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Table of Contents
CASE REPORT
Year : 2017  |  Volume : 7  |  Issue : 3  |  Page : 111-116

Free reverse rotated papillary connective tissue graft and coronally advanced envelope flap technique: A novel surgical approach for treatment of gingival recession


Department of Periodontology, Chandra Dental College and Hospital, Barabanki, Uttar Pradesh, India

Date of Web Publication29-Dec-2017

Correspondence Address:
Awadhesh Kumar Singh
2/108, Vibhav Khand, Gomati Nagar, Lucknow - 226 010, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_30_17

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   Abstract 


A palatal wound becomes when palatal premolar region is used for obtaining connective tissue graft. To overcome this disadvantage, connective tissue graft is obtained from interdental papilla; as a result, there is no palatal wound. Envelope flap has blood supply by both sides because it contains no vertical incisions. Therefore, the purpose of this case report was to evaluate the free reverse rotated papillary connective tissue graft (CTG) and coronally advanced envelope flap (CAEF) technique for the treatment of gingival recession. A patient with the gingival recession of 5 mm depth and 3 mm width was treated by free reverse rotated papillary CTG and CAEF technique. A partial-thickness envelope flap was made on the underlying alveolar mucosa. The recipient bed was prepared by de-epithelialization of adjacent papillae to gingival recession. The donor papilla was de-epithelialized on facial aspect, and CTG was harvested. The papillary CTG was then placed on recipient bed in a reverse manner that is base toward cementoenamel junction and the tip toward the base of gingival recession and sutured. The envelope flap was coronally advanced to fully cover the papillary CTG and sutured. After 1 year, 100% root coverage obtained. The histologic studies will be required to confirm the type of attachment obtained by free reverse rotated papillary CTG and CAEF technique on the root surface.

Keywords: Envelope flap, gingival recession, papillary connective tissue graft, root coverage


How to cite this article:
Singh AK, Saxena A. Free reverse rotated papillary connective tissue graft and coronally advanced envelope flap technique: A novel surgical approach for treatment of gingival recession. J Interdiscip Dentistry 2017;7:111-6

How to cite this URL:
Singh AK, Saxena A. Free reverse rotated papillary connective tissue graft and coronally advanced envelope flap technique: A novel surgical approach for treatment of gingival recession. J Interdiscip Dentistry [serial online] 2017 [cited 2018 Apr 26];7:111-6. Available from: http://www.jidonline.com/text.asp?2017/7/3/111/221891




   Clinical Relevance to Interdisciplinary Dentistry Top


  • Free papillary connective tissue graft can be used in prosthodontics, especially for ridge augmentation procedures in case of ridge deficiency
  • When the ectopic eruption of the tooth occurs in the alveolar mucosa, free papillary connective tissue graft can be used to a facial/apical aspect of erupting tooth to establish a facial zone of gingiva
  • When there is lack of keratinized tissue around the implant, free papillary connective tissue graft can be used in implant dentistry to obtain keratinized tissue around the implant.



   Introduction Top


Gingival recession is defined as the exposure of root surface in the oral cavity, resulting from the detachment, and migration of junctional epithelium toward the apex of the root.[1] Gingival recession may be treated by pedicle soft-tissue graft, free soft-tissue graft, or combination of both along with guided tissue regeneration membrane or regenerative materials. Among various surgical approaches for the treatment of gingival recession, connective tissue graft (CTG) with overlying flap for graft coverage can be considered the gold standard for treatment of gingival recession.[2] To obtain success and predictability of this surgical technique, various modifications have been proposed, including CTG with or without an epithelial collar, partially or totally covered by pedicle flap, with an envelope/pouch or tunnel design preparations covered by undetached papilla.[3]

The main advantages of the CTG procedures are thought to derive from the availability of two sources of blood supply to the graft: One from the recipient bed and the other from the overlying flap, and the perfect chromatic integration and an optimal esthetic outcome.[4] Since the success rate of root coverage depends on the survival of graft tissue itself, it has been suggested that the overlying flap should cover most of the graft. This is thought to provide enough blood supply to nourish the underneath portion of the graft over the denuded root.[5]

The proper flap design is also an important step toward obtaining satisfactory root coverage outcomes with connective tissue grafting approach. Langer and Langer proposed the use of vertical releasing incisions, which might compromise the gingival margin vascularization at the early stages of wound healing resulting in fibrotic scars.[2] Therefore, numerous other authors have provided variations on the techniques and provided support to the original techniques.[6] An envelope or a pouch flap design was proposed by Raetzke eliminating vertical incisions.[7] The advantages of the technique are the maintenance of the blood supply to the flap, a close adaptation to the graft, and reduction in postoperative discomfort and scarring. Tinti and Parma-Benfenati described a bilaminar grafting procedure for root coverage which consists of free rotated papilla autograft along with coronally displaced envelope flap.[8] The aim of this case report was to evaluate the free reverse rotated papillary CTG and coronally advanced envelope flap (CAEF) technique for the treatment of gingival recession in terms of root coverage.


   Case Report Top


A 21-year-old male patient had complained of downward shifting of gum in his lower front tooth region. On intraoral examination, an isolated Miller Class I gingival recession at the labial surface of the lower left central incisor (no. 31) [Figure 1] was present due to plaque and calculus deposits. The depth and width of the gingival recession were 5 mm and 3 mm, respectively [Figure 2] and [Figure 3]. Probing depth and width of keratinized gingiva were equal, that is, 1 mm each. The width of attached gingiva was 00 mm. The intraoral periapical radiographical evaluation showed no bone loss [Figure 4].
Figure 1: Miller Class I gingival recession in lower left central incisor, #31

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Figure 2: Five mm depth of gingival recession

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Figure 3: Three mm width of gingival recession

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Figure 4: Intraoral periapical radiograph showed no bone loss

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Scaling and root planing was done to remove etiological factor. Oral hygiene instructions were given, and the patient was advised to adopt the roll brushing technique in the area of the recession to completely remove plaque without causing trauma to the exposed root surface and thin gingival margin. This resulted in the reduction of inflammation and improvement of soft-tissue health before the surgery. Surgical treatment of recession was not scheduled until the patient was able to maintain full mouth and local plaque score <20% and full mouth and a local bleeding score of <15% according to index proposed by O'Leary et al.[9] Before treatment, verbal and written consent was obtained from the patient. This case report was approved by the institutional ethical committee for human subjects and also conducted in accordance with the declaration of Helsinki in 1975, as revised in 2000.

The patient was instructed to do presurgical rinse by 0.2% chlorhexidine solution. The facial skin around the mouth was cleaned with spirit and scrubbed by 7.5% povidone-iodine solution. The intraoral surgical site was painted with 5% povidone-iodine solution.[10]

After proper part preparation, 2% lignocaine hydrochloride with 1:80,000 adrenaline was administered to anesthetize right and left mental nerves. The initial horizontal right-angle sharp incision was made in the vestibule, following the mucogingival line and extended in a mesiodistal direction to completely include the mesial and distal adjacent papillae to the gingival recession from lower right central incisor to lower left lateral incisor [Figure 5]. A sharp dissection was made to prepare a partial-thickness envelope flap on the underlying alveolar mucosa [Figure 6]. The recipient bed was prepared by de-epithelialization of facial aspect of mesial and distal adjacent papillae to recession [Figure 7]. The exposed root surface convexity was reduced by a micromotor with round diamond bur and conditioned with 24% ethylenediaminetetraacetic acid by the active burnishing technique with the help of applicator tip for 3 min, which was changed every 30 s so as to maintain a steady concentration [Figure 8]. After conditioning of root surface, it was washed with a continuous current of normal saline solution for 2 min [Figure 9]. The donor papilla between lower left lateral incisor and canine was de-epithelialized on facial aspect, and papillary CTG was harvested [Figure 10]. The papillary CTG was then reversed in such a manner that the base of the papillary CTG was at the cementoenamel junction (CEJ) and its tip was at the base of the gingival recession. The papillary CTG was sutured in place by horizontal cross mattress suturing technique with 5–0 absorbable suture [Figure 11]. The partial-thickness envelope flap was coronally advanced to fully cover the papillary CTG and sutured by sling suturing technique with 3–0 black silk suture [Figure 12]. After suturing; finger pressure with saline-soaked gauze piece was exerted against the graft for 5 min to eliminate blood and exudate between graft and recipient bed, to close adaptation of tissue and to prevent dead space. No periodontal dressing was placed to achieve direct chemical plaque control by 0.2% chlorhexidine rinse.
Figure 5: The initial horizontal right angle sharp incision in the vestibule

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Figure 6: Partial-thickness envelope flap

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Figure 7: The recipient bed, de-epithelialized mesial and distal adjacent papillae

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Figure 8: Root conditioned with 24% ethylenediaminetetraacetic acid by active burnishing technique

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Figure 9: After conditioned of root surface

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Figure 10: Papillary connective tissue graft

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Figure 11: Papillary connective tissue graft reversed and sutured

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Figure 12: Envelope flap coronally advanced to fully cover papillary connective tissue graft and sutured

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Antibiotic (amoxicillin 500 mg, 1 tablet every 8 h, for 7 days) and analgesic (nimesulide 100 mg, 1 tablet every 12 h, for 3 days) were prescribed. The patient was instructed to be extremely cautious during mastication at meals and no tooth brushing or chewing on the operated area for 3 weeks. After this period, the patient was advised for mechanical cleaning of the operated area using an extra soft toothbrush by the coronally directed roll technique. Plaque control was obtained by 0.2% chlorhexidine rinse, twice daily for 1 min during the first 2 weeks, and the application of 0.2% chlorhexidine gel onto the operated area two times in a day for another 2 weeks after a meal.

Clinical follow-up was performed once a week in the 1st postoperative month, every 2 weeks in the 2nd postoperative month, once a month up to 6 months, and then 3 months interval till 12 months. At each visit, recall programs including professional tooth cleaning and reinforcement of daily oral hygiene measures were done.

Complete epithelialization was seen in 1 week [Figure 13]. Sutures were removed 2 weeks after surgery [Figure 14]. Healing was without any complications, and the patient was happy with the outcome of surgery. As the postoperative time increased, the healing progress and tissue maturity was obtained. After 1 year, 5 mm, that is, 100% root coverage, 6 mm of keratinized gingiva, 5 mm of attached gingiva, and 1.0 mm of probing depth were obtained [Figure 15].
Figure 13: One-week postoperative showed complete epithelialization

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Figure 14: Two-week postoperative after sutures removal

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Figure 15: One-year postoperative showed complete root coverage

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   Discussion Top


With this surgical approach, the retention of the vascular periosteum on the recipient bed and the overlying coronally advance envelope flap may result in a more rapid re-establishment of circulation within the free reverse rotated papillary CTG and contribute to more predictable and complete root coverage. Complete root coverage has been defined by four clinical findings: The soft-tissue margin must be at the CEJ, clinical attachment to the root, the sulcus depth 2 mm or less, and no bleeding on probing.[11] According to these clinical findings for complete root coverage, free reverse rotated papillary CTG, and CAEF technique has been found to be an effective method of achieving predictable and successful complete root coverage for the treatment of gingival recession.

The free rotated papillary CTG has demonstrated its ability to completely cover denuded root surfaces with a high percentage of success rates. This specific surgical technique can be adapted to satisfy the individual requirements of each situation to avoid the potential of creating recession on the contiguous teeth. The free reverse rotated papillary CTG does not depend on transposing gingiva from the radicular surfaces of adjacent teeth, so it is a preferable alternative to the lateral sliding flap when there is the potential of creating recession on donor's tooth. The free reverse rotated papillary CTG is a delicate technique sensitive operative procedure that requires careful technical attention. For success, the papillary CTG should be as thick and as wide as possible. For this reason, the interdental papilla should be retained as much as possible and should be positioned correctly in reverse rotated position with their larger part at the CEJ and their tip at the bone crest level over the avascular root to be covered. The success of this described grafting procedure is, however, attributed to the favorable coronal positioning of the primary envelope flap mostly represented by alveolar mucosa and to a minimum degree due to the lateral portion of the papillary connective tissue positioned to the underlying periosteum at the periphery of the recession.[8]

The best indication of this technique for the treatment of gingival recessions is only one step and a single surgical site. With this surgical procedure, the clinician may avoid the need for a second surgical site, most frequently represented by the palatal connective tissue. The patient reported relatively minimal discomfort. The technique may be used when adequate donor tissue for neither the laterally positioned nor obliquely positioned nor the double papilla pedicle graft is available. This procedure has the decided advantage of a single surgical site, good color compatibility with adjacent tissue, minimum discomfort for the patient, and healing by primary intention. Furthermore, the impossibility of recession at the donor site may represent strength versus all the above-mentioned pedicle grafts. Despite its limited possibilities for utilization, the free reverse rotated papilla CTG has a unique, specific place for use and should be included in the armamentarium of every periodontal practitioner.[8]

The limitation of free reverse rotated papillary CTG, and CAEF technique is that the adequate papillary volume and dimension are important for the success of this technique. For this reason, this technique is only success in Miller Class I gingival recession, not in Miller Class II or III gingival recession.


   Conclusion Top


By overview of this case report, it may conclude that free reverse rotated papillary CTG and CAEF technique might be potentially useful in achieving the predictable and complete root coverage. The histologic studies will be required to confirm the type of attachment obtained by free reverse rotated papillary CTG and CAEF technique on the root surface.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Singh AK, Gautam A. Platelet-rich fibrin-reinforced periosteal pedicle graft with vestibular incision subperiosteal tunnel access technique for the coverage of exposed root surface. J Interdiscip Dent 2016;6:33-8.  Back to cited text no. 1
    
2.
Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20.  Back to cited text no. 2
    
3.
Harris RJ, Harris LE, Harris CR, Harris AJ. Evaluation of root coverage with two connective tissue grafts obtained from the same location. Int J Periodontics Restorative Dent 2007;27:333-9.  Back to cited text no. 3
    
4.
Wilcko MT, Wilcko WM, Murphy KG, Carroll WJ, Ferguson DJ, Miley DD, et al. Full-thickness flap/subepithelial connective tissue grafting with intramarrow penetrations: Three case reports of lingual root coverage. Int J Periodontics Restorative Dent 2005;25:561-9.  Back to cited text no. 4
    
5.
Souza SL, Macedo GO, Tunes RS, Silveira e Souza AM, Novaes AB Jr., Grisi MF, et al. Subepithelial connective tissue graft for root coverage in smokers and non-smokers: A clinical and histologic controlled study in humans. J Periodontol 2008;79:1014-21.  Back to cited text no. 5
    
6.
Wennström JL. Mucogingival therapy. Ann Periodontol 1996;1:671-701.  Back to cited text no. 6
    
7.
Raetzke PB. Covering localized areas of root exposure employing the “envelope” technique. J Periodontol 1985;56:397-402.  Back to cited text no. 7
    
8.
Tinti C, Parma-Benfenati S. The free rotated papilla autograft: A new bilaminar grafting procedure for the coverage of multiple shallow gingival recessions. J Periodontol 1996;67:1016-24.  Back to cited text no. 8
    
9.
O'Leary TJ, Drake RB, Naylor JE. The plaque control record. J Periodontol 1972;43:38.  Back to cited text no. 9
    
10.
Singh AK, Kiran P. The periosteum eversion technique for coverage of denuded root surface. J Indian Soc Periodontol 2015;19:458-61.  Back to cited text no. 10
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11.
Miller PD Jr. Root coverage with free gingival graft. J Periodontol 1987;58:674-81.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]



 

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