Gingival Recession and Gingival Tissue Graft - Article Example

Gingival recession and gingival tissue graft. al affiliation Gingival recession and gingival tissue graft. Gingival recession is the retraction of the gingival margin or loss of gum tissue leading to root denudation. This dental condition is responsible for early loss of teeth and other dental sequela. Gingival recession is common in adults (over 40 years) because of slow progression, which may hardly be noticeable (Rossi, Pilloni, & Morales, 2009). A few exceptions though occur in teens and these are evidently associated with lifestyle habits such as tongue piercing and smoking. Receding gums may occur with or without concomitant disease, and it has raised both medical and aesthetic concerns in patients and health care givers (Rossi, Pilloni, & Morales, 2009). Receding gum clinical manifestation takes on many forms depending on the causative factor, however, increased root sensitivity, cervical caries and cervical abrasions are typical examples. The widely adopted diagnosis and classification of gingival recession is the Miller’s classification. In this classification, the condition is graded in several classes that correlate with the severity and clinical presentation. In class one; for example, the recession depth does not reach the mucogingival junction, whereas, in class two, it extends beyond this junction. Class three is the advancement of class two with the involvement of the interproximal clinical attachment or rotation of the affected tooth. Lastly class four recession is the most severe form with extensive damage beyond class three. However, this classification is not inclusive of all cases, and several other classification strategies are also in use. A standing example of alternative classification is the Kumar & Masamattis classification, which is more detailed than Miller’s classification. It is also informative and devoid of limitations seen in the later strategy. There are a number of etiologies that lead to recession some of which are pathological in nature and others are not. Pathological etiologies include; recurrent inflammation, self inflicted trauma, and chemical erosion around teeth can lead to recession. On the other hand, mal-positioned teeth, shallow vestibule, inadequate keratinized attached gingival around teeth are non pathological predisposing factors. Other causes include surgical implants associated with any of the above conditions and other factors such as latrogenic factors, thin gingival biotype among others. An example of a surgical procedure as a risk factor to recession is apical surgery. This surgery is normally undertaken to seal an endodontically treated tooth (Von Arx, Alsaeed, & Salvi, 2011). Apical surgery influences the risk for gum recession by the degree of healing achieved as well as the type of incision made during the procedure. The success of peri-apical surgery, which has a low risk to recession, is influenced by other factors such as patient’s satisfaction, age, sex and smoking habits, which act as indirect risk factors for gum recession. (Von Arx, Alsaeed, & Salvi, 2011). It is interesting to note that tongue piercings as an aesthetic treatment is also associated with gingival recession. According to a study conducted by Pires, Cota, and Oliviera, et al, (2010) in Brazil among middle aged adults, individuals with tongue jewelry had a higher frequency of gingival recession than the control group. This risk factor is strongly associated with the trauma involved in the process of placing the jewelry. Apart from recession, tongue piercing significantly increases the risk for tooth fracture, especially the anterior teeth (Pires, Cota, & Oliviera, et al, 2010). Diagnosis of recession is by periodontal examination and subsequent classification of its severity. Demonstration of typical symptoms of gingival recession is the guarding factor in the diagnosis of the condition. Examples of highly indicative signs include; patient’s complaint of sensitive teeth, exposed, and visible roots, presences of cavities in the gum line, inflamed gums among others. Medical history is also fundamental in pinpointing diagnosis and in selecting of the appropriate intervention. Gingival recession measurement is an estimation of the actual recede described in millimeters. There are a number of treatment options for gingival recession all of which have different predictability outcomes. An ideal treatment should address the underlying cause of recession and an artificial correction of the actual recession. Depending on the etiology, some intervention may involve instructions to improve on dental hygiene or advise them on dietary changes and improvement. A variety of corrective techniques, on the other hand, have been proposed with an aim of improving the biological conditions as well as in achieving acceptable aesthetics. For instance, mucogingival surgery such as apically positioned flap and soft tissue grafts were done to preserve keratinized gingival tissue and increase vestibular depth (Fu, Su, & Wang, 2012). An improvement to the mucogingival surgery is the soft tissue grafting surgery, which specifically improves alveolar defects in prosthetic reconstruction. Following the increasing esthetic concerns in gingival recession, the periodontal plastic surgery was adopted as an ideal surgical procedure to handle the condition. This surgical description incorporates all surgical procedures undertaken to prevent or correct an anatomical, traumatic, and developmental, as well as disease induced defect in gingival, bone and mucosa (Fu, Su, & Wang, 2012). Periodontal plastic surgery uses various techniques to regenerate new tissue to cover the areas of recession. These procedures may involve pedicle grafts (repositioning an adjacent gum tissue to cover the recession), gingival graft or sub-epithelial connective tissue graft (Rossi, Pilloni, & Morales, 2009). Examples of pedicle grafts include the coronally and apically positioned flaps. The difference between these two techniques is in the direction the graft is moved to cover the recession. A drawback of this procedure is that it applicable in recession defect with adequate thickness and width of gingival tissue at the base of the defect from which a flap is obtainable. A modification of the pedicle graft involves the use of periosteal flap instead of the connective tissue flap (Mahajan, Karol, & Kashyap, et al, 2012). Despite yielding promising results, this procedure is invasive as it involves exposing the periosteum close to the bone. The procedure is also delicate considering the source of the graft (Mahajan, Karol, & Kashyap, et al, 2012). The advantages of the periosteum pedicle graft are that it results in a single surgical site and has better patient satisfaction than traditional techniques (Mahajan, Karol, & Kashyap, et al, 2012). Another surgical treatment is the gingival grafts also commonly known as free gingival graft, which involves the use of tissue flap removed from the patient’s palate on the recession defect. It is applicable incases with thin gum tissue. The disadvantages of this technique include; surgical trauma caused by the two surgical sites. Progressive healing of the second surgical site causes pain and discomfort to the patient. Sub-epithelial connective tissue graft is one of the widely accepted techniques and involves the use of a gum connective tissue from a healthy donor site on the recession defect. Its wide acceptance is attributed to it excellent success and predictability in root coverage (Rossi, Pilloni, & Morales, 2009). Other techniques include lateral pedicle graft, where the source of the graft is an area adjacent to the defect. However, this technique has limited applicability as a suitable graft may not be obtainable. Acellular dermal matrix is a surgical technique that does not use auto-grafts; the grafts in this technique are freeze-dried akin allo-grafts. Processing of these allo-grafts makes them biocompatible and immunogenically safe to the host. However a notable disadvantage of these is graft contraction, sloughing of the epithelium and scarring during healing. They also pose a unpredictable immunological response in extreme cases (Fu, Su, & Wang, 2012). The use of acellular dermal matrix (ADM) came as an improvement to the limitation of the allogenic grafts (Moolya, Setty, Thaku, & Ravindra, 2012). AMD is an allogenic graft devoid of all cellular components of the epidermis with a maintained collagen scaffold and elastin filaments (Fu, Su, & Wang, 2012). Advantages of ADM include unlimited availability of the graft and it is also less invasive than the other techniques. However, ADM have the disadvantage of inadequate supply of blood, which may affect healing. When compared to connective graft, AMD has a lower root coverage outcome compared to the later according to a clinical study by Moolya, Setty, Thaku, and Ravindra (2012). This lower root coverage may be attributed to the above limiting factors of ADM. Despite, the existing number of interventions, there is ongoing research to improve and discover newer techniques with better root coverage and predictability. Reducing the number of surgical sites and acceptable aesthetics are co-influencing factors into this research (Mahajan, Karol, & Kashyap, et al, 2012). A common challenge faced by periondontologst is in choosing the treatment modality that best suits their clients. To this effect many have opted to modify and combine technique methodologies to achieve the most desirable outcome. For instance Zucchelli and De Sanctis, (2013) describes the use of a two step surgical involving free gingival graft and a subsequent pedicle graft in a miller class II gingival recession. The success of this technique is in the use of the first surgery to create a keratinized tissue band that would be coronally advanced to cover the root. The overall outcome of the technique described by Zucchelli and De Sanctis (2013) is predictable root coverage and good color blending of the treated site. Color blending and proper alignment of the grafted tissue is a challenge with some of techniques such as allogenic grafts, which many have different color pigmentation that are not in harmony with the recipient’s (Zucchelli, & De Sanctis, 2013). Another example is a case study by Vijayendra, Suchetha, and Sharadha, et al, (2011), which incorporated two different techniques in a two step surgical procedure. In this case reports an achievement in root coverage in the mandibular incisor region, which has been a challenge in periodontal plastic surgery. The study firstly used a free gingival graft and then a subsequent sub-epithelial connective tissue graft to achieve full coverage (Vijayendra, Suchetha, and Sharadha, et al, 2011). This study provides further evidence on the manipulation of existing surgical procedures in treating and managing gingival recession. In a nut shell gingival, recession is a dental condition characterized by a displacement of the marginal tissue apical gum tissue (Mahajan, Karol, & Kashyap, et al, 2012). It has several etiologies such as dental implants, latrogenic factors, and recurrent gum inflammation among other factors. There is a variety of treatment options for the condition, each with different predictability and outcome. Whereas other techniques produce desirable outcomes than others, their application may be varied and limited. The choice of a technique is guided by several factors such as the underlying biological conditions and patient satisfaction. There is empirical evidence suggesting synergistic effect in the use of combined treatment modalities. Significant and desirable outcomes in the mixed treatment methods have necessitated continuous search for newer and modified interventions that yield satisfaction. To this effect there is no gold standard technique in the management of the condition and modification remains important. References Fu, J.H., Su, C.Y., & Wang, H. (2012). Esthetic Soft Tissue Management for Teeth and Implants. J Evid Base Dent Pract S1:129-142. Mahajan, A., Karol, S., Kashyap, D., Kumar, A., & Mahajan, P. (2012). Effective management of gingival recession defects using periosteal pedicle grafts. Journal of Dentistry, 2 (3) 193-199. Moolya, N.N, Setty B. S., Thaku, S., & Ravindra, S. (2012). Comparative evaluation of sub epithelial connective tissue graft and acellular dermal matrix graft in the treatment of gingival recession. International journal of clinical dentistry.5 (2) 131-142. Pires, I.L., Cota, L.O, Oliviera, A.C, Costa, J.E, & Costa, F.O. (2010) Association between periodontal condition and use of tongue piercing: A case-control study. Journal of Clinical Periodontology 37(8):712-8. Rossi, R., Pilloni, A., & Morales, R.S. (2009) Qualitative Assessment Of Connective Tissue Graft With Epithelial Component. A Microsurgical Periodontal Plastic Surgical Technique for Soft Tissue Esthetics., The European journal of esthetic dentistry. 4(2) 118-128. Vijayendra, R., Suchetha, A., Sharadha, J., & Khalid, G. (2011).Two-Step procedure for root coverage using a free gingival graft and subepthelial connective tissue graft. Indian Journal of dental research 22(3): 478-481. Von Arx, T., Alsaeed, M., & Salvi, G.E. (2011). Five-year changes in periodontal parameters after apical surgery. J Endod 37:910-8. Zucchelli, G., & De Sanctis, M. (2013). Modified two -stage procedures for the treatment of gingival recession. The European journal of esthetic dentistry 8 (1) 24-42. Read More