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 demon- strated that tooth location is crucial in predicting the level of root cover- age.8 Those authors found that man- dibular incisors, teeth with a high fre- quency 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 © 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. e38 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) tech- nique 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 © 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. e39 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 © 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. e40 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.