DEPARTMENT OF

PERIODONTOLOGY
AND
IMPLANTOLOGY

ROOT COVERAGE PROCEDURES

Santosh Palla, CRRI

Introduction
The term ,Mugogingival
surgery (MGS) was coined
by Friedman, for surgical
alterations in relation to
gingival oral mucosa

BUT now Periodontic-plastic

surgery( Miller 1993) is
acceptable replacement for
the MGS which broadly
includes
1.
Perio-prostho Corrections
2.
Crown lengthening
3.
Root coverage procedures
4.
Papilla reconstruction
5.
Esthetic surgery for implants
6.
Exposure of unerrupted teeth
for Orthodontics

REF: TEXTBOOK OF PERIODONTOLOGY F.Carranza 10,11 th editions

What / Why root

coverage??
1.

Gingival recession
Gingival recession is
defined as exposure of
the root surface due to
a displacement of the
gingival margin apical
to the cemento-enamel
junction*
2.Esthetics
3.Sensitivity symptoms
Ref :Kassab MM, Cohen RE. The etiology and prevalence of gingival recession.
J Am Dent Assoc 2003;134:220-5.

The Disease
Understanding Gingival
recession and its
staging is a must before
peeping into its Surgical
correction
Lets me remind you PD
Millers Classification
REF: Miller Jr PD. A classification of marginal tissue recession.
Int J Periodontics Restorative Dent 1985;18:444-53.

Root Correction
procedures
Its fact that class III
and IV recession cases
have poor prognosis.
Most of the Root
coverage is
implemented for I,II
sometimes III classes.

REF: Decision-making in aesthetics: root coverage revisited PHILIPPE BOUCHARD,

JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000

Free Soft tissue grafts

Free gingival auto graft
Millers classical method
Step1: root planning
Step2: prepare recipient site
Step3: obtain strips of free
gingival graft.
Step4: strips of gingiva
placed at recipient site and
sutured

Free Soft tissue grafts

Free connective tissue auto
graft; Levine,1991

Here the donor tissue is a

connective tissue,
otherwise procedure is
similar to free gingival auto
graft technique.
It could be submerged( under
a flap and sutured) or non
submerged
REF: Decision-making in aesthetics: root coverage revisited PHILIPPE BOUCHARD,
JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000

Pedicle soft tissue grafts

Laterally dispalced flap:
Grupe,Warren 1956.
Used for isolated areas of
denuded root having
adequate donor tissue
laterally.
Step1 prepare recipient site
Step2 partial thickness flap
is raised
Step3 transfer flap laterally
to cover root surface
Step4 protect flap and
donaor site.

Courtesy:
Decision Making in Aesthetics: Root coverage Revisited
PHILIPPE BOUCHARD, JACQUESMALET & ALAIN
BORGHETTI J Periodontology 2000

STEPS REF: TEXTBOOK OF PERIODONTOLOGY F.Carranza 10,th edin

Pedicle soft tissue grafts

Laterally dispalced flap:
Variations:
1. Converging oblique
incisions from recipient to
donor site
2. Preserving marginal
attachment at donor site
3. Sliding partial thickness
grafts from adjacent
edentulous area under flap
4. Use of two flaps
simultaneously
REF: Decision-making in aesthetics: root coverage revisited PHILIPPE BOUCHARD,
JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000

Pedicle soft tissue grafts

Coronally dispalced flap:
Making a split thickness flap
apical to denunded root and
its coronal placement is the
principle of these flaps
Step1 two vertical incisions,
Internal bevel incision to
remove pocket wall. Elevate
flap.
Step2 scaling ,root planning
Step3 return the falp and
suture coronally
VARIATION: submerging a
free gingival autograft under
flap.

Pedicle soft tissue graftsBridge flap method

Coronally dispalced flap:
(Semilunar incison method)
Tarnow technique.

Step1: semilunar incision

made to end 2-3 mm above
papilla of denuded root.
Step 2: make a split
thickness incision coronally
and connect it to
intrasulcular incision
Step3 : Coronally falling
tissue is repostioned 10
min and left as such.
IMAGE REF: Care report: Use of Coronally placed flaps in Root coverage with bridge
flap method.Pushpendra Kumar Verma1, Ruchi Srivastava2, TP Chaturvedi., IMS,BHU.

Sub-epithelial
connective tissue graft
Langer & langer 1985
introduced this method.
Indicated when large defects
with good vestibular health
and gingival thickness is
seen.
Here the donor tissue is
sandwiched between flaps.
Nelson 1987, proposed a
variant subpediclle
connective tissue flap to
improve blood circulation
quality.

Steps:
1. elevate partial thickness
flap carefully
2. Root palnning
3. Obtain graft
4. Palcement in recipient site
and suture with resorbalbe
material
5. Cover graft with outer
part of flap and suture
interdentally
6. Care of donor site and
dressing at surgical site

REF: TEXTBOOK OF PERIODONTOLOGY F.Carranza 10,th edin

Subepithelal Connective tissue

graft

GTR membranes
Pini-Parto et al.:Guided tissue

regeneration GTR
membranes used for large
defects root coverage
Tinti-vencenzi proposed
titanium membranes to
create additional space
beneath flap.
Second surgery is not required
in case of bio-resorbable
material

Steps:
1.

Full thickness MP flap raised

2.

GTR membrane placement

and adapted

3.

Suturing done with

membrane

4.

Flap repositioned coronally +

dressing

5.

weeks later GTR membrane

removed by small envolope
flap.

REF: TEXTBOOK OF PERIODONTOLOGY F.Carranza 10,th edin

GTR membrane

Pouch and tunnel

technique
It is technique that will
aid in intimate contact
of recipient to donor
site
Post surgical aesthetics
are superior after
this method so
indication for
maxillary anterors
IMAGE REF: Review of Tunnel technique in perodontic plastic surgery
Dr David Garber,DMD Maurice,Salama,DMD Henry salama,DMD 10-7-2008

Pouch- Tunnel technique

Steps:

5. Using sutures and curettes

connective tissue is place in
pouch and tunneled while
covering defective of root.

2.

6..Mesial and distal sites of donor

are sutured with catgut and
gingival flap is palced and
horizontal matress sutures uesd.

1.

3.
4.

Sulcular incision with

#15c blade around
recession
Tunnel is made beneath
adjacent buccal papilla
A split thickness pouch is
made apical to papilla
above 12mm defect
Pouch size(= defect area)
measured and equal donor
tissue borrowed

7.

Holding sutures can be given if

required along with periodontal
dressing.

Contents

IMAGE REF: Decision-making in

Aesthetics: Root coverage
Revisited : PHILIPPE BOUCHARD,
JACQUESMALET & ALAIN
BORGHETTI J Periodontology
2000

Root surface
modification agents
Additive treatments
AIM: to order to improve the biological link between the
root surface and the covering soft tissues.

citric acid and

tetracycline
hydrochloride* It has
been recommended to
treat the roots with pH 1
citric acid for 3 min or
with tetracycline (50125
mg/ml for 35 min).

Enamel matrix proteins

Use for time lag of 2
min with a 24%
EDTA containing
enamel (Enamel matrix
proteins gel) P gel
onto root surfaces

REF *:Bouchard P, Nilveus R, Etienne D. Clinical evaluation of tetracycline HCl

conditioning in the treatment of recessions.. J Periodontol 1997 68: 262269

Prognosis??
Prediction of outcome of root
coverage procedures is
based on millers class
defect treated
ClassI , Complete root
coverage achieved
class II, Complete root
coverage may be achieved
Class III Complete root
coverage never achived
, Class IV Any root coverage
not pridicted
REF: Decision-making in aesthetics: root coverage revisited PHILIPPE BOUCHARD,
JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000

Conclusion
Patients general
health, evaluation of
gingival and periodontal
status and
requirements as per
degree of defect must
be understood prior to
choosing one amongst
the various Root
Coverage procedures
AESTHETICS are prime concern in modern world, sensitivity how ever is
the next,,,

I Saw all these things.

INFORMATION :
1. TEXTBOOK OF PERIODONTOLOGY Femin A .Carranza 10,11 th editions
2 Ref :Kassab MM, Cohen RE. The etiology and prevalence of gingival recession.J Am
Dent Assoc 2003;134:220-5
3. REF: Miller Jr PD. A classification of marginal tissue recession. Int J Periodontics
Restorative Dent 1985;18:444-53.
4 Care report: Use of Coronally placed flaps in Root coverage with bridge flap method.
Pushpendra Kumar Verma1, Ruchi Srivastava2, TP Chaturvedi., IMS,BHU.
5. Review of Tunnel technique in perodontic plastic surgery Dr David Garber,DMD
Maurice,Salama,DMD Henry salama,DMD 10-7-2008
6. :Bouchard P, Nilveus R, Etienne D. Clinical evaluation of tetracycline HCl conditioning
in the treatment of recessions.. J Periodontol 1997 68: 262269
7. Decision-making in Aesthetics: Root coverage Revisited : PHILIPPE BOUCHARD,
JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000
IMAGE REF: Care report: Use of Coronally placed flaps in Root coverage with bridge flap
method.Pushpendra Kumar Verma1, Ruchi Srivastava2, TP Chaturvedi., IMS,BHU
IMAGES:.
1. Review of Tunnel technique in perodontic plastic surgery Dr David Garber,DMD
Maurice,Salama,DMD Henry salama,DMD 10-7-2008
2. *:Bouchard P, Nilveus R, Etienne D. Clinical evaluation of tetracycline HCl conditioning
in the treatment of recessions.. J Periodontol 1997 68: 262269
3 .Decision-making in Aesthetics: Root coverage Revisited : PHILIPPE BOUCHARD,
JACQUESMALET & ALAIN BORGHETTI J Periodontology 2000
4. AND NOT BUT NOT THE LEAST WWW.Google.com.....