Use of the grafts for root coverage
The periodontal plastic surgeries are done for the prevention or the correction of any anatomic deformities in the gingiva.
Gingival recession is a muco gingival anomaly characterized by migration of the gingival margin toward the amelocemental junction resulting in the loss of attachment and protective connective tissue fibers followed by resorption of the alveolar bone and necrosis of cement tissue. This results in the symptoms of gingival sensitivity to tooth brushing, dentin hypersensitivity by hot stimuli, aesthetic concerns.
| PREDISPOSING FACTORS | TRIGGER FACTORS |
| Bone dehiscence | Traumatic brushing |
| Bone fenestration | Non carious cervical lesions |
| Thin cortical bone | Inflammation |
| Absence of keratinized tissue | Misfit or fixed dental prosthesis |
| Small thickness of keratinized tissue | Clip, bar or saddle removable prosthesis causing compression |
| Low height of keratinized tissue | Violation of biological space |
| Poor tooth positioning | Incision at the base of the flap, cutting the subjacent periosteum |
| Tension on frenula and frena | Poorly located relaxing incision |
| Shallow vestibule | Extraction |
| Orthodontic movement outside bone limits | |
| Occlusal traumatism | |
| Harmful habits |
Classification of Periodontal Recession (Sullivan And Atkin’s Classification)
- Deep and wide recession
- Shallow and wide recession
- Deep and narrow recession
- Shallow and narrow recession
Miller’s Classification of Periodontal Recession
- Class I – the recession does not attain the Mucogingival line and there is no loss of interproximal tissue.
- Class II — the recession attains or exceeds the Mucogingival line and there is no loss of interproximal tissue.
- Class III – the recession attains or exceeds the Mucogingival line with interproximal tissue loss located apical to the amelocemental junction, although the tissues will remain in a coronal position in relation to the base of the gingival recession.
- Class IV – the recession attains or exceeds the Mucogingival line with interproximal tissue loss located apical to the amelocemental junction, with the latter situated on the level at the base of the gingival recession; involvement of more than one surface of the tooth.
Treatment and its indications
- To prevent the development of Mucogingival defects
- When there is an esthetic demand
- Dentin hypersensitivity
- Root caries or cervical abrasions
- Change in topography to facilitate plaque control
SURGICAL TECHNIQUE FOR ROOT COVERING
| GRAFTS | FREE GRAFTS | COMBINED GRAFTS |
| Laterally positioned flap | Free gingival graft | Connective graft associated with coronally positioned flap |
| Double papilla flap | Gingival connective tissue graft | Connective graft associated with laterally positioned flap |
| Coronally displaced flap | Connective graft with envelope technique | |
| Half moon flap |
- HALF MOON FLAP
Mainly used for single recession.
ADVANTAGES
- Less post-operative pain
- Absence of sutures to stabilize the flap due to the lack of tension on the flap
- Maintenance of the papilla
- Simple and fast technique
- Satisfactory coverage rate
Free grafts
- Techniques of removal of free grafts
- This technique was developed with the purpose of minimizing the patient’s postoperative discomfort and improving healing in the donor area.
- The palate is the region most used as the donor area, with the best region being the one located between premolars and molars due to its thickness.
CONJUNCTIVE TISSUE GRAFT (CG)
The main advantage of this graft is that it favors healing by first intention in the donor area, because the epithelium is preserved and only the connective tissue is removed.
In addition, more harmonious esthetic appearance is obtained, because of the grafted tissue color being adjusted to that of the adjacent areas.
MODIFIED ENVELOPE TECHNIQUE
- This consists of making a lateral, partial thickness incision distal to the recession located in the alveolar mucosa; this is united to the sulcular incision and then the connective tissue graft is slid through this window.
The graft may be introduced by means of a suture thread drawn from the mesial to the distal side, passing over the papillae, the graft is gently drawn into place by means of the suture thread, and it is sutured with a simple stitch on each side