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CASE REPORT
Year : 2018  |  Volume : 22  |  Issue : 3  |  Page : 277-281  

Ascertaining the regenerative potential of the “gold standard” grafts: Achieving 100% root coverage in Miller's Class III recession with periosteal pedicle graft and autogenous bone


Department of Periodontics and Oral Implantology, SGT Dental College Hospital and Research Institute, Gurugram, Haryana, India

Date of Submission05-Dec-2017
Date of Acceptance18-Mar-2018
Date of Web Publication8-Jun-2018

Correspondence Address:
Dr. Shailly Luthra
14, Birch Street, Malibu Towne, Sector-47, Gurugram - 122 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jisp.jisp_333_17

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   Abstract 


Recession of the gingiva is defined as the stripping of a portion of the dental root surface as a result of gingival margin shifting apically. Various techniques have been advocated for root coverage. The practice of utilizing periosteal pedicle graft for covering gingival recession defects is a contemporary development. Utilizing bone grafts for hard tissue regeneration has also been implemented. This case report assesses the effectiveness of the surgical approach utilizing autogenous bone and periosteum for recession coverage. A participant with Miller's Class III gingival recession in #23 and #24 was treated using this technique. The loss of periodontal attachment was recorded to be 8 mm and 5 mm on the mid-buccal surface of the upper left canine and first premolar, respectively. Clinical parameters were recorded at 1, 3, 6, 9, and 12 months postoperatively. Complete root coverage was achieved when evaluated from baseline till 12 months, with clinical attachment level and keratinized tissue gain. The results of esthetics in terms of color match and tissue contours were satisfactory to the patient as well as to the clinicians.

Keywords: Bone, esthetics, gingival recession, periosteum


How to cite this article:
Luthra S, Grover HS, Yadav A, Masamatti S. Ascertaining the regenerative potential of the “gold standard” grafts: Achieving 100% root coverage in Miller's Class III recession with periosteal pedicle graft and autogenous bone. J Indian Soc Periodontol 2018;22:277-81

How to cite this URL:
Luthra S, Grover HS, Yadav A, Masamatti S. Ascertaining the regenerative potential of the “gold standard” grafts: Achieving 100% root coverage in Miller's Class III recession with periosteal pedicle graft and autogenous bone. J Indian Soc Periodontol [serial online] 2018 [cited 2022 May 21];22:277-81. Available from: https://www.jisponline.com/text.asp?2018/22/3/277/233992




   Introduction Top


Recession of the gingiva is defined as the stripping of a portion of the dental root surface as a result of gingival margin shifting apically.[1] Often gingival recession is observed in both periodontally healthy and diseased individuals.[2] Gingival recession can be caused by vigorous toothbrushing, tooth malposition, high muscle attachment, frenal pull, unrestrained gingivitis with accretion of dental plaque and calculus owing to inappropriate brushing methods, and issues related to restorative and orthodontic procedures.[3] Various surgical approaches have been documented in the literature to address the problem of gingival recession.[4] Conventionally, free gingival autografts followed by subepithelial connective tissue grafts have been used successfully. Later on, additive methods such as incorporation of guided tissue regeneration (GTR) membrane and growth factors have become popular.[5] Irrespective of the surgical method, most of the Miller's Class I and II defects show complete root coverage, providing that there are a skilled operator and an appropriate case selection. However, for Miller's Class III cases and IV cases, the surgical outcome cannot be predicted owing to the loss of proximal soft and hard tissues.[6],[7]

This case report presents the esthetic results (100% root coverage) obtained through transposition of the local periosteum along with autogenous bone collected from the same surgical site in addition to a mucoperiosteal-transpositional flap [8] for the treatment of Miller's Class III gingival recession in the maxillary left canine and first premolar teeth.


   Case Report Top


A 49-year-old female reported to the outpatient department of periodontology, with the primary concern of receding gums and sensitivity in the upper left side. She was diagnosed as a case of chronic generalized periodontitis (as per the criteria given by the American Academy of Periodontology [AAP] World Workshop Classification, 1999) [Figure 1]a and [Figure 1]b and had a Miller's Class III gingival recession in the maxillary left canine, and the first premolar was confirmed clinically by bone sounding and radiographically also. On examination, she had cervical abrasion on the canine due to faulty toothbrushing habit [Figure 1]c. The gingival biotype was thick (>1 mm), accompanied by adequate width of attached gingiva and vestibular height. Bleeding on probing, plaque index, loss of periodontal attachment, and the height of the attached gingiva were recorded.[9] The loss of clinical attachment was recorded to be 8 and 5 mm on the mid-buccal surface of the upper left canine and first premolar, respectively. Her general health conditions were good; she was a nonsmoker and was not on any medications for the past 6 months. She underwent a single sitting full-mouth supragingival scaling followed by subgingival after 1 week. The consent form was signed by the patient. The patient underwent oral prophylaxis and was instructed to undergo oral hygiene maintenance program until inflammatory indices reached <1 and a plaque index value of <15% was achieved. A glass ionomer restoration was done for the canine abrasion on the day of the surgery [Figure 2]. Surgery was performed under local anesthesia (Xylocaine with 0.2% adrenaline). A vertical releasing incision extending beyond the mucogingival line was made from the distal corner of the base of the papilla between the maxillary left lateral incisor and canine and also between the maxillary left first and second premolars. A sulcular incision was given to release and raise a full-thickness flap. Bony ledges were reduced at the canine and first premolar region [Figure 3] to ease flap tension, and the autogenous bone obtained by this osteoplastic procedure was utilized as graft [Figure 4]. Root planing was done for the exposed root surfaces using Gracey curettes to achieve a clean, smooth, and hard surface. The cleaned surface was thoroughly rinsed using saline for 60 s. The surface was treated with 24% ethylenediaminetetraacetic acid gel for 2 min and irrigated with normal saline for 60 s [Figure 5]. The periosteal tissue was incised both at the flap base and laterally up to the attached gingival border, enabling its separation from the submucosal tissue to evert the same and reposition it as a membrane [Figure 6]. Already harvested autogenous bone graft was packed in the crater-like defects on the mesial and distal aspect of teeth 23 and 24 and the exposed root surface on the buccal aspect [Figure 7]. The everted pedicled periosteum was transpositioned coronally and secured with a synthetic 5-0 bioabsorbable suture [Figure 8]. The mucoperiosteal flap was also coronally transpositioned and sutured using the same suture material [Figure 9].
Figure 1: Preoperative view

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Figure 2: Glass ionomer cement restoration done

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Figure 3: Harvesting autogenous bone from bony ledges under the canine and first premolar after full-thickness flap reflection

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Figure 4: Harvested autogenous bone

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Figure 5: Root biomodification done

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Figure 6: Periosteal pedicle graft being reflected

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Figure 7: Packing harvested bone on defect site

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Figure 8: Periosteal pedicle graft sutured

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Figure 9: Flap was coronally advanced and sutured

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Antibiotics (amoxicillin 500 mg TDS and Metronidazole 400 mg BD) and analgesics (ibuprofen 400 mg with Paracetamol 325 mg combination) were prescribed for 5 days. Chlorhexidine solution 0.2% was prescribed for 4 weeks.

The sutures were removed after 15 days. Healing was uneventful. Epithelialization of the repositioned periosteal flap for defect coverage was seen 15 days after surgery. A 1 month [Figure 10] 3, 6, 9, and 12 months, clinical follow-up was performed. The obtained results were matched with the presurgical values of bleeding on probing, plaque index, loss of clinical attachment, and the height of attached gingiva. The bulk of the tissue due to infolding of the periosteum reduced by 3 months [Figure 11] and the tissue contour completely merged by 6 months.
Figure 10: One month postoperative

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Figure 11: Three months postoperative

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A 6-month postoperative examination revealed complete root coverage with gain in clinical attachment level in both teeth [Figure 12]. There was increase in keratinized gingiva in both teeth during the 9th [Figure 13] and 12th month which was corroborated with the static position of the mucogingival junction [Figure 14]. The results achieved with a gain in clinical attachment levels and improved esthetics were very satisfying both to the clinician and the patient.
Figure 12: Six months postoperative

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Figure 13: Nine months postoperative

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Figure 14: Twelve months postoperative

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   Discussion Top


The objective of any plastic procedure in periodontology should be to accomplish results which mimic the healthy tissues in the vicinity not only in terms of gingival position, color and texture but also in establishing an anatomically appropriate attached gingival width.

The morphology of the defect determines which technique is ideal in obtaining the best clinical results in terms of root coverage. Care must be taken with the treatment plan and flap design as the perfect results can be attained using the ideally recommended techniques. Minimal isolated recessions are handled successfully using surgical flap techniques only, whereas in areas for the deep-large defects with no attached gingiva, the free gingival or connective tissue grafts or even membranes turn out to be more imperative to help achieve ideal results.[4],[5],[7]

The primary benefit of techniques using GTR along with membranes versus procedures employing tissue grafts is the elimination of problems of an additional donor site. These GTR procedures have proved most effective in cases of gingival recession defects between 4.5 and 5.5 mm when there is an adequate keratinized gingiva.[5],[6] By means of these methodologies, the percentage of complete root surface coverage obtained ranges between an average of 74% recession depth reduction and 41% complete root coverage during a 6- to 18-month postsurgical follow-up.[10] The key setback occurs if there is any dehiscence of the wound and subsequent contamination of the membrane by bacteria. GTR procedures are also not very effective in cases of minimal or no attached gingiva.[8]

The criteria for an absolute recovery of the periodontal tissues are the maintenance of ample blood supply in the grafts or flaps and recolonization of the treated sites by the omnipotent mesenchymal cells of the periodontal ligament.[11] If these prerequisites are not adequately fulfilled, the tissue gets necrosed resulting in scarring causing a reparative instead of regenerative healing.[8],[11]

The periosteum is a rich vascular plexus and is deemed as being the “umbilical cord of bone,”[12] and autogenous bone is the “gold standard” graft material due to its osteogenic capability in achieving the most predictable osseous tissue regeneration.[13] The use of periosteum was initially documented in 2001 and was first employed for covering onlay grafts in alveolar ridge augmentation surgery [14] and was later modified for periodontal surgical procedures.[14] The periosteum as a barrier membrane was used by Lekovic et al. in cases of periodontal defect treatment first in the year 1991[15] and later by him and also Kwan et al. in 1998.[16],[17] Of late, the role of periosteum in gingival recession coverage has also been reported.[18] The methodology employs using the local periosteal tissue as a vascularized membranous graft in covering defects. The periosteum stays pedicled at the Coronal (cresa) end and can be extended and transpositioned coronally with no retractional pull. Just like a connective tissue graft, the abundantly vascularized periosteum can be utilized for recession coverage and it is re-epithelialized by the neighboring mucosa, even in the absence of a mucoperiosteal flap coverage.[8],[18] The theory of this technique is hence comparable with procedures using transpositional flaps along with connective tissue grafts. The main advantage in using the everted periosteum procedure versus all other surgeries utilizing free grafts is no morbidity at the donor site.[8],[18] Moreover, there is a minimal possibility of transplant tissue necrosis in such a highly vascularized tissue.[8],[18]

Bone replacement grafts are the established treatment modality in cases of osseous periodontal defects.[19] Bone grafts are autografts, allografts, alloplasts, or xenografts. The use of these grafts is based on their osteogenic potential or being either osteoinductive or osteoconductive.[20] Autologous bones collected from intraoral or extraoral sites have the advantage of being nonimmunogenic and containing osteoblasts and osteoprogenitor stem cells, capable of proliferation.[13],[19],[20],[21] Therefore, it is the most foreseeable graft for regeneration of osseous tissue and is thus considered as “gold standard” among bone grafts. The use of bone graft along with membrane is proven to give more predictable and successful defect fill.[21]

The parameters for accomplishing successful recession coverage procedures focus not only on objective consequences (root coverage percentage) but also on patient's desires (in terms of esthetic color match, overall discomfort, and cost-effectiveness). This established the need for clinicians to develop novel, cost-effective techniques, along with providing the benefits of comfort and esthetics.

Therefore, it can be inferred that the technique of periosteal eversion along with autogenous bone grafts is extremely effective in covering recession defects. The primary advantage of the procedure is maintenance of a vascularized periosteum with a less traumatic surgical approach. Since both the periosteum and bone graft are harvested from vicinity of the recession defect, there are no additional complications at the donor site. Furthermore, there is no second surgical site, involving that the intraoperative time is reduced with an uneventful postoperative healing along with the added benefit of cost-effectiveness.


   Conclusion Top


Root coverage can be classified as primary coverage, which is achieved immediately after grafting and secondary coverage, when creeping attachment occurs due to activation of the mesenchymal cells of the periodontal ligament. With enough time and in the absence of mechanical and infectious inflammatory stimuli, this can turn into new attachment formation.[22],[23] Periosteum and bone being autogenous grafts contain abundant osteoblasts along with osteoprogenitor cells, fibroblasts, and their progenitor cells. These cells have immense regenerative potential to recreate soft and hard tissue; both these grafts can be put to use in wider recession defect coverage.

One-year postoperative results in this case report using both these tissues revealed that this technique proved highly successful in the coverage of multiple adjacent recession defects, even in cases of Miller's Class III gingival recession where 100% root coverage was achieved. This technique should be employed for the treatment of multiple gingival recession defects to compare results with already established approaches.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
American Academy of Periodontology. Glossary of Periodontal Terms. 4th ed. Chicago, IL: American Academy of Periodontology; 2001. p. 44.  Back to cited text no. 1
    
2.
Serino G, Wennström JL, Lindhe J, Eneroth L. The prevalence and distribution of gingival recession in subjects with a high standard of oral hygiene. J Clin Periodontol 1994;21:57-63.  Back to cited text no. 2
    
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Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc 2003;134:220-5.  Back to cited text no. 3
    
4.
Alghamdi H, Babay N, Sukumaran A. Surgical management of gingival recession: A clinical update. Saudi Dent J 2009;21:83-94.  Back to cited text no. 4
    
5.
Richardson CR, Allen EP, Chambrone L, Langer B, McGuire MK, Zabalegui I, et al. Periodontal soft tissue root coverage procedures: Practical applications: The AAP regeneration workshop. Clin Adv Periodontics 2015;5:2-10.  Back to cited text no. 5
    
6.
Zucchelli G, De Sanctis M. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol 2000;71:1506-14.  Back to cited text no. 6
    
7.
Leong DJ, Wang HL. A decision tree for soft tissue grafting. Int J Periodontics Restorative Dent 2011;31:307-13.  Back to cited text no. 7
    
8.
Gaggl A, Jamnig D, Triaca A, Chiari FM. A new technique of periosteoplasty for covering recessions: Preliminary report and first clinical results. Periodontol Pract Today 2005;2:55-62.  Back to cited text no. 8
    
9.
Virnik S, Chiari FM, Gaggl A. Periosteoplasty for covering gingival recessions: Clinical results. Clin Cosmet Investig Dent 2009;1:13-20.  Back to cited text no. 9
    
10.
Al-Hamdan K, Eber R, Sarment D, Kowalski C, Wang HL. Guided tissue regeneration-based root coverage: Meta-analysis. J Periodontol 2003;74:1520-33.  Back to cited text no. 10
    
11.
Nyman S, Gottlow J, Karring T, Lindhe J. The regenerative potential of the periodontal ligament. An experimental study in the monkey. J Clin Periodontol 1982;9:257-65.  Back to cited text no. 11
    
12.
Chanavaz M. The periosteum: The “umbilical cord” of bone. Quantification of the blood supply of cortical bone of periosteal origin. Rev Stomatol Chir Maxillofac 1995;96:262-7.  Back to cited text no. 12
    
13.
Dragoo MR, Sullivan HC. A clinical and histological evaluation of autogenous iliac bone grafts in humans. I. Wound healing 2 to 8 months. J Periodontol 1973;44:599-613.  Back to cited text no. 13
    
14.
Triaca A, Minoretti R, Merli M, Merz B. Periosteoplasty for soft tissue closure and augmentation in preprosthetic surgery: A surgical report. Int J Oral Maxillofac Implants 2001;16:851-6.  Back to cited text no. 14
    
15.
Lekovic V, Kenney EB, Carranza FA, Martignoni M. The use of autogenous periosteal grafts as barriers for the treatment of class II furcation involvements in lower molars. J Periodontol 1991;62:775-80.  Back to cited text no. 15
    
16.
Lekovic V, Klokkevold PR, Camargo PM, Kenney EB, Nedic M, Weinlaender M, et al. Evaluation of periosteal membranes and coronally positioned flaps in the treatment of class II furcation defects: A comparative clinical study in humans. J Periodontol 1998;69:1050-5.  Back to cited text no. 16
    
17.
Kwan SK, Lekovic V, Camargo PM, Klokkevold PR, Kenney EB, Nedic M, et al. The use of autogenous periosteal grafts as barriers for the treatment of intrabony defects in humans. J Periodontol 1998;69:1203-9.  Back to cited text no. 17
    
18.
Mahajan A. Periosteal pedicle graft for the treatment of gingival recession defects: A novel technique. Aust Dent J 2009;54:250-4.  Back to cited text no. 18
    
19.
Reynolds MA, Aichelmann-Reidy ME, Branch-Mays GL, Gunsolley JC. The efficacy of bone replacement grafts in the treatment of periodontal osseous defects. A systematic review. Ann Periodontol 2003;8:227-65.  Back to cited text no. 19
    
20.
McAllister BS, Haghighat K. Bone augmentation techniques. J Periodontol 2007;78:377-96.  Back to cited text no. 20
    
21.
Rios HF, Bashutski JD, McAllister BS, Murakami S, Cobb CM, Chun YP, et al. Emerging regenerative approaches for periodontal reconstruction: Practical applications from the AAP regeneration workshop. Clin Adv Periodontics 2015;5:40-6.  Back to cited text no. 21
    
22.
Matter J, Cimasoni G. Creeping attachment after free gingival grafts. J Periodontol 1976;47:574-9.  Back to cited text no. 22
    
23.
Pasquinelli KL. The histology of new attachment utilizing a thick autogenous soft tissue graft in an area of deep recession: A case report. Int J Periodontics Restorative Dent 1995;15:248-57.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]


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