Quick reference/description
Overview
Surgical approaches for gingival recession coverage using autogenous soft tissue grafts | Indications | Applications |
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Surgical techniques in combination with free gingival graft (FGG) and partly-epithelialized free gingival graft (PE-FGG) | ||
One-stage FGG/PE-FGG technique | Coverage of single or multiple gingival recession defects Augmentation of the keratinized gingiva, predominantly in the lateral zone | This technique increases the width of attached gingiva for root coverage |
Two-stage FGG technique | Coverage of single or multiple gingival recession | Gingival augmentation is achieved in the first-stage surgery and coronal repositioning of the integrated graft in the second-stage surgery |
Surgical techniques used in combination with subepithelial connective tissue graft (SCTG) and epithelialized-subepithelial connective tissue graft (ESCTG) for single gingival recession coverage | ||
Coronally advanced flap technique | Complete coverage of single Miller’s class I, II gingival recession defects Partial coverage of single Miller’s class III gingival recession defects | Coronally advanced flap approach is the most predictable technique for single gingival recession coverage It was initially described as a cosmetic periodontics-coronally repositioned pedicle graft |
Semilunar coronally advanced flap technique | Single or multiple gingival recessions with a minimum width of 3 mm and thickness of 1 mm of the keratinized gingiva apically from the defect It is only indicated in cases with a thick gingival biotype and favorable baseline mucogingival conditions | SCAF procedure is an alternative to the CAF technique for long-term tissue stability and superior esthetic results |
Envelope technique | Miller’s class I, II, III gingival recessions | ET is a feasible approach for the treatment of sites with a shallow vestibular fold like the anterior mandible |
Surgical techniques used in combination with SCTG and partly epithelialized soft tissue graft for multiple gingival recession coverage | ||
Modified coronally advanced flap technique | Coverage of multiple gingival recessions | The MCAF approach is a redesigned version of the classic CAF technique for multiple gingival recession coverage |
Subperiosteal envelope technique | Coverage of multiple adjacent gingival recessions | SET is a modification of the envelope technique and results in uneventful healing with minimal post-operative complications due to lack of blood supply compromise to the papillae |
Modified coronally advanced tunnel technique | Mainly indicated for perfect color matching and avoidance of scar lines, when used in combination with SCTG for gingival recession coverage in esthetically demanding areas | Provides predictable root coverage in multiple Miller’s class I, II, III gingival recession defects |
Materials/instruments
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Resorbable sutures
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Non-resorbable sutures
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No. 15/15C surgical blade
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Microsurgical blades
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Tunneling knives
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Gracey curettes
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Blunt elevators
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Microsurgical elevators
Procedure
Autogenous soft tissue grafts
Free gingival graft
Subepithelial connective tissue graft
- Enhanced color match and improved esthetic results as the surface characteristics of the overlying flap are similar to that of the adjacent recipient gingiva.
- Wound healing in the donor and recipient sites mostly occurs by primary intention when SCTG is covered by coronally advanced- or tunneled flaps via partial-thickness flap preparation.
- This healing by primary intention can facilitate tissue maturation and decrease postoperative discomfort
Partly epithelialized soft tissue grafts
- Increased resistance against the tension of the muscular-mucosal environment.
- Lowering the risk for displacement of the mucogingival junction (MGJ) or flattening of the vestibule.
- Increased amount of keratinized tissues.
- Acceptable color blending compared to FGG.
Surgical techniques in combination with free autogenous soft tissue grafts
Surgical techniques in combination with FGG and PE-FGG
One-stage FGG/PE-FGG technique
- A split-thickness flap is prepared following root planning. A 3–5 mm wide zone of the superficial layer of the flap is removed for preparing a recipient periosteal bed.
- The hard palate or the maxillary tuberosity is usually used for harvesting the FGG.
- The harvested FGG is adapted carefully to the recipient periosteum and the adjacent gingiva using resorbable or non-resorbable 6/0 monofilament sutures.
- Pressure is exerted for 1–2 min on the surgical site to avoid graft necrosis due to blood clots between the two layers.
Two-stage FGG technique
Surgical techniques used in combination with SCTGs and ESCTGs for single recession coverage
Coronally advanced flap technique
- Presence of shallow crevicular depths on proximal surfaces
- Anatomical interproximal bone heights
- Tissue height within 1 mm of the cemento-enamel junction of adjacent teeth
- 6-week healing of a FGG prior to coronal positioning
- Reduction of any root prominence
- Adequate flap release during surgery to prevent retraction during healing
- Outline of the surgical site is achieved with a bilateral trapezoid incision on the medial and distal aspects of the exposed root surface. Using No. 15C surgical blade or microsurgical blades, bilateral horizontal split-thickness incisions are made at a distance from the tip of the anatomical papilla to level of 1 mm more than the recession depth.
- Following the trapezoid incisions, diverging vertical releasing incisions are placed.
- At the papillary zone, a split-thickness flap is prepared. The split-thickness flap is then followed by elevation of the full-thickness of attached gingiva (from gingival zenith to MGJ) using blunt elevators.
- Split-thickness flap elevation is continued by sharp dissection from the MGJ into the vestibule by detachment of the loose and flexible mucosal-submucosal layers from the underlying muscles and periosteum.
- A harvested SCTG is placed at the level of the CEJ after complete flap mobilization.
- The graft is fixed with mattress sutures to the adjacent mucosa or resorbable sutures to the recipient periosteal bed—complete de-epithelialization of the anatomical papillae is done.
- The flap is coronally advanced for full coverage of the de-epithelialized papillae.
- Double-sling non-resorbable 6/0 monofilament sutures are used to secure the flap margin 1 mm coronally from the CEJ.
- Closure of the vertical incisions is achieved using diagonally placed single interrupted sutures, beginning from the most apical point.
- Pressure is exerted for 1–2 min on the surgical site to avoid graft necrosis.
- Sutures are removed after 14 days.
Semilunar coronally advanced flap technique
- Local anesthesia is administered.
- At the level of the MGJ, a semilunar incision is made.
- A split-thickness flap is elevated beginning from the sulcus.
- Using 6/0 non-resorbable monofilament sutures, the keratinized gingival collar is mobilized and secured at the level of the CEJ. The sutures are removed after 14 days.
Envelope technique
- A sharp dissection using a 15C surgical blade or microsurgical blades is performed commencing from the sulcus towards the adjacent papillae to prepare a split-thickness envelope flap (gingival pouch). The depth of the flap is dependent on the dimensions of the previously harvested graft.
- A SCTG or an ESCTG is inserted into the envelope at the level of the CEJ.
- 5/0 or 6/0 non-resorbable, mono-filament, single interrupted, mattress or sling sutures are used for graft and flap fixation. The sutures are removed after 14 days.
Surgical techniques used in combination with SCTGs and ESCTGs for multiple recession coverage
Modified coronally advanced flap technique
- Split-thickness preparation of the interdental papilla
- Full-thickness preparation of the keratinized gingiva between the gingival zenith and the MGJ
- Split-thickness preparation of the mucosal flap beyond MGJ
Subperiosteal envelope technique
- Local anesthesia is administered.
- The exposed root surfaces are planed after local anesthesia administration.
- Microsurgical or 15C surgical blade is used to place intrasulcular incisions around the involved teeth.
- Elevation of the mucoperiosteal envelope flap is done by blunt preparation up to the level of the MGJ at each individual recession site using tunneling knives without involving the tips of the interdental papillae.
- A confluent tunnel is prepared over all the exposed root surfaces by interconnecting the separate mucoperiosteal envelopes.
- The tunnel preparation is followed by preparation of the MGJ in a split thickness of up to 3–5 mm depth.
- A harvested SCTG or ESCTG is then adapted to the created supraperiosteal envelope using horizontal mattress sutures. The graft can also be secured by sling sutures. The sutures are removed after 14 days.
Modified coronally advanced tunnel technique
- More excessive split-thickness flap mobilization
- Separation and release of inserting collagen fibers and attaching muscles from the inner aspect of the alveolar mucosa via Gracey curettes and tunneling knifes. Therefore, allowing extensive mobilization of the tunneled flap and tensionless coronal advancement.
- Complete flap mobilization is achieved by careful and gentle undermining of the interdental papillae with microsurgical elevators. Disruption of the interdental papillae should be avoided.
- SCTG fixation to the mucosal flap is achieved using horizontal mattress sutures after positioning the coronal margin of the graft at the level of the CEJ.
- Coronal advancement of the flap is done using suspended or sling sutures after securing the graft in the tunnel.
- To allow suspended suturing, preoperative resin bonding of adjacent contact points can be performed at the surgical site. Sling sutures are placed interdentally to facilitate coronal displacement of the tunnel 1 mm over the CEJ when complete coverage of the graft cannot be obtained with the suspended sutures. The sutures are removed after 14 days.
Pitfalls and complications
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Over-augmentation of tissue contours due to graft hyperplasia and impaired color blending between the graft and recipient site are the major common complications associated with FGG use. Therefore, FGG is not considered to be a valid treatment alternative in esthetically demanding situations.
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Following the one-stage FGG/PE-FGG technique of gingival recession coverage, graft loosening or infection can occur and lead to graft necrosis or partial recession.
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A chief limitation of the CAF technique is the lack of keratinized gingiva.
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After soft tissue grafting with the subperiosteal envelope technique, epithelial invagination and cicatrization at the borders of the exposed root surfaces can result in scar lines.