Covering the Uncovered: Complete Root Coverage of Gingival Recession using Sub-Epithelial Connective Tissue Graft

Gingival recession is defined as the displacement of marginal tissue apical to cementoenamel junction, exposing the root surface. It is caused by traumatic toothbrushing, periodontitis, high frenal attachment, and injudicious orthodontic tooth movement. It leads to dentinal hypersensitivity, aesthetic problem, root caries, cervical abrasion and difficulty in oral hygiene maintenance. This can be managed by root coverage procedure which can be achieved by various surgical techniques. This case report shows successful management of Miller’s Class II gingival recession using sub-epithelial connective tissue graft procedure that was followed up for six months without any complications.


INTRODUCTION
Gingival recession is a common finding in daily clinical practice.Its prevalence is about 65% of individuals in Nepalese population. 1 This condition can be managed with several root coverage procedures using free gingival graft (FGG), sub-epithelial connective tissue graft (SCTG), laterally-positioned graft, double-papilla flap, pouch and tunnel technique, and guided tissue regeneration. 2Among these techniques, SCTG described by Langer and Langer in 1985 is considered as the most predictable technique. 3This case report shows successful management of Miller's Class II gingival recession using SCTG and followed up for six months without any complications.to two-digit tooth numbering system) with aberrant frenal attachment and inadequate vestibular depth (Figure 1).The condition was diagnosed as dental plaque induced gingival disease (IA) as per American Academy of Periodontology (AAP) 1999 classification along with mucogingival deformity in relation to 41 (VIII-B, American Academy of Periodontology, 1999 classification).

CASE REPORT
On the first visit, full mouth scaling and root planing was done and oral hygiene instructions were given.After discussing various treatment options with the patient, frenectomy with vestibular deepening at first, followed by root coverage in relation to 41 with SCTG was planned.
All treatment protocols were explained to patient and written consent was taken.Two weeks later, under normal haemogram values, frenectomy with vestibular deepening was performed using #15 surgical blade followed by periosteal suturing with 3-0 silk suture.On one month re-evaluation, good healing was observed (Figure 2).After three months of surgery, root coverage procedure was carried out.Preprocedural mouthrinse using 2 ml of 0.2% diluted chlorhexidine solution and extraoral antisepsis was performed with 5% povidone iodine solution (Betadine).
Local anaesthetic infiltration using 2% lignocaine with adrenaline 1:200,000 was administered.The recession height and width of 5 mm and 3 mm were measured using University of North Carolina-15 (UNC-15) periodontal probe (Figure 3).Two horizontal incisions were made at the base of interdental papillae, two vertical incisions on either side of 41 with #15 blade and split-thickness flap was reflected (Figure 4).Furthermore, de-epithelisation was done on both interdental papillae (Figure 5).
Under right greater palatine nerve block, connective tissue graft was procured from palatal area from molar to canine.
Aluminium foil template of 4 mm x 7 mm was placed on the donor site.Trap-door technique was used for harvesting SCTG (Figure 6). 5 First, two vertical and one horizontal incision were given 3-4 mm below the gingival margin and a partial thickness flap was reflected.Again two vertical and one horizontal incision were given deep to the bone with #15 blades.With the help of Adson's tissue forceps, connective tissue was retrieved and placed on saline.The flap was approximated with 4-0 vicryl suture (Figure 7).
The obtained graft was inspected for tissue tags, glandular tissues, etc. and a uniform thickness of about 1.5 mm thickness was made.On the recipient site, root planing was done with #1-2 Gracey curette.A fresh doxycycline solution was prepared by mixing doxycycline capsule in normal saline (100 mg/ml) was used for root conditioning (Figure 8).The prepared graft was then placed on the recipient bed, secured with sling and interrupted suture with 4-0 vicryl suture (Figure 9, 10).The overlying partial thickness flap was coronally advanced and sutured with sling and interrupted suture on two vertically incised areas (Figure 11).
The surgical site was then covered with aluminum foil and periodontal dressing (COE-PAK TM GC Dental) (Figure 12, 13).
The patient was instructed to refrain from toothbrushing at surgical site for 10 days.Chlorhexidine mouthwash 0.2% 10 ml twice daily for 10 days along with amoxicillin 500 mg thrice daily for five days and analgesics (Ibuprofen 400mg and Paracetamol 325 mg) thrice daily for three days were prescribed.Patient was recalled after 10 days of surgery for suture removal.
On tenth day, periodontal dressing and sutures were removed and the area was thoroughly irrigated with normal saline.Any signs of complications or relevant symptoms were examined.The healing in recipient and donor site was satisfactory (Figure 14a).Recall appointments were made at one, three, and six months.At one month follow-up, wound healing was satisfactory (Figure 14b).At three months recall, normal colour and consistency was maintained.Complete root coverage was obtained without any complications at six months (Figure 14c).

A1
25-year-old female patient reported with complaint of receding gums in lower front teeth region for two years which was associated with tooth sensitivity.Patient had undergone orthodontic therapy three years back.On intraoral examination, there was generalised gingival inflammation and bleeding on probing.Miller's Class II gingival recession 4 was noted in respect to 41 (according Dr. Suraksha Subedi, 1 Dr. Rebicca Ranjit, 1 Dr. Soni Bista 1 Department of Periodontology and Oral Implantology, College of Dental Surgery, Gandaki Medical College, Pokhara, Kaski, Nepal.

Figure 9 :
Figure 9: Connective tissue graft placed on recipient site.

Figure 11 :
Figure 11: Flap coronally advanced over graft and secured with sling suture.

Figure 14 :
Figure 14: Postoperative view: A) After suture removal B) At three months C) At six months.

Figure 12 :
Figure 12: Aluminum foil on the recipient site.