Gingival recession: part 3. Surgical management using free grafts and guided tissue regeneration

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1 Gingivl reession: prt 3. Surgil mngement using free grfts nd guided tissue regenertion M. Ptel, 1 P. J. Nixon 2 nd M. F. W.-Y. Chn 3 VERIFIABLE CPD PAPER IN BRIEF Free grfts re n lterntive to pedile grfts nd re the tretment of hoie in res where the gingivl iotype is thin or there is lk of kertinised tissue. Guided tissue regenertion or the use of llogrfts nd xenogrfts void the need of seond (donor) surgil site. The suepithelil onnetive tissue grft with ornonlly dvned flp is onsidered to e the gold stndrd grfting proedure. PRACTICE This pper is the third in three prt series looking t the etiology nd mngement of gingivl reession. Prt 1 in this series disussed the etiology of gingivl reession nd the non-surgil mngement. Prt 2 disussed in detil the ftors ffeting the outome of periodontl surgery nd the use of pedile flps. This pper ims to disuss the surgil options ville to orret lolised reession defets using free grfts nd guided tissue regenertion. INTRODUCTION Gingivl reession is defined s the pil displement of the gingivl mrgin from the emento-enmel juntion (CEJ). 1 The min inditions for surgil intervention to orret reession defets inlude the need to improve lolised soft tissue esthetis, to redue hypersensitivity, improve plque ontrol nd prevent further progression of reession defet. 2 Miller 3 lssified gingivl reession into four tegories whih were disussed in the seond rtile in this series. These tegories n e used to ssess the reession defet present nd predit the possile outome of ny periodontl plsti surgery proedure whih would im over the reession defet nd restore esthetis. FACTORS AFFECTING OUTCOME OF PERIODONTAL PLASTIC SURGERY There re severl ftors tht n ffet the outome of ny periodontl plsti surgery proedures. These re listed elow nd were disussed in detil in the previous rtile in this series. These should e ssessed nd orreted where possile efore surgery s prt of the pre-surgil preprtion or during surgery in order to improve the overll suess of the proedure: 1* Speilist Registrr in Restortive Dentistry, 2,3 Consultnts in Restortive Dentistry, Deprtment of Restortive Dentistry, Leeds Dentl Institute, Clrendon Wy, Leeds, LS2 9LU *Correspondene to: Dr Mitl Ptel Emil: mitlptel@nhs.net Refereed Pper Aepted 21 July 2011 DOI: /sj.dj British Dentl Journl 2011; 211: Condition of root surfe presene of lulus, ries, ontminted ementum or restortions on root surfe Prominent frenl tthments Depth of vestiule Tissue type Size of the reession defet nd grft mteril Thikness of split thikness flps rised Smoking Poor orl hygiene. FREE GRAFTS IN THE MANAGE- MENT OF GINGIVAL RECESSION Free grfts involve hrvesting soft tissue from distnt site in the mouth nd grfting it over lolised reession defet. In omprison to pedile grfts whih involve one surgil site, the free grfts involve two surgil sites with the reession defet eing the primry reipient site nd the seondry donor site whih is usully the mxillry pltl tissue. The other min differene is tht the grfted tissue does not hve its own lood supply nd therefore relies on lood supply nd nourishment from the reipient site. In order for this to our there needs to e dequte overlp of the grft tissue with the soft tissue round the reession defet t the reipient site. Immoilistion of the grft t the reipient site is lso essentil. The ommonly used free grft tehniques inlude n epithelilised free gingivl grft nd suepithelil onnetive tissue grft pled either with pedile flp, envelope tehnique or using tunnelling tehnique. Fig. 1 Gingivl reession used y high frenl tthment nd mnged using free gingivl grft: () pre-op; () immeditely post-op; () five months post-surgery Epithelilised free gingivl grft linil tehnique The free gingivl grft (Figs 1-), first desried y Ners, 4 involves hrvesting epithelilised tissue from the plte nd pling it on onnetive tissue ed t BRITISH DENTAL JOURNAL VOLUME 211 NO. 8 OCT

2 Fig. 2 Shows reession defet treted with onnetive tissue grft: () pre-opertive view of reession defet t UL2 plnned for onnetive tissue grft with oronlly positioned flp; () linil pperne immeditely post-op; () linil pperne following heling of soft tissues the reipient site with the im of overing the exposed root surfe nd/or inresing the width of kertinised tissue t the reipient site. The epithelilised free gingivl grft n e used in either one stge or two-stge proedure to over the exposed root surfe. In one stge proedure the grft is pled diretly over the root surfe (Figs 1-) wheres in two-stge proedure the grft is pled pil to the reession defet nd following heling seond pedil flp is rised nd moved oronlly to over the exposed root surfe. The two-stge proedure is often used when the gingivl iotype is thin t the reipient site. The linil tehnique for n epithelilised free gingivl grft involves prepring the reipient site y rising split thikness flp round the reession defet or pil to the reession defet for two stge proedure, to remove the epithelil surfe lyer nd expose the underlying onnetive tissue while ensuring the periosteum remins intt. This is importnt s the grft does not hve its own lood supply nd will initilly rely on eing nourished y the trnsudte from the ollterl lood supply while ngiogenesis tkes ple from the host tissue into the grfted tissue. It is lso importnt to ensure tht the reipient site prepred is lrge enough to llow dequte overlp of the donor tissue onto the peripherl reipient ed to ensure suffiient lood supply; usully 3 mm extension round the exposed root surfe mrgin is minimum. The grft tissue is then hrvested from the plte etween the pltl root of the first molr nd the distl line ngle of the upper nine s this is the region where the thikest tissue n e found. 5 d e f Fig. 3 Shows onnetive tissue grft eing rised from the plte nd pled over reession defet: () onnetive tissue grft hrvested from the plte using three sided flp; () hrvested grft tissue; () donor site flp sutured k; (d-e) ross setionl digrmmti view showing pltl onnetive tissue grft eing hrvested; (f) grft sutured in ple over reession defet 354 BRITISH DENTAL JOURNAL VOLUME 211 NO. 8 OCT

3 It is importnt to py ttention to lol ntomy to void the greter nd lesser pltine nerves nd lood vessels. Reiser et l. 5 reported tht this neurovsulr undle on verge lies pproximtely 12 mm from the emento-enmel juntion of the mxillry premolrs nd molrs. It is lso dvisle to void the pltl ruge s this will result in poor estheti pperne of the grfted tissue whih is diffiult to eliminte even with surgery. 6 The size of the grft needed depends on the mount of root overge required nd should e mesured using periodontl proe or sterile foil templte. The grft tissue hrvested should e pproximtely 33% greter thn the mount required to ompenste for the post opertive shrinkge tht will our. 7 An re equivlent to the size of the grft required n e mrked out on the plte using fresh lde, tissue mrking pen or y mking pressure indenttions using the periodontl proe. The grft is then rised keeping n even thikness of 1.5 mm. One the grft hs een hrvested ny ftty tissue must e removed using fine surgil sissor or slpel leving only onnetive tissue under the surfe epithelium. The grft should then e sutured in ple, immoilised nd gentle pressure pplied for few minutes. A periodontl dressing n e pplied if neessry. The donor site n e left to grnulte over or periodontl dressing n e pled with the id of n ryli surgil dressing plte. Alterntively, the donor site n e overed with Orse protetive pste (ConTe In, USA). One disdvntge of the epithelilised free gingivl grft is tht it retins the olour of the donor tissue. This is often different to the reipient site nd therefore this proedure should e voided in res of high estheti onern. 8 Suepithelil onnetive tissue grft linil tehnique The suepithelil onnetive tissue (CT) grft ws first desried y Retzke 9 with the use of n envelope pedile flp. Lnger nd Lnger 10 desried n lterntive tehnique whih involved pling the suepithelil onnetive tissue grft with oronlly positioned pedile flp for overing exposed root surfes. Figures 2- show linil se treted using e g Fig. 4 Reession defet treted with onnetive tissue grft nd doule ppill pedile flp: () pre-opertive view showing 10 mm reession defet on UR3; () doule ppill flp is rised; () sutured together in the midline over the reession defet; (d) onnetive tissue grft rised from the plte is pled over the reession defet; (e) grft sutured into ple over reession defet; (f) grft is then overed with the doule ppill pedile flp; (g) finl post-op view shows signifint root overge ut not omplete root overge; (h) the finl ridge utment is pled t the level of the new gingivl mrgin to restore esthetis this tehnique. As well s providing root overge the suepithelil onnetive tissue grft n lso e used to inrese the thikness of the gingivl tissues in res of gingivl reession to redue the risk of further reession in the future. d f h The proedure involves hrvesting onnetive tissue from the plte nd pling it etween split thikness pedile flp nd the onnetive tissue tthed to the underlying periosteum t the reipient site (Figs 3-f). The pltl flp is rised y mesuring out BRITISH DENTAL JOURNAL VOLUME 211 NO. 8 OCT

4 the size of the grft required using the tehniques disussed for the epithelilised free gingivl grft ove. A three-sided inision is then mde on the pltl tissue to rete trp door (Fig. 3). Alterntive tehniques desried in the literture for this inlude two-sided flp or even single inision. The superfiil epithelil lyer is then disseted wy to expose the underlying onnetive tissue whih n then e hrvested (Fig. 3). The pltl donor site will then require the epithelil flp suturing k (Fig. 3). One the onnetive tissue grft hs een hrvested ny ftty tissue is removed nd the onnetive tissue is pled into the reipient site with the oronl mrgin pled t the level of the CEJ or slightly ove (Fig. 3f). The grft is sutured into ple using fine, preferly resorle sutures. The ul flp is then pulled over the CT grft nd sutured with sling suture using fine suture. Gentle pressure is then pplied to the wound for few minutes nd periodontl dressing n e pled if neessry. The grfted onnetive tissue should extend t lest 3 mm eyond the mrgins of the reession defet to llow suffiient overlp with the reipient onnetive tissue ed. This llows the grfted tissue to enefit from doule lood supply from oth the surrounding onnetive tissue nd the overlying split thikness flp on the outside. The reipient site n e prepred using vrying tehniques. A uff of epithelil tissue is removed from round the reession site. Creviulr inision with relieving inisions n e mde to rise three sided split thikness flp round the reession defet, 10 lterntively n envelope flp n e rised y extending the reviulr inision round djent teeth nd then undermining the tissue to rete pouh. 9,11 Avoiding relieving inisions ensures etter lood supply to the flp nd therefore more preditle outome. Alterntive tehniques inlude those desried y Nelson 12 whih involved the omintion of CT grft with doule ppill repositioned flp (Figs 4-h) or lterlly repositioned pedile flp nd Zlegui et l. 13 who desried the use of tunnelling tehnique (Figs 5-h). GUIDED TISSUE REGENERATION Vrious uthors hve desried the use of resorle nd non-resorle e g Fig. 5 Connetive tissue grft rried out using the tunnelling tehnique: () reession defet over upper entrl inisors; (-) tunnel flp prepred to reeive onnetive tissue grft; (d) onnetive tissue grft hrvested from the plte; (e) the grft is pssed through the tunnel preprtion; (f) nd pked under the lil soft tissue up towrds the reession defet; (g) finl pperne immeditely post plement of the grft; (h) piture shows reession defet t the two month review memrnes for guided tissue regenertion (GTR) to tret reession defets. 14,15 This involves rising full thikness flp round the reession defet, pling memrne nd overing it with oronlly dvned flp. The im of this tretment is to prevent the formtion of long juntionl epithelium ut insted llow norml onnetive tissue tthment to the exposed root surfe. Compred to the trditionl grfting tehniques desried ove GTR hs the dvntge of eliminting the need of seond surgil wound ut if non-resorle memrnes re used d f h seond surgil proedure is required to remove the memrne. Results hve shown tht there is no signifint differene in the outome etween resorle nd non resorle memrnes. 16 While results of guided tissue regenertion hve shown signifint root overge is hievle, the outome is no etter thn the trditionl tehniques desried ove 17 nd on the down side they rry the risk of memrne exposure leding to infetion, foreign ody retion nd diffiulties in primry wound losure. 18, BRITISH DENTAL JOURNAL VOLUME 211 NO. 8 OCT

5 THE USE OF ALLOGRAFTS AND XENOGRAFTS IN MANAGEMENT OF GINGIVAL RECESSION The use of llogrfts nd xenogrfts hve lso reently eome ville nd void the need of seond donor site wound. Silverstein nd Clln 20 desried the use of n ellulr derml mtrix llogrft s n lterntive to the epithelilised free gingivl grft nd Snz et l. 21 hve desried the use of ollgen mtrix xenogrft s n lterntive to the free onnetive tissue grft. While these proedures look promising further reserh is required to ssess the long term outome of these mterils ompred to trditionl tehniques desried ove. A reent systemti review onluded tht these grfts my e useful in situtions where lrge reession defet needs to e treted nd grft tissue hrvested from the plte would provide n insuffiient volume of tissue. The use of Xenogrft one sustitutes omined with ollgen memrnes hs een dvoted in the tretment of gingivl reession, s well s enmel mtrix proteins together with oronlly dvned flp. However, neither of these tehniques hs een shown to demonstrte ny signifint enefit over trditionl grfting proedures. 22 SUTURING Approprite seletion of suture size, mteril nd suture needles will lso ffet the outome of the surgery. In periodontl plsti surgery improved outome is hieved with the use of finer needles nd suture mterils. A finer needle llows urte positioning of the suture in the tissue nd therefore more urte losure. It lso minimises tissue trum s the needle psses through the tissue. The suture size should e s fine s possile, usully 5/0 or 6/0 for mirosurgil proedures. Idelly resorle eg Serfst 5/0 (Serg Wiessner, Generl Medil, UK) or non-resorle monofilment suture mteril eg novfil (Syneture, Coviden Surgil) should e used s it does not umulte plque nd therefore redues risk of wound infetion. The flp should lso e sutured k tension free s ny tension in the flp n redue the mount of root overge hieved. 23 POST-OPERATIVE INSTRUCTIONS Following periodontl plsti surgery the ptient should e dvised to void rushing the surgil site for t lest three weeks while initil heling ours. During this time the ptient should e presried 0.2% hlorhexidine gluonte mouthwsh twie dily. Immeditely following surgery the ptient should lso e dvised ginst lifting their lip or pulling their heek to hve look t the surgil site. This n use displement of the tissues whih hve een refully sutured into position. The sutures should e left in situ for pproximtely dys s it tkes out 8-10 dys for the onnetive tissue union nd dequte lood supply to develop within the grfted tissue. 24 At the review ppointment if suffiient heling hs ourred the sutures should e removed nd the djent teeth n e gently lened with prophy pste nd flossed to remove ny plque deposits. If plque deposits re present t the surgil site, these n e removed gently with otton wool soked in 0.2% hlorhexidine gluonte. After pproximtely three weeks when suffiient heling hs ourred the ptient n e dvised to use soft ristle y toothrush for further two weeks to gently len the re. The ptient should e reviewed gin t four weeks post surgery nd if suffiient heling hs ourred the ptient n resume norml trumti toothrushing regime. Complete heling often ours over severl months nd ny proing of the site should e voided for t lest six months. PROGNOSIS The men root overge hieved with n epithelilised free gingivl grft hs shown to vry etween 9-87% nd omplete root overge vries etween 9-72% of sites. 25 The men perentge root overge hieved with suepithelil onnetive tissue grfts hs een shown to vry etween 65-98%. 22,26-29 The numer of sites showing omplete root overge vries etween 18-87%. 22,28 Chmrone et l. 30 suggested tht onnetive tissue grft ould e onsidered to e the gold stndrd grfting proedure. Hrris 29 showed 98% men root overge ws sustined t 27.5 month follow up on ptients who hd Miller lss I nd II defets. His results lso supported the ide of reeping tthment where there ws smll inrese in mount of root overge etween erly nd long term follow up periods. When the epithelilised free gingivl grfts re ompred to the suepithelil onnetive tissue grft, oth tehniques re effetive in the tretment of reession defets. However, the suepithelil onnetive tissue grft hs een shown to provide greter perentge root overge thn the epithelilised free gingivl grft. 31 Similrly suepithelil onnetive tissue grft omined with oronlly dvned flp hs een shown to provide etter root overge thn the oronlly dvned flp lone over five yer follow up period. 32 The men root overge hieved with guided tissue regenertion hs een shown to vry etween 48-94% nd omplete root overge vries in etween 0-75% of sites. 25 When the suepithelil onnetive tissue grft is ompred with guided tissue regenertion, the suepithelil grft hs shown evidene of hieving greter root overge. 22,33,34 Evidene shows tht the size of the initil reession defet will determine the mount of root overge hieved. 22 Miller lss I defets n hieve omplete root overge in 100% of ses nd in lss II defets omplete root overge ws seen in 88% of ses. 35 Lrger reession defets rrely hieve full overge. One study showed reession defets of 3-5 mm only mnged to ttin 80.6% overge nd reessions greter thn 5 mm only ttined 76.6% root overge with free gingivl grfts. 36 Nelson 12 reported 100% root overge in reession defets less thn 3 mm, 92% root overge in reession defets 4-6 mm nd 88% in reession defets of 7-10 mm. Overll etter results for perentge of omplete nd men root overge n e hieved if defets re less thn 4 mm. 22 CONCLUSIONS A vriety of surgil proedures re ville for the tretment of reession defets nd hve ll shown sttistilly signifint root overge. 22 Clinilly these proedures re tehnilly demnding nd opertor trining nd experiene will ffet suess rtes. In suitle ses omintion of the suepithelil onnetive tissue grft with oronlly dvned pedile flp is onsidered to e the gold stndrd proedure due to the high suess rtes reported in the literture. 33,37 1. Kss M M, Cohen R E. Tretment of gingivl reession. J Am Dent Asso 2002; 133: BRITISH DENTAL JOURNAL VOLUME 211 NO. 8 OCT

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