Surgical Therapies for the Treatment of Gingival Recession
Louis F. Rose, DDS, MD
Dental therapy is increasingly directed at the esthetic outcomes for patients, which extend beyond tooth replacement and tooth color to include the soft tissue component framing the dentition. Certain indications, including esthetics, progression of the defect, hypersensitivity, or difficulties with oral hygiene may support the use of periodontal esthetic surgical procedures.
Periodontal esthetic surgery includes periodontal surgical procedures performed to prevent, correct, or eliminate anatomical, developmental, traumatic, or plaque-induced disease-related defects in the gingival or alveolar mucosa. There are multiple periodontal esthetic surgery approaches noted in the literature for the treatment of gingival recession defects. These treatment approaches generally include the manipulation of the patient’s tissues to augment the soft tissues and cover the exposed root surface.
Independent of the modality of the surgical procedures used to obtain soft tissue root coverage, shallow residual probing depths, gain in clinical attachment, and an increase in gingival height are the common characteristics of treatment outcome.1
Causes of Gingival Recession
There are many causes of gingival recession, including both predisposing and precipitating factors. The predisposing factors include minimal attached gingiva, frenum attachment, and tooth malposition. Tooth position relates to the position of the tooth in the alveolus. The alveolar dehiscence or fenestration with resultant thin bony housing and thin gingival tissue is susceptible to recession.
Precipitating factors that may lead to ginival recession include inflammation related to plaque, improper brushing, which causes abrasion and laceration of the gingival tissue, and iatragenic dental care, including tooth preparation, margin placement, and impression making.2
Classification of Gingival Recession
In 1985, Miller described four categories of recession defects (Figure 1A, Figure 1B, Figure 1C, Figure 1D).3
Class I: Marginal tissue recession that has not extended to the mucogingival junction. There is no loss of interdental bone or soft tissue.
Class II: Marginal tissue recession that extends to or beyond the mucogingival junction. There is no loss of interdental bone or soft tissue.
Class III: Marginal tissue recession that extends to or beyond the mucogingival junction. There is loss of interdental bone, and the interdental soft tissue is apical to the cementoenamel junction (CEJ), but remains coronal to the apical extent of the marginal tissue recession.
Class IV: Marginal tissue recession that extends beyond the mucogingival junction. There is a loss of interdental bone and soft tissue to a level corresponding to the apical extent of the marginal tissue recession
The amount of root coverage that can be achieved regardless of the procedure used is limited by the height of the adjacent papilla. Miller stated that complete root coverage can be achieved in class I and class II recession defects. Partial coverage may be achieved in the type of recession represented by class III and IV.3
Factors Influencing the Degree of Root Coverage
Poor oral hygiene will influence the success of root coverage procedures.4 The predominant causative factor in the development of recession is tooth-brushing trauma; therefore, this factor has to be corrected to secure an optimal outcome in any root coverage procedure. Smoking is an additional factor as it relates to the wound healing aspect of grafting.
The level of interdental periodontal support may be of greatest significance for the outcome of root coverage procedures. From a biological point of view, complete root coverage is achievable in class I and II type recession defects. When the loss of connective tissue attachment also involves proximal tooth sites (class III and IV recession defects), only partial facial root coverage is attainable.
An additional factor shown to influence the degree of attainable root coverage is the dimension of the recession defect. Less favorable treatment outcome has been reported at sites with wide (> 3 mm) and deep (> 5 mm) recession.5
Treatment of the Exposed Root Surface
Before root coverage is attempted, the exposed portion of the root should be rendered free from bacterial plaque. The presence of a filling in the root does not preclude the possibility for root coverage, but the filling should be removed before the root is covered with soft tissue.6
Miller advocated the use of root surface demineralization agents as an important treatment component in the free soft tissue graft procedure.7 In addition tothe removal of the smear layer, the use of acid demineralization of the root surface is intended to facilitate the formation of a new fibrous attachment through exposure of collagen fibrils of the dentine matrix. This also allows subsequent interdigitation of these fibrils with those in the covering connective tissue.7 Flap tension has been reported to be an important factor for the outcome of the coronally advanced flap procedure. The best clinical result is achieved if the flap is passively adapted to the root surface.8,9
Coronally Positioned Flap
Coronally positioned flap is a technique used to cover exposed roots with the available gingiva. This technique has a major drawback because when significant recession occurs, there is rarely enough gingival width or thickness to completely cover the exposed root.
The ideal case for a coronally positioned flap is a patient who has adequate thickness and width of the gingiva on the marginal edge of the flap to be advanced. The keratinized gingiva has to be wide enough to secure the sutures and maintain a stable, tension-free gingival flap during the healing process (Figure 2A and Figure 2B).
The advantages of the coronally positioned flap technique are that only 1 surgical site is involved and it is an excellent color match. Case selection is important because if the grafted tissue is thin, only partial root coverage is achieved, and the tissue is prone to additional recession.
In some cases, a split-thickness dissection is performed, while in other cases, a full-thickness flap is used over the radicular surface of the root to maintain a sufficient flap thickness. The pedicle flap is then advanced in a coronal direction until it comes to rest on the recipient bed for a trial fit. The fit should be a butt joint where the flap is inlayed into or exactly fits into the recipient site. Once the tissue lies passively in place, it should be sutured. Proper suturing should be accomplished without any tension on the flap (Figure 3A and Figure 3B).8
Lateral Position Graft
The use of a laterally repositioned flap to cover areas with localized recession was introduced by Grupe and Warren.10 This technique, which was called the laterally sliding flap operation, involved the reflection of a full-thickness flap in a donor area adjacent to the defect and the subsequent lateral displacement of this flap to cover the exposed root surface (Figure 4A and Figure 4B). To reduce the risk for recession on the donor tooth, Grupe11 suggested that the marginal soft tissue should not be included in the flap. Pfeifer and Heller12 advocated the use of a split-thickness flap to minimize the potential risk for development of dehiscence at the donor tooth.13 Other modifications of the procedure are the double papilla flap,14 the oblique rotational flap,15 the rotation flap, and the transpositioned flap (Figure 5A ; Figure 5B; Figure 5C; Figure 5D).
Subepithelial Connective Tissue Grafts
In 1980, Langer and Calagna16,17 described a subepithelial connective tissue graft for root coverage. The addition of connective tissue under any pedicle flap yields a mean exposed root coverage of 89.3%, which is better than other soft tissue grafting tissue techniques. The harvesting of donor tissue from the subepithelial connective tissue of the palate requires a complete knowledge of the anatomy of the palate. The best quality connective tissue is found closest to the teeth rather than the midline of the palate.
Individuals with thin periodontal biotypes are susceptible to gingival recession. They often have thin palatal mucosa that may not be adequate for grafting. In these patients, another periodontal surgical procedure should be considered. The width of connective tissue needed for most grafts is determined by the extent of root exposure and the amount of root coverage anticipated (Figure 6A and Figure 6B).
The clinician has the option of either completely covering the graft with the flap at the recipient site or leaving a portion of the graft uncovered. This technique can be used for class I, class II, or class III recession defects. The partially covered connective tissue graft was originally described by Langer and Langer.18 The donor tissue must be thick enough to survive over the avascular root of the tooth (Figure 7A; Figure 7B; Figure 7C).
The completely covered connective tissue graft uses a coronally positioned flap either with vertical incisions or with horizontal incisions. The decision to use vertical incisions is the same as with the coronally positioned flap. Vertical incisions allow for more flap advancement but may decrease blood supply and create slight scarring of the mucosa. The technique is indicated for class I recession defects when a thin or average connective tissue graft can be placed under the coronally positioned flap to enhance the soft tissue complex. In class I defects, a band of keratinized tissue exists at the recipient site. In more advanced recession with defects where little or no keratinized tissue exists, covering the grafted tissue completely with a coronally positioned flap often results in total root coverage, but with the presence of a nonkeratinized mucosal margin at the CEJ.
Acellular Dermal Matrix Allografts
Acellular dermal matrix allografts can be used as an alternative donor source with the completely covered connective tissue graft if autogenous connective tissue cannot be used. An accepted tissue bank should recover the donor allograft tissue. In the United States, the guidelines of the American Association of Tissue Banks and the US Food and Drug Administration should be followed for the donor tissue. The new methods of processing the allografts have improved the success of acellular dermal allograft procedures. The dermal cells are removed and the matrix is stabilized through the inhibition of metalloproteinases. The tissue is freeze-dried without damaging the components essential for revascularization and repopulation by the recipient’s normal cells.20 This process renders the dermal matrix free from cellular components, but it still contains blood vessel channels, collagen, elastin, and proteoglycans. This allows for a more organized and rapid healing response by using a biologic scaffold for normal tissue remodeling.
The acellular dermal matrix must be totally covered by the advanced flap if root coverage is desired. The major advantages of this technique are the unlimited amount of donor material available and the lack of postoperative complications related to the palatal wound. Many desire grafting without the palatal complications (Figure 8A; Figure 8B; Figure 8C).21 Each patient must be fully informed of the human donor source and the option of using their own tissue, thereby eliminating any possible complications related to the donor source. When comparing the clinical results of covering exposed roots, autogenous connective grafts and acellular dermal matrix allografts are not statistically different. However, connective tissue grafts heal an average of 2 to 3 weeks faster, with more keratinized soft tissue than the acellular dermal matrix grafts.22,23
The advantages of completely covering a connective tissue graft include better esthetics and the ability to use a thinner graft. A thin graft may not survive over a root surface if it is not completely covered.
When to Graft and When to Restore
A question that is frequently asked is how does one decide the best treatment (restorative versus surgical) for a noncarious cervical lesion. According to Allen,24 each case should be evaluated methodically using the guidelines in Table 1. The presence of a filling in the root does not preclude the possibility for root coverage, but the filling should be removed before the root is covered with soft tissue.
Clinical Outcome of Root Coverage Procedures
Independent of the modality of the surgical procedures used to obtain soft tissue root coverage, shallow residual probing depths, gains in clinical attachment, and increases in gingival height are the common characteristics of treatment outcome. Although the major indication for performing root coverage procedures is the esthetic demands by the patient, almost no studies have included assessments of esthetics as an endpoint of success. Instead, the common outcome variable used isthe amount of root coverage achieved, expressed as a percentage of the initial depth of the recession. In some studies, the proportion of treated sites showing complete root coverage is also reported.21
Conclusion
From an evidence-based review during the Proceedings of the 2003 American Academy of Periodontology Workshop on Contemporary Science and Clinical Periodontology,1 the following was concluded:
- There is evidence to indicate that root coverage procedures result in decreased root sensitivity and improved esthetics.
- There is evidence to indicate that coronally positioned flaps with allogenic soft tissue grafts result in similar root coverage as coronally positioned flaps with autogenous connective tissue.
- There is evidence to indicate that coronally positioned flaps with autogenous connective tissue grafts result in greater root coverage and increased keratinized tissue compared with guided tissue regeneration procedures using bioresorbable membranes.
- The 2003 Workshop on Clinical Science and Clinical Periodontics suggested that future research should include application of cell transplantation, biological mediators, and appropriate bioactive scaffolds to improve the extent and predictability of root coverage.
- There is evidence to indicate that coronally positioned flaps with allogenic soft tissue grafts result in similar root coverage as coronally positioned flaps with autogenous connective tissue.
References
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2. Nevins M, Capetta EG. An overview of mucogingival surgery to cover the exposed root surface. In: Periodontal Therapy. Nevins M, Mellonig JT, eds. Hanover Park, Il: Quintessence; 1998:339-354,
3. Miller PD Jr. A Classification of marginal tissue recession. Int J Periodont Rest Dent. 1985;5(2):9.
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9. Pini Prato G, Pagliaro U, Baldi C, et al. Coronally advanced flap procedure for root coverage. Flap with tension versus flapwithout tension: a randomized controlledclinical study. J Periodontol. 2000;71(2):188-201.
10. Grupe J, Warren R. Repair of gingival defects by a sliding flap operation. J Periodontol. 1956;27:290-295.
11. Grupe J. Modified technique for the sliding flap operation. J Periodontol. 1966;37:491-495.
12. Pfeifer JS, Heller R. Histologic evaluation of full and partial thickness lateral repositioned flaps. A pilot study. J Periodontol. 1971;42(6): 331-333.
13. Staffileno H, Levy S, Gargiulo A. Histologic study of cellular mobilization and repair following a periosteal retention operation via split thickness mucogingival surgery. J Periodontol. 1966;37(2): 117-131.
14. Cohen D, Ross SE. The double papillae flap in periodontal therapy. J Periodontol. 1968;39(2):65-70.
15. Pennel BM, Higgison JD, Towner TD, et al. Oblique rotated flap. J Periodontol. 1965;36:305-309.
16. Langer B, Calagna L. The subepithelial connective tissue graft. J Prosthet Dent. 1980;44(4):363-367.
17. Langer B, Calagna L. Subepithelial connective tissue graft. A new approach to the enhancement of anterior cosmetics. Int J Periodontics Restorative Dent. 1982;2(2):22-33.
18. Langer B, Langer L. Supepithelial connective tissue graft technique for root coverage. J Periodontol. 1985;56(12):715-720.
19. Cordioli G, Mortarino C, Chierico A, et al. Comparison of 2 techniques of subepithelial connective tissue grafts in the treatment of gingival recessions. J Periodontol. 2001;72(11):1470-1476.
20. Lifecell Medical Information Center: Patented process for AltoDerm® processing, on line 1-10-0006. 10-10-2002. Ref Type: Electronic Citation.
21. Harris RJ. Cellular dermal matrix used for root coverage: 18 month follow up observation. Int J Periodontics Restorative Dent. 2002;22(2): 156-163.
22. Tal H, Moses O, Zohar R, et al. Root coverage of advanced gingival recession: a comparative study between acellular dermal matrix allograft and subepithelial connective tissue grafts. J Periodontol. 2002;73(12):1405-1411.
23. Paolantonlo M, Dolci M, Esposito P, et al. Subpedicle acellular dermal matrix graft and autogenous connective tissue graft in the tratment of gingival recessions: a comparative 1-year clinical study. J Periodontol. 2002;73(11):1299-1307.
24. Allen EP. Noncarious cervical lesions: graft or restore? J Esthet Restorative Dent. 2005;17(6):332-334.
About the Author
Louis F. Rose, DDS, MD
Clinical Professor of Periodontics
University of Pennsylvania, School of Dental Medicine
Philadelphia, Pennsylvania
Private Practice
Philadelphia, Pennsylvania
