3. Definition
GINGIVAL RECESSION-
Gingival recession is defined as the
apical migration of the junctional epithelium
with exposure of root surfaces. [Kassab MM, Cohen RE-2003].
Gingival recession is the apical shift
of the marginal gingiva from
its normal position on the
crown of the tooth to levels on the root surface beyond the
cemento enamel junction [Loe H-1992].
4. Free Gingival Graft (FGG) - A soft tissue graft that is completely detached
from one site and transferred to a remote site. No connection with the
donor site is maintained
5. Sub-epithelial Connective Tissue Graft (CTG) - A detached connective tissue
graft that is placed beneath a partial thickness flap. This variation of the free
gingival graft provides the tissue graft with a nutrient supply on two surfaces
12. Non –surgical Treatment
Monitoring and prevention
Use of de-sensitizing agents, varnishes
Composite restoration
Removable gingival veneers
Orthodontics
13. Monitoring and prevention
If the recession is not progressing and does not provoke tooth
sensitivity or poor aesthetics, then tooth- brushing instructions
and regular observation through a strict maintenance program
would be the optimal treatment.
17. Orthodontics
In some cases surgical intervention and grafting may help to treat the
recession defect; however, if orthodontic treatment is an option that the
patient is willing to consider then any surgical intervention should be delayed
until after orthodontic tooth movement has been completed.
18. Indications For Surgical Intervention
The need to improve soft tissue aesthetics
Reduce hypersensitivity
Improve plaque control
Prevent further progression of recession defect
19. Key factors in the selection of surgical
procedures
RECIPIENT SITE
Gingival recession is limited to one tooth or extends to multiple teeth
Degree of gingival recession
Amount and thickness of existing keratinized gingiva in the area of
recession
20. Whether the area of recession protrudes labially from the dental arch
Restorative/Prosthodontic treatment after root coverage is necessary
21. Donor site
Whether area adjacent to gingival recession can be used as a donor site.
Amount of Keratinized gingiva
Thickness of keratinized gingiva
22. Size of adjacent interdental papilla
Thickness of the alveolar bone covering the donor tissue
Thickness of palatal soft tissue used as donor tissue
23. if adequate width is present at
the donor site the following
procedures can be selected:
a. Laterally (horizontally) displaced flap.
b. Double-papilla flap.
c. Coronally-positioned flap
If the donor site is associated
with inadequate width:
Free soft tissue auto graft
Sub epithelial connective tissue grafts
are available
Depending on the width of the attached gingiva
28. Laterally Positioned flap
Advantages
a. One surgical site
b. Good vascularity of the pedicle flap.
c. Ability to cover isolated, denuded roots that have adequate donor tissue
laterally.
29. Disadvantages
a. Limited by the amount of adjacent keratinized attached gingiva.
b. Possibility of recession at the donor site.
c. Dehiscence or fenestration at the donor site.
d. Limited to one or two teeth with gingival recession.
30. Indications:
a. For covering the isolated denuded root.
b. When there is sufficient width of interdental papilla in the adjacent teeth,
and Sufficient vestibular depth.
Contraindications:
a. Presence of deep interproximal pockets.
b. Excessive root prominence.
c. Deep or extensive root abrasion or erosion.
36. Double papilla flap
Indications:
1. When the interproximal papillae adjacent to the mucogingival problem are
sufficiently wide.
2. When the attached gingiva on an approximating tooth is insufficient to
allow for a Lateral Pedicle Flap.
Advantages:
1. The risk of loss of alveolar bone is minimized because the interdental bone
is more resistant to loss than is radicular bone.
2. The papillae usually supply a greater width of attached gingiva than from
the radicular surface of a tooth.
37.
38. Coronally positioned flap
Indications:
• Esthetic coverage of exposed roots.
• For tooth sensitivity owing to gingival recession.
Advantages:
• Treatment of multiple areas of root exposure.
• No need for involvement of adjacent teeth.
• High degree of success.
• Even if the procedure does not work, it does not increase the existing
problem.
40. Step 3: Return the flap and suture it coronal to the pretreatment position.
Step 4: Cover the area with a periodontal dressing.
41. Second Technique (Semilunar flap)
Indication:
Small localized area
Advantages:
• No vestibular shortening, as occurs with the coronally positioned flap.
• No esthetic compromise of interproximal papillae.
• No need for sutures.
42. Disadvantages:
• Inability to treat large areas of gingival recession.
• The need for a free gingival graft if there is an underlying dehiscence or
fenestration.
43. Step 1: Semilunar incision is made and ending about 2 to 3 mm short of the
tip of the papillae.
44. Step 2: Perform a split-thickness dissection coronally from the incision, and
connect it to an intrasulcular incision.
45. Step 3: The tissue will collapse coronally, covering the denuded root. then
held in its new position for a few minutes with a moist gauze. Many cases
do not require either sutures or periodontal dressing.
46. Double Lateral sliding bridge flap
Multiple gingival recession with or without adequate attached gingiva
Coronally
advanced
flap
Vestibular
plastic surgery
47.
48. Reasons for pedicle flap failure
Narrow
Flap
Tension
Bone exposed poor
stabilization
49. Free Gingival Autograft
that consist of epithelium and a thin layer of underlying CT completely
detached from one site and transferred to a remote site.
Advantages
Increase keratinized tissue around teeth, implants or crowns and under
removable prostheses.
Increase vestibular depth.
50. Surgi cal Technique
Step 1: Prepare the recipient site.
Step 2: Root preparation:
Root planing of exposed root to remove cementum and affected dentin.
Etch root surface with tetracycline (pH 2.0).
51. Step 3: Obtain the graft from the donor site:
The ideal thickness of a graft is 1.0 - 1.5 mm.
52. Step 4: Graft transferred to recipient site.
Step 5: Protect the donor site.
53. Sub-epithelial Connective Tissue Graft
Indications:
• Where esthetics is of prime concern
• For covering multiple denuded roots
• In the absence of sufficient width of attached gingiva in the adjacent areas.
Advantages:
• High degree of cosmetic enhancement
• Incurs no additional cost for autogenous donor tissue
• Minimal palatal trauma
• Increased graft vascularity.
55. I. Preparation of recipient site:
The initial horizontal right angle incision is made into the adjacent
interdental papillae at, or slightly coronal to the cementoenamel junction of
the tooth with an exposed root surface. preserve the papillary blood
supply A partial thickness flap is raised without vertical incisions
SRP Root Conditioning with citric acid pH 1.0 or tetracycline HCl in a
concentration of 250 mg mixed in 5 ml of sterile water approximate
mesio distal width necessary for the graft is measured with a periodontal
probe.
56.
57. II. Excision of the donor tissue
1st incision horizontal incision 2-3mm apical to gingival margin
2nd incision parallel to the long axis of the teeth, 1 to 2 mm apical to the
first incision raise a full thickness periosteal connective tissue graft
62. Guided Tissue Regeneration
Indications
• Esthetic demand.
• Indicated for single tooth with wide, deep localized recessions.
• For areas of root sensitivity where oral hygiene is impaired.
• For repair of recessions associated with failing or unesthetic class V
restorations.
63. Advantages:
• Techniques does not require a secondary donor surgical site reducing
postoperative discomfort.
• New tissue blends evenly with the adjacent tissue, providing highly esthetic
results.
Disadvantages:
• It is sensitive technique.
• Insurance of additional cost of barrier membrane.
64. Step 1: A full-thickness flap is reflected to MGJ, continuing as a partial-
thickness flap 8 mm apical to MGJ.
Step 2: Root preparation.
65. Step 3: A membrane is placed over the root surface and the adjacent tissue
at least 2 mm of marginal periosteum.
Step 4: The flap is then positioned coronally and sutured.
66. The use of Allografts and Xenografts in
management
systematic review concluded that these grafts may be useful in situations
where
1- A large recession defect needs to be treated .
2- Graft tissue harvested from the palate would provide an insufficient
volume of tissue.
68. Criteria of successful root coverage
The gingival margin is on the CEJ in class I, Class II.
The depth of gingival sulcus is within 2mm.
There is no bleeding on probing , hypersensitivity.
Color match with adjacent tissue
69. Conclusion
The management of gingival recession and its sequelae is based on a thorough
assessment of the etiological factors and the degree of involvement of the
tissues. The initial part of the management of the patient with gingival recession
should be preventive and any pain should be managed and disease should be
treated.
The degree of gingival recession should be monitored for signs of further
progression. When esthetics is the priority and periodontal health is good then
surgical root coverage is a potentially useful therapy.
Numerous therapeutic solutions for recession defects have been proposed in
the periodontal literature and modified with time according to the evolution of
clinical knowledge.
70. The subepithelial connective tissue graft with a cornonally advanced flap is
gold standard grafting procedure .
Prognosis (amount of root coverage achieved) will depend on the severity
(size )of recession .
Careful case selection and surgical management are critical if a successful
outcome is to be achieved.
71. References
Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, Chambrone LA, Lima
LA. Root coverage procedures for the treatment of localised recession-type
defects (Review). The Cochrane Library 2009, Issue 2
Umberto Pagliaro, Michele Nieri, Debora Franceschi,Carlo Clauser,and
Giovanpaolo Pini-Prato. Evidence-Based Mucogingival Therapy. Part 1: A
Critical Review of the Literature on Root Coverage Procedures. J Periodontol
May 2003
Paulom. Camargo, Philip R.Melnick & E. Barrie Kenney.The use of free
gingival grafts for aesthetic purposes . Periodontology 2000, Vol. 27, 2001,
72. Philippe bouchard, Jacquesmalet & Alain borghetti. Decision-making in
aesthetics: root coverage revisited - - Periodontology 2000, Vol. 27, 2001
Kassab MM, Badawi H, Dentino AR. Treatment of gingival recession. Dent
Clin North Am. 2010;54:129-140.
M. Zalkind.Alternative method of conservative esthetic treatment for gingival
recession J Prosthet dent 1997 77 561-563
Class III
recession extends to, or beyond MGJ
loss of interdental bone or soft tissue apical to CEJ , but coronal to apical extent of marginal tissue recession
Class IV recession extends to, or beyond MGJ loss of interdental bone or soft tissue apical to the extent of marginal tissue recession
I. Shallow-narrow. Ii. Shallow-wide.
iii. Deep-narrow. iv. Deep-wide
Introduced by Grupe and warren 1956
d. Significant loss of interproximal bone height.
Advantage
Prevent recession at donor site
Dhalberg, 19689 ADVANTAGES
Good tissue blend 2. Usually one surgical site 3. Pedicle to be moved over donor site without tension and releasing incision
DISADVANTAGE
1. Possible recession at the donor site
Introduced by Waienberg in 1964
Modified by Cohen and Ross,1968 3. When periodontal pockets are not present.
Disadvantage:Technique sensitive—Having to join together the small flap in such a way so that they act as a single flap
Disadvantage:
There is a need for two surgical procedures if the zone of keratinized gingiva is inadequate
Introduced by norbergHarvey in 1965 used it with FGG
Tarnow in 1986
Introduced by margraff, 1985 adv- does not require separate frenectomy increase vestibular depth
Disadvantages
Difficult to achieve root coverage. High esthetic demand. Large, uncomfortable donor site.