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Table of Contents
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 36-39

Periosteum eversion technique – A preliminary technique for root coverage: A case series

Department of Periodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India

Date of Submission27-May-2019
Date of Acceptance18-May-2020
Date of Web Publication22-Apr-2021

Correspondence Address:
Dr. Avinash Kavarthapu
Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jid.jid_26_19

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The periosteum that covers the bone is highly composed of cellular connective tissue which is rich in vascularity with greater regenerative potential, thereby making it suitable to use as an autogenous graft material. This technique of periosteal eversion uses periosteum to cover the denuded root surface of multiple teeth prior to orthodontic treatment. Therefore, the purpose of the case series was to assess the amount of root coverage obtained with the help of eversion of periosteum where a single surgical site is involved in cases of periodontally compromised teeth that needs orthodontic correction. Patients with Miller's Class II/III were selected with malpositioned teeth. Partial thickness flap was elevated, and the periosteum was separated from the underlying bone surface. It is then everted to cover the exposed root surface and stabilized with vicryl suture. After 6 months of evaluation, periosteal eversion technique covered 75% of the denuded root surface. Hence, the periosteal eversion technique can be used as a preliminary procedure for the treatment of gingival recession that gives support for the tooth for further orthodontic treatment.

Keywords: Gingival coverage, malpositioned teeth, orthodontic treatment, periosteal eversion, root coverage

How to cite this article:
Kavarthapu A, Gurumoorthy K. Periosteum eversion technique – A preliminary technique for root coverage: A case series. J Interdiscip Dentistry 2021;11:36-9

How to cite this URL:
Kavarthapu A, Gurumoorthy K. Periosteum eversion technique – A preliminary technique for root coverage: A case series. J Interdiscip Dentistry [serial online] 2021 [cited 2023 May 30];11:36-9. Available from: https://www.jidonline.com/text.asp?2021/11/1/36/314178

   Clinical Relevance to Interdisciplinary Dentistry Top

This study indicates that, with simultaneous treatment of orthodontic correction and recession coverage with periosteum gives good results.

   Introduction Top

Gingival recession is the migration of the marginal gingiva apical to the cementoenamel junction leaving the root surface exposed to the oral environment.[1] The American Academy of Periodontology's 1996 position paper on mucogingival surgery stated that root coverage is indicated to increase esthetic demands, reduction of root sensitivity, management of root caries, or cervical abrasions.[2] Various techniques have been described in the literature including subepithelial connective tissue graft and subpedicle connective tissue graft.[3],[4],[5] However, the success of these cases is very limited due to various reasons such as donor site morbidity, requires second surgical site, technique sensitive, postoperative pain, and requires blood supply from both periosteum and bone as well. There are several predisposing factors that lead to gingival recession; such factors include bone dehiscence, thin gingival biotype, and malposition of the teeth.[6] Gingival recession could occur as a result of trauma resulting from excessive or improper tooth brushing and any inflammatory reactions of the gingival leading to periodontitis.[7] Malaligned teeth with class II/III recession require two-stage surgical procedure. At baseline, the parameters measured were clinical probing depth, recession depth, and width. All the parameters were evaluated at baseline and 3 months' and 6 months' interval after the surgery. Hence, this case series describes the recession coverage of multiple teeth with a periosteal eversion technique as a preliminary procedure.

   Case Reports Top

Case report 1

A patient aged 23 years old has come to the Dental College and Hospital, Chennai, with a chief complaint of spacing and proclined anteriors in both upper and lower jaw. On clinical examination, class III gingival recession defected was diagnosed according to the classification given by Miller in 1985 in relation to 31.41 [Figure 1]a. Written informed concern was obtained from the patient detailing the procedure with the risks and benefits involved with it. The treatment planned with initiation of orthodontic procedure with simultaneous root coverage with decortication of the edentulous area.
Figure 1: (a) Loss of periodontal attachment at the roots of 31, 41. (b) The whole periosteum pushed to the lingual side. (c) Platelet rich fibrin placed along with periosteum and was stabilized with vicryl 4-0 suture. (d) Six months postoperative after root coverage

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Surgical procedure

The site of incision was anesthetized with 1:80,000 dilution of lignocaine hydrochloride. A partial thickness flap was elevated on the buccal surface from 32 to 42. The periosteum was scored at the base and is separated from the underlying bone. The periosteum was pushed to lingual side where full thickness flap was elevated [Figure 1]b. The edentulous site was decortisized and covered with particulate graft. Later, PRF was placed in the recession site and it was covered by the exposed periosteum and stabilized with vicryl 4-0 suture [Figure 1]c. The flap closed back with the same and coepak as periodontal dressing was given. The patient was instructed to refrain from mechanical plaque control measure for a period of 30 days and advised for chemical plaque control. The follow-up period was carried out at 1 month and at 6 months and the results were satisfactory [Figure 1]d.

Case report 2

A female patient aged 33 years old has come to the department with a chief complaint of spacing and proclination of her lower front teeth with receded gums from 32 to 42 [Figure 2]a. After thorough clinical examination, the treatment planned was orthodontic treatment along with recession coverage using periosteal eversion technique.
Figure 2: (a) Loss of periodontal attachment at the roots of 31, 32, 41, 42. (b) Periosteum incised at baseline and separated from the submucous connective tissue up to the attached gingiva. (c) GTR placed along with periosteum and was stabilized with vicryl 4-0 suture. (d) Six months postoperative after root coverage

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Surgical technique

The exposed roots to be treated were thoroughly planned and a local anesthetic solution was given with 1:80,000 dilution of lignocaine hydrochloride with adrenaline. A partial thickness flap was elevated on both labial and buccal side from 33 to 43. The periosteum was scored at the base on the lingual side and whole of the periosteum was pushed to labial side [Figure 2]b. The edentulous area was decorticised and particulate graft (xenograft-osseograft) was placed. All the exposed root surfaces were covered with GTR (Guided Tissue Regeneration) membrane over which the periosteum was covered passively and sutured with 4-0 vicryl suture [Figure 2]c. The flap was closed back with silk suture. Clinical follow-up was performed at 1st and 6 months [Figure 2]d.

Case report 3

A female patient aged 29 years old has come to the hospital with a chief complaint of spacing and receding gums in her lower front tooth region. On clinical examination, the case was diagnosed to have Millers class II recession in respect to 31, 41 [Figure 3]a. The treatment planned was to correct the spacing with orthodontics and cover recession as well.
Figure 3: (a) Loss of periodontal attachment at the roots of 31, 41. (b) Periosteum incised at baseline and separated from the submucous connective tissue up to the attached gingiva. (c) Mucoperiosteum flap after fixing with interdental non resorbable sutures. (d) One month postoperative after root coverage

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Surgical procedure

After anesthetizing the surgical site, a partial thickness flap has been raised from 32 to 42. The periosteum was scored on the lingual side and the periosteum separated from the underlying bone [Figure 3]b. Decortication of the edentulous area was done with simultaneous grafting (xenograft-osseograft) in that area. GTR was placed covering the recession over which the periosteum was covered and stabilized with vicryl 4-0 suture. The flap was closed with silk suture [Figure 3]c. Follow up was done at 1st and 6 months [Figure 3]d.

   Discussion Top

The purpose of this case series was to describe the importance of recession coverage as a preliminary procedure prior to orthodontic treatment using periosteal eversion technique. The periosteum, an envelope covering the alveolar bone and the root surface was selected for root coverage procedure. Various benefits of using periosteum as a root coverage material were due to the presence of cumbersome properties of it such as its highly osteogenic, fibrogenic nature, it has both neuroproliferative and vasculoproliferative activity caused after surgical trauma.[8],[9] In addition, there was no need of second surgical site for graft procuring and thereby results in less morbidity and patient discomfort as well. Considering the cells present in the periosteum, it has diverse population of cells that include fibroblasts, fibroblast progenitor cells, osteoblast progenitor cells, osteoblast, pericytes, and multipotent stem cells.[9],[10],[11],[12] A study by De Bari et al. reported that when the periosteal progenitor cells and stem cells were subjected to differentiation in culture medium, with good cell viability these cells were able to differentiate into various lineages: osteoblasts, fibroblasts, adipocytes, chondroblasts, and skeletal myocytes.[13]

The periosteal eversion technique which is also called as perioplasty was first proposed by Gaggl et al., where periosteum was used to cover the denuded root surfaces. This technique involves the partial thickness flap reflection, eversion and reposition of flap coronally and is placed on the denuded root surfaces.[14] In this case series, similar technique was used to cover the denuded surfaces of multiple roots. Virnik et al., used the similar technique to cover the single denuded root surface and has showed better results.[15] Mahajan assessed the root coverage with periosteal pedicle graft for a period of 1 year in class I recession case and the results showed that the denuded root surfaces was covered completely.[16] A recent report on isolated tooth root coverage using marginal periosteum as a pedicle graft by Singh and Kiran showed that at the end of 6 months, there was a completed coverage of denuded root surface covering 5 mm of gingival height leaving 1 mm of probing depth.[17] In a recent study, comparing the periosteum eversion techinique and coronally advanced flap, both techniques showed equally effective in Miller's class I and II recession coverages.[18]

It was also reported that, periosteum also contains cytokines and various growth factors such as transforming growth factor-β, platelet derived growth factor, insulin-like growth factor, bone morphogenic proteins 2 and 7. Periosteum itself acting as a scaffold with various cells possessing in it and numerous growth factors is an ideal source of tissue engineering.[19]

   Conclusion Top

Within the limits, with the several benefits of periosteum in terms of quality and quantity and less donor site morbidity, the periosteum can be successfully used as a root coverage material for denuded root surface as an end stage procedure or can be used as a preliminary procedure to cover the root surface that give support for orthodontic therapy in cases where other types of grafts will not be successful.

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


Conflicts of interest

There are no conflicts of interest.

   References Top

Wennstrom JL. Mucogingival surgery. In: Lang NP, Karring T, editors. Proceedings of the 1st European Workshop on Periodontology. Berlin: Quintessence Publisher; 1994. p. 193-209.  Back to cited text no. 1
Consensus report. Mucogingival therapy. Ann Periodontol 1996;1:702-6.  Back to cited text no. 2
Wennström JL. Mucogingival therapy. Ann Periodontol 1996;1:671-701.  Back to cited text no. 3
Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20.  Back to cited text no. 4
Nelson SW. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol 1987;58:95-102.  Back to cited text no. 5
de Molon RS, de Avila ÉD, de Souza JA, Nogueira AV, Cirelli CC, Cirelli JA. Combination of orthodontic movement and periodontal therapy for full root coverage in a Miller class III recession: A case report with 12 years of follow-up. Braz Dent J 2012;23:758-63.  Back to cited text no. 6
Joshipura KJ, Kent RK, DePaola PF. Gingival recession: Intraoral distribution and associated factors. J Periodontol 1994;65:864-71.  Back to cited text no. 7
Goldman HM, Cohen WD. Periodontal Therapy. 6th ed. St. Louis, Toronto, London: C. V. Mosby; 1980.  Back to cited text no. 8
Singh N, Uppoor AS, Nayak DG. Bone's smart envelope-The periosteum: Unleashing its regenerative potential for periodontal reconstruction. Int J Contemp Dent Med Rev 2015;2015:1-5.  Back to cited text no. 9
Squier CA, Ghoneim S, Kremenak CR. Ultrastructure of the periosteum from membrane bone. J Anat 1990;171:233-9.  Back to cited text no. 10
Allen MR, Hock JM, Burr DB. Periosteum: Biology, regulation, and response to osteoporosis therapies. Bone 2004;35:1003-12.  Back to cited text no. 11
Dwek JR. The periosteum: What is it, where is it, and what mimics it in its absence? Skeletal Radiol 2010;39:319-23.  Back to cited text no. 12
De Bari C, Dell'Accio F, Vanlauwe J, Eyckmans J, Khan IM, Archer CW, et al. Mesenchymal multipotency of adult human periosteal cells demonstrated by single-cell lineage analysis. Arthritis Rheum 2006;54:1209-21.  Back to cited text no. 13
Gaggl A, Jamnig D, Triaca A, Chiari FM. A new technique of periosteoplasty for covering recessions: Preliminary report and first clinical results. Periodontal Pract Today 2005;2:55-62.  Back to cited text no. 14
Virnik S, Chiari FM, Gaggl A. Periosteoplasty for covering gingival recessions: Clinical results. Clin Cosmet Investig Dent 2009;1:13-20.  Back to cited text no. 15
Mahajan A. Periosteal pedicle graft for the treatment of gingival recession defects: A novel technique. Aust Dent J 2009;54:250-4.  Back to cited text no. 16
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. 17
[PUBMED]  [Full text]  
Debnath K, Chatterjee A. Evaluation of periosteum eversion and coronally advanced flap techniques in the treatment of isolated Miller's Class I/II gingival recession: A comparative clinical study. J Indian Soc Periodontol 2018;22:140-9.  Back to cited text no. 18
[PUBMED]  [Full text]  
Bathla S. Alveolar bone. In: Bathla S, Bathla M, editors. Periodontics Revisited. New Delhi: Jaypee Brothers Medical Publisher; 2011. p. 30.  Back to cited text no. 19


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