|Year : 2014 | Volume
| Issue : 3 | Page : 206-210
Microsurgically assisted bilamminar free rotrated papilla autograft (FRPA) procedure for root coverage
Arpita Ramisetti1, Sudhir Ramisetti2, Sidhani Siva Vara Prasad3, Songa Vajra Madhuri4
1 Department of Periodontics, Mamata Dental College, Khammam, Telangana, India
2 Department of Oral and Maxillofacial Surgery, Mamata Dental College, Khammam, Telangana, India
3 Department of Periodontics, Aditya Dental College, Beed, Maharashtra, India
4 Department of Periodontics, Government Dental College, Vijayawada, Andhra Pradesh, India
|Date of Web Publication||17-Sep-2014|
Department of Periodontics, Mamata Dental College, Khammam, Telangana
Source of Support: None, Conflict of Interest: None
When esthetic demands of the patient require accentuated precision in surgical technique, incorporation of advanced surgical aids in general clinical practice becomes a necessity. Periodontal plastic surgical procedures have been reviewed in the dental literature and assessed for their validity so as to provide the practitioner with the knowledge required in making patient-centered, evidence-based decisions with respect to the treatment of gingival recession. Connective tissue grafts is considered the gold standard for root coverage procedures due to statistically significantly superior results compared to other procedures. However, the coverage of multiple tooth recessions and patient morbidity due to the need of larger second surgical wound at the donor site in the gingival recession reduction are the major shortcomings. A case report of multiple roots recession treated using a modified connective tissue grafting procedure, the free rotated papilla autograft using periodontal microsurgery has been presented here. The advantages are the use of a single surgical site, avoiding any palatal patient discomfort, good color compatibility with adjacent tissue and healing by primary intension.
Keywords: Bilaminar procedures, coronally advanced flap, free rotated papilla autograft, gingival recession, periodontal microsurgery, root coverage
|How to cite this article:|
Ramisetti A, Ramisetti S, Prasad SV, Madhuri SV. Microsurgically assisted bilamminar free rotrated papilla autograft (FRPA) procedure for root coverage. J NTR Univ Health Sci 2014;3:206-10
|How to cite this URL:|
Ramisetti A, Ramisetti S, Prasad SV, Madhuri SV. Microsurgically assisted bilamminar free rotrated papilla autograft (FRPA) procedure for root coverage. J NTR Univ Health Sci [serial online] 2014 [cited 2020 Apr 1];3:206-10. Available from: http://www.jdrntruhs.org/text.asp?2014/3/3/206/140951
| Introduction|| |
Gingival recession is defined as the apical migration of the junctional epithelium with exposure of root surfaces. ,, It is a common condition and its extent and prevalence increase with age. It has been estimated that 50% of the population has one or more sites with 1 mm or more of such root exposure. , This prevalence rate increases to >88% for individuals who are 65 years or older.  There are various etiological factors and complications that make gingival recession a concern for patients. Etiological factors include, but are not limited to, malposition of teeth, poor oral hygiene, aggressive tooth brushing and orthodontic treatment. ,, Gingival recession puts the patient at risk for root caries and abrasion/erosion of roots due to exposure to the oral environment. The chief complaint of patients who present to dental offices with gingival recession are dentin hypersensitivity and esthetic distress, as a result, of etiological factors and their sequelae.
A variety of periodontal plastic surgical techniques, displaying different degrees of success, have been reviewed in the dental literature and assessed for the validity in treatment for gingival recession. ,,, This provides the practitioner with the knowledge required in making patient-centered, evidence-based decisions with respect to the treatment of gingival recession.  The coronally advanced flap (CAF) combined with free connective tissue graft was proven to be a predictable method for achieving root coverage in buccal gingival recession. Nevertheless, this procedure conventionally requires involvement of a second surgical site. ,
The success of any surgical procedure is dependent upon a surgically atraumatic approach, which is usually limited by the surgeon's skill and the perception of the human eye. The use of optical magnification with the aid of loupes and microscopes permit refinement of the surgical technique. , Surgical loupes have proved to be an invaluable tool in the clinical periodontal microsurgery by enhancing surgeon's visual acuity, allowing better manipulation and more accurate suturing of the soft tissues.  Along with microsurgical instruments, low tissue trauma, excellent flap control and a suturing technique that allows primary wound closure may be responsible for improved clinical success. ,
Free rotated papilla autograft (FRPA) procedure (Tinti and Parma-Benfenati, 1996)  combines subepithelial connective tissue graft (SCTG), CAF and periodontal microsurgery in order to achieve root coverage. This procedure was used to treat cases of two teeth shallow Miller' class I or II recession (2-4.5 mm deep). The purpose of this approach is to minimize the postsurgical course and patient discomfort in single-recession treatment by involvement of a single surgical site. The present case report involves two teeth Miller' class I recession root recession treated using this modified connective tissue grafting procedure, the FRPA using periodontal microsurgery.
| Case report|| |
A 33-year-old woman reported to the Department of Periodontics with multiple maxillary recessions. On intraoral examination, maxillary right first and second premolar , exhibited Miller's class I recession (4 and 3 mm respectively) along with normal alignment of teeth in the arch, radiographic evidence of sufficient interdental bone adjacent to the involved tooth and maintenance of good oral hygiene The lesions were probably caused by anatomic traits associated with traumatic tooth brushing. General health condition of the patient was good, and she had not undergone periodontal surgery within prior 12 months.
After signing a consent form for surgical therapy, the patient was instructed in correct oral hygiene techniques and placed in a prophylaxis program until inflammatory indices reached zero. At the baseline, preoperative photograph was taken [Figure 1] and [Figure 9]a] and the following clinical parameters were recorded using William's graduated periodontal probe-recession height (equal to measured from the cementoenamel junction [CEJ] to the gingival margin), recession width (equal to the distance between the mesial gingival margin and the distal gingival margin measured at CEJ), width of keratinized gingival (equal to the distance from the marginal gingiva to the mucogingival junction), probing pocket depth (equal to the distance from the gingival margin to the base of the pocket), clinical attachment level (equal to the distance from the CEJ to the base of the pocket).
The microsurgical aid used for the FRPA combined with CAF procedure was a simple microsurgical loupe (MS Surgicals, Chennai) with a ×2.5 magnification [Figure 2]. The microsurgical instruments used consisted of a microsurgical scalpel, a microsurgical anatomical forceps, microsurgical needle holder, elevator and a microsurgical scissor, usually used in surgical ophthalmology.
Preparation of the recipient site
After anesthetizing the recession site with 2% lignocaine, a careful debridement of the root surface by hand instruments and flattening of the root prominences by rotating burs was first performed. A vertical beveled sharp incision was placed up in the vestibule distal to the recession, continuing horizontally below the line joining the interdental papillae and finally ending in another vertical beveled releasing incision mesial to the recession itself [Figure 3]a-c]. A full thickness trapezoid flap was then raised, preserving the adjacent papilla and undermining the soft tissue by sharp dissection, taking care to remain parallel to the tooth surface [Figure 4]. The adjacent papillae were de-epithelized to serve as a donor site [Figure 5]a and b].
| Harvesting, transfer, and stabilization of graft|| |
At this point, the buccal papillary tissue of the de-epithelialized papilla was excised [Figure 6]a and b]. These papillary grafts were rotated 180° to place its base at the CEJ, matching with the exposed root surface [Figure 7]a]. The graft was then stabilized by a horizontal absorbable suture (Ethicon monocryl 5/0) secured to the adjacent periosteum [Figure 7]b and c]. The previously raised flap was then coronally positioned, taking care to avoid any tension of the gingival tissue. Vertical mattress sutures for papillae and interrupted through and through sutures for vertical releasing incisions were used to obtain stable and complete coverage of the grafted tissue [Figure 8]a and b].
|Figure 5: (a, b) De-epithelization and preparation of the donor site (interdental papilla)|
Click here to view
|Figure 6: (a) Donor site. (b) Harvested papillary connective tissue graft. (c) Donor site after graft harvestation|
Click here to view
|Figure 7: (a) Graft placed at the recession site. (b, c) graft approximated sutured over the recession|
Click here to view
|Figure 8: (a, b) Flap coronally advanced and sutured over the papillary connective tissue graft|
Click here to view
A periodontal dressing was applied. Antibiotics and analgesics were prescribed. Postoperative instructions were first explained to the patient and hand out of these postoperative instructions was given as reinforcement. Patient was recalled after 14 days for suture and periodontal dressing removal.
On the 14 th postoperative day, the presence of any postoperative sequel was checked. On the removal of periodontal dressing and sutures, the surgical site was examined for uneventful healing. Patient was instructed to use a soft brush for mechanical plaque control in the surgical area by a coronally directed roll technique. About 0.2% chlorhexidine mouth rinse was also prescribed for 4 weeks after the surgery.
On follow-up visits, all the clinical parameters were again recorded, and postoperative clinical photographs were taken for comparison.
| Results|| |
Healing was uneventful throughout the follow-up period. Also, progressive adaptation of the flap edges to the surrounding tissues and increased morphologic and chromatic mimicking was observed. Six months postoperative [Figure 9]b], sulcular probing depth was <2 mm, and no bleeding on probing was present. Root coverage was complete, with gingival margins reaching the CEJ of both teeth. The patient was placed in a maintenance program consisting of prophylaxis and motivation.
| Discussion|| |
The success and predictability of any surgical procedure for treating gingival recessions is based on the amount of complete root coverage. Miller (1987)  defined complete root coverage procedure in clinical terms as location of soft tissue margin at the CEJ, presence of clinical attachment to the root, sulcus depth of 2 mm or less and the absence of bleeding on probing. Using this criterion for success, the SCTG described by Langer and Langer (1985),  has become the gold standard in the treatment of denuded roots. The use of SCTG for root coverage has demonstrated high degrees of success ranging from 64.7% to 95.6%. The combination of CAF with SCTG has predictable and stable results mainly due to the dual blood supply from the underlying connective tissue base and overlying recipient flap associated with excellent color match. ,, The surgical technique per se in any mucogingival surgical intervention has a major role in its successful outcome.
Newer technologies and instrumentation are, therefore, necessary to help the clinician ensure best results and patient satisfaction. Microsurgery has been thoroughly demonstrated as a useful tool in other fields of dentistry such as endodontics. , The effectiveness of microsurgical approach for periodontal regeneration and root coverage has been reported by Cortellini and Tonetti (2001),  Francetti et al. (2005),  etc. Magnification, illumination and increased precision in tissue manipulations result in faster revascularization of graft tissue and minimal tissue damage during surgery. ,
Bilaminar procedures are known to produce excellent results in managing such defects, since these techniques cause minimal damage to the vascular supply of both the periosteum and gingival flap. The presence of this dual blood supply results in a more rapid re-establishment of circulation within the FRPA. In this case report, FRPA as a minimally invasive, bilaminar procedure was used for treatment of two teeth gingival recession. This procedure is indicated in single Miller's class I or II root recessions when a wide papilla is present in the mesial or distal aspect of the involved tooth. The clinical outcome of the procedure was optimized by the aid of microsurgical loupe, at the same time minimizing the morbidity of the surgical procedure.  It is generally seen that when the epithelized or non epilthelized connective tissue graft is taken from the palatal region, the patient experiences a higher degree of discomfort at the donor site than at the area involved in root coverage. ,, The coincidence of the donor site with the recipient site in FPRA used here, reduced the discomfort of the patients, favoring their acceptance of the procedure. At the same time, primary wound care and good color match were also obtained.
A total recession coverage was seen at the receded premolars. The height and width of the papilla serving as a donor site were also recorded remained unchanged throughout the 6 months study period. Thus, no incidence of marginal soft tissue recessions after the procedure were reported at the donor site similar to the results of Francetti et al. (2004).  The change in the clinical parameters at the recipient site are in accordance with various studies by Harris (2002),  Francetti et al. (2004)  and Michaelides (1996). 
| Conclusion|| |
The FRPA combined with CAF using microsurgical aid is a predictable and stable method of root coverage for shallow two teeth gingival recessions. Involvement of single surgical site, faster tissue healing and minimal postoperative morbidity, due to the use of periodontal microsurgery proved invaluable for excellent patient compliance and successful treatment outcome of this procedure.
| References|| |
|1.||Leake J, Mayhall J. Treatment of gingival recession: An analysis of current literature and recommendations. Community 300Y. http://www.dentistry.utoronto.ca/system/files/gingivalrecession.pdf [Last accessed on 2010 March 12]. |
|2.||Tugnait A, Clerehugh V. Gingival recession-its significance and management. J Dent 2001;29:381-94. |
|3.||Hirschfeld I. Toothbrush trauma recession. A clinical study. J Dent Res 1931;11:61-3. |
|4.||Joshipura KJ, Kent RL, DePaola PF. Gingival recession: Intra-oral distribution and associated factors. J Periodontol 1994;65:864-71. |
|5.||Löe H, Anerud A, Boysen H. The natural history of periodontal disease in man: Prevalence, severity, and extent of gingival recession. J Periodontol 1992;63:489-95. |
|6.||Consensus report. Mucogingival therapy. Ann Periodontol 1996;1:702. |
|7.||Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localized gingival recessions: A systematic review. J Clin Periodontol 2002;29 Suppl 3:178-94. |
|8.||Tackas VJ. Root coverage techniques: A review. J West Soc Periodontol Periodontal Abstr 1995;43:5-14. |
|9.||Belcher JM. A perspective on periodontal microsurgery. Int J Periodontics Restorative Dent 2001;21:191-6. |
|10.||Nordland WP. The role of periodontal plastic microsurgery in oral facial esthetics. J Calif Dent Assoc 2002;30:831-7. |
|11.||Pieptu D, Luchian S. Loupes-only microsurgery. Microsurgery 2003;23:181-8. |
|12.||Tibbetts LS, Shanelec DA. An overview of periodontal microsurgery. Curr Opin Periodontol 1994:187-93. |
|13.||Tibbetts LS, Shanelec D. Periodontal microsurgery. Dent Clin North Am 1998;42:339-59. |
|14.||Tinti C, Parma-Benfenati S. The free rotated papilla autograft: A new bilaminar grafting procedure for the coverage of multiple shallow gingival recessions. J Periodontol 1996;67:1016-24. |
|15.||Francetti L, Del Fabbro M, Testori T, Weinstein RL. Periodontal microsurgery: Report of 16 cases consecutively treated by the free rotated papilla autograft technique combined with the coronally advanced flap. Int J Periodontics Restorative Dent 2004;24:272-9. |
|16.||Miller PD Jr. Root coverage with the free gingival graft. Factors associated with incomplete coverage. J Periodontol 1987;58:674-81. |
|17.||Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20. |
|18.||Langer L, Langer B. The subepithelial connective tissue graft for treatment of gingival recession. Dent Clin North Am 1993; 37:243-64. |
|19.||Bouchard P, Etienne D, Ouhayoun JP, Nilvéus R. Subepithelial connective tissue grafts in the treatment of gingival recessions. A comparative study of 2 procedures. J Periodontol 1994;65:929-36. |
|20.||Rosetti EP, Marcantonio RA, Rossa C Jr, Chaves ES, Goissis G, Marcantonio E Jr. Treatment of gingival recession: Comparative study between subepithelial connective tissue graft and guided tissue regeneration. J Periodontol 2000;71:1441-7. |
|21.||Apotheker H, Jako GJ. A microscope for use in dentistry. J Microsurg 1981;3:7-10. |
|22.||Leknius C, Geissberger M. The effect of magnification on the performance of fixed prosthodontic procedures. J Calif Dent Assoc 1995;23:66-70. |
|23.||Cortellini P, Tonetti MS. Microsurgical approach to periodontal regeneration. Initial evaluation in a case cohort. J Periodontol 2001;72:559-69. |
|24.||Francetti L, Del Fabbro M, Calace S, Testori T, Weinstein RL. Microsurgical treatment of gingival recession: A controlled clinical study. Int J Periodontics Restorative Dent 2005;25:181-8. |
|25.||Burkhardt R, Lang NP. Coverage of localized gingival recessions: Comparison of micro- and macrosurgical techniques. J Clin Periodontol 2005;32:287-93. |
|26.||Harris RJ. Root coverage with connective tissue grafts: An evaluation of short- and long-term results. J Periodontol 2002;73:1054-9. |
|27.||Michaelides PL. Connective-tissue root coverage using microsurgery. Dent Today 1996;15:74-9. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]