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CASE REPORT Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 3  |  Page : 126-30
Root coverage with free gingival autografts--a clinical study.


Department of Periodontics, Meenakshi Animal Dental College and Hospital, Maduravoyal, Chennai, India

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   Abstract 

AIM: To assess the percentage of root coverage with autogenous free gingival grafts. MATERIALS & METHODS: Ten non-smoking patients with Miller's class I or class II recessions were included in the study. The clinical parameters such as recession depth, recession width, probing pocket depth, clinical attachment level and width of the keratinized gingiva were recorded at the baseline, at the end of 1 month, 3 months, and 6 months after the surgical procedure. Autogenous free gingival grafts harvested from the palatal mucosa were used to cover the denuded roots. RESULTS: Four out of ten sites showed 100% root coverage. A mean percentage of 80.3% of root coverage was achieved.

Keywords: Gingival autografts, autogenous free gingival grafts, soft tissue grafts, root coverage, gingival recession, periodontal plastic surgery, esthetic surgery

How to cite this article:
Deepalakshmi D, Arunmozhi U. Root coverage with free gingival autografts--a clinical study. Indian J Dent Res 2006;17:126

How to cite this URL:
Deepalakshmi D, Arunmozhi U. Root coverage with free gingival autografts--a clinical study. Indian J Dent Res [serial online] 2006 [cited 2020 Oct 22];17:126. Available from: https://www.ijdr.in/text.asp?2006/17/3/126/29876

   Introduction Top


Successful coverage of exposed roots for esthetics as well as functional reasons has been the objective of various mucogingival problems. This has been achieved by pedicle grafts and free grafts like autogenous free gingival grafts and subepithelial connective tissue grafts.

When adequate gingiva exists, repositioning it over the denuded root surface provides the most esthetic result. However, adequate gingiva does not always exist in adjacent locations. For this reason, grafting of gingiva from a remote location is often required to augment the area Traditionally, this augmentation of the gingival complex at the time of root coverage has been performed with autogenous free gingival grafts or connective tissue grafts harvested from the palate. Considering, the invasiveness of the subepithelial connective tissue graft technique, root coverage was done with autogenous free gingival grafts in this study.

First described by Bjom (1963)[1] free gingival grafts have been widely used in the treatment of certain mucogingival problems like lack of attached gingiva and gingival recession. By using this technique, attached gingiva can be increased in a very predictable way. Furthermore, the results obtained using this procedure have been reported to be stable [2]. Although gingival grafting is a procedure with few clinical complications, excessive hemorrhage of the donor area, failure in the graft union, delay in healing and esthetic alterations due to disparity in the colour of the palatal gingiva with respect to the grafted area, have been described [3]. In addition, a few reports of exostoses developing after the placement of a free gingival graft have also been published [4],[5],[6],[7].

This study was aimed to assess the root coverage obtained with autogenous free gingival grafts.


   Materials and methods Top


Ten non-smoking patients (5 males and 5 females) were selected for the study. The selected patients had Miller's class I or class It recession.

The inclusion criteria were

1. Patients within the age group of 25 - 40 years. 2. Recession depth more than or equal to 2mm. 3. Normal teeth alignment.

4. No interdental bone loss. 5. Good oral hygiene.

The exclusion criteria were: 1. Root surface restorations. 2. Root caries

3. Smoking.

4. Auto-immune disorders. 5. Drug allergy. At the baseline, the gingival recession was evaluated using the following parameters.

1. Recession depth from the CEJ to the gingival margin.

2. Recession width measured at the widest point. (It is the distance between the mesial gingival margin andthe distal gingival margin ofthe tooth.

3. Width of the keratinized gingiva. 4. Probing pocket depth.

5. Clinical attachment level.

All measurements were made with a William's periodontal probe. The measurements were recordedat baseline, 1 month, 3 months and 6 months after the surgical procedure.

Surgical Procedure [8]

1. Region in relation to 31, 32, 41, 42 was anesthetized [Figure - 1].

2. Root convexity was reduced using airrotor bur in order to reduce the dead space between the graft and the recipient site. Roots were planed using Gracey curettes.

3. A no. 15 blade was used to make horizontal incisions in the interdental papilla at the level of the CEJ. The horizontal incision was made at the level where the root coverage is expected and extended atleast 3 mm to the line angle of the adjacent teeth bilaterally.

4. The vertical incision was made mesio-distally so that the outline of the recipient site was trapezoidal.

5. A partial thickness flap was raised consisting of the epithelium and connective tissue and the recipient site was prepared 3mm apical to the most apical part of the exposed root. Scissors and no. 15 blade were used for preparing the recipient site. The reflected partial thickness flap was excised [Figure - 2].

6. A tin foil was placed on the recipient site and a template was prepared.

7. The tin foil template was then placed overlie palatal area and an incision was made all round the template to a depth of 2mrn and lnnn larger than the outline of the tin foil to accommodate graft shrinkage [Figure - 3].

8. Small tissue pliers was used to lift the graft's edge and the graft was separated along the outline. The undersurface of the graft was trimmed to remove the overhanging tissues.

9. The harvested graft was placed onto gauze soaked in normal saline solution [Figure - 4].

10. The graft was tried and adapted to the recipient site so that it extended 3-5mm apical to the margin of the exposed root.

11. The graft was compressed and held in position for few minutes to reduce the dead space and immobilized with 4-0 black silk sutures. The suturing technique of Holbrook and Oschenbein [9] was followed to hold the graft in place [Figure - 5]. 12. The donor and recipient sites were protected with periodontal pack [Figure 6 and 7].

The patient was put on analgesics and chlorhexidme mouthwash 0.2% was prescribed for 2 weeks.

The post-operative instructions were given as follows_ 1. Rest on the day of surgery.

2. Avoid intake of hot and hard food.

3. Don't disturb the operated area with fingers or tongue.

4. Report if dressing dislodges.

5. Take the prescribed medication regularly.

6. Avoid injury or movement at the grafted site. 7. Return after 10 days for suture removal.

8. Do not brush at the grafted site for atleast 1 month from the day of surgery. Use cottontip application gently to clean the area Resume gentle brushing as adviced by the dentist.


   Results Top


Gingival recession is treated to reduce root sensitivity and to improve esthetics. Complete success is reached when the following criteria[10] are satisfied: 1. Gingival margin is at the CEJ or slightly coronal to it.

2. Sulcus depth is lessthan or equal to 2mm. 3. Presence of attached gingiva

4. No bleeding on probing at the treated sites. Keeping all the above factors in mind, the selected 10 patients were surgically treated with autogenous free gingival grafts and assessed. The following parameters such as recession depth, recession width, probing depth, clinical attachment level and width ofthe keratinized gingiva were recorded pre-operatively, 1 month 3 months and 6 months after the surgical procedure.

Table 1 shows the pre-operative and post-operative measurements and percentage of root coverage in terms of recession depth. The mean reduction in post-operative recession depth at the end of 1 month, 3 months and 6 months was 0.6mra. Fou out of ten sites showed 100% root coverage. A mean percentage of 80.3% of root coverage was achieved.


   Discussion Top


The aim of each intervention of plastic surgery on gingival tissues is the correction of gingival recessions when they cause functional or esthetic problems and nowadays, the indication to the surgical procedure derives from the amount of keratinized gingiva available. In the present study, Miller's class I recession cases were selected for the autogenous free gingival grafts after considering the factors like reduced width of attached gingiva, reduced thickness of keratinized gingiva, reduced thickness of alveolar bone covering the donor tissue and presence of dehiscence in the donor area [8]. Hence the cases were not considered for pedicle graft techniques. Selection of Miller's class I recession cases was done in accordance with the studies conducted by Paolantonio et al [11], Mohammed et al [12], Allen AL [13], Harris RJ et al [14] and Burkhardt et al [15]. In this study, thekeratinizedgingivaunderwent a significant increase after the surgical technique and clinically, significant results were obtained with successful coverage of denuded roots.

Drug allergy is one of the most common side effects of treatment (present in 5-10 % of patients). It can affect any tissue of the body and reactions range from mild atopy to fatal anaphylaxis [16]. Allergic reactions requiring medical intervention in patients with drug allergy has been reported in the study conducted by Harris RJ et al [14]. In order to limit such post-operative complications, patients with drug allergy were not included in the study. Patients with autoimmune disorders were excluded from the study as the chances of graft rejection are high in these individuals.

In this study, the recipient site was prepared in a manner such that a butt joint was achieved between the coronal margin of the recipient site and the graft [17], [18]. This brought about better adaptation of the graft with the underlying recipient site.

Thorough planing of the root surface was done to reduce the thickness of the cementum thereby reducing the mesio-distal dimension of the root surface [17], [18]. Citric acid conditioning of the root surface was not done as it has been demonstrated in man that citric acid conditioning does not affect clinical results of free gingival autografts (Ibbot et al . 1985, Bertrand and Dunlap 1988).

The donor site was the palatal mucosa in relation to the canine, premolars and the first molar. The harvesting was done considering a recent study which measured the thickness of the masticatory mucosa in the palate and the tuberosity to determine the optimal donor sites. It was concluded that the palatal root of the first molar and the canine formed the posterior and the anterior anatomic barriers respectively for harvesting the grafts [19].

The thickness of the harvested graft ranged from 1.5-2mm [17],[18].

The graft was stretched and sutured to regenerate vascularity [17],[18]. The suturing technique used was the one advocated by Holbrook and Oschenbein 1983. This unique suturing technique reduces the dead space which interferes with the blood supply and thus increases the survival rate of the graft.

In the present study, an average root coverage percentage of 80.3% was achieved and is in accordance with the results obtained by Jahnke et a1. 1993 [20]. who demonstrated an average root coverage percentage of 80% with autogenous freegingival grafts.

The literature on free gingival autografts, reports very differentresultswithpercentagesofrootcoverage ranging from 11%-100%. (Minek et al . 1973, Matter and Cimasoni 1976, Matter 1980, Holbrook and Oschenbein 1983, Miller 1985, Ibboteta1.1985, Bertrand andDunlap 1988, Sbordone et al . 1988, Borghetti Gardella 1990, Tolmie et al 1991). These differences may be attributed to the differences in the severity of gingival lesions and in the surgical techniques.


   Conclusion Top


At present, eventhough the autogenous free gingival grafts have lost their race to subepithelial connective tissue grafts as far as root coverage is concerned, they still hold an edge in considerations like being less invasive and easy tissue handling. In conclusion, by following certain innovative designs [10],[11]and suitable suturing techniques the results with autogenous free gingival grafts can be upgraded atleast to be on par with subepithelial connective tissue grafts.



 
   References Top

1.Bi.om: Free transplantation of gingival propria. Sveriges Tandlakar Forbunds Tidning, 22: 684, 1963.  Back to cited text no. 1    
2.Matter J: Creeping attachment of free gingival grafts. A 5-year follow up study, JPeriodontol, 51: 681-685,1980.  Back to cited text no. 2    
3.Brasher J, Rees T, Boyce W: Complications of grafts of masticatory mucosa, J Periodontol, 46: 133-138,1975.  Back to cited text no. 3    
4.Pack A,GaudieW,JenningsA:Bony exostoses as a sequela to free gingival grafting: Two case reports, JPeriodontol, 62: 269-271,1991.   Back to cited text no. 4    
5.Efeoglu.A. Demirel K: A further report of bony exostoses occurring as a sequela to free gingival grafts, Periodontol Clinical Investigations, 16: 20-22,1994.  Back to cited text no. 5    
6.Czuzak CA, Tolson GE, Kudryk VI, Hanson BS, Billman MA: Development of an exostoses following a free gingival graft: Case report. J Periodontol, 67: 250-253,1996.  Back to cited text no. 6    
7.Otero Cagide F, Singer D, Hoover J: Exostoses is associated with autogenous gingival grafts: A report of9 cases, JPeriodonto167: 611-616,1996.   Back to cited text no. 7    
8.Sato N: Periodontal surgery -Aclinical atlas (356).   Back to cited text no. 8    
9.Holbrook T, Oschenbein C: Complete coverage of denuded root surfaces with a one-stage gingival graft, Int J Periodontics Restor Dent, 3: 9-12,1983.  Back to cited text no. 9    
10.Miller PD: Root coverage using a free soft tissue autograft following citric acid application. Part It. A successful and predictable procedure in areas of deep wide recession. Int J Periodontics Restor Dent, 5[2]:15-37,1985.  Back to cited text no. 10    
11.Paolantonio M, diMurro C, Cattabriga A. CattabrigaM:Subpedicle connective tissue graft versus free gingival graft in the coverage of exposed root surfaces: A 5-year clinical study JClinPeriodonto1,24:51-56, 1997.  Back to cited text no. 11    
12.Al Zahrani MS, Bissada NF, Ficara AL Cole B: Effect of connective tissue graft orientation on root coverage and gingival augmentation, hit J Periodontics Restor Dent, 24: 65-69,2004.  Back to cited text no. 12    
13.Allen AL: Use of gingival unit transfer in soft tissue grafting: Report of three cases, hit J Periodontics Restor Dent, 2004.  Back to cited text no. 13    
14.Harris RJ, Miller R, Miller LIE Harris C: Complications with surgical procedures utilizing connective tissue grafts: A follow-up of 500 consequtively treated cases, J Periodontol, 65: 448-461, 1994.  Back to cited text no. 14    
15.Burkhardt R, Lang NP: Coverage of localized gingival recessions; Comparison of micro and macrosurgical techniques, J Clin Periodontol, 32: 287-293,2005.  Back to cited text no. 15    
16.Foundations in Microbiology 4'sub ed.- Kathleen ParkTalaro andArthur Talaro. P. N505  Back to cited text no. 16    
17.Miller PD: Root coverage with free gingival graft. Factors associated with incomplete root coverage. JPeriodonto1,58:674-681,1987.  Back to cited text no. 17    
18.Miller PD: Root coverage using a free soft tissue autograft following citric acid application. Part I: Int J Periodontics Restor Dent, 212: 65-70,1982.  Back to cited text no. 18    
19.Studer SP, Allen EP, Rees TD, Kouba A: The thickness of masticatory mucosa in the human hard palate and tuberosity in potential donor sites for ridge augmentation, J Periodontol, 68: 145151,1997.  Back to cited text no. 19    
20.Jahnke PV, Sandifer JB, Gher ME et. al: Thick free gingival and connective tissue autografts for root coverage, JPeriodontol, 64: 315-322,1993.  Back to cited text no. 20    

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Correspondence Address:
D Deepalakshmi
Department of Periodontics, Meenakshi Animal Dental College and Hospital, Maduravoyal, Chennai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.29876

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    Figures

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

    Tables

[Table - 1]

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