol 1956; to cover the recession defect. The tooth Pedicle flaps can be useful in correct- 27: 92–95. ing small Miller’s Class I and II recession 17. Hattler A B. Mucogingival surgery ‑ utilization of has also had some minor enameloplasty interdental gingiva as attached gingiva by surgical to decrease the length and some composite defects. The graft has the advantage of displacement. Periodontics 1967; 5: 126–131. bonding to improve the overall shape of retaining its own blood supply which can 18. Cohen D W, Ross S E. The double papillae reposi- tioned flap in periodontal therapy. J Periodontol the tooth. aid healing; however, this graft should be 1968; 39: 65–70. restricted to cases where the gingival bio- 19. Pfeifer J S, Heller R. Histologic evaluation of full and partial thickness lateral repositioned flaps: a PROGNOSIS type is thick and there is sufficient amount pilot study. J Periodontol 1971; 42: 331–333. Periodontal plastic surgery has been shown of keratinised tissue adjacent to the reces- 20. Bernimoulin J P, Luscher B, Muhlemann H R. Coronally repositioned periodontal flap. Clinical to be effective in reducing gingival reces- sion defect. In cases with thin gingival bio- evaluation after one year. J Clin Periodontol 1975; sion defects with a concomitant improve- type or limited keratinised tissue it may be 2: 1–13. 21. Allen E P, Miller P D, Jr. Coronal positioning of ment in attachment levels.23 Achieving full more sensible to consider a free graft, pos- existing gingiva: short term results in the treatment root coverage following a single periodon- sibly in combination with a pedicle graft. of shallow marginal tissue recession. J Periodontol 1989; 60: 316–319. tal plastic surgical procedure is difficult The authors would like to thank Dr Paul Baker, 22. Maynard J G, Jr. Coronal positioning of a previously and success is often considered to be any Specialist Periodontist for contributing the clinical placed autogenous gingival graft. J Periodontol pictures shown in Figures 1e-1g. 1977; 48: 151–155. decrease in amount of exposed root sur- 23. Roccuzzo M, Bunino M, Needleman I, Sanz M. face (Fig. 1g) ie an increase in gingival 1. Kassab M M, Cohen R E. Treatment of gingival Periodontal plastic surgery for treatment of local- recession. J Am Dent Assoc 2002; 133: 1499–1506. ized gingival recessions: a systematic review. J Clin height from the mucogingival line to the 2. Saha S, Bateman G J. Mucogingival grafting Periodontol 2002; 29(Suppl 3): 178–194. gingival margin.24 The size of the initial procedures – an update. Dent Update 2008; 35: 24. Wennström J L, Zucchelli G. Increased gingival 561-562, 565–568. dimensions. A significant factor for successful recession defect will also influence the 3. Miller P D, Jr. A classification of marginal tissue outcome of root coverage procedures? A 2-year final outcome. A recent systematic review recession. Int J Periodontics Restorative Dent 1985; prospective clinical study. J Clin Periodontol 1996; 5: 8–13. 23: 770–777. found that overall a better percentage of 4. Lindhe J, Nyman S. Long-term maintenance of 25. Wennström J L. Mucogingival therapy. Ann complete and mean root coverage was seen patients treated for advanced periodontal disease. Periodontol 1996; 1: 671–701. J Clin Periodontol 1984; 11: 504–514. 26. Pagliaro U, Nieri M, Franceschi D, Clauser C, Pini- in recession defects less that 4 mm.9 5. Lindhe J, Westfelt E, Nyman S, Socransky S S, Prato G. Evidence based mucogingival therapy. Part The mean root coverage achieved with a Haffajee A D. Long-term effect of surgical/non- 1: A critical review of the literature on root cover- surgical treatment of periodontal disease. J Clin age procedures. J Periodontol 2003; 74: 709–740. laterally repositioned flap and the double Periodontol 1984; 11: 448–458. 27. Caffesse R G, Guinard E A. Treatment of localized papilla flap have shown to vary between 6. Miller P D, Jr. Root coverage using the free soft gingival recessions. Part IV. Results after three tissue autograft following citric acid application. III. years. J Periodontol 1980; 51: 167–170. 34-81% and complete root coverage var- A successful and predictable procedure in areas of 28. Pini Prato G P, Baldi C, Nieri M et al. Coronally ies between 40-50% of sites.25,26 With deep-wide recession. Int J Periodontics Restorative advanced flap: the postsurgical position of the Dent 1985; 5: 14–37. gingival margin is an important factor for achieving these procedures there is a risk of donor 7. Polson A M, Frederick G T, Ladenheim S, Hanes P J. complete root coverage. J Periodontol 2005; site recession particularly with the later- The production of a root surface smear layer by 76: 713–722. instrumentation and its removal by citric acid. 29. Chambrone L, Faggion C M, Jr, Pannuti C M, ally repositioned flap of approximately J Periodontol 1984; 55: 443–446. Chambrone L A. Evidence based periodontal plastic 1 mm.27 The mean root coverage achieved 8. Baker P. The management of gingival recession. surgery: an assessment of quality of systematic Dent Update 2002; 29: 114-120, 122-124, 126. reviews in the treatment of recession-type defects. with a single stage coronally repositioned 9. Chambrone L, Sukekava F, Araújo M G, Pustiglioni J Clin Periodontol 2010; 37: 1110–1118. flap varies between 55-99% and complete F E, Chambrone L A, Lima L A. Root-coverage proce- 30. Cairo F, Pagliaro U, Nieri M. Treatment of gingival dures for the treatment of localized recession-type recession with coronally advanced flap procedures: root coverage ranges from 24-95% of defects: a Cochrane systematic review. J Periodontol a systematic review. J Clin Periodontol 2008; sites.25,26 Pini-Patro et al.28 concluded that 2010; 81: 452–478. 35(8 Suppl): 136–162. BRITISH DENTAL JOURNAL VOLUME 211 NO. 7 OCT 8 2011 319 © 2011 Macmillan Publishers Limited. All rights reserved.