| Abstract|| |
Gingival recession is a multifaceted problem, for which several treatment options are available. Both epithelized and subepithelial connective tissue grafts offer predictable solutions for the treatment of gingival recession.The case report involved a 30-year-old man with gingival recession of 8 mm on 41 (Miller's class II recession). Before surgery, full mouth scaling and polishing were performed. Recession height, width, probing depth, clinical attachment level (CAL), and width of the attached gingiva (WAG) were measured at the baseline, two months postoperatively, and six months postoperatively. Four weeks after scaling, the first step of increasing the width of the attached gingiva was carried out, using a free gingival graft. Two months after this step, the subepithelial connective tissue was harvested from the palate and placed in relation to 41, to cover the residual defect.Two months postoperatively, there was a 3 mm gain in WAG and 35% root coverage. Six months postoperatively there was a significant increase in WAG, CAL; and reduction in height and width of recession (root coverage achieved was 75%). These results suggested that this two-stage surgical procedure could be successful for root coverage in case of deep recession and lack of attached gingiva in the mandibular anterior region.
Keywords: Free gingival graft, gingival recession, periodontal aesthetic surgery, subepithelial connective tissue graft, two-stage technique
|How to cite this article:|
Vijayendra R, Suchetha A, Jaganath S, Gurfan K. Two-step procedure for root coverage using a free gingival graft and a subepthelial connective tissue graft. Indian J Dent Res 2011;22:478-81
Gingival recession is defined as the location of the gingival margin apical to the cementoenamel junction.  Increased root sensitivity, cervical abrasion, and cervical caries are usually the clinical sequelae of gingival recession. Also, gingival recession can be unsightly and be of aesthetic concern to the patient, especially when it occurs in the anterior regions of the mouth. ,, The periodontal literature is replete with techniques for the correction of gingival recession. , Various factors need to be taken into consideration before deciding on the technique for root coverage. These include- the extent of the recession (Miller's classification), the width of the attached gingiva at the site, the position of the tooth in the arch, and some patient characteristics like smoking and oral hygiene. , Procedures are being constantly modified or used in combination to achieve successful and predictable root coverage. The aim of this case report is to demonstrate that a two-step surgical procedure using a free gingival graft and a subepithelial connective tissue graft is suitable and successful in areas that have a lack of attached gingiva and deep recession.
|How to cite this URL:|
Vijayendra R, Suchetha A, Jaganath S, Gurfan K. Two-step procedure for root coverage using a free gingival graft and a subepthelial connective tissue graft. Indian J Dent Res [serial online] 2011 [cited 2019 Jul 22];22:478-81. Available from: http://www.ijdr.in/text.asp?2011/22/3/478/87075
| Case Reports|| |
A 30-year-old male reported to the department with a chief complaint of, "a long lower front tooth that was sensitive to cold." The patient was also interested in improving the appearance of his long front tooth. The patient was systemically healthy and exhibited good oral hygiene.
Examination of the area of chief complaint revealed that 41 had 8 mm of recession (Miller's class II) and long, narrow class I interproximal papilla (Nordland and Tarnow's classification  ). A thin and narrow keratinized gingiva was present adjacently; 41 was labially positioned and hypersensitive [Figure 1].
Clinical procedures consisted of phase I therapy followed by a maintenance period and root coverage procedures.
Phase 1 therapy was initiated four weeks prior to the first root coverage procedure. It consisted of scaling and polishing of all teeth and root planing in relation to 41. Oral hygiene instructions were given, to eliminate the faulty brushing technique.
Stage 1 - Use of a free gingival graft
The first step of the surgery used a free gingival graft (FGG). The patient was asked to rinse with 10 ml of 0.2% Chlorhexidine (CHX) for 30 seconds, following which, local anesthesia was administered. The root was planed to reduce its convexity. Root conditioning was achieved by burnishing the root using a cotton pellet saturated with tetracycline solution for about 3 minutes. The recipient site was prepared using the technique described by Miller.  Using a tin foil template, the outline of the graft was obtained. The FGG was harvested using a No. 15 blade and was one-and-a-half times the recession width. The FGG was adapted over the root and stabilized using sling sutures [Figure 2]. A 4.0 vicryl was used. The recipient site was protected using a tin foil and periodontal dressing and the donor site was protected with a Hawley's appliance, which the patient wore for two weeks. Following surgery, the patient was placed on the soft diet. He was instructed to avoid contact or trauma to the grafted site, as well as pulling the lip in any direction. Piroxicam 20 mg twice daily was prescribed for three days, for pain control. The patient was also asked to rinse twice daily with a 0.2% CHX, for two days.
Healing following the stage 1 surgery was uneventful. The patient was recalled once every week for two months. At a two-month postoperative check, there was a significant gain of 3 mm in the width of the attached gingiva [Figure 3].
Stage 2 - Use of a subepithelial connective tissue graft
The second stage of the surgery was performed eight weeks after the first procedure. As before, the patient was advised a pre-procedural rinse and the necessary areas were anesthetized. As in stage 1, the root was planed and conditioned. The recipient site was prepared using the Raetzke's technique, 9 wherein, a partial thickness pouch was created. The subepithelial connective tissue graft (SECTG) was harvested from the opposite side of the palate using the trap door technique described by Edel.  SECTG was then adapted to the tooth surface and sutured using 4.0 vicryl sling sutures [Figure 4]. The donor site was sutured and the recipient site protected using a tin foil and periodontal dressing. The postoperative instructions were similar to those given during stage I surgery.
Healing was uneventful. The patient was recalled once a month for the next six months.
| Results|| |
[Table 1] shows clinical parameters at baseline, two months and six months post-operatively.
There was a decrease in the recession height from 8 mm to 2 mm and a decrease in recession width from 4 mm to 2 mm at six months post-operatively. The site was not probed at the end of two months. Probing depth six months post-operatively was 2 mm, and a gain of 6 mm in CAL was achieved. The width of the attached gingiva inrelation to 41 showed a significant increase from 0 mm to 6 mm.
The root coverage following the first stage was achieved by using an FGG - 35%. The root coverage following the second stage was obtained using an SECTG - 75% [Figure 5].
| Discussion|| |
Root coverage in the mandibular incisor region is a challenge in periodontal plastic surgery for several reasons. There is often a high frenal attachment, shallow vestibule and thin or nonexistent quantities of keratinized gingiva. This poses problems during root coverage procedures due to compromised blood supply as well as excess flap tension which hinder graft stabilization. 
Various techniques either singly or in combination have been proposed for the management of marginal tissue recession. These techniques offer different rates of success and predictability. The reported success rate of rotational flaps is 41 - 74%, coronally advanced flap is 70 - 99%, guided tissue regeneration is 54 - 68%, connective tissue grafts is 52 - 98%, and that of FGG is 11 - 87%. The predictability of these procedures is varied; coronally advanced flap 24 - 95%, guided tissue regeneration 0 - 42%, connective tissue grafts 27 - 89%, and FGG 0 - 90%. 4 Thus, it can be inferred that FGG and SECTG offer high predictability and success.
- The different treatment options for this case were:
- A free gingival graft.
- Coronally advanced flap.
- A two-step procedure, consisting of a free gingival graft followed by a coronally advanced flap two months later.
- Guided tissue regeneration utilizing a barrier membrane in combination with a coronally advanced flap.
- Acellular dermal matrix graft.
- Subepithelial connective tissue graft.
A free gingival graft has been used for increasing the width of the keratinized and attached gingiva, but complete root coverage is not achieved and this is often a limitation of this procedure.  FGG alone was opted for because of the large size of the defect. The idea of CAF alone or with FGG was rejected because of lack in the width of the attached gingiva. Using a GTR membrane would have placed the flap under tension, predisposing the site to recession once again.  Excess flap tension would have to be placed in order to fully cover the membrane, and the risk of membrane exposure could risk an unsuccessful result, which could possibly be worse than the initial presentation. The success with an acellular dermal matrix was unpredictable and also this allograft was expensive.  As a result, it was not used in this case.  SECTG alone would not have helped in gaining sufficient width of the attached gingiva and thus the option was discarded.
Therefore, in this case we decided to use a free gingival graft to increase the width of the attached gingiva, followed by a connective tissue graft, to obtain an increase in the width of the attached gingiva and for root coverage. The use of an FGG for increasing the width of the attached gingiva had shown predictable results in the past. Also, the additional use of SETCG offered advantages like excellent color matching and high predictability. ,
In the present case, the tooth presenting with marginal tissue recession was also lacking in the attached gingiva. Thus, a combination of the two highly predictable techniques was adopted. The first stage involved increasing the width of the attached gingiva by the use of an FGG from the palate. The second stage was performed two months following the first; an SECTG was obtained from the palate and used to cover the residual defect. At the end of six months following the first procedure, root coverage of 75% was achieved with a reduction in recession height from 8 mm to 2 mm. There was a minimal probing depth of 2 mm at the treated site with no evidence of hidden recession. These results suggested that the two-stage procedure described, may be of value in treating recessions in the mandibular anterior region.
There is very limited literature available on the use of FGG and SECTG in a two-stage procedure. Various case series and case reports have been published regarding the use of FGG alone, FGG and a coronally advanced flap or the use of SECTG alone, but a technique as described in this case report is rare. Also, this combination technique addresses the three main criteria for root coverage as described by Gray - inadequate gingival width, impaired aesthetics, and root hypersensitivity,  and it helps in the correction of all the three. This calls for more case reports and case series, to establish the predictability of the two-stage procedure.
| Conclusion|| |
The results obtained in this case suggest that this two-stage surgical procedure is highly predictable for root coverage in the case of deep recession and lack of attached gingiva in the mandibular anterior region. The procedure holds promise for the successful management of complex marginal tissue recessions, although further studies are warranted.
| References|| |
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|3.||Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13. |
|4.||Camargo PM, Melnick PR, Kenney EB. The use of free gingival grafts for aesthetic purposes. Periodontol 2000 2001;27:72-96. |
|5.||Bouchard P, Malet J, Borghetti A. Decision-making in aesthetics: Root coverage revisited. Periodontol 2000 2001;27:97-120. |
|6.||Gray JL. Commentary -when not to perform root coverage procedures. J Periodontol 2000;71:1048-50. |
|7.||Nordland WP, Tarnow DP. A classification system for loss of papillary height. J Periodontol 1998;69:1124-6. |
|8.||Miller PD Jr. Root coverage using the free soft tissue autograft following citric acid application. III. A successful and predictable procedure in areas of deep-wide recession. Int J Periodontics Restorative Dent 1985;5:15-37. |
|9.||Sedon CL, Breault LG, Covington LL, Bishop BG. The Subepithelial Connective Tissue Graft: Part I. Patient Selection and Surgical Techniques. J Contemp Dent Pract 2005;6:146-62. |
|10.||Popova C, Boyarova T. Two-step surgical procedure for root coverage (free gingival graft and coronally positioned flap). Int Med Assoc Bulgaria 2007;2:21-4. |
Department of Periodontics, D A Pandu Memorial R V Dental College, Bangalore
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]