|Year : 2008 | Volume
| Issue : 3 | Page : 247-252
|Free gingival graft in the treatment of class III gingival recession
V Remya, K Kishore Kumar, Sabitha Sudharsan, KV Arun
Department of Periodontics, Ragas Dental College and Hospital, Chennai - 600 119, Tamil Nadu, India
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|Date of Submission||13-Dec-2006|
|Date of Decision||24-Feb-2008|
|Date of Acceptance||10-Mar-2008|
| Abstract|| |
Aim: The purpose of this study was to assess the success and predictability of root coverage and esthetics obtained with free gingival grafts (FGGs) in the treatment of early class III gingival recessions for a period of 12 months.
Materials and Methods: Ten patients contributed to 12 sites, each with early class III recession with interdental bone loss £4 mm from cemento enamel junction(CEJ). Clinical parameters recorded at baseline and at 1, 6, and 12 months were probing depth (PD), recession depth (RD), recession width (RW), and clinical attachment level (CAL).
Results: Reduction of recession resulted in a significant gain in CAL and PD at the end of 12 months. A statistically significant mean root coverage of 41.25 ± 21.07% was obtained at the end of 12 months. A statistically significant improvement in Visual Analog Scale score was seen after a 12-month follow-up period.
Conclusion: In a south Indian population, early class III gingival recessions treated with FGG procedures resulted in 40-50% root coverage with fairly acceptable esthetics.
Keywords: Esthetics, free gingival graft, gingival recession, melanin, root coverage
|How to cite this article:|
Remya V, Kishore Kumar K, Sudharsan S, Arun K V. Free gingival graft in the treatment of class III gingival recession. Indian J Dent Res 2008;19:247-52
Gingival recession is the apical shift of the gingival margin leading to exposed root surfaces, resulting in an unaesthetic appearance. The exposed root surfaces may further lead to hypersensitivity and increase the predilection for developing root caries. Therapeutic modalities are aimed at correction of both the esthetic and functional components of gingival recession.  A variety of techniques such as pedicle grafts,  free gingival autografts,  connective tissue grafts,  Guided tissue regeneration,  etc. have been used for the treatment of gingival recession.
|How to cite this URL:|
Remya V, Kishore Kumar K, Sudharsan S, Arun K V. Free gingival graft in the treatment of class III gingival recession. Indian J Dent Res [serial online] 2008 [cited 2019 May 21];19:247-52. Available from: http://www.ijdr.in/text.asp?2008/19/3/247/42959
Although Miller et al.,  proposed that FGG is a predictable method of root coverage, the obvious disadvantage of poor color match and donor site morbidity render it unsuitable for use as a root coverage procedure. However, even with the advent of subepithelial connective tissue graft and allogenous grafts like Alloderm, FGG continues to be the most predictable method to increase the apico-coronal dimension of the keratinized mucosa.  The controversy in the literature regarding the necessity of a band of attached gingiva for maintenance of optimal periodontal health remains unresolved. While Lang and Löe  suggested that 2 mm of gingiva is an essential prerequisite for periodontal health, Miyasato et al .,  demonstrated that, with proper oral hygiene and absence of bacterial plaque, clinically healthy gingiva can exist in areas with minimal or no attached gingiva.
Anatomical factors such as aberrant frena, muscle attachment,  and gingival phenotype  are also thought to contribute to the etiology of gingival recession. Racial variation in the gingival phenotype has been demonstrated with the south Indian population exhibiting the thinner phenotype.  Muller and Eger  proposed that individuals with thin phenotype are more prone to develop gingival recession and gingival bleeding. Poor oral hygiene is a well-recognized risk factor for periodontal diseases. Lack of awareness and socioeconomic factors are thought to contribute to oral hygiene practices or the lack of it that persists in the ethnic south Indians that comprises our study population.
As a consequence, the prevalence of periodontal diseases in this population is high, with the attachment loss scores significantly higher than the probing pocket depth (PD).  Hence, number of patients seeking treatment for class III recession resulting from a combination of thin gingival phenotype and poor oral hygiene, is not inconsiderable. The predominant goal of therapy in this patient group is functional restoration of the periodontal attachment apparatus rather than esthetics.
Further, the gingiva of this patient population is characterized by heavy melanin pigmentation - racial differences in pigmentation has been previously documented.  This pigmentation often extends into the hard palate and we hypothesized that FGGs may yield superior esthetic results in this population when compared to Caucasian population.
Most reports on root coverage have focused on the treatment of class I and II recession.  While there is a general agreement on the lack of predictability of the success and the inability to obtain 100% coverage in class III recessions, very few reports have focused on the predictability and factors governing the degree of coverage expected in these situations.
This study was instituted to assess the stability of the results and color match obtained in a south Indian population with class III recession treated with FGGs.
| Materials and Methods|| |
The study group consisted of 10 patients aged 20-40 years who were referred to the Department of Periodontics. A total of 12 sites were selected - 6 male and 4 female patients each with class III recession on a vital tooth without any restoration on the denuded root surfaces. Class III recessions exhibiting an interdental bone loss ≤4 mm, measured from CEJ as a reference point were included in this study, as those exceeding this were deemed unfit for root coverage procedures.
The patients agreed to the study protocol and informed consent was obtained prior to treatment. The selection criteria were: (1) Presence of Miller class III gingival recession with interdental bone loss ≤4 mm, (2) Absence of severe cervical abrasion/root caries that would require restoration, (3) Absence of abnormal frenal attachment, (4) Nonsmokers, (5) Noncompromised systemic health and no contraindications for periodontal surgery.
Initial therapy comprised of scaling and root planning and oral hygiene instructions were reinforced till the patients included in this study achieved a full mouth plaque score ≤25%. Prior to surgery, all selected sites presented a healthy periodontium with the gingiva exhibiting no evidence of bleeding on probing [Figure 1] and [Figure 5]. The following measurements were taken at the mid-buccal aspect of each tooth at baseline, 1 month, 6 months, and 12 months post-surgery.
- Probing pocket depth (PD) was measured with a standard periodontal probe to the nearest millimeter from the gingival margin to the bottom of sulcus.
- Clinical attachment level (CAL) was measured from CEJ to the bottom of the sulcus.
- Recession depth (RD) measured from CEJ to gingival margin.
- Recession width (RW) measured across the buccal surface at the CEJ level
A visual analog scale (VAS) was used to analyze the color match of the grafts. To determine the color match, the examiner fixed a "0-10 scale" criteria, in that "0" score was no color match and "10" score was absolute color match. A score <5 was considered to be unsatisfactory. The scoring was done at the end of 1, 6, and 12 months in all the patients.
The recipient site was prepared by horizontal papillary incisions made at right angles to the papilla at the level of CEJ. Two vertical incisions were made from the cut gingival margin to the alveolar mucosa. A split thickness flap was separated without disturbing the periosteum at the recipient site [Figure 2]. An aluminum foil template of the recipient site was made and placed over the donor site in the palate. The harvested FGG from the palate was then placed at the recipient site and sutured at the lateral borders and to the underlying periosteum [Figure 3]. The graft was firmly held in place using digital pressure for 5 min and Coe-pak was placed at the donor site and over the graft.
The patient was advised not to brush the treated site for 4 weeks. They were prescribed 0.12% chlorhexidine rinse twice a day for 4 weeks. Analgesics were administered as needed. All the patients were examined weekly for the first month and then once a month for the next 3 months. They were seen at 3 months intervals for oral hygiene instructions and supra gingival scaling until the end of the study period.
Descriptive statistics were computed for measurement of each clinical parameter at baseline, 1, 6, and 12 months. The significance of changes in clinical parameters during the follow-up period was tested by repeated measures. P < 0.05 was considered as statistically significant.
Individual mean values for VAS scores were calculated in each site and used for calculation of overall mean values and standard deviation for the various time intervals. Statistical analysis with respect to alteration in VAS scores during baseline, 1, 6, and 12 months postoperative were performed using the repeated measures.
| Results|| |
All sites healed uneventfully, without complications except for mild inflammation associated with the treated sites.
The results of the root coverage obtained in all the patients were summarized in [Table 1].
Changes in clinical parameters
Overall findings at 1, 6, and 12 months postsurgery showed that favorable results were obtained using FGGs in the treatment of class III gingival recession.
Mean and standard deviation of baseline, 1, 6, and 12 months postoperative parameters (n = 12 sites) [Table 2].
At base line, a mean RD of 4.0 ± 1.4 mm, probing depth (PD) of 1.75 ± 0.45 mm, CAL of 5.75 ± 1.42 mm and RW of 3 ± 0.43 mm were recorded.
At the end of 1 month, the mean RD was reduced from 4 ± 1.4 mm to 2.83 ± 0.94 mm, the probing pocket depth from 1.75 ± 0.45 mm to 1.58 ± 0.51 mm, RW from 3 ± 0.43 mm to 2.75 ± 0.45 mm and CAL from 5.75 ± 1.42 mm to 4.42 ± 1.08 mm.
At the end of 6 months, the mean RD was reduced from 2.83 ± 0.94 mm to 2.58 ± 1.24 mm, probing pocket depth from 1.58 ± 0.51 mm to 1.33 ± 0.49 mm and CAL from 4.42 ± 1.08 mm to 3.92 ± 1.31 mm. RW was same as that of 1 month.
At the end of 12 months, the mean RD was reduced from 2.58 ± 1.24 mm to 2.3 ± 1.15 mm, probing pocket depth from 1.33 ± 0.49 mm to 1.08 ± 0.29 mm, and CAL from 3.92 ± 1.31 mm to 3.42 ± 1.16 mm. RW at 6 and 12 months was same as that of 1 month. There was no statistically significant reduction in RW between 1 and 12 months. Statistically significant reduction in RD (P < 0.01) and clinical attachment gain (P < 0.01) was attained at 1, 6, and 12 months [Table 2].
The mean root coverage was 25.08 ± 19.43% at 1 month, 36.25 ± 19.85% at 6 months, and 41.25 ± 21.07% at 12 months. Statistically significant gain (P < 0.01) in root coverage obtained during the follow-up period [Table 3].
Root coverage related positively with RD [r = 0.59 (P = 0.045)] and negatively with RW [r = 0.32 (P = 0.31)].
The VAS score for the first month indicated unsatisfactory esthetic result while the sixth month scores a more favorable esthetic result (P < 0.01). At the end of 12 months, the esthetic results, while not excellent, was certainly acceptable [Table 4] and [Table 5].
| Discussion|| |
Predictability of root coverage procedures is dependent on several factors such as anatomical factors, surgical skill of the operator, and postoperative maintenance of the patients. Complete root coverage has been reported in class I and II gingival recessions with connective tissue grafts and is usually considered the gold standard. 
Several factors are associated with successful or incomplete root coverage when using the FGG technique.  Adequate blood supply from the tissues adjacent to the graft bed, the level of the interproximal gingival tissue, the characteristics of the incision are important for the survival of the grafted tissue over the avascular root surface. The lack of good adaptation between graft and the recipient site, and the loss of interdental bone, that is characteristic of class III recessions, resist any attempts at complete root coverage. 
Wide interdental papilla provides the grafted tissue with more abundant blood supply as compared to narrow ones. Further, the height of the interdental papilla is an important prognostic factor in determining the amount of root coverage that can be obtained.  The relative inadequacy of interdental papilla seen in class III recession contributes to the lack of complete root coverage.
Previous studies have reported a coverage of 40-70% using FGG in class I and II recessions.  There is a paucity of literature regarding the root coverage obtained in class III recession as a result of which there is insufficient evidence to characterize the factors that affects the degree of predictability of success obtained with this procedure. While the loss of the crest of alveolar bone and interdental papilla precludes the possibility of 100% root coverage, treatment results of deep and wide class III recession are unlikely to be similar to that of shallow and narrow class III recession.
In the present study, we included only those class III recession with interdental bone loss ≤4 mm empirically as there is very little evidence in literature to indicate the level of bone loss beyond which no root coverage can be expected. The high prevalence of class III recession in our patient population, however, demands institution of therapy for want of which, their periodontal health would be severely compromised.
The goal of therapy in such situations is functional to a large extent rather than cosmetic. Free gingival auto grafts were used in this study in preference to connective tissue grafts for the following reasons. 
- It is more successful in increasing apico coronal width of keratinized mucosa.
- The establishment of a band of keratinized mucosa even if narrow as may be expected even with partial coverage, may prolong the longevity of the tooth.
- A shallow palatal vault such as that observed in thin phenotype population may not be ideal for precuring a connective tissue graft.
A relatively few number of studies have been published with long-term follow-up for class III recessions.  Borghetti and Gardella  reported 87% root coverage in class III gingival recession. Although the results obtained in our study does not compare favorably with this study, the results of this study suggest that the root coverage obtained was stable for a period of 12 months. The greater loss of hard and soft tissues exhibited by our patient population could have contributed to the relatively lesser degree of success obtained. The improvement in the periodontal health of these patients is clearly demonstrated by the significantly better gingival status and CAL after 12 months. While the absence of gingival inflammation could be attributed to the improvement of oral hygiene practices, the establishment of a band of keratinized mucosa, may also be a contributing factor to both the absence of inflammation and improvement in oral hygiene practices.
The influence of the preoperative RW vs depth on the final outcome therapy has been previously documented.  In agreement with the previous studies, our results suggested that the RW negatively correlates with the root coverage obtained, while the RD positively influences the attached gingiva obtained, provided there are no other confounding factors.
The results of the VAS are somewhat surprising as the fairly satisfactory esthetics obtained in this study is in contradiction to previously published reports [Figure 4] and [Figure 6]. Most of these studies have been conducted in Caucasian population, where the degree of melanin pigmentation is low. The almost 70% color match indicated by the VAS score of our patient population few exceeds the esthetic expectation normally associated with FGGs, could be a result of the high melanin pigmentation of the palatal donor tissue. Previous reports indicate that the grafted tissue might retain a few characteristics of the donor site.  After the initial pallor demonstrated by the grafted tissue, the melanization reappeared after a period of 6 months, as a result of which the color match with the adjacent tissue was sufficiently good enough to warrant a high VAS score. It is also possible that the patient population in our study do not have as exacting standards of esthetics as may be expected in Caucasian populations.
The results of this study indicate that while the complete root coverage was not possible, nearly 50% of the denuded root surfaces could be covered with FGGs in class III recession, contributing to an over all improvement in the periodontal health.
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Department of Periodontics, Ragas Dental College and Hospital, Chennai - 600 119, Tamil Nadu
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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