Connective Tissue Grafting for the Resolution of Full-Mouth Recession

Gingival recession usually has a multifactorial cause; however, only one solution is required typically—autogenous subepithelial connective tissue grafting (CTG). As the "go to" therapy for mucogingival defects, connective tissue autografts provide a mean root coverage (MRC) of 85%, and 60% of defects become completely covered; such results best those of other interventions, including coronally positioned flaps (80% MRC vs 50% [complete root coverage [CRC]), guided tissue regeneration (75% vs 40%), laterally positioned flaps (70% vs 40%), and free gingival grafts (60% vs 30%).¹ Moreover, connective tissue transplants are used to treat the greatest diversity of recession types (thin or thick mucosa, wide or shallow deformities, little or abundant keratinized mucosa, single or multiple roots) and blends well with the surrounding native mucosa; only the use of human acellular dermal matrix (ADM) rivals CTG. The major shortcoming of CTG is the need for a second surgical site—usually palatal—from which to harvest mucosa; this consumes time, introduces infection risk to the mouth, causes bleeding and pain, and restricts the volume of graft available based on donor site anatomy.^2-5 In cases of widespread recession, CTG should be supplemented with ADM, especially in patients who have appointment frequency constraints. Alternating autogenous and allogenous material use in recipient sites allows the surgeon to perform multiple quadrant root coverage in one sitting. But do receded areas respond as well to ADM as they do to connective tissue?

Based on a few relatively short-term (6 months) studies, CTG and ADM seem to generate comparable MRC and color match outcomes.⁶ However, these results differ over time; after 4 years, the MRC achieved via connective tissue application remains at 97% while the MRC in regions treated by ADM drops from an initial 93% to 66%.⁷

Because of the robust evidence in favor of CTG regarding efficacy and sustainability, CTG remains the gold standard for root coverage care, as supported by several systematic reviews and meta-analyses. Thoma and colleagues found more consistent volume gain by CTG compared with free gingival grafting.⁸ Likewise, the Clauser, Chambrone, and Oates groups independently reported higher predictability of root coverage and keratinized tissue widening with CTG than with several alternatives, including guided tissue regeneration and allografting.^1,9,10 If a patient with extensive recession consents to a number of surgical procedures spaced over several months or even years, then this therapy is the option that guarantees the most consistency. The case presented here describes full-mouth recession reversed by CTG alone over 3 years.

A healthy, nonsmoking 17-year-old man presented with recession defects spanning teeth Nos. 3 to 6, 11 to 14, and 19 to 30 (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, and Figure 7). He complained of esthetic compromise and cold hypersensitivity.

One year prior to presentation, the patient had completed full-mouth orthodontic treatment, which attempted to compensate for a Class III malocclusion associated with a skeletal Class III discrepancy. Orthodontic movement was unable to transform the occlusion to a Class I or eliminate crossbites, although some resolution occurred.

On examination, the patient exhibited generalized mild, localized moderate gingivitis with probing depths of 1 mm to 3 mm. An absolute lack of attached tissue or the presence of only < 1 mm of attached tissue exacerbated the inflamed and/or edematous appearance of the gingival margins around teeth Nos. 3, 5, 11, 14, 19, and 21 to 30. All recession defects were categorized as Miller Class I except for those on teeth Nos. 3 and 14, which were determined to be Miller Class II. No interproximal attachment loss or mobility was detected. The patient exhibited a relatively thin gingival biotype, as well as a coronally displaced maxillary midline frenum.

A full-mouth radiographic series showed no bone loss, periapical pathology, periodontal ligament (PDL) widening, or caries (Figure 8). All third molars were present, with an impacted tooth No. 17.

Based on the Miller Class I and Class II diagnoses of the receded areas (ie, recession coronal to or at the level of the mucogingival junction without interproximal attachment loss), the prognosis was deemed good.¹¹ For final stage predictability, the team opted to partition the CTG treatment into four procedures, each scheduled during the patient’s annual summer holidays. It was decided to convert the patient from a thin to thick biotype in hopes of discouraging future recession, so that teeth without recession (Nos. 7 to 10) also received grafting. Nine to 13 months of healing occurred between surgeries to ensure adequate palatal regeneration. The patient’s grafting schedule was as follows:

2005: Teeth Nos. 9 to 14

2006: Teeth Nos. 3 to 8

2007: Teeth Nos. 21 to 28

2008: Teeth Nos. 19, 20, 29, and 30

Each grafting procedure was executed according to the steps outlined in this section (Figure 8 through Figure 24). A maxillary midline frenectomy was also performed at the time of grafting at teeth Nos. 9 to 14.

Sedation and Anesthesia

Sedation was performed intravenously. Anesthesia with 2% lidocaine with 1:100,000 epinephrine, 4% articaine with 1:200,000 epinephrine, and 0. 5% bupivicaine with 1:200,000 epinephrine was given at the recipient site via local infiltration one tooth past each terminal tooth to be grafted. The bilateral palatal donor sites were anesthetized via local infiltration using the formulations described above.

Flap Design and Site Preparation

Recipient site: Buccal sulcular incisions were made along each tooth to be grafted and extended one tooth past each distal-most one. A full-thickness flap was elevated past the mucogingival junction, and the periosteum was scored near the base of the flap to facilitate coronal advancement (Figure 10). The site was degranulated with a carbide finishing bur and Neumeyer bur. To create flat surfaces required for graft adaptation, any exposed radicular surfaces were root planed and leveled to the buccal plate using a 7/8 Gracey curette, carbide finishing bur, and Neumeyer bur. Cotton pellets soaked with tetracycline solution were applied for 2 to 5 minutes, after which the root surfaces were irrigated with sterile water (Figure 14).

Donor site: Following the design described by Langer and Langer, two subepithelial connective tissue grafts were harvested bilaterally from the palate¹² (Figure 13). A No. 15 scalpel was used. Each side of the palate received a full-thickness linear incision extending from the distal aspect of the canine to the mesial aspect of the second molar and lying at least 4-mm apical to the marginal gingiva of the teeth. The greater palatine foramina were identified. On each side, a secondary split-thickness incision was made parallel to the slope of the palate such that a 1-mm to 1.⁵-mm epithelial layer was left. This secondary incision was extended along the entire length of the first cut and at a depth of approximately 10 mm. Tertiary full-thickness vertical incisions were made at the terminal ends of and perpendicular to the primary incision (approximately 10-mm deep). A final incision was created along the apical base of the donor site, below the epithelium. The scalpel-delineated connective tissue was elevated and extracted from under the epithelial layer with a periosteal instrument and tissue forceps. The bilateral incisions were primarily closed with 4-0 expanded polytetrafluoroethylene (ePTFE). The two connective tissue grafts were trimmed with a No. 15 scalpel to conform to the defect morphology.

Graft Stabilization and Closure

The connective tissue grafts were positioned over the recipient root surfaces and secured by sling and periosteal sutures with 5-0 plain gut (Figure 9, Figure 11, Figure 12, and Figure 18, Figure 19 and Figure 20). The flap was positioned coronally to cover the CTG and sutured with 4-0 ePTFE in a simple interrupted configuration. Primary closure was planned, although minor segments of graft material were occasionally exposed.

Bioactive Adjuncts

A bioactive agent was employed during the final surgery (teeth Nos. 19, 20, 29, and 30). Extracted from autologous blood, plasma rich in growth factors (PRGF) contains various degrees of anabolic elements, chemokines, and active metabolites.¹³ The growth factors consist of platelet-derived growth factor (PDGF), transforming growth factor-β (TGF-β), insulin growth factor-1 (IGF-1), vascular endothelial growth factor (VEGF), and epidermal growth factor (EGF). In theory, these substances hasten healing and tissue formation.

Autologous PRGF was prepared via the method described by Anitua.¹³ A total of 30 mL of blood was drawn from a peripheral vein in the right antecubital fossa into tubes coated with sodium citrate anticoagulant. The blood was centrifuged for 8 minutes at 460 x g. Extraction of a 0.5 mL plasma fraction above the red blood cell sediment, and buffy coat layer from each tube occurred. This PRGF liquid was applied directly on top of the stabilized connective tissue grafts. The flap was subsequently sutured over the PRGF-saturated donor tissue.

Postoperative Instructions

After each surgical procedure, the patient was instructed to take ibuprofen 600 mg every 4 to 6 hours, hydrocodone 7.5 mg/acetaminophen 750 mg every 4 to 6 hours as necessary for pain, and doxycycline 100 mg once a day for 10 days. He was directed not to brush at or near the surgical site for 3 weeks but instead to rinse with 0.1 2% chlorhexidine or warm saline twice daily. Suture removal occurred at 7 to 10 days postsurgery.

The patient had no significant postsurgical discomfort, and healing was uneventful (Figure 17). Minor food impaction was seen around tooth No. 30 approximately 4 weeks after the grafting operation of that side; this may have influenced the root coverage result as 100% defect resolution was not obtained. The application of PRGF to the graft material over sites Nos. 19, 20, 29, and 30 generated a tissue appearance similar to that seen after grafting in areas not treated with PRGF.

A maturation of 9 to 13 months occurred between each CTG appointment. There has been a 14-month to 4-year follow-up of grafting results.

CRC was achieved in all areas except No. 30, which had 0.5 mm to 1 mm of exposed root surface (Figure 21, Figure 22, Figure 23 and Figure 24). Coverage has been maintained for at least 14 months after surgical completion. There is more than a 1-mm band of attached gingiva supporting each tooth, and the biotype has been thickened. A frenectomy effectively relocated the maxillary midline frenum to a more apical position, decreasing the chance of tissue pull.

There seems to be no thoroughly documented procedure that rivals connective tissue grafting with respect to the range of treatable conditions, root coverage results, and long-term stability. That is not to say that other techniques fail to show promise or unique benefits. Guided tissue regeneration for recession defects potentially regenerates the attachment apparatus, while ADM grafting does what CTG does without the problem of finite availability.¹ Both therapies avoid the morbidity associated with a second surgical site. Even the old standard of care—free gingival grafting—supplies more keratinized tissue. Still, the relative unpredictability (or undetermined reliability) of these methods makes CTG attractive, multiple surgeries aside. As the case above demonstrates, the palate has an excellent capacity for renewal given time, and re-harvesting without complications is possible. Treating mucogingival defects with subepithelial tissue transplants not only entirely resolves root exposure issues but also normalizes the width of keratinized tissue in cases of Miller Class I or Class II recession, providing the patient with an ideal smile and a healthy, symptom-free mouth.

Michael Sonick, DMD
Director, Sonick Seminars
Private Practice
Fairfield, Connecticut

Debby Hwang, DMD
Private Practice
Fairfield, Connecticut