A commonly employed procedure for complete root coverage is Zucchelli`s technique which was given for both single and multiple recession sites.[1] A major drawback faced during this procedure was the presence of unesthetic scars in the anterior esthetic region which led to its modifications without vertical releasing incisions.[2] Till date, Zucchelli’s technique, coronally advanced flap and modified coronally advanced flap required the flap to be stabilized coronally while using bio-fillers.
Treatment duration has often dictated patient’s compliance toward dental treatment and the authors feel that using commercially available, biodegradable, and volume-stable collagen membrane (Ossix plus) instead of conventional donor sites could be beneficial in spite of limited literature supporting their uses for soft-tissue augmentation.[3] The present case compared the use of such a matrix with coronally advanced flap for recession management in upper left canine.
A 45-year-old male patient had presented with sensitivity in the upper front teeth for the past 1 year. The general and oral health of the patient was assessed, which revealed a visible exposure of the root of the upper left front tooth region while smiling coinciding with multiple adjacent recession sites [Figure 1a]. The area #23 presented with Miller’s Class II recession on the buccal aspect with minimal width of attached gingiva despite healthy periodontal parameters assessed clinically and radiographically. Complete scaling and root planing was done while emphasizing on oral hygiene maintenance instructions and patient education. The patient was recalled after 4 weeks and scheduled for periodontal plastic surgery.
;)
Figure 1: (a) Preoperative gingival recession in relation to the upper left canine with a periodontal probe to measure of gingival recession on the buccal aspect of #23 with attached gingiva of about 1.71 mm. (b) Intraoperative surgical site after coronally advanced flap in #23 with biodegradable collagen membrane stabilized by periosteal anchoring suture with 4-0 Vicryl
A prophylactic dose of ciprofloxacin 500 mg was administered 20 min prior to the surgical appointment which was continued twice daily for 3 days postoperatively. Under adequate local anesthesia, a crevicular incision was given from #22 to 24 with 2 subsequent vertical relieving incisions along the mesiobuccal and distobuccal line angle of 23. A full-thickness flap was elevated exposing 3 mm of healthy bone margin beyond which the flap was converted to split thickness flap. Ossix plus was placed as a bio-filler within the flap which was stabilized by a periosteal anchor suture around #23 [Figure 1b]. The flap was then effortlessly advanced beyond the cemento-enamel junction suspended by interrupted sling 5-0 vicryl sutures around the tooth and multiple direct loop sutures to stabilize the vertical incision [Figure 2a]. A periodontal dressing was given along with a tin foil template to facilitate patient comfort. The patient was prescribed 10 mg of ketorolac as an analgesic for 3 days with postoperative instructions.
Figure 2: (a) Immediate postoperative clinical picture of surgical site in relation to #23 which was advanced beyond the cemento-enamel junction suspended by interrupted sling. (b) Complete healing with epithelial maturation in relation to surgical site of #23 after 9 months with increased thickness of attached gingiva to 3 mm
At 1-week follow-up, the dressing was removed which revealed soft-tissue expansion of the flap in relation to the surgical site 23 which caused a few sutures to tear along the vertical incision. Re-suturing was performed along the vertical incisions under anesthesia. After 2 weeks, the dressing and sutures were removed, which was followed by copious saline irrigation. Clinical examination revealed complete healing of the surgical site along with maturation of epithelium postoperatively after 9 months [Figure 2b].
The authors’ interpretations based on the current scenario included a clinically visible enhanced soft tissue bulk, resulting in change of the gingival biotype thickness evident from ripping of sutures 1 week postoperatively which required re-suturing. Gingival thickness assessed using digital calipers was found to be 1.71 mm preoperatively which drastically increased to 3 mm over a period of 9 months. The authors hypothesized that these clinical findings could have been a result of utilization of ribose sugars instead of glutaraldehyde in the production of the discussed membrane or the simply the preserved structural integrity of the membrane. Using commercially available bio-filler greatly reduced chair side time to just about 20 min as compared to 45 min with donor grafts, while simultaneously minimizing the comorbidity associated with a second surgical site. In studies comparing wound size and complete re-epithelialization using different graft procurement techniques, the Langer and Langer technique was preferred over unigraft knife technique to procure connective tissue graft, but commercially available grafts could eliminate the need for such procedures entirely.[4]
In conclusion, despite the small size of collagen membranes, patient affordability and the fixed dimensional sizes which could not be customized to the surgical site these membranes produced thick amounts of bulky keratinized tissue with mean root coverage, prompting the need for randomized clinical trials to assess the same.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Zucchelli G, De Sanctis M. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol 2000;71:1506–14.
2. Zucchelli G, Mele M, Mazzotti C, Marzadori M, Montebugnoli L, De Sanctis M. Coronally advanced flap with and without vertical releasing incisions for the treatment of multiple gingival recessions:A comparative controlled randomized clinical trial. J Periodontol 2009;80:1083–94.
3. Kim DH, Jeong SN, Lee JH. Soft tissue augmentation with volume stable collagen matrix:Two cases report. Oral Biol Res 2019;43:161–8.
4. Pandit N, Khasa M, Gugnani S, Malik R, Bali D. Comparison of two techniques of harvesting connective tissue and its effects on healing pattern at palate and recession coverage at recipient site. Contemp Clin Dent 2016;7:3–10.
