726Indian Journal of Dental Research, 22(5), 2011

short coMMunIcatIon

Root coverage using epithelial embossed connective tissue graft

Ramakrishnan T, Manmeet Kaur, Kriti Aggarwal

Received : 14-07-10Review completed : 27-09-10Accepted : 04-07-11

ABSTRACTIn periodontal practice, root coverage after marginal soft tissue recession requires daily clinical decisions. Numerous longitudinal human studies have been presented to support the efficacy and predictability of different mucogingival surgical techniques for root coverage. Over the years, root coverage procedure using the subepithelial connective tissue graft with variations has emerged as the favorite surgical technique. In the case presented in this report, subepithelial connective tissue graft with embossed epithelium was used to cover Miller’s class II gingival recession in the upper right canine. The design is such that embossed epithelium exactly fits the recession site and the connective tissue portion is tucked below the gingival margin of the recipient site. In this technique, coronal advancement of flap is not needed. Wider zone of attached gingiva at the recipient site was achieved by this technique.

Key words: Embossed epithelium, recession, root coverage

Department of Periodontics, Meenakshi Ammal Dental College and Hospital, Chennai, India

attached gingiva was achieved when coronal displacement of flap was not employed.[3] In the case presented in this report, Miller’s class II gingival recession in relation to upper right canine was treated using subepithelial connective tissue embossed with epithelium. The epithelium exactly covered the recession site and the connective tissue was placed underneath the well-prepared gingival margin. Complete root coverage was achieved.

CASE REPORT

A 38-year-old female patient was referred to Department of Periodontics, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai. The chief complaint of the patient was sensitivity in relation to right upper canine region. On clinical examination, Miller’s class II gingival recession was found in relation to right upper canine region [Figure 1]. Treatment plan included root coverage procedure using epithelium-embossed connective tissue graft. The procedure was explained to the patient. With the consent of the patient, surgery was carried out.

Surgical procedureRecipient siteUnder local anesthesia, sulcular incision was made in the upper right canine region, also involving mesial aspect of the first premolar and distal aspect of the lateral incisor. Full thickness flap was raised without making vertical incisions [Figure 2]. Thorough root planing was done. Tinfoil was cut exactly to the defect size and transferred to the palate from where the donor tissue was obtained [Figure 3].

Address for correspondence: Dr. Ramakrishnan T E‑mail: ramki_dentist@yahoo.co.in

Gingival recession is defined as an apical displacement of soft tissue with respect to cementoenamel junction.[1] This gingival pathology is not esthetically pleasing and can be associated with sensitivity and root caries. Full thickness or partial thickness flap associated with or without autograft or allograft has been used to address gingival recession and has shown high predictability in terms of root coverage. Autogenous free gingival graft was proposed by Miller as the first predictable technique to obtain root coverage. Esthetically, ideal result was not obtained using free gingival graft.[2] The usage of subepithelial connective tissue graft in root coverage is a predictable and versatile technique in which a bilaminar vascular environment is created to nourish the graft. To increase the graft viability during healing, retention of epithelial collar at the coronal border of the graft was advocated. In another technique, graft was completely covered via flap advancement coronally. In the study done by Bouchard, he found that greater zone of

Access this article onlineQuick Response Code: Website:

www.ijdr.in

PMID: ***

DOI: 10.4103/0970-9290.93466

[Downloaded free from http://www.ijdr.in on Tuesday, August 07, 2012, IP: 125.16.60.178]  ||  Click here to download free Android application for this journal

Root coverage using epithelial embossed connective tissue graft Ramakrishnan, et al.

Indian Journal of Dental Research, 22(5), 2011727

Figure 7: Sutures placed Figure 8: After 10 days

Figure 9: After 1 month Figure 10: After 6 months

Figure 1: Pre‑operative Figure 2: Full thickness flap raised

Figure 3: Template placed in the donor site Figure 4: Epithelium embossed connective tissue graft

Figure 5: Donor site Figure 6: Graft tissue placed in the recipient site

[Downloaded free from http://www.ijdr.in on Tuesday, August 07, 2012, IP: 125.16.60.178]  ||  Click here to download free Android application for this journal

Root coverage using epithelial embossed connective tissue graft Ramakrishnan, et al.

728Indian Journal of Dental Research, 22(5), 2011

Donor siteThe tinfoil was placed in relation to upper left premolar palatal region. Incision was made around the tinfoil and also extended 3 mm close to the gingival margin on either side. Epithelium was undermined 3 mm from the incision made around the tinfoil on all the sides. Releasing incision was given so that only the connective tissue of the surrounding 3 mm was separated. Then, the donor tissue was removed. The graft tissue had connective tissue on all the sides and the center region was embossed with epithelium which matched the defect exactly [Figure 4]. Bleeding was checked in the donor site [Figure 5].

The donor tissue was positioned on the defect site in such a way that the connective tissue portion of the graft was covered by the full thickness flap raised in relation to the recipient site as well as the embossed epithelium covered the recession site completely. Then, non-resorbable 4.0 ethicon sutures were placed [Figures 6 and 7]. Prefabricated acrylic stent was placed in the donor site. Sutures were removed on the 10th day. Healing was uneventful. Complete root coverage was obtained [Figures 8-10].

DISCUSSION

In this surgical technique, the key feature is retained embossed epithelium on the coronal border of the subepithelial connective tissue graft which exactly fits the defect to be treated. This technique was used in this case because if we had taken only the connective tissue graft from the donor site and placed to cover the recession site, the connective tissue would have been exposed even after coronal displacement of the flap as the width of attached gingiva in that site was only 3 mm. When the connective tissue is exposed after suturing, healing may be delayed.

Studies have shown that the flap advancement over connective tissue graft failed to yield significant increase in the zone of attached gingiva, with the flap remaining

non-keratinized. An increase in zone of attached gingival width has been reported where connective tissue graft is not accompanied by coronally advanced flap.[4,5]

Free gingival graft was not used in this case because recipient site was visible while smiling since the site comes under esthetic zone. So, free gingival graft was avoided.

By using this embossed epithelium over the connective tissue, the following benefit was achieved. First of all, the connective tissue was not exposed, and healing was not affected and was predictable; secondly, there is a chance for graft epithelium and flap epithelium to heal by primary intention. Only disadvantage of this technique is a portion of donor site is left open to heal by secondary intention.

CONCLUSION

This simple technique helped in complete root coverage as well as increased the zone of attached gingiva, and can be tried successfully in Miller’s class I and class II wide defects.

REFERENCES

1. Wennstrom JL. Mucogingival therapy. Ann Periodontal 1996;1:671-701.2. Miller PD. Root coverage using free tissue auto graft citric acid

application, Part I tehnique. Int J Periodont Restorat Dent 1982;1: 65-70.

3. Bouchard P, Malet J, Borghetti A. Decision making in aesthetics: Root coverage revisited. Periodontol 2000 2001;27:97-120.

4. Karring T, Lang NP, Loe H. The role of gingival connective tissue in determining epithelial differention. J Periodontal Res 1975;10:1-11.

5. Bouchard P, Etienne D, Ouhayoun JP. Subepithelial connective tissue graft in the treatment of gingival recessions: Comparative study of 2 procedures. J Periodontal 1994;65:929-36.

How to cite this article: Ramakrishnan T, Kaur M, Aggarwal K. Root coverage using epithelial embossed connective tissue graft. Indian J Dent Res 2011;22:726-8.Source of Support: Nil, Conflict of Interest: None declared.

[Downloaded free from http://www.ijdr.in on Tuesday, August 07, 2012, IP: 125.16.60.178]  ||  Click here to download free Android application for this journal