Gingival Recession and Coronal Reposition Flap, A Way To Restore Your Aesthetic Apperance
Gingival recession is defined as the apical migration of the junctional epithelium with exposure of root surfaces. It is a common condition seen in both dentally aware populations and those with limited access to dental care.
The etiology (causes) of the condition is multifactorial but is commonly associated with underlying alveolar morphology, tooth brushing, mechanical trauma and periodontal disease. Given the high rate of gingival recession defects among the general population, it is imperative that dental /maxillofacial (surgeon)practitioners have an understanding of the etiology, complications and the management of the condition.
Epidemiological studies show that more than 50% of subjects in the populations studied have one or more sites with recession of at least 1 mm, buccal sites being most commonly affected. Higher levels of recession have been found in males than females (Susin et al., 2004). Recession at the buccal surfaces is common in populations with good oral hygiene (Serino et al., 1994; Neely et al., 2005; Sangnes and Gjermo, 1976) whereas with poor standards of oral hygiene it may affect other tooth surfaces (Baelum et al., 1986). Gingival recession at the lingual surfaces of lower anterior teeth showed a strong association with the presence of supragingival and subgingival calculus (van Palenstein Helderman et al., 1998).
The etiology of the condition is multifactorial and may include plaque-induced inflammation, calculus and restorative iatrogenic factors, trauma from improper oral hygiene practices, tooth malposition’s, high frenum attachment, improper periodontal treatment procedures, and uncontrolled orthodontics movements (Wennstrom, 1996; Tugnait and Clerehugh, 2001). Gingival recession is also a common outcome of the therapies delivered to treat periodontal disease.
Even though gingival recession may occur without any symptoms it can give rise to pain from exposed dentine, patient concern about loss of the tooth, poor esthetics or root caries. The denuded root surfaces cause deterioration in the esthetic appearance, dentin hypersensitivity, and inability to perform proper oral hygiene procedures (Zucchelli et al., 2006; Seichter, 1987).
The management of gingival recession and its sequelae is based on a thorough assessment of the etiological factors and the degree of tissue involvement. The initial part of the management of the patient with gingival recession should be directed towards correcting the etiological factors. The degree of gingival recession has to be monitored for signs of further progression. Surgical root coverage is indicated when esthetics is the prime concern and periodontal health is good.
2. Surgical procedures2. Classification of gingival recession
Two main types of marginal gingival recession have been identified. A generalized one, which may involve interproximal areas, is mainly found in periodontally untreated populations with poor oral hygiene. The other type is usually related to traumatic factors and often involves only a few teeth or a group of teeth. The latter frequently occurs in buccal areas where the lesions commonly are associated with plaque-free, smooth, and well polished hard tissue defects proposed a useful recession defect classification based on the height of the interproximal papillae and interdental bone adjacent to the defect area, and the relation of the gingival margin to the mucogingival junction (Miller, 1985). This classification is useful when deciding on treatment options (Maynard, 2004).
Miller’s classification of gingival recession defects (1985).
Class I Recession within attached gingiva. No loss of interdental bone and soft tissue papillae covering interdental bone at full height.
Class II Recession extending to or beyond the mucogingival junction. No loss of interdental bone and soft tissue papillae covering interdental bone at full height.
Class III Recession extending to or beyond the mucogingival junction. Loss of interdental bone but interdental bone height coronal to apical extent of recession defect. Reduction in height of the soft tissue papillae covering interdental bone.
Class IV Recession extending to or beyond the mucogingival junction. Loss of interdental bone apically to recession defect. Gross flattening of interdental soft tissue papillae.
The techniques used for root coverage are based on tissue displacement whether by translation (pedicle flap procedures) or by grafting (free gingival or connective tissue graft procedures), and use of resorbable and non-resorbable membranes according to the principles of guided tissue regeneration (GTR) Several modifications to the conventional techniques have been developed in an attempt to obtain optimal root coverage and a better aesthetic integration.
Surgical procedures may be broadly divided into two different types:
Pedicle soft tissue graft procedures. These types of graft remain attached at their base and involve the positioning of soft tissue over the recession defect; they retain their own blood, supply during their transfer to a new location. Examples include:
⦁ • Rotational flap procedures, including laterally positioned flap, double papilla flap.
⦁ • Flap advancement procedures, including coronally repositioned flap.
Free soft tissue graft procedures. Soft tissues are transferred from an area distant to the recession to cover the defect. These techniques are used where there is inadequate donor tissue close to the recipient site or where the aim of treatment is to increase tissue thickness.
⦁ • Free gingival graft.
⦁ • Subepithelial connective tissue graft.
In periodontal practice, root coverage therapies for gingival recession defects require daily clinical decisions. Numerous studies have been reported to support the efficacy and predictability of different proposed surgical techniques. The selection of the surgical techniques should be dictated by several factors, including the anatomy of the defect site, such as the size of the recession defect, the presence or absence of keratinized tissue adjacent to the defect, the width and height of the interdental soft tissue, and the depth of the vestibule or the presence of frenula the existence of esthetic considerations, the desired outcome, and the evidence-based predictability of various procedures should be also evaluated.
Among patient-related factors, the attempt to reduce the number of surgeries and intraoral surgical sites, together with the patient’s expectations must be considered. Age of the patient, medical conditions and smoking status may also affect the results of root coverage surgical procedures. The surgeon’s clinical experience may be a potential factor influencing judgments, case selection, and surgical skills. However, case selection has proven the critical beneficial in promoting clinical outcomes.
3. Presurgical preparation
Root surfaces are mechanically prepared prior to any mucogingival procedure to allow biological attachment of the grafted tissue to it. The root surface is thoroughly debrided with ultrasonic or hand instruments and irrigated with sterile saline. Mechanical modification of the root surface as well as root conditioning procedures have been used prior to the surgical root coverage techniques to achieve improved results (Miller, 1985).
Root surface modification using agents such as citric acid or tetracycline hydrochloride has been advocated in an effort to promote the healing response following root surface coverage, although clinical studies have failed to show any improvement in root surface coverage when using such agents.