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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 41-44

Esthetic management of multiple gingival recession by Zucchelli's coronally advanced flap with bioabsorbable collagen membrane


Department of Periodontology and Implantology, Government Dental College and Hospital, Patiala, Punjab, India

Date of Submission26-Jul-2019
Date of Acceptance11-Nov-2019
Date of Web Publication16-Jul-2020

Correspondence Address:
Dr. Sachin Dhingra
Department of Periodontology and Implantology, Government Dental College and Hospital, Patiala, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_35_19

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  Abstract 


The importance of esthetics is increasing for the patients as well as for the dentist. Gingival recession is one of the most common causes of unesthetic appearance. Hence, it is important to maintain a balance between pink and white components. Various techniques have been used to cover gingival recession in the past. Coronally advanced flap (CAF) is most commonly performed among the free pedicle tissue grafts. This case report describes the esthetic treatment of multiple gingival recession by Zucchelli's CAF with bioabsorbable collagen membrane.

Keywords: Collagen membrane, coronally advanced flap, esthetic, gingival recession, Zucchelli's


How to cite this article:
Dhingra S. Esthetic management of multiple gingival recession by Zucchelli's coronally advanced flap with bioabsorbable collagen membrane. Int J Oral Health Sci 2020;10:41-4

How to cite this URL:
Dhingra S. Esthetic management of multiple gingival recession by Zucchelli's coronally advanced flap with bioabsorbable collagen membrane. Int J Oral Health Sci [serial online] 2020 [cited 2020 Oct 25];10:41-4. Available from: https://www.ijohsjournal.org/text.asp?2020/10/1/41/289877




  Introduction Top


In recent years, the importance of esthetic zone is increasing for the patients as well as for the dentist. It is not only limited to the morphology of teeth anymore but gingiva also plays a key role by the amount of teeth that it covers. The operator needs to keep in mind that it is important to maintain the balance between pink and white while planning the treatment. In periodontal practice, the imbalance between pink and white components is encountered on a regular basis. Some patients seek treatment for the same, while others are unaware of the condition until they visit the dentist. Covering gingival recession is not a new concept. Various techniques have been used such as free gingival autograft, free connective tissue autograft, free pedicle autograft (laterally positioned and coronally positioned), and subepithelial connective tissue graft or combination of these.[1] Coronally advanced flap (CAF) is the most commonly performed among the free pedicle tissue grafts. This case report describes the esthetic treatment of multiple gingival recession by Zucchelli's CAF with bioabsorbable collagen membrane.


  Case Report Top


A 32-year-old male patient reported to the Department of Periodontology, Government Dental College and Hospital, Patiala with the chief complaint of receding gums in the right upper back region for 12 months. There was no relevant medical history or family history. The patient was working in Indian railways, nonsmoker and did not use tobacco in any form, brushed twice daily with vigorous horizontal motion, which was found to be the cause of the condition.

Examination

On clinical examination, gingival recession on multiple sites was noted involving right side maxillary incisors, canine, and first premolar with clearly demarcated cementoenamel junction (CEJ) as shown in [Figure 1]a. The marginal gingiva was not extending beyond the mucogingival junction (MGJ). Gingival biotype was found to be thick with at least 2–3 mm of attached gingiva present. The oral hygiene of the patient was good with least amount of plaque and calculus. On interdental probing, 0–2 mm of pocket depth was found in the region of interest with minimal amount of bleeding. A diagnosis of Miller's Class I recession was made on the basis of clinical observations.
Figure 1: (a) Preoperative clinical photograph. (b) Schematic diagram of anatomical and surgical papillae. Anatomical papillae in red colour and Gingival Margin is marked with black line. (c) Clinical photograph after periodontal dressing and suture removal on day 12. (d) Clinical photograph on 6 month follow up

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Treatment plan

Surgical treatment was planned keeping in mind the desires of the patient regarding esthetics and function. On the basis of clinical examination, Zucchelli's CAF was planned to cover the gingival recession. CAF is the most common type of flap used to cover the gingival recession with good results. This type of flap has the advantage of providing good esthetic results because it advances the adjacent tissue present apically to the recession.

Surgical procedure

The patient was explained the treatment plan along with risks and benefits and informed consent was obtained. Oral prophylaxis was done before surgical treatment.

Preanesthetic medication was given to the patient 1 h before the surgery. The whole procedure was carried under a stress-free environment. Perioral and intraoral structures were disinfected using 2% povidone-iodine solution. The area of interest was anesthetized using 2% lignocaine HCl with 1:200,000 epinephrine.

With the help of explorer, CEJ was located on each tooth from the right maxillary central incisor to the second premolar of the same arch. The right maxillary canine was selected as the central tooth. An oblique submarginal incision was made with the help of no. 15c B. P. blade starting from the central tooth to central incisor and then up to second premolar as shown in [Figure 2]a.
Figure 2: (a) Oblique submarginal incision from right central incisor to the right second premolar. (b) A combined full and partial thicknesses flap raised. (c) Root planing with the help of curettes. (d) Ethylenediaminetetraacetic acid applied with the applicator brush. (e) De-epithelization of anatomical papillae. (f) A collagen membrane placed 1mm apical to the cementoenamel junction. (g) Interrupted sling suturing done. (h) Periodontal dressing placed

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The oblique submarginal incision was given in a way that it extend interdentally from the CEJ of the central tooth to the gingival margin of the adjacent tooth on each side till the last tooth selected.

Then, intrasulcular incision was given along the gingival margin of each tooth. A split-thickness flap was then raised dividing the interdental papilla into surgical papilla and anatomical papilla as shown in [Figure 1]b. A full-thickness flap was raised from the papillary region to the MGJ, and the underlying muscular attachments were detached from the periosteum keeping the blade parallel, as shown in [Figure 2]b. Root planing of the previously exposed cementum was done with the help of a curette, as shown in [Figure 2]c. Ethylenediaminetetraacetic acid (EDTA) was applied to the root surfaces for 2 min and then rinsed copiously as shown in [Figure 2]d. The anatomic interdental papillae were de-epithelized to create connective tissue beds where surgical papillae were positioned later on as shown in [Figure 2]e. The flap was then repositioned coronally to check the passivity. In case the flap does not rest passively on the CEJ, raise the flap even more apically and detach the muscular attachment as before and then check again. After the passive check of the flap, a collagen membrane was placed 1 mm apical to the CEJ of all the teeth, as shown in [Figure 2]f. The area was rinsed with normal saline and chlorhexidine 0.2%, and interrupted sling suturing was done with periodontal dressing placed over it as shown in [Figure 2]g and h. Postoperative instructions were given. Periodontal dressing and sutures were removed after 12 days, as shown in [Figure 1]c. Regular follow-ups were done, as shown in [Figure 1]d.


  Discussion Top


This case report talks about the esthetic management of multiple gingival recession by Zucchelli's CAF with bioabsorbable collagen membrane. Gingival recession is one of the most common clinical condition encountered by the periodontist. However, not all cases can be considered for surgical management. Both esthetics and functional aspects should be taken into consideration prior to the treatment. The predictability of the outcome of the treatment should match patient's desires and aspirations. According to Miller's classification, complete root coverage can be achieved in cases of Miller's Class I and II recession defects.[2] Over the years, gingival recession coverage has been done by a number of procedures including coronally or laterally positioned pedicle grafts (Robinson 1964, Tarnow 1986, Allen and Miller 1989), rotational flaps (Harvey 1965), epithelialized free tissue grafts (Miller 1982), connective tissue grafts (Edel 1974, Miller 1993), etc., CAF is the most commonly performed among the free pedicle tissue graft which was introduced by “Norberg” (1926).[3] Zucchelli's CAF is a modification of CAF with advantages over the conventional technique.[4] Characteristic features of this technique are the absence of vertical releasing incisions (which does not compromise the blood supply and no postoperative scar formation), a variable thickness of the flap combining areas of split- and full-thickness (advantage of placing the full-thickness flap over the previously exposed root surface) and the coronal repositioning of the flap with oblique submarginal incisions in the interdental area (shape of original papillae can be achieved). A bioabsorbable collagen membrane was used in the present case report which has the advantage of gaining new attachment and more stable long-term results.[5] Oral health-related quality of life is also found to be improved in long-term basis using this technique.[6]


  Conclusion Top


There are a number of techniques used for covering the gingival recession, and new techniques are constantly being developed, which are slowly being adopted into clinical practice. Periodontist should be aware of new methods and techniques published in the literature. Although the technique described in the present case report is not very new, still need more awareness amongst the periodontists. In the present case report, Zucchelli's CAF is found to be very effective for the treatment of multiple gingival recessions. Results obtained were stable in terms of root coverage, increased the thickness of attached gingiva. However, regular follow-up recalls are necessary to evaluate oral hygiene and stability of the periodontal treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to b'e reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Padma R, Shilpa A, Kumar PA, Nagasri M, Kumar C, Sreedhar A. Asplit mouth randomized controlled study to evaluate the adjunctive effect of platelet-rich fibrin to coronally advanced flap in miller's class-I and II recession defects. J Indian Soc Periodontol 2013;17:631-6.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8-13.  Back to cited text no. 2
    
3.
de Sanctis M, Zucchelli G. Coronally advanced flap: A modified surgical approach for isolated recession-type defects: Three-year results. J Clin Periodontol 2007;34:262-8.  Back to cited text no. 3
    
4.
Zucchelli G, De Sanctis M. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol 2000;71:1506-14.  Back to cited text no. 4
    
5.
Banihashemrad A, Aghassizadeh E, Radvar M. Treatment of gingival recessions by guided tissue regeneration and coronally advanced flap. N Y State Dent J 2009;75:54-8.  Back to cited text no. 5
    
6.
Aggarwal T, Dhingra S, Gupta H. Zucchelli's coronally advanced flap as treatment of multiple gingival recession and its effect on oral heath related quality of life: A case report. Int J Curr Res 2019;11:2531-4.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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