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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 79-82

Multiple teeth recession coverage using Zucchelli's technique


Department of Periodontics, Dr. Hedgewar Smruti Rugna Seva Mandal's Dental College and Hospital, Hingoli, Maharashtra, India

Date of Submission08-Feb-2020
Date of Decision17-Mar-2020
Date of Acceptance31-May-2022
Date of Web Publication23-Aug-2022

Correspondence Address:
Dr. Amit Sunil Saragade
Dr. Hedgewar Smruti Rugna Seva Mandal's Dental College and Hospital, Hingoli - 431 513, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_4_20

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   Abstract 

Gingival recession can lead to a variety of functional and esthetic problems. The problems associated with the gingival recession include unacceptable esthetics, hypersensitivity, root caries, and difficult plaque control. Gingival recession is a common clinical condition not only in populations with poor standards of oral hygiene but also in people maintaining good oral hygiene. In an esthetically driven era, the success of root coverage requires consideration of each one of the prognostic criteria. Various procedures have been popularized to treat the gingival recession. Zucchelli's technique is a modification of the coronally advanced flap for the treatment of teeth having multiple recessions. The upper hand of this procedure includes the absence of vertical releasing incisions, an appropriate thickness, combining sites of split and full thickness, and the coronal advancement of the flap. This case report presents the treatment of multiple adjacent gingival recessions using Zucchelli's coronally advanced flap.

Keywords: Coronally advanced flap, gingival recession, root coverage, Zucchelli's technique


How to cite this article:
Saragade AS, Mahajani MJ, Shelke AU, Gaikwad SP. Multiple teeth recession coverage using Zucchelli's technique. J Interdiscip Dentistry 2022;12:79-82

How to cite this URL:
Saragade AS, Mahajani MJ, Shelke AU, Gaikwad SP. Multiple teeth recession coverage using Zucchelli's technique. J Interdiscip Dentistry [serial online] 2022 [cited 2022 Oct 4];12:79-82. Available from: https://www.jidonline.com/text.asp?2022/12/2/79/354450


   Clinical Relevance to Interdisciplinary Dentistry Top


  • Gingival recession is considered a major esthetic problem all over the world
  • Apart from poor esthetics, gingival recession may cause root caries and hypersensitivity
  • Zucchelli's technique is the modification of coronally advanced flap used to cover the gingival recession
  • Root coverage using Zucchelli's technique can solve many problems related to recession such as root caries, poor plaque control, and hypersensitivity of roots
  • The present case report demonstrates a multiple teeth recession coverage using Zucchelli's technique.



   Introduction Top


Gingival recession is often described as an exposure of the root surface caused by the apical displacement of the gingival margin past the cementoenamel junction.[1] Too many dental problems are often getting unnoticed by the patients. However, patients always notice gingival recession and they might seek the treatment from the dentist.[2]

Gingival recession is treated by various root coverage procedures. They are classified as pedicle soft-tissue graft procedures and free soft-tissue graft procedures. Pedicle soft-tissue graft procedures include rotational flap procedures (laterally sliding flap, oblique rotated flap, and double papilla flap); advanced flap procedures (coronally advanced flap and semilunar coronally advanced flap); and regenerative procedures (with barrier membrane or by application of enamel matrix proteins). Free soft-tissue graft procedures include epithelialized graft and subepithelial connective tissue graft.[3]

Coronally advanced flap is always the first choice in patients with the recession defect having a residual amount of keratinized tissue apically. Sufficient root coverage and color matching with adjacent soft tissue are the outcome measures to be considered for successful surgical procedures. Complete recovery with the marginal morphology of presurgical soft tissue is also the criterion for the measurement of successful surgery.[4] Furthermore, less discomfort is experienced during the postoperative period as other treatment areas distant from the tooth with recession site are not involved.[5] In 2000, Zucchelli and de Sanctis modified coronally advanced flap procedure to treat teeth with multiple recession defects. The split–full-split approach was used to elevate the envelope flap. The superficial incision was used to achieve the coronal advancement of the envelope flap. The incision eliminated lip muscle insertion occupying the thickness of the flap.[6]

Zucchelli's coronally advanced flap does not consist of vertical releasing incisions. The flap contains variable thickness with the split–full-split approach. Another feature of Zucchelli's technique is the submarginal oblique incisions in the interdental area connecting the cementoenamel junction of one tooth to the marginal gingiva of the adjacent tooth.[7] In this case report, Zucchelli's coronally advanced flap with envelope technique is used to treat multiple Miller's Class I recession defects in the patient.


   Case Report Top


Case detail

A 50-year-old male patient reported a chief complaint of sensitivity and poor esthetics in the upper left front teeth region of the jaw due to receded gums. After taking the written consent and proper case history, a clinical examination was done. On clinical examination, it was observed that maxillary right canine 13 and maxillary right first premolar 14 had a Miller's Class I recession. Maxillary right canine 13 showed recession with 2-mm depth [Figure 1] and 4-mm width [Figure 2], whereas 14 had a recession of 3-mm depth and 3-mm width. Scaling and root planing was done after the case history. Zucchelli's coronally advanced flap was planned as the root coverage procedure. Surgery was planned immediately after 1 week of scaling and root planing as there were no signs of inflammation in the periodontium. The procedure was explained to the patient, and the signature on the consent form was taken.
Figure 1: Recession depth of 13

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Figure 2: Recession width of 13

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Surgical procedure

Extraoral scrubbing was done with 5% povidone-iodine whereas rinsing with 0.2% chlorhexidine mouthwash was done. Local anesthesia (lignocaine HCL with 2% epinephrine 1:200,000) was given to the patient. After successful local anesthesia, the horizontal incision was given with 15 no. blade and envelope flap was designed. One tooth on each side of the recessed tooth was involved in the incision for easy coronal advancement of the flap to cover the exposed root surfaces. The horizontal incision was given in such a manner that it included oblique submarginal incisions interdentally and intrasulcular incisions over the recession defects [Figure 3]. The oblique submarginal incisions aid in the formation of new interdental papillae. A 15 no. blade was used to dissect the flap in a split–full-split manner [Figure 4]. The flap was raised from the coronal to the apical direction [Figure 5]. Tissue apical to the recession was dissected in a split-thickness manner. Gingiva apical to the recession was raised in a full-thickness manner. This full-thickness approach was used to provide the thick portion of the flap for root coverage. At last, the split-thickness approach was used to elevate the apical most portion of the flap. This split-thickness approach was used for easy coronal displacement of the flap. Root planing was done mechanically using curettes (Hu-Friedy, 2R-2 L, 4R-4 L) [Figure 6]. De-epithelization of the remaining interdental papillae was done to provide a surgical bed for the coronally advanced flap [Figure 7]. The flap was then advanced coronally over the exposed root surfaces. The newly prepared interdental papillae were rotated on the de-epithelized surgical bed. The flap was secured with interrupted sutures (Ethicon 3-0) [Figure 8]. After confirmation of the precise advancement of a flap, periodontal dressing (Coe-Pak) was given to cover the surgical site [Figure 9].
Figure 3: Horizontal incision

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Figure 4: Flap dissection in a split–full-split thickness manner

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Figure 5: Envelope flap elevated

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Figure 6: Root planing

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Figure 7: De-epithelization of the interdental papillae

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Figure 8: Suturing with coronal advancement

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Figure 9: Periodontal dressing application

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Postoperative care

The patient was advised to avoid any injury or traction at the site of surgery. The patient was asked not to consume hard food during the first 5 days and not to brush the teeth in the treated area. Amoxicillin 500 mg and ibuprofen 400 mg were prescribed twice a day for 3 days. Chlorhexidine mouthwash (0.2%) twice daily for 1 min was also prescribed. Periodontal dressing and the sutures were removed after 2 weeks of surgery. Satisfactory healing along with adequate root coverage was obtained. Recall after 1 month revealed very good results with root coverage and color match of the advanced flap [Figure 10]. The root coverage observed was almost 100% in both the teeth after 1 month. Stable results were noticed in both the teeth even after 6 months.
Figure 10: One-month postoperative view

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   Discussion Top


Coronally advanced flap procedure has been a popularized treatment option for root coverage. The concept of this procedure is the coronal advancement of soft tissue to cover receded root surfaces.[8] Initially, periosteal incisions were used in most of the procedures to displace the flap coronally, to overcome muscle traction on the flap.[9] The present modification of coronally modified flap as described by de Sanctis and Zucchelli in 2000 allows coronal displacement through the elimination of muscle insertions. This technique not only eliminates the tension but also provides passive displacement of flap till cementoenamel junction without using sutures as there is an absence of muscle pull. Therefore, this technique achieves stable and better root coverage.[6] A systemic review by Hofmänner et al. stated that in the cases of Miller Class I and II multiple gingival recessions, the complete root coverage obtained with modified coronally advanced flap were maintained over a period of 5 years.[10] In a systemic review and meta-analysis of Graziani et al., modified coronally advanced flap showed a higher level of complete root coverage in the treatment of multiple gingival recessions.[11] Following these two systemic reviews, the present case report showed better root coverage by Zucchelli's technique.


   Conclusion Top


With recent requirements in the root coverage procedures, Zucchelli's coronally advanced flap has received acceptance as a better procedure with less scar formation, better root coverage, and proper color blending with adjacent tissues. The present case report suggested that Zucchelli's coronally advanced flap can show successful results in the treatment of multiple gingival recessions.

Acknowledgment

The authors express their thanks to the research team from the Department of Periodontics for their support during data collection and analysis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Merijohn GK. Management and prevention of gingival recession. Periodontol 2000 2016;71:228-42.  Back to cited text no. 1
    
2.
Mythri S, Arunkumar SM, Hegde S, Rajesh SK, Munaz M, Ashwin D. Etiology and occurrence of gingival recession – An epidemiological study. J Indian Soc Periodontol 2015;19:671-5.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Zucchelli G, Mounssif I. Periodontal plastic surgery. Periodontol 2000 2015;68:333-68.  Back to cited text no. 3
    
4.
Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localized gingival recessions: A systematic review. J Clin Periodontol 2002;29 Suppl 3:178-94.  Back to cited text no. 4
    
5.
de Sanctis M, Zucchelli G. Coronally advanced flap: A modified surgical approach for isolated recession-type defects: Three-year results. J Clin Periodontol 2007;34:262-8.  Back to cited text no. 5
    
6.
Zucchelli G, De Sanctis M. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol 2000;71:1506-14.  Back to cited text no. 6
    
7.
Baldini N, Zucchelli G, Sanctis M. A novel surgical technique for soft tissue management in aesthetic areas of the mouth at implacement – A case report. J Parodontol Implantol 2010;29:1-8.  Back to cited text no. 7
    
8.
Allen EP, Miller PD Jr. Coronal positioning of existing gingiva: Short term results in the treatment of shallow marginal tissue recession. J Periodontol 1989;60:316-9.  Back to cited text no. 8
    
9.
Wennström JL, Zucchelli G. Increased gingival dimensions. A significant factor for successful outcome of root coverage procedures? A 2-year prospective clinical study. J Clin Periodontol 1996;23:770-7.  Back to cited text no. 9
    
10.
Hofmänner P, Alessandri R, Laugisch O, Aroca S, Salvi GE, Stavropoulos A, et al. Predictability of surgical techniques used for coverage of multiple adjacent gingival recessions – A systematic review. Quintessence Int 2012;43:545-54.  Back to cited text no. 10
    
11.
Graziani F, Gennai S, Roldán S, Discepoli N, Buti J, Madianos P, et al. Efficacy of periodontal plastic procedures in the treatment of multiple gingival recessions. J Clin Periodontol 2014;41 Suppl 15:S63-76.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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