Mele.qxd 1/11/08 12:37 PM Page 62

The International Journal of Periodontics & Restorative Mele.qxd 1/11/08 12:37 PM Page 63

63

Bilaminar Technique in the Treatment of a Deep Cervical Defect

Monica Mele, DDS* The is clinically recog- Giovanni Zucchelli, DDS** nized by a scalloped line, which, in a Marco Montevecchi, DDS*** healthy state, follows the outline of the Luigi Checchi, MD, DDS**** cementoenamel junction (CEJ) at a dis- tance of 1 to 2 mm. The scalloped line, however, varies greatly in both the New materials (restorative and adhesive) for the treatment of cervical abrasions shape and the degree of scalloping. have produced better results in terms of esthetics (choice and stability of colors) This and tooth morphology (principally and duration (marginal fit and wear resistance). Nevertheless, conservative square-shaped or cylindric) are genet- restoration of cervical abrasion cannot be considered the most suitable treatment ically determined. In the case of in certain clinical situations: (1) when the abrasion defect involves the root surface, square-shaped teeth (mesiodistal either exclusively or primarily; (2) when a site has difficult esthetic demands result- dimension similar to the apicocoronal ing from excessive tooth length with ; and (3) in the presence of dimension), a flat pattern of the gingi- root caries. The aim of this case report is to describe the application of the bilami- val margin corresponds, since the CEJ nar technique to treat a deep cervical abrasion associated with a recession-type outline is flat (flat morphotype). In the defect. The bilaminar surgical approach shown here consisted of a connective tis- case of cylindric teeth (mesiodistal sue graft covered by a coronally advanced pedicle flap. The connective tissue dimension smaller than the apico- graft was placed inside the root concavity to compensate the abrasion space and coronal dimension), there is a scalloped to prevent soft tissue flap collapse internally. The graft, by acting as a “biologic outline of the gingival margin that par- filler” or space maintainer inside the concave abrasion area, stabilized the cover- ing flap and helped restore a correct tooth emergence profile. (Int J Periodontics allels the CEJ (scalloped morphotype). Restorative Dent 2008;28:63–71.) Gingival recession is a periodon- tal pathology that frequently affects the highly scalloped morphotype. Kassab and Cohen1 emphasized that *Resident, Department of and Implantology, University of Bologna, Italy. 88% of patients older than 65 have at **Associate Professor, Department of Periodontology and Implantology, University of least one recession and that the extent Bologna, Italy. ***Researcher, Department of Periodontology and Implantology, University of Bologna, Italy. and number of recessions increase ****Professor and Chairman of Periodontology and Orthodontics, Department of with age. Gingival recession is defined Periodontology and Implantology, University of Bologna, Italy. as a shift of the gingival margin to a

Correspondence to: Prof Luigi Checchi, Via S. Vitale 59, 40125 Bologna, Italy; fax: +390- position apical to the CEJ with expo- 2 514391718; e-mail: [email protected]. sure of the root surface. The conse-

Volume 28, Number 1, 2008 Mele.qxd 1/11/08 12:37 PM Page 64

64

quence of recession is a longer clinical bone are lost.8,12,13 Mucogingival sur- crown. The disharmony of the gingival gical techniques mainly address the margin may be apparent in the treatment of buccal gingival recession patient’s smile or even during function that is not accompanied by severe loss (speaking, chewing). The result of of interdental bone and clinical attach- recession is often patient discomfort ment levels. and/or inadequate . In fact, In recent years a number of surgi- a symptom frequently related to gin- cal techniques have been proposed gival recession is dentin hypersensitiv- for the treatment of gingival reces- ity. Pain is usually sharp, of short dura- sions: (1) free gingival grafts, (2) pedi- tion, and closely associated with cle flaps (both advanced and rota- thermal or chemical stimuli. The irreg- tional), (3) regenerative techniques ular outline of the gingival margin, even (guided tissue regeneration), and (4) in the absence of tooth hypersensitiv- bilaminar methods. The selection of ity, may render plaque control more one surgical technique over another difficult for the patient to perform, depends on several factors, some of especially when the recession is trian- which are related to the type or char- gular shaped, with acute angles (the so- acter of the defect and others that are called “Stillman cleft”). Furthermore, as related to patients’ wishes.13 In the root surface becomes exposed to patients with esthetic demands, if there the oral environment, the risk of root is adequate keratinized tissue apical caries increases. These lesions may or lateral to the recession defect, pedi- occur at all tooth surfaces but are found cle flap surgical techniques (coronally predominantly at the approximal and advanced or laterally moved flaps) are buccal surfaces.3 Significant loss of hard recommended.14–19 In these surgical tissue can occur at root surfaces as well approaches, the soft tissue used to when the brushing technique is too cover exposed roots is similar to that aggressive; these lesions are called originally present at the buccal aspect “abrasion defects.”3 of the tooth with the recession defect, Gingival recession is well repre- and thus the esthetic result is satisfac- sented in populations having a good tory. The use of a to standard of oral hygiene3–8 and in treat recession defects in patients with those with a high Plaque Index (PI).9–11 esthetic needs is not recommended In particular, when the PI is low, the because of the poor esthetic outcome recession is often present at the buc- and the poor predictability of root cov- cal surface and/or is associated with erage.2 The use of a pedicle flap to abrasion of the enamel and/or the cover the graft (bilaminar technique) exposed root surface.3,5,6,11 Gingival improves the predictability of root cov- recession may occur in the presence of erage (because it provides the graft normal sulci and healthy interdental with an additional blood supply) and bone and attachment levels, or it may the esthetic result, because it hides be one of the clinical signs of peri- the “white scar” appearance of the odontitis, in which interdental con- that frequently nective tissue attachment and alveolar results after a free graft procedure.19–24

The International Journal of Periodontics & Restorative Dentistry Mele.qxd 1/11/08 12:37 PM Page 65

65

During the last two decades, clin- certain clinical situations, namely (1) icians have introduced several modifi- when the abrasion defect involves only cations to the original bilaminar pro- or mainly the root surface, (2) when cedure described by Ratzke,23 there are esthetic demands caused by resulting in more predictable root cov- excessive length of a tooth with gingi- erage and greater esthetic satisfaction val recession, and (3) in the presence for patients. These modifications are of root caries. In all these circum- related both to the type of graft (par- stances, in fact, the abrasion defect tially or completely de-epithelialized) should be treated and covered with harvested from the and to the soft tissues. design of the covering flap (envelope- The aim of this case report is to type or with vertical releasing inci- describe the application of a bilaminar sions).19–24 The main objective of bi- technique to a recession defect asso- laminar procedures is to increase the ciated with a deep cervical abrasion gingival thickness and thus reduce the involving only the root surface (cemen- recurrence of gingival recession. This tum and dentin). outcome is frequently achieved with- out regard for the resulting inadequate tooth emergence profile and patient Patient report discomfort caused by the excessive increase in soft tissue volume. This hap- The patient presented with a Miller pens more frequently when the tooth Class I recession defect25 on the max- with gingival recession is buccally illary right canine. The tooth presented located or features a prominent root. a deep abrasion involving only the On the other hand, in the pres- anatomic root surface (Figs 1a and 1b). ence of cervical abrasion associated The CEJ was located just coronal to the with gingival recession, bilaminar tech- most coronal extent of the abrasion niques should be considered as the area; thus, the risk of collapse of the primary option, since the connective tis- pedicle flap into the abrasion area was sue graft (CTG) placed inside the abra- very high. sion defect might increase gingival The planned surgical approach thickness and, at the same time, restore was the bilaminar technique consisting a correct tooth emergence profile. of a CTG covered by a coronally Treatment of cervical abrasions is advanced pedicle flap. The CTG was traditionally considered to be an area placed inside the root concavity to of competence of the restorative clin- compensate the abrasion space and to ician. New materials (restorative and prevent internal collapse of the soft adhesive) have provided better results tissue flap. The graft, by acting as a in terms of esthetics (choice and sta- filler or space maintainer inside the bility of colors) and duration of treat- concave abrasion area, was able to ment (marginal fit and wear resistance). provide stability to the covering flap, Nevertheless, conservative restoration which was coronally advanced about of cervical abrasion cannot be consid- 1 mm past the location of the CEJ. ered the most suitable treatment in

Volume 28, Number 1, 2008 Mele.qxd 1/11/08 12:37 PM Page 66

66

Fig 1a (above) A single recession defect affects the maxillary right canine. A small (1 mm) amount of keratinized tissue remains apical to the exposed root.

Fig 1b (right) Lateral view of the canine with gingival recession and deep abrasion defect.

Fig 1c (left) A split-thickness trapezoidal flap is elevated.

Fig 1d (right) Lateral view of the canine with the open flap. Note the concavity of the root profile after mechanical treatment.

The International Journal of Periodontics & Restorative Dentistry Mele.qxd 1/11/08 12:38 PM Page 67

67

Figs 1e and 1f A CTG has been positioned and sutured inside the abrasion defect, just Fig 1g The covering flap is advanced and apical to the CEJ. sutured coronally to the CEJ.

Surgical technique The CTG was harvested from the de-epithelialized to create a connective palate with the “trap-door” approach tissue bed to which the surgical papillae The coronally advanced pedicle flap described by Harris and Harris.24 The of the covering flap were sutured. had a trapezoidal design (Fig 1c). Two mesiodistal length of the graft was 6 Closure of the covering flap horizontal incisions extended 3 mm mm greater than the width of the started with two interrupted sutures mesially and distally and were made at recession, as measured at the level of performed at the most apical extent of a distance from the vertex of the the CEJ. The height of the graft was the mesial and distal releasing inci- anatomic papilla equal to the depth of equal to the apicocoronal dimension sions and then proceeded coronally the recession. Two bevelled vertical of the root abrasion.26 with other interrupted sutures, each of releasing incisions then extended into A double vertical mattress suture them directed from the flap to the the alveolar mucosa. was performed to anchor the CTG to adjacent buccal soft tissue in the apic- A split-thickness flap was elevated the adjacent buccal soft tissues27 (Figs ocoronal direction. After these sutures and all muscle insertions were elimi- 1e and 1f). This suture permitted the were completed, the most marginal nated to facilitate its coronal displace- positioning of the graft just apical to portion of the covering flap was stable ment. The root surface was mechani- the CEJ inside the root concavity. The in its coronal position without disrupt- cally treated with the use of curettes. thickness of the connective tissue was ing forces acting on it at the time of the Only that portion of the root surface equal to the depth of the abrasion final sling suture.27 This sling suture with loss of clinical attachment (gingi- defect. Thus the graft was able to com- was performed to permit precise adap- val recession and probing pocket pensate for the abrasion space and pre- tation of the buccal flap on the under- depth) was instrumented. Root planing vent the collapse of the covering flap lying CTG and to stabilize the surgical was terminated when a clean and hard inside it. The remaining tissue of the papillae over the interdental connec- surface was obtained (Fig 1d). anatomic interdental papillae was tive tissue bed (Fig 1g).

Volume 28, Number 1, 2008 Mele.qxd 1/11/08 12:38 PM Page 68

68

Fig 2a Site at 3 months. Complete root Fig 2b Lateral view at 1 year. Complete coverage has been achieved. root coverage, a good emergence profile, and filling of the root abrasion with an increased thickness of gingival tissue have been achieved.

Postsurgical treatment and After 3 months, complete root follow-up coverage was apparent (Fig 2a). At 1 year after surgery, complete root cov- The patient was instructed not to brush erage was still observed. At the treated the treated area but to rinse the mouth tooth, the gingival margin was located with solution (0.12%) at the level of the CEJ. The covering twice daily for 1 minute. Fourteen days flap was still in place, hiding the unes- after the surgical treatment, the sutures thetic appearance of the graft (Figs 2b were removed. Plaque control in the and 2c). Good color blending of the surgically treated area was maintained treated area with the adjacent soft tis- by chlorhexidine rinsing for an addi- sues was accomplished. The increase tional 2 weeks. After this period the in gingival thickness was demonstrated patient was instructed again to in a comparison of the preoperative mechanically clean the treated region (see Fig 1b) and postoperative (see with a soft and a roll tech- Fig 2c) lateral views; the abrasion space nique. The patient was recalled for was filled with soft tissue and the cor- prophylaxis 1, 3, and 5 weeks after rect tooth emergence profile was re- suture removal and, subsequently, established. once every 3 months until the final examination (12 months).

The International Journal of Periodontics & Restorative Dentistry Mele.qxd 1/11/08 12:38 PM Page 69

69

imal with the coronally advanced flap because the harvesting of soft tissue from distant areas of the mouth (eg, the palate) is avoided. However, since the CEJ was very close (less than 1 mm) to the most coronal extent of the abrasion defect, the risk of a coronally advanced flap collapsing inside the concave area was very high. Furthermore, because deep abrasions were present, a coro- nally advanced flap would not be suf- ficient to restore a correct tooth emer- gence profile. Placement of a CTG inside the abrasion defect prevents soft Fig 2c Clinical view at 1 year postoperative. A good esthetic outcome tissue collapse and provides stability to has been obtained. The treated area is not distinguishable from the the coronally advanced flap, which can adjacent soft tissues. be positioned and maintained at the level of the CEJ. The thickness of the CTG should be varied according to the depth of root structure loss that must be compensated. Treatment of cervical abrasions has been considered the ideal situation for conservative restorative therapy. Discussion control difficult for the patient to per- Nevertheless, conservative therapy form. Thus, two main goals needed cannot be considered a first-choice The goal of this case report was to to be accomplished with the surgical solution when the abrasion involves describe the application of the bilam- procedure: root coverage with good the anatomic root either exclusively or inar procedure for the treatment of a esthetic results, and restoration of a predominantly. In fact, from both the deep root abrasion associated with correct tooth emergence profile. biologic and esthetic points of view, gingival recession. The selection of The recession site was character- the root surface should be covered by one mucogingival surgical technique ized by an intact interdental soft and gingival tissues. Therefore, mucogin- over another depends on the patient’s hard tissue height (Miller Class I gingi- gival surgery and bilaminar procedures demands, the local anatomic charac- val recession)25 and a small residual in particular should be considered the teristics of the recession site to be amount of keratinized tissue apical to ideal therapy for root abrasion associ- treated, and other surgical objectives, the exposed root. Therefore, the ated with the gingival recession. including root coverage. The patient potential to obtain complete root cov- The bilaminar procedures enrolled in the present study com- erage (ie, a gingival margin level or adopted in the present study consisted plained about the exposure of the gin- coronal to the CEJ) was present. This of a CTG covered by a coronally gival recession when smiling. Thus, a could also be accomplished by means advanced flap. The graft was posi- good esthetic outcome was an impor- of a coronally advanced flap by itself, tioned inside the abrasion defect and tant objective. A deep abrasion defect since this is a very predictable and sutured just apical to the CEJ to act as altering the tooth emergence profile esthetic mucogingival surgical proce- a “biologic filler” in the concave area was also present, rendering plaque dure.14 Also, patient discomfort is min- and to prevent the collapse of the cov-

Volume 28, Number 1, 2008 Mele.qxd 1/11/08 12:38 PM Page 70

70

ering flap into the abrasive lesion. The not only alter the esthetic harmony of graft was able to compensate for the mucogingival tissues but can also cause lost root structure and provided sta- food accumulation, which is very bility to the covering flap, which could unpleasant for the patient. be positioned coronally on the stable and convex enamel surface. The positioning of the graft just Conclusions apical to the CEJ contributes in two ways to an improved esthetic outcome Within the limits of the present study after performance of the bilaminar pro- it can be suggested that: cedure adopted in the present study: first, it makes the most apical portion of 1. The bilaminar procedure is the first- the anatomic crown (close to the CEJ) choice surgical technique for the available for the positioning of the ker- treatment of gingival recession atinized gingival tissue originally pres- associated with root abrasion. ent apical to the recession defect.27 2. The CTG acts as a biologic filler of Therefore, the chromatic characteristics the abrasion area, preventing the and the thickness of the gingival mar- internal collapse of the covering gin are not modified and are thus indis- pedicle flap. tinguishable from those of the adja- 3. The increase in gingival thickness cent teeth. Second, the apical permits the restoration of a cor- positioning of the graft contributed to rect tooth emergence profile. an increase in the vascular area lateral to the root exposure and thus reduced Further controlled clinical studies the risk of flap dehiscence and unes- will be needed to confirm the efficacy thetic graft exposure. The end result of the presented surgical approach for was satisfying from both the esthetic the treatment of cervical abrasions and the functional points of view, since associated with gingival recession. the coronally advanced flap was able to mask the unesthetic appearance of the graft, and the graft was able to restore References a correct tooth emergence profile. The main advantage of the chosen 1. Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am surgical procedure was that the increase Dent Assoc 2003;134:220–225. in gingival thickness achieved by means 2. Wennstrom JL. Mucogingival surgery. In: of the CTG was not accompanied by an Lang NP, Karring T (eds). Proceedings of excessive growth in the external volume the 1st European Workshop on of soft tissues, whereas it did restore a Periodontology. Berlin: Quintessence, 1994:193–209. correct tooth emergence profile. The negative impact of excessive soft tissue 3. Levitch LC, Bader JD, Shugars DA, Heymann HO. Non-carious cervical thickness on patients’ evaluations of lesions. J Dent 1994;22:195–207. the esthetic appearance of surgically treated area has been demonstrated recently.27 This excessive thickness may

The International Journal of Periodontics & Restorative Dentistry Mele.qxd 1/11/08 12:38 PM Page 71

71

4. Checchi L, Daprile G, Gatto MR, Pelliccioni 16. Grupe HJ, Warren R. Repair of gingival GA. Gingival recession and toothbrushing defects by sliding flap operation. J in an Italian school of dentistry: A pilot Periodontol 1956;49:457–461. study. J Clin Periodontol 1999;26: 17. Guinard EA, Caffesse RG. Treatment of 276–280. localized gingival recession. III. 5. Murtomaa L, Meurman JH, Rytomaa I, Comparison of results obtained with lateral Turtola L. Periodontal status in university sliding and coronally repositioned flaps. J students. J Clin Periodontol 1987;14: Periodontol 1978;457–461. 462–465. 18. Tenebaum H, Klewansky P, Roth JJ. Clinical 6. Loe H, Anerud A, Boysen H. The natural evaluation of gingival recession treated by history of in man: coronally repositioned flap technique. J Prevalence, severity, extent of gingival Periodontol 1980;51:686–690. recession. J Periodontol 1992;63:489–495. 19. Caffesse R, Kon S, Castelli WA, Nasjleti 7. Sangnes G. Traumatization of teeth and CE. Revascularization following the lateral gingiva related to habitual tooth cleaning sliding flap procedure. J Periodontol procedures. J Clin Periodontol 1976;3: 1984;55:352–358. 94–103. 20. Wennstrom J, Zucchelli G. Increased gin- 8. Sangnes G, Gjermo P. Prevalence of oral gival dimensions. A significant factor for soft and hard tissue lesion related to successful outcome of root coverage pro- mechanical tooth cleaning procedures. cedures? A 2-year prospective clinical Community Dent Oral Epidemiol 1976;4: study. J Clin Periodontol 1996;23:770–777. 77–83. 21. Langer B, Langer L. Subepithelial connec- 9. Serino G, Wennström JL, Lindhe J, Eneroth tive tissue graft technique for root cover- L. The prevalence and distribution of gin- age. J Periodontol 1985;56:715–720. gival recession in subjects with a high stan- 22. Nelson SW. The subpedicle connective dard of oral hygiene. J Clin Periodontol tissue graft. A bilaminar reconstructive pro- 1994;21:57–73. cedure for coverage of denuded root sur- 10. Baelum V et al. Oral hygiene, faces. J Periodontol 1987;58:95–102. and periodontal breakdown in adult 23. Ratzke PB. Covering localized areas of root Tanzanians. J Periodontal Res 1986; exposure employing the “envelope tech- 21:221–232. nique.” J Periodontol 1985;56:397–402. 11. Baelum V, Fejerskov O, Manji F. 24. Harris RJ, Harris AW. The coronally posi- Periodontal diseases in adult Kenyans. J tioned pedicle graft with inlaid margins: A Clin Periodontol 1998;15:445–452. predictable method to obtain root cover- 12. Yoneyama T, Okamoto H, Lindhe J, age of shallow defects. Int J Periodontics Socransky SS, Haffajee AD. Probing depth, Restorative Dent 1994;14:229–241. attachment loss and gingival recession. 25. Miller PD. A classification of marginal tis- Findings from a clinical examination in sue recession. Int J Periodontics Ushiku, Japan. J Clin Periodontol 1998;15: Restorative Dent 1985;5(2):8–13. 581–591. 26. Bruno JF. Connective tissue graft tech- 13. Baker D, Seymour G. The possible patho- nique assuring wide root coverage. Int J genesis of gingival recession. A histologi- Periodontics Restorative Dent 1994;14: cal study of induced recession in the rat. J 127–137. Clin Periodontol 1976;3:208–219. 27. Zucchelli G, Amore C, Sforza NM, et al. 14. Löe H, Anerud A, Boysen H, Smith M. The Bilaminar techniques for the treatment of natural history of periodontal disease in recession-type defects. A comparative man. The rate of periodontal destruction study. J Clin Periodontol 2003;30:862–870. before 40 years of age. J Periodontal Res 1978;49:607–620. 15. Zucchelli G, De Sanctis M. Treatment of multiple recession type defects in patients with aesthetic demands. J Clin Periodontol 2000;71:1506–1514.

Volume 28, Number 1, 2008