Root coverage procedures in periodontics.

1. Root Coverage Procedures.
BDS FINAL PROF
Submitted by :- Wani Dayim Manzoor
Roll No:- 92/19
Guided by :- Dr Malvika Singh

2. Contents
 Introduction and background
 Definition of Recession
 Classification of recession
 Techniques of root coverage
 Other techniques
 Conclusion
 References

3. Introduction
 In the last three decades, the scope and ambit of
periodontal therapy has gone far beyond arresting the
disease and eliminating the pockets.
 Further, the periodontist is now an important member of
the interdisciplinary team, which aims at overall
maintenance of the dentition in a state of health,
function, and esthetic harmony.

4. Recession
 Gingival recession may de defined as the exposure of root
surface by an apical shift in the position of gingiva.
(Carranza)
 The predictability of root coverage can be enhanced by
the pre-surgical examination and the correlation of the
recession by using the classification proposed by Miller in
the year 1985.

5. Miller’s classification of gingival recession (1985) On the
basis of extent of interdental tissue loss and the
relationship to the mucogingival junction.
 CLASS I :- Marginal tissue recession does not extend to the
mucogingival junction. There is no loss of bone or soft tissue in
the interdental area. This type of decision can be narrow or
wide.

7.  CLASS II :- Marginal tissue recession extends to or
beyond the mucogingival junction. There is no loss of
bone or soft tissue in the interdental area. This type
of recession can be sunclassified into wide and
narrow.

8.  CLASS III :- Marginal tissue recession extends to or
beyond the mucogingival junction. There is bone and
soft tissue loss interdentally or malpositioning of the
tooth.

9.  CLASS IV :- Marginal tissue recession extends to or
beyond the mucogingival junction. There is severe
bone and soft tissue loss interdentally or severe tooth
malposition.

10. Techniques:-
The following is a list of techniques used for root
coverage.
1. Free gingival autograft.
2. Pedicle graft (laterally or horizontally displaced flap)
3. Coronally advanced flap.
4. Subepithelial connective tissue graft.
5. Guided tissue regeneration (GTR)
6. Pouch and tunnel technique.

11. Free Gingival Autograft
Successful and predictable root coverage has been
reported using free gingival autografts.
 The classic Technique
Miller applied the classic free gingival autograft
described previously with a few modifications.

12. Step 1:- Root planing:
• Root planing is performed with the application of
saturated citric acid for 5 minutes on the root
surface.
• The application of this acid has not been validated
by some studies, but numerous clinicians practice
this technique.

13. Step 2 :- Prepare the recipient site:
• Make a horizontal incision in the interdental papillae
at right angles to create a margin against which the
graft may have a butt joint with the incision.
• Vertical incisions are made at the proximal line
angles of adjacent teeth and the retracted tissue is
excised. Maintain an intact periosteum in the apical
area.

14. Step 3 and 4 :- The technique results in predictable
coverage of the denuded root surface but may present
esthetic colour discrepancies with the adjacent gingiva
because of a lighter colour.

15. Step 5 :- Transfer the graft:
Transfer the graft to the recipient site and suture it to
the periosteum with a gut suture. Good adaptability to
the graft must be attained with adequate sutures.
Step 6 :- Cover the graft:
Cover the graft site with dry aluminium foil and
periodontal dressing.

16. Free Gingival Autograft. A, Preoperative lack of attached gingiva on 43(recipient
site) B, Surgical recipient bed prepared. C, Incision at the donor site. D, Donor tissue
placed and sutured at recipient site. E, Donor site in the palatal area immediately
after removal of tissue for grafting. F, Recipient site showing increased attached
gingiva.

17. Pedicle Autograft
Laterally (Horizontally) Displaced Pedicle Flap. The
displaced pedicle flap technique originally described by
Grupe and Warren in 1956, was the standard technique for
many years and is still indicated in some cases. The
laterally positioned flap can be used to cover isolated,
denuded rot surfaces that have adequate donor tissue
laterally. Adequate vestibular depth must also be present.

18. The following is a step by step surgical description:–
Step 1:- Prepare the recipient site:
Epithelium is removed around the denuded root
surface. The exposed connections tissue will be the
recipient site for the laterally displaced flap. The
root surface will be thoroughly scaled and root
planned.

19. Step 2 :- Prepare the flap:
• The periodontium of the donor site should have a
satisfactory width of attached gingiva and minimal loss of
bone, without dehiscence or fenestration.
• A full thickness or partial thickness flap may be used.

20. Step 3 :- Transfer the flap:
Slide the flap laterally onto the adjacent root, making
sure that it lies flat and firm without excess tension on
the base. Fix the flap to the adjacent gingiva and
alveolar mucosa with interrupted sutures. A suspensory
suture may be made around the involved tooth to
prevent the flap from slipping apically.

21. Step 4 :- Protect the flap and donor site:
• Cover the operative field with aluminium foil and a
soft periodontal dressing, extending it interdentally
and onto the lingual surface to secure it.
• Remove the dressing and sutures after 1 week.

22. Laterally displaced flap. A, Preoperative view maxillary bicuspid B,
Recipient site is prepared by exposing the connective tissue around
the recession. C, Incisions are made at the donor site in preparation
of moving the tissue laterally. D, Pedicle flap is sutured in position.
E, Postoperative result 1 year.

23. Accomplishments of Pedicle Autograft.
 Coverage of the exposed root with the sliding-flap
technique has been reported to be 60, 61 and 71%.
Histological studies in animals have reported 50%
coverage

24. Coronally Advanced Flap.
The purpose of the coronally displaced flap procedure is
to create a split-thickness flap in the area apical to the
denuded root and position it coronally to cover the
root.
Two techniques are available for this purpose.
1. Classic Technique
2. Semilunar Flap Technique

25.  CLASSIC TECHNIQUE
Step 1 :- With two vertical incisions, delineate the
flap. These incisions should go beyond the
mucogingival junction. Make a crevicular incision from
the gingival margin to the bottom of the sulcus.
Elevate a mucoperiosteal flap using careful sharp
dissection.

26. Step 2 :- Scale and plane the root surface.
Step 3 :- Return the flap and suture it at a level coronal
to the pretreatment position. Cover the area with a
periodontal dressing, which is removed along the
sutures after 1 week.

27. Coronally displaced flap. A, Preoperative view. B, After
placement of a free gingival graft. C, Three months after
placement of the graft. D, Flap, including the graft, positioned
coronally and sutures. E, Six months later. Compare with A.

28.  Semilunar Flap Technique
Tarnow has described the semilunar coronally
repositioned flap to cover isolated denuded root
surfaces.
Step 1 :- A semilunar incision is made following the
curvature of the receded gingival margin and ending
about 2-3 mm short of the tip of the papillae.

29.  The location is very important because the flap
derives its blood supply from the papillary areas. The
incision may need to reach the alveolar mucosa if the
attached gingiva is narrow.

30. Step 2 :- Perform a split-thickness dissection coronally
from the incision and connect it to an intrasulcular
incision.

31. Step 3 :-
• The tissue will collapse coronally, covering the
denuded root.
• It is then held in its new position for a few minutes
with moist gauze.
• Many cases do not require either sutures or
periodontal dressing. This technique is simple and
predictably provides 2-3 mm of root coverage.

32. • It can be performed on several adjoining teeth. This
technique is indicated where the recession is not
extensive (3 mm) and the facial gingival biotype is
thick.
• It is successful for the maxilla, particularly in covering
roots left exposed by the gingival margin receding from
a recently placed crown margin.
• It is not recommended for the mandibular dentition.

33. Semilunar coronally positioned flap. A, Class 1 recession on the
facial surface of the maxillary right central incisor. B, A semilunar
incision is made and tissue separated from the underlying bone. C,
Crevicular incision. D, The flap collapses covering the incision, no
sutures given. E, Appearance after 7 weeks showing complete root
coverage.

34. Subepithelial Connective Tissue
Graft(Langer and Langer)
The Subepithelial connective tissue procedure is
indicated for larger and multiple defects with good
vestibular depth and gingival thickness to allow a split
thickness flap to be elevated. Adjacent to the denuded
root surface, the donor connective tissue is sandwiched
between the split flap. This technique was described by
Langer and Langer in 1985.

35. Step 1 :- Raise a partial-thickness flap with a horizontal
incision 2 mm away from the tip of the papilla and two
vertical incisions 1-2 mm away from the gingival margin
of the adjoining teeth. These incisions should extend at
least one tooth wider mesiodistally than the area of
gingival recession. Extend the flap to the mucobuccal
fold.

36. Step 2 :- Thoroughly plane the root, reducing its
convexity.
Step 3 :- Obtain a connective tissue graft from the
palate by means of a horizontal incision 5-6 mm from
the gingival margin of molars and premolars. The
palatal wound is sutured in a primary closure.

37. Step 4. Place the connective tissue on the denuded
root(s). Suture it with resorbable sutures to the
periosteum.
Step 5. Cover the graft with the outer portion of the
partial-thickness flap and suture it interdentally.

38. Step 6. Cover the area with dry foil and surgical
dressing. After 7 days, the dressing and sutures are
removed. The esthetic results are favorable with this
technique since the donor tissue is connective tissue.
The donor site heals by primary intention, with
considerably less discomfort than after a free gingival
graft.

39. A variant of the subepithelial connective tissue graft, called
a (subpedicle bilaminar) connective tissue graft, was
described by Nelson in 1987. This technique uses a pedicle
over the connective tissue that covers the denuded root
surface. Therefore, the blood supply is increased over the
donor tissue and the gingival margin is thickened for better
marginal stability.

40. Subepithelial connective tissue graft for root coverage. A,
Preoperative view: recession on mandibular 1st premolar, B,
Graft site prepared, C, Graft placed on the recipient site, D,
Flap replaced and covered over the graft. E, Postoperative view
showing complete root coverage.

41. F-J , Schematic representation of Sub-epithelial
connective tissue graft technique.

42. Pouch and Tunnel Technique (Coronally
Advanced Tunnel Technique)
 To minimise incisions and the reflection of flaps and
to provide abundant blood supply to the donor site,
the placement of the subepithelial donor connective
tissue into pouches beneath papillary tunnels allows
for intimate contact of donor tissue to the recipient
site.

43.  The positioning of the graft in the pouch and through
the tunnel and the coronal placement of the recessed
gingival margins completely covers the donor tissue.
Therefore the esthetic result is excellent.

44.  The technique is especially effective for the anterior
maxillary area in which vestibular depth is adequate
and there is good gingival thickness.
 The work by Azzi et al in this area of surgery has
contributed to a better understanding of the
technique and outcome of this procedure.
 This surgery is also referred to as the Coronally
Advanced Tunnel Technique.

45. Steps as outlined by Azzi.
Step 1 :- Preparation of the patient includes plaque
control instruction and careful scaling and root planing
several weeks before the surgical procedure. The patient is
instructed to rinse for 3.0 s with chlorhexidine gluconate
solution 0.12%.
Step 2 :- After adequate anaesthesia of the region, the
surgical procedure, as follows, is performed.

46. Step 3 :- Composite material stops are placed at the
contact points (temporary) to prevent the collapse of
the suspended sutures into the interproximal spaces
before the surgery.
Step 4 :- Root planing of the exposed root surfaces is
performed using Gracey curettes.

47. Step 5 :- Initial sulcular incisions are made using 15c and
12d blades. Small, contoured blades and mini curettes are
used to create the recipient pouches and tunnels.
Step 6 :- On the buccal aspect, an intrasulcular incision is
made around the necks of the teeth. The incision is
extended to one adjacent tooth both mesially and distally
using a 15c blade.

48. • This incision maintains the full height and
thickness of the gingival component and
enables access beneath the buccal gingiva
with Gracey curettes.
• The cutting edge is directed toward the bone
to dissect the connective tissue beyond the
mucogingival line and free the buccal flap
from its insertions to the bone around each
other.

49. Step 7 :- Muscle fibers and any remaining collagen fibers
on the inner aspect of the flap, which prevent the buccal
gingiva from being moved coronally, are cut using Gracey
curettes.
Step 8 :- The papillae are kept intact and undermined to
maintain their integrity and carefully released from the
underlying bone, which allows the coronal positioning of
the papillae.

50. Step 9 :- An envelope, full-thickness pouch and
tunnel are created and extended apically
beyond the mucogingival line by blunt dissection
for the insertion of the free connective tissue
graft through the intrasulcular incision. Saline-
moistened gauze is placed over the recipient
site.

51. Step 10 :- The size of the pouch, which includes the area of
the denuded root surface, is measured so that an equivalent
size donor connective tissue can be procured from the
tuberosity.
Step 11 :- A second surgical site is created to obtain a
connective tissue graft of adequate size and shape to be
placed at the recipient site. The connective tissue harvested
from the tuberosity area is contoured to fit into the
recipient tunnel and pouch.

52. Step 12 :- A mattress suture placed at one end of the
graft is helpful in guiding the graft through the sulcus
and beneath each interdental papilla. The border of the
tissue is gently pushed into the pouch and tunnel using
tissue forceps and a packing instrument.

53. Step 13 :-
• A mattress suture placed on one end of the graft will help
maintain the graft in position while the buccal tissue
covers the connective tissue graft.
• This connective tissue graft is anchored to the inner
aspect of the buccal flap in the interdental papilla area. A
vertical mattress suture is used to hold the connective
tissue in position beneath the gingiva. The connective
tissue graft is completely submerged beneath the buccal
flap and the papillae.

54. Step 14 :- The entire gingivopapillary complex (buccal
gingiva with the underlying connective tissue graft and
papillae) is coronally positioned using a horizontal
mattress suture anchored at the incisal edge of the
contact area. The contact areas are splinted
presurgically using a composite material.

55. Step 15 :- Other holding sutures may be placed through
the overlying gingival tissue and donor tissue to the
underlying periosteum to secure and stabilize the donor
tissue and the overlying gingiva in a coronal position.
The area is not covered with periodontal dressing.

56. • The patient is instructed to rinse daily with
chlorhexidine gluconate and to avoid touching the
sutures during oral hygiene procedures.
• Antibiotics can be administered (Amoxicillin 500
mg 3 times a day), if deemed necessary.

57. Pouch and tunnel technique for root coverage. A, Preoperative view. B, Sulcular incision is made
from the mesial to the facial line angles. C, A tunnel is made through the papilla using a blunt incision.
D, A connective tissue graft is taken from the palate. E, The connective tissue is placed through the
papillary tunnel and apically beneath the pouch. F, The facial gingival margin covers the connective
tissue using horizontal mattress sutures interdentally. G, Postoperative view. Note complete root
coverage and thickened gingival margin at 3 months.

58. Other Techniques.
In the last few years, a number of new techniques have developed
particularly for multiple root coverage.
1. Vestibular incision subperiosteal tunnel access (VISTA)
2. The Pinhole approach
3. Zuchellis technique
4. Use of acellular dermal matrix
5. Dento gingival transfer
6. Periosteal transfer

59. Conclusion
 As defined earlier, these procedures are based on
soft-tissue relationships and manipulations. In all of
these procedures, blood supply is the most significant
concern and must be the underlying issue for all
decisions regarding individual surgical procedure.
 Critical analysis of newly presented techniques should
guide our constant evolution toward better clinical
methods.

60. References
Takei HH, Scheyer ET, Azzi RR, Allen EP, Han TJ,
Dwarakanath CD. Periodontal plastic and esthetic surgery.
Newman and Carranza'a Clinical Periodontology.Elsevier
Publishers India 2016; 2(1): 582-590.