Jan Lindhe. Clinical Periodontology

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594 - CHAPTER 27

Fig. 27-28. A 9-year-old boy showing recession at tooth 41. The tooth is rotated and buccally positioned (a). The

minimal amount of gingiva found apical to the recession shows pronounced signs of inflammation. The plaque con

trol in the region was improved but surgical intervention was postponed. (b) The same tooth area at the age of 14

years. Note the spontaneous soft tissue repair that has taken place at tooth 41 as a consequence of the improved

plaque control and the growth in the alveolar process.

Fig. 27-29. Spontaneous repair of soft tissue recessions following orthodontic tooth movement. A 22-year-old

woman showing recessions and thin marginal tissues at prominently positioned teeth, particularly 23, 33, 41 and 43

(a). Following proper alignment of the teeth (b), the recessions have spontaneously been resolved and an increased

gingival height can be noted.

periodontal tissue support at the proximal surfaces of

the tooth.

Recession defects in the child need particular atten-

tion. In the growing child, recession defects may be

eliminated spontaneously, provided an adequate

plaque control is established and maintained (Fig.

27-

28). Andelin-Sobocki et al. (1991) reported from a

year prospective study that 25 out of 35 recessions

with an initial depth of 0.5-3.0 mm spontaneously

healed following improvement of the oral hygiene

standard. Furthermore, all but three of remaining re-

cessions showed a decrease and no site demonstrated

an increase in depth. Hence, reparative surgical treat-

ment of soft tissue recessions in the developing denti-

tion may not be necessary and should preferably be

postponed until the growth has been completed.

Furthermore, in an orthodontic case showing a re-

cession defect and a thin (delicate) gingiva due to

prominent position of the tooth (Fig. 27-29a), surgical

treatment for root coverage should be postponed until

the orthodontic therapy is completed. The recession, as

well as the dehiscence, will decrease as a conse

quence of the lingual movement of the tooth into a

more proper position within the alveolar bone (Fig.

27-

29b) and, if still indicated, the root coverage proce

dure

will show higher predictability if performed after

than

before the tooth movement.

Root coverage procedures

Surgical procedures used in the treatment of recession

defects may basically be classified as (1) pedicle soft

tissue graft procedures and (2) free soft tissue graft

procedures.

The pedicle graft procedures are, depending on the

direction of transfer, grouped as (1) rotational flap

procedures (e.g. laterally sliding flap, double papilla

flap, oblique rotated flap) or (2) advanced flap proce-

dures (e.g. coronally repositioned flap, semilunar

coronally repositioned flap). The latter procedures do

not include rotation or lateral movement of the pedicle

graft. Within the group of pedicle graft procedures,

guided tissue regeneration procedures may also be

596 • CHAPTER 27

Fig. 27-32a-e.

Rotational flap procedure.

Schematic drawings illustrating the surgical technique in utilizing rotational

pedicle grafts to cover localized recession defects (see text for explanation).

depth between teeth that had been instrumented (root

planed) or polished only (Oles et al. 1985, Pini Prato

et al. 1999). Extensive root planing may therefore only

be performed in situations where a reduced root

prominence would be considered beneficial for graft

survival or tissue regeneration, or if a shallow root

caries lesion is diagnosed. The presence of a filling in

the root does not preclude the possibility for root

coverage (Fig. 27-30), but the filling should be re-

moved before the root is covered with soft tissue.

Miller (1985b) advocated the use of root surface

demineralization agents to be an important treatment

component in the free soft tissue graft procedure. In

addition to the 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 and allow subsequent interdigitation of these

fibrils with those in the covering connective tissue.

However, controlled clinical trials comparing the ef-

fect of free gingival graft procedures with and without

root conditioning (Ibbott et al. 1985, Bertrand & Dun

lap 1988, Laney et al. 1992, Bouchard et al. 1997, Caf

fesse et al. 2000) have failed to demonstrate a benefi-

cial clinical effect from the use of acid root biomodifi-

cation. Also, controlled studies comparing the effect

of laterally positioned flap with and without root

conditioning showed no statistically significant posi-

tive effect of the use of acid root conditioning (Oles et

al. 1985, Caffesse et al. 1987). Gottlow et al. (1986)

evaluated the healing following treatment of localized

gingival recessions with coronally positioned flaps

and

citric acid root biomodification in a controlled

study in

dogs. The histological analysis after 3 months

healing disclosed no differences in the amount of

root

coverage or new connective tissue attachment

MUCOGINGIVAL THERAPY - PERIODONTAL PLASTIC SURGERY •

597

between citric acid treated sites and saline treated

control sites. Although root resorption was a common

finding among the citric acid treated teeth in this dog

model, such a finding has not been commonly re-

ported in humans. Hence, the literature clearly indi-

cates that the inclusion of root conditioning does not

improve the healing outcome of root coverage proce-

dures.

Pedicle soft tissue graft procedures

Rotational flap procedures

The use of a laterally repositioned flap to cover areas

with localized recession was introduced by Grupe &

Warren (1956). 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 (Fig. 27-19). In

order to reduce the risk for recession on the donor

tooth, Grupe (1966) suggested that the marginal soft

tissue should not be included in the flap. Staffileno

(

1964) and Pfeifer & Heller (1971) advocated the use

of a split thickness flap to minimize the potential risk

for development of dehiscence at the donor tooth.

Other modifications of the procedure presented are

the

double papilla flap

(Fig. 27-31) (Cohen & Ross 1968),

the

oblique rotational flap

(Pennel et al. 1965),

the rotation flap

(Patur 1977), and

the transpositioned flap

(Bahat et al.

1990).

Technique

• The rotational flap procedure (Fig. 27-32) is initiated

with the preparation of the recipient site. A reverse

bevel incision is made all along the soft tissue mar-

gin of the defect (Fig. 27-32a). After removal of the

dissected pocket epithelium, the exposed root sur-

face is thoroughly curetted.

• At a distance of approximately 3 mm from the

wound edge which delineates the defect at the side

opposite the donor area, a superficial incision is

made extending from the gingival margin to a level

approximately 3 mm apical to the defect (Fig. 27-

32b). Another superficial incision is placed horizon

tally from this incision to the opposite wound edge.

The epithelium together with the outer portion of

the connective tissue within the area delineated by

these incisions and the wound edges is removed by

sharp dissection (Fig. 27-32c). In this way a 3-mm-

wide recipient bed is created at the one side of the

defect, as well as apically to the defect.

• A tissue flap to cover the recession is then dissected

in the adjacent donor area. The preparation of this

flap is initiated by a vertical superficial incision

placed parallel to the wound edge of the recession

and at a distance which exceeds the width of the

recipient bed and the exposed root surface of ap-

proximately 3 mm (Fig. 27-32c). This incision is

extended beyond the apical level of the recipient

bed and is terminated within the lining mucosa

with an oblique releasing incision directed towards

the recession site. An incision connecting the verti-

cal incision and the incision previously made

around the recession is placed approximately 3 mm

apical to the gingival margin of the donor site.

A split thickness flap is then prepared by sharp

dissection within the area delineated by these inci-

sions so that a layer of connective tissue is left

covering the bone in the donor area when the flap

is laterally displaced over the denuded root surface

(

Fig. 27-32d). It is important that the oblique releas

ing incision is made so far apically that the tissue

flap can be placed on the recipient bed without

being subjected to tearing forces when adjacent soft

tissues are moved. The prepared tissue flap is ro-

tated about 90° when sutured at the recipient bed

(

Fig. 27-32e).

The suturing of the flap should secure a close

adaptation of the pedicle graft to the underlying

recipient bed. Pressure is applied against the flap for

2-3 min in order to further secure a good adaptation.

To protect the surgical area during the initial phase

of healing, a periodontal dressing is applied. Alight

curing dressing material, e.g. Barricai

`" (Dentsply

International Inc., Milford, DE, US), is preferably

used since this can be applied without dislocating

the flap and has a favorable esthetic appearance.

Following removal of the dressing and the sutures,

usually after 10-14 days, the patient is instructed to

avoid mechanical toothcleaning for a further 2

weeks, but to use twice daily rinsing with a chlor-

hexidine solution as a means of plaque control.

Advanced flaps

Since the lining mucosa is elastic, a mucosal flap raised

beyond the mucogingival junction can be stretched in

coronal direction to cover exposed root surfaces (

Harvey 1965, Sumner 1969, Brustein 1979, Allen &

Miller 1989, Wennstr6m & Zucchelli 1996, Pino Prato

et al. 1999). The coronally advanced flap can be used

for root coverage of a single tooth as well as multiple

teeth, provided suitable donor tissue is available. In

situations with only shallow recession defects and

minimal probing pocket depth labially, the

"semilunar

598 • CHAPTER 27

Fig. 27-33a-c.

Coronally advanced flap procedure.

Schematic drawings illustrating the surgical technique in utilizing

coronally advanced pedicle grafts to cover localized recession defects (see text for explanation).

coronally repositioned flap"

may offer an alternative

approach (Harlan 1907, Tarnow 1986).

Technique

Coronally advanced flap procedure (Fig. 27-33)

• The coronally advanced flap procedure is initiated

with the placement of two apically divergent verti-

cal releasing incisions, extending from a point coro

nal to the cemento-enamel junction at the mesial

and distal line axis of the tooth and apically into the

lining mucosa (Fig. 27-33a).

• A split thickness flap is prepared by sharp dissec-

tion mesial and distal to the recession and con-

nected with an intracrevicular incision. Apical to the

receded soft tissue margin on the facial aspect of the

tooth, a full thickness flap is elevated to maintain

maximal thickness of tissue flap to be used for root

coverage (Fig. 27-33b). Approximately 3 mm apical

to the bone dehiscence, a horizontal incision is made

through the periosteum, followed by a blunt dissec-

tion into the vestibular lining mucosa to release

muscle tension. The blunt dissection is extended

buccally and laterally to such an extent that the

mucosal graft can be easily positioned coronally at

the level of the cemento-enamel junction.

The tissue flap is coronally advanced, adjusted for

optimal fit to the prepared recipient bed, and se-

cured at the level of the cemento-enamel junction by

suturing the flap to the connective tissue bed in the

papilla regions (Fig. 27-33c). Additional lateral su-

tures are placed to carefully close the wound of the

releasing incisions. A light curing dressing may be

applied to protect the area during initial healing.

Fig. 27-34 illustrates the treatment of a recession defect

with the use of the coronally advanced flap procedure.

MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY • 599

Fig. 27-34.

Coronally advanced flap procedure.

A deep and wide recession defect on a canine with a composite resin

restoration in the exposed root portion (a). Before preparation of the pedicle graft, the root is polished with pumice

and a rubber cup. A split flap has been dissected mesial and distal to the root, and a full thickness flap apical to the

recession (b). Approximately 4 mm apical to the bone dehiscence the periosteum has been cut and a blunt dissec-

tion performed to facilitate the coronal positioning of the pedicle graft. The composite resin restoration is removed

(c)

followed by a close suturing of the pedicle graft to cover the exposed root surface (d). Healing outcome 1-year

postoperatively (e).

600 • CHAPTER

Fig. 27-35a-c.

Semi-lunar coronally repositioned flap procedure.

Schematic drawings illustrating the surgical technique

utilizing coronally displaced pedicle grafts to cover shallow localized recession defects (see text for explanation).

Semi-lunar coronally repositioned flap procedure (Fig

27-35)

A semi-lunar incision is placed apically to the reces-

sion and at a distance from the soft tissue margin,

which should be approximately 3 mm greater than

the depth of the recession. The outline of the incision

should be parallel to the curvature of the gingival

margin (Fig. 27-35a). The incision is extended into

the papilla region on each side of the tooth, but care

should be taken to maintain a broad base of anchor

age to secure a collateral blood supply to the pedicle

graft.

A split thickness dissection of the facially located

tissue is then made by an intracrevicular incision

extending apically to the level of the semi-lunar

incision (Fig. 27-35b). The mid-facial soft tissue graft

is coronally repositioned to the level of the cemento-

enamel junction (Fig. 27-35c) and stabilized by light

pressure for 5 min.

No suturing is needed but a light curing dressing is

applied for wound protection.

Coronally advanced flap procedure for multiple recessions

(

Fig.

27-36)

Zucchelli and De Sanctis (2000) described a flap de-

sign for the treatment of multiple recessions, which

allows for optimal adaptation of the flap following its

coronal advancement without placement of vertical

releasing incisions.

• Oblique submarginal incisions are placed in the

interdental areas and connected with intracrevicu

lar

incisions at the recession defects. The incisions are

extended to include one tooth on each side of the

teeth to be treated to facilitate a coronal reposition-

ing of the flap. The oblique incisions over the inter-

dental areas are placed in such a manner that the

surgically created papillae" mesial to the midline

the surgical field are dislocated apically and dis

tally,

while the papillae of the flap distal to the

mid-line are

shifted in a more apical and mesial

position (27-36a).

• Starting at the oblique interdental incisions, a split-

thickness flap is dissected (Fig. 27-36c). Apical to the

level of the root exposures, a full-thickness flap is

raised to provide maximum soft tissue thickness of

the flap to be coronally positioned over the roots

(Fig.

27-36d).

• At the most apical portion of the flap, the pe

riosteum

is incised and followed by dissection into

the

vestibular lining mucosa to eliminate all muscle

tension. The mobilized flap should be able to pas-

sively reach a level coronal to the CEJ at each single

tooth in the surgical field.

• The remaining facial portion of the interdental pa-

pillae is de-epithelialized to create connective tissue

beds to which the flap can be sutured.

• Sutures are placed to accomplish a precise adapta-

tion of the coronally advanced flap against the teeth

and to the interdental connective tissue beds (Fig.

MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY

• 6o1

Fig. 27-36.

Coronally advanced flap procedure for multiple recessions. (a-e)

The oblique incisions over the interdental ar

eas are placed in such a manner that the "surgically created papillae" mesial to the midline of the surgical field

are

dislocated apically and distally, while the papillae of the flap distal to the mid-line are shifted in a more apical

and

mesial position (see text for explanation). (f) The 1-year post-treatment view.

27-36e). In addition, a horizontal double mattress

suture is placed to reduce lip tension on the mar-

ginal portion of the flap.

Pedicle soft tissue graft procedures combined with

membrane barriers

The use of a membrane barrier, according to the prin-

ciples of guided tissue regeneration (GTR, see Chapter

28), in conjunction with pedicle soft tissue graft pro-

cedures was introduced as a treatment modality for

root coverage (Pini Prato et al. 1992). A membrane

barrier is placed between the graft and the root in

order to favor the regeneration of the periodontium.

According to the concept of the GTR, a critical factor

for the outcome of the treatment procedure is that a

space for tissue formation is established between the

facial root surface and the membrane and maintained

during the healing. In order to create such a space, Pini

Prato et al. (1992) suggested that extensive root plan-

ing should be carried out to produce a concave root

morphology. In addition, bending of the membrane by

the placement of a Teflon suture (Fig. 27-37) in mesio-

distal direction through the membrane could facilitate

the maintenance of an adequate space. Specially de-

signed membranes for the treatment of recession type

defects are also available, such as non-absorbable tita-

602 • CHAPTER 27

Fig. 27-37a,b. Membrane barrier for treatment of reces

sion defects. A Teflon suture has been placed in mesio

distal direction through an expanded polytetrafluore

thylene (ePTFE) membrane in order to establish ade-

quate space between the barrier and the root

surface.

nium-reinforced expanded polytetrafluorethylene

(

ePTFE) membranes (Fig. 27-38). In addition, a variety

of bioabsorbable membranes are commercially avail-

able, but many of these may not be rigid enough for

maintaining required space during healing.

Technique

The principles of using a GTR procedure in the treat-

ment of recessions were originally outlined by Pini

Prato et al. (1992). Commonly, the pedicle graft used

in the GTR procedure is generated through a coronally

advanced flap (Fig. 27-38).

•

Apically divergent vertical releasing incisions are

made at the mesial and distal line axis of the tooth,

extending from a point coronal to the cemento-

enamel junction and apically into the lining mucosa

(Fig. 27-38b). A trapezium-shaped full-thickness

flap is raised beyond the bone dehiscence. A hori-

zontal incision is then made through the periosteum

at the base of the raised mucoperiosteal flap, fol-

lowed by a blunt supraperiosteal dissection to such

a depth that the trapezoidal flap can be easily ad-

vanced coronally to the desired position. Depend-

ing on the degree of coronal repositioning, the facial

portion of the interdental papillae may need to be

de-epithelialized to prepare proper recipient beds

for the pedicle graft.

•

The root is extensively planed or ground to obtain

concave profile of the root surface, thereby provid

ing space for tissue formation. If a titanium-rein-

forced membrane is used, the root profile may not

need to be changed to establish the required space

between the root and the membrane.

•

The membrane barrier to be used is trimmed to

cover the exposed root and approximately 3 mm of

the bone laterally and apically of the dehiscence

(

Fig. 27-38c). Following trimming, the membrane is

positioned over the root and anchored to the tooth

by a sling suture placed at the level of the cemento

enamel junction.

•

The mobilized flap is coronally positioned and se-

cured by interdentally placed interrupted sutures

(

Fig. 27-38d). The membrane should be completely

covered by the flap to reduce the risk for bacterial

contamination during the healing. Additional su-

tures are placed to close the lateral wound of the

releasing incisions.

•

To avoid the risk of collapse of the membrane over

the root, which may limit the space for blood clot

formation, a periodontal dressing should not be

applied.

•

The patient is advised to use a chlorhexidine

mouthrinse for plaque control and not to use any

mechanical cleaning devices for at least 6 weeks in

the tooth region subjected to surgery.

•

The use of non-biodegradable membrane barriers

requires a second surgery for membrane removal,

usually after 5-6 weeks (Fig. 27-38e-f). A partial

thickness trapezoidal flap is raised to expose the

membrane. Following its removal, the flap is repo-

sitioned at the level of the cemento-enamel junction

to completely cover the newly formed tissue. Me-

chanical plaque control is reinstituted 4 weeks after

membrane removal.

MUCOGINGIVAL THERAPY — PERIODONTAL PLASTIC SURGERY • 603

Fig. 27-38a-g.

Coronally advanced flap procedure combined with a non-biodegradable membrane barrier.

A recession defect

at tooth 23 requiring treatment due to the patient

s esthetic demands (see text for explanation). (g) The 1-yr postop-

erative healing result.

604 • CHAPTER 27

Fig. 27-39.

Two-stage epithelialized free soft tissue graft procedure. (a-c)

An epithelialized soft tissue graft is placed api

cal

to the recession and allowed to heal. At a second stage surgery a coronally advanced flap procedure is per-

formed to

achieve coverage of the denuded root. (d) The 1-year postoperative healing result.

Fig. 27-40a-f.

Epithelial/zed free soft tissue graft procedure.

A recession defect at a mandibular central incisor treated

with the free graft procedure (see text for explanation).