Implant Tribune Canada No. 1, 2016

Novel approach to gingival grafting: Singlestage augmentation graft for root coverage

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Novel approach to gingival grafting: Singlestage augmentation graft for root coverage
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IMPLANT TRIBUNE
The World’s Dental Implant Newspaper · Canada Edition

March 2016 — Vol. 4, No. 1

www.dental-tribune.com

Clinical

Novel approach to gingival grafting: Singlestage augmentation graft for root coverage
By Preety Desai, DDS,
Dip Periodontics

he existence and preservation
of attached keratinized gingiva
around natural teeth and dental implants plays an important role in periodontal1 and peri-implant
health.46,47 This article describes a novel
surgical technique that addresses multiple adjacent Miller Class II and III recession defects5 in a predictable one-staged
surgical procedure. The goals of treatment
are to improve esthetic outcomes and gain
clinical attachment and keratinized tissue
levels in addition to possible root coverage.
A combination of traditional periodontal plastic procedures is used, following
sound, evidence-based techniques. To date,
more than 100 surgical cases have been
completed. Surgical steps and rationale for
this new technique are detailed here, and
representative cases are shown (Figs. 1–12).

Introduction
As many epidemiological reports suggest,
gingival recession affects the majority of
the adult population.2,3 Gingival recession
is defined as the apical migration of the
soft-tissue margin around teeth leading to
exposure of the cementoenamel junction
(CEJ) and the dentinal root surface4 and
is classically categorized by Miller.5,6 The
philosophy for increasing the zone of keratinized tissue for teeth is for attachment
stability, facilitation of plaque control and
to prevent further gingival recession from
frenal/muscle pulls.6,7
Periodontal plastic procedure articles
in the literature evidentially demonstrate
very predictable and esthetic root coverage in the majority of Miller Class I and
II single- or adjacent-tooth sites with and
without the adjunct of a subcutaneous
connective tissue graft (SCTG).3,7 This holds
true irrespective of surgical technique(s)
used, i.e., pedicles, tunnels, coronally positioned flaps (CPF), guided-tissue regeneration (GTR), etc., provided that biologic
principles for obtaining root coverage
are satisfied, i.e., interproximal papillary
height and interseptal bone height.
Additionally, the results of long-term
clinical retrospective studies in private
practice demonstrate that not only is there
effective root coverage but mean root
coverage tends to improve over time after
initial surgery.8 In acellular dermal matrix
and GTR studies over the short and long
term, neither showed a statistically significant increase in root coverage compared
with the use of autogenous tissues.9,10 More

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Fig. 5

Fig. 1: Case 1, lower-right sextant presurgery. Fig. 2: Case 1, lower-right sextant pre-op X-ray. Fig. 3: Case 1, post-op. Fig. 4: Case 2, upper
left sextant pre-op. Fig. 5: Case 2, surgery — flap elevation. Photos/Provided by Dr. Preety Desai

Fig. 6

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 6: Case 2, surgery — coronally positioned flap. Fig. 7: Case 2, upper-left sextant — four weeks post-op. Fig. 8: Case 2, upper-left
sextant — six weeks post-op. Fig. 9: Case 3, upper-left sextant pre-op. Fig. 10: Case 3, upper-left sextant post-op.

recently, the literature also shows clinical cases of inexplicable root resorption
in SCTG cases performed in a traditional
manner.47,48 In contrast, the presence of
multiple recessed sites in a posterior sextant that have advanced recession beyond
Miller Class I/II, presents a clinical conundrum that has not been addressed until recently in the literature of periodontics3,11,12
and clinical periodontal practice. Nevertheless, the goal of periodontal therapy
should be to address the needs and wishes
of each patient, and treatment options
should be made available to each patient
accordingly.13
Recession in multiple adjacent teeth
can occur for a variety of reasons: the patient’s iatrogenic habits; history and/or
treatment of chronic periodontal disease
by traditional flap therapy; anatomy/malpositioned teeth in the alveolar ridge corridor compromising attachment apparatus; muscle/frenal attachment levels at or
beyond the mucogingival junction (MGJ);
secondary parafunctional habits; and the
obvious long-standing results of a history
of chronic untreated periodontal disease.
A two-staged surgical procedure — free
gingival graft (FGG) plus surgical repositioning coronally positioned flap (CPF)12,14
— can aid individual sites in some Miller
II/III recessed areas. These surgical sites
that have experienced two surgeries are
prone to double the postoperative surgical
shrinkage, fibrotic scar tissues and morbidity.30 Patients also report discontent
with this two-surgery treatment option
because of increased costs, healing time,
work absences and scheduling issues. In
difficult economic times, the dental profession must streamline treatment options for patients but still continue to deliver excellent surgical skills and subsequent
clinical benefit. No treatment options are

available in posterior sextants with multiple recessed Miller Class II/III sites that
have a lack of adequate keratinized and
attached gingiva regardless of if the adjacent papillae is affected. As such, an effort
has been made to fill this void with a corrective surgical procedure able to stabilize progressive recession with the added
benefit of some root coverage in Miller III
recessions.11

Inclusion criteria
for single-stage CPF/FGG
Patients eligible for the one-stage CPF/FGG
procedure included those with:
1) No health issues as a contraindication
for periodontal surgery.
2) Presence of at least two to three adjacent teeth with Miller Class II/III facial
recession with a frenal/ligamental attachment deemed to be playing a role in creating a stable gingival margin.
3) Chief complaint of impaired esthetics
associated with the recession.
4) Absence of anatomical defects, caries
or restorations needed in the site.
5) No periodontal surgical treatment of
the involved sites during the previous 24
months.
6) Adequate oral hygiene.
7) Non smokers.

Procedure
Patients chosen exhibit posterior sextants
of recession with interproximal bone loss
(Miller II or III) and encroachment of gingival recession on the MGJ, commonly
with frenal pulls and muscle attachments,
which may or may not have played a role
in the etiology of attachment loss but will
play a role on the success and stability of
surgical treatment to resolve progressive
recession.15,49
A modified one-staged FGG + CPF12,14 sur-

gical approach is suggested: Implementing
Sumner’s full-thickness envelope16 and
Sorrentino and Tarnow’s17 semilunar procedure augmented with a traditional
FGG18 apical to the coronally positioned
semilunar flap is suggested. This combination procedure proposes to inhibit the
coronal reattachment of the musculature
and freni, which can play havoc with graft
stability in the long term,49 in addition to
increasing the zone of keratinized and attached tissues. Results showed that most
Class III recessed cases even showed some
root coverage in addition to an ample gain
in keratinized and attached tissues.11,12
The first incision was performed by the
Er,Cr:YSGG laser (with appropriate softtissue settings due to its known properties
of hemostasis). The T4 laser tip incises precisely at the MGJ in a contact/non-contact
manner depending on the extent of fibrous and ligamentous frenal attachment
to make a split-thickness-incision release
of all musculature/fibres prior to reaching
the periosteum. All elastomeric fibres are
thus incised and denatured at the MGJ.
This allows the mucosa to apically relax,
laying passively, extending the vestibular
region without causing any tension on the
future graft’s recipient surgical site. Rarely
was vestibular suturing needed for hemostasis in the region unlike with a traditional blade incision. Resorbable 4-0 gut
sutures are used in the vestibule for this
purpose.
Dentinal root preparation is done in a
conservative manner if the anatomy is
deemed to be inhibitory to coronal-flap
positioning and stability (i.e., in root abrasion, horizontal grooving, caries cases, etc.).
The root surfaces are traditionally modified with root planing to remove calculus,
” See GRAFTING, page B2

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CLINICAL

“ GRAFTING, Page B1
plaque, debris and to
create a flat/convex
architecture; and they
Fig. 11a
Fig. 11b
Fig. 12
are etched with the
hard-tissue
setting
Fig. 11a,b: Case 4, pre-op surgery. Fig. 12: Case 4, postop surgery.
with the Er,Cr:YSGG at
the coronal gingival
weeks following surgery and were premargins prior to suturing of the coronal
scribed 0.12 percent chlorhexidine mouthflap.
wash three to four times per day during
The second incision is the release of the
the three weeks after the procedure.
coronally attached keratinized tissues in19
cised as an envelope flap from the sulcus
Results
in a full-thickness manner20 with microsurgical blades — without the use of vertiAll patients demonstrated surgical results
cal incisions on the facial aspect and split
that had an improved and stable zone of
thickness in the papillary regions. The flap
attached and keratinized tissues with no
is coronally positioned with vertical matevidence of muscle or frenal reattachment
tress interrupted sutures using 6-0 noncompromising the zone of KT. Most often,
resorbable monofilament microsurgical
there was evidence of partial root coversutures. Once the coronally placed flap is
age in Class III Miller recessions. The typsecure, then the soft-tissue laser setting of
ical white “scar line” evidenced at the MGJ
the Er,Cr:YSGG allows gingivoplasty/gindiscussed in Sorrentino and Tarnow’s17 origivectomy via microplastiying of the marginal paper is rarely seen in this one-staged
ginal tissue outline and adaptation of the
procedure. Patients also found the procedmarginal papillary regions of the gingival
ure no more arduous than any other perimargins.
odontal plastic procedure and, more often
An ideal scalloping in the manner of a
then not, the treatment was more comfort“paintbrush” stroke of the laser tip allows
able than expected using the Er,Cr:YSGG
the coronal architecture of the free gingilaser for the initial incision.
val margin (FGM) adjacent to the teeth to
The author has done this procedure in
adapt the marginal tissues precisely. This
more than 100 cases with no untoward
gingivoplasty allows the whole site to have
results and with great patient satisfaction.
a more finessed marginal gingival adaptaDiscussion
tion and contoured appearance against the
dentition. The whole coronally positioned
In recession studies available to review,
tissue is still attached with its mesial and
Miller I and II recessions are the majority
distal blood supplies intact and is now
found in the literature. In one such study,21
fixed with interproximal sutures, gaining
coronally advanced flaps were used for
blood supply from the split-thickness papmultiple teeth in the esthetic zone for root
illae and the alveolar bone beneath it. The
coverage and were noted to be stable at one
coronally positioned tissue is immobile
year’s time with a statistically significant
and well adapted interproximally to have
increase in the amounts of KT. Yet in anthe best chance of blood vessel anastomoother study by Gurgan,49 after five years,
ses, but at the apical aspect it lays passively
50 percent of these cases receded to the
on the periosteal bed.
presurgical levels as surmised by using
The donor FGG is then placed apical to
alveolar connective tissue as donor as opthe coronally positioned flap onto the
posed to gingival tissue as donor.
periosteum and alveolar bone, which has
Research papers looking at both animal
been cleared of any elastomeric fibres and
and human subjects demonstrate that alsutured with resorbable interrupted 6-0
tered gingival circulation and vitality, as
sutures, which engages the periosteum
determined by fluorescein angiography,
and the apical aspect of the CPF, binding
show that more vascularity is associated
the coronal aspect of the donor FGG down.
with greater graft survival.23 Hwang and
This creates immobility and no dead space
Wang24 also indicated that a positive asso— to ensure the best blood supply.
ciation exists between weighted flap thickThe Er:YSGG laser is used at appropriate
ness and mean and complete root coversettings to actually “weld” and plasty the
age.
donor FGG with paintbrush strokes to the
Langer and Langer’s25 technique used
CPF at the junction of the new augmented
partial-thickness flap elevation to enhance
KT/AT. This creates a more esthetic result
revascularization of the graft, which was
and strengthens tissue junction.
then stabilized on the recipient site using
Pressure on the whole surgical site aids
periosteal sutures. Raetszke,19 however,
in hemostasis and immobility if needed
advocated the use of the split-thickness
prior to pack placement, avoiding any dead
envelope in isolated areas only, reporting
space or blood clots that may hinder a
difficulty in obtaining sufficient tissue
healthy blood supply for vascularity of the
for use in more extensive areas of recesnewly placed graft and tissue. Surgical glue
sion. Surgically, though, the elevation of
is used if necessary for additional stabilizaa partial-thickness flap can be arduous to
tion, minding any subtissue leakage, which
perform, particularly in patients with a
will impede healing. Thus, the whole site
thin gingival biotype. A partial-thickness
is tension free, with an increased vestibuflap also reduces the KT tissue thickness;
lar depth and an increased zone of AT/KT
and mucosal flaps less than 1-mm thick
without frenal/muscle hindrance, in addihave been correlated with a reduction in
tion to the potential of root coverage.
the percentage of root coverage in defects
Traditional postoperative instructions
treated using coronally advanced flaps.22,27
are provided, and analgesics and antiBecause bilaminar vascularity is reinflammatories are prescribed. Patients
quired only to provide blood supply to a
are followed at one- (pak removal), threeSCTG, a full-thickness CPF was used in this
(suture removal) and six-week intervals for
procedure.
follow-up, as with traditional periodontal
Any chance of fenestration or dehiscense
plastic procedures. Patients were asked
over the roots26 remaining after a fullto refrain from any mechanical hygiene
thickness CPF is compensated for by the
techniques in the treated area for the three
FGG placed over these denuded sites, and

Implant Tribune Canada Edition | March 2016

historically that has proven
to not be an issue28,29 when
grafts were placed straight
onto the alveolar bone. No
issues were observed due to
coronally positioning a fullthickness flap vs. a partialthickness flap,26,29 and yet,
the benefit of maintaining
the full buccal lingual thickness of KT remains a huge asset.20 Also, the elevation of
a full- or partial-thickness flap did not appear to influence the amount of KT or the
percentage of root coverage achieved postsurgically.20
Literature comparing the CPF vs. semilunar flaps showed that both designs
were effective in obtaining and maintaining a coronal displacement of the gingival margin. The CPF resulted in clinical
improvements significantly better than semilunar flaps for percentage of root coverage, frequency of complete root coverage
and gain in clinical attachment level.27
A recent review50 points out that aberrant frenal pulls are a contraindication to
the traditional CPF/SCTG. Aberrant freni
cannot be corrected at the time of surgery
because incisions would compromise the
blood supply available to the graft. When
indicated, a frenectomy is scheduled
four to six weeks prior to grafting.15,50 The
beauty of the single-stage laser CPF/FGG
is that all aberrant frenal attachments are
dealt with immediately in order not to
compromise graft stability, microvasculatature from the recipient bed and graft
longevity — and thus future recession of
the new donor tissue.
In another paper, Harris10 treated 266
defects with connective tissue grafts associated with a coronally advanced or a
double-papilla flap and reported that the
average results of deep recessions (≥ 5 mm)
were less favorable (87 percent vs. 95 percent), when connective tissue grafts were
associated with a coronally advanced flap.
Although these results were for Miller I
and II recessions and showed better results
then seen in the Miller III laser CPF/FGG
procedure, they confirm limitations when
recessions reach 5 mm.30
In the traditional SCTG + CPF without
vertical releasing incisions, results in Miller III root coverage ranged from 1 to 3
mm (mean 1 ± 1.5); and Miller IV recessions
ranged from 2 to 10 mm (mean 1.86 ± 0.14).
The number of Class III and IV recessions
were fewer than Class I and II recessions.
Nevertheless, the authors noted that these
type III/IV clinical situations can be improved with this procedure.12
It has also been shown that when CPF
plus CTG versus CPF procedures for root
coverage were compared, the two surgical
procedures resulted in similar degree of
root coverage, but the CPFs alone reverted
to presurgical positions of the MGJ.31 In
addition, other long-term papers evaluating CPF with CTG all show that an apical
rebound of the MGJ occurs, resulting in
unstable root coverage and increased recession.31,45,52 These findings may be explained by Ainamo et al.,51 who reported
that the MGJ will regain its original apical
position over time, resulting in unstable
root coverage – with a brand new MGJ reestablished by adding keratinized FGG
apically.
In a study comparing CPF techniques
with and without the use of vertical releasing incisions, both were shown to be
effective in reducing recession depth, but
” See GRAFTING, page B4

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B4
“ GRAFTING, Page B2
the envelope type of CAF was associated
with an increased probability of achieving
complete root coverage — and with a better postoperative course.
Keloid formation along the vertical releasing incisions was responsible for a
poor esthetic outcome along with a longer
healing period and a more uncomfortable postoperative course.32 Complete root
coverage has been shown to be more likely
in Miller I and II type recessions, when
marginal tissue recessions are shallower:
66 percent for an average attachment level
of 3.81 mm, compared with 50 percent and
33.3 percent for mean attachment levels of
5.23 and 5.5 mm, respectively.33,34 Glise and
Monnet-Corti also reported that percentage of root coverage was inversely proportional to width and height of initial recession dimensions.35 Thus, even though the
literature indicates that Miller III and IV re-

Ad

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CLINICAL

cessions have little probability of 100 percent root coverage, increasing the KT and
AT can increase the longevity of a patient’s
dentition. Even if only some slight root
coverage (based on individual anatomy
and physiology) is possible, this may be a
significant improvement for the patient
esthetically; and it also increases the chances of additional root coverage as a result of
creeping attachment for the patient.36
The Er,Cr:YSGG laser is used here for the
first time in surgical grafting procedures
because it achieves a precision not possible
with a surgical blade. Erbium lasers also
have the unique ability to vaporize watercontaining tissue because of its wavelength and provide a hemostatic effect to
cauterize blood vessels.
What is clearly observed is that the
Er:YSGG laser enables the operator to take
a “microsurgical approach” — to finesse
the marginal-tissue adaptation at the coronal edges along with “laser welding” the

Implant Tribune Canada Edition | March 2016

FGG-donor portion to the CPF portion of
the surgical site and control the hemostasis without additional suturing. Pini
Prato37 showed that the gingival marginal
position at the end of plastic surgery allowed for complete root coverage in Class I
and Class II gingival recession defects, and
applying this philosophy of treatment to
the laser CPF/FGG will only enhance any
probability of root coverage in Miller III/IV
recession defects.
The elevation of a full- vs. partialthickness flap does not appear to influence
either the amount of keratinized tissue or
the percentage of root coverage achieved
post-surgically.20 In fact, the thicker coronal tissue, allows an increase in blood
supply, surgical anchorage and less tissue
trauma with better potential root coverage.38 Pedicle and envelope flaps are successful if the grafted tissues remain vital
on the exposed dental avascular root surface, and soft-tissue healing is critically

controlled by this vascularity.28,29 Most reaffirming was Romanos et al.43 showing
that the lateral bridging flap technique,
designed similar to this paper’s CPF, exhibited the most stable location of the repositioned MGJ, which was 2-3 mm coronally over five to eight years, with stable root
coverage and gingival margins.
Of further interest is that treatment
success is more predictable, with limited
interproximal bone loss and undamaged
interproximal soft tissue.5,39
Gurgan commented that tooth location,
vestibular depth, and muscular and frenum insertions may affect wound stability
once a flap is advanced.50
Fombellida analyzed the significance of
the “vascular supply” as a critical factor on
the prediction of root coverage success; a
positive balance between the vascularized
and nonvascularized areas of the surgical
field yields better results in terms of root
coverage, even in those less favorable cases,
such as Miller Class III recessions.40

Conclusions
Clinicians all too often are faced with the
request: “Can you not do something to
cover these teeth?” Many times the concern is not related to sensitivity but rather
that of esthetics, after recession has increased over a period of time for a patient
on a stable maintenance schedule. Once
the periodontal health was assessed to be
stable, the remaining compromised zone
of KT/AT and the location of the muscle/
frenal attachment often appeared to play
a role in progressive recession. Thus, the
single-staged laser CPF/FGG was developed
and completed in more than 100 patients
— and was reported to be a comfortable
procedure with an esthetic improvement.
Additionally, there have even been documented areas of root coverage in Miller III
and IV situations and, over the years, some
“creeping attachment” has been documented.36
Additional investigation through a prospective clinical study with volumetric
methodology44 needs to be done to assess
the statistical significance of increases in
KT and root-coverage results of this new
procedure — or with the adjunct of tissue
engineering and biological adjuncts, such
as enamel matrix derivative, PRP (platelet
rich plasma) or PRF (platelet rich fibrin).41
The CAF procedure is effective in the
treatment of gingival recessions. However,
recession relapse and reduction of KT occurred during follow-up periods without
any FGG adjunct.42 The baseline width of
KT is a predictive factor for recession reduction when using the CAF technique.
Thus the new single-staged laser CPF/FGG
is an effective and predictable method to
increase the zone of KT and AT width. The
technique can also anecdotally be shown
to increase root coverage in Miller III and
IV cases and fulfills the need of the patient,
while at the same time reducing the number of appointments and patient costs.
A list of references is available from the
publisher on request.
Preety Desai, BSc, DDS, Dip
Periodontics, has been in fulltime specialty periodontal practice in Kamloops, British Columbia, since 1997. She has no
financial interests in, and has received no materialistic or financial benefit from, corporations
with respect to this article. She can be contacted by
email at kamloopsperiodontics@gmail.com.

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Table of contents

Novel approach to gingival grafting: Singlestage augmentation graft for root coverage
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Novel approach to gingival grafting: Singlestage augmentation graft for root coverage

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