Complete Coverage of a Class III (RT2) Gingival Recession With the Combination of a Free Sub-epithelial Connective Tissue Graft and a Laterally Positioned Flap

Abstract

Introduction: Gingival recession (GR) presents a major concern for patients, especially when associated with tooth sensitivity or esthetic concerns.
Case Presentation: This report describes the complete coverage of a class III gingival recession with the combination of a free sub-epithelial connective tissue graft (SCTG) and a laterally positioned flap (LPF). After treatment of gingival recession of the mandibular right canine with clinical attachment loss (AL) 12mm there was complete coverage and an increase in keratinized gingiva.
Conclusion: A promising technique is presented, yielding 100% of defect coverage and gingival tissue enhancement on single teeth.

Full text

Clinical Advances in Periodontics; Copyright 2015 DOI: 10.1902/cap.2015.140076
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Complete Coverage of a Class III (RT2) Gingival Recession With
the Combination of a Free Sub-epithelial Connective Tissue
Graft and a Laterally Positioned Flap
Andreas L. Ioannou, DDS, Resident*, Georgios A. Kotsakis, DDS, Resident*, Georgia I.
Kamintzi, DDS, Resident†
*Advanced Education Program in Periodontology, University of Minnesota.
†International Postgraduate Program in Orthodontics, Tel Aviv University.
Introduction: Gingival recession (GR) presents a major concern for patients, especially when
associated with tooth sensitivity or esthetic concerns.
Case Presentation: This report describes the complete coverage of a class III gingival recession
with the combination of a free sub-epithelial connective tissue graft (SCTG) and a laterally positioned flap
(LPF). After treatment of gingival recession of the mandibular right canine with clinical attachment loss
(AL) 12mm there was complete coverage and an increase in keratinized gingiva.
Conclusion: A promising technique is presented, yielding 100% of defect coverage and gingival
tissue enhancement on single teeth.
Key Words:
dentin sensitivity; esthetics; gingival recession; root coverage; surgical flap; tissue graft;
treatment outcome;
Background
Gingival recession (GR) is defined as the apical displacement of the gingival margin in
relation to the cemento-enamel junction (CEJ). Although coverage of recessions that fall
into the first category of Miller’s classification is generally a straight-forward procedure,
the treatment of recessions that are associated with lack of attached keratinized tissue
(Miller’s class II) and/or loss of interdental tissues (class III, or IV) remains a challenge
even for skilled surgeons.1
Various techniques have been proposed for recession coverage, such as the free
gingival graft,2,3 the laterally positioned flap,4 the coronally positioned flap,5 tunneling6
and the double papilla graft techniques.7 Laterally positioned flaps (LPFs) are efficacious
treatment modalities that perform extremely well in specific indications.8 Grupe and
Warren were among the first to introduce a method in which they repaired gingival
recessions by sliding a flap laterally to ascertain success via maintenance of the apical
blood supply to the transpositioned tissue.4 As with all treatment approaches, this
technique in not a panacea and it does come with some disadvantages, such as the
potential for additional recession in the donor site and/or bone loss.9 To address these
issues, Grupe (1966)10 and Espinel et al. (1981)11 introduced a modification of the
technique proposed by Grupe and Warren (1956).4 In the revised technique, the LPF was
initially reflected as a full thickness mucoperiosteal flap from the donor site adjacent to
the gingival defect and continued as a partial thickness mucoperiosteal flap further
distally to provide better fixation of the connective tissue onto the root surface and to

Clinical Advances in Periodontics; Copyright 2015 DOI: 10.1902/cap.2015.140076
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yield a better reparative dynamic potential owing to the increased tissue thickness of the
coronal aspect of the flap.11
The purpose of this case report is to document the success of a laterally positioned
flap (LPF) in combination with a free sub-epithelial connective tissue graft (SCTG) in
treating an isolated class III gingival recession.
Clinical Presentation
An 18-years-old non-smoker male with non-contributory medical history presented on
April 11th, 2013 to the Advanced Education Program in Periodontology Clinic,
University of Minnesota on April, 2013 with a chief complaint of “gum” recession and
hypersensitivity associated with the right mandibular canine (#27). Intraoral examination
revealed good oral hygiene, bilateral posterior cross-bite, and generalized GR with the
lower right canine showing 12mm loss of attachment on the facial aspect and limited, but
clinically noticeable loss of interdental papillae on the site (~1 mm). [Fig. 1, Table 1]
Specifically, periodontal probing with a North-Carolina type probe on #27 revealed the
following measurements: probing depth (PD) of 3 mm; recession depth of 9mm;
recession width of 3mm; and clinical attachment loss (AL) of 12 mm. No keratinized
gingiva was present on #27, while a wide band of keratinized tissue was present on the
adjacent teeth.[Fig. 1b] Intraoral periapical radiograph of #27 showed approximately
1mm of interdental bone loss on the mesial.[Fig. 2] Based on the mesial interproximal
attachment loss and the very prominent root, a Class III gingival recession according to
Miller’s Classification or a class RT2 gingival recession according to Cairo’s
classification with localized gingivitis for #27 were diagnosed.1,12
Patient refused to proceed with any treatment plan involving orthodontic treatment or
extraction of #27. The patient opted to proceed with surgical treatment of the defect for
recession coverage. It was decided to employ a modification of the SCTG technique
combined with a LPF as used by Grupe and Warren (1966) due to the lack of keratinized
tissue on the recipient site.10 Written informed consent for periodontal surgery was
obtained.
Case Management
Following administration of anesthesia via a Gow-Gates nerve block (recipient site) and a
major palatine block (donor site) as well as local infiltrations, a #15c blade was utilized to
trace an incision distal of #31. The incision was initiated as an oblique releasing incision
(cut-back incision) extending to the oral mucosa, to provide adequate mobility of the flap.
Subsequently, the incision extended through the keratinized attached tissue of the molars
to the distal line angle of the lower right premolar with care to leave a 3mm collar of
gingival tissue to avoid future recession and to provide ease of suturing.10[Fig. 3A] The
incision continued sulcular around #28 extending to the mesial of #24. A full-thickness
flap was reflected up to the mucogingival junction, to provide mobility.[Fig. 3B]
Following planing of the exposed root surface the intact papillae were de-epithelialized to
expose the underlying connective tissue.11 A single-incision palatal harvest technique was
employed to harvest a SCTG from the palate.13 The graft was then trimmed, adapted on
the exposed root, and immobilized at the level of the CEJ via a sling suture and periosteal
sutures with a 5.0 absorbable suture.‡ The graft did not extend to the underlying bone,

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and secured blood supply from the overlying flap and the PDL. The donor site was
secured via single interrupted suturing and a surgical stent was placed to facilitate
hemostasis and ensure patient comfort.[Fig. 4]
The sliding flap was rotated laterally to completely cover the graft and the defect and
was extended 2 mm coronally to the CEJ. The flap was then carefully sutured with sling
sutures and routine interrupted sutures to avoid micromovement and to decrease
tension.[Fig. 5] Subsequently, tactile pressure was applied for 5 minutes for flap
adaptation. The patient was instructed to refrain from oral hygiene practices in the
surgical site for 2 weeks and instructed to take Amoxicillin 500 mg (q8h) for 7 days,
Ibuprofen 600 mg (qid per pain), and to rinse with 0.12% chlorhexidine gluconate (bid)
for 2 weeks. Sutures were removed at 2 weeks after surgery. The post-operative follow-
ups were conducted at 1 and 3 months after surgery for professional plaque control and
further oral hygiene instructions.
Clinical Outcomes
Healing was uneventful on both the donor and recipient sites. At suture removal, the
tissue appeared slightly edematous as a result of normal post-surgical inflammation. [Fig.
6a,b,c] The patient reported no residual dental hypersensitivity or post-operative pain.
Complete coverage was noted at #27 at 3 months post-surgery with excellent tissue
contours and texture.[Fig. 6d] A 3mm gain in keratinized tissue width was noted with
9mm of recession coverage on the facial. No bleeding on probing was present. (Fig. 6e)
The patient was an undergraduate student that moved to a different state upon graduation
and did not return for the 12-month follow-up. Phone contact was established and the
patient reported no recurrence of subjective symptoms (i.e. hypersensitivity) or clinically
noticeable recession at the site.
Discussion
The ultimate goal of root coverage procedures is complete root coverage. Complete root
coverage can lead to resolution of hypersensitivity, prevention of root abrasion, or further
progression of the defect and esthetic reconstruction of the site.14 LPFs have been shown
to yield high percentages of complete root coverage, when the indications for the use of
this technique are followed.15 The results of the present case study indicate that the use of
a LPF in combination with a SCTG can yield complete root coverage even in the
challenging scenario of a Class III recession. The result of the presented case is supported
by the evidence-based classification of gingival recessions by Cairo et al. that suggests
the predictability of attaining complete root coverage for gingival recessions with
incipient interproximal attachment loss (RT2 with ≤ 3mm interproximal loss).
Full-thickness flaps are not routinely utilized in LPF procedures due to the risk for
additional recession.4,10 With the presented technique an oblique releasing incision (cut-
back incision) was performed. Furthermore, a collar of gingival tissue 3 mm from the
margin of the adjacent teeth was maintained. These modifications facilitated the lateral
reposition of the flap, reduced flap tension and aided in avoiding further recession
adjacent to the original defect.10,11 The technique described in this case report where we
combined a full-thickness flap with a free connective tissue graft presents a promising
treatment option for complete root coverage in an isolated class III GR with color

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matching with adjacent tissues. It is important to emphasize that this is a case study with
short-term follow-up and that longitudinal clinical studies are required to provide solid
evidence of the predictability of complete root coverage with this surgical approach.
Summary
Why is this case new information?


This case study presents a complete coverage of a
class III gingival recession with the combination
of a free sub-epithelial connective tissue graft and
a laterally positioned flap
What are the keys to successful management of this case?


Adequate thickness and width of keratinized tissue
at the donor site are prerequisites for the
successful transpositioning of the pediculated flap
to cover ginigival recessions.


The flap technique described is designed to allow
increased and tension-free lateral repositioning.
What are the primary limitations to success in this case?


A relatively short follow-up period is
presented.


Experience with soft tissue grafting procedures
and flap management is required to perform this
advanced surgical technique.
Acknowledgements
The authors would like to express their gratitude to Dr. Deborah Johnson, Clinical Associate Professor,
Division of Periodontology, University of Minnesota, MN, USA for her clinical guidance. None of the
authors have any conflict of interest regarding this paper.
References
1. Miller PD Jr. A classification of marginal gingival recession. Int J Periodontics Restorative Dent.
1985;5(2):8-13.
2. Sullivan HC and Atkins JH. Free autogenous gingival grafts. I. Principles of successful grafting.
Periodontics. 1968 Jun;6(3):121-9.
3. Miller PD Jr. Root coverage using the free soft tissue autograft following citric acid application. III. A
successful and predictable procedure in areas of deep-wide recession. Int J Periodontics Restorative
Dent. 1985;5(2):14-37.
4. Grupe H and Warren R. Repair of gingival defects by sliding flap operation. J Periodontol. 1956
(27):92–95.

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5. Allen EP and Miller PD Jr. Coronal positioning of existing gingiva: short term results in the treatment
of shallow marginal tissue recession. J Periodontol. 1989 Jun;60(6):316-9.
6. Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz M. Treatment of multiple adjacent gingival recessions
with the tunnel subepithelial connective tissue graft: a clinical report. Int J Periodontics Restorative
Dent. 1999 Apr;19(2):199-206.
7. Cohen DW and Ross SE. The double papillae repositioned flap in periodontal therapy. J Periodontol.
1968 Mar;39(2):65-70.
8. Chambrone LA, Chambrone L. Treatment of Miller Class I and II localized recession defects using
laterally positioned flaps: a 24-month study. Am J Dent. 2009 Dec;22(6):339-44.
9. Guinard EA. and Caffesse RG. Treatment of localized gingival recessions. Part I. Lateral sliding flap. J
Periodontol. 1978 Jul;49(7):351-6.
10. Grupe HE. Modified technique for the sliding flap operation. J Periodontol. 1966 Nov-Dec;37(6):491-
5.
11. Espinel MC, Caffesse RG. Lateral positioned pedicle sliding flap-revised technique in the treatment of
localized gingival recessions. Int J Periodontics Restorative Dent. 1981;1(5):42-51.
12. Cairo F, Cortellini P, Tonetti M, Nieri M, Mervelt J, Cincinelli S, Pini-Prato G. Coronally advanced
flap with and without connective tissue graft for the treatment of single maxillary gingival recession
with loss of inter-dental attachment. A randomized controlled clinical trial. J Clin Periodontol. 2012
Aug;39(8):760-8.
13. Lorenzana ER, Allen EP. The single-incision palatal harvest technique: a strategy for esthetics and
patient comfort. Int J Periodontics Restorative Dent. 2000 Jun;20(3):297-305.
14. Chambrone, L., Pannuti, C.M., Tu, Y.K., Chambrone, L.A., 2012. Evidence-based periodontal plastic
surgery. II. An individual data meta-analysis for evaluating factors in achieving complete root
coverage. J. Periodontol. 83, 477–490.
15. Santana, R.B., Furtado, M.B., Mattos, C.M., de Mello Fonseca, E., Dibart, S., 2010. Clinical
evaluation of single-stage advanced versus rotated flaps in the treatment of gingival recessions. J.
Periodontol. 81, 485–492.
Correspondence address: Andreas Ioannou, DDS Advanced Education Program in
Periodontology University of Minnesota 515 Delaware Street SE Minneapolis, MN
55455
Submitted October 12, 2014; accepted for publication November 24, 2014.
Figure 1
(a) Clinical preoperative photograph of the patient at the time of the examination showing the generalized
gingival recession and the bilateral posterior cross-bite (b) Note the severity of the gingival recession on
the lower right canine and the localized inflammation of the site. Tooth number 27 showing minimum width
of keratinized tissue in contrast with the adjacent teeth and CAL of 12mm.
Figure 2
Intraoral periapical radiograph of #27 showing approximately 1mm of interdental bone loss.
Figure 3
(a) The incision was initiated distal of the 2nd molar as a cut-back incision, extending to the oral mucosa,
leaving a 3mm collar of gingival tissue. (b) Blunt dissection is performed with periosteal elevators and a
full-thickness flap up to the mucogingival junction is reflected.

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Figure 4
(a) Illustrating the single-incision palatal harvest technique used to harvest a sub-epithelial connective
tissue graft from the palate (b) The sub-epithelial connective tissue graft as harvested from the palate. Note
the adequate size and dimensions and the yellowish fat tissue prior removal (c) The sub-epithelial
connective tissue graft after the fat tissue is removed, trimmed, transferred to the recipient site and
immobilized at the level of the CEJ.
Figure 5
The flap rotated laterally to completely cover the graft and the defect, extending 2mm coronal to the CEJ.
The flap is carefully sutured with sling and routine interrupted sutures in a tension free way.
Figure 6
(a,b,c) Note the uneventful healing phase on both the donor and recipient sites after 2 weeks (d) Note the
complete root coverage achieved on #27 with excellent contour and color after 3 months (e) Note the depth
of the pocket at 3mm indicating that the new attachment and root coverage was complete.
Table 1
Clinical parameters at baseline and 3 months following treatment.
Clinical Parameters Baseline 3 months
PD 3 mm 3mm
AL 12 mm 3mm
Recession Depth 9mm 0mm
Keratinized Tissue Width 0mm 3mm
Vitality + +
Mobility - -
‡ (Vicryl Rapide, Ethicon, Johnson & Johnson, New Brunswick, NJ)

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