I

I

•

NEW TREATMENT OF GINGIVAL RECESSION USING CORONALLV ADVANCED FLAP

Treatment of Gingival Recession Using Coronally Advanced Flap·A Case Report

Authors:

1. Dr. HarpreetSinghGrover

Professor a nd Head

WESTOELHI

Department of Periodontics & Orallmplantology SGT Dental College, Hospital and Research Insti tute, Gurgaon, Haryana, IN DIA.

2. Dr. Shailly Luthra

Private Practice

Gurgaon, Haryana, INDIA.

3. Dr. Shruti Maroa

Post Graduate Student

Department of Periodontics & Orallmplantology SGT Dental College, Hospital and Research Institute, Gurgaon, Haryana, IN DIA.

Corresponding Author:

Dr. Shailly Luthra

Gurgaon, Haryana, INDIA.

Email: shaillyluthra@gma il.com

Tel: 08800235100.

Treatment of Gingival Recession Using Coronally Advanced Flap-A Case Report

The main goal of periodonta l therapy is to improve periodontal health and thereby to maintain a patient's functiona l dentit ion t hroughout

their life. However, esthetics represents an inseparable part of today's dental treatment plan, and severa l procedures have been proposed to

preserve or enhance patient esthetics. Gingival recession is defined as the displacement of the soft tissue margin apical to the

cemento-enamel junction and is a frequent clinical feature in populations w ith both good and poor standards of oral hygiene. The aim of th is

case report is to eva luate the efficacy of the coronally advanced flap for treating single site recession defect's (Miller's class I) proposed by

Zucchelli and De Sanctis in the year 2009.Th is technique is proposed as an effective modal ity to ach ieve about 100% root coverage in cases of

M iller'sclass I recession.

Keywords: Coronally Advanced Flap,G ingival Recession, Root Coverage

Treatment of Gingival Recession UsingCoronaily Advanced Flap-A Case Report

Introduction

Gingival recession is defined as the displacement of the soft tissue margin apical to the cemento-ena mel junction. ' lt may affect single or

multiple root surfaces and is a frequent clinical feature in popu lations w ith both good and poor standards of oral hygiene' An untreated

gingival recession has a strong impact on both esthetics and dentine hypersensitivity. Moreover, the absence of the gingival tissue protecting

the root surface may facilitate the development of cervical abrasion in some cases increasing susceptibil ity to root caries w hich eventually

leads to poor oral hygiene. 'Tissue trauma caused by vigorous tooth brushing is considered to be a dominating causative factor for the

development of recessions. Tooth malposition, high muscle attachment, frenal pull, uncontrolled marginal inflammation with accumulation

of dental plaque and ca lculus due to improper brushing tech niques and iatrogenic factors related to restorati ve, periodontal treatment

procedures and incisor inclination and orthodontic treatments have also been associated with gingival ti ssue recession.4

Several surgica l

approaches have been proposed in the last few years to obtain root coverage on exposed buccal root surfaces such as free gingival grafts,

subepithelia l connective tissue grafts, lateral sliding flap, sem ilunar f laps, coronally advanced flaps alone or associated with free

gingival/connective tissue graft.' The aim of this case report is to eva luate the efficacy of the coronally advanced flap for treating single site

recession defect's (Miller's class I) proposed by Zucchelli and De Sanctis in the yea r 2009.'

Case Report

A 27-year old male patient reported to the Outpatient Department of SGT Dental College, Hospital and Research Institute, Gurgaon with a

chief comp la int of sensitivity to hot and cold f lu ids in upper front teeth region since 1 month along with esthetic concern. He had n

underlying medical conditions and was not taking any medications that would have compromised a soft hea ling response.

1

On examination M ille r's Class I gingival recession was seen wit h tooth 22, 23(Fig:l) .Gingival bi otype was measured at t he mid buccal 2 mm

apical to free gingiva l margin by penetrating UNC probe into the tissue and reco rded to the nearest 0.5 mm. It was 1 mm in t he all t he above

mentioned teeth. The patient underwent a session of prophylaxis including inst ruction in proper ora l hygiene measures and scaling and

polishing. A coronally directed rol l tech nique was prescribed for teeth with recession-type defects in order to min imize toothbrushing trauma

to the gingiva l margin.

The following clin ical measurements were taken to the nearest millimeter for the tooth at baseline (before surgery after initial periodontal

therapY), 1 month and 3 months after surgery.

(1) Gingival recession depth (GRD), measured as the distance between t he most apica l point of the CEJ and the gingival margin (GM).

(2) Gingival recess ion width (GRW), measu red as the distance bet ween the mesia l GM and the distal GM of the tooth (measurement was

recorded on a horizont al line tangent ial atthe CEJ).

(3) Probing dept h (PD), measured as t he distance f rom the GM tothe bottom ofthegingival sulcus.

(4) Clin ical attachment level (CAL), measured as the dist ance from the CEJ to the bottom olthe sulcus.

(5) Ap ico-coronal width of keratinized t issue (KTW), measured as the distance from the mucogingival junction (MGJ) to th e GM, w ith MGJ

location determ ined using a visual method.

(6) Recession depth reduction .

(7) Complete/ Part ial Root Coverage.

GRD, PD, CAL and KTW measurements w il l be performed atthe mid-bucca l point of the involved tooth. A Hu-Friedy periodontal probe (UNC-

15 periodontal probe) w ill be used for all clin ical measurementsalong w it h a custom made acryl ic st ent(Fig.2) .

Surgical Procedure

After administration of local anesthesia (Xyl oca ine w ith 0.2% adrenaline), a horizontal incision was given together with the intra-su lcular

starting from tooth 21 extend ing to the 24. Two oblique incisions were given at the mesial and distal li ne angles of these teeth extending

beyond the mucogingival junction. (Fig:3). The anatomic inter-denta l papillae were de-epithelialized. The flap was elevated as splitthickness

fl ap, followed by fu ll th ickness flap apica l t o t he root exposures terminating ti l13-4mm apical to the bone dehiscence exposing denuded bone.

The apical most portion of the flap was undermined to convert it to a split thickness fl ap, facili tating coronal displacement of t he flap (Fig :4).

The surgical papilla was stabilized using loop sutures (with 5-0 Et h icon-(NW-3316) overthe interdenta I co nnective tissu e bed .Suturing olthe

flap started with two interrupted periosteal 5-0 sutures at the most apical extension of the vertical releasing Incision; it was continued •

coronally with other interrupted sutures, each of them directed from the flap to the adjacent bucca l soft tissue, in the apica l--coronal

direction. The fina l position of the flap margins was overcorrected to be at least 3- 4mm corona l to t he CEJ of all t eeth at the end of the

surgery. (Fig:5). Periodontal dressing was applied to avoid any mechanica l t rauma. (Fig:6).

Post surgica l Treatment and Follow-up

Post operative instructions were given. The patient was instructed to avoid brushing and flo ssing in the area of surgery and to consume on ly

soft food during the first week. Amoxicillin 500mg T.D.S for 5 days and Ibuprofen 400 mg S. D were prescribed to the patient. Instructions to use

chlorhexid ine gluconate rinse 0.2 % twice daily for 15 days were given. The patient was advised to consume only soft food during the first

week. The periodontal dressing and sutureswere removed 2 weeks after surgery. The patient were instructed to resume mechanical tooth

cleaning of t he treated areas using a soft toothbrush and a careful roll tech nique after 3 w eeks of surgery was recalled for prophylaxis 2 and 4

weeks after suture removal. The patient was evaluated at 1(Fig:7)& 3 mont hs post-operatively(Fig:8). The recall showed uneventfu l heali ng

along with root coverage with reduction of dentin hypersensitivity without any probing defect or signi fica nt compl ication .

Discussion

The presence of mucogingiva l problems and gingival recession around anterior, highly visible teeth can render patients aesthe -ca l

conscious and epitomizes a situation where a remedy that addresses both biological and aesthetic demands is required from the thera!:>"-.5i ..

According to Pin i-Prato coronally advanced flaps result in 70-99% of root coverage.7Complete root coverage can be achieved in C ass :::""=

defects, on ly partial root coverage (70% to 75%) can be accomplished in Class III defects, and Class IV defects are not amenab ." :.: '::<It

coverage,7Clin icians are chal lenged to achieve outcomes that meet these exacting standards, and therefore need a sou nd, clinically or2-:?::

,

)l. p....'I1 CDE NOII\N DENTAL ASSOCIATION

WEST DELH I

and scientifically supported decision-making process to plan the t herapeutic approach, to predict the outcome and, finally, to achieve it. It

would therefore be desirable to use a coronally advanced flap approach which alone can successfully applied when the residual gingiva is

thick8 and wjde~. The functional aspects of root coverage may be controversial, but the cosmetic aspect and satisfact ion is not debatabl e. In

this case the root coverage achieved was 100%. A coronally advanced flap is less invasive for the patient, requi res less chair-time and less

surgical skills. It also resu Its in good colour blending of the t reated area . Addit iona lly with, the post-operative course being less troubleso me

for the patient as other surgica I sites distant from the tooth with recession defect are not involved. Also, the costs of mucogingival operations

may arise when other biomateria ls materia ls such as acellular dermal matrix, enamel matrix derivative and bioabsorbable membrane are

in cluded.

Conclusion

In conclusion, the results of the present study demonstrated that coronally advanced flap technique is effective and successful fo r the

treatment of isolated gingival recession or multiple gingival recessions in patients with esthetic demands resulting in satisfactory root

coverage.

References

1. American Academy of Periodontology. Glossary of Periodontal Te rms, 3rd edn. Ch icago: The Amer ican Academy of Periodonto logy,

1992.

2. Loe H, Aneru d A, Boysen H. The natural history of periodontal disease in man: prevalence, severi ty, and extent of gingiva l recession. J

PeriodontoI 1992;63: 489-495 .

3. Goldstein, M., Nasatzky, E., Gou ltschin, J., Boyan, B. D. & Schwartz, Z. Coverage of previously carious roots is as predictable a

procedure as coverage of intact roots. Journal of Periodontology 2002; 73: 1419-26.

4. Ustun K, Sari Z, Orucoglu H, Duran I, Hakki S. Severe gingival recession caused by tra umatic occlusion and mucogingival stress: A Case

Report. Eur J Dent. 2008;2:127-133.

5. Bouchard P, MaletJ, Borghetti Decision-making in aesthetics: root coverage revisited. Periodontol2000. 2001;27:97-120.

6. Zucchelli, G., Mele, M., Mazzotti, c., Marzadori, M., Montebugnoli, L. & De Sanct is, M. Coronally advanced f lap w ith and w ithout

vertical releasing incisions for the treatment of multiple gingival recessions: a comparative contro lled randomized clinical trial. J

Period onto I 2009;80:1083-94.

7. Wennstr6m JL, Pin i Prato G P. M ucogingiva l th erapy. In: Lindhe J, Karring T, Lang N P, ed. Clinica l Periodontology and impla nt denti stry.

3rd edn. Copenhagen: Munksgaard, 1997: 550- 596.

8. Ba ldi C, Pini Prato GP, Pagliaro U, Nieri M, Saletta D, M uzzi L, Cortel lini P. Coronally advanced f lap procedure for root coverage. Is f lap

thickness a relevant predictor to achieve root coverage? A 19- case series. J Periodontol. 1999; 70: 1077-84.

9. Zucchelli G, Cesari C, Amore C, Montebugnoli L, De Sanctis M. Laterally moved, corona lly advanced flap: a modif ied surgical approach

for isolated recession type defects. J Period onto I. 2004:75:1734-41.