ROOT COVERAGE PROCEDURES

Santosh Palla, CRRI

DEPARTMENT OF PERIODONTOLOGY AND IMPLANTOLOGY

Introduction…

The term ,Mugogingival surgery (MGS) was coined by Friedman, for surgical alterations in relation to gingival oral mucosa

BUT now Periodontic-plastic surgery( Miller 1993) is acceptable replacement for the MGS which broadly includes …

1. Perio-prostho Corrections2. Crown lengthening3. Root coverage procedures4. Papilla reconstruction5. Esthetic surgery for implants6. Exposure of unerrupted

teeth for Orthodontics

REF: TEXTBOOK OF PERIODONTOLOGY F.Carranza 10,11 th editions”

What / Why root coverage??

1. Gingival recession “Gingival recession is

defined as exposure of the root surface due to a displacement of the gingival margin apical to the cemento-enamel junction’*

2.Esthetics 3.Sensitivity symptoms

Ref :Kassab MM, Cohen RE. The etiology and prevalence of gingival recession.

J Am Dent Assoc 2003;134:220-5.    

Understanding Gingival recession and its staging is a must before peeping into its Surgical correction…

Lets me remind you PD Miller’s Classification

The Disease…

REF: Miller Jr PD. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;18:444-53.  

Its fact that class III and IV recession cases have poor prognosis.

Most of the Root coverage is implemented for I,II sometimes III classes.

Root Correction procedures

REF: Decision-making in aesthetics: root coverage revisited PHILIPPE BOUCHARD, JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000

Free Soft tissue grafts

Free gingival auto graft

Miller’s classical method

Step1: root planningStep2: prepare recipient

siteStep3: obtain strips of free

gingival graft. Step4: strips of gingiva

placed at recipient site and sutured

Free Soft tissue grafts

Free connective tissue auto graft; Levine,1991

Here the donor tissue is a connective tissue, otherwise procedure is similar to free gingival auto graft technique.

It could be submerged( under a flap and sutured) or non submerged

REF: Decision-making in aesthetics: root coverage revisited PHILIPPE BOUCHARD, JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000

Pedicle soft tissue grafts

Laterally dispalced flap:Grupe,Warren 1956. Used for isolated areas

of denuded root having adequate donor tissue laterally.

Step1 prepare recipient site

Step2 partial thickness flap is raised

Step3 transfer flap laterally to cover root surface

Step4 protect flap and donaor site.

Courtesy: Decision Making in Aesthetics: Root coverage Revisited PHILIPPE BOUCHARD, JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000

STEPS REF: TEXTBOOK OF PERIODONTOLOGY F.Carranza 10,th edin

Pedicle soft tissue grafts

Laterally dispalced flap:Variations:1. Converging oblique

incisions from recipient to donor site

2. Preserving marginal attachment at donor site

3. Sliding partial thickness grafts from adjacent edentulous area under flap

4. Use of two flaps simultaneously

REF: Decision-making in aesthetics: root coverage revisited PHILIPPE BOUCHARD, JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000

Pedicle soft tissue grafts

Coronally dispalced flap: Making a split thickness

flap apical to denunded root and its coronal placement is the principle of these flaps

Step1 two vertical incisions, Internal bevel incision to remove pocket wall. Elevate flap.

Step2 scaling ,root planningStep3 return the falp and

suture coronallyVARIATION: submerging a

free gingival autograft under flap.

Pedicle soft tissue grafts- Bridge flap method

Coronally dispalced flap:(Semilunar incison method)

Tarnow technique.

Step1: semilunar incision made to end 2-3 mm above papilla of denuded root.

Step 2: make a split thickness incision coronally and connect it to intrasulcular incision

Step3 : Coronally falling tissue is repostioned 10 min and left as such.

IMAGE REF: Care report: Use of Coronally placed flaps in Root coverage with bridge flap method.Pushpendra Kumar Verma1, Ruchi Srivastava2, TP Chaturvedi., IMS,BHU.

Sub-epithelial connective tissue graft

Langer & langer 1985 introduced this method.

Indicated when large defects with good vestibular health and gingival thickness is seen.

Here the donor tissue is sandwiched between flaps.

Nelson 1987, proposed a variant subpediclle connective tissue flap to improve blood circulation quality.

REF: TEXTBOOK OF PERIODONTOLOGY F.Carranza 10,th edin

Steps:1. elevate partial thickness

flap carefully2. Root palnning3. Obtain graft4. Palcement in recipient

site and suture with resorbalbe material

5. Cover graft with outer part of flap and suture interdentally

6. Care of donor site and dressing at surgical site

Subepithelal Connective tissue graft

GTR membranes

Pini-Parto et al.:Guided tissue regeneration GTR membranes used for large defect’s root coverage

Tinti-vencenzi proposed titanium membranes to create additional space beneath flap.

Second surgery is not required in case of bio-resorbable material

Steps:1. Full thickness MP flap

raised2. GTR membrane

placement and adapted3. Suturing done with

membrane4. Flap repositioned

coronally + dressing 5. weeks later GTR

membrane removed by small envolope flap.

REF: TEXTBOOK OF PERIODONTOLOGY F.Carranza 10,th edin

GTR membrane

Pouch and tunnel technique

It is technique that will aid in intimate contact of recipient to donor site

Post surgical aesthetics are superior after this method so indication for maxillary anterors

IMAGE REF: Review of Tunnel technique in perodontic plastic surgery

Dr David Garber,DMD Maurice,Salama,DMD Henry salama,DMD 10-7-2008

Pouch- Tunnel technique

Steps:1. Sulcular incision with

#15c blade around recession

2. Tunnel is made beneath adjacent buccal papilla

3. A split thickness pouch is made apical to papilla above 12mm defect

4. Pouch size(= defect area) measured and equal donor tissue borrowed

5. Using sutures and curettes connective tissue is place in pouch and tunneled while covering defective of root.

6..Mesial and distal sites of donor are sutured with catgut and gingival flap is palced and horizontal matress sutures uesd.

7. Holding sutures can be given if required along with periodontal dressing.

Contents…

IMAGE REF: Decision-making in Aesthetics: Root coverage Revisited : PHILIPPE BOUCHARD, JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000

Root surface modification agents

• citric acid and tetracycline hydrochloride* It has been recommended to treat the roots with pH 1 citric acid for 3 min or with tetracycline (50–125 mg/ml for 3–5 min).

Enamel matrix proteins

Use for time lag of 2 min with a 24%

EDTA containing enamel (Enamel matrix proteins gel) P gel

onto root surfaces

Additive treatmentsAIM: to order to improve the biological link between the

root surface and the covering soft tissues.

REF *:Bouchard P, Nilve´us R, Etienne D. Clinical evaluation of tetracycline HCl conditioning in the treatment of recessions.. J Periodontol 1997 68: 262–269

Prognosis…??

Prediction of outcome of root coverage procedures is based on miller’s class defect treated

ClassI , Complete root coverage achieved

class II, Complete root coverage may be achieved

Class III Complete root coverage never achived

, Class IV Any root coverage not pridicted

REF: Decision-making in aesthetics: root coverage revisited PHILIPPE BOUCHARD, JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000

Conclusion…

Patients general health, evaluation of gingival and periodontal status and requirements as per degree of defect must be understood prior to choosing one amongst the various Root Coverage procedures…

AESTHETICS are prime concern in modern world, sensitivity how ever is the next,,,

I Saw all these things…. • INFORMATION :• 1. TEXTBOOK OF PERIODONTOLOGY Femin A .Carranza 10,11 th editions• 2 Ref :Kassab MM, Cohen RE. The etiology and prevalence of gingival recession.J Am

Dent Assoc 2003;134:220-5• 3. REF: Miller Jr PD. A classification of marginal tissue recession. Int J Periodontics

Restorative Dent 1985;18:444-53.   • 4 Care report: Use of Coronally placed flaps in Root coverage with bridge flap method.

Pushpendra Kumar Verma1, Ruchi Srivastava2, TP Chaturvedi., IMS,BHU.• 5. Review of Tunnel technique in perodontic plastic surgery Dr David Garber,DMD

Maurice,Salama,DMD Henry salama,DMD 10-7-2008• 6. :Bouchard P, Nilve´us R, Etienne D. Clinical evaluation of tetracycline HCl conditioning

in the treatment of recessions.. J Periodontol 1997 68: 262–269• 7. Decision-making in Aesthetics: Root coverage Revisited : PHILIPPE BOUCHARD,

JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000• IMAGE REF: Care report: Use of Coronally placed flaps in Root coverage with bridge flap

method.Pushpendra Kumar Verma1, Ruchi Srivastava2, TP Chaturvedi., IMS,BHU• IMAGES:.• 1. Review of Tunnel technique in perodontic plastic surgery Dr David Garber,DMD

Maurice,Salama,DMD Henry salama,DMD 10-7-2008• 2. *:Bouchard P, Nilve´us R, Etienne D. Clinical evaluation of tetracycline HCl conditioning

in the treatment of recessions.. J Periodontol 1997 68: 262–269• 3 .Decision-making in Aesthetics: Root coverage Revisited : PHILIPPE BOUCHARD,

JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000• 4. AND NOT BUT NOT THE LEAST WWW.Google.com.....