root coverage technique

1. I
WESTOELHI
•
NEW TREATMENT OF GINGIVAL RECESSION USING
CORONALLV ADVANCED FLAP
Treatment of Gingival Recession Using Coronally Advanced Flap·A Case Report
Authors:
1. Dr. HarpreetSinghGrover
Professor a nd Head
Department of Periodontics & Orallmplantology SGT Dental College, Hospital and Research Institute, Gurgaon, Haryana, IN DIA.
2. Dr. Shailly Luthra
Private Practice
Gurgaon, Haryana, INDIA.
3. Dr. Shruti Maroa
Post Graduate Student
Departm ent of Periodontics & Orallmplantology SGT Dental College, Hospital and Research Institute, Gurgaon, Haryana, IN DIA.
Corresponding Author:
Dr. Shailly Luthra
Gurgaon, Haryana, INDIA.
Email: shaillyluthra@gma il.com
Tel: 08800235100.
Treatment of Gingival Recession Using Coronally Advanced Flap-A Case Report
The main goal of periodonta l therapy is to improve periodontal health and thereby to maintain a patient's functiona l dentition t hroughout
their life. However, esth eti cs represents an inseparable part of today's dental treatment plan, and severa l procedures have been proposed to
preserve or enhance patient esthetics. Gingival recession is defined as the displacement of the soft tissue ma rgin apical to the
cemento-enamel junction and is a frequent clinical feature in populations w ith both good and poor standards of oral hyg iene. The aim of th is
case report is to eva luate the efficacy of the coronally advanced flap for treating single site recession defect's (Miller's class I) proposed by
Zucchelli and De Sanctis in the year 2009.Th is technique is proposed as an effective modal ity to ach ieve about 100% root coverage in cases of
M iller'sclass I recession.
Keywords: Coronally Advanced Flap,G ingival Recession, Root Coverage
Treatment of Gingival Recession UsingCoronaily Advanced Flap-A Case Report
Introduction
I
Gingival recession is defined as the displacement of the soft tissue margin apical to the cemento-ena mel ju nction. ' lt may affe ct single or
multiple root surfaces and is a frequent clinical feature in popu lations w ith both good and poor standards of oral hygiene' An untreated
gingival recession has a strong impact on both esthetics and dentine hypersensitivity. Moreover, the absence of t he gingival tissue protecting
the root surface may facilitate the development of cervical abrasion in some cases increasing su sceptib il ity to root caries w hich eventually
leads to poor oral hygiene.'Tissue trauma caused by vigorous tooth bru shing is considered to be a dominating causative factor for the
development of recessions. Tooth malposition, high muscle attachment, frenal pull, uncontrolled marginal inflammation with accumulation
of dental plaque and ca lculus due to impro per brushing tech niques and iatrogenic factors related to restorati ve, periodontal treatmen t
4
procedures and incisor inclination and orthodontic treatments have also been associated with gingival ti ssue recession. Several surgica l
approaches have been proposed in the last few years to obtain root coverage on exposed buccal root surfaces such as free gingival grafts,
subepithelia l connective tissue grafts, lateral sliding flap, sem ilu nar f laps, co ronally advanced fl aps alone or associated with free
gingival/connective tiss ue graft.' The aim of this case report is to eva luate the effica cy of the coronally adva nced flap for treating single site
recession defect's (Miller's class I) proposed by Zucchelli and De Sanctis in the yea r 2009.'
Case Report
A 27-year old male patient reported to the Outpatien t Departmen t of SGT Dental College, Hospital and Research Institute, Gurgaon with a
chief comp la int of sensitivity to hot and co ld f lu ids in upper front teeth region since 1 month along with esthetic concern. He had n
underlying medical conditions and was not taking any medications that would have co m promised a soft hea ling response.

2. On examination M ille r's Class I gingival recess ion was seen wit h tooth 22, 23(Fig:l) .Gingival bi otype was measured at t he mid buccal 2 mm
apical to free gingiva l margin by pe netrating UNC prob e into the tissue and reco rded to the nearest 0.5 mm. It was 1 mm in t he all t he above
m entioned teeth. The pati ent underwent a session of prophy lax is includi ng inst ruction in proper ora l hygiene me as ures an d scaling and
polishing. A coronally directed rol l tech nique was prescribed for teeth with recession-type defects in orde r to min imize toothbrushing traum a
to the gingiva l margin.
The fo llowing clin ical measurements were take n t o t he nearest millimeter for the tooth at ba se line (before surgery after initial pe riodontal
therapY), 1 month and 3 months after surgery.
(1) Gingival recession depth (GRD), measured as th e di stance between t he most apica l poi nt of th e CEJ and the gingival margin (GM).
(2 ) Gingival recess ion width (GRW), measu red as the distance bet ween the mesia l GM and the distal GM of the to oth (meas u re ment was
recorded on a horizont al line ta ngent ial atthe CEJ).
(3) Probing dept h (PD), measured as t he dista nce f rom the GM tothe bottom ofthegingival sulcus.
1
(4) Cli n ical attachment level (CAL), measured as the dist ance from the CEJ to the bottom olthe sulcus.
(5) Ap ico -corona l width of keratinized t is sue (KTW), measured as the d istance from the mucogingival junction (MGJ) to th e GM, w ith MGJ
location dete rmined using a visual method.
(6 ) Recess ion depth reduction .
(7) Complete/ Partial Root Coverage.
GRD, PD, CAL and KTW measurements w il l be perform ed atthe mi d-bu cca l point of the involved t ooth . A Hu-Friedy periodontal probe (UNC15 periodontal probe) w ill be used for all clin ical measurementsalong w it h a cu st om made acryl ic st ent(Fig.2) .
Surgical Procedure
After administration of local anesthesia (Xyl oca ine w ith 0.2% adrenaline), a horizontal inci sion was given together with the intra-su lcul ar
starting from tooth 21 extend ing to the 24. Two oblique incisions were given at the mesial and d istal li ne angles of these teeth extending
beyond the mucogingival junction. (Fig:3). Th e anatomic inter-denta l pap illae were de-epithelialized. The fla p was elevated as splitthickness
fl ap, followed by fu ll th ickness flap ap ica l t o t he root exposures t e r m in ating ti l13-4mm apical t o the bone d ehiscence exposing denuded bone.
The apical most portion of the flap was undermined to convert it to a sp lit thickness fl ap, facili tating coro nal displacement of t he flap (Fig :4).
Th e surg ical papilla was stab ili zed using loop sutures (w ith 5-0 Et h icon-(NW-3316) overthe interd enta I co nnective tissu e bed .Suturing olth e
flap started with two interrupted periosteal 5-0 sutures at the most apical exte nsion of th e vertical releasing Incision; it was continued
•
coronally with other interrupted sutures, each of t hem directed from the flap to the adjacent bucca l soft tissue, in the apica l--co ronal
direction. The fina l position of the flap m arg ins was ove rco rrect ed to be at least 3- 4mm corona l t o t he CEJ of all t eeth at the end of th e
surge ry. (Fig:5). Period ontal dressing was appli ed to avo id any mechanica l t raum a. (Fig:6).
Post surgica l Treatment and Follow-up
Post operative instructions were given. The patient was instructed to avoid brushing and flo ssing in the are a of surgery and to consume on ly
soft food during the first week. Amoxicillin 500mg T.D.S for 5 days and Ibuprofen 400 mg S. D were prescribed to th e patient. Instructions to us e
chlorhexid ine gluconate rinse 0.2 % twice daily fo r 15 days we re given. Th e patient was advised to consume only soft food during the first
week. The periodontal dressing and sutureswere removed 2 weeks after surgery. The patient we re instru cted to resume mechanical to oth
cleaning of t he treated areas using a soft tooth brush and a careful roll t ech nique after 3 w eeks of su rgery was recalled for prop hylaxis 2 and 4
weeks after suture removal. The patient was evaluated at 1(Fig:7)& 3 mont hs post-operatively(Fig:8). The recall showed uneventfu l heali ng
alo ng with root coverage wit h reduction of dentin hypersensitivity without any probing defect or signi fica nt compl ication .
Di scussion
The presence of mucogingiva l problems and gingival recession around anterior, highly visible teeth can render patients aesthe -ca l
consci ous and epitomizes a situation wh ere a remedy that addresses both biological and aesthetic demands is required from the thera!:>"-.5i..
7
According to Pin i-Prato coronally advanced fl aps res ult in 70-99% of root coverage. Complete root coverage can be achieved in C ass :::""=
defects, on ly partial root coverage (70% to 75%) can be accomp lished in Class III defects, and Class IV d efects are not ame nab ." :.: '::<It
coverage, 7
Clin ician s are chal len ged to achieve outcomes that meet these exacting standards, and t herefore need a sou nd, clinically or2-:?::

3. )l. p....'I1CDE
NOIIN DENTAL ASSOCIATION
WEST DELH I
and scientifically supported decision-making process to plan the t herapeuti c approach, to predict the outcome and, fi nally, to achieve it. It
would therefore be desirable to use a coronally advan ced flap approach which alone can successfully applied when the residual gingiva is
thick and wjde~. The functional aspects of root coverage may be controversial, but the cosmetic aspect and satisfact ion is not debatabl e. In
8
this case the root coverage achieved was 100%. A coronally advanced fl ap is less invasive for the patient, requi res less chair-time and less
surgical skills. It also resu Its in good co lour blending of the t reated area . Addit iona lly with, the post-operative course being less troubleso me
for t he patient as other surgica I sites distant from the tooth with recession defect are not involved . Also, the costs of mucogingival operations
may arise whe n other biomateria ls materia ls such as acellular dermal matrix, enamel matrix derivative and bioabsorbable membrane are
in cluded.
,
Conclusion
In conclusion, the results of the present study demonstrated that coronally advanced flap technique is effective and successful fo r the
treatment of isolated gingival recession or multiple gingival recessions in patients with esthetic demands resulting in satisfactory root
coverage.
References
1.
American Academy of Periodontology. Glossary of Periodontal Te rms, 3rd edn. Ch icago: The Amer ican Academy of Periodonto logy,
1992.
2.
Loe H, Ane ru d A, Boysen H. The natu ral history of periodontal disease in man: prevalence, severi ty, and extent of gingiva l recession. J
Periodonto I 1992;63: 489-495 .
3.
Goldstein, M., Nasatzky, E., Gou ltschin, J., Boyan, B. D. & Schwartz, Z. Coverage of previously carious roots is as predictable a
procedure as coverage of intact roots. Journal of Periodontology 200 2; 73: 1419-26.
4.
Ustun K, Sari Z, Orucoglu H, Duran I, Hakki S. Severe gingival recession caused by tra umatic occlu sion and mucogingival stress: A Case
Report. Eur J Dent. 2008;2:127-133.
5.
Bouch ard P, MaletJ, Borghetti Decision-making in aest hetics: root coverage revisited. Periodontol2000. 2001;27:97-120.
6.
Zucchelli, G., Mele, M., Mazzotti,
c.,
Marzadori, M., Montebugnoli, L. & De Sanctis, M. Coronally advanced flap w ith and w ithout
vertical releasing incisions for the treatment of multiple gingival recessions: a comparative contro ll ed randomized clinical trial. J
Peri od onto I 2009;80:1083-94.
7.
Wennstr6m JL, Pin i Prato G P. M ucogingiva l th erapy. In: Lindhe J, Karring T, Lang N P, ed. Clinica l Periodontology and impla nt denti stry.
3rd edn. Copenh agen: Munksgaard, 1997: 550- 596.
8.
Ba ldi C, Pini Prato GP, Pagliaro U, Nieri M, Saletta D, M uz zi L, Cortel lini P. Coronally advanced flap procedure for root cove rage. Is flap
thickness a relevant predictor to achieve root coverage? A 19- case series. J Periodontol. 1999; 70: 1077-84.
9.
Zucchelli G, Cesari C, Amore C, Montebugn oli L, De Sanctis M. Laterally moved, corona lly advanced flap: a modif ied surgical approach
f or isolated recession type defects. J Period onto I. 2004:75:1734-41.