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Treatment of Recession and Mucogingival Defects Using Connective Tissue Grafts on Teeth and Implants Bueno Rossy, Luis *, Ferrari, Roberto**, Shibli, Jamil ***

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Treatment of Recession and Mucogingival Defects Using Connective Tissue Grafts on Teeth and Implants Bueno Rossy, Luis *, Ferrari, Roberto**, Shibli, Jamil *** Treatment of recession and mucogingival defects using connective tissue grafts on teeth and implants Bueno Rossy, Luis *, Ferrari, Roberto**, Shibli, Jamil *** Abstract Gingival recession is a common clinical finding that entails an esthetic problem, causes hypersensitivity and hinders effective dental plaque control. In the case of implants, recession causes esthetic problems and its progression does not seem to be so frequent (1). Periodontal plastic surgery procedures are indicated in these cases. These techniques must be adapted to treat peri-implant areas (1). While the literature presents different treatment approaches, connective tissue grafts have become the gold standard as they provide a higher rate of success and predictability. Keywords: recession, periodontal and peri-implant plastic surgery, connective tissue grafts. *Professor in the Department of Periodontics, Director of the Postgraduate Degree in Periodontics, Udelar. Uruguay. Specialist in Implant Dentistry, University of Guarulhos. Brazil. ** Specialist in Periodontics, Master’s Degree in Implant Dentistry, Professor in the Postgraduate Degree in Implant Dentistry, University of Guarulhos. Brazil. *** Master’s Degree in Periodontics, PhD in Periodontics, University of Araraquara. Professor and Director in the Postgraduate Degree in Implant Dentistry, University of Guarulhos, Brazil. Received on: 11 Mar 15 - Accepted on: 27 Jul 15 Treatment of recession and mucogingival defects using connective tissue grafts on teeth and implants 35 Methodology of the Literature Review Definition, etiology, gingival and The abovementioned keywords were searched peri-implant recession classification for in the following databases: Pubmed, Tim- Gingival recession is the exposure of root bó, Scielo and the Virtual Health Library. surfaces due to apical migration of the gin- gival tissue margins; the gingival margin mi- grates apical to the cementoenamel junction Introduction (CEJ) (12). It can appear in its localized or Esthetics is one of the most frequent reasons generalized form (13). why patients seek consultation in the areas It is even frequent in developed countries of implant dentistry and periodontics (2-6). with very effective dental plaque control (14). Clinicians have become concerned about the There is no epidemiological data regarding management of peri-implant and periodontal peri-implant recession. Regarding its etiolo- hard and soft tissue (7). The esthetic zone is gy, its causes can be divided into predisposing defined as the area delimited by the lip pe- factors and precipitating factors (15). rimeter (7). Restorative and esthetic dentistry Predisposing factors: Narrow band of at- requires a comprehensive approach: the first tached gingiva (narrow band of attached mu- step of any treatment plan must be basic ther- cosa), high frenum attachment, tooth malpo- apy (8, 9). sition (implant malposition), dentoskeletal Periodontal plastic surgery is defined as the disharmony, bone dehiscences and fenestra- plastic surgical procedures designed to cor- tions, periodontal biotype. rect defects in morphology, position, and/or Thin periodontal biotypes are a predisposing amount of gingiva surrounding the teeth (2). factor for gingival or peri-implant recession This definition also applies to peri-implant (16, 17) and condition the results of any tissue management. Some indications: esthet- plastic surgery, be it periodontal or periim- ic concerns, cases where dental plaque is dif- plant (8, 16). ficult to control in the recession area, prior to An implant placed in these patients may de- orthodontic treatment in cases where move- velop recession and color changes (18). ment can entail risk of recession, and prior to Periodontal biotype and the integrity of bone rehabilitation in areas without attached gingi- structures are crucial when placing an im- va (4). We now have the concept of evidence- plant in esthetic areas (19, 20), especially if based periodontal plastic surgery, which is it is placed immediately. The combination of defined as the “systematic evaluation of clin- connective tissue grafts and immediate place- ically significant scientific evidence intended ment has had excellent results, even on sites to investigate the esthetic and functional ef- where the extracted tooth showed signs of re- fects of treatment of defects of the gingiva, al- cession and lack of attached gingiva (19-23). veolar mucosa, and bone, based on clinician’s Precipitating factors: Traumatic brushing, knowledge and patient’s centered outcomes, inflammatory disease of gingival-periodontal such as perception of esthetic conditions, or peri-implant tissues (Gum disease because functional limitations, pain/discomfort, root of plaque build-up, Periodontitis, Mucositis, sensitivity, level of sociability post-surgery, Peri implantitis), orthodontic treatment and and preferences” (10). Many times there are iatrogenesis (24). differences between the esthetic perceptions Predisposing factors affect the position and of dentists and patients (11). stability of the gingival or mucosal margin 36 Bueno Rossy, Luis *, Ferrari, Roberto**, Shibli, Jamil *** (in implants), and precipitating factors affect cementoenamel junction, the gingival sulcus predisposing factors causing periodontal or has a probing depth lower than 2 mm and periimplant recession. It is said that even with when there is no bleeding on probing. This lack of attached gingiva/peri-implant mucosa coverage can be achieved in a primary or sec- on a patient with good dental plaque control, ondary way. The latter is achieved through the gingiva can remain healthy (25, 26). the coronal migration of the gingival margin The most widely accepted classification of in the months after the surgery (30). gingival recession is the one presented by Bone height and width are the main factors Miller in 1985 (27). It is based on the most determining the height of soft tissue. Factors apical margin of the recession regarding the like dental morphology, location of point of mucogingival junction, and on the amount contact and quality of soft tissue can affect its of tissue loss (gingiva and bone) in interprox- appearance (18-20). The greater the gingival imal areas adjacent to the recession site. recession, the smaller the chance of achieving Dr. Preston Miller estimates the prognosis for complete root coverage (10). each class: complete coverage in class I and Miller’s class I recession has a better prognosis class II, partial coverage in class III, and no than class II recession (10). root coverage in class IV, but he does suggest Smoking has a crucial role in the potential increasing the band of keratinized gingiva. percentage of root coverage (31). The size of papillae, the tooth type and the Regardless of the periodontal plastic surgery degree of proximal bone tissue loss can also technique used, they can all significantly im- affect the prognosis (9). prove the treated sites compared with the ini- In 2011, Dr. Francesco Cairo put forward a tial clinical parameters (10). new classification: R1- gingival recession with Peri-implant soft tissue is similar to periodon- no loss of interproximal attachment; proxi- tal tissue. It is formed by epithelium and a mal cementoenamel junction (CEJ) was not connective attachment parallel to the implant detectable; R2- gingival recession associated with tissue that is more fibrous and less vascu- with loss of interproximal attachment. The larized than periodontal tissue (32). Peri-im- amount of proximal loss was less or equal to plant plastic surgery is indicated for the treat- the vestibular loss, measured from the CEJ ment of peri-implant recession, for increasing (proximal and vestibular) to the depth of the clinical attachment level, for increasing the pocket; R3- the amount of proximal loss was length and width of the attached gingiva, and higher than the vestibular loss, measured from for gingival reconstruction. the CEJ to the depth of the pocket). Level of Periodontal plastic surgery techniques can be proximal attachment is the main parameter applied in cases with no loss of interproximal in this classification. R1 is associated with tissue nor exposure of implant threads. This healthy patients; R2 and R3 are associated provides stability and esthetic results for the with periodontal disease. It does not consider future rehabilitation process, improving tis- the amount of keratinized tissue (28). sue contour, increasing keratinized mucosa Dr. Henry Salama’s classification (1998) and the height of soft tissue to avoid food stresses the importance of proximal bone and impaction and phonation problems (10, 16, the presence of peri-implant papillae to pre- 33, 34). dict esthetic results (19, 20, 29). It is important to respect the 3-mm mesiodis- Complete coverage is achieved when the gin- tal space between implants and the 1.5-mm gival margin is placed at the same level as the space between implant and tooth to facili- Treatment of recession and mucogingival defects using connective tissue grafts on teeth and implants 37 tate the development of papillae. Respecting which justified the development of connec- the 2mm width of the vestibular bone table tive tissue graft techniques (41). will prevent the loss of such table and also They were first described by Edel in 1974, recession. In the apico-coronal direction, the popularized by Langer and Langer in 1985, implant must be placed at 2 mm in the api- and modified by several authors (42-49). cal direction towards the CEJ of the adjacent They were initially
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