Esthetic dentistry for multiple gingival recession cases: Coronally advanced flap with bracket application.

Treatment of gingival recession is essential to rectify the esthetic and functional deficiencies of the patient and to combat further periodontal destruction. However, treating multiple recession cases is quite challenging, and therefore requires constant modifications of the prevalent treatment strategies as per the severity of the condition. The objective of this case report was to evaluate the effectiveness of coronally advanced flap (CAF) technique without vertical incisions using CAF brackets (CAF+B) for treating a patient presenting with class II gingival recession defects in relation to maxillary anteriors. Complete root coverage was observed, and the results were consistent even after 6 months. The current case report demonstrates good outcomes of the CAF + B technique without the use of any additional soft tissue grafts or vertical incisions, therefore, endorsing the promising potential of the CAF + B technique in multiple gingival recession cases.

INTRODUCTION

Gingival recession, i.e., apical migration of gingival margin leading to exposure of root surface or unaesthetic elongation of the crown portion of tooth, as generally addressed by laymen, usually presents in a localized or generalized pattern. Cosmetic correction of gingival recession is necessary, not only to cater to the esthetic concerns of the patient but also to prevent root caries, plaque calculus accumulation, abrasion, and hypersensitivity, as well as to improve the overall oral health of the patient. Yet, according to a survey conducted by the American Academy of Cosmetic Dentistry for better understanding the dynamics of the cosmetic dentistry and its impact, 96% of the respondents indicated “appearance” as the issue of their primary concern, and the survey also reported an increase in the percentage of patients electing for cosmetic dentistry as compared to previous years.[1] This growing interest of patients in dental esthetics has compelled the dental surgeons and researchers to be in a constant pursuit of developing treatment strategies that would create or restore patient's confident smile.

One of the most challenging of these dental cosmetic interventions is periodontal plastic surgery, which aims at achieving complete root coverage. Persistent search over the ages has led to the innovation of innumerable techniques to treat gingival recession, which have been frequently modified and customized according to the situation, and degree of recession, and various other factors, especially when considering treatment planning for multiple adjacent recession-type defects (MARTD). In MARTD, as the area of surgical operation is multiple, it is important that the technique to be used must be practically easy, must not take a long time, and should not require second operation area.[2]

Keeping in mind the abovementioned factors, a modified coronally advanced flap (CAF) technique was proposed by Zucchelli and De Sanctis in 2000[3] for MARTD, yet, it was accompanied with an unaesthetic white scar formation at the area of vertical incisions. To avoid this unaesthetic keloid formation along the vertical releasing incisions, the technique was further improvised, and the flap was advanced coronally without vertical incisions, which was further associated with an increased probability of achieving complete root coverage and with a better postoperative course.[4]

Apart from this, maintaining the most possible coronal position of gingival margin during early healing period is one of the most critical factors determining the surgical outcome. Correspondingly, to maximize the stabilization of the immediate postoperative flap location, Ozcelik et al. in 2011 additionally used orthodontic buttons to secure the flap in most coronal position and reported complete root coverage in 84% of the defects in CAF with button application (CAF+B) group as compared to 61% defects in CAF group.[2] Subsequently, many case reports following CAF+B technique have been reported satisfactorily to complete root coverage in cases involving recession on one or few adjacent teeth.[567]

The objective of this case report was to coronally advanced flap without the use of any additional soft tissue grafts or vertical incisions using brackets (CAF+B) for treating a patient presenting with class II gingival recession defects in relation to maxillary anteriors.

CASE REPORT

A systemically 36-year-old healthy male patient reported to the Department of Periodontics, Babu Banarasi Das College of Dental Sciences, Lucknow, with the chief complaint of visible root exposure of upper front teeth while smiling. The patient's oral and general health was assessed, and intraoral examination of the patient revealed multiple recession defects, however, his chief concern was related to the display of gingival recession in relation to maxillary anteriors [Figure 1]. The area 13–23 (maxillary right and left canine, right and left lateral incisor, and right and left central incisor) was presented with Miller's class II recession on the buccal aspect, yet, the periodontal parameters and orthopantomogram revealed healthy periodontium in this region. The patient gave a history of improper brushing technique, which resulted in gingival recession further aggravated by the buccal proclination of teeth and patient's 6 years of smoking habit, which the patient affirmed, he had ceased 1 year ago. Oral hygiene instructions and education were given to the patient. Complete scaling and root planning was done and the patient was recalled after 4 weeks to commence the mucogingival surgery. Before surgery, i.e. after initial treatment at baseline and 6 months after surgery, the following clinical parameters were recorded: (1) Gingival recession width was measured as the distance between the mesial and the distal gingival margin of the tooth at an imaginary horizontal line tangential at the cemento-enamel junction (CEJ); (2) gingival recession depth measured as the distance between the most apical point of the CEJ and the gingival margin; (3) probing depth measured as the distance from the gingival margin to the bottom of the gingival sulcus at distofacial, facial, mesiofacial, distolingual, lingual, and mesiolingual sites using University of North Carolina 15 probe; (4) clinical attachment level measured as the distance from the CEJ to the bottom of the sulcus.

Figure 1

Recession on 11, 12, 13, 21, 22, and 23

Prior to surgery, brackets were bonded to the teeth no. 13–23. Surgery was started with a crevicular incision given in region 14–24 using no. 12 blade; care was taken to preserve as much tissue as possible while de-epithelializing interdental papillae to reflect the flap. No vertical incisions were given and a full thickness flap on the facial aspect was reflected exposing not more than 2 mm of alveolar bone, beyond this the flap was undermined to be reflected as a split thickness flap and also to release tension on the flap when it will be coronally advanced, i.e., a split-full-split thickness flap was raised during the surgery [Figure 2]. The flap was then effortlessly advanced beyond the CEJ toward the brackets and suspended by sutures using brackets as anchors [Figure 3a and b]. Interdental interrupted sutures were also given to further stabilize and secure the flap. A Coe-pack dressing was given to safeguard the flap and the brackets. The patient was prescribed medications and discharged with postoperative instructions. At the follow-up visit after 1 week, the older Coe-pack dressing was replaced with a new one, and after 2 weeks, the Coe-pack was removed, sutures were cut, and the brackets were debonded. The region 13–23 showed remarkable complete root coverage and the patient was completely satisfied with the results [Figure 4]. Results for this case have been summarized in Table 1. Oral hygiene instructions were reinforced, and consistent results were observed even after 6 months follow-up, which substantiated satisfactory long-term outcome of the CAF+B procedure [Figure 5]. The patient was henceforth advised to undergo gingivoplasty procedure in the maxillary anterior region for further enhancement of esthetics.

Figure 2

Flap reflected

Figure 3

(a) Passively placed coronally advanced flap, (b) after suturing

Figure 4

Complete root coverage after 2 weeks

Table 1

Periodontal parameters at baseline and 6 months for region 13-23

Figure 5

After 6 months follow-up

DISCUSSION

Various procedures such as free gingival graft, connective tissue graft, and tunnel technique have been developed to treat multiple gingival recession defects.[8] These techniques require harvesting soft tissue autograft from the donor site (e.g., palate) and stabilizing them at the recipient site (recession defect), generally constraining the patient to forgo the surgery due to the fear of associated second (donor) site morbidity. Furthermore, the results attained depend profoundly on the quality and quantity of graft harvested from the donor site, to procure which becomes extremely challenging, especially, for multiple recession cases. Apart from the limitations of graft inadequacy and second site morbidity, these procedures are also associated with other shortcomings such as technique sensitivity (Any technical flaw can lead to the graft necrosis and scarring of the site.) and unpredictable esthetics (The color of the graft might not match with the recipient site.). In order to overcome these limitations, several soft tissue allograft alternatives (like alloderm) have been introduced, yet, they prove to be very expensive. Hence, considering all these inadequacies CAF wherein vertical incisions are given, and full thickness flap is advanced coronally to cover the root, can be postulated as one such technique, which fits best for the treatment of multiple recession. This technique has been further customized to avoid vertical incisions that could hinder blood supply to the flap and ultimately could even lead to keloid formation.[4]

In the present case report, the modified CAF technique was employed and additionally secured with bracket application to achieve predictable results. Ozcelik et al., in 2011, evaluated the effectiveness of this new treatment approach, using orthodontic buttons for the treatment of multiple recession-type defects and reported very high patient satisfaction with esthetics in CAF+B group when compared with CAF group. Ozcelik et al. further demonstrated mean root coverage of the sites in CAF+B group, and the CAF group from baseline to 6 months after surgery to be 96.2% and 89.1%, respectively, with complete root coverage seen in 84.6% of the sites treated by the CAF+B compared to 61.1% treated with the CAF alone.[2]

Fatima et al. further achieved recession coverage and even bone gain between maxillary central incisors on using CAF+B technique along with membrane and bone graft.[5] Complete root coverage was also reported on the maxillary canine tooth at 3 months following CAF+B technique by Maroo et al.[6]

Remarkably, in the current case report, 100% root coverage was achieved at all the maxillary anterior teeth following this technique, with results consistent even after 6 months, which can also be contributed to the presence of adequate width of attached gingiva, and the absence of any alveolar bone defect in the maxillary sextant of the patient, as well as to the excellent patient compliance. This procedure has also been validated as a promising technique in terms of both clinical- (root coverage, keratinized tissue height, and minimum surgical time) and patient-centered (minimum surgical time and esthetics) parameters.[56] Since this approach accomplishes optimum root coverage and recuperation of the original morphology of the gingival margin along with good color matching,[9] esthetically pleasing results could be achieved as seen in the current case report. Yet, the technique is not without limitations, the major limiting factor being a lack of adequate width of keratinized and attached gingiva along with the requirement for a considerable amount of vestibular space adjacent to the recession defects. The presence of these limiting factors further necessitates the use of additional soft tissue grafts. Therefore, careful analyses of patient- and defect-related factors, however, are key considerations prior to selecting an appropriate surgical technique,[10] so is the case with CAF+B, which is best suited to class I, II recession defects with adequate amount of attached gingiva.

CLINICAL RELEVANCE

Increased patient awareness of dental esthetic procedures has increased the demand as well as the responsibility of cosmetic dentists to exhibit outstanding skills and create pleasing results. The current case report endorses the promising potential of CAF+B technique in multiple gingival recession cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest