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CASE REPORT
Year : 2011  |  Volume : 3  |  Issue : 2  |  Page : 74-77

Gingival augmentation procedure prior to fixed orthodontic treatment


1 Department of Periodontics, Vasantdada Patil Dental College and Hospital Kavalapur, Sangli, India
2 Department of Periodontology, Vasantdada Patil Dental College and Hospital Kavalapur, Sangli, India

Date of Web Publication21-Nov-2013

Correspondence Address:
Surekha Bhedasgoankar
Department of Periodontics, Vasantdada Patil Dental College and Hospital Kavalapur, Sangli - 416 306
India
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DOI: 10.4103/2231-0754.121870

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   Abstract 

Patients seek orthodontic treatment for correction of malocclusion and aesthetic improvement. A strong correlation between labially placed teeth and gingival recession has been found. If such cases are left untreated with or without orthodontic therapy, it may lead to an increase in the severity of the disease. A similar case of a 21-year-old male patient with gingival recession in the mandibular anterior region is reported. The patient was successfully treated using a free gingival graft technique. This technique not only improves the aesthetic aspect but also avoids future attachment loss and thus makes the patient more stable for further orthodontic treatment. The aim behind the treatment of gingival recession is not only to cover the exposed root surface, but also to improve aesthetics and reduce dentinal hypersensitivity. Different soft tissue-grafting procedures have been proposed for the treatment of gingival recession, of which free gingival graft is the most reliable one. The purpose of this case report is to illustrate the importance of root coverage prior to orthodontic treatment and to describe the planning for successful treatment which will improve the overall periodontal status of the patient.

Keywords: Free gingival graft, gingival recession, orthodontic treatment


How to cite this article:
Bhedasgoankar S, Kapadia J, Bhandari S. Gingival augmentation procedure prior to fixed orthodontic treatment. J Int Clin Dent Res Organ 2011;3:74-7

How to cite this URL:
Bhedasgoankar S, Kapadia J, Bhandari S. Gingival augmentation procedure prior to fixed orthodontic treatment. J Int Clin Dent Res Organ [serial online] 2011 [cited 2014 Oct 30];3:74-7. Available from: http://www.jicdro.org/text.asp?2011/3/2/74/121870


   Introduction Top


An adequate amount of attached gingiva is necessary to maintain gingival health and to prevent gingival recession. Free gingival graft surgery is used to increase the amount of attached gingiva since ancient times. In the 1980s, Miller modified the basic grafting technique to achieve more predictable and successful root coverage. [1] Friedman, in 1962 stated that an inadequate zone of attached gingiva facilitates the formation of subgingival plaque because of improper sulcus closure resulting from movement of the marginal tissue. [1] The Goldman and Cohen concept of 'tissue barrier' stated that the keratinized attached mucosa consists of a dense band of collagenous connective tissue which can retard or obstruct the spread of gingival inflammation better than the loose connective tissue of the alveolar mucosa. [2],[3],[4] So, the keratinized attached gingiva can be augmented to improve the inflammatory problem in the area of gingival recession. [1] Research in the past had proved clearly that areas of gingival recession were more prone to gingival inflammation than areas with an adequate zone of attached gingiva. A fixed orthodontic appliance is one of the major plaque-retentive factors which leads to severe gingival inflammation resulting in future attachment loss in the area of inadequate attached gingiva. [5] The importance of an adequate zone of keratinized attached gingiva before tooth movement for an adequate outcome of treatment cannot be overemphasized. Hence, a similar case is being presented here, where the mucogingival surgery improved the width of the attached gingiva, making the patient fit for further orthodontic treatment.


   Case Report Top


A 21-year-old male was referred to the clinic at the Department of Periodontology of the Vasantdada Patil Dental College and Hospital, Sangli (Maharashtra), for evaluation and treatment of gingival recession associated with left mandibular central incisor region. Orthodontic treatment of the patient had already been started with the maxillary arch. Brackets were placed in the mandibular arch, but due to inadequate width of the attached gingiva, further treatment could not be carried out. On examination, a positive tension test revealed inadequate width of attached gingiva, on the labial aspect of the left mandibular central incisor, with 10 mm of gingival recession (class II according to the Miller classification) [6] [Figure 1] . The marginal gingiva of the mandibular left central incisor was reddish pink in color, accentuated, soft and edematous, and bled on probing. An intraoral periapical (IOPA) X-ray was taken of the mandibular anterior region to assess the height of the alveolar bone which was found at the cementoenamel junction (CEJ). The patient was systemically healthy and a complete hemogram showed all blood counts within normal limits. As aesthetics was not of great concern due to the site being in a nonrevealing area, it was decided to treat the site with an 'autogenous free gingival graft' to achieve root coverage and to increase the width of the attached gingiva. The patient gave his consent for this treatment plan, and treatment was initiated with instructions for control of plaque, followed by thorough scaling and root planing and free gingival graft surgery.
Figure 1: Preoperative image of left mandibular central incisor region showing gingival recession of 10 mm

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   Surgical Procedure Top


During the surgical appointment, after local anesthesia was achieved, the exposed root was planed thoroughly with a Gracey 1/2 curette. It was followed by biomodification of the root by burnishing a tetracycline hydrochloride solution (125 mg/mL) over the root with a cotton tip for three minutes. The area on the left mandibular central incisor that was to receive the gingival graft was prepared by the creation of a partial-thickness flap; [Figure 2] graft tissue (approximately 2 mm in thickness) was harvested from the palatal side at the level of the left premolars and first molar. After harvesting the graft, the donor site was protected by a prefabricated acrylic stent. A conventional autogenous gingival graft (approximately 1.5 mm thick) was placed on the prepared recipient site. The graft was sutured in place by means of interrupted sutures (5-0 Ethilon sutures) at the coronal, lateral, and apical corners. A crisscross type of suture was also used to obtain good adaptation of the graft to the recipient site and to avoid dead space [Figure 3].
Figure 2: Photograph showing preparation of recipient site

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Figure 3: Photograph showing placement and adaptation of graft to the recipient site

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A non-eugenol periodontal dressing was applied to the recipient site after covering the graft with a sterile aluminium foil. The patient received routine postsurgical instructions, including a 0.12% chlorhexidine mouth rinse twice daily along with 400 mg ibuprofen thrice daily for seven days. The patient was recalled after seven days. The graft had adapted properly to the recipient site and healing was satisfactory. Periodic recall was done every week consecutively for 12 weeks, and 9 mm of attached gingiva was recorded by the end of 12 weeks [Figure 4].
Figure 4: Photograph showing follow-up after 12 weeks; 9 mm of attached gingiva width is obtained

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   Discussion Top


The present concept is that gingival recession occurs secondary to an alveolar bone dehiscence, if the overlying tissue is stressed by toothbrush trauma, plaque-induced inflammation, or the stretching and thinning of the gingiva that might be created by labial movement. [7],[8] In an animal study, it was suggested that thickness of the gingival attachment, rather than its surface qualities (keratinized or mucosal), maybe a major factor in the occurrence of recession. [9] For an adult orthodontic patient, it is much better to prevent gingival recession than to try to correct it later. The protective effect of a free gingival graft maybe due to greater gingival thickness and wider zone of the attached gingiva. Soft tissue augmentation procedures aims at increasing the zone of attached gingiva as well as covering the root that causes functional or aesthetic trouble. [8],[10]

Successful mucogingival surgery depends not only on the co-operation of the patient but also on anatomical factors and surgical skill of the surgeon. Complete root coverage has been reported in class I and II gingival recession with free gingival graft. It is regarded as the gold standard treatment in such cases. It not only increases the width of attached gingiva but also improves the aesthetics of the patient. [1],[2],[11]

Adequate blood supply, level of interproximal gingival tissue, and the type of incision are important factors that influence survival of the graft. Failure of graft does occur if graft beds are not prepared adequately. [1],[12]

A wide interdental papilla favors better blood supply. Furthermore, the height of the interdental papilla acts as an important prognostic factor in determining the amount of root coverage that can be obtained. The relative inadequacy of interdental papilla seen in class III recession contributes to the lack of complete root coverage. [1],[12]


   Conclusion Top


Prior to adult orthodontic treatment, periodontal evaluation must include not only periodontal probing, but also position and condition of the attached gingiva. Sometimes, labial movement of teeth leads to gingival recession and loss of attachment. The risk is greatest when irregular teeth are aligned by expanding the dental arch.

Free gingival graft is the most versatile, most widely used, and predictable mucogingival procedure of choice today. It is used to increase the band of attached gingiva and to cover the exposed root. The advantage of this procedure lies in the fact that it can be done for a single tooth or a group of teeth at one time. Other advantages are root coverage for functional aesthetics and preventing the progression of recession. The weakness of the procedure is that there are two surgical sites, the donor and the recipient site. Another weakness is the mismatch of color between tissues and the unknown nature of its attachment to the root. Finally, the lack of predictability in attempting root coverage and the compromised blood supply to the graft must be mentioned. The connective tissue graft technique was originally described by Edel in 1974; the advantage of this technique is that there is less discomfort to the patient postoperatively at the donor site because the donor tissue is obtained from the undersurface of the palatal flap, which is sutured back in primary closure; therefore, healing is the first intention. Another advantage is that better aesthetics can be achieved because of a better color match of the grafted tissue with the adjacent area. [13]


   Future Direction Top


In the quest for new technologies to reduce trauma during surgery, further research is needed to investigate treatment methods such as acellular dermal matrix. The advantage of this procedure is that patient need not be subjected to further surgery and it also gives a better aesthetic result. [1]

 
   References Top

1.Cohen ES. Atlas of cosmetic and reconstructive periodontal surgery. 3 rd ed. Hamilton: BC Decker Inc; 2007.  Back to cited text no. 1
    
2.Williams RC, Paquette DW. Mucogingival therapy- periodontal plastic surgery. Clinical Periodontology and Implant Dentistry. 5 th edition. Lindhe; p. 955-1001.  Back to cited text no. 2
    
3.Lang NP, Löe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol 1992;43:623-7.  Back to cited text no. 3
    
4.Miyasato M, Crigger M, Egelberg J. Gingival condition in areas of minimal and appreciable width of keratinized gingival. J Clin Periodontol 1977;4:200-9.  Back to cited text no. 4
[PUBMED]    
5.Coatoam GW, Behrents RG, Bissada NF. The width of keratinized gingiva during orthodontic treatment: Its significance and impact on periodontal status. J Periodontol 1981;52:307-13.  Back to cited text no. 5
[PUBMED]    
6.Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:9-13.  Back to cited text no. 6
    
7.Vandhana KL, Savitha B. Thickness of gingiva in association with age, gender and dental arch location. J Clin Periodontol 2005;22:828-30.   Back to cited text no. 7
    
8.William R. Proffit: Contemporary orthodontics. 2 nd ed. Mosby: p. 594-5.  Back to cited text no. 8
    
9.Wennström JL, Lindhe J, Sinclair F, Thilander B. Some periodontal tissue reactions to orthodontic tooth movement in monkey, J Clin Periodontol 1987;14:121-9.  Back to cited text no. 9
    
10.Boyd RL. Mucogingival considerations and their relationship to orthodontics J Periodontol 1978;49:67-76.  Back to cited text no. 10
    
11.Miller OD. Root coverage with the free gingival graft. Factor associated with incomplete root coverage. J Periodontol 1987;58:674-81.  Back to cited text no. 11
    
12.Bouchard P, Malet J, Borghetti A. Decision-making in aesthetics: Root coverage revisited. Periodontology 2000;27:97-120.  Back to cited text no. 12
    
13.Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinized gingiva. J Clin Periodontol 1974;1:185.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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  In this article
    Abstract
   Introduction
   Case Report
   Surgical Procedure
   Discussion
   Conclusion
   Future Direction
    References
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