Periodontal microsurgery for management of multiple marginal tissue recession using Zucchelli's modification of coronally advanced flap and pericardium membrane in an esthetic zone.

Marginal tissue recession (MTR) by definition is an apical shift of gingival margin, which leads to exposure of root surface. Patients affected with MTR often complain of sensitivity to cold on exposed root surfaces apart from esthetic concerns. In this article, a case of multiple Miller's class I MTR who presented with sensitivity to cold in relation to maxillary anterior teeth region was treated using Zucchelli's coronally advanced flap with pericardium membrane under operating microscope. The application of principles of periodontal microsurgery and guided tissue regeneration results in significant root coverage with reduction/elimination of sensitivity. Long-term success of root coverage procedures depends on the removal of etiology and maintenance therapy.

INTRODUCTION

Periodontal plastic surgery is a continuously evolving field in periodontology. These surgical procedures are performed to prevent or correct anatomic, developmental, traumatic, or disease-induced defects of the gingiva, alveolar mucosa, or bone. Marginal tissue recession (MTR) by definition is the location of the gingival margin apical to the cementoenamel junction.[1] MTR may affect single tooth or involve multiple teeth. It has been considered the most common mucogingival problem which affects a large number of patients worldwide. In the United States, a survey of adults estimated that 23% of adults have one or more tooth surfaces with 3 mm or more MTR.[2] On an average, up to 40% of young adults and up to 88% of older adults have been found with at least one site with 1 mm or more of recession. The prevalence, extent, and severity of MTR depend on multiple factors which are confounded by poorly defined predisposing and precipitating factors.[34] Predisposing factors for MTR are tooth malposition, bone dehiscence, inadequate keratinized/attached mucosa, thin phenotype, dehiscence, fenestration, and frenum pull. Precipitating factors consist of habits (e.g., smoking and oral piercing), traumatic forces (e.g., excessive brushing), plaque-induced inflammation, and dental treatment (e.g., certain types of orthodontic tooth movement, subgingival restorations).[5] Whenever MTRs present in the anterior region, it may lead to esthetic problems due to excessively long-appearing teeth. A high smile line further complicates the disharmony. Sometimes, root exposure may lead to severe dentine hypersensitivity which consequently causes discomfort and/or difficulty in maintaining oral hygiene. Such receded gingival margins with the irregular outline may render plaque control more problematic for the patient, even in the absence of tooth hypersensitivity. The selection of any surgical technique for the management of MTR depends on numerous factors, some of which are related to the defect, whereas others are related to the patient. Patient-related factor includes minimum postoperative discomfort and improved esthetics. The selection of the most appropriate surgical technique is critical for simultaneous root coverage of multiple recession defects affecting adjacent teeth in esthetic areas of the mouth when associated with sensitivity to cold and difficulty in maintaining plaque control. Management of multiple recessions poses a significant challenge to any clinician. In such cases, the aim is to reduce the number of surgeries with minimum trauma.[6]

Connective tissue graft (CTG) is the gold standard for root coverage and has been successfully documented over ages. Difficulty in harvesting adequate graft material, increased intraoperative time and need for the second surgical site for CTG have motivated periodontists to test newer methods. Melcher's hypothesis of selective cell repopulation forms the basis of the biologic principle of guided tissue regeneration (GTR) using collagen membranes (CMs) in periodontology.[7] It is believed that the placement of a subgingival barrier achieves the following: (a) epithelial cells are impeded from apically migrating and interfering with periodontal regeneration, (b) gingival connective tissue from the flap is excluded from healing sites, and (c) progenitor cells from the periodontal ligament are favored to repopulate the root surface, thereby facilitating the formation of a new periodontium. With the advances in GTR, restoration and reconstruction of the periodontium can be achieved more predictably. There is sufficient evidence available in both animal and human studies describing periodontal regeneration using GTR.[8] Many of conventional root coverage procedures do not result in regeneration of the lost attachment apparatus; however, application of GTR using CM in the treatment of MTR could be of great significance when the aim is not only root coverage but also the regeneration of lost periodontal tissues. The presence of collagen in membranes has got some distinct advantages which include hemostatic function and early wound stabilization. It has chemotactic properties to attract fibroblasts with semi-permeability which allows nutrient transfer.[9] Different pericardium membranes mostly of equine, bovine, and porcine origin consisting of type I, type III collagen fibers, and elastic fibers are available. The pericardium membrane is derived from natural pericardium which has got a specific tridimensional structure with preserved links between collagen fibers and elastin. The pericardial membrane has got good biocompatibility and handling property with slow degradation rate.[10]

Coronally advanced flap (CAF) is a commonly used and reliable periodontal plastic surgical procedure to achieve root coverage. Multiple MTR in the esthetic zone can be predictably managed with Zucchelli's modification of CAF technique.[6] Recent developments in periodontology have shown that magnification and microsurgery can greatly improve clinical practice. Periodontal microsurgery is a methodology that improves all aspects of surgical techniques using magnification and improved ergonomics. The continuous development of operating microscopes, refinement of surgical instruments, improved suture materials, and suitable training laboratories have played an important role in the establishment of the microsurgical techniques in many specialties including periodontology, especially in the field of perioplastic surgery.[11] In the present-day scenario, periodontal therapy goes beyond treating periodontal disease and patients expect us to deliver results with minimum trauma and discomfort with excellent cosmetic results which can only be achieved with periodontal microsurgery.

The aim of this case report is to discuss the role of pericardium membrane and periodontal microsurgery in the management of multiple MTR in esthetic area of maxillary teeth using Zuccchelli's modification CAF.

CASE REPORT

A 28-year-old male patient reported to the Department of Periodontology with a complaint of sensitivity to cold in front teeth region of upper jaw for 1 year. The patient noticed difficulty in brushing his teeth in the same region with increased sensitivity to cold. Intraoral examination revealed Miller's class I MTR in relation to 22, 23, and 24 [Figure 1]. After phase I therapy, the patient was reviewed at 1 month, and root coverage surgery for management of MTR was planned. The technique utilized was a microsurgical approach using modified CAF (Zucchelli's) with pericardium membrane. The patient was treated using minimally invasive surgical technique with the aid of a surgical microscope under ×8 and microsurgical instruments [Figures 2 and 3].

Figure 1

Preoperative recession depth

Figure 2

Operating microscope

Figure 3

Microsurgical instruments

Presurgical preparation

After initial examination and case history, written informed consent from the patient and Institutional Ethical Committee approval were obtained. Full mouth scaling and root planing were carried out with plaque control instructions. All relevant clinical measurements were noted using UNC-15 probe at baseline (postphase I therapy), 6 months, and 12 months which included recession depth, pocket depth (PD), width of keratinized tissue (KT), and plaque index (PI) (Sillness and Loe, 1964) [Tables 1 and 2].

Table 1

Clinical parameters at baseline, 06 months and 12 months

	Baseline (mm)	6 months	12 months	Percentage of root coverage
RD
22	2	0	0	100
23	3	0	0	100
24	2	0.5	0.5	75

RD – Recession depth

Table 2

Clinical parameters at baseline, 06 months and 12 months

	Baseline (mm)	6 months	12 months
PD
22	1	1	1
23	1	1	1
24	1	1	1
KT
22	4	5	5
23	5	6	6
24	4	4	4

PD – Pocket depth; KT – Width of keratinized tissue

Surgical therapy

After presurgical preparation of the site, under local anesthesia, using operating microscope and microsurgical instruments, a horizontal incision was given with a microsurgical scalpel to design an envelope flap. This consisted of oblique sub-marginal incisions in the interdental areas. These incisions were extended to continue with the intrasulcular incision at the recession defects [Figure 4]. Keeping the interdental papilla intact, only the surgical papilla was reflected by the oblique interdental incisions [Figure 5]. The surgical papilla mesial to the flap midline was dislocated more apically and distally, while the papilla distal to midline was shifted more apically and mesially. Subsequently, full-thickness flap was raised apical to the root exposure [Figure 6] and continued as a partial-thickness flap. Deep vestibular incision was given to release muscle fibers in the most apical portion of the flap which facilitated the coronal displacement of the flap. Root planing and saline irrigation of recipient site were done, and it was left undisturbed by placement of moist sterilized gauze.

Figure 4

Oblique submarginal incision

Figure 5

Split-thickness flap

Figure 6

Full-thickness flap

A pericardium membrane (HEART, BIOTECK, 15 mm × 20 mm, 0.2 mm × 0.4 mm) [Figure 7] was shaped and hydrated for 3–5 min in sterile normal saline. The interdental papilla was de-epithelialized for the placement of the flap. The membrane was secured over the defect area and the flap was advanced coronally to completely cover the membrane [Figure 8] and secured with 6–0 (polyglactin 910) absorbable sutures using independent sling sutures. In the apical portion, horizontal double-mattress suture was given using 3–0 black braided silk to reduce lip tension on the marginal portion of the flap [Figure 9]. Periodontal pack was placed postoperatively. Postsurgical plaque control instructions were given with prescription of antibiotics and 0.12% chlorhexidine. The patient was recalled after 10 days for suture removal and kept on recall maintenance program every month for the first 3 months and subsequently reevaluated after 6 months and 12 months. One-year postoperatively, mean root coverage (MRC) of 91.6% was achieved with complete reduction in sensitivity to cold. Complete root coverage in two teeth (22 and 23) was achieved and calculated by % of root coverage [Table 1]. The width of KT was marginally increased with no change in PD and PI [Table 2 and Figure 10].

Figure 7

Pericardium membrane

Figure 8

Membrane placement

Figure 9

Suturing

Figure 10

Twelve months postoperatively

DISCUSSION

The ultimate goal of periodontal plastic surgery is to improve the health, function, and esthetics of the periodontal tissues with minimum trauma and discomfort. Root coverage procedures form a major part of these surgeries to prevent complications associated with gingival recession. As per the Miller's classification of gingival recession, the percentage of root coverage has also been described. Both Class I and II gingival recessions are associated with no loss of interproximal soft and bone height and complete root coverage can be achieved, whereas in Class III, only partial root coverage is possible due to mild-to-moderate loss of the interdental periodontal support; in Class IV, root coverage is not feasible due to severe loss of the of interproximal bone.[12] Emphasis should be given to the best available evidence to select the most predictable surgical approach among those possible in a given clinical situation. Multiple MTR is a common finding in most of the patients. These types of recessions should be treated simultaneously to limit the number of surgeries and to enhance the esthetic results.[6] High percentage of root coverage in multiple gingival recessions can be carried out successfully using various techniques including the CAF alone or in combination with CTG. Studies have confirmed that CAF + CTG compared to CAF alone provided better recession reduction and more complete root coverage after 5 years in multiple recessions.[13] Despite CTG being the gold standard in root coverage procedures, patient acceptance is low due to the need for a second surgical site and post-operative discomfort.[14] CAF technique which has been modified by Zucchelli and De Sanctis is very effective in the management of multiple MTR in esthetic areas with single surgery which results in predictable root coverage as well as an increase in KT.[6] Following the principles of minimally invasive surgery, in this technique, vertical releasing incisions are avoided to prevent any damage to the blood supply of the flap. The design of the flap in this technique is a split-full-split thickness, which helps in easy coronal advancement with the thickest portion of the flap on the exposed root surface. Tissue engineering has developed and tested different substitute materials for achieving similar clinical outcomes as the CTG. Out of these substitutes, CM has been successfully used with CAF in root coverage procedures. McGuire and Scheyer in their split-mouth study reported an MRC of 88.5% for CAF + CM as compared with 99.3% for CAF + CTG. They concluded that despite statistically significant differences in the outcome, CM was a feasible alternative for CTG.[14] Another 12-month study has shown no differences between CAF + CTG and CAF + CM (94.3% vs. 96.9%).[15] In this case report, the pericardium membrane of equine origin was used. Literature has limited evidence regarding the use of this membrane for root coverage procedures, but available studies have confirmed MRC of 88.8% with a significant increase in the width of KT at the end of 6 months.[16] This membrane has a slow resorption time with long protection time.[10]

In this case, the procedure was performed under 8× using an operating microscope. The workshop of AAP has stated that results of root coverage procedure can be improved using magnification.[17] Bittencourt et al., carried out a clinical trial in which they compared post-operative morbidity and esthetic outcomes of subepithelial CTG technique with or without the use of an operating microscope in the treatment of MTR and concluded that use of the operating microscope has additional clinical benefits in the management of MTR.[18] Periodontal microsurgery through improved visual acuity, smaller incisions, and use of a precise hand grip results in minimal tissue trauma.[11] The only disadvantage of microsurgery is that surgery takes a slightly longer time compared to surgery done without magnification. However, with regular practice, the same can be improved. The MRC achieved in the present case was 91.6% which is comparable to previous studies where MRC was 86.7% and 88.8%, respectively.[1016] In this case, the pericardium membrane integrated well within host connective tissues and gave good root coverage. However, well-controlled longitudinal studies are required to assess the type of attachment and postsurgical stability of the outcome achieved with pericardium membrane and periodontal microsurgery.

CONCLUSION

Zucchelli's modification of CAF technique using principles of microsurgery and pericardium membrane gives predictable results in multiple recession areas with single surgery. Pericardium membrane gets well integrated with gingival connective tissue which leads to excellent esthetics with an increase in keratinized tissue. However, long-term evaluation of well-controlled studies with larger sample size is required to evaluate the potential of this membrane in root coverage. As periodontal plastic surgery is moving toward minimally invasive concept and smaller incisions, root coverage procedures under magnification always have an added benefit of reducing patients' discomfort leading to an overall enhanced treatment outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.