CASE REPORT

Gingival Biotype Enhancement and Root Coverage Using HumanPlacental Chorion Membrane

D.K. Suresh* and Akanksha Gupta*

Introduction: Various surgical techniques have been proposed to cover denuded root surfaces, but, the qualitativeparameters of gingiva, such as gingival biotype, have been overlooked. Very few attempts have been made to convert gin-gival biotype to a more favorable one. This case report shows the potential of human placental chorion membrane for rootcoverage and enhancement of gingival biotype. The rationale behind its use was based on the membrane’s properties.

Case Presentation: A 56-year-old male with a vertical recession depth of 2 mm in the maxillary right canine wastreated with coronally advanced flap along with placement of chorion membrane. Before treatment, the soft-tissue biotypeexamined through transgingival probing was thin. Three months after surgery, there was 100% root coverage, and the soft-tissue biotype also changed from thin to thick.

Conclusion: Chorion membrane, which is a rich source of various collagen and non-collagen proteins, such aslaminin, fibronectin, and proteoglycans, can be used for root coverage and enhancement of thin gingival biotype tothick biotype. Clin Adv Periodontics 2013;3:237-242.

Key Words: Amnion; chorion; collagen; gingiva; gingival recession; placenta.

BackgroundKnowledge of gingival thickness or biotype is a vital tool inpatient and technique selection for gingival augmentationprocedures. In clinical practice, identification of tissuebiotype is essential because variations in it may signifi-cantly affect treatment outcomes. The term “periodontalbiotype” was introduced to describe thickness of gingivain a bucco-lingual dimension and was categorized into“thick-flat” and “thin-scalloped” biotypes.1 Thin-tissuebiotype was defined as gingival thickness <1.5 mm, andthick-tissue biotype as gingival thickness ‡2 mm (mea-surements 1.6 to 1.9 mm were not defined).2 Thick flatgingiva responds to irritation with enlargement, and thindelicate keratinized tissue may result in attachment loss.There is need for a material that has potential to augment

this parameter. One of the biomaterials used for scaffoldsis fetal membrane. Amnion tissue is the innermost lining ofthe amniotic sac, the part of the placenta that enclosesa fetus through term; chorion tissue is the next layer of theamniotic sac. Collagen layers of chorion are rich in types I,IV, V, and VI, proteoglycans, laminin, and fibronectin3,4

(Table 1). To the best of our knowledge, this is the firsttime that human chorion membrane was used for rootcoverage, as well as for enhancement of thin gingivalbiotype to thick biotype.

Proper evaluation of the effect of gingival thickness onroot coverage stability (i.e., no change, additional recession,or creeping attachment) requires additional investigationswith longer follow-up time.5 Enhancement to thick gingivalbiotype was considered in this case report because the base-line gingival biotype was thin and the root coverage proce-dure alone would have covered the root surface, withoutenhancing the gingival biotype. This thin biotype in a healthymouth could maintain its position, but with even minimalirritation, it would result in more gingival recession.6 Thus,enhancement of this qualitative feature of gingiva was takeninto account along with the root coverage procedure.

* Department of Periodontology and Oral Implantology, MaharishiMarkandeshwar College of Dental Sciences and Research, MaharishiMarkandeshwar University, Mullana, Ambala, Haryana, India.

Submitted April 13, 2012; accepted for publication July 17, 2012

doi: 10.1902/cap.2012.120039

Clinical Advances in Periodontics, Vol. 3, No. 4, November 2013 237

Clinical PresentationA56-year-old systemically healthymale patient presented totheDepartment of Periodontics,MaharishiMarkandeshwarCollege of Dental Sciences and Research,Mullana, Ambala,Haryana, India, in February 2011 with a buccal gingivalrecession of 2 mm in the maxillary right canine and thingingival biotype (<1mm thicknessmeasured atmid-buccallevel and examined using the transgingival method). Hewas considered for root coverage and gingival biotypeenhancement using a chorion membrane with coronallyadvanced flap. Following satisfactory Phase 1 therapy, sur-gical treatment was planned and written informed consentwas obtained from the patient.

Presurgical clinical parameters, suchasvertical gingival re-cession depth of 2mm, clinical probing depth (PD) of 3mm(Fig. 1), and gingival thickness of <1 mm, were assessed.

Case ManagementAfter obtaining adequate local anesthesia, two horizontalbeveled 3-mm incisions were made, mesial and distal to therecession defect located at a distance from the tip of theanatomic papillae equal to the depth of the recession plus1 mm.7 This was followed by two beveled oblique, slightlydivergent incisions, starting at the end of the two horizontalincisions and extending to the alveolar mucosa (Figs. 2aand 2b). The resulting trapezoidal-shaped flap was ele-vated in the coronal–apical direction (Fig. 2c). For coronaladvancement of the flap, a periosteal releasing incisionwas made. Coronal mobilization of the flap was consid-ered adequate when the marginal portion of the flap couldpassively reach the level coronal to the cemento-enamel junc-tion of the tooth. Facial soft tissue of the anatomic interdentalpapillae coronal to horizontal incisions was de-epithelized tocreate connective tissue beds towhich surgical papillae of thecoronally advanced flap were sutured. Exposed root surface,

after thorough root planing, was conditionedwith EDTA for2 minutes (Fig. 2d) to remove smear layer and then thor-oughly rinsed with normal saline. The desired width andlength of the chorionmembrane was placed over the defectcovering the root surface (Figs. 3a and 3b). The materialused was composed of chorion membrane† and 24%EDTA as root biomodifier. The flap was replaced by co-ronally advancing to cover the root surface and mem-brane and then securing with horizontal and verticalsutures using a 5-0 non-resorbable suture (Fig. 3c). Aperiodontal pack was placed to protect the surgical site(Fig. 3d). The patient was given postoperative instructionsand medications (500mg amoxicillin three times daily for 5days as antibiotic coverage and diclofenac sodium twicedaily for 5 days as an anti-inflammatory drug) and in-structed to rinse with chlorohexidine twice daily for 2weeks.

The patient was revaluated after 24 hours for any discom-fort, swelling, pain, bleeding, or displacement of the peri-odontal pack. Ten days after surgery, the periodontal packand sutures were removed, and the area was irrigated withnormal saline. The patient was recalled every 2 weeks aftersurgery for 1 month and subsequently every month for thenext 2months (Fig. 4). Clinicalmeasurementswere recordedpreoperatively and 3 months postoperatively.

Clinical OutcomesThree months after surgery, there was 100% root cover-age, with a 1-mm increase in gingival thickness and 1-mmreduction in PD. Tissue at the site appeared healthy, with novisible signs of inflammation.

DiscussionCollagen layers of chorion are rich in collagen types I, IV, V,and VI, proteoglycans, laminin, and fibronectin. Collagen

TABLE 1 Structural Components of Placental Membranes

Layer Extracellular Matrix Components

Amnion

Epithelium

Basement membrane Collagen types III, IV, and V, fibronectin, laminin, and nidogen

Compact layer Collagen types I, III, V, and VI and fibronectin

Fibroblast layer Collagen types I, III, and VI, fibronectin, laminin, and nidogen

Intermediate (spongy layer) Collagen types I, III, and IV and proteoglycans

Chorion

Reticular layer Collagen types I, III, IV, V, and VI and proteoglycans

Basement membrane Collagen type IV, fibronectin, and laminin

Trophoblasts

† Tissue Bank, Tata Memorial Hospital, Mumbai, India.

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is well-tolerated and bioabsorbable, has hemostatic prop-erties, encourages migration of adjacent autogenous con-nective tissue,8 and has epithelial cells over its surface.Laminins exhibit a variety of biologic activities, includingpromotion of cell attachment, growth, and differentiationof a number of cell types.9-11 Fibronectin is involved inmany cellular processes, including tissue repair, blood clot-ting, cellmigration, and adhesion.12,13 Based on these prop-erties, chorion membrane was used for root coverage andgingival biotype enhancement. Gingival biotype was as-sessed because it is an important parameter when definingthe qualitative nature of gingiva. In this case report, gingi-val thickness was augmented by 1mm together with 100%root coverage, whichwas in harmonywith the adjacent tis-sues. Because chorion consists of various adhesion mole-cules, such as laminins, there was no need to suture themembrane, thusmaking it even easier to use. Unlike cadav-eric allograft, xenograft, and alloplast barrier membranes,placental allografts have an advantage because they arecomposed of immunoprivileged tissue, possess antibacte-rial and antimicrobial properties, reduce inflammation atthe wound site, and provide a protein-enriched matrix tofacilitate cell migration.14 n

FIGURE 1a Preoperative. 1b Recession depth of 2 mm. 1c PD of 3 mmand relative clinical attachment level of 15 mm.

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FIGURE 2a Crevicular and horizontal incisions.2b Vertical releasing incisions. 2c Flap elevationand debridement. 2d Root conditioning.

FIGURE 3a Chorion membrane. 3b De-epithe-lization of papillae and placement of the chorionmembrane. 3c Horizontal and vertical sutures.3d Placement of a periodontal pack.

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Summary

Why is this case new information? j This case describes not only covering exposed root surfaces but alsoenhancing the gingival biotype.

What are the keys to successfulmanagement of this case?

j Proper patient selection based on gingival biotype and recessiondepth

j Appropriate selection of material based on its biologic properties.Chorion membrane was selected in this case since it is a rich sourceof various collagen and non-collagen proteins and isimmunoprivileged in nature.

What are the primary limitations tosuccess in this case?

j Studies with a large sample size, longer follow-up, and histologicevaluations are need to verify the results of this case report.

AcknowledgmentThe authors report no conflicts of interest related to thiscase report.

CORRESPONDENCE:Dr. D.K. Suresh, Department of Periodontology and Oral Implantology,Maharishi Markandeshwar College of Dental Sciences and Research,Maharishi Markandeshwar University, Mullana, Ambala 133207, India.E-mail: sureshkedige@rediffmail.com.

FIGURE 4 Postoperative. 4a 10 days. 4b 21days. 4c 1 month. 4d 3 months.

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