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Periodontology2000, Vol. 11,1996,3948 Printed in DeiiinarL. All rights reserved

Copyright 0 M u n t s g a a r d 1996

PERIODONTOLOGY 2000 ISSN 0906-6713

Double pedicle flap predictability and aesthetics using connective tissue RANDALL J. HARRIS

The search for the perfect root coverage technique has taken many differing approaches. The ideal technique must be predictable in producing aesthetic root coverage in a wide variety of clinical situations. Additionally, the root coverage obtained should be aesthetic to the patient and the clinician.

Several techniques have been used over the years with various degrees of success.

Historically, the lateral pedicle graft was utilized for root coverage (7, 8). There were problems associated with this technique, such as incomplete root coverage and recession in the donor area (7,9, 25). Moreover, the lateral pedicle procedure was limited to cases where there was an adequate donor area adjacent to the teeth being treated.

Several other approaches were proposed to solve this limitation.

One approach to overcome the limitations of the lateral pedicle graft was to use different types of pedicle grafts, including coronally positioned pedicles, obliquely positioned pedicles and double papilla pedicle grafts (1). The goal of these procedures was to elevate tissue near the defect and position it over the exposed root. Defects treated with pedicle grafts had the advantage of superior aesthetics and color match because of the similarity of the adjacent donor tissue.

In cases where there was not adequate keratinized tissue adjacent to the defect to be treated, a free gingival graft could be performed prior to a pedicle graft. After allowing the free gingival graft to heal, a pedicle graft could be performed. However, the resulting aesthetics had the color associated with a free gingival graft. This technique also had the disadvantage of two separate surgical procedures (2,4, 16,171.Maynard

(17) suggested a possible variation of performing the pedicle graft first and then placing a free gingival graft.

When Miller (18, 19) demonstrated a more predictable result with a thick free gingival graft, the advantages of the two step, free gingival graft followed by a pedicle graft technique disappeared.

Laney et al. (13) compared the thick free gingival graft technique against the two-step technique and found no difference between the methods. The thick free gingival graft described by Miller had many advantages over the lateral grafts and the two step grafts. The predictability of his technique and the ability to use it in a wide variety of clinical situations led to the technique’s rapid assimilation into periodontal practice. The downside of the technique related to the sensitive nature of the procedure (20), the sometimes bulky results and the color discrepancy between the grafted tissue and the surrounding tissue (15).

The major restriction in using pedicle grafting procedures was related to the need for an adequate donor area adjacent to the area to be treated. In the case of a coronally positioned pedicle, there must be adequate tissue apical to the defect. In the case of the obliquely positioned graft, the tissue must be adjacent, either mesial or distal, to the defect. The double papilla grafting technique evolved from treating defects where the sum of the tissue mesial and distal to the defect was adequate to cover the defect (10).

Cohen & Ross (6) proposed the use of the double papilla graft in 1968.Their technique was similar to the obliquely positioned pedicle graft (23), only it was performed on both the mesial and distal aspects of the defect. The pair of obliquely

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Harris

Fig. 1. a. Preoperative recession on tooth 27; caries is present on the exposed root surface. b. Preoperative recession on tooth 27; pencil mark was used to mark the goal of root coverage procedure (since cementoenamel junction can not be delineated). c. Postoperative 4 months.

Fig. 2. a. Preoperative recession on tooth 11.b. Root surface following root planing and preparation with tetracycline. c. Incisions to outline pedicle flaps. d. Reflection of partial thickness pedicle flaps. e. Pedicle flaps sutured together. f. Connective tissue graft sutured into recipient site over root surface. g. Pedicle flaps sutured over connective tissue graft and denuded root surface. h. Postoperative 1 week. i. Postoperative 4 months.

positioned pedicles were sutured together over the defect. The indications for the procedure included recession areas with intact healthy papilla adjacent to the defect and no other more predictable procedure possible (1, 6, 10). The contraindications included the adjacent papilla being

relatively small or the presence of a gingival groove in the papilla (1, 10). Cohen & Ross’s (6) results were drawn from their clinical experience of using the surgical treatment for 5 years. They reported “more than 85% success in repairing denuded root surfaces”. Their results produced a “postoperative

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Predictability and aesthetics using connective tissue

probing (that) averages about 1 mm”. No data or statistical analysis was presented. Neither the total number of cases treated nor the follow-up period was reported.

The double papilla graft has had little written about it since Cohen & Ross proposed the technique. In 1984, Hall (10) stated that the double papilla graft had “a very low predictability of success in most practitioners’ hands. Most of the published cases are shown less than six months postoperatively. Many of these grafts seem to split down the middle with time.” This low probability of success and possible complications, even where the graft was initially successful, limited the number of

practitioners willing to perform the procedure. In 1989, the World Workshop in Clinical Periodontics (1) concluded that “the double papilla pedicle has very limited usefulness”. The greatest weaknesses of the procedure were the poor predictability and the technical skill levels required to perform the procedure successfully. The greatest strength of the procedure relates to the extremely aesthetic results obtainable with the procedure. This becomes more important when the color of the palate is significantlydifferent from the area being treated or there is inadequate donor tissue adjacent to the area to permit the use of more predictable pedicle procedures. It was recommended that the double

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pedicle graft still be utilized in specific situations because “no alternative to meeting the specific combined therapeutic and aesthetic needs in such (certain specific) cases exists” (1).

To address the problem of predictability of the double papilla graft, Nelson (21) proposed a technique combining a free connective tissue graft (similar to that used by Langer & Langer (15) and Raetzke (24)) with a full-thickness double papilla pedicle graft, when treating isolated defects. He used a free connective tissue graft combined with a lateral pedicle graft when treating multiple tooth cases. The flaps were full thickness pedicle flaps rather than the partial thickness flaps utilized by Cohen & Ross (6). The results in all cases treated revealed a mean root coverage of 91%. In Nelson’s technique for treating isolated defects, some of the problems associated with the double papilla pedicle graft seemed to be eliminated. The placement of a connective tissue graft between the pedicles and the defect improved the predictability of the procedure while still retaining the excellent aesthetics of the double papilla graft. Nelson suggested that the function of the connective tissue graft was to prevent the clefting seen with a double papilla graft. The results tended to be thicker than the results of a pedicle graft, but there was no mention of needing a secondary gingivoplasty (6).

The next modification involving the double papilla graft was proposed by Harris in 1992 (11).

The technique involved the use of partial-thickness double pedicle flaps overlaying a free connective tissue graft. The double pedicle design was utilized in both isolated and multiple tooth cases. The double pedicles were a slightly different design than the double papilla used by Cohen & Ross, who included papillary tissue occlusal to the cementoenamel junction. The double pedicle flap proposed by Harris (11, 12) only involved tissue apical to the cementoenamel junction. This was done so that the recipient bed would have butt joints at the cementoenamel junction. This design had many similarities to the recipient bed used by Miller (18-20, 14) for a thick free gingival graft. The major difference was the retention and repositioning of the tissue adjacent to the defect. In the Miller technique, this tissue was excised. The connective tissue with partial-thickness double pedicle graft seemed to eliminate the problem of predictability seen with the double papilla technique proposed by Cohen & Ross (6). At the same time, the technique maintained the high

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degree of aesthetics associated with pedicle procedures. Another interesting outcome of the procedure was that there did not seem to be the same learning curve as associated with other procedures. Even from early attempts, a high rate of success was obtained (11, 12).

Surgical technique The connective tissue with partial-thickness double pedicle graft has many similarities with other techniques used in root coverage procedures. After adequate anesthesia was obtained, the exposed root surface was root planed. The goal is to eliminate any calculus, bacteria, bacterial contamination, “glassy” areas on the exposed root and soft tooth structure, and caries. Additionally, any root prominence that could be reduced without removal of excessive tooth structure was eliminated.

Universally, root planing seems to be a common step to most root coverage procedures.

The presence of caries on the exposed root is generally not a major problem. The only concern is related to the depth of the caries (and the possibility of a pulpal exposure) and the location of the caries relative to the cementoenamel junction.

The closer the carious lesion is to the cementoenamel junction, the greater the possible problem in creating a smooth area for the gingival margin. Fig. 1 shows a case with caries extending to the cementoenamel junction. When determining the final location of the gingival margin may be difficult, it may be helpful for patient education and treatment planning to mark the proposed final gingival margin with a pencil (Fig. 1b, c).

The exposed root surface was treated with a tetracycline solution. The concentration of the solution was 125 mg of tetracycline per milliliter of saline. This solution was burnished into the exposed root surface with cotton pledgets for 3 minutes. The tetracycline treatment was utilized in a similar manner to other techniques using citric acid (18-20). Although the need for this modification of the tooth surface is controversial, many clinicians use some form of biomodification of the root surface when attempting root coverage procedures (20). After the root surface was treated with tetracycline, the area was rinsed with water and dried with the air from a 3-way syringe. The resulting surface appeared frosted (Fig. 2a, b, 3a, b).

Predictability and aesthetics using connective tissue

If there was a frenum near the tooth being treated, then it was evaluated at this time. A frenum was judged to be a factor only if it was possible to move the gingival margin in the area of the defect by placing tension on the tissue buccal to the defect. This “pull� on the gingival margin was eliminated by a superficial dissection of the frenum. The frenectomy was accomplished in this manner so that it would be possible to reflect the tissue in the area without creating a perforation.

The incisions were significantly different from a conventional frenectomy. The need to perform this step has not been confirmed.

Incisions were made to create the double pedicles and a recipient bed with butt joint margins. In isolated tooth cases a pair of horizontal incisions were made starting at the cementoenamel junction mesial and distal to the defect and extending toward the adjoining tooth.

These incisions were terminated approximately 0.5 mm from the adjoining tooth. At the termination of the horizontal incisions, a vertical incision was made apically into the alveolar mucosa.

These incisions were made perpendicular to the gingival surface so they would create butt joints in the surrounding tissue.

The pair of initial horizontal incisions were connected with a sulcular incision (Fig. 2c). In multiple tooth cases, the incisions were similar except that an additional horizontal incision was made between the cementoenamel junctions of the adjoining defects (Fig. 3c).

Partial-thickness pedicle flaps were reflected by sharp dissection as close to the periosteum as possible (Fig, 2d, 3d). Any marginal tissue that appeared chemically cauterized by the tetracycline or damaged was excised. In isolated tooth cases, the pedicles were joined with 5-0 gut sutures (Fig. 2e). In multiple tooth cases, the pedicle between the defects was bisected with a vertical incision.

Each half of the original pedicle was treated as a separate pedicle. The pedicles were sutured to the pedicle on the opposite side of the defect with 5-0 gut suture (Fig. 3e). In this manner, it was possible to bring blood flow from the mesial and distal of all defects to the area over the avascular root. The sutured double pedicle flaps were placed over the defects to be sure that they would remain without being supported (Fig. 3f).

Several techniques exist for obtaining a suitable connective tissue graft from the palate. The choice of technique was a matter of operator preference.

In the series of articles examining the connective tissue with partial-thickness double pedicle graft (11,121the parallel incision method was used most often. This technique has proven itself to be a reliable technique with minimal postoperative complications.

After obtaining adequate anesthesia, parallel incisions were made in the palate (Fig. 4a). To aid in keeping the blades separated at a predetermined distance, a scalpel with parallel blades (Harris Double Blade Graft Knife (1.0 mm or 1.5 mm), H & H Company, Ontario, CA) was used (Fig. 4b). This instrument removes some of the variability associated with free-hand dissection techniques. One single 10- to 12-mm deep pass of the instrument was made.

Vertical releasing incisions were made from the external incision, if necessary, to improve access. A 4-0 silk suture was placed through the palatal tissue to retract the palatal flap (Fig. 4c). The tissue between the two original parallel incisions was dissected free. The tissue was placed in and covered by saline-soaked gauze. The donor area was closed with the silk suture used to retract the palatal flap (Fig. 4d). The graft was trimmed to remove the epithelial border and adjusted in the mesial distal dimension to fit the recipient site (Fig. 4e). Although not all root coverage techniques remove this epithelial border, the need to retain it has not been documented. It has been suggested that removal of the epithelial border may reduce the chance of problems and possible cyst formation (22). However, none of the studies that leave the epithelial border have reported any complications (14).Any glandular or adipose tissue present in the graft was not removed.

The graft was sutured into the recipient site with 5-0 gut sutures at the corners of the graft. The goal was to passively inlay the graft into the recipient bed, making contact with the lateral borders as well as the base of the bed. Additional sutures were added, as needed, to assure good contact of the graft with the bed. No attempt was made to stretch the graft (Fig. 2f, 3g).

The previously joined pedicles were sutured over the connective tissue graft in the area of the original defect with a 5-0 gut sling suture (Fig. 2g, 3h). Isobutyl cyanoacrylate dressing (Iso-Dent@, Ellman International, Hewlett, NY) was applied to the area, being careful not to allow the material under the pedicles. A periodontal dressing (Barricaid@,Dentsply, L.D. Caulk Division, Milford, DE) was applied to the area. The dressing was

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Fig. 3. a. Preoperative recession on tooth 10 and 11 (tooth 9 was scheduled for a different root coverage procedure). b. Root surface following root planing and preparation with tetracycline. c. Incisions to outline pedicle flaps. d. Reflection of partial thickness pedicle flaps. e. Pedicle flap between tooth 10 and 11 bisected with a vertical incision and

the double pedicle flaps sutured together. f. Sutured double pedicle flaps placed over defects. g. Connective tissue graft sutured into recipient site over root surfaces. h. Pedicle flaps sutured over connective tissue graft and denuded root surfaces. i. Postoperative 1 week. j. Postoperative 12 weeks.

secured to the area with a piece of floss weaved through the interproximal spaces.

All patients were placed on 0.12% chlorhexidine gluconate (Peridex" Procter & Gamble, Cincinnati, OH) rinse for 4-6 weeks. No systemic antibiotics were used. Patients were advised not to pull on the tissue near the surgical site. Additionally, patients were told not to place ice on the surgical area.

Patients were seen at 1, 2, 4, 8 and 12 weeks for postoperative care. At the 1-week postoperative visit, the dressing and the silk suture used to retract the palatal tissue and close the donor area were removed (Fig. 2h, 3i, 4f). No attempt was made to remove any absorbable sutures still present. At this and all subsequent postoperative visits, plaque was removed from the teeth in the

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__

surgical area. Oral hygiene instructions were given, and the importance of good oral hygiene was stressed. For the first 4 weeks these instructions included brushing the incisal one-half of the tooth with a soft toothbrush and cleaning the gingival area with a cotton-tipped applicator. Additionally, patients were instructed to lightly “comb� across the surgical area with a cotton-tipped applicator.

Patients restarted gentle flossing as soon as it was possible. They were gradually returned to normal oral hygiene. After the 12-week evaluation, patients were returned to periodontal maintenance (Fig. 2i, 3j, 4g). With this root coverage technique, high levels of predictability were demonstrated, 97.4-97.7% mean root coverage. Complete root coverage, or 100% root coverage, was demonstrated in 80-89% of the cases, and the results were aesthetically pleasing (11, 12).

Complications As with any surgical procedure, operative and postoperative complications are possible. The connective tissue with partial-thickness double pedicle

Predictability arid aesthetics using connective tissue ~-

graft seems to have minimal complications. Similar to most soft tissue-grafting procedures using a separate donor area, the main source for potential problems is the donor area. This is consistent with clinical experience in using a free gingival graft.

However, an advantage of the connective tissue graft over the traditional free gingival graft is that the wound size is significantly smaller when harvesting a connective tissue graft. This decreases possible complications.

Several techniques have been developed to aid in the removal of a connective tissue graft for grafting purposes. All are well documented to produce a usable graft. It seems to be a matter of operator preference as to which technique to use.

The free-hand technique used by Langer & Langer (15), the trap door technique with periosteal elevator used by Nelson (21), a trap door flap with sharp dissection of the graft used by Calura et al.

(5), the free gingival graft knife technique described by Harris (11) and the parallel incisions method described previously have all been used successfully. The location from which the graft is removed is generally palatal to the premolars. This location provides a site with few anatomical hazards, thus limiting potential complications.

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Harris

Fig. 4. a. Parallel incisions in palate. b. Parallel blade scalpel (1.5 mm between blades). c. Reflect palatal tissue with suture. d. Sutured donor area. e. Graft in the process of being trimmed. f. Postoperative 1 week donor area. g. Postoperative 6 months donor area.

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Predictability and aesthetics using connective tissue

However, other areas, such as the tuberosity region or an edentulous ridge, can also be utilized.

The most common clinically significant complication encountered when using a connective tissue with partial-thickness double pedicle graft was a bulky result. These results were more objectionable to the clinician than the patient. The patients were generally pleased to have “too much tissue� rather than the exposed root surfaces. It was sometimes difficult to convince patients to undergo minor procedures to improve the results, because they did not perceive a problem. A gingivoplasty was performed in 10% of the cases treated in a recent study (12).

Incomplete root coverage does occur in some cases. In a recent study of 100 consecutively treated defects, 11%of the defects still had some exposed root structure after treatment (12). This was not a clinically significant factor in most cases because the amount of exposure was not noticed by the patient. Only 4% of the defects had greater than 0.5 mm of recession after therapy. In that study all results were considered clinical successes.

Another complication that can occur when using a connective tissue with partial-thickness double pedicle graft is visibility of the outline of the connective tissue graft. The graft prominence seemed more pronounced in areas where the overlying tissue in the area was relatively thin. This prominence seemed to diminish with time in most cases. However, in some cases it was still possible to see the outline of the graft for as long as the patients were followed. A secondary procedure (gingivoplasty)was suggested to reduce these areas in some cases. However, in most cases the patient did not seem concerned enough about the area to have a secondary procedure done.

The color match is not perfect in all cases.

Occasionally, there was a slight color discrepancy between the grafted area and the surrounding tissue. Additionally, sometimes slight scar lines could be seen in the area. Both of these problems seemed to diminish with time and were judged significantly less pronounced than in cases treated with a thick free gingival graft.

by Cohen & Ross. The most important is the documented predictability. The addition of a free connective tissue graft with redesigned pedicles, precise recipient bed preparation and tetracycline treatment of the exposed roots seem important in achieving this predictability. Clinically, the results retain the good aesthetics demonstrated with any pedicle graft combined with the predictability of the thick free gingival graft. Several other techniques enjoy similar results. All of these techniques involve a free connective tissue graft with a pedicle graft or envelope bed. The subepithelial connective tissue graft proposed by Langer & Langer (15) combines a coronally positioned graft with a predominately connective tissue graft. The connective tissue graft technique described by Raetzke (24) uses an envelope bed. The subpedicle graft described by Nelson (21) combines a connective tissue graft with a full thickness double papilla graft or a lateral pedicle graft. The choice of technique should depend on the clinical situation and operator preference. To say one technique is superior in all cases would be a mistake. Clinicians should choose the technique that they determine would produce the best clinical result in a given situation.

Conclusions The double papilla graft described by Cohen & Ross has limited indications. The technique has had minimal documentation and support compared with the other surgical procedures used to treat recession. The connective tissue with partialthickness double pedicle graft can be a useful technique in a variety of clinical situations. The technique combines the highly aesthetic results of a pedicle graft with the predictability and usefulness of the free gingival graft. The connective tissue with partial-thickness double pedicle graft is an effective and predictable method for obtaining aesthetic root coverage.

Acknowledgments Advantages

I designed and developed the double blade scalpel,

There are several advantages to the connective tissue with partial-thickness double pedicle graft compared with the double papilla graft described

Harris Double Blade Graft Knife, mentioned in this chapter. I thank Bill Holden of H & H Company for manufacturing and providing to me the double blade scalpels and several other instruments used.

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Harris

References 1. American Academy of Periodontology. Proceedings of the World Workshop in Periodontics. Chicago, IL: American Academy of Periodontology, 1989: VII-1-VII-21.

2. Bernimoulin JR Luscher B, Muhleman HR. Coronally repositioned periodontal flap. Clinical evaluation after one year. J Clin Periodontol 1975: 2: 1-13.

3. Caffesse RG, Guinard EA.Treatment of localized gingival recessions. 11. Coronally repositioned flap with a free gingival graft. J Periodontol 1978: 49: 357-361.

4. Caffesse RG, Alspach SR, Morrison EC, Burgett FG. Lateral sliding flaps with and without citric acid. Int J Periodontics Restorative Dent 1987: 7: 42-57.

5. Calura G, Giustiniano M. Parma-Benfenati S, De Paoli S, Lucchesi C, Fugazzotto PA. Ultrastructural observations on the wound healing of free gingival connective tissue grafts with and without epithelium in humans. Int J Periodontics Restorative Dent 1991: l l: 282-301.

6. Cohen DW, Ross SE. The double papilla repositioned flap in periodontal therapy. J Periodontol 1968: 39: 6570.

7. Groupe HE. Modified technique for the sliding flap operation. J Periodontol 1966:37: 491-495.

8. Groupe HE, Warren RE Repair of gingival defects by a sliding flap operation. J Periodontol 1956: 27: 92-95.

9. Guinard EA,Caffesse RG. Treatment of localized gingival recessions. I. Lateral sliding flap. J Periodontol 1978: 49: 351-356.

10. Hall WB. Pure mucogingival problems. Chicago, IL: Quintessence Publishing Co., 1984: 117-126.

11. Harris RJ. The connective tissue and partial thickness double pedicle graft: a predictable method of obtaining root coverage. J Periodontol 1992:63: 477-486.

12. Harris RJ. The connective tissue mith partial thickness double pedicle graft: the results of 100 consecutively treated defects. J Periodontol 1994: 65: 448-461.

13. Laney JB, Saunders VG, Garnick JJ. A comparison of two techniques for attaining root coverage. J Periodontol 1992: 63: 19-23.

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14. Langer L. Enhancing cosmetics through regenerative periodontal procedures. Compendium 1994: 18(suppl): S699-S705.

15. Langer B, Langer, L. Subepithelial connective tissue graft technique for root coverage. J Periodontoll985: 56: 715-720.

16. Liu WJ, Solt CW. A surgical procedure for the treatment of localized gingival recession in conjunction with root surface citric acid conditioning. J Periodontol 1980: 51: 505-509.

17. Maynard JG. Coronal positioning of a previously placed autogenous gingival graft. J Periodontol 1977: 48: 151155.

18. Miller PD. Root coverage using the free tissue autograft citric acid application. I. Technique. Int J Periodontics Restorative Dent 1982: 2: 65-70.

19. Miller PD. Root coverage using the free tissue autograft citric acid application. 111. A successful and predictable procedure in deep-wide recession. Int J Periodontics Restorative Dent 1985: 5: 15-37.

20. Miller PD. Root coverage with the free gingival graft: factors associated with incomplete coverage. J Periodontol 1987: 58:674-681.

2 1. Nelson SW. The subpedicle connective tissue graft, a bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontoll987: 58: 95-102.

22. Ouhayoun JI? Khattab R, Serfaty R, Feghaly-Assaly M, Swarf MH. Chemically separated connective tissue grafts: clinical application and histological evaluation. J Periodontoll993: 64: 734-738.

23. Pennel BM, Higgason JD, T o w e r JD, King KO, Fritz BD, Salder JF. Oblique rotated flap. J Periodontol 1965: 36: 305-309.

24. Raetzke PB. Covering localized areas of root exposure employing the “envelope� technique. J Periodontol 1985: 56: 397-402.

25. Smukler H. Laterally repositioned mucoperiosteal pedicle grafts in the treatment of denuded roots. J Periodonto1 1976: 47: 590-595.