Subepithelial Connective Tissue GraftAssociated with Apicoectomy and

Root-End Fillings in the Treatment ofDeep Localized Gingival Recession with

Apex Root Exposure: Case Report

Sergio Kahn, André Medina et alIJPRD 2009;29.

Shilpa Shivanand II MDS

Introduction• Marginal tissue recession may result in esthetic

complaints, especially in those with a high smile line, and may lead to dental hypersensitivity as well.

• Since the 1950s, free and pedicle gingival grafts have been greatly used for treating gingival recession.

PD Miller 1985

• Because of Miller gingival recession classification, and development of other appropriate techniques that make use of subepithelial connective tissue grafts, gingival recession treatments have resulted in more predictable outcomes, especially with respect to Class I and II sites, in the absence of interproximal bone loss.

Langer B, Langer L 1985

• Deep gingival recession may lead to exposure of the root apex. In such cases, endodontic treatment, associated with dental apicoectomy, may be combined with root coverage surgery.

• Various materials have been used in apicoectomies and in root-end fillings, such as amalgam, glass ionomer, and mineral trioxide aggregate (MTA).

Torabinejad M 1995

Aim

• The following case report examines a case of deep, localized gingival recession with a root apex exposure that was treated with both a subepithelial connective tissue graft (SCTG) and apicoectomy with root-end filling using MTA.

Case Description

• .• A 25-year-old man

attended the Periodontics Clinic at the Central Army Odontoclinic to investigate gingival recession associated with the maxillary right lateral incisor.

• The patient was in good health, had no history of systemic diseases, and did not smoke

• Upon examination, the patient was found to have a deep and narrow Miller Class II gingival recession, with an 11-mm vertical extension all the way to the root apex.

• Additionally, whenever the patient smiled, the esthetic problem became apparent.

• Radiographic examination showed radiopaque material in the root canal, which suggested earlier endodontic treatment.

• The patient reported a history of dental trauma that had taken place 8 years earlier.

• The patient not only feared losing the tooth but was also looking for an esthetic solution to the problem.

• To treat the problem, an SCTG was recommended in conjunction with a dental apicoectomy using MTA root-end filling.

Surgical Procedure

• Prior to surgery, the patient was provided with oral hygiene instructions, supragingival scaling, and root planing.

• On the appointed surgical day, the patient was given a single dose of 8 mg dexamethasone to minimize postoperative edema.

• Mepivacaine (2%) with 1:100,000 epinephrine was used for anesthesia.

• Two divergent, oblique incisions were made with a 15C blade on the mesial and distal sides of the recession, extending to the alveolar mucosa.

• Two partial thickness flaps, one mesial and one distal, were dissected beyond the alveolar mucosa, eliminating any tension that might hinder the free movement of the flaps.

• The mesial and distal flaps were positioned over the root to ensure that they would remain in place without tension.

• If there was any residual tension, the flaps were extended apically to relieve such tension.

• The apical lesion was removed and the most apical portion of the root was cut with a 702 tungsten carbide bur.

• The exposed root was scaled with McCall 13/14 and Gracey 1/2 curettes (Hu-Friedy) and planed with a finishing bur. The root end filling was performed with MTA.

• The root end filling was performed with MTA.• The recipient site was measured with a 15-mm

periodontal probe to estimate the amount of tissue required for grafting.

• The length of the graft had to equal the distance between the center of the distal papilla and that of the mesial papilla.

• The SCTG was removed from the palate in the region between the canine and the first molar with a 15C double-blade scalpel measuring 1.5 mm between blades.

• The epithelial band of the graft was removed and discarded.

• The graft was placed in the recipient site and sutured with 6-0 Vicryl.

• The flaps were sutured together and placed over the graft with a suspensory suture using 5-0 Vicryl.

• The palate was sutured with 4-0 silk.

• Following surgery, the patient was instructed to take a single dose of 8 mg dexamethasone and analgesic medication (500 mg dipyrone) and to rinse with 0.12% chlorhexidine digluconate solution twice a day for 7 days.

• One week later, the sutures were removed from the palate.

• Two weeks later, the sutures were removed from the grafted area.

• Postoperative maintenance was provided weekly for the first 3 months after surgery and once a month for the remainder of the year.

• After 1 year, the recession was seen to have diminished from 11 mm to 1 mm.

• The probing depth did not exceed 1 mm.

• Radiographs showed radiopacity in the periapical area, suggesting complete repair in this region.

• A porcelain veneer was used to improve the esthetic appearance.

• This site has now been followed for 30 months, with stable conditions.

Discussion

• Gingival recession may cause serious esthetic problems for patients, especially when patients have a high smile line.

• Various surgical techniques aimed at solving this problem have been proposed as treatment.

• The most successful of these techniques is root coverage with a subepithelial connective tissue graft.

Roccuzzo M et al 2002

• In the current case, the presented gingival recession was a deep narrow Miller Class II type involving root apex exposure, making this a complex case to treat.

• The vertical extension of the recession limited the surgical possibilities, ruling out coronally positioned flap for root coverage.

• Because studies have shown better results for root coverage with SCTGs, the clinicians decided to associate this graft with a double pedicle flap, as was initially proposed by Nelson and later by Harris.

• After 12 months, a reduction from 11 mm to 1mm in gingival recession was noted, with 91% root coverage, a result that can be achieved by the use of this technique, according to Harris.

• At the end of the treatment, the probing depth was 1.0 mm.

• No bleeding on probing was observed, and an adequate band of keratinized tissue was seen.

• In addition, acceptable esthetic tissue contour and coloration were provided to the patient, so that the treatment could be characterized as successful.

Conclusion

• This report serves as a good example of how a subepithelial connective tissue graft can successfully be used in association with mineral trioxide aggregate for the treatment of localized Miller Class II gingival recessions with root apex exposure.

Critical evaluation

• Sample size low

CROSS REFERENCE

The connective tissue with partial thickness double pedicle graft: the results of 100 consecutively-treated defects. Harris RJ, JOP 1994.• Obtaining predictable root coverage has been a goal

of periodontal therapy for some time. The connective tissue with partial thickness double pedicle graft has been shown to produce predictable esthetic root coverage. The purpose of this study was to examine the results of the surgical technique on 100 consecutively treated defects. The procedure produced a mean root coverage of 97.7%. Root coverage of 100% was obtained 89% of the time. With this technique, esthetic root coverage can be accomplished in a predictable manner.

The Subpedicle Connective Tissue Graft A Bilaminar Reconstructive Procedure for the Coverage of Denuded Root Surfaces. Stephen WN, JOP 1987.• The subpedicle connective tissue graft, is a bilaminar graft

that is composed of a free connective tissue graft and an overlying pedicle graft. By overlaying grafted free connective tissue with a pedicle, the otherwise compromised section of free graft which covers a denuded root surface is supplied by plasmatic circulation from capillaries in the vascular portion of the pedicle allowing it to survive.In this report 29 teeth were treated and monitored for as long as 42 months. In the group with advanced recession of 7 to 10 mm, there was an average of 88% coverage. The subpedicle graft created a healthy, functional, and esthetic result that appeared resistant to further breakdown.