Periodontal Plastic Surgery – What are the important principles? – Dr PierPaolo Cortellini

• Reasons for treating gingival recession – aesthetics, dentine hypersensitivity and prevention of progression.
• Do not assume that recession defects do not improve or even heal spontaneously – after oral hygiene modifications, wait before accepting for mucogingival surgery, don’t rush this.
• Recession classification – Miller or Cairo classification.
• Important principals – patient, site and surgical procedure.

• Patient – age (no influence), gender (males have deeper recession defects), diabetes and stress (influence on therapy) – weak evidence for root coverage procedures.
• Smoking habits – controversial evidence. Chambrone 2009 – last meta-analysis concluded that smoking may negatively influence gingival recession coverage.
• Oral hygiene habits and compliance of patient – the scientific community strongly believes that are relevant, but there is weak evidence.

• Site – Number and location of involved teeth is important in deciding the procedure – coronally advanced (CAF) or free gingival graft (FGG). Tooth position is important to give an idea of root coverage. Some recession on misaligned teeth can be solved with orthodontic therapy. Better to realign teeth before mucogingival surgery. This is according to clinical experience rather than evidence. Frena and fornix are also clinically important.
• Impact of papilla morphology – weak evidence. Complete coverage is not correlated to papillae area and height (Saletta 2006). Even with short papillae it is possible to get full coverage.
• Recession depth- strong evidence that the deeper the recession, the more difficult the root coverage.
• Cairo, Cortellini – coronally advanced flap with or without connective tissue graft. Both can achieve full coverage but more predictable coverage if add graft.
• Keratinised tissue extension and thickness plays an important role for CAF – strong evidence (Baldi 1999).Thick gingiva > 1.1 mm, thin gingivae < 0.6 mm. 0.8 mm or more is enough thickness to allow for complete root coverage. What is the solution if the tissue is too thin? – Graft and coronally advanced flap (Cortellini). Long term evidence on stability is the same (Pini Prato 2010).

• Dental tissues – tooth wear (erosion, abrasion, abfraction, attrition), caries, cervical filling – clinical evidence present. Dental and periodontal lesions – frequently a matter of a combined loss of tooth substance, not just gingivae. Discuss food and beverage intake. Differential diagnosis – erosion (lenticolar, enamel, acidity) abrasion (flat, oral hygiene trauma), abfraction (CEJ, cuneiform, occlusal forces). Can use a basic erosive wear examination index (Bartlett) and cause related therapy. Also consider oral hygiene and diet habits. Identify main pathology and develop strategies to eliminate the impact.
• Classification of dental surface defects in areas of gingival recession (Pini Prato 2010) – CEJ detectable/not detectable (A/B), presence or absence of abrasion (+\-). Only 47% of cases have pure periodontal lesions – the rest have dental lesions too, 24% of which are severe dental lesions. Therefore important to screen and risk assess your patients from a periodontal and tooth viewpoint.
• Need to assess the dental tissues to check for the presence or absence of the CEJ and steps.

• Surgical procedure – presurgical (filling removal, caries removal, restore CEJ, step filling, root preparation, orthodontic movement).
• If you don’t identify the CEJ or reconstruct it, the gingival margin may not fit the tooth structure. Formerly restoration after coverage. However, the gingival margin will be flat if the tooth is flat due to the adaptation of the soft tissues. Need the convexity to provide the correct contour.
• Step filling – strong evidence – 3 ways to solve – apply barriers (environment for blood clot and regeneration, Pini Prato 1992), graft to fill in the step (Mele 2008), fill with composite.
• CEJ – if detectable then go to surgery. If not detectable restore CEJ with composite. If no steps go to surgery. If step, use a graft (best way) or a barrier graft or composite under the flap to take care of the step.
• Root preparation – mechanical or chemical. Chemical – removes smear layer, exposure of collagen, removes cytopathic substances – none of studies show differences between sites. If there is a treatment that does not show additional benefit there is no point including more complexity. Mechanical – roughen root surfaces – Pini Prato 1999 – light polishing is equivalent to root planing. Mechanical therapy all have similar outcomes (hand, ultrasonic, tooth cleaning) and chemical therapy does not add any further advantages.
• Flap tension – key issues with strong evidence. Important to give freedom to the flap. Keep the blade parallel surface of flap to exclude the muscles. The flap should lie in the final position without the sutures.
• Split mouth study on tension – no further dissection versus further dissection to get zero tension. No tension 45% coverage versus 18% for no further dissection. Aim for less than 4 g of tension.
• Flap position – position flap with sutures and displace as coronally as possible. Then complete suturing. How coronal – the more coronal positioning of the flap, the higher the probability of complete root coverage. E.g. recession of 3 mm and want 100% root coverage – need 2.5 mm coronal to CEJ.
• Consider all the above factors and place within a strategy. Technical ability is also very important.

Predictable Root Coverage – What are the options? – Professor Mariano Sanz

Aetiology and diagnosis

• Localised gingival recessions – aetiology is usually traumatic and happens in patients with excellent plaque control. Trauma – vigorous toothbrushing, piercings, iatrogenic. Predisposing factors – teeth which are prominent and out of alignment in the arch.
• Combined lesion – associated lack of keratinised gingivae, chronic gingival inflammation and clinical attachment loss.
• Make a clear diagnosis! Need to differentiate between enamel, cementum and gingivae. Mostly lesions are combined (Sanz) – difficult to say just erosion, abrasion or a gingival component.
• Pure localized/traumatic – mostly Miller class 1 or 2 as interdental region not affected – proposed 100% root coverage. Class 4 or 5 may get complete coverage but not as predictable.
• Diagnosis important to ensure predictable treatment.

Treatment

• Reasons to treat – aesthetics, sensitivity, progressive.
• Non-surgical therapy – monitoring and prevention, desensitising agents (varnishes and bonding agents), composite restorations, orthodontics.
• Surgical therapy – pedicle flaps (coronally/laterally), grafts (connective tissue, allografts e.g. alloderm, biologicals e.g. emdogain)
• The size and morphology of the interdental papillae determines if complete a vertical or oblique incision.
• Raise the flap – full thickness over the root and split thickness in the most apical area to minimise tension.
• Root surface debridement – not vigorous root debridement but enough to make sure the surface is clean.
• Palate for harvesting the graft – check probing depths of premolars as you want don’t want tissue part of sulcus or pocket. First a horizontal incision perpendicular along length of graft then trap door or one horizontal incision. One parallel to the palatal tissue – tissue in between what you retrieve. Depending on how thick flap is. Suture palatal wound.
• Suture connective tissue graft on top of vascular root – without tension – start with the most apical part of flap. Sutures to anchor the graft.

Evidence

• Evidence based periodontal plastic surgery – systematic review by Sanz 2002 – improvements in recession and clinical attachment level with all surgical techniques. Connective tissue graft is superior in comparison to other techniques.
• Chambrone’s systematic review – in cases where root coverage and keratinised tissue expected, use of connective tissue graft is advised.
• Chambrone – 22 RCTS – compete root coverage 50% of the time. Sub-epithelial connective graft superior to achieve full root coverage than coronally advanced flap (CAF) alone.
• Latest systematic review – Cairo 2014 – 25 RCTs, 500 patients. CAF is a safe and predictable approach for root coverage but connective tissue graft and enamel matrix derivative enhances clinical outcomes of CAF in terms of complete root coverage. Contradictory results were associated with the use of acellular dermal matrix.
• Multiple recessions – different variations of techniques, such as Zuchelli’s technique.
• Efficacy of periodontal plastic procedures (Granziani) – modified CAF and tunnel approaches show higher level of complete root coverage.
• Key factors that influence success (Cortellini) – incisions, tension, thickness, microsurgery.
• In the single recessions, the CAF is the most used technique. Multiple – number and location of recession defects guide the surgical design.
• Future for substitutes for CT graft? Mucograft – xenogenic collagen matrix – dense layer and porous (different from membrane as this is porous). Main biological function is to collect in-growth of vessels, nutrients and tissue from adjacent areas – scaffold for new tissue ). Evidence: Jepsen. CAF compared to CAF plus collagen matrix – mean percentage of root coverage was similar. When analysed secondary outcomes – reduction in recession, increase width of keratinised tissue, increase thickness – combination provided better. Improved outcomes in deeper recessions (McGuire 2010, Cardaropoli 2010, Aroca 2013) – CT graft better results than xeogenic collagen matrix.
• Vignoletti 2011 – collagen matrix on top of single tooth recession – pig experimental model – help improve adaption of blood clot and reconstruction of soft tissues.
• Other ways of measuring outcome – patient centered and aesthetics.
• Stability dependent upon type of approach and patient compliance. Involve the patient in the decision making process, ensuring the expense and morbidity has been discussed.

Flap Design & Suturing, the most important part – Professor Anton Sculean 

• Rationale to treatment – reduction of probing depths and gain of clinical attachment by minimising soft tissue recession, eliminating intrabony (angular) defects and furcation defects to facilitate plaque control, gain more tooth support and improve tooth prognosis.
• Rationale for reconstructive periodontal therapy (Matuliene 2008) – association between tooth related factors and tooth loss – a probing depth of more than 6 mm is a risk factor for tooth loss and furcation defects of grade II or III also mean there is a high chance of tooth loss. Intrabony defects lead to progressive disease. Papapanou 1991 – assigned defects a degree from 1-3. 70% of degrees 3 were extracted. Rationale to treat otherwise these teeth will have a poor prognosis.
• Occurrence of bony defects – Papapanou 1988 – 8%, Ainamo 1994 – 51%.
• Treatments goals of regeneration – periodontal pocket depths of less than 5 mm, no bleeding on probing and regeneration.
• How intrabony defects can be treated – non surgically, surgically (conventionally with access flaps or regeneration).
• The surgical approach itself appears to be a critical factor that influences the outcome of surgery. Therefore it is important to focus on flap design as it does make a difference (Graziani 2012).
• Healing studies (Wikesjo 2010) – need to support the flap. Need – cells, stability, space and primary intention healing.
• Flap design – papilla preservation flaps (Takei, Murphy, Cortellini). If interdental space less than 2 mm cannot perform procedure – modified papilla preservation technique – Cortellini 1995. New developments – modified coronally advanced tunnel (Sculean 2014) and the laterally moved double tunnel.
• Relevance of suture materials and techniques. Braided silk elicits more severe tissue reactions than ePTFE or monofilament regardless of infection control (Leknes).
• Reconstructive surgeries at recessions – treatment concept – use flap designs aiming to enhance wound stability (e.g. avoid vertical relieving incisions), use of biologic materials, sub-epithelial grafts and tension-free suturing.
• The understanding of the biology should serve as a basis for any new treatment concept. Surgical techniques aiming to improve wound stability combined with biologically sound materials should be considered to improve outcomes.

Periodontology