Treatment of recession and mucogingival defects using connective tissue grafts on teeth and implants Bueno Rossy, Luis *, Ferrari, Roberto**, Shibli, Jamil ***

Abstract is a common clinical finding that entails an esthetic problem, causes hypersensitivity and hinders effective control. In the case of implants, recession causes esthetic problems and its progression does not seem to be so frequent (1). Periodontal plastic 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 , 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 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 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, 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 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 . 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 , 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 . 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 indicated to thicken kerati- tooth (18, 35). nized gingiva, and are currently indicated for After treatment with connective tissue grafts, the coverage of gingival recession, the thick- the periodontometer can penetrate between ening of soft tissue in edentulous areas, the 1 and 2 mm into the sulcus. Healing is pos- thickening of tissue surrounding implants or sible through the formation of a long junc- teeth, papilla reconstruction, scar correction tional epithelium both on the tooth and the and modification of periodontal or peri-im- implant (10, 36). plant biotype (50). Connective tissue grafts All peri-implant plastic surgery procedures are considered the gold standard for root cov- have a better prognosis if conducted before erage given their predictability, stability over implant placement (34). time, increase in thickness and length/width of keratinized gingiva (10, 51). lIf this technique cannot be applied, a sec- Evolution of mucogingival surgical ond choice might be coronally advanced techniques flaps combined with allogenic or xenogeneic As of 1900 there are indications of mucogin- matrices. The last choice would be coronally gival surgical techniques, but more predict- advanced flaps or guided tissue regeneration able techniques began to appear in the 50s. (10, 51, 52). The first treatments involved a sliding flap op- As there is only limited literature available eration (37). According to the displacement on plastic in connection direction they can be rotated flaps or coro- with implants, the results obtained on teeth nally advanced flaps. The main limitation of should be used as a clinical guide for the these techniques is the need to have attached treatment of peri-implant recession/mucosal gingiva around the area to be treated (38). defects. Selecting the right type of graft (size They are indicated mainly for the treatment and shape) as well as complete root coverage of one tooth/implant. Their main advantag- achieved with the coronally advanced flap es are technical ease and the esthetic results will enhance the final esthetic results (53). achieved. Connective tissue grafts are an essential tool Free grafts were indicated if there was no kera- in periodontal and implant mucogingival sur- tinized tissue (39). Their main disadvantages gery, both functionally and esthetically (54). are the esthetic results and the management They are highly esthetic and predictable for of the palatal area. It is a predictable tech- root coverage: percentages of complete root nique to increase the width of the attached coverage reach 89% (53). gingiva (40). There is partial root coverage in 80.94% of In 1974, Karring proved that the character- cases and complete root coverage in 46.63% istics of epithelial tissue are genetically de- of cases (51). The postoperative process is termined by the subjacent connective tissue, better with connective tissue grafts than with free graft techniques. The double blood sup-

38 Bueno Rossy, Luis *, Ferrari, Roberto**, Shibli, Jamil *** ply to the graft increases its success rate (10, towards the palatal suture (60). The palatal 55, 56). mucosa is thickest with age and is thinner in There is a direct correlation between flap ten- women (60). sion and reduced root coverage, and between The thickness of the palatal mucosa and the tissue thickness and the percentage of cover- height of the palatal vault are essential con- age achieved: flaps more than 0.8 mm thick siderations when selecting a graft harvesting have a better prognosis (57, 58). technique (60). Different techniques have been proposed for The harvesting of an epithelial-connective graft the use of grafts: tunnel techniques (Raetz- is recommended in the case of thin . ke,1985; Allen, 1994) (44, 45); reposition of Once the graft has been harvested, the epithe- the flap partially covering a connective graft lium is eliminated, the graft is repositioned with an epithelial border (Langer, B; Langer, at the donor site, sutured, and surgical cement L.) (43); coronally advanced flaps with ver- is applied. This makes it possible to obtain tical releasing incisions (Nelson, S.; Wenn- the graft more superficially, hence avoiding strom, J.) (46, 47); or without them (Bruno, complications in patients with thin biotypes. J.) (48); or lateral sliding papillae flaps (Har- Replacing the epithelialized graft promotes ris, R.) (49). faster healing (60). The references to consider In all techniques, graft size is greater than are the palatal rugae (anterior area), the pala- bone dehiscence and the graft is placed and tal root of the first molar (posterior area) and sutured at CEJ level (53). the neurovascular bundle coming from the Connective tissue grafts with epithelial bor- greater palatine foramen (medially). der were used by Langer and Langer (1985), Regarding the shape of the and the Allen (1994) and Raetzke (1985) (43-45). position of the palatine artery, Reiser et al. Connective tissue grafts have an exposed (1996) identified three possible palatal vaults: section in the techniques described by Nel- shallow, average and high. According to this son (1987), Bruno (1994), Wennstrom and classification, depending on the size of the Zuchelli (1996) (46-48). The exposed root is arch, the neurovascular bundle is located at usually treated with curettes (53). 7 mm, 12 mm or 17 mm from the adjacent In the past, mucoperiosteal flaps were used tooth (54). Hemorrhaging can be avoided by on the recipient site, but nowadays mucosal respecting this structure. grafts are preferred as they allow for greater Several types of incision provide access to the graft mobility and coverage (59). connective tissue. The initial critical factor is whether we will obtain a graft with or without epithelial Donor sites border. At first this border was included to They are the palate, the inner side of the mu- provide a better transition with the existing coperiosteal flap and/or an edentulous area epithelial border when treating gingival reces- (42). sion (43). But later it was noted that if the Palate harvesting in the area between the ca- epithelium was maintained, the esthetic out- nine and the first molar is the procedure of come was not better, and that the final result choice. It is there that the palatal mucosa is depended mainly on the connective tissue thickest, as it decreases towards the molar graft. Both the natural appearance, shape and area. It increases from the gingival margin color of the new epithelium will depend on the subjacent connective tissue (41). Harvest-

Treatment of recession and mucogingival defects using connective tissue grafts on teeth and implants 39 ing the graft with an epithelial border hinders Post-treatment healing healing by first intention in the donor site, which leads to pain and potential postopera- By using connective tissue grafts or epitheli- tive bleeding. Acrylic plates and haemostatic al-connective grafts we can achieve the for- drugs have been used to prevent such situa- mation of a long with tions (43). a fibrous attachment (66, 67), although a few If the epithelial strip is not harvested with the studies report variable degrees of regeneration graft, access can be achieved with one (sin- (68-70). Only the areas where the gleincision technique), two (angular-incision was preserved were able to form new cemen- technique) or three (trapdoor technique) in- tum (70). cisions. If there are more incisions, the con- Periosteum cannot regenerate after it has nective tissue can be better visualized, but the been detached from the bone surface, there- flap has lower vascularization which may lead fore its presence does not seem to condition to postoperative necrosis (42, 61, 62). The the type of healing the root surface will have current trend is to harvest the graft with only (71-74). The mechanical trauma of detaching one incision (63). DE the periosteum from the bone destroys The single-incision technique has the follow- the cell layer called “cambium layer” in the ing advantages: optimal vascularization of the periosteum. This layer has the potential for cover flap, a small number of sutures, no need regeneration, hence the risk run by detaching for additional haemostatic or compressive it (59). measures, a better postoperative process and the possibility of obtaining grafts of variable Case report 1 dimensions (59). The palatal sliding flap technique is cited as Male patient who attends the School of Den- an alternative to the conventional connective tistry of Udelar to seek treatment for retrac- tissue graft. It has a better prognosis because tion on teeth #23 and #24. It is a case of Mill- the flap remains vascularized and is easier to er Class I recession (figure 1). stabilize. It is specially indicated when used jointly with bone grafts or membranes that make vascularization harder (64). All these different techniques place have in common a connective tissue graft on the root surface to be covered and above it the flap, which provides partial or total coverage. This can be achieved with suturing, but the possibility of using cyanoacrylate has been described with promising results (65). The same technique would be used on im- plants with recession (59).

Figure 1

40 Bueno Rossy, Luis *, Ferrari, Roberto**, Shibli, Jamil *** Treatment plan: 1- Basic therapy adapting his habits to his specific situation (75). 2- Treatment of gingival recession using a connective tissue graft. A tunnel technique was chosen for the procedure. The graft was harvested through a single palatal incision (Figure 2) (33, 63).

Figure 4

As the gingival morphology was not the Figure 2 necessary one at that level, a connective tis- sue graft was placed when the implant was installed (76). Figure 5 shows the results 6 Results 12 months post-treatment (Figure 3). months posttreatment.

Figure 3

Figure 5 Case report 2 Male patient, 43, who attends a private clin- Conclusions ic in Montevideo, Uruguay. He was referred To achieve success it is essential to follow a to another professional to have tooth #22 re- diagnosis protocol strictly (29). Subepithelial placed (figure 4). connective tissue grafts are the gold standard in periodontal/peri-implant surgery. Tissue replacement, vascular areas irrigating the tissue and its attachment are basic con- siderations (77). The need for periodontal/

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Luis Bueno: [email protected]

46 Bueno Rossy, Luis *, Ferrari, Roberto**, Shibli, Jamil ***