Creeping Attachment in Miller Class III Recessions

CASE REPORT
Creeping Attachment in Miller Class III Recessions: A Report of Five Cases

Deepak Kochar,* Satish Narula,* Rajinder Kumar Sharma,* Shikha Tewari,* and Deepak Chopra
Introduction: Creeping attachment, a postoperative migration of gingival marginal tissue in a coronal direction, is best
observed in mandibular anterior teeth with narrow recessions. In this case report, recession coverage through creeping
attachment is observed in wide gingival recessions (GRs) belonging to Miller Class III cases, when gingival augmentation
by free gingival graft (FGG) apical to the recession area was attempted.
Case Presentation: Five patients (four males and one female, aged 27 to 30 years) with Miller Class III GRs on both
mandibular central incisors, underwent FGG for gingival augmentation. The graft was placed apical to the recession. Clinical
parameters were evaluated 1 year after surgery. At the end of 1 year, vestibular deepening with an increase of 3.5 to 5.5 mm
of keratinized gingiva was achieved, and root coverage through creeping attachment was noticed in range of 0.4 to 2.8 mm.
Conclusion: Partial root coverage through creeping attachment can be anticipated in isolated Miller Class III recession when FGG is done for augmenting the keratinized tissue apical to the GR. Clin Adv Periodontics 2012;2:217-222.
Key Words: Gingiva; gingival recession; oral hygiene; plastic surgery; tissue grafts.
Background
Free gingival graft (FGG) is commonly used for the
management of mucogingival problems, such as insufficient or absent attached gingiva, high frenal insertion, and
shallow vestibule. The procedure has proven reliable in
increasing attached gingiva and to halt progressive
gingival recession (GR).1 Subsequently, its application
for root coverage has been proved successfully.2-4
Successful root coverage is predictable with Miller Class
I and Class II GRs. However, only partial root coverage is
* Department of Periodontics and Oral Implantology, Government Dental
College, Postgraduate Institute of Medical Sciences, Rohtak, Haryana,
India.
Department of Periodontics, Inderprastha Dental College, Ghaziabad,

India.
Submitted September 12, 2011; accepted for publication October 24,

2011
doi: 10.1902/cap.2012.110082
usually achieved in Class III recessions,5 with coverage proportional to the level of attachment on proximal surfaces.
Treatment of such cases is challenging mainly as a result
of loss of interproximal bone and soft tissues. Anatomic
factors, such as aberrant frena, muscle attachment,6 and
gingival phenotype,7 also affect the treatment.
Creeping attachment is a postoperative migration of gingival marginal tissue in a coronal direction over portions of
a previously denuded root.8 The gingival tissue becomes
firmly attached to the root surface, and probing does not
demonstrate an increase in sulcular depth. Creeping attachment must be differentiated from bridging in which
the graft attaches directly to the exposed root surface after
surgery. As proposed by Matter and Cimasoni,9 creeping
occurs either by progressive movement of the attachment
apparatus coronally or neoformation of attached gingiva
and periodontal fibers on the denuded root surface. Creeping attachment is apparently best observed on mandibular
anterior teeth with narrow recession.9-11 This case report
presents five cases with Miller Class III recessions in the
Clinical Advances in Periodontics, Vol. 2, No. 4, November 2012
217
C A S E
R E P O R T
TABLE 1 WKG at Baseline and After 1 Year (mm)

Tooth #24
Case
Tooth #25
Baseline
1 Year
Change
5.0
5.0
1.4
5.0
1.0
4
5
Baseline
1 Year
Change
5.5
5.5
3.6
1.5
5.5
4.0
5.5
4.5
1.0
5.5
4.5
1.0
5.5
4.5
1.0
5.0
4.0
5.5
5.5
2.0
5.5
3.5
TABLE 2 RD at Baseline and After 1 Year (mm)

Tooth #24
Case
Baseline
1 Year
Tooth #25
Change
Baseline
1 Year
Change
5.5
4.0
1.5
3.5
3.0
0.5
3.0
2.3
0.7
3.5
2.5
1.0
3.0
0.5
2.5
3.0
0.2
2.8
2.5
1.5
1.0
2.5
2.0
0.5
4.5
4.1
0.4
2.0
1.6
0.4
FIGURE 1 Surgical procedure. 1a Before

surgery. 1b Recipient bed preparation. 1c Donor
site. 1d Graft sutured and stabilized. 1e One year
after surgery.
mandibular central incisor region in which FGG was used

for gingival augmentation apical to the recession. One
year later, adequate keratinized tissue along with partial
root coverage attributable to creeping attachment was
achieved.
Clinical Presentation
Five patients (four male and one female, aged 27 to 30 years)
diagnosed with Miller Class III recessions in 10 teeth (left and
right mandibular central incisors, teeth #24 and #25), were
treated at the Government Dental College, Rohtak, Haryana,
India, from October 2009 to November 2009. Clinical findings in all five patients included: 1) wide recessions and shallow
218
vestibule with minimal or absence of keratinized gingiva (KG);

2) high frenal pull; 3) progressive GR; and 4) difficulty in maintaining oral hygiene in affected area. All patients were nonsmokers. Phase I therapy was provided. Recession depth
(RD) (mid-facial), probing depth (PD), and width of KG
(WKG) were recorded immediately before surgery (baseline).
A millimeter graded periodontal probe with rubber stopper was used for all measurements and determined with
a caliperx to the nearest 0.1 mm. PD was within normal
limits on the day of surgery.
PCP-UNC 15, Hu-Friedy, Chicago, IL.

Mitutoyo America Corporation, Aurora, IL.
Creeping Attachment in Miller Class III Recessions
C A S E
R E P O R T
FIGURE 2 Case 1. 2a Before surgery. 2b One year after surgery.

Case Management
Prior to the procedures, written informed consent was obtained from all patients. Gingival augmentation apical to
the recession with FGG was performed in all five patients.
After obtaining anesthesia, the submarginal recipient bed
was prepared by a horizontal incision 1 mm apical to the
base of the sulcus in the alveolar mucosa. Two vertical incisions were made at the end of horizontal incision. The
partial-thickness flap was separated and a firm periosteal
bed was obtained. An approximately 1-mm-thick graft
was harvested from the premolar region of the palate.
The graft was positioned and sutured on the periosteal
bed (Fig. 1). A periodontal pack was applied. The patients
received routine postsurgical instructions and were advised
not to brush the treated site for 4 weeks. They were prescribed 0.12% chlorhexidine mouthrinse twice daily for
4 weeks, systemic antibiotics (500 mg amoxicillin, every
8 hours for 5 days), and analgesics (400 mg ibuprofen,
every 8 hours for 5 days). Scaling, if needed, was done 1
month after surgery. PD, RD, and WKG were recorded
at 1 year after surgery. PD was the same preoperatively
and after 1 year. There were increases in the WKG and
decreases in RD in all 10 teeth (Figs. 2 through 6; Tables
1 and 2).
Kochar, Narula, Sharma, Tewari, Chopra
Clinical Outcomes
There was considerable improvement in the gingival status
after gingival augmentation apical to recession. Increase in
WKG was 3.5 to 5.5 mm (Table 1). Decrease in RD as a result of creeping attachment was in range of 0.4 to 2.8 mm
(Figs. 2 through 6; Table 2).
Discussion
Treatment of Miller Class III GR cases poses a challenge to
the periodontist in day-to-day practice because of loss of
interproximal bone and soft tissues. The amount of root
coverage in these situations depends primarily on interproximal attachment level. Gingival augmentation apical
to the recession is equally important and is more predictable than root coverage in these cases.
Ward3 observed a decrease in recession of 0.5 to 1.5 mm
in two thirds of patients treated with FGG. Matter10 observed creeping attachment for 5 years and stated that it
occurred from 1 month to 1 year after surgery and was negligible after 1 year. On the contrary, Agudio et al.12,13 observed that creeping attachment continued during the
entire follow-up period of 10 to 25 years. Bell et al.11 determined the extent and rate of creeping and found
219
C A S E
R E P O R T

a 0.89 0.46 mm average with a range of 0.38 to 1.61 mm

over 1 year. Matter and Cimasoni9 studied 20 cases of
localized GR treated by FGGs and described five factors
that influence creeping: 1) width of recession; 2) position
of the graft; 3) interproximal bone height; 4) position of
220
the tooth; and 5) patient oral hygiene. In our cases, FGG

apical to recession area was successful in achieving adequate vestibular depth, halting progressive GR, and improving patients oral hygiene status. In addition, partial
root coverage as a result of creeping attachment was also
observed. n
C A S E
R E P O R T
Summary
Why is this case new information?
To the best of our knowledge, root coverage through creeping

attachment in Miller Class III recessions has not been previously
reported.
What are the keys to successful

management of this case?
FGG facilitated plaque control. It favored long-term creeping

attachment.
What are the primary limitations to

success in this case?
Root coverage was not attempted because there was little difference
in the attachment levels on surfaces bearing the recession and
neighboring proximal surfaces.
Acknowledgments
The authors acknowledge Dr. Shikha Mukhija, Senior Resident, Department of Periodontics, Government Dental
College, Postgraduate Institute Of Dental Sciences, Rohtak, Haryana, India, for her help in manuscript preparation. The authors report no conflicts of interest related
to this case report.
Kochar, Narula, Sharma, Tewari, Chopra
CORRESPONDENCE:
Dr. Deepak Kochar, Department of Periodontics and Oral Implantology,
Government Dental College, Postgraduate Institute of Medical
Sciences, Rohtak 124001, Haryana, India. E-mail: drdeepakkochar77@
gmail.com.
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C A S E
R E P O R T
References
1. Rateitschak KH, Egli U, Fringeli G. Recession: A 4-year longitudinal
study after free gingival grafts. J Clin Periodontol 1979;6:158-164.
2. Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles of
successful grafting. Periodontics 1968;6:121-129.
3. Ward VJ. A clinical assessment of the use of the free gingival graft for
correcting localized recession associated with frenal pull. J Periodontol
1974;45:78-83.
4. Vandersall DC. Management of gingival recession and a surgical
dehiscence with a soft tissue autograft: 4 year observation. J Periodontol 1974;45:274-278.
5. Miller PD Jr. A classification of marginal tissue recession. Int J
Periodontics Restorative Dent 1985;5(2):8-13.
6. Bouchard P, Malet J, Borghetti A. Decision-making in aesthetics: Root
coverage revisited. Periodontol 2000 2001;27:97-120.
7. Muller HP, Eger T, Schorb A. Gingival dimensions after root coverage
with free connective tissue grafts. J Clin Periodontol 1998;25:424-430.
8. Goldman HM, Cohen DW. Periodontal Therapy, 5th ed. St. Louis: C.
V. Mosby; 1973:715-758.
9. Matter J, Cimasoni G. Creeping attachment after free gingival grafts.
J Periodontol 1976;47:574-579.
10. Matter J. Creeping attachment of free gingival grafts. A five-year
follow-up study. J Periodontol 1980;51:681-685.
11. Bell LA, Valluzzo TA, Garnick JJ, Pennel BM. The presence of
creeping attachment in human gingiva. J Periodontol 1978;49:513517.
12. Agudio G, Nieri M, Rotundo R, Cortellini P, Pini Prato G. Free
gingival grafts to increase keratinized tissue: A retrospective longterm evaluation (10 to 25 years) of outcomes. J Periodontol 2008;79:
587-594.
13. Agudio G, Nieri M, Rotundo R, Franceschi D, Cortellini P, Pini
Prato GP. Periodontal conditions of sites treated with gingivalaugmentation surgery compared to untreated contralateral homologous sites: A 10- to 27-year long-term study. J Periodontol 2009;80:
1399-1405.
indicates key references.
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Creeping Attachment in Miller Class III Recessions

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CASE REPORT