The periosteum eversion technique for coverage of denuded root surface.

The periosteum is highly cellular connective tissue with rich vascularity and regenerative potential, which make it suitable autogenous graft. The periosteum eversion technique utilized periosteum for coverage of denuded root surface. The purpose of this case report was to evaluate the periosteum eversion technique that involves a single surgical site, in terms of root coverage, gingival height, and probing depth. A patient with Miller class I gingival recession of 3.0 mm, gingival height of 2.0 mm and probing depth of 2.0 mm was treated by the periosteum eversion technique. Root conditioning was done with 24% ethylenediaminetetra-acetic acid. In this technique, marginal periosteum was used as a pedicle graft. At the end of 6 months, 100% root surface was covered successfully with 5.0 mm of gingival height and 1.0 mm of probing depth. The periosteum eversion technique can be used for the treatment of gingival recession defect successfully.

INTRODUCTION

Gingival margin is clinically represented by a scalloped line that follows the outline of the cementoenamel junction (CEJ), 1–2 mm coronal to it. Gingival recession is defined as an apical shift of the gingival margin with exposure of root surface to the oral cavity.[1] According to the American Academy of Periodontology's 1996 position paper on mucogingival therapy, esthetic demands, reduction of root sensitivity and management of root caries or cervical abrasions are the indications for root coverage.[2] A variety of techniques[3] displaying different degrees of success can be classified as pedicle soft tissue grafts, free soft tissue grafts or a combination of the two. Among the soft tissue grafts, the subepithelial connective tissue graft[4] and the subpedicle connective tissue graft[5] are the most used predictable techniques in the esthetic treatment of soft tissue recessions. Both techniques require a donor site for the connective tissue graft, whichever technique is used (a trap-door approach, a single incision or a parallel incision technique) a second surgical site, usually in the palatal premolar area is needed, therefore increasing patient morbidity. Ideal technique should be technically within the grasp of the periodontist, without requiring a number of learning failures. Additionally, ideal technique should be predictable in producing a result with characteristics as root coverage to the CEJ or the height of papilla mesial and distal to the defect, tissue tightly attached to the root with probing sulcus depth of ≤2 mm, no bleeding on probing, an “adequate” band of keratinized tissue, an acceptable color match to the surrounding tissue and esthetic tissue contour. There should be minimal pain to the patient during the procedure and during the postoperative period and no increase in sensitivity.[6] To obtain these goals and to exploit the advantages of a connective tissue graft, on the other hand, a surgical technique was used, which was originally discovered by Gaggl et al.[7] for coverage of denuded root surface. They utilized marginal periosteum for covering recession. The advantages of the techniques harvesting the marginal periosteum over the free periosteum are the presence of periosteum close to the recession defect in sufficient amount, which to be pedicle to prevent its necrosis and avoid two surgical sites, resulting in less surgical trauma, less postoperative complications with better patient satisfaction. The periosteum is a highly vascular connective tissue sheath covering the external surface of all the bones except sites of articulation and muscle attachment.[8] The periosteum consists of two layers, a thin inner cellular or cambium layer that is adjacent to bone and a thick outer fibrous layer. The inner layer composed of osteoblasts surrounded by osteoprogenitor cells, which have the potential to differentiate into osteoblasts, and the outer layer rich in blood vessels and nerves, composed of dense collagen fibers, fibroblasts and their progenitor cells;[9] hence, the regenerative potential of periosteum is immense. Bundles of periosteal collagen fibers penetrate the bone, binding the periosteum to the bone. In all age groups, the cells of the periosteum retain the capacity to differentiate into fibroblasts, osteoblasts, chondrocytes, adipocytes and skeletal myocytes. The tissues produced by these cells include cementum, bone and periodontal ligament with their fibers.[10] The aim of this case report was to evaluate the periosteum eversion technique that involves a single surgical site, in terms of root coverage, gingival height, and probing depth.

CASE REPORT

A 30-year-old female patient had the complaint of receding gum in lower front tooth region. On intra-oral examination, an isolated Miller class I gingival recession at labial surface of the lower right canine (no. 43) was present due to trauma from occlusion. The recession depth was 3 mm recorded using University of North Carolina-15 periodontal probe-measured from CEJ to the gingival margin [Figure 1]. Gingival height was 2.0 mm when measured from the apical portion of the gingival margin to mucogingival line and probing depth was 2.0 mm as when measured from the bottom of the sulcus to the most coronal end of the gingival margin.

Figure 1

Preoperative clinical situation showing gingival recession in no. 43

The patient underwent basic periodontal treatment of phase I therapy including scaling, root planing and instructions for proper oral hygiene measures. Occlusal therapy including occlusal adjustments or coronoplasty was done for treatment of trauma from occlusion. A coronally directed “roll” technique was advised for tooth with gingival recession to minimize toothbrushing trauma of the gingival margin. Surgical treatment of gingival recession was not scheduled until the patient could able to maintain full mouth bleeding score[11] of ≤20% and full mouth plaque score[12] of ≤20% along with absence of plaque that is, “plaque-free” (area where plaque could not be removed with a manual probe) and bleeding on probing at the surgical tooth site.

Patient was instructed to do presurgical rinse by 0.2% chlorhexidine solution. The facial skin around the mouth was cleaned with spirit and scrubbed by 7.5% povidone iodine solution. Intra-oral surgical site was painted with 5% povidone iodine solution.[13]

After proper part preparation, 2% lignocaine hydrochloride with 1:80,000 adrenaline was administered to anesthetize lingual, labial and inferior alveolar nerves. After local anesthesia, marginal incision was given all along the soft tissue margin of the recession defect. Two lateral vertical incisions along proximal side of recession defect were made, and a mucoperiosteal flap was reflected [Figure 2]. The exposed root surface was cleaned thoroughly by scaling and root planing to remove any root surface deposits. An attempt was made to flatten the root in the area of the root prominence. Root conditioning was done with 24% ethylenediaminetetra-acetic acid for 3 min [Figure 3] and washed with a normal saline solution for 60 s [Figure 4]. A basal incision was given at the baseline to incise the periosteum, and then it was separated from the submucous connective tissue up to the borderline of the attached gingiva. The crestly pedicle periosteum was everted [Figure 5] and transposed coronally where it was sutured with 5–0 absorbable suture [Figure 6]. After that, a coronal transposition of mucoperiosteal flap was done, and it was also sutured with 5–0 absorbable suture [Figure 7].

Figure 2

Reflected mucoperiosteal flap showing denuded root surface and bone

Figure 3

Root conditioning done with ethylenediaminetetra-acetic acid

Figure 4

After root conditioning of denuded root surface

Figure 5

Crestally pedicle everted periosteum

Figure 6

The periosteum transposed coronally over the denuded root surface and sutured

Figure 7

The periosteum covered with overlying mucoperiosteal flap and sutured

Antibiotic (amoxicillin 500 mg, 1 tablet every 8 h, for 7 days) and analgesic (nimesulide 100 mg, 1 tablet every 12 h, for 3 days) were prescribed. Patient was instructed to be extremely cautious during mastication at meals and not to brush the teeth in the treated area for 2 weeks but to use 0.2% chlorhexidine mouthwash twice daily for 1 min. After this period, patient was advised to mechanical cleaning of treated tooth region using an extra soft toothbrush by coronally directed “roll” technique, together with 0.2% chlorhexidine mouthwash twice daily, 1 min for more 4 weeks. After this period, routine oral hygiene procedures could be reintroduced.

Clinical follow-up was performed once a week in the 1st postoperative month, every 2 weeks in the 2nd postoperative month and once a month after that up to 6 months. At each visit, recall programs including professional tooth cleaning and reinforcement of daily oral hygiene measures were done.

Healing was uneventful. Patient was satisfied with the treatment outcome. Complete epithelialization of the everted periosteum was seen 2 weeks after surgery. As the postoperative time increased, the progressive adaptation and morphologic resemblance were observed. After 6 months, 3.0 mm that is, 100% root coverage, 5.0 mm of gingival height and 1.0 mm of probing depth were obtained [Figure 8].

Figure 8

Six months postoperative showing complete root coverage

DISCUSSION

The main aim of periodontal surgery is to achieve healthy and esthetically satisfying periodontal condition. One of the important goals of the periodontist is to obtain predictable root coverage in patient with gingival recession defects using the most appropriate technique.[7] Periosteal pedicle graft for the treatment of gingival recession defect was used by Mahajan.[14] At the end of 1 year, recession defect was completely covered because rich vascularity of periosteum prevents its necrosis and make it a suitable graft over avascular root surface. Buccal grade II furcation defect in lower molar was treated with the periosteal membrane, as a barrier membrane by Verma et al.[15] After 6 months, the mean gain of vertical and horizontal bone level were 1.67 mm and 1.50 mm, respectively. In this study, periosteal membrane maintained its vascular supply as it was attached at one side to the mucoperiosteal flap. This was important for the healing and maintenance of the vital cambium layer that has the potential to stimulate bone formation. Role of space provision in regeneration of localized two-wall intrabony defects using periosteal pedicle graft as an autogenous guided tissue membrane was studied by Singhal et al.[16] After 6 months, they found 48.88% decrease in bone defect area and concluded that space provision by an alloplastic graft material increases the regenerative potential of marginal pedicle periosteum as a guided tissue regeneration membrane and results in increased defect fill. A comparative evaluation of periosteum as a barrier membrane with and without an alloplastic bone graft in periodontal osseous defects was done by Kumar et al.[17] After 9 months, they found that alloplastic graft material supplementation results in better regeneration with the periosteum used as a barrier membrane. The periosteum stimulates the osteogenesis in the periodontally involved area by the ability to stimulate osteogenic factors and provides the wound area with osteoprogenitor cells that may compensate for the deficient cells available in the periodontal defect. In this case report, we choose periosteum eversion technique because the technique is based on using the marginal periosteum as a vascularized transplant graft for root coverage. The periosteum is separated from the mucoperiosteal flap after baseline incision so that the basal part of periosteum is used for defect coverage after eversion. The periosteum remains pedicle in the crestal part and can be elongated and coronally transposed without retraction forces. The vascularized periosteum can be used for defect coverage in a similar way as to a connective tissue graft and can be epithelialized by the neighboring mucosa as a vital and well-vascularized tissue.

The principle of tissue regeneration in this technique is similar to the conventional technique of using connective tissue graft in combination with transposition flap and thus results of the periosteum eversion technique should be comparable with the results of conventional techniques. In this case report of periosteum eversion technique 3.0 mm that is, 100% root coverage was obtained after 6 months that was similar to subepithelial connective tissue graft[4] in which 2–6 mm of root coverage was reported, but this technique surpassed the result of the subpedicle connective tissue graft[5] in which the average root coverage of 88% was reported.

The evaluation period used in this case report was 6 months from last surgical treatment because this period is considered adequate to provide soft tissue maturity and stability as reported in systematic reviews[18] dealing with root coverage procedures.

The advantages of the periosteum eversion technique in comparison to all other techniques using the free soft tissue graft are no donor site morbidity, periosteum harvested as much as required because periosteum exits in every location of alveolar bone and lowest risk of infection, necrosis, and graft removal because well-vascularized periosteum has the possibility to react to bacterial contamination like any other vital tissue. A study showed that periosteal cells release vascular endothelial growth factor.[19] Periostin is a recently identified protein that is termed so because it was initially identified in the periosteum. It is secreted cell adhesion protein that is 90 kDa in size. Structurally, it is a disulfide-linked protein that favors osteoblast attachment and spreading. Osteoblast attachment is mediated through the presence of αvβ3 and αvβ5 integrins that are upregulated in the presence of periostin. Osteoblasts produce type I collagen, noncollagenous proteins (osteocalcin, osteopontin, and osteonectin) and various glycoproteins. They also produce cytokines and growth factors like bone morphogenic proteins (BMPs) as BMP-2 and BMP-7, transforming growth factor-β, insulin-like growth factor and platelet-derived growth factor that take part in the regeneration.[20]

As like in any study, this study of case report of the periosteum eversion technique has certain limitations. The technique, although simple, needs surgical dexterity for the operator, especially during the reflection of periosteum, which is firmly attached to the underlying bone and during the separation of periosteum from submucous connective tissue as there may be chances of tear or perforation of flap.

CONCLUSION

Based on the results obtained, it can be concluded that the periosteum eversion technique is the predictable technique for the treatment of gingival recession. The main advantage of this technique is that periosteum remains vascularized and that there is no donor site morbidity. The biological mechanisms of tissue regeneration caused by the periosteum eversion technique have to be examined in further studies.