|Year : 2013 | Volume
| Issue : 2 | Page : 98-100
Palatal gingival recession treated with connective tissue graft
Deepa Dhruvakumar, Priyanka Srivastava
Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh, India
|Date of Web Publication||4-Jul-2014|
Department of Periodontology, Subharti Dental College and Hospital, Delhi-Haridwar By-Pass Road, Meerut - 250 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Labial and buccal gingival recession is a common finding in the adult population that occurs due to various etiologies. When present, it can lead to unaesthetic appearance and also cause hypersensitivity. However, very limited literature is available quoting the incidence of palatal gingival recessions and, sometimes, it can go unnoticed during routine clinical examinations. These too can cause sensitivity and also pose a technical challenge in surgical correction due to poor accessibility and visibility when present. Herein, we report a case of palatal gingival recession treated successfully by connective tissue graft.
Keywords: Connective tissue graft, gingival recession, palatal gingival recession, periodontal plastic surgery
|How to cite this article:|
Dhruvakumar D, Srivastava P. Palatal gingival recession treated with connective tissue graft. Int J Oral Health Sci 2013;3:98-100
| Introduction|| |
Harmonious and symmetric alignment of the teeth with a consistent shape and size is essential for a healthy gingival position. Gingival recession is often associated with unpleasing esthetics, root hypersensitivity and fear of tooth loss. In cases of Miller Class I and II recessions, where the level of periodontal proximal tissues are not affected, it can be predictably covered by various periodontal plastic surgical procedures, including pedicle flaps, subepithelial connective tissue grafts (CGs), acellular dermal matrix grafts and guided tissue regeneration.  Based on the absence of reporting on any palatal lesions, it would seem reasonable to assume that no palatal lesions were included in earlier clinical studies. 
There are many factors that can complicate treating palatal recession defects. Probably the most important factor is whether or not a palatal recession defect ever needs to be treated. Certainly, there are no esthetic concerns in this region. Also, there is always an abundant amount of keratinized tissue present in the area. In addition, there are many technical factors that make treatment of palatal recession defects difficult. The tissue surrounding a palatal recession defect cannot be coronally or laterally repositioned as a pedicle graft or to cover a connective tissue graft. Access to perform surgical therapy to the area can be difficult. Protecting the area from trauma during the healing period can be less predictable than when treating buccal recession defects. Despite these limitations, there are situations where treatment of a palatal recession defect may be indicated. 
This article reports a case of palatal gingival recession on the maxillary left central incisor successfully treated with the connective tissue graft.
| Case Report|| |
A 38-year-old male patient presented to the Department of Periodontology, Subharti Dental College and Hospital, Meerut, Uttar Pradesh with a chief complaint of hypersensitivity in the upper anterior teeth region. The patient was a non-smoker. On intra-oral examination, the patient's oral hygiene was excellent in most areas, with minimal bleeding on probing. Palatal gingival recession measuring around 4 mm was present #21. There was no loss of papilla height on the mesial or distal of #21. There was an increased thermal sensitivity on the palatal surface of #21. There were no other periodontal concerns except slight mobility #21. The patient was in good health, with no contraindications to surgical periodontal therapy.
After the phase-I therapy, connective tissue graft procedure was planned. An informed consent form was signed by the patient. Under local anesthesia, the exposed root was thoroughly planed. Intra-sulcular incisions were made at the palatal gingival sulcus of both the left central incisor and the lateral incisor, and the palatal muco-periosteal flap was elevated. Then, a pouch was created to enable the placement of connective tissue graft. The free connective tissue graft was obtained from the left side of the palate using a trap door approach proposed by Langer and Langer.  The graft was at least as wide as the pouch created and thick enough to assure the sufficient papillary space fill. A sling suture was placed in the graft, entering through the graft, and then the palatal flap using a 5-0 silk suture without tension [Figure 1],[Figure 2] and [Figure 3]. Post-operative antibiotic amoxicillin 500 mg three times daily for 5 days, non-steroidal anti-inflammatory drug ibuprofen three times daily and chlorhexidine rinses twice daily was advised. The sutures were removed after 14 days. The graft had completely survived with 100% root coverage and epithelization without even color mismatch [Figure 4]. Clinically, the grafted tissues seemed to be attached to the root surfaces. This technique resulted in a significant gain in the papillary volume along with complete coverage of the palatal gingival recession#21. The patient was instructed to clean the area with a soft end-tufted brush. The patient was followed for a period of 3 months, with oral hygiene reinforcement at each subsequent visit.
|Figure 1: Pre-operative photograph showing palatal gingival recession #21|
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|Figure 2: Graft placed gently in the pouch without creating excessive tension inside the pouch|
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| Discussion|| |
A wide variety of periodontal plastic surgical procedures have been described to correct mucogingival problems and to cover denuded root surfaces. The clinical studies have proven that the esthetic root coverage is an obtainable goal. However, little has been reported to show root coverage of a palatal root surface. Subepithelial connective tissue graft was first introduced by Langer and Langer  and modified by Harris,  Allen  and Bruno.  It combines the advantages of the pedicle flap procedure and guarantees a double blood supply from both the overlying pedicle flap and the underlying periosteum. Other advantages of connective tissue graft is the good color match with neighboring soft tissues, less invasive palatal wound as well as long-term results in terms of root coverage. 
However, histologic studies on connective tissue grafts show unpredictable results related to the regeneration of periodontal tissues. The histology of the result is unknown because to obtain this information would require the removal of a block section that was considered practically not required for this case. Based on the results of Pasquinelli  and Bruno and Bowers,  there is at least the possibility that some regeneration may have occurred. Contrary to this are the results of Harris, which suggest that regeneration may not have occurred. Clinically, the area appeared healthy. There was a 2 mm sulcus with no bleeding on probing.
There may be limited indications of treating gingival recession for palatal root coverage. Certainly, there are no esthetic demands when treating palatal recession defects. However, there are situations where root coverage is desirable. Some of these situations could be to decrease sensitivity, treat or prevent root caries, eliminate a plaque trap or reestablish a normal gingival contour. The technique used in the present report was to place the base of the connective tissue graft within an "envelope" prepared by an undermining partial-thickness incision from the soft tissue margin, i.e. part of the graft will rest on the root surface coronal to the soft tissue margin.  The technique utilized in this case produced a good clinical result.
| Conclusion|| |
The treatment of palatal gingival recession is technically challenging and has not been routinely reported or is not performed. Predictable root coverage can still be obtained provided the surgery is performed meticulously along with patient compliance and post-operative care.
| References|| |
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|3.||Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20. |
|4.||Harris RJ. The connective tissue and partial thickness double pedicle graft: A predictable method of obtaining root coverage. J Periodontol 1992;63:477-86. |
|5.||Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage. I. Rationale and technique. Int J Periodontics Restorative Dent 1994;14:216-27. |
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|9.||Raetzke PB. Covering localized areas of root exposure employing the "envelope" technique. J Periodontol 1985;56:397-402. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]