Vol-III, Issue - 1, Jan-Apr 2016
Case Report
Treatment Of Millers Class I Gingival Recession Defects Using Coronally Advanced Flap.- Case Report Of Two Cases.
Dr. Ramanarayana. Boyapati1
Boyapati R. Treatment Of Millers Class I Gingival Recession Defects Using Coronally Advanced Flap.Case Report Of Two Cases. J Periodontal Med Clin Pract 2016;03: 56-64
Affiliation
1. Senior Lecturer,
Department of Periodontics
Mamata Dental college and hospital Khammam,
Telanagana.
Corresponding Author:
Dr. Ramanarayana. Boyapati
Senior Lecturer,
Department of Periodontics
Mamata Dental college and hospital Khammam,
Telanagana.
Conflict of Interest – Nil
ABSTRACT
Mucogingival therapy is defined as the correction of
defects in morphology, position, or amount of soft
tissue and underlying bone.Friedman introduced it
in1957 and was defined as “surgical procedures
designed to preserve gingiva, remove aberrant
frenulum or muscle attachments, and increase the
depth of the vestibule. Factors implicated in the
etiology of GR, include traumatic, overzealous tooth
brushing technique (i.e; forceful, horizontal)
frequently associated with a pre-existing lack of
cortical bone or acquired bone deformities,
uncontrolled marginal inflammation with
accumulation of dental plaque or high muscle
attachment and frenal pull.
Gingival recession (GR) occurs in population with
low oral hygiene levels. Root coverage may be
achieved by a number of surgical techniques,
56
including pedicle gingival grafts, free grafts,
connective tissue grafts, GTR may also be used. The
objective of the present study was to evaluate
Coronally advanced flap (CAF) procedure in the
treatment of Miller's class I gingival recession defects
in maxillary teeth.
Key words: Gingival recession, Flap surgery,
Mucogingival surgery.
INTRODUCTION
The oral exploration of the root surface
due to displacement of the gingival margin apical to
CEJ leads to tactile and thermal dental
hypersensitivity, root abrasion and deterioration of
[1]
smile easthetics. The main goal of the periodontal
therapy is to improve periodontal health and thereby
to maintain patients functional dentition throughout
[2]
his/her life.
Numerous procedures and different
Vol-III, Issue - 1, Jan-Apr 2016
Treatment Of Millers Class I Gingival Recession Defects Using Coronally Advanced Flap.- Case Report Of Two Cases.
techniques have been designed to provide predictable
[3]
root coverage.
According to Zucchelli and De
Sanctis the selection of one surgical technique over
another depends on several factors, some of which are
related to the defect i.e the size of the recession defect,
the presence or absence of keratinized tissue adjacent
to the defect, width and height of the interdental soft
tissue, depth of the vestibulum or the presence of
frenuli while others are related to patients such as oral
[4]
hygiene maintenance, smoking.
In patients with aesthetic requests if there
is adequate keratinized tissue apical or lateral to the
recession defect, pedicle flap surgical techniques
(coronally advanced or laterally moved flaps) are
recommended (Grupe & Warren 1956). Kalmi (1949)
first described a type of coronally repositioned flap
that was performed after gingivoplasty of the attached
gingiva. Nordenram (1969) and Harvey (1965, 1970)
employed surgical techniques to cover denuded roots
by coronally repositioning mucoperiostial flaps. In
addition, Sumner (1969) and Ward (1973) have
modifications of the coronal repositioned flap to
repair gingival recession using straight horizontal
incisions in the alveolar mucosa. Bernimoulin et al.
(1975), reported the clinical evaluation of a two-step
[5]
coronally repositioned periodontal flap. Zucchelli
and De Sanctis modified the coronally advanced
procedure. The aim of the present study is to evaluate
the clinical efficiency of modified CAF procedure in
the treatment of class I and class II gingival recession
defects.
CASE REPORTA female patient aged 42 years reported to the
department of periodontics Mamata Dental Collge &
Hospital with the chief complaint of receded gums.
On Clinical examination isolated Miller's class I
Gingival recessions in relation to Maxillary right
57
canine.
Probing depth 2mm with no bleeding on probing,
Width of the keratinized tissue 3mm . Recession
height 3mm and Clinical attachment level 5mm. ( Fig1).
CASE REPORT-2
A male patient aged 35 years reported to the
department of periodontics Mamata Dental Collge &
Hospital with the chief complaint of receded gums.
On Clinical examination isolated Miller's class I
Gingival recessions in relation to Maxillary right
canine.
Probing depth 3mm with no bleeding on probing,
Width of the keratinized tissue 3 mm . Recession
height 5mm and Clinical attachment level 8mm ( Fig7).
For both cases written and verbal informed consent
was obtained after a thorough explanation of nature,
risks and benefits of the clinical investigations and
surgical procedures. The study was approved by the
Institutional Ethical Committee. Patient was
subjected to full mouth scaling and root planning.
Clinical data collection
Baseline full mouth plaque and gingival index scores
were recorded according to Silness & Loe, and Loe &
Silness, respectively. Clinical parameters were
assessed at the mid-facial surface of teeth using CEJ
as the reference point. All measurements were
recorded using a Williams
periodontal probe at baseline 3 months and 6 months.
Measurements were recorded to the nearest
millimeter. Recession Height (RH) was measured as
the distance from CEJ to GM. Width of Keratinized
Tissue (WKT) was measured as the distance between
the GM and the MGJ, PD was measured from GM to
the base of the sulcus. CAL is calculated from PD and
gingival recession.
Vol-III, Issue - 1, Jan-Apr 2016
Treatment Of Millers Class I Gingival Recession Defects Using Coronally Advanced Flap.- Case Report Of Two Cases.
Surgical procedure
The modified Coronally advanced flap as described by
Zucchelli and De Sanctis in 2000 was performed. The
area was anesthetized with 2% lignocaine
hydrochloride containing adrenaline at a concentration
of 1: 80,000. An intra-sulcular incision was made at the
buccal aspect of the involved tooth.(Fig-2) Two
horizontal incisions were made at right angles to the
adjacent interdental papillae, at the level of the CEJ,
without interfering with the gingival margin of the
neighboring teeth( Fig-3). Two oblique vertical
incisions were extended beyond the muco gingival
junction to relieve muscle tension and a trapezoidal
split- full- split thickness flap was raised and extended
apically beyond the mucogingival junction, releasing
the tension and favoring the coronal positioning of the
flap (Fig-4). If the root is prominent, then as the flap is
advanced over the root the flap must cover more area
because of the root prominence, if the incisions are
parallel, the flap will be too short mesial to distal. If
there is no root prominence, then the incisions can be
more parallel because the mesial to distal distance will
not change. The amount of flap divergence is dictated
by the root prominence. The epithelium on the adjacent
papillae was de-epithelized. The root surface was
instrumented with curettes and irrigated with sterile
saline solution. The tissue flap is coronally advanced,
adjusted for optimal fit to the prepared recipient bed,
and secured at the level of the CEJ by suturing the flap
to the connective tissue bed in the papilla regions by
single sling sutures. Additional lateral interrupted
58
sutures are placed to carefully close the wound of the
releasing incisions using a small reverse cutting needle
and 5-0 or 4-0 sutures. Proper suturing should allow
adaptation of the donor tissue without any tension on
the flap. Pulling the lip out to see if the donar tissue
moves is the best way to check for graft stability. If the
movement is detected, additional sutures may need to
be placed. Non-Eugenol periodontal dressing (Coe –
Pak™) was placed over the surgical site and sutures
were removed after 14 days.
Post surgical care
Patient was instructed to discontinue tooth brushing
around the surgical site for the first 3 weeks after the
surgery. During this period, patients were advised to
use 0.2% chlorhexidine solution twice daily for 3
weeks. Systemic antibiotics and analgesics were
prescribed for 7 days post surgically (Amoxicillin
500mg t.i.d). The sutures were removed after 14 days.
After suture removal patient advised for gentle topical
application of 2% chlorhexidine gluconate gel. Three
weeks after the surgery, the patient was instructed to
resume careful mechanical tooth cleaning of the
treated areas using a soft bristled toothbrush. Patients
were given instructions to report to the department if
they had any discomfort following surgery. Patient
was periodically recalled every month for evaluation.
The clinical parameters were measured during the
follow up visit at 3 ( Fig-5 & Fig-8)months and at 6
months (Fig-6&Fig-9).
Vol-III, Issue - 1, Jan-Apr 2016
Treatment Of Millers Class I Gingival Recession Defects Using Coronally Advanced Flap.- Case Report Of Two Cases.
FIGURE-1- PRE OPERATIVE RECESSION HEIGHT
FIGURE-2-INCISIONS GIVEN
59
FIGURE-3-OPERATIVE
FIGURE-4-OPERATIVE-
FIGURE-5- Three ( 3) months
CORONALLY ADVANCED FLAP
post op- CASE-1
Vol-III, Issue - 1, Jan-Apr 2016
Treatment Of Millers Class I Gingival Recession Defects Using Coronally Advanced Flap.- Case Report Of Two Cases.
FIGURE-6-Six (6) months post op- 1
FIGURE-7-- Pre op Recession height- CASE-I
CASE- II
FIGURE-8- Post op 3 months- CASE-II
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FIGURE-9-Post op 6 months-CASE-II
Vol-III, Issue - 1, Jan-Apr 2016
Treatment Of Millers Class I Gingival Recession Defects Using Coronally Advanced Flap.- Case Report Of Two Cases.
Discussion
The objectives of root coverage is complete
restoration of of all anatomical structures in the area
of recession. This evident histologically as
regeneration of the periodontal attachment with the
formation of new cementum, periodontal ligament
and bone[12] .Treatment of gingival recession is
becoming an important issue in clinical
periodontology due to the increasing demand for
cosmetic treatment. The few millimeters of root
exposure poses problem when smiling. Thus, only
surgical procedures that provide the clinician with a
very high percent of complete root coverage should
be included in the mucogingival plastic surgical
techniques. Moreover, excessive thickness or poor
colour blending of the surgically treated areas, as
those resulting from soft tissue graft, should be
avoided. Patient-related aesthetic considerations
would suggest the utilization of surgical techniques
that can predictably obtain complete root coverage by
using the soft tissue adjacent to the defect (de Sanctis
& Zucchelli 1996).[6] The only limiting criteria in
utilizing a coronally advanced flap is the need of a
band of at least 1mm of keratinized tissue;
Wennstrom & Zucchelli (1996) have stated that the
amount of root coverage utilizing coronally advanced
flap with or without the presence of a connective
tissue graft will not show any significance difference
at the 2-year interval. More recently, the results from
a systematic review on periodontal plastic surgery
61
(Roccuzzo et al. 2002) [2] stated that the use of a barrier
membrane or connective tissue, together with a
coronally advanced flap, do not give better results
than coronally advanced flap alone when root
coverage is considered.
In the present study, the patients were nonsmokers ,smoking causes alteration in physiological
and cellular functions causing negative impact on the
gingival blood flow. Nicotine inhibits proliferation,
adhesion and chemotaxis of periodontal ligament
cells, alters the interaction between the epithelial
cells and gingival fibroblasts [7] . A modified CAF
procedure (Zucchelli and de Sanctis in 2007)[6] was
selected as there were some clinical and biological
advantages over the conventional as proposed by
Allen and Miller. Complete root coverage seems to
be influenced by post surgical positioning of GM and
by baseline depth.[8] The gingival margin is placed
2mm coronal to CEJ so as to counteract the gingival
retraction following the surgery. This was in
accordance with the previous studies conducted by
Pini Prato and Baldi,[8] Cairo et al.[9] Healing
progressed normally as that occurs in periodontal
flaps with the gingival colour, texture and contour
identical to the adjacent soft tissues. The ultimate
goal of root coverage procedures is the complete
resolution of the recession defect, with minimal
probing depths after treatment, along with a nice
chromatic and texture integration of the covering
tissues with the adjacent resident soft tissues.[10]
Vol-III, Issue - 1, Jan-Apr 2016
Treatment Of Millers Class I Gingival Recession Defects Using Coronally Advanced Flap.- Case Report Of Two Cases.
TABLE-1
Comparison of clinical parameters in CASE-1 and CASE -2
PD
CAL
RH
WKT
BASELINE
CASE-1
2.0
CASE-2
3.0
3 MONTHS
1.0
1.0
6 MONTHS
1.0
1.0
BASE LINE
5.0
8.0
3 MONTHS
1.0
1.0
6 MONTHS
1.0
1.0
BASE LINE
3
5
3 MONTHS
0.2
0.2
6 MONTHS
0.2
0.2
BASELINE
3
3
3 MONTHS
4
5
6 MONTHS
4
5
The gain in probing attachment and clinical
attachment level ( CAL ) was mostly due to formation
of the new connective tissue attachment and
epithelial attachment.This was in accordance with
[11]
previous studies conducted by Carlo Baldi et al ,
[7]
Cleverson Oliveira Silva et al
Giovanpaolo Pini
[13]
[13]
Prato et al, Mauro Padrine Santamaria et al,
[14]
[15]
Ignazio Berlucchi et al, Andrea Pilloni et al . The
gain in CAL was mostly due to improvement of
probing depth
at 3 months and 6 months
postoperatively
There was significant reduction in both cases
Recession height from baseline to 3 months and 6
months. The percentage of root coverage obtained in
case-I is 93.3% and in Case II is 90% , which was
consistent with the findings of other investigators,
62
7
[6]
Cleverson Oliveira Silva et al, Pini Prato et al , M.
[16]
[17 ]
Del Pizzo et al, James G.Woodyard et al Michael
[18]
K McGuiere et al. There was increase in width of
keratinized tissue ( WKT) in both cases from baseline
to 3 months and 6 months in agreement with the
13
previous studies conducted by Pini Prato et al , Eun –
[6,19]
Ju Lee et al, Cem A.Gurgan et al.
Conclusion.
Overall considering all the aspects, Coronally
advanced flap provides consistently better esthetics,
healing and improvement in all the clinical
parameters including
increase
in width of
keratinized tissue.
References
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Treatment Of Millers Class I Gingival Recession Defects Using Coronally Advanced Flap.- Case Report Of Two Cases.
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Competing interest / Conflict of interest The author(s) have no competing interests for financial support, publication of
this research, patents and royalties through this collaborative research. All authors were equally involved in discussed
research work. There is no financial conflict with the subject matter discussed in the manuscript.
Source of support: NIL
Copyright © 2014 JPMCP. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work
is properly cited.
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