Periodontal Plastic Surgery in The Management of Multiple Gingival Recessions Two Therapeutic Approaches
Periodontal Plastic Surgery in The Management of Multiple Gingival Recessions Two Therapeutic Approaches
Periodontal Plastic Surgery in The Management of Multiple Gingival Recessions Two Therapeutic Approaches
ISSN No:-2456-2165
Abstract:- Aim: The aim of this case report study was to simultaneously or manifest as a lesion localized to a single
describe two different surgical techniques for treating tooth. They can be a concern for patients for a number of
multiple gingival recessions. reasons. In addition to root hypersensitivity and cervical
lesions, aesthetic considerations may also come into play,
Background: Multiple recessions are of concern to patients especially in patients with a high smile line. [2]
for a number of reasons: aesthetic problems,
hypersensitivity, and carious or non-carious cervical However, multiple recessions are even more difficult
lesions. However, their treatment represents a challenge in defects to manage, as the surgical site is larger and more
periodontal plastic surgery with difficulties added to those anatomical variations may be present (prominent roots, shallow
encountered in the management of single recessions such vestibules, malpositioned teeth, etc.).
as the extension of the avascular surface, different depths
of recessions or the position of the teeth concerned on the In these cases, the goal of periodontal plastic surgery is to
arch. Many techniques have been described to cover these achieve complete root coverage and optimal esthetics with
recessions. perfect integration of the overlying tissues.
Case description: A patient with multiple recessions of Several specific surgical procedures have been proposed
type 1 according to the Cairo classification (RT1) in the to treat this type of lesion, including coronally advanced flaps,
maxillary arch was treated with two different techniques laterally positioned flaps, free gingival grafts, combination of
of periodontal plastic surgery. On the right side, a lateral flaps and connective tissue grafts or acellular dermal matrices.
sliding flap from the edentulous ridge on the former site of
the 2nd premolar was performed without the addition of a II. MATERIAL AND METHODS
connective tissue graft. For the left side, a modified
coronally advanced flap with a connective tissue graft was A. Description
performed. For the right hemi-arch, a partial root A 48 years old female patient, non smoker and in good
coverage of 90% for the canine and the first premolar. As general health consulted our periodontology department at the
for the modified coronally advanced flap with a connective Dental University clinic of Monastir complaining of multiple
tissue graft, partial coverage for all the teeth concerned by recessions on the maxillary arch causing an aesthetic prejudice
the flap varied between 50 and 90%. These coverages badly perceived by this patient. (fig1)
remained stable during the 1-month and 6-month follow-
up appointments. The good oral hygiene and the non-carious cervical
lesions suggest that the recessions are of traumatic origin
Conclusion: The different techniques of periodontal plastic associated with anatomical predisposing factors (fine gingival
surgery have shown their effectiveness in the treatment of typology) and dental malposition.
multiple recessions and especially with the introduction of
the technical modifications of the coronally advanced flap All recessions are of type 1 according to the Cairo
by Zucchelli and by the addition of a connective tissue classification, i.e. without loss of interproximal attachment.
graft. They involved both hemi-arcades and extended from the first
molar to the canine on the right side and from the first molar to
Keywords:- Multiple Gingival Recessions, Root Coverage, the lateral incisor on the left side.
Surgical Flaps, Dental Esthetics.
The patient was treated with different techniques on each
I. INTRODUCTION side. She received a laterally displaced flap from the edentulous
ridge at the former site of the second premolar without the
Gingival recessions are defined as an apical migration of addition of a connective tissue graft (Fig2). The choice of this
the marginal gingiva from the amelo-cementary junction technique was due to the absence of keratinized tissue apical to
resulting in an exposure of the root surface. [1] These lesions the recessions and their presence in abundance at the level of
affect both subjects with poor oral hygiene and those with good the edentulous crest with a good thickness. On the left side, a
hygiene. They can affect several teeth in the same arch
Prior to surgical treatment, initial therapy was performed The vertical releasing incision extends beyond the muco-
(complete scaling, teaching of a more appropriate brushing gingival junction. From this point on, it becomes oblique and
technique, prescription of a less traumatic toothbrush and an takes the direction of the recessions to be covered.
antiseptic mouthwash with Chlorhexidine). Once all etiological
factors were controlled, and after ensuring the absence of A partial thickness dissection of the flap was performed
inflammation during the re-evaluation phase, surgical at the level of the keratinized tissues followed by a dissection
treatment could be initiated. in the alveolar mucosa in order to liberate the flap and allow it
to be moved without tension.
Fig 1:Initial situation Initial situation : a) appearance of the The canine was selected as the central recession. The
smile ; b) right hemi-arcade; c) left hemi-arcade. height of the recession was measured for this tooth and then
transferred from the tops of the interdental papillae distal and
B. Surgical protocol: mesial to the canine by adding 1mm.
Lateral sliding flap: After a local para-apical anesthesia
(lidocaine 2% with vasoconstrictor), the edges of the most For the posterior recessions, the same measurements were
mesial recession were prepared with a 15 scalpel blades: made for each tooth but were only transferred distal to the
- An external bevel gingivectomy around the recession, recessions.
extending to the alveolar mucosa, on the side opposite the
donor site was performed to expose the connective tissue. The incision tracing was performed with a 15c scalpel
- An internal bevel incision joining the first incision was made blades and includes the intrasulcular incisions continued at the
on the side of the donor site. level of the papillae by oblique incisions going from the most
The incision pattern was continued at the level of the sloping point of the marginal gingiva of the teeth to the most
interdental papilla with a horizontal incision, an intrasulcular apical point of the previously reported measurement (fig 3).
incision at the level of the first premolar and then a crestal This line will determine the surgical papillae that will
incision. The horizontal and crestal incisions were made at the subsequently cover the anatomical papillae. [3]
After 6 months.
Fig 2: Lateral sliding flap: a) bevel incisions + horizontal interdental incisions + crestal incisions ; b) partial thickness dissection
of the flap; c) sutures; d) healing after 6 months.
For the right hemi-arcade, i.e., the one that benefited from
a lateral sliding flap, healing was satisfactory on the day the
sutures were removed, with 90% partial coverage for the canine
and first premolar. The healing of the donor site was
satisfactory
This coverage remained stable over time during the 1-
Fig 3:Incision pattern: Blue line: Gingival recession depth; month and 6-month follow-up appointments. The patient was
Green line: Depth of Gingival recession reported from the top satisfied with the results.
of the papilla; interrupted orange line: Interdental
submarginal incisions. With regard to the modified coronally advanced flap
associated with a connective tissue graft, healing was
The flap was released using the split-full-split thickness satisfactory at the first follow-up appointment at one week with
technique: The surgical papillae were dissected in partial a partial coverage for all the teeth affected by the flap varying
thickness from the oblique incisions. The marginal gingiva between 50 and 90%. This coverage also remained stable over
apical to the recessions was raised in full thickness until 3mm time during the 1-month and 8-month follow-up appointments,
of the bone surface was exposed apically to the dehiscence. with a progressive harmonization of the graft edges with the
Subsequently, partial-thickness dissection was repeated at the surrounding tissues and a homogenization of the color.
alveolar mucosa apically to the full-thickness portion of the In addition to the coverage, a thickening of the keratinized
flap (Fig4). The exposed root surface was treated tissue could be observed.
mechanically.
As for the right hemi-arcade, the patient was satisfied with
The anatomic papillae were then de-epithelialized and the the results.
flap passively tried in its final position.
IV. DISCUSSION
A free gingival graft was harvested from the palate and
de-epithelialized. It was then sutured with a vicryl 4.0 Several surgical procedures have been described in the
absorbable sutures at the level of the anatomical papillae by literature to correct mucogingival problems and improve the
interrupted "o" sutures. Finally, the flap was sutured with sling aesthetics of the patient's smile.
sutures around the teeth. A paracetamol-based analgesic and an
antiseptic 0.12% chlorexidine mouthwash were prescribed.
The sutures were removed after ten days. The coronally advanced flap is a suitable technique in
cases where there is still gingiva adherent apically to the defect.
Bernimoulin described this technique in 1975 for the treatment
of multiple recessions. He performed a free gingival
augmentation graft followed by a coronally advanced flap after
3 months. Complete coverage was obtained in 43% of sites at
one year follow-up. [4]
Fig 5:Modified coronally advanced flap: a) Intrasulcular + interdental submarginal incisions; b) Split-full-split thikness flap
release ; c) free gingival graft; d) sutures of the deepithelialized graft; e) sutures of the flap; f) healing after 8 months.