Dr Fenyő Attila
This is a case of severe gingival recession treated by a combined approach in a compromised situation. Complete coverage with PECTG and SCTG and preserved FPD. 8 months follow-up.
The patient is a 76-year-old man, who has been urged by his dentist to ask for periodontal examination on emergency. He showed up with several lichenoid lesions affecting both gingiva and alveolar mucosa. After symptomatic therapy and several control visits, he reported no more pain from the affected area, but a slight trauma on the marginal gingiva near tooth 11. After two weeks, he has been referred to his general practitioner to find and eliminate any predisposing factors, and also his dentist, for maintenance therapy.
1 year after his first visit, the patient presented with already developed Miller class I. and II. recessions. He complained about tooth sensitivity and was eager to have this issue solved. His only wish was to preserve the existing FPD, what he had been wearing the past 13 years.
Signs of trauma from excessive tooth brushing are easily noticeable between teeth 11 and 21.
Treatment strategy was the following:
-correction of brushing technique according to the principles of iTOP: effective-acceptable-atraumatic
-thorough cleaning of the exposed root surface and the root-crown interface
-thickening soft tissue to overcome the thick crown margins of the FPD.
Diffculties of the case:
-The pontic site on position 14 poses great challenge. The prosthetic papilla has nice height, but surgical management is difficult in this situation. Both flap elevation, instrumentation and suturing are uneasy under the pontic.
-It is hard to determine the position of the cementoenamel junction. Hence, any prognosis had to be cautious.
-We can’t change the emergence profile of the teeth by making cervical composite restorations.
-Surgical manipulation is much more difficult next to these thick crowns. It is less favorable for individual oral hygiene as well.
During donor site management, no hemostatic agent had been used. Flap repositioned and fixated with Borghetti sutures.
The second graft harvested from the tuberal area had been fixed in the pouch around tooth 13.
Flap closure was obtained by sling and suspended sutures and a 5/0 monofilament non-resorbable suturing material.
Epithelialized portion of tuberosity graft intentionally left uncovered over the area of recession.
There has been a great amount of creeping attachment over the first months of healing. Finally I achieved total coverage of the recessions and nice widening of keratinized tissue.
After 8 months of follow-up it can be stated that this result is stable and provides optimal conditions for individual oral hygiene. There are no signs of traumatic toothbrushing or gingivitis.
