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Dental Tribune Middle East & Africa Edition | July-August 2015 31Referral Clinic < Page 30 Dr. Olivier Carcuac DDS, MSc, Specialist in Peri- odontics at Dr Roze & Associates Clinic, Dubai, UAE Odont Dr. - PhD - Department of Periodontology, Institute of Odontology, The Sahlgrenska Academy at University of Go- thenburg, Sweden Periodontist Specialist at Dr. Roze & Associates Dental Clinic olivi- er@dradubai.com About the Author been described in the literature to treat the gingival recessions. - Pedicle soft tissue graft proce- dures A pedicle graft involves repo- sitioning donor tissue from an area adjacent to the recession defect to cover the exposed root surface (coronally advanced flap, laterally sliding flap, bipap- illary flap, tunneling technique). These techniques have many advantages as no second sur- gical site is needed and as the flap retains its own vasculariza- tion from the base of the flap. To minimize tissue trauma and thus improve the aesthetic re- sult, these surgical techniques have over the years been modi- fied and improved (Raetzke 1985, Allen 1994, Bruno 1994, Zucchelli and De Sanctis 2000). The use of enamel matrix de- rivative proteins (Straumann Emdogain®) in conjunction with a coronally advanced flap procedure increases the rate of success and predictability (Cairo et al. 2008). - Free soft tissues graft procedures A free soft tissue graft is indi- cated when there is no accept- able donor site present in the area adjacent to the gingival re- cession defect or when a ticker marginal tissue is desirable. This surgical approach requires a donor site, which is usually the maxillary palatal mucosal tissue. The commonly used free graft techniques include (i) an epi- thelialized graft (Figure 3) and (ii) a sub-epithelial connective tissue graft (Figure 4) placed ei- ther with a pedicle flap or using a tunneling technique. Connective tissue grafts substi- tute materials like Geistlich Mu- cograft® (Sanz et al. 2009, Aroca et al. 2013) may be useful in situ- ations where a large recession defect needs to be treated and graft tissue harvested from the palate would provide an insuffi- cient volume of tissue (Figure 5). The outcome of surgical treat- ment of gingival recession is commonly expressed as success rate (i.e. the average percentage of root that has been covered). The type of recession according to Miller’s classification influ- ences the outcome of the surgi- cal procedure. Factors related to the surgical technique used (tissue tension, flap thickness) may also influence the treat- ment results (Pini Prato et al. 2000, Hwang et al. 2006). Many authors consider that gingival grafting is less successful in smokers than in non-smokers (Trombelli et al 1997, Roccuzzo et al 2002, Erley et al. 2006). Thepresentarticlereportsaclin- Figure 3. Clinical case treated by epithelialized graft: Cl II buccal gingival reces- sion at tooth #41 (a), harvested epithelialized graft (b), positioning and suturing of the epithelialized graft over the recipient site (c); coverage (95%) of the gin- gival recession defect buccal #41 observed at the 2 year-examination following mucogingival surgery (d). Figure 5. Clinical case treated by connective tissue grafts substitute materials (Geistlich Mucograft®): multiple gingival recessions at teeth #34, #35 and #36 (a); Geistlich Mucograft® is positioned under the modified coronal advanced flap (b) which is then sutured (c); healed situation showing a complete root coverage 1 year after surgery (d). Figure 4 : Clinical case treated by sub-epithelial connective tissue graft: multiple gingival recessions at teeth #14, #13 and #12 (a); preparation of the recipient site according to the tunneling technique (b); harvested sub-epithelial connective tissue graft (c) which is positioned under the tunneled flap (d) and sutured (e); 1 year post-op visit : full root coverage was achieved (e). Figure 6. Clinical case treated by coronally advanced flap combined with a sub- epithelial connective tissue graft and the adjunctive use of enamel matrix deriva- tive proteins (Straumann Emdogain®) (a - l) Donor Site Preparation The second step was to harvest a sub-epithelial connective tis- sue graft from the palatal muco- sa. The selected area extended from the distal aspect of the right first premolar to the mesial as- pect of the right first molar. The single-incision technique was used to remove the graft. The graft was removed with a thick- ness of 1.5 mm (Figure 6g) and the palatal site was stitched with single sutures. Graft Positioning and Suturing The graft was positioned under the flap and over the exposed root surface of tooth #13 and secured with 6/0 Prolene® su- tures. The buccal flap was then coronally advanced and sutured with 6/0 Prolene® sutures (Fig- ure 6h). Straumann Emdogain® was applied over the gingival margin for 5 minutes to enhance soft tissue healing (Figure 6i). Postoperative Instructions The patient was instructed to take analgesic medication (par- acetamol, 750 mg) three times a day for 4 days and to use mouth- rinse (0.12% chlorhexidine di- gluconate) twice a day for 15 days. All sutures were removed after 14 days (Figure 6j). The patient was followed up weekly during the first month, monthly up to the third month, and annu- ally up to the second year. Clinical Evaluation The healing process was un- eventful, and the patient did not report pain or discomfort during the overall postoperative period. The color of the tissues was ho- mogeneous 2 weeks following the surgical procedure. Esthetic improvements were observed 12 months postoperatively (Fig- ure 6k) and were maintained during 2 years of follow-up (Fig- ure 6l). No scars were noticed. A full coverage of the recession, a gain of keratinized tissue and an increase in the tissue thickness were observed. Conclusion Gingival recession is a common clinical observation. Underly- ing etiology of the recession should always be investigated and addressed. Appropriate oral hygiene aids and cleaning techniques should be reviewed. In cases where the recession is more significant, causing aesthetic concerns or ongoing problems with root hypersensi- tivity, surgical treatment should be recommended. Due to the highly specialized nature of mu- cogingival surgery and the fact that root coverage procedures are very technique sensitive, pa- tients requiring surgical correc- tion of recession defects should be referred to a periodontist for management. References 1. Allen AL. (1994) Use of the supraperiosteal envelope in soft tissue grafting for root coverage. II. Clinical results. Int J Peri- odontics Restorative Dent 14(4): 302-315 2. Aroca S., Molnár B., Windisch P., Gera I., Salvi G.E., Nikolidakis D., Sulean A. (2013) Treatment of multiple adjacent Miller class I and II gingival recessions with a Modified Coronally Advanced Tunnel (MCAT) technique and a collagen matrix or palatal connective tissue graft. A rand- omized, controlled clinical trial. J Clin Periodontol 40(7):713-720. 3. Bruno JF. (1994). Connective tissue graft technique assuring wide root coverage. Int J Peri- odontics Restorative Dent 14: 127-137 4. Burkhardt, R. & Lang, N.P. (2005). Coverage of localized gingival recessions: comparison of micro- and macro-surgical techniques. J Periodontol 32, 287–293. 5. Cairo F, Pagliaro U, Nieri M. (2008). Treatment of gingival re- cession with coronally advanced flap procedures: a systematic review. J Clin Periodontol 15 (suppl 8): 136-162) 6. Cortellini P, Tonetti M. (2007). A minimally invasive surgical technique with an enamel ma- trix deritative in the regenera- tive treatment of intra-bony de- fects : A novel approach to limit morbidity J Clin Periodontol 34:87-93 7. Daprile G., Gatto M. R., Chec- chi L. (2007) The evolution of buccal gingival recessions in a student population: a 5-year follow-up. J Periodontol 78:611- 614. Cat 1 8. Erley, K.J., Swiec, G.D., Her- old, R., Bisch, F.C. & Peacock, M.E.(2006). Gingival recession treatment with connective tis- sue grafts in smokers and non- smokers. J Periodontol 77, 1148– 1155. 9. Hwang, D. & Wang, H.L. (2006). Flap thickness as a pre- dictor of root coverage: a sys- tematic review. J Periodontol 77, 1625–1634. 10. Kassab MM, Cohen RE. (2003). The etiology and preva- lence of gingival recession. JADA; 134: 220-225 11. Miller PD. (1985). A classifi- cation of marginal tissue reces- sion. Int J Periodontics Restora- tive Dent 5(2): 9-13 12. Pini Prato, G., Pagliaro, U., Baldi, C., Nieri, M., Saletta, D., Cairo, F. & Cortellini, P. (2000a). Coronally advanced flap proce- dure for root coverage. Flap with tension versus flap without ten- sion: A randomized controlled clinical study. J Periodontol 71, 188–201 Editorial note: The full list of references is avail- able from the publisher. ical case after a 2-year follow-up in which a coronally advanced flap was used in combination with a sub-epithelial connective tissue graft and enamel matrix derivative proteins (Straumann Emdogain®) to treat a single gingival recession. Clinical case A 39-year-old male patient was referred to our Clinic for evalu- ation and treatment of a single gingival recession defect at tooth #13. The patient presented good systemic health and non-smok- er. He brushed his teeth with a hard-bristle toothbrush using horizontal motions. His chief complaints were esthetics and root sensitivity. The clinical examination re- vealed a plaque index (PI) of 8% and a gingival index (GI) of 5%, with a 3 mm probing depth. Tooth #13 was in infraclusion and aplasia of tooth #12 was noticed. At first examination (baseline), tooth #13 showed a 5mm large and 4mm deep class I Miller’s type buccal gingival recession defect (figure 6a). The gingival recession defect was caused by anatomic features as- sociated with traumatic tooth- brushing. The patient, who refused ortho- dontic treatment, underwent teeth polishing, oral hygiene instructions with appropriate brushing technique (i.e. modi- fied Bass technique), using of a soft-bristle toothbrush. After 1 month, coronally advanced flap was proposed in association with a sub-epithelial connective tissue graft and the adjunctive use of enamel matrix derivative proteins (Straumann Emdo- gain®), aiming for root coverage of teeth #13. Receptor Site Preparation Following local anesthesia, the exposed root surface was scaled. A sulcular incision was then made through the buccal aspect of the tooth with a #MB69 micro-blade. The incision was extended horizontally towards the adjacent interdental area at a predetermined level. Two vertical, diverging releasing in- cisions were performed (Figure 6b). Split-thickness flaps were elevated on both sides of the recession and continued in full- thickness with an extension that corresponds to the amount of flap displacement (Figure 6c). The releasing incisions were extended into the alveolar mu- cosa and a periosteal incision was performed in the most api- cal portion to eliminate tension and allow the coronal displace- ment of the flap (Figure 6d). The buccal aspect of the interdental papillae was de-epithelialized distally and mesially in order to secure anchorage of the flap onto a connective recipient site. Root conditioning Root conditioning using Strau- mann PrefGel® (EDTA 24%) was performed on the root sur- face for 2 minutes (Figure 6e) followed by abundant saline rinse. The root surface was then air-dried and Straumann Emdo- gain® applied from the apical to the coronal part of the exposed root surface (Figure 6f).