A young, non-smoking patient presents with a deep recession on tooth 3.1 (5mm depth). She reports an inability to perform adequate home oral hygiene measures.
After a careful assessment of the case, patient complained to reconstruct the thickness and quality of the soft tissues at the site of the recession (which is classified as RT1).
Due to the shallow vestibule, as performing a coronally advanced flap or a tunnel technique would be unpredictable and difficult, we decided to employ a two-stage procedure: first, the keratinized tissue was reconstructed using a free gingival graft placed apical to the recession.
Subsequently, once healing had occurred — approximately two months later — a coronally advanced flap procedure was performed according to the Zucchelli and De Sanctis technique, which enabled complete coverage of the recession.
Flap was coronally displaced and sutured with 7-0 PGA sutures.
The one-year follow-up demonstrates that it was possible to achieve complete root coverage and a significant increase in keratinized tissue, thereby enhancing the tissue’s long-term stability and resistance.
Fig.1
The clinical situation showed a RT1 recession due to orthodontic treatment.
Lack of keratinized tissue and poor vestibule depth. In this condition a 2 step approach was recommended.
Fig.2
Recession depth (5 mm).
Fig.3
Apically repositioned flap with periostea split thickness vascular bed; the flap was stabilized in an apical position to reestablish vestibule depth and help the free gingival graft stabilization.
Fig.4
Free gingival graft secured by isolated sutures to stabilize the graft in the correct position, and compressive sutures to enhance vascular connections.
Fig.5
15 days after free gingival graft, picture shows a good stability and revascularization.
Fig.6
2 months healing; graft maturation and recession reduction.
Fig.7
A coronally advanced flap was designed including the previously grafted free gingival graft.
Fig.8
Flap was elevated split thickness in correspondence of anatomical papillae, full thickness in the whole area concerning the graft and again deep and superficial split thickness in the muscular area to promote coronally displacement of the flap.
Fig.9
Anatomical papillae were disepithelized, root was planned.
Fig.10
Flap coronally moved and stabilized with 7-0 PGA sutures.
Fig.11
1 year healing shows great stability with keratinized tissue enhancement and complete root coverage.
Conclusions
The use of this technique allows not only to achieve complete root coverage but also to restore of adequate vestibular depth and a significant amount of keratinized tissue.
These factors give patients greater long-term tissue stability and improve their ability to clean the area and increase properly home oral hygiene procedures.
This approach should be carefully considered in cases where the patient shows deep recession and an inadequate vestibule depth.
Bibliography
- J Clin Periodontol. 2007 Mar;34(3):262-8. Coronally advanced flap: a modified surgical approach for isolated recession-type defects: three-year results. de Sanctis M. , Zucchelli G.
- J Clin Periodontol 2011 Jul;38(7):661-6. doi: 10.1111/j.1600-051X.2011.01732.x. Epub 2011 Apr 20. The interproximal clinical attachment level to classify gingival recessions and predict root coverage outcomes: an explorative and reliability study.
- Treatment of localized gingival recessions. Part II. Coronally repositioned flap with a free gingival graft R G Caffesse et al. J Periodontol. 1978 Jul.
