CASEREPORT

Partly Deepithelialized Free Gingival Graft for Treatmentof Lingual Recession

Bassam M. Kinaia,∗† Shahrdad Kazerani,∗ Yung-Ting Hsu∗ and Anthony L. Neely∗†

Introduction: Gingival recession (GR) is an unhealthy root exposure that could result in sensitivity, abrasion, rootcaries and higher chance of plaque collection. The prevalence of GR is higher on the facial surfaces but could also affect thelingual tooth surfaces. Despite the etiology and location of GR, treatment is warranted to improve the long-term periodontalstability around the affected teeth. This case report describes the use of partly deepithelialized free gingival graft (PE-FGG)to augment lingual GR post orthodontic treatment.

Case Presentation: The current report evaluates the results of PG-FGG to correct lingual recession in a 21-year-old female. The patient presented with 5 mm lingual recession on a previously orthodontically rotated tooth (#21). Therecession was treated using a PE-FGG to increase keratinized gingiva (KG) and reduce root exposure. Follow-up at 24months showed adequate root coverage and KG.

Conclusion: The use of PE-FGG can be used to enhance KG for lingual recession with adequate root coverage.Clin Adv Periodontics 2019;9:160–165.

Key Words: Autografts; esthetics; gingival recession; tissue grafts; orthodontics.

BackgroundGingival recession (GR) is associated with root exposure,often leading to hypersensitivity concerns esthetically anddif!culty maintaining optimum oral hygiene.1,2 The eti-ology of GR is multifactorial including periodontal dis-ease, aging, toothbrush abrasion, mechanical trauma, thinphenotype, high frenal attachment, lip or tongue pierc-ing position, tooth malposition, and orthodontic toothmovements.2–5 The latter, tooth movement, can predis-pose patients to GR especially in the presence of thin

∗Division of Graduate Periodontics, University of Detroit Mercy Schoolof Dentistry, Detroit, MI

†Private practice, Sterling Heights, MI

Received November 9, 2018; accepted February 19, 2019

doi: 10.1002/cap.10062

phenotype, in"ammation, and pre-existing recession.6–8

Further, plaque-induced in"ammation and the thicknessof the marginal soft tissue are also determining factors fordevelopment of GR and attachment loss during orthodon-tic tooth movement.2

GR occurs facially and lingually and the goal oftreatment is to maintain healthy periodontium. Treatmentof lingual GR is warranted and the literature describesindications and techniques to increase the amount ofkeratinized gingiva (KG).9–11 Many different therapiesare used to treat GR. The goal for these therapies includereconstructing the receded gingival tissues, facilitatingplaque control, and reducing root sensitivity.6,11

Procedures include autograft, allograft, xenograft, andguided tissue regeneration. Autografts are considered thegold standard treatment.12 The two most commonly usedautografts are free gingival grafts (FGG) and connectivetissue grafts (CTG). FGG has excellent mean root

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FIGURE 1 Initial presentation showing 5 mm lingual recessiondefect on tooth #21.

FIGURE 2 Bitewing radiograph of tooth #21 at baseline.

coverage of 88% but sometimes results in a unestheticappearance.13,14 CTG provides better esthetic resultscompared with FGG with mean root coverageapproaching 98.4%.15 The use of partly deepithelializedfree gingival graft (PE-FGG) in the treatment of facialGR provides a better alternative to traditional FGG.16

While the literature mainly evaluates treatment of facialGR, treatment of lingual GR has its own challenges dueto tongue position, speech, and adequately securing thegraft.17 This case report describes the use of a partlydeepithelialized free gingival graft to treat lingual GRpost-orthodontic treatment.

Clinical PresentationA healthy 21-year-old female presented in 2014 with lin-gual GR and root hypersensitivity post-orthodontic rota-tion of tooth #21. Clinically, there was 5 mm of GR (CairoRT1 or Miller Class III)13,18 with secondary occlusaltrauma and inadequate attached gingiva (Fig. 1). Radio-graphically, loss of crestal lamina was noticed with slightwidening of the periodontal ligament (PDL) (Fig. 2). Thepatient used desensitizing agents with no resolution and

FIGURE 3 Initial incisions at themucogingival junction of #21withpartial thickness !ap re!ection apically and laterally.

FIGURE 4 Free gingival graft obtained from the left side of thepalate and secured.

presented for solutions to address root exposure. Treat-ment options included limited occlusal adjustment andPE-FGG to increase the zone of attached/KG and reduceroot sensitivity. The patient signed a written informedconsent for treatment.

Case ManagementNon-surgical periodontal treatment with limited occlusaladjustment was completed as part of phase I treatment.Under local anesthesia, the recipient site was preparedusing horizontal incisions at the cemento-enamel junc-tion of #20 through #22 followed by a partial thick-ness "ap apically (Fig. 3). A FGG measuring 7 × 6mm was obtained from the palatal areas #12 through#13 (Figs. 4 and 5). The epithelial layer of the FGGwas removed from a portion of the graft using a 15cblade chairside. The partly deepithelialized FGG sec-tion was inserted below the lingual "ap and the coro-nal deepithelialized portion was left exposed to coverthe exposed root (Fig. 6). The PE-FGG was stabi-lized using sling and interrupted resorbable sutures.‡ An

‡Vicryl, Ethicon Inc., Somerville, NJ.

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FIGURE 5 Part of the free gingival graft was deepithelializedso that that portion could be inserted below the lingual !ap.

FIGURE 6 The partly deepithelialized free gingival graft (PE-FGG) was tucked under the partial thickness !ap and securedusing crisscross resorbable suture, with the deepithelializedportion left exposed.

absorbable wound dressing§ was applied to cover thedonor palatal site and secured with crisscross sutures(Fig. 7). The patient received a non-steroidal anti-in"ammatory drug‖ for 7 days and an antibacterialmouthwash.¶ The patient was followed up at 1, 2,4 weeks and 6, 12, 24, and 36 months. Suture removalwas completed after 4 weeks of healing to allow adequateconnective tissue maturation and stability.19

Clinical OutcomesHealing was normal with slight in"ammation at 1 and2 weeks (Figs. 8 and 9). The in"ammation signi!cantlyreduced with adequate root coverage (≈1- to 2-mmremaining GR) with thick irregular KG present at 4 weeks

§Collagen Tape, Zimmer Dental Inc., Carlsbad, CA.‖Ibuprofen, USP, 600mg, Dr. Reddy’s Laboratories LA LLC, Shreve-port, LA.¶Chlorhexidine gluconate 0.12%, 3M ESPE Dental Products, St. Paul,MN.

FIGURE 7 Wound dressing§ was applied to cover the donorpalatal site and secured with crisscross resorbable sutures.

FIGURE 8 Lingual view of recipient site showing normalhealing at 2 weeks post-surgery, with adequate root coverage.

FIGURE 9 Palatal donor site healing normally at 2 weekspost-surgery.

postoperatively (Fig. 10). There was ≈3-mm reduction ininitial recession, 2-mm sulcus depth plus smoother andthicker KG (Fig. 10). The results remained stable at 4and 12 weeks follow-up with continued improvement incolor, consistency, and contour of the PE-FGG (Figs. 9through 11). The patient was satis!ed with the reduction

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FIGURE 10 Four weeks post-surgery with probe showing2 mm of residual recession.

FIGURE 11 Three months post–PE-FGG showing about1.5 mm of remaining recession, with adequate tissue thick-ness and width of keratinized tissue.

of hypersensitivity and increased root coverage. At 24 and36 months (Figs. 12 and 13), there was nearly 4 mm ofreduction in GR (3.7 mm or 74% root coverage). About1.2 mm of the change (32.4%) was creeping attachment(Table 1).20

DiscussionLingual root coverage is a technique-sensitive treatment.Case selection and treatment approach are important forsuccessful treatment outcome. Initial treatment must aimto eliminate the etiologic factors before surgical interven-tion. Movement of the anterior teeth out of the bonyhousing may lead to bony dehiscence and/or fenestrationresulting in GR.3,4 Several factors dictate the treatmenttechnique and the outcomes, including tooth position,amount of bone loss, papilla !ll, and presence of KT.Anatomic limitations like a shallow vestibule could affectcomplete root coverage by making it dif!cult to fully

FIGURE 12 Twenty-four months follow-up showing stable rootcoverage and keratinized tissue thickness.

FIGURE 13 Adequate root coverage and tissue thickness weremaintained at 36-months follow-up.

coronally advance the "ap (CAF) to cover the graft.6

Other factors include muscle and tongue movements thatmay disrupt wound healing5 or presence of malpositionedteeth creating a challenge to stabilize the graft on the rootsurface(s).3

PE-FGG is a good alternative to gain KG with rootcoverage for lingual GR. The use of exposed CTG inroot coverage procedures to achieve adequate root cov-erage and KG width was !rst reported by Nelson usinga bilaminar graft composed of CTG and an overlyingpedicle graft to cover GR.21 The PE-FGG serves as subep-ithelial CTG combined with FGG to cover the exposedroot and increase KG width.22 Compared with recentlyreported studies,11,22 PE-FGG has the advantage oftreating patients with shallow lingual vestibule whereCAF is dif!cult to achieve. PE-FGG enhances the phe-notype and improves the color match with surround-ing tissues. This technique has previously been usedfor facial root coverage in the lower esthetic zone byCortellini et al.,16 who reported 94% to 96% root cover-age with promising esthetic results. Further, treatment ofpalatal/lingual GR have been reported in a recent system-atic review showing complete root coverage in 70.8% to100%.23 The literature cites only case reports using FGGfor treatment of lingual GR.10,11

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TABLE 1 Pre- and Post-Surgical Mid-Lingual Gingival Margin Position and Amount of Root Coverage

Timeline Mid-lingualrecession (mm)

Root coverage(mm)

Root coverage(%)

Presurgical 5 0 0

3 months 2 3 60

24 months 1.5 3.5 70

36 months 1.3 3.7 74

ConclusionsThe management of GR defects in mandibular lingualsites is challenging with data based mainly on case reportsdescribing a treatment regimen. The current case reportshowed the use of PE-FGG as a viable technique toincrease KG and increase root coverage. The 36-month

follow-up reports stable results indicating longer reliabletreatment. Nonetheless, longitudinal studies with largersample sizes and higher evidence level are necessary toinvestigate the predictability of the PE-FGG for lingualroot coverage.!

Summary

Why is this case newinformation?

! Limited data are available for treatment of lingual/palatal GR.! This case report is thought to be the "rst using the PE-FGG technique for

lingual root coverage with promising results.

What are the keys tosuccessful managementof this case?

! Careful case selection and surgical technique.! PE-FGG adaptation to the recipient site with adequate graft coverage.! PE-FGG coverage and securing/suturing technique for graft stabilization.

What are the primarylimitations to successin this case?

! Flap re!ection/shallow distance from FGM to the !oor of the mouth.! Severe tooth inclination preventing !ap and graft adaptation.! Stabilization of the graft and suture removal after 4 weeks (initial CT

maturation phase).

AcknowledgmentsThe authors declare that they have no con"icts of interest.No author received any monetary compensation for thismanuscript.

CORRESPONDENCEDr. Bassam M. Kinaia, Graduate Periodontics Program Department ofPeriodontology and Dental Hygiene, University of Detroit Mercy, 2700Martin Luther King Jr. Blvd., Detroit, MI 48208-2576E-mail: kinaiabm@udmercy.edu; kinaiaperio@gmail.com

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