The patient complained of pain during brushing on the lower central incisors; this situation was associated with a lack of keratinized tissue, a thin phenotype and buccoversion of the incisors following orthodontic treatment.
The treatment consisted in a V-CAF (Vertically Coronally Advanced Flap) involving both elements, with a connective tissue graft harvested from the palate; the larger portion of the graft was stabilized on 3.1 for root coverage , the remaining on 4.1 to modify the phenotype.
The results at 1 year, 3 years and 5 years confirm not only complete coverage on 3.1 and increased tissue thickness for both teeth, but also the long-term stability of the tissues; the patient restart to brush comfortably and without any pain.
Fig.1
Initial situation; Rt1 recession on lower left central incisor, thin phenotype for left and right central incisors.
Fig.2
Occlusal vision.
Fig.3
Recession evaluation and depth.
Fig.4
Flap design.
Fig.5
Flap elevation split thickness on surgical papillae, full thickness apically to the recession defect, and superficial and deep split thickness on muscular side to promote a free tension flap. A sub mucosal muscular tissue removal was performed to get verticality in the flap.
Fig.6
Graft stabilization , 7-0 pga sutures.
Fig.7
Flap stabilization.
Fig.8
Clinical situation at 1 year.
Fig.9
Clinical situation at 3 years.
Fig.10
Clinical situation at 5 years.
Fig.11
Thickness comparison before and after 5 years (occlusal view).
Fig.12
Thickness comparison before and after 5 years (lateral view).
Conclusions
The 5-year result shows high stability of the soft tissues and gingival margins, with thickening and a change in phenotype; the patient restarted a pain-free brushing just two months after the procedure; the V-CAF allowed us not only to cover the recession on 3.1 and thicken the tissue on 4.1, but also to re-establish a vertical position in the fornix; the depth of the fornix together with the thickening of the tissues are essential for maintaining the patient’s oral hygiene.
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.
- Int J Periodontics Restorative Dent 2021 May-Jun;41(3):325-333. doi: 10.11607/prd.4925. Vertically Coronally Advanced Flap (V-CAF) to Increase Vestibule Depth in Mandibular IncisorsMartina Stefanini, Ilham Mounssif, Matteo Marzadori, Claudio Mazzotti, Monica Mele, Giovanni Zucchelli.
- 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 Francesco Cairo Michele Nieri, Sandro Cincinelli, Jana Mervelt, Umberto Pagliaro.
