Minimizing Shrinkage of Interdental Papilla Height when Treating Multiple Miller Class III Gingival Recession Defects
Miller Class III and IV gingival recession defects have interdental bone and soft-tissue loss that limit root coverage. Given the importance of the interdental papilla, protecting the integrity of this structure would seem prudent. Tunnel techniques have been successfully used to protect the interdental papilla. This article discusses the results of two cases in which multiple Miller Class III gingival recession defects were treated
using tunnel-grafting techniques and an acellular dermal matrix. In both cases, root coverage was achieved while protecting the interdental papilla height.
In 1985, the Miller classification of marginal tissue recession was published,1 in which four categories of gingival recession defects were described. The limiting factor guiding the amount of root coverage that could be expected from any grafting procedure was the height of the adjacent papilla. Class III and IV gingival recession defects have interdental bone and soft-tissue loss that limit root coverage.
The interdental papilla consists of dense connective tissue covered by epithelium.2 Tarnow et al found a relationship between the vertical distance between the interdental contact point and the crest of bone to the presence of an interdental papilla that fills the embrasure space.3 Considering the importance given to this structure, Nordland and Tarnow proposed a classification system for the loss of papilla height.4
Given the challenges in reconstructing lost interdental papilla, maintaining its integrity would seem prudent. Several tunnel techniques have been developed to protect the interdental papilla.5-9 These techniques may be useful in the treatment of Miller Class III gingival recession defects. This article presents two case reports where connective tissue grafting using a tunnel technique and an acellular dermal matrix (ADM) was used to improve the gingival thickness and gain root coverage of multiple teeth while protecting the interdental papilla and maintaining its height. Case 1 is depicted in Figure 1 through Figure 5, while Case 2 is shown in Figure 6 through Figure 10.
In both cases, profound local anesthesia was achieved using 2% lidocaine with 1:100,000 epinepherine (Figure 1 and Figure 6). Intrasulcular incisions were made using a Bard-Parker #15 blade along the facial surfaces of the teeth to be treated. In Case 1, this included teeth Nos. 6 through 11. In Case 2, this included teeth Nos. 23 and 24. Leaving the interdental papilla intact, an Orban knife was used to dissect a full-thickness flap. At each tooth site, an individual gingival pouch was created. These pouches were extended beneath the mucogingival tissues until there was a continuous tunnel. In Case 1, the facial gingiva between Nos. 5 to 6 and 11 to 12 were detached from the underlying interdental papillary bed (Figure 2). In Case 2, using the “modified tunnel” technique,7,8 vertical incisions were made into the mucosa (Figure 7). Utilizing the access provided by either the reflection of the facial gingiva (Case 1) or the vertical incisions (Case 2), a patent tunnel was created and confirmed present using an Orban knife and periosteal elevator. Prominent root surfaces and root irregularities were then reduced via hand scaling and root planing.
The ADMs (AlloDerm® Regenerative Tissue Matrix, BioHorizons, www.biohorizons.com) were trimmed to approximately 5 mm in height. Case 1 required an ADM approximately 40 mm in length, while Case 2 required an ADM approximately 25 mm in length. In both cases, the ADMs were inserted into the mucogingival tunnel through one of the distal access openings. The ADM was pushed and pulled through the tunnel using the Orban knife. Complete placement was confirmed by visualizing the ADM through both distal access openings (Figure 3 and Figure 8).
By weaving around the lingual of the teeth, a continuous 4.0 chromic gut suture was used in both cases to secure the ADM in place and then to secure the gingival flap over the ADM and root surfaces (Figure 4 and Figure 9). In Case 2, additional 4.0 chromic gut sutures were required to close the vertical incisions.
Each patient was prescribed twice-daily amoxicillin (875 mg) for 1 week. Ibuprofen (600 mg) was prescribed for discomfort. The patients were instructed to use a 0.12% chlorhexidine rinse for
1 week. In the first week, the patients did not brush the surgical sites. For the next 5 weeks, the patients were permitted to brush gently. Remaining sutures were removed at the 1-week postoperative appointments. After week 6, the patients were allowed to resume normal brushing. At 12 weeks, all sites were re-evaluated (Figure 5 and Figure 10).
All areas healed uneventfully and without infection. Patients reported minimal discomfort, which was easily managed in the first couple of days with prescription pain medications. No problems with bleeding were reported. All sites treated appeared thicker at the re-evaluation. All patients reported being happy with the results of treatment.
Between the two cases presented, a total of 10 teeth were treated, as shown in Table 1. The average amount of gingival recession was 3.7 mm prior to treatment. At the re-evaluation, an average of 1.6 mm of recession was present. The average change was 2.1 mm, or 60% root coverage.
Table 2 shows the amount of change in papillary height. Prior to treatment, the average distance from the interproximal contact point to the height of the interdental papilla was 2 mm. At the re-evaluation, the average distance was 2.2 mm. Average change was 0.2 mm. This represents an average of about 10% shrinkage in papillary height. Only two of the 12 interdental papillae showed signs of change in height.
The goal of soft-tissue grafting is the establishment of a stable and natural-appearing soft-tissue architecture. Free gingival grafting is an effective method of improving the zone of attached keratinized gingiva with minimal trauma to the interdental papilla.10 It does, however, have problems associated with its palatal donor site wound and an unnatural appearance.
Papilla sparing techniques for gingival flap management have been used for many years to minimize shrinkage of the interdental papilla.11 Especially in Miller Class III cases, preventing further reduction in the interdental papilla would seem desirable. Tunnel techniques have been found to be effective in protecting the interdental papilla while achieving root coverage and improving the gingival thickness.5-9
The palatal connective tissue graft (CTG) has been used for many years and has been considered the gold standard.12 CTGs have been shown to be effective when used in combination with a tunnel technique.5,6 With regards to Miller Class III gingival recession defects, complete root coverage was possible using CTGs if specific parameters were present.13 These parameters included interproximal soft-tissue integrity, reduced bone loss, a 2-mm graft thickness, and minimum recession width. A long-term comparison of root coverage using a CTG versus an ADM found CTGs to have superior results. After 3+ years, 84% of patients maintained complete root coverage with a CTG as compared to 32% with an ADM.14 Palatal tissue, however, does have issues regarding availability and thickness variability,15 while ADMs do not have these limitations. ADMs are supplied with a uniform thickness between 0.89 mm to 1.65 mm and are easily trimmed to desired dimensions. Unlike CTGs, ADMs must be completely covered.16
The two cases presented show the effectiveness of tunnel techniques using ADMs in the treatment of multiple Miller Class III recession defects. In Case 1, the ADM was placed through the intrasulcular space adjacent to the most distal tooth in the treatment site.5,6 A small flap was elevated in this area to facilitate graft placement and minimize esthetic impact. In Case 2, the ADM was easily placed using a lateral approach provided by vertical incisions via the “modified tunnel” technique.7,8 Using this technique, involvement of any interdental papilla was avoided. In both cases, the facial gingival was mobilized to provide tension-free placement of the flap over the graft and root surfaces. Using a lateral approach to graft placement allowed proper placement of the graft and protected the interdental papilla.
Given the Miller Class III classification and the amount of interproximal attachment loss, complete root coverage was not expected in either case.1 The primary consideration in grafting these teeth was improvement in the gingival thickness to reduce the risk for future deterioration. Improvement in gingival thickness, as well as root coverage, was seen with all teeth in both cases. An average of 2.1 mm (60%) of root coverage was achieved. Minimal reduction in interdental papilla height was found.
Longer-term follow-up would be valuable in determining stability. While two cases do not provide statistically significant information, the clinical results indicate that a lateral tunnel approach can be useful in treating multiple Miller Class III recession defects in terms of improving gingival thickness, increasing root coverage, and protecting the interdental papilla in the maxillary and mandibular anterior sextants.
The use of tunnel techniques with an ADM can be an effective method for treating multiple teeth with Miller Class III recession defects. Root coverage can be achieved while protecting the interdental papilla and maintaining its height.
About the Authors
Douglas H. Mahn, DDS
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