Dayananda Sagar College of Dental Sciences, Bengaluru - 560078
Author responsible for correspondence:
Dr. Harsha M. B.,
865, 11th B cross, 23rd main, 2nd phase, J P Nagar,
Bengaluru – 560078,
Phone: +919845735007, 91 080 26596730
Total number of pages: 18
Word count of abstract: 145
Word count of manuscript: 2023
Total number of photographs: 10
Running title: Guided tissue regeneration based gingival recession therapy
Summary: The Collagen membrane used in this case series could be effectively used for localized gingival recession therapy.
Background: Gingival recession (GR), often an esthetic concern to the patient, is also associated with root sensitivity, and has a predilection to root caries. The purpose of this case series was to evaluate the effect of a bioabsorbable collagen membrane for root coverage with guided tissue regeneration (GTR) procedure, in localized gingival recession defects.
Methods: Three cases presented in this case series, showing a localized Miller’s Class I or Class II gingival recession, were treated for root coverage with GTR-based collagen membrane. The graft was completely covered with coronally advanced flap and followed up to 6th month postoperatively.
Results: Six months following the procedure, the root coverage was found to be 100% in all three cases. The root coverage obtained appeared structurally and functionally stable.
Conclusion: It may be concluded that the resorbable collagen membrane could be reliably used in the treatment of gingival recession.
Gingival recession or marginal soft tissue recession is the location of the gingival margin apical to the cementoenamel junction.1 Although marginal tissue recession seldom results in tooth loss, it is associated with root hypersensitivity, frenal involvement, marginal tissue irritation, esthetic concerns, and a predilection to root caries.2 Recession of gingival tissues from the root surfaces of teeth has long been a concern of many patients who feel that the “long-in-the-tooth” look is universally accepted as a sign of ageing and tooth loss.3 Hence, intense desire for esthetics could prompt the patient to seek treatment for gingival recession.
Numerous surgical techniques, such as pedicle flaps, free gingival grafts, coronally repositioned flaps and connective tissue grafts have been developed in the treatment of gingival recession. Each of these has disadvantages. Pedicle flaps which require a neighbor donor site with adequate gingival height and thickness for rotation of the flap, may lead to development of gingival recession and/or loss of gingival height at the donor area.4 Studies using epithelialized free gingival grafts for the treatment of gingival recession demonstrated a wide range of success, varying from 11% to 87% with respect to root coverage.5 Results of FGG procedures are associated with an unsatisfactory ﬁnal esthetic appearance and discomfort during secondary intention healing of the donor site. The use of subepithelial connective tissue grafts has been highly predictable in gingival recession therapy with respect to a high percentage of root coverage, better healing and less postoperative discomfort at the donor site when compared to free gingival grafts.6 However, this procedure requires a second surgical site for harvesting the graft, which could be associated with post surgical bleeding and patient discomfort during the healing phase.7
More recently, guided tissue regeneration (GTR) has emerged as a predictable alternative to subepithelial connective tissue grafts for the treatment of gingival recession using either non-absorbable or absorbable membranes. However, the need for a second surgical procedure for the removal of non-absorbable membrane and its associated complications has made use of absorbable barrier membranes more favorable. Of these absorbable membranes, collagen membranes are being widely used.8
Hence, a bioabsorbable collagen membrane was used for the treatment of localized gingival recession in the following case series.
Materials and Method
Three systemically healthy patients, showing localized Miller’s class I or class II gingival recession,9 from among the patients referred to department of Periodontics, JSS Dental College and Hospital, Mysore, received GTR-based gingival recession therapy. Patients were explained the procedure in detail and their written consent for the same was obtained.
The patients were educated and motivated with emphasis on proper oral hygiene maintenance. All the patients underwent the initial phase of treatment which consisted of thorough scaling and root planning. GTR based gingival recession therapy was performed on the patients after assessing their ability to maintain good oral hygiene.
A 21 year-old male patient reported with sensitivity for cold and sweet food and beverages, in relation to upper right first premolar. On examination, the upper right first premolar showed Miller’s class I gingival recession of about 5 mm. Inadequate width of attached gingiva and a 2mm probing depth were observed and the patient had noticed progressive recession since 7 months (Figure 1).
The surgical area was prepared with adequate anesthesia using 2% Lignocaine HCl containing 1:80,000 adrenaline. A trapezoidal flap was designed using 3 different types of incisions. Primary incisions were made in mesial and distal directions from the cementoenamel junction up to 1 mm of the proximal line angle of the adjacent teeth, leaving the interdental papilla intact. Second, a sulcular incision was made connecting the primary incisions, preserving all the existing radicular gingiva. Third, two apically diverging vertical incisions are made starting at the end of each of the primary incisions and extending apically into the alveolar. An initial blunt followed by a sharp dissection with a No. 15 scalpel blade was made to raise a combined full-partial thickness flap (Figure 2). The flap was extended well beyond the mucobuccal fold so that it exhibited no tension when pulled coronally beyond the cementoenamel junction. The root was thoroughly planed and any convexities of the root were reduced. The intact papillae mesial and distal to the recession were deepithelized.
The sterile collagen membrane was trimmed and contoured as needed to cover the recipient site, covering at least 2 mm of the bone all around (Figure 3). Firm pressure was applied over the collagen membrane with sterile moist gauze for 5 minutes to adapt and adhere to the recipient site. The membrane was secured in position with 5-0 vicryl sutures (Figure 4). The flap was coronally repositioned over the collagen membrane to completely cover it, and secured in position with sling sutures (Figure 5). Post-surgical instructions were given and patient was recalled for suture removal after 1 week. A follow up at the end of 6 months, revealed 100% root coverage with excellent color match (Figure 6). The percentage of root coverage was calculated according to the following formula:10
A 23 year-old female patient reported with a complaint of long clinical crown in relation to upper right canine. On examination, Miller’s class I gingival recession of about 4 mm and 2 mm width of keratinized gingiva was recorded on the upper right canine. Initial incision (Figure 7) was given, and a similar procedure as described under case 1 was performed. At a follow up of 6 months, 100% root coverage was noted (Figure 8), with an increase of width of keratinized gingiva to 4 mm.
A 28 year-old male patient reported with long looking tooth and sensitivity in relation to upper left first premolar. On examination, the upper left first premolar showed Miller’s class II gingival recession of about 4 mm (Figure 9). GTR based gingival recession therapy was carried out as described for case 1. 100% root coverage with 2 mm increase of width of keratinized gingiva was observed at follow up after 6 months (Figure 10).
Gingival recession is an intriguing and complex phenomenon. Recession frequently disturbs patients because of sensitivity and esthetics. Hence, gingival recession coverage therapy forms an important part of periodontal therapy.
Many surgical techniques have been introduced to treat gingival recession, including those involving autogenous tissue grafting, various flap designs, orthodontics, and guided tissue regeneration.11 The use of GTR has been suggested for treatment of recession. Tinti and Vincenzi first reported a case where GTR using an expanded polytetrafluoroethylene (ePTFE) membrane was used to treat recession defects.12 Cortellini, Clauser, and Pini Prato also demonstrated, histologically, that the root coverage obtained with an ePTFE membrane included new connective tissue attachment as well as new bone formation.13
Collagen is a natural protein and an integral part of mammalian tissues. There is a similarity between collagen in human skin and certain animal tissues. The rationale for selecting collagen were: Collagen is the major extracellular macromolecule of the periodontal connective tissue and is physiologically metabolized by these tissues, it has been shown to be chemotactic for fibroblasts, acts as a barrier for migrating gingival epithelial cells, serves as a fibrillar scaffold for early vascular and tissue ingrowth, facilitates early wound stabilization and maturation, possess hemostatic properties through its ability to aggregate platelets and is very weakly immunogenic, hence biocompatible.7, 14
The collagen membrane used in this case series was developed by Central Leather Research Institute, Chennai, which was type I collagen prepared from purified soluble bovine Achilles tendon.15 The collagen membrane was cross-linked by gluteraldehyde and sterilized by ethylene oxide gas and had a resorption time of 3-4 weeks. The resorption of the collagen membrane falls well within the time specified by a study which has reported that during GTR procedures, bone and/or periodontal ligament cell migration reach their peaks in 2 to 7 days after surgery, with a decrease in mitotic activity to almost normal levels by the end of 3-4 weeks.16 Shieh et al reported 51.6% root coverage with GTR based gingival recession therapy using collagen membrane.10 Zahedi et al reported mean root coverage of 82.2% after 2 years using collagen membrane.17 Comparing connective tissue graft and GTR for root coverage, other studies have reported thus, Zucchelli et al18 GTR=85.7%; Trombelli et al19 GTR=48%; Harris et al20 GTR=75.1%. Rosetti EP et al6 reported root coverage of 84.2% for collagen based GTR techniques.
The outcome of any root coverage procedure is influenced by many factors, such as the oral hygiene maintenance, pretreatment defect size and location. In addition, the root coverage being a very sensitive or technically demanding procedure, the surgical experience of the clinician is another very important factor which can affect the final treatment outcome. The patients of the present case series showed excellent oral hygiene maintenance contributing to the success of the treatment procedure.
The resorbable collagen membrane used for GTR based root coverage therapy in the present case series, was well tolerated by the patients and effectively achieved structurally and functionally stable root coverage. Improvement in esthetics and reduction of tooth sensitivity were the successful outcomes. It could be concluded that collagen membrane could be used to achieve predictable root coverage.
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Zahedi S, Bozon C, Brunel G. A 2-year clinical evaluation of a diphenylphosphorylazide-cross-linked collagen membrane for the treatment of buccal gingival recession. J Periodontol 1998;69:975-981.
Zucchelli G, Clauser C, DeSanctis M, Calandriello M. Mucogingival versus guided tissue regeneration procedures in the treatment of deep recession type defects. J Periodontol 1998;69:138-145.
Trombelli L, Scabbia A, Tatakis DN, Calura G. Subpedicle connective tissue graft versus guided tissue regeneration with bioabsorbable membrane in the treatment of human gingival recession defects. J Periodontol 1998;69:1271-1277.
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Figure 1: Pre-Operative gingival recession on maxillary right first premolar