Periodontal plastic surgery for root coverage in a case of gingival recessions associated with cervical abrasion

Different approaches have been suggested in such cases. Some authors propose to first proceed with the filling of the roots defect and then perform the surgery, while others suggest the opposite. In this case the second option was selected.

A 45 years old female non-diabetic and non-smoker, presented with gingival recessions associated with cervical abrasions complaining about esthetics and root sensitivity.

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Fig.1

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Fig.2
Bi-laminar technique without vertical releasing incisions was chosen with connective tissue graft as a filler of cervical abrasions. Abrasions, inadequate fillings, and multiple recessions are visible in the maxillary left region.

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Fig.3
Removal of the old fillings with a Rhode chisel and reduction of the step in the CEJ with a multiblade dental bur.

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Fig.4
Horizontal incision connecting the apical margins of adjacent recessions.

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Fig.5
Apical to the recessions, the tissue is elevated with a full-thickness dissection with an Ochsenbein chisel for approximately 3 mm. The full-thickness flap will cover the exposed root.

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Fig.6
In the picture on the left, the entire area that will be covered can be seen. In the other picture, in the more apical area, the flap is again partial thickness. The blade is parallel to the bone surface and detaches the lip muscular insertions from the periosteum.

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Fig.7
Now the blade is parallel to the mucosal surface and separates the muscular insertions from the flap in order to allow coronal displacement. The receiving site before de-epithelialization of the papillae and before correction of the bone ledge between 24 and 25, which prevents good adaptation of the connective tissue.

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Fig.8
Elimination of bone ledge with consequent opening of bone marrow spaces. Detachment of connective tissue from palate.

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Fig.9
The connective tissue is positioned at the point of greatest recession and abrasion of the root surface. The suture of the flap after coronal displacement.

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Fig.10
Healing after 1 month shows filling of the cervical abrasions with the connective tissue. A small irregularity remains at the CEJ and is treated with a composite restoration.

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Fig.11

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Fig.12
A clinical comparison between the status before surgery (Img. 11) and the result 1 year later (Img. 12), shows solving of the esthetic problems affecting the entire area.

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Fig.13

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Fig.14
Comparison between radiographs before the surgery (Img. 13) and 1 year later (Img. 14) shows the result achieved in the deep periodontium. (Courtesy of Dr. Andrea Ricci.)

Conclusions

In cases of root abrasion the soft tissue can be used as a filler of the defect. If a small root irregularity remains, it can be treated with adhesive tecniques after tissue maturation.

Bibliography

Pini Prato G, Pagliaro U, Baldi C, Nieri M, Saletta D, Cairo F, Cortellini P. Coronally advanced ?ap procedure for root coverage. Flap with tension versus ?ap without tension: a randomized controlled clinical study. J Periodontol. 2000 Feb; 71(2): 188-201.
Saletta D, Pini Prato G, Pagliaro U, Baldi C, Mauri M, Nieri M. Coronally advanced ?ap procedure: is the interdental papilla a prognostic factor for root coverage? J Periodontol. 2001 Jun; 72(6):760-766.
Andia DC, Martins AG, Casati MZ, Sallum EA, Nociti FH. Root coverage outcome may be affected by heavy smoking: a 2-years follow-up study. J Periodontol. 2008 Apr;79(4): 647-653.
Rotundo R, Mori M, Bonaccini D, Baldi C. Intra-and inter-rater agreement of a new classi?cation system of gingival recession defects. Eur J Oral Implantol. 2011 Summer;4(2):127-33.
Allen EP, Miller PD Jr. Coronal positioning of existing gingiva: short term results in the treatment of shallow marginal tissue recession. J Periodontol. 1989 Jun;60(6):316-9.
Zucchelli G, De Sanctis M. The coronally advanced ?ap for the treatment of multiple recession defects: a modi?ed surgical approach for the upper anterior teeth. J Int Acad Periodontol. 2007 Jul;9(3):96-103.
Cairo F, Pagliaro U, Nieri M. Treatment of gingival recession with coronally advanced ?ap procedures: a systematic review. J Clin Periodontol. 2008 Sep;35(8 Suppl):136-62.

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