TREATMENT OF MILLERS CLASS I GINGIVAL RECESSION … · flap with or without the presence of a connective tissue graft will not show any significance difference at the 2-year interval

Boyapati R. Treatment Of Millers Class I Gingival Recession Defects Using Coronally Advanced Flap.-

Case Report Of Two Cases. J Periodontal Med Clin Pract 2016;03: 56-64

1Dr. Ramanarayana. Boyapati

Treatment Of Millers Class I Gingival Recession Defects Using Coronally Advanced Flap.- Case Report Of Two Cases.

Case Report

Affiliation

1. Senior Lecturer,

Department of Periodontics

Mamata Dental college and hospital Khammam,

Telanagana.

Corresponding Author:

Dr. Ramanarayana. Boyapati

Senior Lecturer,

Department of Periodontics

Mamata Dental college and hospital Khammam,

Telanagana.�Conflict of Interest – Nil

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ABSTRACT

Mucogingival therapy is defined as the correction of

defects in morphology, position, or amount of soft

tissue and underlying bone.Friedman introduced it

in1957 and was defined as “surgical procedures

designed to preserve gingiva, remove aberrant

frenulum or muscle attachments, and increase the

depth of the vestibule. Factors implicated in the

etiology of GR, include traumatic, overzealous tooth

brushing technique (i.e; forceful, horizontal)

frequently associated with a pre-existing lack of

cortical bone or acquired bone deformities,

uncontrolled marginal inflammation with

accumulation of dental plaque or high muscle

attachment and frenal pull.

Gingival recession (GR) occurs in population with

low oral hygiene levels. Root coverage may be

achieved by a number of surgical techniques,

including pedicle gingival grafts, free grafts,

connective tissue grafts, GTR may also be used. The

objective of the present study was to evaluate

Coronally advanced flap (CAF) procedure in the

treatment of Miller's class I gingival recession defects

in maxillary teeth.

Key words: Gingival recession, Flap surgery,

Mucogingival surgery.

INTRODUCTION

� The oral exploration of the root surface

due to displacement of the gingival margin apical to

CEJ leads to tactile and thermal dental

hypersensitivity, root abrasion and deterioration of [1]

smile easthetics. The main goal of the periodontal

therapy is to improve periodontal health and thereby

to maintain patients functional dentition throughout [2]

his/her life.

Numerous procedures and different

Vol-III, Issue - 1, Jan-Apr 2016


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techniques have been designed to provide predictable [3]

root coverage. According to Zucchelli and De

Sanctis the selection of one surgical technique over

another depends on several factors, some of which are

related to the defect i.e the size of the recession defect,

the presence or absence of keratinized tissue adjacent

to the defect, width and height of the interdental soft

tissue, depth of the vestibulum or the presence of

frenuli while others are related to patients such as oral [4]

hygiene maintenance, smoking.

In patients with aesthetic requests if there

is adequate keratinized tissue apical or lateral to the

recession defect, pedicle flap surgical techniques

(coronally advanced or laterally moved flaps) are

recommended (Grupe & Warren 1956). Kalmi (1949)

first described a type of coronally repositioned flap

that was performed after gingivoplasty of the attached

gingiva. Nordenram (1969) and Harvey (1965, 1970)

employed surgical techniques to cover denuded roots

by coronally repositioning mucoperiostial flaps. In

addition, Sumner (1969) and Ward (1973) have

modifications of the coronal repositioned flap to

repair gingival recession using straight horizontal

incisions in the alveolar mucosa. Bernimoulin et al.

(1975), reported the clinical evaluation of a two-step [5]

coronally repositioned periodontal flap. Zucchelli

and De Sanctis modified the coronally advanced

procedure. The aim of the present study is to evaluate

the clinical efficiency of modified CAF procedure in

the treatment of class I and class II gingival recession

defects.

CASE REPORT-

A female patient aged 42 years reported to the

department of periodontics Mamata Dental Collge &

Hospital with the chief complaint of receded gums.

On Clinical examination isolated Miller's class I

Gingival recessions in relation to Maxillary right

canine.

Probing depth 2mm with no bleeding on probing,

Width of the keratinized tissue 3mm . Recession

height 3mm and Clinical attachment level 5mm. ( Fig-

1).

CASE REPORT-2

A male patient aged 35 years reported to the

department of periodontics Mamata Dental Collge &

Hospital with the chief complaint of receded gums.

On Clinical examination isolated Miller's class I

Gingival recessions in relation to Maxillary right

canine.

Probing depth 3mm with no bleeding on probing,

Width of the keratinized tissue 3 mm . Recession

height 5mm and Clinical attachment level 8mm ( Fig-

7).

For both cases written and verbal informed consent

was obtained after a thorough explanation of nature,

risks and benefits of the clinical investigations and

surgical procedures. The study was approved by the

Institutional Ethical Committee. Patient was

subjected to full mouth scaling and root planning.

Clinical data collection

Baseline full mouth plaque and gingival index scores

were recorded according to Silness & Loe, and Loe &

Silness, respectively. Clinical parameters were

assessed at the mid-facial surface of teeth using CEJ

as the reference point. All measurements were

recorded using a Williams

periodontal probe at baseline 3 months and 6 months.

Measurements were recorded to the nearest

millimeter. Recession Height (RH) was measured as

the distance from CEJ to GM. Width of Keratinized

Tissue (WKT) was measured as the distance between

the GM and the MGJ, PD was measured from GM to

the base of the sulcus. CAL is calculated from PD and

gingival recession.


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Surgical procedure�The modified Coronally advanced flap as described by

Zucchelli and De Sanctis in 2000 was performed. The

area was anesthetized with 2% lignocaine

hydrochloride containing adrenaline at a concentration

of 1: 80,000. An intra-sulcular incision was made at the

buccal aspect of the involved tooth.(Fig-2) Two

horizontal incisions were made at right angles to the

adjacent interdental papillae, at the level of the CEJ,

without interfering with the gingival margin of the

neighboring teeth( Fig-3). Two oblique vertical

incisions were extended beyond the muco gingival

junction to relieve muscle tension and a trapezoidal

split- full- split thickness flap was raised and extended

apically beyond the mucogingival junction, releasing

the tension and favoring the coronal positioning of the

flap (Fig-4). If the root is prominent, then as the flap is

advanced over the root the flap must cover more area

because of the root prominence, if the incisions are

parallel, the flap will be too short mesial to distal. If

there is no root prominence, then the incisions can be

more parallel because the mesial to distal distance will

not change. The amount of flap divergence is dictated

by the root prominence. The epithelium on the adjacent

papillae was de-epithelized. The root surface was

instrumented with curettes and irrigated with sterile

saline solution. The tissue flap is coronally advanced,

adjusted for optimal fit to the prepared recipient bed,

and secured at the level of the CEJ by suturing the flap

to the connective tissue bed in the papilla regions by

single sling sutures. Additional lateral interrupted

sutures are placed to carefully close the wound of the

releasing incisions using a small reverse cutting needle

and 5-0 or 4-0 sutures. Proper suturing should allow

adaptation of the donor tissue without any tension on

the flap. Pulling the lip out to see if the donar tissue

moves is the best way to check for graft stability. If the

movement is detected, additional sutures may need to

be placed. Non-Eugenol periodontal dressing (Coe – ™Pak ) was placed over the surgical site and sutures

were removed after 14 days.

Post surgical care

Patient was instructed to discontinue tooth brushing

around the surgical site for the first 3 weeks after the

surgery. During this period, patients were advised to

use 0.2% chlorhexidine solution twice daily for 3

weeks. Systemic antibiotics and analgesics were

prescribed for 7 days post surgically (Amoxicillin

500mg t.i.d). The sutures were removed after 14 days.

After suture removal patient advised for gentle topical

application of 2% chlorhexidine gluconate gel. Three

weeks after the surgery, the patient was instructed to

resume careful mechanical tooth cleaning of the

treated areas using a soft bristled toothbrush. Patients

were given instructions to report to the department if

they had any discomfort following surgery. Patient

was periodically recalled every month for evaluation.

The clinical parameters were measured during the

follow up visit at 3 ( Fig-5 & Fig-8)months and at 6

months (Fig-6&Fig-9).



59

FIGURE-1- PRE OPERATIVE RECESSION HEIGHT

FIGURE-2-INCISIONS GIVEN FIGURE-3-OPERATIVE

FIGURE-4-OPERATIVE- FIGURE-5- Three ( 3) months

CORONALLY ADVANCED FLAP post op- CASE-1



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FIGURE-6-Six (6) months post op- 1 FIGURE-7-- Pre op Recession height- CASE-I

CASE- II

FIGURE-8- Post op 3 months- CASE-II FIGURE-9-Post op 6 months-CASE-II



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Discussion

The objectives of root coverage is complete

restoration of of all anatomical structures in the area

of recession. This evident histologically as

regeneration of the periodontal attachment with the

formation of new cementum, periodontal ligament [12] .and bone Treatment of gingival recession is

becoming an important issue in clinical

periodontology due to the increasing demand for

cosmetic treatment. The few millimeters of root

exposure poses problem when smiling. Thus, only

surgical procedures that provide the clinician with a

very high percent of complete root coverage should

be included in the mucogingival plastic surgical

techniques. Moreover, excessive thickness or poor

colour blending of the surgically treated areas, as

those resulting from soft tissue graft, should be

avoided. Patient-related aesthetic considerations

would suggest the utilization of surgical techniques

that can predictably obtain complete root coverage by

using the soft tissue adjacent to the defect (de Sanctis [6] & Zucchelli 1996). The only limiting criteria in

utilizing a coronally advanced flap is the need of a

band of at least 1mm of keratinized tissue;

Wennstrom & Zucchelli (1996) have stated that the

amount of root coverage utilizing coronally advanced

flap with or without the presence of a connective

tissue graft will not show any significance difference

at the 2-year interval. More recently, the results from

a systematic review on periodontal plastic surgery

[2] (Roccuzzo et al. 2002) stated that the use of a barrier

membrane or connective tissue, together with a

coronally advanced flap, do not give better results

than coronally advanced flap alone when root

coverage is considered.

In the present study, the patients were non-

smokers ,smoking causes alteration in physiological

and cellular functions causing negative impact on the

gingival blood flow. Nicotine inhibits proliferation,

adhesion and chemotaxis of periodontal ligament

cells, alters the interaction between the epithelial [7] cells and gingival fibroblasts . A modified CAF

[6]procedure (Zucchelli and de Sanctis in 2007) was

selected as there were some clinical and biological

advantages over the conventional as proposed by

Allen and Miller. Complete root coverage seems to

be influenced by post surgical positioning of GM and [8] by baseline depth. The gingival margin is placed

2mm coronal to CEJ so as to counteract the gingival

retraction following the surgery. This was in

accordance with the previous studies conducted by [8] [9] Pini Prato and Baldi, Cairo et al. Healing

progressed normally as that occurs in periodontal

flaps with the gingival colour, texture and contour

identical to the adjacent soft tissues. The ultimate

goal of root coverage procedures is the complete

resolution of the recession defect, with minimal

probing depths after treatment, along with a nice

chromatic and texture integration of the covering [10] tissues with the adjacent resident soft tissues.



TABLE-1

Comparison of clinical parameters in CASE-1 and CASE -2

CASE-1 CASE-2

BASELINE 2.0 3.0

3 MONTHS 1.0 1.0

6 MONTHS 1.0 1.0

BASE LINE 5.0 8.0

3 MONTHS 1.0 1.0

6 MONTHS 1.0 1.0

BASE LINE 3 5

3 MONTHS 0.2 0.2

6 MONTHS 0.2 0.2

BASELINE 3 3

3 MONTHS 4 5

6 MONTHS 4 5

PD

CAL

RH

WKT

The gain in probing attachment and clinical

attachment level ( CAL ) was mostly due to formation

of the new connective tissue attachment and

epithelial attachment.This was in accordance with [11]

previous studies conducted by Carlo Baldi et al , [7]

Cleverson Oliveira Silva et al Giovanpaolo Pini [13] [13]

Prato et al, Mauro Padrine Santamaria et al, [14] [15]

Ignazio Berlucchi et al, Andrea Pilloni et al . The

gain in CAL was mostly due to improvement of

probing depth at 3 months and 6 months

postoperatively

There was significant reduction in both cases

Recession height from baseline to 3 months and 6

months. The percentage of root coverage obtained in

case-I is 93.3% and in Case II is 90% , which was

consistent with the findings of other investigators,

7 [6]Cleverson Oliveira Silva et al, Pini Prato et al , M.

[16] [17 ] Del Pizzo et al, James G.Woodyard et al Michael

[18] K McGuiere et al. There was increase in width of

keratinized tissue ( WKT) in both cases from baseline

to 3 months and 6 months in agreement with the 13

previous studies conducted by Pini Prato et al , Eun – [6,19]

Ju Lee et al, Cem A.Gurgan et al.

Conclusion.

Overall considering all the aspects, Coronally

advanced flap provides consistently better esthetics,

healing and improvement in all the clinical

parameters including increase in width of

keratinized tissue.

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62

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Competing interest / Conflict of interest The author(s) have no competing interests for financial support, publication of this research, patents and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript.Source of support: NIL

Copyright © 2014 JPMCP. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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TREATMENT OF MILLERS CLASS I GINGIVAL RECESSION … · flap with or without the presence of a connective tissue graft will not show any significance difference at the 2-year interval