|Year : 2013 | Volume
| Issue : 3 | Page : 174-177
A case of successful management of class III gingival recession using subepithelial connective tissue graft
Wahengbam Brucelee1, Saini Ashish2, Wahengbam Pragya3, Somorendro Singh4
1 Department of Conservative and Endodontics, Babu Banarasi Das, College of Dental Sciences, Uttar Pradesh, India
2 Department of Periodontics, Babu Banarasi Das, College of Dental Sciences, Uttar Pradesh, India
3 Department of Conservative and Endodontics, Faculty of Dental Sciences, King George's Medical University, Lucknow, Uttar Pradesh, India
4 J N Medical College, Imphal, Manipur, India
|Date of Web Publication||21-Apr-2014|
Department of Conservative and Endodontics, Babu Banarasi Das, College of Dental Sciences, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Marginal tissue recession presents a common condition in Periodontology. Recession defects around teeth are usually treated to achieve patient-centered outcomes such as reduction in root sensitivity, ease in plaque control, and aesthetic concerns regarding excessive tooth length and abnormal gingival contour. It is believed that cases of recession in which the etiological factors are well diagnosed and eliminated show a great percentage of recession coverage. According to Miller, Class I and II show complete recession coverage whereas cases with class III are only capable of partial coverage. A variety of surgical procedures have been described for recession coverage. The present case report presents a clinical case classified as Miller's class III recession which was treated using coronally advanced partial thickness flap with subepithelial connective tissue graft to obtain root coverage and also eliminate the aesthetic deficiency.
Clinical Relevance To Interdisciplinary Dentistry
- Thorough knowledge of anatomy of donor and recipient site is important for success of coronally advanced partial thickness flap with subepithelial connective tissue graft.
- Proper case selection and elimination of etiologic factors is key to successful management of gingival recession.
- Subepithelial connective tissue graft if used.
Keywords: Coronally advanced partial thickness flap, miller′s class III gingival recession, subepithelial connective tissue graft
|How to cite this article:|
Brucelee W, Ashish S, Pragya W, Singh S. A case of successful management of class III gingival recession using subepithelial connective tissue graft. J Interdiscip Dentistry 2013;3:174-7
|How to cite this URL:|
Brucelee W, Ashish S, Pragya W, Singh S. A case of successful management of class III gingival recession using subepithelial connective tissue graft. J Interdiscip Dentistry [serial online] 2013 [cited 2022 Jul 3];3:174-7. Available from: https://www.jidonline.com/text.asp?2013/3/3/174/131217
| Introduction|| |
Marginal tissue recession is a common feature amongst population with high standards of oral hygiene as well as amongst population with poor oral hygiene.  Recession is frequently associated with aesthetic concerns, fear of tooth loss, and root hypersensitivity.
Several etiological factors that may account for it are: traumatic tooth brushing, malpositioned tooth, periodontal disease, frenum and bridle insertions, occlusal trauma, restoration with subgingival overhangs, maladapted crowns, extractions of adjacent teeth, orthodontic movement, iatrogenic factors, and bone dehiscence. 
Langer and Langer (1985)  first described subepithelial connective tissue graft (SCTG) for root coverage and outlined the indications and protocols necessary for achieving success. Later on, it has also been described with variations in surgical techniques by many other eminent clinicians. ,,,
Miller  classified gingival tissue recession into four types. The prognosis for class I and II is good to excellent whereas for class III only partial coverage can be expected and the prognosis is poor.  Class IV has a very poor prognosis.
This case report presents a clinically successful treatment of Miller's class III gingival recession using SCTG with coronally advanced partial thickness flap.
| Case Report|| |
A 55-year-old female patient visited my office with the complaint of receding gum in relation to tooth # 41. She was a non-smoker with no abusive oral habits and her systemic health history was non-contributory. Her oral hygiene was poor and had localized chronic severe periodontitis. The concerned tooth had mobility slightly greater than Grade I and recession of 7 mm on labial surface. Recession was well beyond mucogingival junction (MGJ) with associated interdental hard and soft tissue loss. Slight malpositioning of anterior teeth was also evident [Figure 1]a. Therefore, it was Miller's class III gingival recession. This recession has been evident to her since past 5 years and had a history of two failed surgical attempts, but no written records were available to comprehend the nature of previous attempts.
As a preliminary routine, thorough scaling and root planing was done and the tooth was splinted to the adjacent teeth using composite resin [Figure 1]b. The incisal guidance was so adjusted that no lateral deleterious forces is exerted. After completion of Phase I therapy, the patient was recalled regularly for maintenance therapy for a period of 2 months.
On the elected day, following routine presurgical protocols and after establishing profound local anesthesia, a partial thickness flap was raised on the facial aspect of teeth # 31, 41, and 42 using blade # 15 by sharp dissection, keeping the blade close to the periosteum. The flap extended beyond the MGJ so that it exhibits no tension when pulled coronally beyond the cementoenamel junction (CEJ) [Figure 1]c. Further de-epithelialization of the papillae to its highest extent was accomplished using ophthalmic keratome knife and small scissors. The exposed root prominence was reduced to flush within the bone envelope using fine finishing burs and it was further planed smooth to remove any remaining necrotic cementum, toxins, and other irregularities. But no chemical root modifiers were used. Contrangle sickle was used to remove any remaining epithelium or granulation tissue and to induce bleeding.
Right palatal vault was the donor site. After establishing profound local anesthesia, a horizontal incision was placed 5 to 6 mm from the gingival margin in such a way that blade # 15 undermines a partial thickness flap; thin enough that sufficient connective tissue (1.5-2 mm) could be harvested below it and thick enough that the blade is not/barely visible through the epithelium over it. The incision extended forward from the first molar to the first premolar region horizontally and carried to the depth slightly short of the junction of the horizontal and vertical walls of the palate. The second incision was carried out parallel to the previous incision but at a distance of 3 mm from the gingival margin keeping the blade very close to the periosteum. It was also carried apically to the same depth as the first incision. The graft was then harvested after scoring at the mesial, distal, and apical ends in the envelope fashion, and stored in cold saline moistened gauze [Figure 1]d. The donor site was sutured [Figure 2]a and bleeding stopped within few minutes. Acrylic stent was not delivered as she opted it out.
|Figure 1: (a) Preoperative Photograph showing Miller's Class III gingival recession. (b) Photograph after scaling root planing and splinting. (c) After flap reflection beyond the mucogingival junction. (d) Graft stored in cold saline moistened gauze|
Click here to view
The connective tissue graft was then trimmed according to the template foil to approximate the recipient site. The graft was positioned and stabilized slightly above the level of CEJ by interrupted sutures laterally and by sling sutures about the necks of the teeth using 5-0 chromic gut. The lateral interrupted suture helps to stretch the graft and counteract the primary contraction as well. Intimate graft to root/periosteal bed contact was further established by suturing the graft to the periosteum and by interdental concavity sutures [Figure 2]b.
|Figure 2: (a) donor site sutured. (b) graft sutured to periosteum and by interdental concavity sutures (c) stabilised graft connective tissue covered with coronally advanced flap held by lateral interrupted and sling sutures using 4-0 silk. (d) After suture removal at two weeks|
Click here to view
The stabilized graft connective tissue was then covered with coronally advanced flap held by lateral interrupted and sling sutures using 4-0 silk [Figure 2]c. Barricaid surgical dressing (caulk, Dentsply) was packed for one week following manufacturer's instructions. The patient was then discharged after giving routine postoperative instructions and medications.
Healing was uneventful; the patient was recalled at weekly intervals after surgery. Sutures were removed after two weeks [Figure 2]d. On the sixth week, gingivoplasty and vestibuloplasty/vestibulodeepening was done to characterize the gingival architecture and deepen the vestibule [Figure 3]a which was obliterated due to coronal advancement during the first surgery. By deepening the vestibule, the frenular attachments and its pull were minimized to prevent recurrence. Improved esthetics was achieved along with stable and 5 mm of root coverage at the end of one year. There was also increase in the zone of keratinized gingival [Figure 3]b. She was advised for guided bone regeneration (GBR) procedure to correct the apico-marginal bone dehiscence at the earliest. Patient was pleased with the outcome of treatment and was not wiling for any further surgery.
|Figure 3: (a) On sixth week After gingivoplasty and vestibuloplasty on sixth week. (b) Followup photograph after one year of surgery|
Click here to view
| Discussion|| |
Several mucogingival techniques have been introduced in the literature to achieve root coverage. Coronally positioned flap, laterally positioned flap, semilunar flap, free gingival graft, SCTG, subpedicle connective tissue graft, transpositional flap, connective tissue pedicle graft, guided tissue regeneration, and regenerative tissue matrix like Alloderm are some of the conventional and contemporary examples. 
Of all these techniques, SCTG is the single most effective way to achieve predictable root coverage with a high degree of cosmetic enhancement  and it has been the foundation on which modern periodontal plastic surgery was built. Additionally, this technique is relatively less invasive at the palatal/donor area. The predictable successful outcome of the SCTG technique is attributed to its bilaminar flap design that provides double source of plasmatic diffusion and vascularization to the graft.  Its high aesthetic outcome is also attributed to the secondary intention healing of the connective tissue graft. 
It is indicated not only for the treatment of single or multiple gingival recessions but also for papilla volume correction, ridge augmentation, creation and/or increasing the amount of the keratinized mucosa.  Furthermore, it is also employed for improved recession coverage associated with restorative procedures pertaining to cervical abrasion and caries, and these days very much in implant dentistry. 
Apart from technique sensitivity and complicated suturing, SCTG has certain other disadvantages also. Need of greater size of graft tissue to compensate tissue contraction and difficulty of graft thickness standardization are few of them.  It is relatively contraindicated in broad, shallow palate where greater palatine artery could be jeopardized.
According to Polson et al.,  the aforementioned technique presents less predictability of root coverage in such recessions due to difficulty in graft adaptation and nutrition. In our case, we were able to achieve approximately 80% coverage with absence of bleeding on probing and presence of an adequate amount of attached gingiva. We didn't use acrylic stent and root conditioner as clinical evidences and literature says its use to be optional (reference) but GBR would be required for such case of dehiscence to ensure long-term stability.
Some primary reasons of previous failures with this case and in general could be due to: (1) incorrect choice of technique or inadequate skill, (2) insufficient recipient bed preparation or size, (3) insufficient graft size/thickness or excessive thickness, (4) Poor root preparation and non-reduction of root prominence, (5) Inability to control mobility and elimination of deleterious lateral forces, (6) Flap perforation, (7) Inadequate suturing and stabilization of the graft and the flap, (8) Patient's negligence in postoperative home care, (9) Shallow vestibule and strong frenum pull.
The choice of technique and the long-term success of the procedure depend on the careful evaluation of the defect type, recession's etiology, operator's ability, presence of keratinized tissue, tissue width, predictability, single or multiple gingival recessions, healing, aesthetic result, and risk factors. 
| Conclusion|| |
The present case report demonstrates successful management of miller's class III gingival recession using coronally advanced partial thickness flap with SCTG. 80% root coverage was achieved. Although patient was advised GBR, she was pleased with the outcome of treatment and was not wiling for any further surgery.
| References|| |
|1.||Ustun K, Sari Z, Orucoglu H, Duran I, Hakki SS. Severe gingival recession caused by traumatic occlusion and mucogingival stress: A case report. Eur J Dent 2008;2:127-33. |
|2.||Juliana A. Subepithelial connective tissue graft: A case report. Rev Sul-bras Odontol 2011;8:357-62. |
|3.||Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20. |
|4.||Bouchard P, Etienne D, Ouhayoun JP, Nilvéus R. Subepithelial connective tissue graft in treatment of gingival recessions. A comparative study of 2 procedures. J Periodontal 1994;65:929-36. |
|5.||Holithius AF. The subepithelial connective tissue graft for root coverage in periodontal therapy- Rationale and Technique. J Can Dent Assoc 1994;60:885-90. |
|6.||Bruno JF. A subepithelial connective tissue graft procedure for optimal root coverage. Atlas Oral Maxillofac Surg Clin North Am 1999;7:11-28. |
|7.||Nelson SW. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987;58:95-102. |
|8.||Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13. |
|9.||Batista EL Jr, Batista FC, Novaes AB Jr. Management of soft tissue ridge deformities with acellular dermal matrix. Clinical approach and outcome after 6 months of treatment. J Periodontol 2001;72:265-73. |
|10.||Oates TW, Robinson M, Gunsolley JC. Surgical therapies for the treatment of gingival recession. A systematic review. Ann Periodontol 2003;8:303-20. |
|11.||Harris RJ. The connective tissue and partial thickness double pedicle graft: A predictable method of obtaining root coverage. J Periodontol 1992;63:477-86. |
|12.||Bernimoulin JP, Lüscher B, Mühlemann HR. Coronally repositioned periodontal flap. Clinical evaluation after one year. J Clin Periodontal 1975;2:1-13. |
|13.||Chung S, Rungcharassaeng K, Kan JY, Roe P, Lozada JL. JOral immediate single tooth replacement with subepithelial connective tissue graft using platform switching implants: A case series. J Oral Implantol 2011;37:559-69. |
|14.||Polson AM. Periodontal regeneration: Current status and direction. Hong Kong: Quintessence Books; 1994. p. 53-70. |
[Figure 1], [Figure 2], [Figure 3]