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Recession coverage

A less invasive technique for greater success

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Different techniques and biomaterials can be used for recession coverage. When is the coronally advanced flap beneficial, when a tunneling approach?

Dr. Yoon Euy Hong | South Korea

Gingival recession takes place when the free gingiva migrates apical to the cementoenamel junction with concurrent displacement of the biologic width complex, including connective tissue, root cementum and alveolar bone. This is called clinical attachment loss. It is crucial to understand that this phenomenon increases the risk of tooth loss.

The etiology of gingival recession is diverse. However, if appropriate periodontal flaps and grafts are selected, recession coverage can be beneficial for patients, providing satisfactory outcomes for recession coverage and gains in keratinized gingiva. Techniques in which connective tissue grafts or tissue biomaterials are used with coronally advanced flaps or tunneling procedures have been well-documented and proven to be effective.1


Tunneling technique vs. coronally advanced flap

In periodontal plastic surgery, the coronally advanced flap (CAF) has been used most widely for recession coverage and increasing keratinization, with or without connective tissue grafts or graft substitute biomaterials. The literature and the clinical community have supported the superior outcomes of CAF.1 The CAF includes vertical releasing incisions that allow predictable coronal advancement of the flap. However, the incisions delay post-surgical wound healing and tend to expose grafts.

Therefore, many clinicians have considered alternative surgical techniques that avoid vertical incisions. The tunneling technique was first introduced by Zabalegui et al2 and can be used for periodontal plastic surgery in multiple adjacent defects. Advantages of tunneling techniques include the absence of vertical releasing incisions, intact papilla due to lack of papilla reflections and graft adaptability with increased blood supply.2

All of these factors accelerate initial wound healing. However, tunneling techniques require operator skill and experience and are rather time consuming. The tunneling technique can minimize trauma to the gingiva, and the least traumatic surgical techniques are beneficial for patients and surgeons.

The Clinical tips: flap technique

The coronally advanced flap is preferred when dealing with thin mucosal tissue (thin biotype), since the preparation of a tunnel is likely to cause perforations or tearing of the gingiva. The coronally advanced flap is also recommended when a greater amount of coronal advancement is planned and if the scalloped nature of the free gingiva is absent – flatly contoured gingival zenith, such as in the lower anterior region.
The tunneling technique is ideal when working with a thick biotype, highly scalloped free gingiva and suitable keratinized tissue. The tunneling technique should also be considered if esthetics are critical and a mild to moderate coronal advancement is anticipated. One of the key factors for success is the proficiency of the periodontal surgeon.

Connective tissue graft vs. biomaterial

Connective tissue grafts help create keratinized gingiva, based on a study of tissue specificity by Karring and co-workers.3 In this epithelial differentiation study, Karring was able to demonstrate that free grafts harvested from the palate produced keratinized gingiva, whereas grafts transplanted from the non-keratinized alveolar mucosa produced alveolar mucosa.4

Advantages of connective tissue grafts include plasmatic circulation (capillary beds within the grafts) that help with high graft survival, outstanding color match after healing and dimensional stability. Disadvantages include patient morbidity, e.g. bleeding, delayed healing and pain, along with the secondary graft harvest sites. (Figs. 1, 2)

Accordingly, clinicians have been interested in developing a graft substitute. Such biomaterials not only avoid connective tissue graft harvest and associated morbidity but also provide unlimited supply with consistent quality. Working with such biomaterials, complete primary closure with a tension-free flap is recommended. Ideal biomaterials should act as scaffolding to promote ingrowth and regeneration by host cells, while remaining dimensionally stable. (Fig. 3)

Clinical tips: biomaterial

When the connective tissue graft is chosen as a graft material, its availability must be determined prior to the intervention using bone sounding. Reiser5 emphasized the importance of the anatomy of the donor area and classified the vault dimension as shallow, medium or high.
The collagen matrix Geistlich Mucograft® should be handled, trimmed, positioned and sutured before the biomaterial becomes wet. Therefore, it is beneficial to finish any necessary preparation of the biomaterial extra-orally in order to minimize intra-oral working time. In this way the volumetric dimension is not compromised.
The periodontal flap should be reflected without tension. A tension-free flap is critical for primary closure, and a passive flap will not compress the underlying Geistlich Mucograft® collagen matrix.

Minimally invasive approach

A meticulous periodontal surgeon is always investigating advances in periodontal plastic surgery. How can we improve surgical techniques in order to improve predictability and reduce complications? Can the surgical time be shortened or post-surgical wound healing be accelerated? Minimally invasive surgery can be the answer. Shanelec and Tibbetts first introduced periodontal surgery using a microscope, which provided clinical benefits over conventional treatment.6 Cortellini and Tonetti studied a minimally invasive surgical approach to periodontal surgery.7 Atraumatic flaps, harvest graft substitute biomaterials, use of microscopes and loupes (without increasing surgery time due to unfamiliarity), teamwork, proper armamentarium, surgical skill and experience can all help with the minimally invasive approach in periodontal plastic surgery.

Clinical tips: minimum invasion

These are the key factors for a minimally invasive approach to periodontal plastic surgery:

  • Limited flap reflections
  • Use of SM67 or SM69 blades (Swann-Morton)
  • Use of 5–0 or 6–0 sutures
  • Introduction of microscopes or loupes
  • Use of specified instruments, such as tunneling instruments
  • Combination of tunneling techniques and biomaterials.

Dr. Yoon Euy Hong

Dr. Yoon Euy Hong | South Korea

Private Practice

Center for Oral Plastic Surgery

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