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Year : 2013  |  Volume : 4  |  Issue : 1  |  Page : 48-52

Coronally repositioned flap with highly purified resorbable membrane for treatment of gingival recession: A report of two cases

1 Department of Periodontics, Dr. Harvansh Singh Judge Institute of Dental Sciences and Hospital, Panjab University, Chandigarh, India
2 Department of Periodontics, B.R.S Dental College and Hospital, Barwala, Panchkula, Haryana, India

Date of Submission20-Jan-2013
Date of Acceptance27-May-2013
Date of Web Publication20-Sep-2013

Correspondence Address:
Nandini Bhaskar
Department of Periodontics, Dr. Harvansh Singh Judge Institute of Dental Sciences and Hospital, Panjab University, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-6944.118549

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Gingival recession is one of the most common aesthetic and functional concerns associated with periodontal tissues. Other associated problems include plaque retention, gingival bleeding, and abrasion, pain due to cervical dentine hypersensitivity, root caries and fear of tooth loss. This article highlights on 2 cases treated with coronally repositioned flap with highly purified resorbable membrane for gingival coverage. Two patients with Millers's ClassII gingival recession with respect to anteriors reported to the department O.P.D were selected. The clinical parameters were recorded - probing depth, clinical attachment level and gingival recession. The clinical recordings were done at baseline, 3 months and 6 months follow-ups. As compared to baseline full gingival coverage was gained in first case and was stable till 6 months follow-up. In second case a gingival coverage of 3 mm as compared to baseline was gained and was stable till 6 months follow-up. Coronally repositioned flap combined with bilayer collagen membrane is a safe and effective method for the coverage of denuded root surfaces.

Keywords: Full-thickness flap, gingival recession, guided tissue regeneration, root coverage

How to cite this article:
Bhaskar N, Chhabra V. Coronally repositioned flap with highly purified resorbable membrane for treatment of gingival recession: A report of two cases. Indian J Oral Sci 2013;4:48-52

How to cite this URL:
Bhaskar N, Chhabra V. Coronally repositioned flap with highly purified resorbable membrane for treatment of gingival recession: A report of two cases. Indian J Oral Sci [serial online] 2013 [cited 2020 Feb 20];4:48-52. Available from: http://www.indjos.com/text.asp?2013/4/1/48/118549

  Introduction Top

Gingival recession (GR) or marginal tissue recession is one of the common signs of periodontal disease in which gingiva occupy a position apical to cementogingival junction (CEJ) and result in exposure of the root surfaces.

The principal cause of concern with GR is loss of tooth support, which leads to compromised aesthetics. Other GR associated problems include plaque retention, gingival bleeding and abrasion, pain due to cervical dentine hypersensitivity, root caries and fear of tooth loss.

The clinicians have been trying various periodontal plastic procedures to cover denuded root surfaces, but all these procedures have resulted in repair involving a combination of connective tissue adhesion and formation of long junctional epithelium rather than regeneration, which is by definition a rebirth of the periodontium and can add longevity to the dentition. [1]

Currently, dentistry strives for regeneration, which is a contemporary goal of periodontal therapy. Studies on periodontal wound healing have resulted in development of the treatment modality viz. guided tissue regeneration (GTR) based on the hypothesis originated by Melcher, 1976 and Nyman et al., 1982 who used GTR in the first human tooth and carried out histologic analysis. [2],[3] The rational of GTR is to impede apical migration of the epithelium by placing a barrier membrane (epithelial exclusion), which allows the repopulation of the periodontal ligament cells onto the dental root surface.

Earlier the non-resorbable barrier membranes (first generation materials) which required the second surgical intervention for their retrieval were available viz. thin aluminum foil, millipore (ethyl cellulose filter), dense polytetrafluoroethylene, expanded polytetrafluoroethylene, rubber dam material etc., Later on, bioresorbable materials were introduced to eliminate the need for second surgical procedure and potential morbidity associated with it. These membranes are classified as second generation membranes, which include atelocollagen, polylactic acid, polyurethanes, oxidized cellulose, polycaprolactones, polyhydroxybutyrate, polycarbonate, polyglactin 910 and type I-III collagen (Bio-Gide) ® etc. [4]

The aim of development of resorbable bilayer collagen membrane (Bio-Gide) ® was to reproduce the physiological barrier function of periosteum with a natural tissue material. This membrane has two layers, one compact and other porous. The compact layer has a smooth surface, which is cell occlusive and is turned toward soft-tissue, whereas porous layer stabilizes the blood clot and encourages the integration of bone forming cells and is turned towards the bone. [5]

In this study, an attempt has been made to clinically evaluate the efficacy of highly purified collagen of porcine origin as a membrane barrier in the treatment of human localized GR.

Patient selection and pre-surgical preparation

Two patients with miller Class II GR with respect to anterior teeth reported to out-patient department. Each patient was in good health and had received no periodontal therapy for previous 6 months. After an explanation of the proposed study criteria, including alternative treatment and potential risks and benefits, the participants were asked to sign an informed consent. Prior to therapy data was obtained including dimensions of GR, probing depth (PD) and clinical attachment level (CAL) using a William's graduated periodontal probe. The clinical parameters were similarly repeated at 3 months and 6 months post-operative. Pre-operative instructions included oral hygiene instructions, scaling and root planning and necessary plaque control measures.

Surgical procedure

The area to undergo surgery was anesthetized with local anesthetic solution (lignocaine hydrochloride 2% with adrenaline 1:200, 000).

Intrasulcular incision was given involving one tooth mesial and one tooth distal. Full-thickness mucoperiosteal flap was raised until the dehiscence defect to gain access. With the help of curettes and burs, the exposed root surface of the tooth was planned to obtain a flattened or concave profile. Split thickness flap was raised from the base of the dehiscence defect to mucogingival junction and a relieving incision was given at the base of the flap so as to facilitate its coronal repositioning. Following the procedure area was profusely irrigated.

Resorbable bilayer collagen membrane ([Bio-Gide] ® Geistlich Inc., Switzerland) was cut to obtain the required size with the help of a template and was placed over the denuded root surface/surfaces extending from CEJ to 2-3 mm beyond the bony margins both laterally as well as apically. The membrane was secured by suturing to the periosteum with 4-0 bio absorbable vicryl suture and the flap was coronally repositioned at CEJ to cover the membrane completely and facial and lingual flaps were approximated in interproximal area.

Antibiotic therapy (Amoxycillin 250 mg + cloxacillin 250 mg + lactobacillus 60 million spores) for 8 days along with an anti-inflammatory agent for 3 days was prescribed post-operatively. Patients were asked to follow dietary instructions strictly and perform adequate plaque control by rinsing with 10 ml of 1% betadine mouth rinse twice daily for 2 weeks post-operatively.

Post-operative assessments were performed and measurements were recorded at 3 and 6 months and photographs were taken.

  Case Reports Top

Case 1

Patient with age 25/F with Miller's Class II isolated GR i.r.t 13 was selected. On clinical examination, the dimensions of GR (from CEJ to the gingival margin [GM]) were recorded 3 mm in depth. The CAL (from CEJ to base of the pocket) was 4 mm and PD (from GM to base of the pocket) was 1 mm. After scaling and root planning, the coronally repositioned flap with highly resorbable collagen membrane was done i.r.t 13 [Figure 1], [Figure 2], [Figure 3], [Figure 4] and [Figure 5]. Regular check-ups demonstrated the root coverage and CAL remained stable at 3 and 6 months. Patient maintained good oral hygiene and PD in mid facial surface of treated tooth was normal (1 mm) throughout 3 and 6 months follow-up [Figure 6] and [Figure 7].
Figure 1: Pre-operative site with gingival recession in relation to right upper canine

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Figure 2: The root planning and flattening of the root surface being done with rotary instruments

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Figure 3: The coronally displaced flap

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Figure 4: The dehiscence defect covered with bilayer resorbable collagen membrane

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Figure 5: The sutured coronally repositioned flap

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Figure 6: The operated site 3 months post-operative

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Figure 7: The operated site 6 months post-operative

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Case 2

28/F was treated for Miller's Class II isolated GR i.r.t 43. The dimensions of GR were 5 mm in depth. The CAL was 7 mm and PD was 2 mm. Similar surgical procedures were performed and satisfactory root coverage of 3 mm was obtained [Figure 8], [Figure 9] and [Figure 10]. The results remained unchanged during the clinical follow-up of 6 months.
Figure 8: Pre-operative site with gingival recession in relation to the right lower canine

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Figure 9: The operated site 3 months post-operative

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Figure 10: The operated site 6 months post-operative

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  Discussion Top

The predictable root coverage remains an elusive goal of periodontal therapy. The dental literature is replete with a variety of periodontal plastic procedures that have been developed and have shown varying results in correcting the GR. Most of them eventually culminated in healing with a long junctional epithelium and/or with minor amounts of connective tissue attachment which may give a good clinical result, but fail to satisfy the goal of regeneration. [6],[7],[8],[9]

With the advent of a method like GTR, the regeneration of periodontium is being achieved more predictably. [10],[11],[12],[13]

The GTR membrane may also serve to relieve the functional stresses on the gingival flap, which might otherwise disrupt the fragile adhesions of the maturing fibrin clot to the root during the early surface and most critical phase of healing. [13],[14],[15]

Many investigators have utilized non-absorbable and resorbable barrier membrane over the time.

Collagen is a primary structural protein of connective tissue and is well-tolerated by the surrounding tissues. Being semi-permeable, it allows the nutrient passage, gaseous exchange and supports cell proliferation through its lattice such as structure and cell binding domains. Collagen is hemostatic, possesses an ability to stimulate platelet attachment and to enhance fibrin linkage, which may facilitate initial clot formation and clot stabilization, leading to enhanced regeneration. Another useful benefit of collagen is that it might augment the tissue volume as it is naturally absorbed and replaced by host tissue. [14],[15],[16],[17]

In this study, pre-operative recession of 3 mm has shown the complete root coverage as compared to 5 mm, which is also supported by Boltchi et al. 2000 who indicated that shallow recession defects (<4.0 mm) better clinical outcome than deep clinical recession defects (>4.0 mm). [18]

A significant root coverage has been seen in this study and this finding is concurrent with Burns et al. 2000, [19] Peacock et al. 2001, [20] Kimble et al. 2004, [21] Cardaropoli et al. 2012. [22]

  Conclusion Top

The present study demonstrated that coronally repositioned flap when combined with highly purified resorbable membrane is an effective treatment modality for treatment of GR in esthetic areas of the mouth. To further confirm the use of collagen membrane as a good alternative for the treatment of GR, more longitudinal studies are required in this field of periodontal plastic surgery.

  References Top

1.Tugnait A, Clerehugh V. Gingival recession-its significance and management. J Dent 2001;29:381-94.  Back to cited text no. 1
2.Melcher AH. On the repair potential of periodontal tissues. J Periodontol 1976;47:256-60.  Back to cited text no. 2
3.Nyman S, Lindhe J, Karring T, Rylander H. New attachment following surgical treatment of human periodontal disease. J Clin Periodontol 1982;9:290-6.  Back to cited text no. 3
4.Al-Hamdan K, Eber R, Sarment D, Kowalski C, Wang HL. Guided tissue regeneration-based root coverage: Meta-analysis. J Periodontol 2003;74:1520-33.  Back to cited text no. 4
5.Bio-Gide Product Geistlich Biomaterials Innovation of Geistlich. regeneration by nature.  Back to cited text no. 5
6.Hiatt WH, Stallard RE, Butler ED, Badgett B. Repair following mucoperiosteal flap surgery with full gingival retention. J Periodontol 1968;39:11-6.  Back to cited text no. 6
7.Listgarten MA, Rosenberg S, Lerner S. Progressive replacement of epithelial attachment by a connective tissue junction after experimental periodontal surgery in rats. J Periodontol 1982;53:659-70.  Back to cited text no. 7
8.Stahl SS, Froum SJ, Kushner L. Periodontal healing following open debridement flap procedures. II. Histologic observations. J Periodontol 1982;53:15-21.  Back to cited text no. 8
9.Bowers GM, Chadroff B, Carnevale R, Mellonig J, Corio R, Emerson J, et al. Histologic evaluation of new attachment apparatus formation in humans. Part I. J Periodontol 1989;60:664-74.  Back to cited text no. 9
10.Trombelli L, Minenna L, Farina R, Scabbia A. Guided tissue regeneration in human gingival recessions. A 10-year follow-up study. J Clin Periodontol 2005;32:16-20.  Back to cited text no. 10
11.Sculean A, Nikolidakis D, Schwarz F. Regeneration of periodontal tissues: Combinations of barrier membranes and grafting materials-biological foundation and preclinical evidence: A systematic review. J Clin Periodontol 2008;35:106-16.  Back to cited text no. 11
12.Hitti RA, Kerns DG. Guided bone regeneration in the oral cavity: A review. Open Pathol J 2011;5:33-45.  Back to cited text no. 12
13.Bottino MC, Thomas V, Schmidt G, Vohra YK, Chu TM, Kowolik MJ, et al. Recent advances in the development of GTR/GBR membranes for periodontal regeneration: A materials perspective. Dent Mater 2012;28:703-21.  Back to cited text no. 13
14.Wikesjö UM, Nilvéus RE, Selvig KA. Significance of early healing events on periodontal repair: A review. J Periodontol 1992;63:158-65.  Back to cited text no. 14
15.Bunyaratavej P, Wang HL. Collagen membranes: A review. J Periodontol 2001;72:215-29.  Back to cited text no. 15
16.Wang HL, Carroll MJ. Guided bone regeneration using bone grafts and collagen membranes. Quintessence Int 2001;32:504-15.  Back to cited text no. 16
17.Patino MG, Neiders ME, Andreana S, Noble B, Cohen RE. Collagen as an implantable material in medicine and dentistry. J Oral Implantol 2002;28:220-5.  Back to cited text no. 17
18.Boltchi FE, Allen EP, Hallmon WW. The use of a bioabsorbable barrier for regenerative management of marginal tissue recession. I. Report of 100 consecutively treated teeth. J Periodontol 2000;71:1641-53.  Back to cited text no. 18
19.Burns WT, Peacock ME, Cuenin MF, Hokett SD. Gingival recession treatment using a bilayer collagen membrane. J Periodontol 2000;71:1348-52.  Back to cited text no. 19
20.Peacock ME, Cuenin MF, Mott DA, Hokett SD. Treatment of gingival recession with collagen membranes. Gen Dent 2001;49:94-7.  Back to cited text no. 20
21.Kimble KM, Eber RM, Soehren S, Shyr Y, Wang HL. Treatment of gingival recession using a collagen membrane with or without the use of demineralized freeze-dried bone allograft for space maintenance. J Periodontol 2004;75:210-20.  Back to cited text no. 21
22.Cardaropoli D, Tamagnone L, Roffredo A, Gaveglio L. Treatment of gingival recession defects using coronally advanced flap with a porcine collagen matrix compared to coronally advanced flap with connective tissue graft: A randomized controlled clinical trial. J Periodontol 2012;83:321-8.  Back to cited text no. 22


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]


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