Root Coverage Surgical Techniques and Criteria factors influencing choise of surgical techniques for root coverage Reference : Mucogingival Esthetic Surgery - Giovanni Zucchelli

1. ROOT COVERAGE SURGICAL TECHNIQUES
Dr Hossein Salehivaziri
DDS – DMD
Resident of
Periodontics

2. ROOT COVERAGE SURGICAL PROCEDURES
•Flap techniques cover the root with soft tissue that remains attached to the
adjacent tissue by a pedicle
•Graft consists of soft tissue harvested and detached from another source, typically
the palatal mucosa

3. FLAP TECHNIQUES
•Coronally Advanced Flap
•Lateral Sliding Flap

4. CORONALLY ADVANCED FLAP
1. Releasing Incisions [trapezoidal or triangular flaps]: mainly indicated for isolated
recession defects
2. Envelope Flap: suitable for multiple gingival recessions

5. CORONALLY ADVANCED FLAP: RELEASING INCISIONS

6. ENVELOPE FLAP WITHOUT RELEASING INCISIONS

7. LATERAL SLIDING FLAP
•In a Lateral Sliding Flap, the soft tissue mesial or distal to the exposed root is used
for coverage.
•This technique is indicated for treatment of isolated recession defects.

8. GRAFTING TECHNIQUE
1. Free Gingival Graft
A. Epithelium-connective tissue graft is used to cover the root
2. Bilaminar Technique
A. Include several variation but all have in common a connective tissue graft covered with
a pedicle flap
3. Two Step Technique
A. Epithelium-connective tissue graft with a coronally advanced flap
B. Epithelium-connective tissue graft with a lateral sliding graft

9. FREE GINGIVAL GRAFT

10. BILAMINAR TECHNIQUES

11. TWO STEP TECHNIQUE

12. FACTORS INFLUENCING CHOICE OF SURGICAL
TECHNIQUE FOR ROOT COVERAGE
Chapter 10

13. INTERDENTAL PERIODONTAL SUPPORT INTEGRITY
Gingival recession can be successfully treated with a wide range of surgical
techniques provided that there is the biologic prerequisite to obtain root coverage,
named interdental periodontal support integrity

14. CHOICE OF SURGICAL TECHNIQUE
1. Local Anatomical Characteristics of the Site Requiring Treatment
2. Objectives (other than root coverage) hoped to be gained with the surgery
3. Data in the International Literature Complete Root Coverage predictability
4. Patient’s Requests (most important)

15. LOCAL ANATOMICAL CONDITIONS
A. REGARDING TEETH
1. Size of root exposure (depth and especially width of the recession)
2. Number of recession defects
3. Loss of tooth/root or cervical material (abrasion and/or caries) in association with root exposure

16. LOCAL ANATOMICAL CONDITIONS
B. REGARDING SOFT TISSUES
1. Keratinized Tissue apical and lateral to the exposed root
 Quality
 Color
 Thickness
 Probing depths
 Quantity
 Apicocoronal and Mesrodistal
2. Quality and Dimensions of the Interdental Papillae
3. Vestibulum Depth
4. Presence of Frenulum or Muscle inserting into the margin

17. OTHER OBJECTIVES
1. Increase Gingival Thickness
 Prosthetic/Orthodontic purposes
 hide Root Pigmentation
 hide unesthetic Prosthetic/Implant metal edges
 to compensate for loss of Tooth Structure
2. Increase Vestibule Depth
3. Improve Keratinized Tissue Quantity or Quality for esthetic reasons

18. PURPOSE OF GINGIVAL THICKNESS AUGMENTATION

19. TO INCREASE VESTIBULE DEPTH

20. TO AUGMENT KERATINIZED TISSUE
FOR ESTHETIC REASONS

21. DATA FROM THE LITERATURE

22. DATA FROM THE LITERATURE
chance of obtaining complete root coverage depends not so much on the surgical
technique as on the state of interdental periodontal health and the anatomical
characteristics of the site or sites requiring treatment.
Only situation can the facial gingival margin be returned to the level of the CEJ:
1. Interdental Periodontal Support is Intact
2. The Interdental Papillae are of normal height
3. There is no serious tooth Malposition

23. DATA FROM THE LITERATURE

24. DATA FROM THE LITERATURE

25. THE PATIENT'S REQUESTS
Chief Complaint:
•Dissatisfied with their appearance
•Color difference between crown and root
•Presence of a white root area amid the red gingiva of the adjacent teeth
Gingival Color and Thickness are important factors in the patient's assessment of
the postsurgical esthetic outcome.

26. THE NEW DEFECT IS MORE UNATTRACTIVE THAN
THE RECESSION DEFECT

27. THE PATIENT'S REQUESTS
There is No Scientific Documentation proving that deeper recession defects are
likely to progress further or that they constitute a greater risk Factor for periodontal
disease than minor defects.
The main cause of postoperative pain/discomfort is the palatal mucosa donor site,
especially when wound healing takes place by secondary intention.

28. TO REDUCE PATIENT MORBIDITY TO A MINIMUM
•Perform the least number of procedures of the shortest possible duration possible
•Keep to a minimum the number of intraoral Sites affected by the surgery
•Reduce the patient's postoperative pain and discomfort

29. FOR PATIENTS COMPLAINING OF RECESSION-RELATED
ESTHETIC PROBLEMS, THE “IDEAL" SURGICAL
TECHNIQUE MUST THEREFORE
1. Be effective and predictable In obtaining complete root coverage as far as the CEJ
2. Permit treatment of all recession defects on neighboring teeth in a single surgical procedure
3. Use gingival tissue adjacent to the recession areas to obtain root coverage
4. Maintain or hopefully augment facial keratinized tissue
5. Avoid leaving unesthetic scarring
6. Guarantee good integration of the area treated (in terms of color and thickness) with the
adjacent soft tissues
7. Be minimally invasive, avoiding causing the patient excessive postoperative inconvenience or
pain

30. CHOICE OF SURGICAL TECHNIQUE Chapter 11

31. CHOICE OF SURGICAL TECHNIQUE
• ISOLATED RECESSION DEFECTS
• MULTIPLE RECESSION DEFECTS

32. ISOLATED RECESSION DEFECTS
APICAL KERATINIZED TISSUE ADEQUATE FOR ROOT COVERAGE
Yes
Coronal Flap
No
Esthetic
No
Adequate Lateral
Attached Gingiva
Yes
Apical Keratinized Tissue
Margin

33. ISOLATED RECESSION DEFECTS
Apical Keratinized Tissue Margin
Yes
CORONAL FLAP + CONNECTIVE TISSUE
GRAFT PLACED APICALLY
No
Adequate Distal Attached Gingiva
No
MUSCLE TRACTION MARGINAL FRENULA?
SHALLOW VESTIBULE?
Yes
LATERAL FLAP TAKEN FROM DISTAL
SIDE

34. ISOLATED RECESSION DEFECTS
MUSCLE TRACTION MARGINAL FRENULA? SHALLOW VESTIBULE?
No
Bilaminar Techniques
Yes
Two-Step Techniques
Dehiscence Depth
≤6 FGG & Coronal Flap
≥7 FGG & Lateral Flap

35. ISOLATED RECESSION DEFECTS
Adequate Lateral Attached Gingiva
Yes
Lateral Flap
No
Apical Keratinized Tissue Margin
No
MUSCLE TRACTION MARGINAL FRENULA?
SHALLOW VESTIBULE?
Yes
Coronal Flap + CTG Placed Apically

36. ISOLATED RECESSION DEFECTS
MUSCLE TRACTION MARGINAL FRENULA? SHALLOW VESTIBULE?
No
Bilaminar
Techniques
Yes
Recession Width
≤3
FGG
≥4
Two-Step Techniques

37. ISOLATED RECESSION DEFECTS
Among the various root coverage techniques, the coronally advanced flap is the
method of choice in that it is a straightforward procedure, is welt:
1. Tolerated by the patient (good postoperative recovery)
2. Excellent results from an esthetic point of view because of its high
percentage of complete root coverage
3. Camouflages the area treated to blend well with the adjacent soft tissue

38. ISOLATED RECESSION DEFECTS
The keratinized tissue apical to the exposed root is considered adequate for a
coronally advanced flap when:
1. Its thickness and apicocoronal dimension are suitable
 According to the patients biotype and the depth of gingival recession
2. The vestibule is sufficiently deep
3. There is no deep cervical abrasion
4. The tooth root is not displaced too facially

39. MULTIPLE RECESSION DEFECTS
APICAL KERATINIZED TISSUE ADEQUATE FOR ROOT COVERAGE
Yes
Coronal Advanced Flap
No
Esthetic
No
Combine Surgical
Technique
Yes
Apical Keratinized Tissue
Margin

40. MULTIPLE RECESSION DEFECTS
Apical Keratinized Tissue Margin
Yes
CORONAL FLAP + CONNECTIVE TISSUE
GRAFT PLACED APICALLY
No
Combine Surgical Technique?
No
MUSCLE TRACTION MARGINAL FRENULA?
SHALLOW VESTIBULE?
Yes
Combined Techniques

41. MULTIPLE RECESSION DEFECTS
MUSCLE TRACTION MARGINAL FRENULA? SHALLOW VESTIBULE?
No
Multiple Bilaminar Techniques
Yes
Combine Surgical Technique?
Yes
Combined Techniques
No
Two-Step Technique
FGG & Coronal Flap

42. COMBINED TECHNIQUES IN MULTIPLE
RECESSION DEFECTS
combination of coronally advanced flaps and lateral sliding flaps permits
treatment of the greatest possible number of recession defects in a single
surgical procedure
the only alternative is a two-step approach consisting of an epithelium-
connective tissue free graft placed apical to the deepest dehiscence,
followed 2 to 3 months later by a coronally advanced flap

43. CASUAL THERAPY OF PATIENTS PRIOR TO
MUCOGINGIVAL SURGERY
Chapter 12

44. HYGIENE TRAINING AND MOTIVATION
Supragingival and intrasulcular scaling as necessary with an ultrasonic scaler
Polishing with rubber cups and prophylaxis paste
Nontraumatic brushing with an apicocoronal Roll technique with Soft-Bristle brushe
the area planned for surgery must be free of both Plaque and Bleeding on Probing
Plaque Index and Bleeding Index of the entire mouth should be No Higher than 20%

45. ROLLING TOOTHBRUSHING TECHNIQUE

46. ROLLING
TOOTHBRUSHING
TECHNIQUE

47. SPONGY FL0SS

48. SPONGY FL0SS