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Modified Double-Papillae Flap Technique With Subepithelial Connective Tissue Graft for Root Coverage in the Esthetic Zone: Case Report
Gustavo Javier Salazar Littuma, DDS, MSc; Leonardo Bez, DDS, MSc; Camilo Andres Villabona lopez, DDS, MSc; Cesar Augusto Magalhães Benfatti, DDS, MSc, PhD; and Ricardo de Souza Magini, DDS, MSc, PhD
Gingival recession can compromise the esthetic appearance, leading to functional problems, hypersensitivity, and root caries. Several techniques have been implicated for root coverage, which includes pedicle grafts, free gingival grafts, connective tissue grafts, and guided-tissue regeneration. The double-papillae flap associated with subepithelial connective tissue is a predictable technique to cover isolated areas with insufficient attached gingiva apical to a recession. This case report demonstrates a surgical alternative to the technique using a sling periosteal suture to stabilize the connective tissue and pedicle flap during the initial phase of healing, increasing the potential of this periodontal procedure for gingival recession coverage.
Root-surface coverage has become an integral part of the surgical periodontal practice.1 Gingival recession is defined as the displacement of the gingival margin apical to the cemento-enamel junction (CEJ).2 The sulcular and junctional epithelia and apical migration of the connective tissue attachment associated with crestal bone resorption results in exposure of the root surface to the oral environment.3
In addition to the patient`s esthetic concern, exposed root surfaces are frequently associated with hypersensitivity, plaque retention, and further breakdown if inflammation or thin tissue is present.4 Numerous factors may play a role in gingival recession, such as vigorous tooth brushing, chronic gingival inflammation, and different anatomic features such as thin gingival biotype, lack of keratinized tissue, buccal prominence of teeth, and high frenum attachment.5 The use of pedicle grafts,6,7 free gingival grafts,8,9 free connective tissue grafts,10,11 and guided tissue regeneration have shown effective results for root coverage.12,13
The Miller classification of recession provides guidelines to clinicians for predictability of root coverage.14 Considering that complete root coverage (CRC) represents the ultimate goal after treatment of recession defects, many studies have extensively demonstrated that in Miller class I and II single gingival recession cases, CRC can be achieved by using various techniques.15-17
Cohen and Ross18 described the double-papillae repositioned flap by joining both papillae to form a flap with the advantages of minimal exposure of underlying connective tissue and periosteum with an individual vascular papillae blood supply. Nelson19 reported a bilaminar technique that combines a free connective-tissue graft with a full-thickness double-papillae graft. Harris20,21 proposed the use of a partial-thickness double-pedicle flap overlying a free connective tissue graft.
When dealing with periodontal procedures, healing in a submerged environment is essential to accomplish the desired treatment result. Fundamental factors such as a careful handling of the soft tissues and the use of an adequate tension-free suture technique are key elements involved in the establishment of primary closure after surgical intervention.22
The aim of the present article is to introduce two cases with an additional step in the double-papillae flap technique with subepithelial tissue graft by using a sling periosteal suture for the stabilization of connective tissue graft, as well as the pedicle flap, providing a tension required to maintain the flap cover for precise wound healing and complete root coverage in the esthetic zone.
Case Report 1
A 25-year-old female patient was referred to the department of implant dentistry at the Federal University of Santa Catarina in Brazil with the chief complaint of receding gum line and hypersensitivity in relation to the mandibular right central incisor (Figure 1).
On clinical examination, a Miller class II gingival recession in tooth No. 41 with an inflammation area and an inadequate amount of attached gingiva was observed. Preoperative photographs were taken and initial clinical measurements were recorded including: probing depth (1 mm), recession depth (5.5 mm), recession width (3.5 mm), and clinical attachment level (6.5 mm) using a WHO periodontal probe (LM Dental, lm-dental.com).
On thorough history taking, the etiology of gingival recession was thought to be possibly attributed to orthodontic tooth movement due to buccal displacement of the root surface. Oral-hygiene instructions were given, and the patient was recalled to assess the gingival status of the previous treatment. Informed consent was taken. After adequate anesthesia (2% lidocaine with 1:100.000 epinephrine), a “V” shaped incision was made around the marginal tissue removing the epithelium ulcerated over the exposed root, and two horizontal incisions were made mesial and distal to the interdental papilla, parallel to the cemento-enamel junction of the involved tooth with a No. 15 C blade (Figure 2).
In addition, two lateral releasing incisions were made obliquely at the line angles of the adjacent teeth extended into the alveolar mucosa, allowing firstly a mesial partial-thickness pedicle flap to be reflected gently with the blade separated from the underlying connective tissue and be sutured across to the distal papilla using interrupted sutures 5.0 Vicryl® (Ethicon, ethicon.com) (Figure 3). Once coaptation of the pedicles is done, the flap is completely reflected until it could to be passively positioned over the defect without tension (Figure 4).
The exposed root surface was then carefully planned using a sharp curette. Root conditioning was performed using 24% ethylenediaminetetra acid (EDTA) for 2 minutes with the subsequent use of a saline rinse. A subepithelial connective tissue graft was then obtained from the palate with precise dimensions using a single parallel incision and then placed on the recipient bed at the level of the cemento-enamel junction and suture over the defect using 5-0 Vicryl suspensory and periosteal suture (Figure 5).
At this point, a periosteal release incision was made 4 mm to 5 mm beneath the apical position of the connective tissue graft to relieve tension to the flap, allowing the double-papillae pedicle to be sutured over the connective tissue with 5.0 suspension-type suture and the releasing vertical incisions by interrupted sutures. Furthermore, a sling periosteal suture was placed, which helps to maintain the flap in a coronal position and to avoid dislocation of the connective tissue graft, keeping it completely immobilized. Coronally, the suture was pulled away from the surgical area by stitching the periostium from the distal to the mesial of the tooth No. 42 using a 5.0 resorbable material and then from the mesial to the distal of tooth No. 32, engaging the same amount of tissue and returning back to the distal of the tooth No. 42 to perform a surgeon’s knot to stabilize the suture. Apically at the level of the alveolar mucosa, the same steps were followed, using a 5.0 non-resorbable monofilament suture (Figure 6).
After surgery, the patient was instructed to discontinue toothbrushing at the surgical area for 2 weeks and to rinse with 0.12% chlorhexidine solution three times daily for 2 weeks. Amoxicilin 500 g 3 times a day for 5 days, meloxicam 15 mg 2 times a day for 3 days, and paracetamol 500 mg 4 times a day for 3 days were prescribed. Suture removal was performed at 15 days (Figure 7), and the patient was reviewed once a week for the first month (Figure 8). Complete root coverage was observed at 5 (Figure 9) and 8 months follow-up (Figure 10). Regular plaque-control and oral-hygiene instructions were provided.
Case Report 2
A 30-year-old non-smoking female patient was referred to the periodontal practice for treatment of tooth No. 31, which had a Miller class II recession defect with an inadequate amount of attached gingiva. On thorough clinical history, the patient complained of hypersensitivity in the lower anterior region since orthodontic treatment had been finished. Clinical parameters noticed were: a probing depth of 1 mm, recession depth of 5 mm, recession width of 2 mm, and clinical attachment level of 6 mm (Figure 11).
The possible etiology of gingival recession could be attributed to orthodontic tooth movement leading to root buccal displacement and consequently bone resorption, which results in exposure of the root surface. The procedure was explained to the patient, and informed consent was taken. After adequate anesthesia (articaine 4% 1:100.000), a “V” shaped incision was made around the marginal tissue removing the epithelium, ulcerated with a No. 15 C blade (Figure 12). Two horizontal incisions were made on both sites, parallel to the cemento-enamel junction of the involved tooth, and lateral releasing incisions were made on the mesial and distal aspects of the surgical site. The cuts were extended into the mucosa alveolar without making contact with the bone.
After coaptation of the distal partial-thickness pedicle flap into the mesial papilla using interrupted sutures 5.0 Vicryl (Figure 13), the flap was totally reflected beyond the mucogingival junction.(Figure 14) The exposed root surface was planed and subsequently conditioned using 24% EDTA for 2 minutes with saline rinse. Once a recipient bed was created, a palatal connective tissue graft covered the largest portion of the recession defect trough a 5.0 Vicryl suspensory and periosteal suture (Figure 15).
Afterward, a horizontal periostal incision was done apically to connective tissue graft, for flap advancement, allowing the double-papilla pedicles to be sutured over the connective tissue with a 5.0 suspension suture as well as the vertical releasing incisions by interrupted sutures. Finally, a sling-periosteal containment suture was made apically at the level of alveolar mucosa, avoiding dislocation of the connective tissue graft (Figure 16).
After surgery, the patient was instructed to discontinue toothbrushing at the surgical area for 2 weeks and to rinse with 0.12% chlorhexidine solution three times daily for 2 weeks. Antibiotics and anti-inflammatory drugs were prescribed. Suture removal was done at 15 days (Figure 17), and the patient was reviewed once a week for the first month (Figure 18). At 5 months (Figure 19) and 8 months follow-up complete root coverage was observed (Figure 20).
An exposed root surface is associated with deterioration of the dental esthetics and dentin hypersensitivity.16 Despite the fact that complete root coverage represents the clinical outcome after treating a recession defect, the knowledge of the etiologic factors is mandatory to prevent, correct, or eliminate an anatomic, traumatic, or plaque-induced recession defect in the gingiva.4
Ideally, the treatment of gingival recession must be a complete anatomic regeneration of the periodontal tissue loss with the gingival margin, sulcular epithelium, and junctional epithelium coronal to the junctional epithelium.3 Several surgical techniques have been proposed for root coverage such as pedicle grafts, free gingival grafts, free-connective tissue grafts, and guided-tissue regeneration.1
Two case reports describe the use of a double-papillae flap using a subepithelial connective tissue graft by joining the pedicles together to cover the localized root exposure, preventing clefting of the tissue and achieving a thicker dimension of the gingiva, which may offer a greater resistance for future recession.19 Minimal exposure of the underlying tissues at the interdental donor sites, a thicker interdental papillae, and individualized papillae blood supply minimize the risk for necrosis when a pedicle flap is used to cover a root surface.18
In the above cases, to achieve a predictable treatment result, some considerations were taken. First, mesial or distal partial-thickness pedicle needs to be sutured to the interdental papilla before the flap has been reflected and not later, as some authors describe in literature.18-20 This variation could facilitate the procedure with less tissue manipulation and trauma at the surgical site. Secondly, the use of a subepithelial connective tissue graft leads to an increase in the attached gingiva. This helps prevent the need for longer procedures such as a free gingival graft with the risk for color discrepancy and postoperative pain from the palate, followed by a coronally repositioned flap to cover the gingival recession.19-20
The predictability of a connective tissue graft under a partial -thickness double-papillae flap is well documented. Borghetti and Louise23 reported 70.5% of mean root coverage at 12 months, and Harris20 observed 97.4% of mean root coverage at 12 weeks and 98.4% at 27.5% months.21
Aside from the consistency of these results, this research shows a substantial increase of keratinized tissue with reduction in probing depth. In addition to the clinical and esthetic effects of connective tissue, the phenomenon of creeping attachment may be enhanced after the early phases of healing by a coronal displacement of the gingival margin.8
Even though with this technique, a satisfactory color match and esthetic tissue contour was obtained, this procedure is technically demanding by joining the pedicle’s flap leading to delicate tissue manipulation and an effective root-surface decontamination. The conditioning agent employed in the present cases was 24% EDTA. The use of this material was based on its benefits in removing the smear layer and exposure of the collagen fibrils.24
With regard to a suture technique, the sling periosteal suture has been selected because this process does not require penetration in the surgical area, reducing the risk for damaging the graft and the interdental papilla. It also allows the coronal stabilization of the pedicle flap and immobilization of the connective tissue graft, considering the importance of having a graft supported by vascular tissue. The procedure helps avoid the risk for necrosis during the initial week of healing.25
The present case reports demonstrate a predictable procedure for root coverage of isolated Class II Miller recession defects in the esthetic zone. Combine a containment sling periostal suture within a double papilla flap technique associated with subepithelial connective tissue graft demonstrate to be reliable step to achieve the desire treatment result of complete root coverage with the increase of attached gingival, addressing the health, functional and esthetic needs of the patient.
About the Authors
Gustavo Javier Salazar Littuma, DDS, MSc
Implantology Federal University of Santa Cataria
Leonardo Bez, DDS, MSc
Implantology and Periodontics
University Extremo Sul Catarinense Criciuma
Federal University of Santa Catarina
Camilo Andres Villabona Lopez, DDS, MSc
University of Santo Tomás
Bucaramanga, Santander, Colômbia
Federal University of Santa Catarina
Cesar Augusto Magalhães Benfatti, DDS, MSc, PhD
Professor Titular School of Dentistry-Federal University of Santa Catarina
Florianópolis, SC, Brazil
Ricardo de Souza Magini, DDS, MSc, PhD
School of Dentistry-Federal University of Santa Catarina
Florianópolis, SC, Brazil
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