2.7. PPG ​+ ​CAF (test group)

The patients were treated with a combination of periosteal pedicle graft and coronally advanced flap as illustrated by Mahajan.¹⁷ An intrasulcular incision was given on the buccal aspect of each tooth involved with 15C (Swann-Morton Ltd., Sheffield, UK) blade followed by a horizontal right angle incision slightly coronal to the CEJ was placed into the adjacent interdental papilla. This horizontal incision was connected by the vertical incisions which was placed divergent extending from the gingival margin to the alveolar mucosa on the two sides of the last tooth involved (Fig. 1a, Fig. 1b, Fig. 1c). A full thickness flap was raised 3–4 ​mm apical to the bony dehiscence, from this point apically, partial thickness flap was created by sharp dissection to expose adequate periosteum. The exposed periosteum was slowly separated from the apical end using periosteal elevator (Hu-freidy P-24) from the underlying bone, while care was taken that it remained attached at it coronal most ends. De-epithelisation of the papillae adjacent to the defect was performed.

Baseline situation showing multiple gingival recessions in the mandible with tobacco stains before oral prophylaxis.

Baseline situation showing multiple gingival recessions in the mandible at the surgery day.

Full thickness flap reflected 3–4 ​mm apical to gingival margin and then split thickness flap reflected, exposing the underlying periosteum.

The periosteum as a pedicle graft was harvested and inverted over the exposed root surface (Fig. 1d, Fig. 1e).

The periosteum is slowly detached from its apical end while care is taken that it is attached at the coronal most end and everted slowly to cover the exposed root surface.

the apically detached periosteal pedicle graft is stabilised on the root surface, covering the recession defects.

No sutures were placed to stabilise the PPG coronally as it remained stable over the root surface. This modification was done from conventional PPG technique to reduce the time and suture expense. The PPG covering the denuded root surface was completely covered with coronally advanced flap and stabilised with resorbable vicryl suture (4–0) (Ethicon, Johnson & Johnson, Aurangabad, India) using sling sutures. Interrupted sutures were placed to close the releasing incisions (Fig. 1f). The surgical area was covered with noneugenol periodontal dressing (Coepack, GC America).

Coronally advanced flap covering the periosteal pedicle graft and stabilised with sling sutures.