Managing root exposure

March 10, 2010 | dentalproductsreport.com
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The take-aways

• The soft-tissue reconstruction management of root exposure, while complex, can be a predictable and beneficial procedure.

• There is no single approach to soft-tissue reconstruction of root exposure.

Managing root exposure

Soft-tissue reconstruction of root exposure is a detailed, complex process. Dr. Peter Cabrera offers several case examples to illustrate the different surgical approaches.

by Dr. Peter O. Cabrera

The Set-Up

“The diagnosis and successful management of exposed roots is a key aspect of clinical dentistry. In this article, we review some general concepts of the surgical reconstruction of damaged areas,”  Dr. Peter O. Cabrera, Team Lead.

In an article that appeared in the March issue of DPR, I made the case for the term “root exposure” instead of the typically used term “gingival recession.” I argued the former is a more accurate and descriptive term for the actual clinical process, which is a multifactorial set of problems, expressing themselves as loss of attachment and damage to the roots.

In this article, I will discuss the soft-tissue reconstruction aspect of managing root exposure. It is essential to understand three important aspects in approaching this problem:

1.    An exact diagnosis: Identifying all contributing factors
2.    Correcting the loss of attachment
3.    Attending to the residual root damage and other contributing factors 

• Refer to the slideshow for figures

A little background

For years, the free gingival graft was considered the standard of care in soft-tissue reconstruction; however, this approach had several drawbacks, including limited potential for root coverage and the post-surgical discomfort inherent in an open palatal wound. Over the years other surgical approaches were introduced, including the use of pedicle flaps, but all of these approaches had limited applicability in the broad range of problems encountered in root exposure.  

Langer1 introduced the connective tissue graft in 1985, and although there were many others who contributed to the development of the connective tissue graft, Langer is largely credited with bringing this surgical modality into mainstream dentistry. The success of the connective tissue graft lies in the bilaminar vascular support provided to the graft in that the graft receives nutrients from the underlying connective tissue and the overlying flap. Also, the minimally invasive approach in procuring the tissue from the palate dramatically decreases post-operative morbidity.

Many variations of this surgical approach have been introduced over the years, but the basic principles of the surgical approach remain the same. As of this writing, there are two principle approaches to soft-tissue reconstruction. The first is in the use of palatal tissue, and the other is in the use of acellular dermal matrix.  The surgical approaches as well as indications, advantages, and disadvantages will be reviewed in this presentation. The sequencing of root preparation, flap reflection in its many varieties, and the insertion of the connective tissue are common to both approaches. The following cases illustrate the different surgical approaches.

Case No. 1
Tooth Nos. 21 and 22 present with root exposure and no residual attached tissue. The tooth is positioned outside of the alveolar bone, which is a key predisposing factor to root exposure.

After root preparation, a partial thickness dissection is made, including the interproximal papillae mesial and distal to the tooth. This soft-tissue flap is extended apically beyond the mucogingival junction to provide flap mobility. As demonstrated in Fig. 2, the amount of bone loss is typically much more significant than indicated by the clinical appearance. Periodontists often call this hidden recession.

A partial thickness palatal dissection is then conducted to obtain the donor tissue. The initial incision is made approximately 2 mm from the marginal gingiva and extended approximately 8 mm to the apical. After the envelope flap is completed, the connective tissue graft is then dissected. Depending on the size of the graft taken, 3-5 dissolvable sutures are used to close the wound. If the flap has been properly dissected, the palate will typically close by primary intent.

At the recipient site, the donor tissue is sutured in place and completely covered with the flap originally dissected. 

Case No. 2
The presence of a frenum or a shallow vestibule is often problematic in terms of flap mobility. In 1995, Cabrera introduced a surgical approach to take advantage of the elasticity of the vestibular connective tissue to help with flap mobility. This was described as a combination of the connective tissue approach originally described by Langer and a labial vestibular extension used for denture stabilization. By using an external incision in the vestibule, the flap can be significantly mobilized for a coronally positioned flap. 

Fig. 5 shows the pre-operative appearance with root exposure, no attached tissue and a shallow vestibule.

Fig. 6 is a schematic demonstrating the flap reflection along with the vestibular extension, while Fig. 7 shows the final result one year after surgery. Although the tooth continues in labial version, we have obtained an excellent zone of attached tissue and complete root coverage.

Case No. 3
The introduction of acellular dermal matrix into the periodontal surgical armamentarium has been a significant adjunct in soft-tissue reconstruction. This is particularly useful in cases where multiple teeth need to be treated or there is limited tissue availability from the palate. In this case, the patient presented with extensive root exposure. Previous attempts at soft-tissue reconstruction had been completed several years prior with free gingival grafts (Fig. 8). No root coverage was achieved.

The dissection of the recipient site is demonstrated using a tunnel procedure with alternate papillae reflection, which was described by Allen3 (Fig. 9). The dissection is carried beyond the mucogingival junction and includes the papillae. Once the tunnel has been completely dissected, the graft material can be inserted (Fig. 10). 

 The 18-month post-surgical view shows complete root coverage in all areas of the maxilla (Fig. 11). The residual cervical abrasion/abfraction lesions, as well as any occlusal components, now can be addressed.

As with all procedures, there are advantages and disadvantages as well as indications and contraindications to different approaches. I believe that in areas of single tooth recession or excessively thin tissue where teeth are prominently positioned in the alveolar bone, using palatal tissue holds significant advantages. In my experience, the built-in circulation as well as the blending with adjacent tissue tends to be superior with palatal tissue. In addition, where the existing tissue is excessively thin, using a tunnel approach for the insertion of the acellular dermal matrix typically results in flap perforations and graft exposure.

Acellular dermal matrix is generally the treatment of choice when multiple teeth require treatment, and when there is ample papillae width and height for atraumatic dissection. The presence of some existing keratinized gingiva is desirable from a surgical, technical perspective and an esthetic perspective. The overlying tissue will generally dictate the character and quality of superficial tissue. In other words, wherever you are covering the acellular dermal matrix with alveolar mucosa, the appearance of the residual tissue will be mucosal in nature, although this typically has no bearing on long-term function. From an esthetic perspective, it may present some compromises.

We’ve come a long way
Soft-tissue reconstruction of root exposure is a detailed and complex process. There is no single approach that can address all patient needs. As with all clinical problems, an early and accurate diagnosis is crucial for ideal results. The soft-tissue reconstruction management of root exposure has seen significant advances in the past few years and continues to be a most predictable and beneficial procedure for our patients.

References

1. Langer B, Langer L.  Subepithelial connective tissue graft technique for root coverage.  J Periodontal 1983; 56:  175.

2. Cabrera P.  The connective tissue graft with labial vestibular extension. Practical Periodontics and Aesthetic Dentistry 1994; 6(5):  57-63.

3. Minsk, L. The use of acellular dermal connective-tissue graft for root coverage in periodontal plastic surgery. Compend Contin Educ Dent, 2004 Mar;25(3)

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