Abstract
Gingival recession and inadequate keratinized tissue are prevalent problems encountered in dental practice and negatively impact prosthodontic and esthetic outcomes. Traditionally, gingival recession has been treated with numerous types of soft tis.sue procedures, which include coronally positioned flaps, connective tissue grafts, lateral and pedicle grafts, as well as guided tissue regeneration. These procedures are often lengthy, induce donor morbidity, and have poor patient acceptance because of post-operative pain. The semi-lunar incision technique was introduced by Dr. Dennis Tarnow in 1985. The technique discussed in this article builds upon the basic principles of the semilunar incision technique with the introduction of tricalcium phosphate, has a successful prognosis, and is well accepted by patients.
INTRODUCTION
Gingival recession is a multifactorial and relatively common problem among patients. Newman et al. outlines numerous etiological factors for gingival recession, which include gingival abrasion from improper tooth brushing, tooth malposition, gingival ablation, gingival inflammation, abnormal frenum attachment, and iatrogenic dentistry.(1) Prior to performing esthetic periodontal surgery, it is important to identify the precise cause of the recession. For example, if the patient presents with an abfraction, the patient’s occlusion should be adjusted in addition to soft tissue augmentation. Gingival recession is a significant problem for dental practitioners, as patients may complain of increased sensitivity, caries, and unpleasant esthetics. The literature discusses many techniques for the treatment of gingival recession, such as autogenous gingival grafts, autogenous connective tissue grafts, and pedicle autografts. In 1985, Tarnow described the utilization of a semilunar incision and coronally positioned flap to treat gingival recession.2 The technique described in this article encompasses the same basic principles with the addition of tricalcium phosphate to increase the amount of attached gingiva.
TECHNIQUE
One of the most significant parameters for a successful case is patient selection; this procedure is most successful at achieving root coverage in patients that present with Miller Class I and select Class II defects.(3) In patients presenting with more extensive gingival recession, the procedure can be repeated in stages, gaining root coverage with each attempt and eventually the desired end result. In the first phase of treatment, the patient is educated on proper oral hygiene instructions, and there is removal of calculus and root planning. If the patient has active periodontal disease, re-evaluation of the patient’s periodontal health is completed in four to six weeks. The patient must demonstrate adherence to strict oral hygiene protocol and there must be an absence of inflammatory periodontal disease before proceeding to phase two of therapy, the surgical phase. Prior to performing surgical therapy, the patient is informed of the risks, benefits, and alternatives of the procedure and given the opportunity to ask questions. The patient is anesthetized using local anesthesia. The root surface is scaled and debrided, and the surface is etched with 37% phosphoric acid. A semilunar incision is made following the contour of the gingival margin with a 15c blade to the alveolar bone. An intrasulcular incision is made with a 15c blade along the gingival margin, as well as a full thickness incision that extends from the free gingival margin to the semilunar incision; this allows for the maintenance of the interproximal papillae.(2) Ideally, the tissue is positioned coronally to the cemento-enamel junction with a periotome, but this can be modified based on the amount of recession and position of the interproximal papilla. The tissue is then held in this new position for five to ten minutes using digital pressure. Tricalcium phosphate is then placed apical to the semilunar incision to increase the amount of attached gingiva and promote hemostasis. The patient is given both written and verbal post-operative instructions. The patient is advised not to brush, examine, or touch the area during healing for one to two weeks. The patient is then advised to take over-the-counter analgesics, such as acetaminophen or ibuprofen, before the anesthesia wears off and then as needed. Healing occurs by secondary intention and the patient returns for a post-operative follow up two weeks after the surgery. The procedure has a short surgical time and does not require intra-oral donor tissue, which greatly reduces post-operative discomfort in comparison to traditional procedures that involve retrieving donor tissue from the palate. With this procedure, patients experience minimal to no post- operative discomfort and generally do not require analgesics or antibiotics.
DISCUSSION
There are numerous indications for root coverage procedures including sensitivity and esthetics. Esthetics may range from recession on a natural tooth to a newly visible margin on a porcelain fused to metal crown. The semilunar coronally advanced flap with the utilization of tricalcium phosphate has numerous advantages over other techniques for root coverage. First, by utilizing a conservative incision and maintaining the integrity of the interproximal papillae, the blood supply is preserved. This significantly improves healing time and overall success of the procedure. Furthermore, this technique does not require the use of sutures, which has multiple advantages: it minimizes tissue trauma, maintains the integrity of the blood supply, and allows for faster healing. The utilization of sutures in soft tissue augmentation procedures has multiple negative side effects, such as post-operative tissue shrinkage and acting as a reservoir for bacteria and food. This induces further inflammation of the tissue and causes delayed healing. The additional use of tricalcium phosphate has numerous benefits. Carranza et al. explains that calcium phosphate materials are biocompatible and osteoconductive.1 As demonstrated in this technique, tricalcium phosphate establishes hemostasis and functions as a scaffold for wound healing.1 One of the overarching goals of soft tissue surgeries is to regenerate the lost periodontal attachment apparatus; many studies have demonstrated the usefulness of tricalcium phosphate in these techniques. McGuire et al. compared the use of tricalcium phosphate and recombinant human platelet derived-growth factors with a coronally advanced flap to the traditional subepithelial connective tissue graft.(4) While both techniques demonstrated clinical success in achieving root coverage, the growth-factor mediated approach histologically demonstrated formation of cementum, connective tissue fibers, and supporting alveolar bone.(4) The tricalcium phosphate dually functions as a graft and membrane, promotes the establishment of hemostasis, and leads to the development of keratinized tissue.
While this procedure has the best prognosis in cases that present with Miller3 Class I defects and select Class II defects, it can also be performed in patients with more extensive recession. In more severe cases, the procedure can be done multiple times, each time gaining approximately 1-2 mm of gingival coverage until the desired gingival margin is achieved. It is important to note that this technique can be performed on a single tooth or two adjacent teeth simultaneously. Achieving root coverage on adjacent teeth using other techniques becomes more difficult due to donor site morbidity, lack of blood supply, and predictability.
Patient selection is crucial to the success of this procedure. Patients must demonstrate dili.gent oral hygiene compliance to ensure a predictable outcome. Additionally, this technique is well accepted by patients and is a practice builder for many reasons. The procedure can be performed in approximately fifteen minutes and patients generally do not require analgesics or antibiotics. As there is minimum postoperative discomfort, patients can engage in their daily activities with no impediment.
Disclosure
The authors report no conflicts of interest with anything in this article.
References:
1. Newman M, Takei HH, Klokkevold PR, Carranza FA., Carranza’s Clinical Periodontology. 12. St Louis, Missouri: Elsevier Saunders; 2015.
2. Tarnow DP. Semilunar Coronally Repositioned Flap. Journal of Clinical Periodontology. 1986; 13: 182-185
3. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent. 1985; 5(2):8-13.
4. Mcguire, MK, Scheyer ET, Schupbach P. Growth Factor-Mediated Treatment of Recession Defects: A Randomized Controlled Trial and Histologic and Micro-computed Tomography Examination. 2009; 80 (4): 550-564.
