Modified Free Gingival Graft Technique for Root Coverage at Mandibular Incisors: a Case Series

e37

Modified Free Gingival Graft Technique for Root Coverage at Mandibular Incisors: A Case Series

Olivier Carcuac, DDS, MSD, PhD1 Gingival recession defects (GRDs), Jan Derks, DDS, MSD, PhD1 defined as displacement of the gingival margin apical to the ce- mentoenamel junction (CEJ),1 are frequent findings in the general population.2 According to Albandar et al,3 who examined almost 10,000 Numerous surgical techniques for root coverage have been suggested with adults aged 30 to 90 years in the different degrees of success, as assessed by the proportion of complete United States, gingival recessions root coverage. Mandibular incisors, teeth with a high frequency of gingival ≥ 1 mm were most prevalent at recession defects (GRDs), were associated with the least favorable outcomes maxillary first molars and mandibu- due to unfavorable anatomical conditions. In the present series of three cases, a modified version of the free gingival graft technique for the purpose of root lar central incisors, both affecting coverage at mandibular incisors is illustrated. The purpose of the modification 35% of all individuals. of the original technique was to achieve improved blood supply from the Numerous surgical techniques recipient site to the graft, with the ultimate aim of enhancing predictability and for root coverage have been sug- outcomes of the procedure. In all included cases, complete or almost complete gested with different degrees of root coverage was achieved at challenging GRDs in the mandibular incisor area. success, as assessed by the pro- Int J Periodontics Restorative Dent 2021;41:e37–e44. doi: 10.11607/prd.5398 portion of complete root coverage (CRC).4,5 The influence of anatomical factors, such as a shallow vestibule, root prominence, and limited width of keratinized tissue, on treatment outcomes has been highlighted.6,7 Moreover, Zucchelli et al demonstrated that tooth location is crucial in predicting the level of root coverage.8 Those authors found that mandibular incisors, teeth with a high frequency of GRDs,3 were associated with the least favorable outcomes. These lower success rates may be 1Department of Periodontology, Institute of Odontology, Sahlgrenska Academy, University explained by the aforementioned, of Gothenburg, Gothenburg, Sweden. unfavorable anatomical conditions typically found at such sites: margin- Correspondence to: Dr Olivier Carcuac, Department of Periodontology, Institute of Odontology, The Sahlgrenska Academy at University of Gothenburg, Box 450, SE 405 30 al frenum attachment, high muscle Göteborg, Sweden. Email: [email protected] pull, and a shallow vestibule.9 Different surgical procedures Submitted August 25, 2020; accepted October 12, 2020. ©2021 by Quintessence Publishing Co Inc. aiming at root coverage have been

Volume 41, Number 2, 2021

Fig 2 Initial status of Patient 2. Note the Fig 1 Initial status of Patient 1. Note the 5-mm recession depth, the thin phenotype, Fig 3 Initial status of Patient 3. Note the 5-mm recession depth, the thin phenotype, the high frenulum attachment, and the lack 6-mm recession depth, the thin phenotype, the high frenulum attachment, and the of any attached/keratinized gingival tissues the frenulum, the high muscle pull, and shallow vestibule at the mandibular right apical to the defect at the mandibular right the shallow vestibule at the mandibular left central incisor. central incisor. central incisor.

described in the literature.10 While Materials and Methods Initial Status the free gingival graft (FGG) technique was shown to be the most Three patients presenting with GRDs Patient 1 was a 28-year-old woman. effective procedure for gingival at mandibular incisors were treated The patient presented with a 5-mm augmentation at sites with minimal using a modified FGG technique. buccal GRD (RT1) at the mandibu- amount of keratinized tissue,11 it was Treatment was carried out aiming at lar right central incisor. The band initially suggested to be used for the outcomes CRC and an increase of keratinized tissue apically to the root coverage.12–14 However, great in keratinized tissue dimensions. GRD was < 1 mm wide (Fig 1). The variability in terms of proportion All patients were in good general patient requested root coverage at of root coverage has been report- health, were nonsmokers, were tooth 41 for esthetic reasons. ed when applying this technique periodontally healthy, had a thin Patient 2 was a 41-year-old man. (range: 11% to 87%; mean: 63%).15 phenotype, and presented with low The patient presented with a 5-mm One of the challenges when using full-mouth plaque scores and with buccal GRD (RT1) at the mandibu- FGG for the purpose of root cover- at least one buccal GRD (recession lar right central incisor. The labial age may be the inadequate blood type [RT] 1)16 in the mandibular inci- torque of the root was addressed by supply to the portion of the graft sor area. The tooth/teeth to be treat- orthodontic treatment prior to the placed on the exposed root surface. ed demonstrated a probing pocket surgical procedure (Fig 2). The pa- The purpose of this case series depth (PPD) of ≤ 3 mm, no excessive tient requested root coverage due was to present a modified version tooth mobility, no cervical composite to hypersensitivity. of the FGG technique, aiming at restorations or noncarious cervical Patient 3 was a 32-year-old improving the vascularity of the re- lesions, a shallow vestibule, and no woman. The patient presented a cipient site over the denuded root excessive crowding or misalignment. 6-mm buccal GRD (RT1) at the man- surface. Ultimately, improved blood The present case series was dibular left central incisor. Gingival supply to the graft could enhance carried out in accordance with the tissues were thin (Fig 3), and the predictability and treatment out- Declaration of Helsinki. All patients patient suffered from pronounced comes of root coverage procedures. received detailed information re- hypersensitivity. garding the planned intervention and alternative methods. Informed consent was obtained.

The International Journal of Periodontics & Restorative Dentistry

a b Fig 4 (a) The recipient site, extended to the adjacent tooth, was delimited coronally by a horizontal incision placed at the level of the CEJ and laterally by two divergent releasing incisions. (b) A thin partial-thickness flap was then created and excised.

Initial Therapy and Clinical Preparing the recipient site tical and slightly diverging, coronally Measurements Following local anesthesia, the ex- directed incisions were performed, posed root surface was instrument- outlining the connective tissue Following a screening examination, ed using Gracey curettes and thor- pedicle flap. The flap was then care- all patients received instructions in oughly rinsed with saline. Initially, fully dissected from the periosteum proper oral hygiene measures, scal- an intrasulcular incision was made in a coronal direction. No dissec- ing, and professional tooth clean- along the exposed root surface, fol- tion was performed in the region ing. lowed by 2-mm–long horizontal inci- directly apical to the root surface, Measurements were performed sions placed at the level of the CEJ. leaving the flap attached at its most with a manual periodontal probe The area of the recipient site was coronal aspect. The connective tis- and rounded to the nearest millime- thereby extended to the adjacent sue pedicle graft was then flipped ter mark. The following parameters tooth. From each horizontal incision, coronally and anchored over the ex- were recorded 1 week prior to sur- vertical releasing incisions were posed root surface through laterally gical therapy and at the 6-month then placed in a diverging manner, placed biorebsorbable sutures (6-0 follow-up visit: (1) PPD, measured extending well into the alveolar mu- Monocryl 6/0, Ethicon, Johnson & from the gingival margin to the bot- cosa. A thin partial-thickness flap Johnson) (Fig 5). tom of the pocket; and (2) recession was created and excised, thereby depth, measured from the CEJ to delimiting the recipient area. The Harvesting the FGG the gingival margin at the midfacial dimension of the recipient site was The graft dimensions were outlined aspect of the tooth. carefully measured and reported on in the palate adjacent to the pre- a foil template (Fig 4). molars and first molar using the foil template created to match the re- Surgical Procedure Preparing the connective tissue cipient bed. A partial-thickness graft pedicle flap consisting of epithelium and a thin All surgical procedures were per- Apical to the recession defect, at layer of underlying connective tis- formed by one experienced perio- a distance corresponding to the sue was harvested, about 1.5 mm dontist (O.C.). height of the exposed root surface, thick. After harvesting the FGG, sev- one horizontal incision and two ver- eral drops of high-viscosity cyano-

Volume 41, Number 2, 2021

a b Fig 5 Illustrations of (a) the dissection of the connective tissue pedicle graft and (b) its coronal placement.

Fig 6 Illustration of the application of the free gingival graft to the recipient site. Stability is achieved through simple interrupted and vertically suspended sutures.

acrylate tissue adhesive (PeriAcryl, was continued along the lateral bor- idine digluconate solution and to GluStitch) were applied to the pala- ders of the graft until complete sta- avoid any mechanical trauma, tooth- tal wound before covering it with a bility of the graft was achieved. Ver- brushing, and excessive muscle porcine-derived collagen sponge tically suspended cross sutures were traction in the surgical area for 2 (Collacone, Botiss).17,18 The sponge placed, when needed, to achieve a weeks. Sutures were removed after was stabilized by crossed sutures slight compression of the graft to the 14 days, and patients were instruct- (6-0 nonresorbable monofilament; recipient site (Fig 6). ed to resume mechanical plaque Prolene, Johnson & Johnson). Clinical view of the flap prepa- control measures using a soft tooth- ration and graft placements are brush for the subsequent 2 months. Placing the graft shown in Figs 7 to 9. Patients were recalled at 1, 3, and The FGG was adapted to the recipi- 6 months after surgery for profes- ent site and anchored to the perios- Postsurgical instructions and infec- sional tooth cleaning and reinforce- teum by means of simple interrupted tion control ment of patient-performed infection sutures using a 6-0 nonresorbable Patients were firmly instructed to control. monofilament (Prolene). Suturing rinse twice daily with 0.2% chlorhex-

The International Journal of Periodontics & Restorative Dentistry

a b c Fig 7 Surgical procedure in Patient 1. (a) Preparation of the recipient site and (b) translocation of the connective tissue pedicle graft. (c) The FGG was fixated with simple and suspended sutures.

a b c Fig 8 Surgical procedure in Patient 2. (a) Preparation of the recipient site and (b) positioning of the pedicle graft over the exposed root. (c) The FGG was fixated with simple sutures.

a b c Fig 9 Surgical procedure in Patient 3. (a) Preparation of the recipient site and (b) positioning of the pedicle graft over the exposed root surface. (c) The FGG was fixated with simple sutures.

Volume 41, Number 2, 2021

a b Fig 10 Healing in Patient 1. (a) Two weeks after the procedure, no signs of necrosis were observed, and sutures were removed. (b) At 6 months, the previously exposed root was almost completely covered, and a wide band of keratinized and attached gingiva was present.

a b Fig 11 Healing in Patient 2. (a) The clinical examination 2 weeks after the procedure revealed uneventful healing. (b) CRC was achieved at 6 months, and the width of keratinized and attached gingiva was increased.

Results vealed healthy periodontal condi- lying flap as well as from both the tions, free of any deep pocketing or periodontal and supraperiosteal Postsurgical healing was uneventful bleeding on probing. plexus from the areas bordering the for all patients. Good healing and recession defect,19,20 the healing of no signs of necrosis of the grafted the nonsubmerged graft depends tissues were noted at suture remov- Discussion primarily on the formation of anas- al (Figs 10a, 11a, and 12a). At the tomoses between existing vessels in 6-month evaluation, CRC or near- In root-coverage procedures, the the graft and circulation in the peri- CRC was achieved in all patients avascular surface of the exposed osteal connective tissue bed via new (Figs 10b, 11b, and 12b). In addi- root represents a challenge in sinusoidal vessels.21 Thus, the size of tion, the amount of keratinized and wound healing. While revascular- the connective tissue bed relative attached soft tissue was increased. ization of a submerged connective to the defect area to be covered is The clinical examination also re- tissue graft occurs from the over- one important factor determining

The International Journal of Periodontics & Restorative Dentistry

a b Fig 12 Healing in Patient 3. (a) Two weeks after the procedure, no signs of necrosis were observed, and sutures were removed. (b) At 6 months, the previously exposed root was almost completely covered, and a wide band of keratinized and attached gingiva was present.

the survival of such nonsubmerged were reported. In this context, it FGG technique, in which vascular- grafts: The larger the GRD, the larg- should be noted that the majority ity to the gingival graft is enhanced er the avascular surface, resulting in of patients presenting with GRDs through an underlying connective compromised blood supply and a at mandibular incisors also display tissue pedicle flap. In all includ- higher risk for postoperative necro- a thin phenotype, characterized by ed cases, CRC or near-CRC was sis of the graft. thin gingival tissues and prominent achieved at challenging GRDs in In the three cases presented in roots. Thus, it may be argued that the mandibular incisor area. In ad- this report, the denuded root sur- the harvesting of a connective tis- dition, the amount of keratinized face was covered by a connective sue flap from the areas lateral to a and attached soft tissue increased tissue pedicle graft prior to cover- GRD is more technically demanding after 6 months of healing. How- age by an FGG. The connective when compared to the area located ever, it should be kept in mind that tissue pedicle graft was “flipped” apically to the recession. the number of patients included in from its base, located apically to the Recently, Zucchelli et al8 dem- the present report is small, that the recession defect, and its purpose onstrated the importance of tooth follow-up period covered only 6 was to improve the vascularity of location when using coronally ad- months, and that clinical recommen- the underlying recipient site to the vanced flaps (CAFs) with or without dations ultimately need to be based graft over the sensitive defect area. connective tissue grafts (CTGs) for on randomized controlled trials. A similar modification of the FGG isolated GRDs. The authors report- technique was previously proposed: ed that mandibular incisors were In 1982, Carvalho et al22 included 10 found to be the most challenging Conclusions patients with localized GRDs at man- teeth to be treated by this tech- dibular incisors in a case series. Con- nique due to the typically unfavor- This article represents a proof-of- nective tissue pedicle grafts were able anatomical conditions, such as principle for a modified FGG ap- obtained from both sides of the marginal frenum attachment, high proach for the management of GRD recession and displaced laterally to muscle pull, and shallow vestibule. at mandibular incisors. Randomized cover the exposed root. According Thus, modified FGG could present controlled trials comparing modi- to the authors, the treated sites dis- a valid alternative to CAF+CTG in fied FGG to conventional FGG and played a good band of keratinized such cases. other commonly applied techniques tissue and significant root coverage The aim of this article was to il- are required to assess the long-term after healing, but no measurements lustrate the use of a novel modified efficacy of this novel technique in

Volume 41, Number 2, 2021

© 2021 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. e44 terms of root coverage and patient- 6. Huang LH, Neiva REF, Wang HL. Factors 14. Holbrook T, Ochsenbein C. Complete affecting the outcomes of coronally ad- coverage of the denuded root surface reported outcomes. vanced flap root coverage procedure. J with a one-stage gingival graft. Int J Periodontol 2005;76:1729–1734. Periodontics Restorative Dent 1983;3:8– 7. Aroca S, Barbieri A, Clementini M, 27. Renouard F, de Sanctis M. Treatment 15. Wennström JL. Mucogingival therapy. Acknowledgments of Class III multiple gingival recessions: Ann Periodontol 1996;1:671–701. Prognostic factors for achieving a com- 16. Cairo F, Nieri M, Cincinelli S, Mervelt plete root coverage. J Clin Periodontol J, Pagliaro U. The interproximal clini- The authors declare no conflicts of interest. 2018;45:861–868. cal attachment level to classify gingival 8. Zucchelli G, Tavelli L, Barootchi S, et al. recessions and predict root coverage The influence of tooth location on the outcomes: An explorative and reliability outcomes of multiple adjacent gingival study. J Clin Periodontol 2011;38:661– References recessions treated with coronally ad- 666. vanced flap: A multicenter re‐analysis 17. Tavelli L, Asa’ad F, Acunzo R, Pagni G, 1. Consensus report on mucogingival study. J Periodontol 2019;90:1244–1251. Consonni D, Rasperini G. Minimizing pa- therapy. Proceedings of the World 9. Zucchelli G, Tavelli L, Ravidà A, tient morbidity following palatal gingi- Workshop in Periodontics. Ann Peri- Stefanini M, Suárez- López Del Amo val harvesting: A randomized controlled odontol 1996;1:702–706. F, Wang HL. Influence of tooth loca- clinical study. Int J Periodontics Restor- 2. Serino G, Wennström JL, Lindhe J, tion on coronally advanced flap proce- ative Dent 2018;38:e127–e134. Eneroth L. The prevalence and distri- dures for root coverage. J Periodontol 18. Tavelli L, Ravidà A, Saleh MHA, et al. bution of gingival recession in subjects 2018;89:1428–1441. Pain perception following epithelial- with a high standard of oral hygiene. J 10. Cairo F. Periodontal plastic surgery ized gingival graft harvesting: A ran- Clin Periodontol 1994;21:57–63. of gingival recessions at single and domized clinical trial. Clin Oral Investig 3. Albandar JM, Kingman A. Gingival re- multiple teeth. Periodontol 2000 2019;23:459–468. cession, gingival bleeding, and dental 2017;75:296–316. 19. Guiha R, el Khodeiry S, Mota L, Caffesse calculus in adults 30 years of age and 11. Tonetti MS, Jepsen S, Working Group R. Histological evaluation of healing and older in the United States, 1988–1994. J 2 of the European Workshop on Peri- revascularization of the subepithelial Periodontol 1999;70:30–43. odontology. Clinical efficacy of peri- connective tissue graft. J Periodontol 4. Cairo F, Nieri M, Pagliaro U. Efficacy of odontal plastic surgery procedures: 2001;72:470–478. periodontal plastic surgery procedures Consensus report of Group 2 of the 20. Janson WA, Ruben MP, Kramer GM, in the treatment of localized facial gin- 10th European Workshop on Periodon- Bloom AA, Turner H. Development gival recessions. A systematic review. J tology. J Clin Periodontol 2014;41(suppl of the blood supply to split-thickness Clin Periodontol 2014;41(suppl 15):s44– 15):s36–s43. free gingival autografts. J Periodontol s62. 12. Miller PD Jr. Root coverage with the free 1969;40:707–716. 5. Graziani F, Gennai S, Roldán S, et al. gingival graft. Factors associated with 21. Nobuto T, Imai H, Yamaoka A. Micro- Efficacy of periodontal plastic pro- incomplete coverage. J Periodontol vascularization of the free gingival auto- cedures in the treatment of multiple 1987;58:674– 681. graft. J Periodontol 1988;59:639–646. gingival recessions. J Clin Periodontol 13. Nabers JM. Free gingival grafts. Peri- 22. Carvalho JC, Pustiglioni FE, Kon S. 2014;41(suppl 15):s63–s76. odontics 1966;4:243–245. Combination of a connective tissue pedicle flap with a free gingival graft to cover localized gingival recession. Int J Periodontics Restorative Dent 1982;2:26–33.

The International Journal of Periodontics & Restorative Dentistry