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 Table of Contents  
Year : 2022  |  Volume : 17  |  Issue : 4  |  Page : 949-953

Periosteal pedicle graft: A leading technique for the treatment of single and multiple recession defects: A case series

Department of Periodontology, JSS Dental College and Hospital, Mysuru, Karnataka, India

Date of Submission27-Feb-2022
Date of Decision07-Oct-2022
Date of Acceptance10-Oct-2022
Date of Web Publication10-Feb-2023

Correspondence Address:
Dr. Vidya Priyadharshini
Department of Periodontology, JSS Dental College and Hospital, Bannimantap, Mysuru - 570 015, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_84_22

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Gingival recession is a very common periodontal defect where gingiva moves apically and results in the exposure of root surface causing hypersensitivity, root caries that further leads to shallow vestibule and narrowing the amount of attached gingiva. Various surgical techniques are performed multiple times to get predictable results. In order to avoid patients' discomfort and number of invasive procedures, an intense need for an autograft is required, which has an adequate vascular supply and can be obtained from the same surgical site. Hence, we presented a case series where periosteal pedicle graft is used in treating Miller's class I and II single and multiple recession defects and its effectiveness over a 6-month period.

Keywords: Gingival recession, multiple gingival recession defects, periosteal pedicle graft, root coverage

How to cite this article:
Maity S, Priyadharshini V, Nisha S, Shashikumar P. Periosteal pedicle graft: A leading technique for the treatment of single and multiple recession defects: A case series. J Datta Meghe Inst Med Sci Univ 2022;17:949-53

How to cite this URL:
Maity S, Priyadharshini V, Nisha S, Shashikumar P. Periosteal pedicle graft: A leading technique for the treatment of single and multiple recession defects: A case series. J Datta Meghe Inst Med Sci Univ [serial online] 2022 [cited 2023 Apr 1];17:949-53. Available from: http://www.journaldmims.com/text.asp?2022/17/4/949/369521

  Introduction Top

The primary concern of periodontal plastic surgery is esthetic and functional rehabilitation of the periodontium. Gingival recession is one such periodontal defect where the gingiva moves apically that exposes the root surface forming shallow vestibule and decreases the width of the attached gingiva.[1]

Among various root coverage procedures, subepithelial connective tissue graft (SCTG) is still a gold-standard technique. The new techniques are emerging with an aim to avoid the second surgical site which causes severe postoperative pain to the patients. Thus, to increase the predictability with optimal esthetic demand, there is an intense need for an autograft having optimum blood supply and can be obtained from the same surgical site.[1]

Gaggl et al. first described the utilization of periosteum for root coverage,[2] and the procedure using periosteal pedicle graft (PPG) was described by Mahajan.[1] Periosteum is highly vascular with rich source of pluripotent stem cells that differentiates into a variety of cell types. It has the potential to regenerate periodontium and helps in promoting neovascularization.[3]

The present case series assessed the usefulness of PPG with coronally advanced flap (CAF) procedure in the treatment of Miller's Class I and II single and multiple recession over a 6-month period.

  Case Series Top

Four systemically healthy patients, nonsmokers, with Miller's Class I and II single and multiple recessions of ≥4 mm with an adequate width of attached gingiva were included [Table 1] and [Figure 1], [Figure 2], [Figure 3], [Figure 4]. Of four patients, two patients came with a chief complaint of sensitivity and two patients had a complaint of unesthetic appearance. The patients were referred to the department of periodontology and enrolled for the treatment from October 2018 to April 2019.
Table 1: Baseline defect characteristics and clinical measurements

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Figure 1: Preoperative view of patient A

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Figure 2: Preoperative view of patient B

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Figure 3: Preoperative view of patient C

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Figure 4: Preoperative view of patient D

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Presurgical procedure

All the patients with written consent underwent phase I therapy. Preclinical measurements were taken by one examiner. These are as follows:

  • Cementoenamel junction (CEJ): The reference point.
  • Recession depth: From CEJ to gingival margin.
  • Recession width: The widest point from mesial to distal gingival margin.
  • Clinical attachment level (CAL): From CEJ up to the base of sulcus.
  • Width of keratinized gingival (KG): From gingival margin to the mucogingival junction.

All the parameters were measured at the baseline, 3, and 6 months.

Surgical procedure

One month followed by phase I therapy; the surgical procedures were carried out by a single periodontist. After injecting local anesthesia, CAF was preceded with the placement of horizontal and intracrevicular incisions on the involved teeth. Two vertical releasing incisions were extended beyond the mucogingival junction [Figure 5]. Using 15c blade, a split thickness flap was reflected [Figure 6]. Muscle tension was released apically to mobilize the flap, and periosteum was exposed. The facial interdental papillae were de-epithelialized properly to get a connective tissue surface. A thorough root planing was done [Figure 7]. A horizontal incision was placed at the most apical extent of the periosteum which is attached to the bone. Periosteum was separated, leaving the coronal extent that acted as a pedicle graft. The reflected periosteum was inverted onto the denuded root surface [Figure 8] and secured with absorbable suture [Figure 9]. The overlying flap was coronally advanced and sutured [Figure 10]. Light finger pressure application was done for 5 min to remove dead spaces and covered with noneugenol periodontal pack.
Figure 5: Incisions

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Figure 6: Partial thickness flap reflected

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Figure 7: Root planing done

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Figure 8: Periosteum reflected and inverted on the root surface

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Figure 9: PPG sutured with Vicryl. PPG: Periosteal pedicle graft

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Figure 10: Flap coronally advanced and sutured

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Antibiotics and analgesics were prescribed. Patients were advised not to brush in the surgical site for 2 weeks. The brushing technique was modified. Follow-up appointments were scheduled weekly for the 1st month and then at 3rd and 6th month to assess the clinical parameters.

  Results Top

Healing was uneventful after 2 weeks. Complete root coverage was noticed in all the cases with increased width of attached gingiva, no variation in probing depths, and a favorable esthetic result after 6 months was noted from the clinical appearance of the sites and from the perspective of patients [Figure 11], [Figure 12], [Figure 13], [Figure 14] and [Table 2].
Figure 11: 6 months' postoperative of patient A

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Figure 12: 6 months' postoperative of patient B

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Figure 13: 6 months' postoperative of patient C

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Figure 14: 6 months' postoperative of patient D

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Table 2: Difference of the selected parameters over 6 months' observation period

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  Discussion Top

The periosteum is a “Sleeping Giant” that starts its action during surgical trauma, providing “a river of regenerative tissue” that displays collagen and ultimately osteogenesis.[3] In 1998, Kwan et al. compared periosteum and connective tissue as a barrier membrane for the treatment of recession defects, resulted in successful resolution of interproximal defects using periosteal graft.[4] Gamal and Mailhot in 2008 showed the CAL gain with periosteal pedicle flap in intrabony defects, which proved a superior treatment option for open flap debridement.[5] This result forwarded Gamal et al. in 2010 to present a histologic study with PPG as guided tissue membrane. Coarse-fibered woven bone filled the defect in 9 months with cementum-like tissue deposition in apical root notches.[6] However, there are very limited histopathological studies with PPG available to confirm the presence of regenerative components in the treatment of gingival recession.[7],[8]

Our case series showed complete root coverage with the optimum esthetic outcome and patient satisfaction with PPG over a 6-month period. The result is in accordance with the study done by Mahajan in 2009 where all defects were completely covered after 1 year, considering periosteum as a suitable autogenous graft for the treatment of periodontal defects.[1] Our case series focused on both single and multiple recession defects. Similar to this, Mahajan in 2010 successfully treated multiple gingival recession defects with PPG showing an increase in width of attached gingiva after 1 year.[9] Gupta et al. in 2017 observed increased attached gingiva using PPG after 6 months.[8]

In 2012, Mahajan et al. observed a comparable clinical efficacy of PPG and SCTG.[10] Hence, the second surgical site can be eliminated with the introduction of PPG, harvested from the same area with minimal surgical trauma, reduction of postoperative complications, and better patient acceptance. The success of our present cases may be due to its optimum vascular property required to survive on the avascular root surface.[7] The inner layer of the periosteum is the cambium layer, contains osteoblasts and osteoprogenitor cells, covers the denuded root that stimulates bone formation. The outer layer has a plenty of fibroblasts, collagen fibers, and their progenitor cells that undergo regeneration of periodontal ligament fibers. Apart from that, an ample amount of periosteum can be obtained from the surgical site.[3] Hence, we have succeeded to use it in multiple recession cases.

  Conclusion Top

Based on the properties, the potential of regeneration of the periosteum is immense. This procedure provides a successful and predictable alternative for coverage of single and multiple gingival recession defects. The use of PPG thus reduces the risk of the second surgical site, which in turn reduces the severity of postoperative pain without compromising the optimum outcome of root coverage. Although the result of PPG is quite encouraging, in future, quality clinical studies with extended follow-ups and histological evaluation are suggested to assess its mechanism of healing pattern and regenerative potential.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Mahajan A. Periosteal graft for the treatment of gingival recession defects: A novel technique. Aust Dent J 2009;54:250-4.  Back to cited text no. 1
Gaggl A, Jamnig D, Triaca A, Chiari FM. A new technique of periosteoplasty for covering recessions: Preliminary report and first clinical results. Periodontol Pract Today 2005;2:55-62.  Back to cited text no. 2
Mahajan A. A review of periosteal pedicle graft technique for the management of gingival recession defects. Adv Surg Res 2018;2:10-4.  Back to cited text no. 3
Kwan SK, Lekovic V, Camargo PM, Klokkevold PR, Kenney EB, Nedic M, et al. The use of autogenous periosteal grafts as barriers for the treatment of intrabony defects in humans. J Periodontol 1998;69:1203-9.  Back to cited text no. 4
Gamal AY, Mailhot JM. A novel marginal periosteal pedicle graft as an autogenous guided tissue membrane for the treatment of intrabony periodontal defects. J Int Acad Periodontol 2008;10:106-17.  Back to cited text no. 5
Gamal AY, Attia-Zouair MG, El Shall OS, Khedr MMF, El-farag MA, Mailhot JM. Clinical re-entry and histologic evaluation of periodontal intrabony defects following the use of marginal periosteal pedicle graft as an autogenous guided tissue membrane. J Int Acad Periodontol 2010;12:76-89.  Back to cited text no. 6
Gautam A, Raaj V. An innovative technique for root coverage using inverted periosteal. J Dent Med Sci 2018;17:44-9.  Back to cited text no. 7
Gupta HL, Faizan SM, Kumar P, Gupta R, Panwar VR, Qureshi S. Periosteal fenestration: A single stage surgical procedure for root coverage along with vestibular deepening. Int J Appl Dent Sci 2017;3:14-8.  Back to cited text no. 8
Mahajan A. Treatment of multiple gingival recession defects using periosteal pedicle graft: A case series. J Periodontol 2010;81:1426-31.  Back to cited text no. 9
Mahajan A, Bharadwaj A, Mahajan P. Comparison of periosteal pedicle graft and sub-epithelial connective tissue graft for the treatment of gingival recession defects. Aust Dent J 2012;57:51-7.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]

  [Table 1], [Table 2]


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