5.gingival recession seminar

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1. GINGIVAL RECESSION AND ITS MANAGEMENT PRESENTER-PUNIT

2. Contents Introduction Definitions Classifications Etiology Factors affecting treatment outcome Treatment Conclusion Reference

3. INTRODUCTION Gingival recession is characterized by the displacement of the gingival margin apically from the cemento -enamel junction, or CEJ, or from the former location of the CEJ in which restorations have distorted the location or appearance of the CEJ . Gingival recession can be localized or generalized and be associated with one or more surfaces. The resulting root exposure is not esthetically pleasing and may lead to sensitivity and root caries. (Smith RG-1976 ). Recession is not simply a loss of gingival tissue, it is a loss of clinical attachment and the supporting bone of the tooth that was underneath the gingiva.

4. DEFINITIONS Gingival recession is defined as the apical migration of the junctional epithelium with exposure of root surfaces . [ Kassab MM, Cohen RE-2003]. Gingival recession is the apical shift of the marginal gingiva from its normal position on the crown of the tooth to levels on the root surface beyond the cemento enamel junction [ Loe H-1992] .

5. Gingival recession is defined as “the displacement of marginal gingiva apical to the cemento -enamel junction (CEJ ).” (American Academy of Periodontology 1992) The term “marginal tissue recession” is considered to be more accurate than “gingival recession,” since the marginal tissue may have been alveolar mucosa . Marginal tissue recession is defined as the displacement of the soft tissue margin apical to the cemento -enamel junction (CEJ ) (American Academy of Periodontology 1996)

6. CLASSIFICATIONS

7. Sullivan and Atkins. (1968) F irst classification. Concentrated on recession involving mandibular incisor teeth, used the descriptive terms to classify recession into four groups. Narrow Wide Shallow and Deep

8. Sullivan and Atkins. (1968) Narrow Wide

9. Mlinek et al (1973) Reported their results of root coverage with mucosal grafts, quantified ''shallow-narrow" clefts as being <3 mm in both dimensions, "deep-wide'" defects as being >3 mm in both dimensions .

10. Liu and Solt (1980) According to their classification, Visual recession is measured from the cemento -enamel junction to the soft tissue margin. Hidden recession refers to the loss of attachment within the pocket, i.e., apical to the tissue margin.

11. Miller (1985) Class I : Marginal tissue recession not extending to the mucogingival junction (MGJ). No loss of interdental bone or soft-tissue. 100% root coverage

12. Class II : Marginal recession extending to or beyond the MGJ. No loss of interdental bone or soft-tissue. 100% root coverage.

13. Class III : Marginal tissue recession extends to or beyond the MGJ. Loss of interdental bone or soft-tissue is apical to the CEJ, but coronal to the apical extent of the marginal tissue recession . Partial root coverage

14. Class IV : Marginal tissue recession extends to or beyond the MGJ. Loss of interdental bone extends to a level apical to the extent of the marginal tissue recession . No root coverage .

15. Limitations Although Miller’s classification has been used extensively, there are limitations that need to be considered:

16. 1 . The reference point for classification is MGJ. The difficulty in identifying the MGJ creates difficulties in the classification between Class I and II. There is no mention of presence of keratinized tissue. A certain amount of keratinized gingiva (in the form of free gingiva) will be evident in any tooth with the gingival recession; the marginal tissue recession cannot extend to or beyond the MGJ. In such a case, Class II cannot be a distinct class and Classes I and II would represent a single group .

17. 2 .In Miller’s Class III and IV recession, the interdental bone or soft-tissue loss is an important criterion to categorize the recessions. The amount and type of bone loss has not been specified. Mentioning Miller’s Class III and IV doesn’t exactly specify the level of interdental papilla and amount of loss. A clear picture of severity of recession is hard to project.

18. 3 . Class III and IV categories of Miller’s classification stated that marginal tissue recession extends to or beyond the MGJ with the loss of interdental bone or soft-tissue is apical to the CEJ . The cases, which have inter-proximal bone loss and the marginal recession that does not extend to MGJ cannot be classified either in Class I because of inter‑proximal bone or in Class III because the gingival margin does not extend to MGJ.

19. 4. Miller’s classification doesn’t specify facial (F) or lingual (L) involvement of the marginal tissue. 5 . Recession of interdental papilla alone cannot be classified according to the Miller’s classification. It requires the use of an additional classification system.

20. 6 . Classification of recession on palatal aspect , t he difficulty of the applicability of Miller’s criteria on the palatal aspect of the maxillary arch can be reasoned out to the fact that there is no MGJ on palatal aspect. Therefore , a classification is required, which specifies the type of recession and can also quantify the amount of loss. The classification should be able to convey the status of the gingival recession and the severity of the condition on palatal aspect.

21. 7 . Miller’s classification, estimates the prognosis of root coverage following grafting procedure. Miller stated that 100% coverage can be anticipated in Class I and II recessions, partial root coverage in Class III and no root coverage in Class IV . This theoretical affirmation is not demonstrated by studies. Miller also published a case report of an attempt to obtain 100% root coverage in a class IV recession by coronally positioning a previously free gingival graft (Miller & Binkley 1986 ), 1- year post-operative root coverage was slightly <100 % on the facial aspect of the tooth.

22. Mahajan’s modification of Miller’s classification (2010) M odifications suggested: The extent of gingival recession defect in relation to MGJ should be separated from the criteria of bone/soft tissue loss in interdental areas . Objective criteria should be included to differentiate between the severity of bone /soft tissue loss in class III and class IV Prognosis assessment must include the profile of the gingiva as thick gingival profile favors treatment outcome and vice versa

23. An outline of classification system including the above mentioned changes is presented: Class I GRD not extending to the MGJ. Class II GRD extending to the MGJ/beyond it. Class III GRD with bone or soft-tissue loss in the interdental area up to cervical 1/3 of the root surface and/or mal-positioning of the teeth. Class IV GRD with severe bone or soft- tissue loss in the interdental area greater than cervical 1/3rd of the root surface and/or severe mal-positioning of the teeth.

24. Prognosis : BEST Class I and Class II with thick gingival profile . GOOD Class I and Class II with thin gingival profile . FAIR Class III with thick gingival profile. POOR Class III and Class IV with thin gingival profile .

25. Francesco Cairo et al (2011) C lassification based on the assessment of clinical attachment level at both buccal and interproximal sites . Recession Type 1 (RT1): Gingival recession with no loss of interproximal attachment. Interproximal CEJ was clinically not detectable at both mesial and distal aspects of the tooth

26. Recession Type 3 (RT3): Gingival recession associated with loss of inter- proximal attachment. The amount of interproximal attachment loss ( measured from the interproximal CEJ to the depth of the pocket) was higher than the buccal attachment loss ( measured from the buccal CEJ to the depth of the buccal pocket)

27. Most of the classifications of gingival recession are unable to convey all the relevant information related to marginal tissue recession. This information is important for shaping diagnosis, prognosis, treatment planning. Also, with a broad variety of cases with different clinical presentations, it is not always possible to classify all gingival recession defects according to present classification systems.

28. Proposed classification of gingival recession (ASHISH KUMAR AND SUJATHA MARIAMSETTI 2013) This classification can be applied for facial surfaces of maxillary teeth and facial and lingual surfaces of mandibular teeth . Interdental papilla recession can also be classified according to this new classification. A distinct classification for gingival recession on palatal aspect is also being proposed.

29. Class I: There is no loss of interdental bone or soft-tissue. This is sub‑classified into two categories: Class I-A : Gingival margin on F/L aspect lies apical to CEJ, but coronal to MGJ with attached gingiva present between marginal gingiva and MGJ

30. Class I-B : Gingival margin on F/L aspect lies at or apical to MGJ with an absence of attached gingiva between marginal gingiva and MGJ.

31. Class II: The tip of the interdental papilla is located between the interdental contact point and the level of the CEJ mid- buccally/mid-lingually. Interproximal bone loss is visible on the radiograph. This is sub‑classified into three categories : Class II-A : There is no marginal tissue recession on F/L aspect.

32. Class II-B : Gingival margin on F/L aspect lies apical to CEJ but coronal to MGJ with attached gingiva present between marginal gingiva and MGJ.

33. Class II-C : Gingival margin on F/L aspect lies at or apical to MGJ with an absence of attached gingiva between marginal gingiva and MGJ

34. Class III : The tip of the interdental papilla is located at or apical to the level of the CEJ mid-buccally/mid-lingually. Interproximal bone loss is visible on the radiograph. This is sub‑classified into two categories : Class III-A : Gingival margin on F/L aspect lies apical to CEJ, but coronal to MGJ with attached gingiva present

35. Class III-B : Gingival margin on F/L aspect lies at or apical to MGJ with an absence of attached gingiva between marginal gingiva and MGJ.

36. INDEX OF RECESSION BY SMITH 1997 Index of Recession. It would have observational and descriptive value, as well as denoting severity and would also provide a basis for evaluating treatment modalities and experimental studies . Facial and lingual sites of root exposure on the same tooth are assessed separately . The IR being proposed consists of two digits separated by a dash ( e.g F2- 4* ). The first digit denotes the horizontal and the second the vertical component of a site of recession, with the pre- fixed letter (F or L) denoting whether the recession is on the facial or lingual aspects of the tooth, and an asterisk (*) denoting involvement of the MGJ.

37. The recession is determined by the actual position of the gingiva not by its apparent position Recession can be studied as, VISIBLE HIDDEN

38. Localised Generalised

39. Deep-Wide Deep-Narrow Shallow-Wide Shallow-Narrow Sullivan & Atkins classification 1968a

40. Mlinek, Smukler, Buchner 1973 Quantified shallow narrow clefts as being <3mm in both dimensions and deep wide defects as being > 3mm in both dimensions

41. P.D.MILLER (1985) CLASSIFICATION

42. Mahajan's modification Class I: GRD not extending to the MGJ. Class II: GRD extending to the MGJ/beyond it. Class III: GRD with bone or soft-tissue loss in the interdental area up to cervical 1/3 of the root surface and/or malpositioning of the teeth. Class IV: GRD with severe bone or soft tissue loss in the interdental area greater than cervical 1/3rd of the root surface and/or severe malpositioning of the teeth. Prognosis BEST: ClassI and Class II with thick gingival profile. GOOD: Class I and Class II with thin gingival profile. FAIR: Class III with thick gingival profile. POOR: Class III and Class IV with thin gingival profile.

43. Class I-A. Class I-B Class I: There is no loss of interdental bone or soft-tissue. This is sub-classified into two categories: • Class I-A : Gingival margin on F/L aspect lies apical to CEJ, but coronal to MGJ with attached gingiva present between marginal gingiva and MGJ • Class I-B : Gingival margin on F/L aspect lies at or apical to MGJ with an absence of attached gingiva between marginal gingiva and MGJ. ASHISH ET AL., 2013

44. Class II-A. Class II-B. Class II-C Class II: The tip of the interdental papilla is located between the interdental contact point and the level of the CEJ midbuccally/ mid-lingually. Interproximal bone loss is visible on the radiograph. This is sub-classified into three categories: • Class II-A : There is no marginal tissue recession on F/L aspect • Class II-B : Gingival margin on F/L aspect lies apical to CEJ but coronal to MGJ with attached gingiva present between marginal gingiva and MGJ • Class II-C : Gingival margin on F/L aspect lies at or apical to MGJ with an absence of attached gingiva between marginal gingiva and MGJ.

45. Class III: The tip of the interdental papilla is located at or apical to the level of the CEJ mid-buccally/mid-lingually. Interproximal bone loss is visible on the radiograph. This is sub-classified into two categories: Class III-A: Gingival margin on F/L aspect lies apical to CEJ, but coronal to MGJ with attached gingiva present between marginal gingiva and MGJ. Class III-B: Gingival margin on F/L aspect lies at or apical to MGJ with an absence of attached gingiva between marginal gingiva and MGJ. Either of the subdivisions can be on F or L aspect or both (F and L).

46. CLASSIFICATION OF PALATAL GINGIVAL RECESSION The position of interdental papilla remains the basis of classifying gingival recession on palatal aspect. The criteria of sub-classifications have been modified to compensate for the absence of MGJ. PR-I deals with marginal tissue recession on palatal aspect with no loss of interdental bone or soft-tissue. PR-II and PR-III deal with the loss of interdental bone/soft tissue with marginal tissue recession on palatal aspect.

47. Palatal recession-I There is no loss of interdental bone or soft-tissue. This is sub-classified into two categories: PR-I-A: Marginal tissue recession ≤3 mm from CEJ. PR-I-B: Marginal tissue recession of >3 mm from CEJ .

48. Palatal recession-II The tip of the interdental papilla is located between the interdental contact point and the level of the CEJ mid-palatally. Interproximal bone loss is visible on the radiograph. This is sub-classified into two categories: PR-II-A: Marginal tissue recession ≤3 mm from CEJ. PR-II-B : Marginal tissue recession of >3 mm from CEJ

49. Palatal recession-III The tip of the interdental papilla is located at or apical to the level of the CEJ mid-palatally. Interproximal bone loss is visible on the radiograph. This is sub-classified into two categories: PR-III-A: Marginal tissue recession ≤3 mm from CEJ. PR-III-B: Marginal tissue recession of >3 mm from CEJ.

50. Prevalence According to ALBANDEN & KINGMEN(1988-1994) 58 % between 30-90 yrs 37.8% between 30-39 yrs Women has more recession as compared to men. More on buccal surface Canine, premolar, molars.

51. Development of recession Goldman, 1973, Baker,1976 subclinical inflammation Clinical inflammation and proliferation of rete pegs Increased epithelial proliferation resulting in loss of ct core Merging of epithelium and resulting in separation and recession of gingival tissues.

52. (Susin et al.) Inflammation of the connective tissue of free gingiva and its consequent destruction, where the gingival epithelium migrates into the connective tissue and gets destroyed, here the gingival epithelial basement membrane and sulcus epithelium reduce the thickness of the connective tissue between them, thus reducing the blood flow by impairing the repair of the initial injury. As the lesion progresses, the connective tissue disappears and fusion occurs between the gingival epithelium and the sulcular and union epithelia, which will subsequently withdraw due to lack of blood flow

53. Moscow and Bressman,1966 Aldritt,1968 Alveolar bone dehiscence Etiology of gingival recession

54. Hall,1977

55. Clinical examination Measurement of amount of gingival recession is made by Periodontal probe from CEJ to the gingival crest

56. 1. Exposed root surfaces are susceptible to caries. 2. Abrasion or erosion of the cementum Underlying dentinal suface Sensitivity 3. Hyperemia of pulp may also result from excessive exposure of root surfaces. 4. Interproximal recession creates oral hygiene problems & resulting plaque accumulation Clinical significance:

57. Index of Recession - Smith Described by two digits separated by a dash prefixed letter F or L –denotes facial or lingual * denotes involvement of mucogingival junction

58. Treatment Non-surgically Surgically

59. Miller,1994 Root coverage to CEJ Adequate band of attached gingiva An accelerated color match to surrounding tissue An esthetic tissue contour Minimal postop pain No increase in sensitivity Rationale for treatment of recession

60. NON – SURGICAL METHOD 1. Correction of tooth brushing technique 2. Removal of masochistic habits 3. Correction of malocclusion 4. Treating the dentinal sensitivity

61. Key factors in the selection of surgical procedures Recipient Site Donor Site Gingival recession is limited to one tooth or extends to multiple teeth Degree of gingival recession Amount and thickness of existing keratinized gingiva in the area of recession Whether the area of recession protrudes labially from the dental arch The relation between the gingival recession area and smile line Restorative/ Prosthodontic treatment after root coverage is necessary Whether area adjacent to gingival recession can be used as a donor site Amount of Keratinized gingiva Thickness of keratinized gingiva Size of adjacent interdental papilla Thickness of the alveolar bone covering the donor tissue 2. Thickness of palatal soft tissue used as donor tissue

62. Root coverage techniques: 1 . Pedicle soft tissue graft procedures : Rotational flaps Laterally positioned flap Double papilla flap Advanced flaps Coronally positioned flap Semilunar flap 2. Free soft tissue grafts Nonsubmerged graft One stage (free gingival graft) Two stage (free gingival graft + coronally positioned flap) Submerged grafts Connective tissue graft + laterally positioned flap Connective tissue graft + double papilla flap Connective tissue graft + coronally positioned flap ( subepithelial connective tissue graft) Envelope techniques 3. Additive treatments Root surface modification agents Enamel matrix proteins Guided tissue regeneration Nonresorbable membrane barriers Resorbable membrane barriers

63. Pedicle Gingival Grafts Advantages One surgical area Blood supply of flap preserved Post op color match is in harmony with surrounding tissues Disadvantages Applicable for single tooth Minor and shallow recession

64. Contraindications Narrow oral vestibule Multiple teeth Recession area extremely protrusive Thin gingiva and bone at adjacent donor site

65. Preparation of recipient site Removal of root prominence Root biomodification V shaped incision removing adjacent epithelium and ct Beveling on side opposite to donor area to cause overlap

66. Laterally Positioned Flap Introduced by Grupe and warren 1956

67. Laterally positioned flap

68. VARIANTS

69. Advantage Prevent recession at donor site Submarginal pedicle flap

70. Dhalberg,1969 Oblique rotated pedicle flap

71. ADVANTAGES 1. Good tissue blend 2. Usually one surgical site 3. Pedicle to be moved over donor site without tension and releasing incision 4. Usually complete root coverage DISADVANTAGE 1. Possible recession at the donor site

72. Introduced by Bahat,1990 Advantages Disadvantages Predictability in areas of narrow root exposure Possible to avoid recession at donor site Sufficient length and width of interdental papilla adjacent to recession area necessary Not suitable for multiple teeth It is a modification of oblique rotated flap Trans positional flap

73. Goldman,1982 S p lit partial full thickness rotated pedicle flap Advantage Coverage of exposed donor site with periosteum

74. Introduced by Waienberg in 1964 Modified by Cohen and Ross,1968 Indications When interdental papilla adjacent to receded area is sufficient wide AG on approximating teeth is insufficient to cause lateral displacement Advantages Risk of loss of bone is less as interdental bone is more resistant Papilla usually supply greater width of AG Reasons for failure Inadequate suturing Double papillae Laterally positioned flap

75. Introduced by Hatler in 1967 Requires broad interdental papilla Horizontal lateral sliding paillary flap

76. Introduced by Norberg in 1956 Harvey in 1965 used it with FGG Bernomoulin in 1975 Coined by Pini and Prato in 1999 Prerequisites Adequate zone of AG>3mm Coronally advanced flap

77. Introduced by Tarnow in 1986 Semilunar coronally advanced flap

78. Zucchelli , 2000 Coronally advanced flap for multiple recession

79. Introduced by Margraff,1985 Multiple gingival recession with or without adequate attached gingiva Double Lateral sliding bridge flap

80. Reasons for pedicle flap failure Tension Narrow Flap Bone exposed poor stabilization

81. The actual position of the gingiva is the level of the attached periodontal tissue. It is not directly visible but can be determined by probing. The apparent position of the gingiva is the level of the gingival margin or crest of the free gingiva that is seen by direct observation. Actual recession. The actual recession is shown by the position of the attachment level.The “receded area” is from the cementoenamel junction to the attachment. Visible recession . The visible recession is the exposed root surface that is visible on clinical examination. It is seen from the gingival margin to the cementoenamel junction

82. Cut back incision- Made at apical aspect of releasing incision and directed towards base of the flap in laterally positioned flap  for relieving the muscle tension. Given with the help of 11 or 15 no. surgical blade.

83. Introduced by Bjorn in 1963 Described by Sullivan and Atkins in 1968 Indications Covering roots in areas of gingival recession . For covering non pathologic dehiscence and fenestration Increasing the amount of keratinized tissue Increasing the vestibular depth Free Gingival Graft

84. Procedure Preparation of recipient site The purpose of this step is to prepare a firm connective tissue bed to receive the graft. Submarginal incision, either a single horizontal incision at MGJ or 2 vertical incisions joined at MGJ Extend the incisions to approximately twice the desired width of the attached gingiva, allowing for 50% contraction of the graft when healing is complete.

85. Insert a #15 blade along the cut gingival margin and separate a flap consisting of epithelium and underlying connective tissue without disturbing the periosteum. Extend the flap to the depth of the vertical incisions. If a narrow band of attached gingiva remains after the pockets are eliminated, it should be left intact. Make an aluminum foil template of the recipient site to be used as a pattern for the graft. Suture the flap where the apical portion of the free graft will be located.

86. Reiser et al. in 1996 reported that the neurovascular bundle could be located 7–17 mm from the cemento-enamel junction (CEJ) of the maxillary premolars and molars. According to these authors, in an average palatal vault the distance from the CEJ to the neurovascular bundle is 12 mm. That distance is shortened to 7 mm in case of a shallow palatal vault and lengthened to 17 mm in case of a high palatal vault. Other research has shown gender-related variations. The mean height of the palatal vault, as measured from the midline of the palate to the CEJ of the first molars, is 14.90± 2.93 mm in men and 12.70 ± 2.45 mm in women (Redman et al 1965). Anatomy of a donor region. Palatal vessels and nerve running from the greater and lesser palatine foramina to the interincisive foramen. The anterior palatal submucosa is mainly fatty, whereas the posterior palatal submucosa is mainly glandular Preparation of donor site

87. After measuring the denuded area with a periodontal probe at the recipient site, the measurements of the palate should be recorded and the graft outline traced with the scalpel . The graft thickness should be close to 1.5 mm, which approximately corresponds to the length of the bevel on a no. 15 blade, and should not be too thick or too thin. The dissection is done with a no. 15 blade kept parallel to the epithelial outer side of the graft, not the long axis of the tooth. . Palatal donor site. The graft to be harvested had been delineated with a no. 15 blade.

88. Orban 1966 Raterschak,1979 minimal primary contraction due to the presence of less elastic fibres and 25 to 45% secondary contraction in thin to intermediate. Davis,1966 greater primary contraction in thick to full thickness but minimal secondary contraction due to the presence of thicker lamina

89. Introduced by Langer and Langer, 1985 Subeithelial connective tissue autograft

90. After anesthesia, root planing and root conditioning, horizontal incisions are made at the level of the CEJ, preserving the interdental papillae. This is followed by vertical incisions at least one tooth away from each side of the recession . This point is critical, because the portion of the free gingival graft placed over the denuded root will not survive if the recipient bed is not large enough to provide collateral vascularization. Therefore, the bed should be as wide as possible, given the anatomical limitation of the area. It should extend apically at least 3 mm below the margin of the denuded root. The wider the bed, the better chance the patient has for root coverage. A large periosteal bed is prepared to receive the graft. The large size of the bed is to compensate for the avascular area of the root to be covered and eliminate frenum fiber attachment. The predictability and superior aesthetics provided by this technique make it the gold standard for root coverage.

91. Harvesting the graft from the donor site Two parallel incisions, perpendicular to the long axis of the teeth, are made in the palate, close to the CEJ (Langer & Langer 1985). Two vertical releasing incisions help dissect the superficial flap and free the subepithelial connective tissue graft . Once the graft is harvested, the success rate of the procedure does not appear to be influenced by removing the epithelial collar from the graft (Bouchard et al. 1994). The trapdoor enabling the retrieval of the connective tissue graft.

92. Donor site

93. Causes of failure of ct grafts Recipient bed too small to provide sufficient blood supply Flap penetration Inadequate root planing Insufficient blood supply Graft too small or too thick Subepithelial connective tissue autograft

94. Advantages For multiple adjacent teeth Minimize incisions and reflection of flap Abundant blood supply Introduced by Zabalegui , 1999 Tunnel flap technique

95. This technique consists of the following steps: Step 1. Using a #15C or #12D blade, a sulcular incision is made around the teeth adjacent to the recession. This incision separates the junctional epithelium and the connective tissue attachment from the root. Step 2. Using either a curette or a small blade such as the #15C, a tunnel is created beneath the adjacent buccal papilla, into which the connective tissue is placed.

96. Step 3. A split-thickness pouch is created apical to the papilla, which has been tunneled, and the adjacent radicular surface. This pouch may extend 10 to 12 mm apical to the recessed gingival margin and papilla and 6 to 8 mm mesial and distal to the denuded root surface. Step 4. The size of the pouch, which includes the area of the denuded root surface, is measured so that an equivalent size of donor connective tissue can be procured from the palate.

97. Step 5. Using sutures, curettes, and elevators, the connective tissue is placed under the pouch and tunnel, with a portion covering the denuded root surface. Step 6. The mesial and distal ends of the donor tissue are secured by gut sutures. The gingival margin of the flap is coronally placed and secured by horizontal mattress sutures that extend over the contact of the two adjacent teeth

98. Step 7. Other holding sutures are placed through the overlying gingival tissue and donor tissue to the underlying periosteum to secure and stabilize the donor tissue beneath the gingiva. Step 8. A periodontal dressing is used to cover the surgical site.

99. 76 to 100 % root overage Indications Ideal when recession is greater than 4.98mm apicoincisally (Pini Prato et al 1992) Pini Prato et al 1992 Cortellini et al 1993 reported 3.66mm of connective tissue attachment with 2.48mm of new cementum and 1.84mm of bone growth histologically. GTR

100. Technique After proper anesthesia, the recession is root planed thoroughly and flattened using a Gracey curette or a back-action chisel. The root is conditioned for 5 min with tetracycline paste. Two vertical releasing incisions are made at the line angles of the tooth with the recession . These releasing incisions must pass the mucogingival junction for the flap to be mobile. Two vertical incisions are placed, avoiding the interproximal papillae. GUIDED TISSUE REGENERATION

101. An intrasulcular incision connects the two verticals coronally . A full-thickness flap is raised using a periosteal elevator that will enable bone visibility 3 mm apical to the exposed root. The flap is then converted to a partial thickness one apically that will enable coronal mobilization. At this stage, the buccal flap, full at the top and partial at the bottom, when moved coronally should be able to cover and lie passively on the recession. This is critical because any tension while suturing will affect the positive outcome of the procedure. The papillae are de-epithelialized, and the membrane is trimmed and adjusted to cover the recession. The flap is reflected exposing the alveolar bone. Trimming the reabsorbable membrane and adjusting it to fit the site.

102. The membrane should extend approximately 2 mm beyond the borders of the recession mesially, distally, and apically. The membrane should be coronally placed at the level of the cemento-enamel junction and sutured in place with a circumferential suture and a palatally tied knot. The knot is then palatally tucked into the gingival sulcus. When the sulcus is shallow, a small intrasulcular incision will help deepen it. Once the membrane is secured, the buccal flap is coronally moved and secured to the papillae with interrupted sutures . The buccal flap is sutured with the aim of covering as much of the membrane as possible.

103. Free gingival autograft

104. Horizontal suture After making the ligature, pass the needle through the body of the graft and pull it out from the bottom without cutting the thread. Engage the periosteum 2-3 mm from the mesial edge of the flap. Leave a slack in the suture. Last, make a ligature and stretch to eliminate the sag. Stretching prevents primary shrinkage of the graft (primary contraction) and regenerates graft vascularity. Suture technique of Holbrook and Ochsenbein.

105. Circumferential suture Insert the needle in the periosteum of the recipient site slightly apical to the bottom edge of the graft. Carry the suture around the cervical area and tie it to the tail on the lingual aspect. The thread presses the graft at the border of the exposed root (dotted line). Interdental concavity suture Insert the needle in the periosteum at the bottom of the interdental concavity area. Circle the needle around the tooth, suture the graft diagonally, make a sling, and make a ligature on the lingual aspect. Perform the same procedure in the other Interdental area.

106. Subepithelial connective tissue graft

107. Primary incision. Make a horizontal incision with a partial-thickness flap 3-5 mm apical to the gingival margin in the palate (preparation of primary flap). Secondary incision. Make a secondary incision 1-2 mm coronal to the primary horizontal incision line. This incision, which is perpendicular to the surface of the gingiva, should extend to the bone. Make a vertical incision mesiodistally approximating the width and length of the necessary graft. Prepare a primary partial-thickness flap (1.5-mm thick) toward the center of the palate, parallel to the palatal gingiva. Expose the underlying connective tissue. Subepithelial connective tissue graft

108. For the secondary incision, the blade contacts the bone. Use a small periosteal elevator or Kirkland knife to reflect the connective tissue graft, bringing it toward the center of the palate. Extend the base of the primary incision to the bone. Separate the connective tissue graft from the bone. After harvesting of the connective tissue graft, the bone surface is exposed.

109. Suture the primary flap. Close the wound with an interrupted suture and a cross horizontal sling suture. Make an interrupted suture in the interdental papilla with resorbable suture material and then stabilize the graft Displace the flap coronally, covering the graft as much as possible, and suture

110. An interrupted suture is made on the graft epithelium and interdental papilla with absorbable suture thread. b. A suture is made to cover the graft with the flap as completely as possible

111. HEALING FOLLOWING FREE SOFT TISSUE GRAFTS Healing of free soft tissue grafts placed entirely on a connective tissue recipient bed has been studied in monkeys and can be divided into the following three phases. (Oliver et al.1988) 0 – 3 day (Initial phase): Plasmatic circulation The epithelium of the free graft degenerates early in the initial healing phase, and subsequently it becomes desquamated.

112. After 4-5 days of healing, anastomoses are established between the blood vessels of the recipient bed and those in the grafted tissue. At the same time, a fibrous union is established between the graft and the underlying connective tissue bed . If a free graft is placed over the denuded root surface, apical migration of epithelium along the tooth-facing surface of the graft may take place at this stage of healing. 2-11 day (revascularization phase)

113. After approximately 14 days the vascular system of the graft appears normal. Also the epithelium gradually matures with the formation of a keratin layer during this stage of healing. Another healing phenomenon frequently observed following the free graft procedures is “Creeping Attachment” i.e. coronal migration of the soft tissue margin. This occurs as a consequence of tissue maturation during a period of about 1 year post treatment. 11-42 days (tissue maturation phase):

114. Silverstein and callan,1997 AlloDerm is donated human soft tissue that is processed to remove dermal cells, leaving behind a regenerative collagen matrix. It provides a matrix consisting of collagen, elastin, blood vessel channels, and proteins that support Acellular dermal grafts

115. After scaling and root planning, the root surfaces are conditioned. A partial thickness flap creating a pouch is formed using a no. 15 blade. The AlloDerm is rehydrated in two consecutive 10- to 15- min sterile saline baths (depending on size and thickness of the piece used). The graft is inserted into the pouch with the connective tissue against the recipient bed. The papillae are de-epithelialized, and the graft is immobilized with resorbable sutures at the level of the cemento-enamel junction .

116. The buccal flap is then sutured over the AlloDerm to cover the graft as much as possible. It is important to not leave any AlloDerm exposed. The buccal flap is sutured over the AlloDerm by using a sling suture to provide the graft with maximum coverage.

117. Significant revascularization occurs in just over 1 week. Allo-Derm is repopulated with cells and will begin remodeling into the patient’s own tissue over the next 3–6 months. Up to 41% shrinkage of the graft has been reported during that period (Batista et al. 2001). The material will also take the characteristics of the underlying and surrounding tissues (for example, keratinized tissue or mucosa). [Do not be concerned by the whitishness of the graft after surgery; it is not tissue necrosis. This color reflects normal healing.] GRAFT HEALING By 1 week after surgery, some of the AlloDerm is exposed. The whitishness is a normal feature of this healing process.

118. The final results are seen 2–3 years later. It is important to remember that, when evaluating the results, the concept of gain of attached gingiva or keratinized gingiva is replaced by gain of gingival volume. The absence of keratinized tissue with this technique after successful root coverage is not uncommon, nor detrimental to the results. By 3 years after surgery, the recessions have been covered.

119. Advantages Decreases pain and bleeding as less invasive Increases tissue thickness Decreases infection and graft sloughing Decreases healing time, mature tissue within 1 week Promotes vascularization Accelerates wound healing Griffin, 2004 suggested use of platelet concentrate carried by collagen sponge as graft substitute Lien Hui,2005 used it with CAF Yen and Jankovic,2007 used PRP with ctg and found accelerated wound healing and attachment formation PRP

120. Platelet-rich plasma (PRP)preparations Strategy is to amplify and accelerate the effects of growth factors contained in platelets Modulate and up regulates one growth factor’s function in the presence of other growth factors Platelets play fundamental role in hemostasis and are natural source of growth factors Growth factors are stored in - granules of platelets

121. Venous blood is drawn into a tube containing an anticoagulant to avoid platelet activation and degranulation. The first centrifugation is called .soft spin.,of 2400rpm for 5 min which allows blood separation into three layers, namely bottom-most RBC layer (55% of total volume), topmost acellular plasma layer called PPP (40% of total volume), and an intermediate PRP layer (5% of total volume) called the .buffy coat.. Using a sterile syringe, the operator transfers PPP, PRP and some RBCs into another tube without an anticoagulant. This tube will now undergo a second centrifugation, which is longer and faster than the first, called hard spin. 5600rpm for 15min. This allows the platelets (PRP) to settle at the bottom of the tube with a very few RBCs, which explains the red tinge of the final PRP preparation. This PRP is then mixed with bovine thrombin and calcium chloride at the time of application. This results in gelling of the platelet concentrate PRP preparation

122. PRF Choukroun’s PRF, is a second-generation platelet concentrate, PRF consists of an intimate assembly of cytokines, glycanic chains, and structural glycoproteins enmeshed within a slowly polymerized fibrin network. These biochemical components have well-known synergetic effects on healing processes.

123. Prior to surgery IV blood is collected in 10 ml vials without anticoagualnt & centrifuged at 2700 rpm for 10 min

124. Criteria for the success

125. Treatment plan

126. Conclusion The management of gingival recession and its sequelae is based on a thorough assessment of the etiological factors and the degree of involvement of the tissues. The initial part of the management of the patient with gingival recession should be preventive and any pain should be managed and disease should be treated. The degree of gingival recession should be monitored for signs of further progression. When esthetics is the priority and periodontal health is good then surgical root coverage is a potentially useful therapy. Numerous therapeutic solutions for recession defects have been proposed in the periodontal literature and modified with time according to the evolution of clinical knowledge. Careful case selection and surgical management are critical if a successful outcome is to be achieved.

127. References Carranza’s Clinical periodontology – 10TH & 12 h ed Clinical Periodontology and Implant Dentistry – Jan Lindhe 6 th ed Periodontal Surgery – a clinical atlas - NaoshiSato Practical periodontal plastic surgery – Serge Dibart Chambrone L, Sukekava F, Araújo MG, Pustiglioni FE, Chambrone LA, Lima LA. Root coverage procedures for the treatment of localised recession-type defects (Review). The Cochrane Library 2009, Issue 2

128. Umberto Pagliaro, Michele Nieri, Debora Franceschi,Carlo Clauser,and Giovanpaolo Pini-Prato. Evidence-Based Mucogingival Therapy. Part 1: A Critical Review of the Literature on Root Coverage Procedures. J Periodontol • May 2003 The etiology and Prevalence of gingival recession – Moawia M.Kassab, Rober E. Cohen – JADA Feb 2003 The use of free gingival grafts for aesthetic purposes Paulom. Camargo, Philip R.Melnick & E. Barrie Kenney : Periodontology 2000, Vol. 27, 2001, Decision-making in aesthetics: root coverage revisited - Philippe bouchard, jacquesmalet & alain borghetti - Periodontology 2000, Vol. 27, 2001

129. THE END