Department of Periodontics, Manipal College of Dental Sciences, Manipal University, Mangalore 575001, IndiaIndia
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Background: The periosteum being a highly cellular connective tissue also has a good regenerative potential. This quality makes it a suitable for use as autogenous graft. Here, is technique, the inverted periosteal technique that utilizes this property of the periosteum and is used for root. Method: Four patients with Miller Class I and II recessions ≥3 mm were treated utilizing the inverted periosteal technique. Results: At the end of 6 months, satisfactory results were achieved. Conclusion: The inverted periosteal technique can be used for the treatment of gingival recession defects in multiple teeth successfully.
Keywords: Gingival recession; Inverted periosteal technique; Periosteum
Gingival recession causes an esthetic as well as discomfort due to dentinal hypersensitivity to the patient. For the treatment of these cases, a need for a graft for root coverage which has its own blood supply, regenerative potential and that which can be harvested adjacent to the recession defect in sufficient amounts without requiring any second surgical site is required.
One such autogenous graft material is the periosteum, which is highly cellular, rich in 1,2 vascularity and has a high regenerative potential.1,2
The alveolar bone is covered by periosteum and the endosteum. The periosteum consists of progenitor cells responsible for regenerating new cells which differentiate into osteoblasts aiding in the formation of new bone and soft tissue,which is made use of in this case 3,4 series.3,4
Four patients in the age group of 25-40 years reported to the outpatient department of periodontology who were randomly selected for this procedure. The four recruited patients had Millers Class I or II recession defects of ≥3 mm in upper/lower anterior teeth or premolars, there was no periapical involvement in the selected teeth, and all were systemically healthy
The patients were explained about the procedure and a written informed consent was
recession and the thickness of attached gingiva. These recordings were taken at baseline and 6 months post operatively. (Table 1) (Figure 1)
Pre-op measurements of recession Post-op results (In mm) (In mm) Operated case Age sex Thickness Thickness area Length Width of attached Length Width of attached
13 3 3 2 0 0 2 1. 36 yrs F 14 5 3 2 0 0 2 15 2 3 1 0 0 2 13 5 5 2 0 0 2 2. 32 yrs F 14 5 5 1 0 0 2 15 3 5 1 0 0 1 31 5 5 1 1 1 2 32 5 5 1 2 2 2 3. 27 yrs F 41 5 5 1 1 2 2 42 5 3 1 2 3 2 31 3 5 2 2 2 2 4. 39 yrs M 32 3 3 1 2 1 2 41 3 3 1 2 1 2
All the surgeries were performed under local anaesthesia using 2% lignocaine hydrochloride containing 1:1000000 epinephrines. Once the area was anaesthetized, with a number 15C blade, horizontal incisions were made perpendicular to the adjacent interdental papillae at the level of the CEJ preserving the gingival margin of the affected teeth along with sulcular incisions on the buccal/facial aspect of the involved teeth. At the line angles of the distal most and the mesial most teeth, vertical incisions extending beyond the mucogingival junction were given. A partial thickness flap was then elevated till an adequate
amount of periosteum was exposed (Figure 2).
gingiva gingiva
Partial thickness flap reflected
A horizontal incision was then given at the apical extent of the periosteum where it was attached to the bone. A periosteal elevator was used to separate the periosteum from the underlying bone, and was reflected coronally to an extent where it was still attached to the bone (Figure 3).
placement of a periodontal dressing (voco-pac). Post-operative instructions were given. All the patients were prescribed antibiotics and analgesics. (Amoxicillin-500 mg to be taken thrice daily for 5 days and lyser-D to be taken twice daily for 2 days).
The surgical area was healing uneventfully (Figure 6).
At the end of 6 months, complete root coverage was achieved on two of the patients with good color resemblance with the surrounding tissues. In the other two patients, about
3mm coverage was achieved. It was also noticed that the thickness of the attached gingiva was increased by about 1mm. It was observed that the root coverage and the thickness of the attached gingiva achieved with this technique remained stable.
The ultimate goal of the clinician should be to improve patient care and satisfy their requirements. Root recession can cause discomfort to the patient with the presence of teeth hypersensitivity and root caries, esthetics could also be a cause of concern in some patients. One of the techniques for root coverage is the inverted periosteal technique.
The use of periosteum in medicine and dentistry is not new. The use of Periosteum as a barrier membrane for the treatment of periodontal defects has been reported by Lekovic et al. They observed similar gain in clinical attachment level which was comparable to the gain in clinical attachment levels with use 5,6 of other barrier membranes.5,6
The potential of using Periosteum for root coverage is because it is a highly vascular tissue and because of the presence of osteoprogenitor cells in the inner layer, which have been pub- 7,8 lished in various research papers.7,8
Wound healing after periodontal plastic surgery depends on clotting, revascularization and maintenance of blood supply. Also, a vascular graft is more likely to survive on an avascular root surface. The periosteum has a rich vascular plexus. A recent study showed that periosteal cells release vascular endothelial growth factor these qualities make periosteum a suitable graft 9,10 over an avascular root surface.9,10
Also, with this technique it was noticed that the thickness of attached gingiva increased.
Among all the root coverage procedures, subepithelial connective tissue having the highest predictability rate is
sidered to be the gold standard.11 The main shortcoming of this technique is that it requires a second surgical site for the harvesting of the connective tissue.
The advantage of the inverted periosteal technique is the presence of periosteum adjacent to the defect and in sufficient quantity avoiding two surgical sites, resulting in less surgical trauma, postoperative complications and better patient satisfaction.
Gingival recession is one of the most common periodontal problems that can cause aesthetic problems to the patient. The need for developing newer techniques for root coverage is to increase predictability, reduce the number of surgical sites, and improve patient comfort together with the need to reconstruct the lost periodontal tissues. One such technique is the inverted periosteal technique as it can be harvested adjacent to the recession defect in sufficient amounts.
Without requiring any second surgical site, and has the potential to promote the regeneration of lost periodontal tissue. The long-term complications of this technique, e.g. the potential for resorption of root surface by the periosteum are yet to be assessed. Further studies are necessary to support its regular use.