Connective Tissue Graft for Gingival Recession in Mandibular Incisor Area: A Case Report

Transcription

1 Bull Tokyo Dent Coll (2017) 58(3): Case Report doi: /tdcpublication Connective Tissue Graft for Gingival Recession in Mandibular Incisor Area: A Case Report Masahiro Egawa 1), Satoru Inagaki 2,3), Sachiyo Tomita 1) and Atsushi Saito 1) 1) Department of Periodontology, Tokyo Dental College, Misaki-cho, Chiyoda-ku, Tokyo , Japan 2) Department of Microbiology, Tokyo Dental College, Misaki-cho, Chiyoda-ku, Tokyo , Japan 3) Inagaki Dental Clinic, Takayama Building 1F, Kamiochiai, Shinjuku-ku, Tokyo , Japan Received 23 September, 2016/Accepted for publication 12 October, 2016 Abstract We report a case of gingival recession in the mandibular incisor region requiring a connective tissue graft. The patient was a 17-year-old girl who visited the Tokyo Dental College Chiba Hospital in 2014 with the chief complaint of gingival recession in the lower incisor region. She had received orthodontic treatment for 5 years and noticed the gingival recession on completion of active orthodontic treatment in Gingival recession in tooth #31 extended 3 mm beyond the muco-gingival junction (MGJ) and was clinically diagnosed as Miller Class II recession; probing depth was 6 mm. Following initial periodontal therapy, a connective tissue graft procedure was implemented. The connective tissue was harvested from the left palate. Healing was uneventful, and the grafted site showed a favorable outcome at 6 months postoperatively. We are continuing to carefully monitor the condition of periodontal tissue. Key words: Connective tissue graft Periodontal plastic surgery Gingival recession Root coverage Introduction Gingival recession is defined as the displacement of marginal tissue apical to the cemento-enamel junction (CEJ), exposing the root surface 17). Its causes include excessive brushing, periodontitis, occlusal trauma, and aging 3,12). Gingival recession, which may be observed during or after orthodontic treatment, compromises esthetics and increases the risk of periodontitis, root caries, and dentinal hypersensitivity 19). In treating this condition, various etiological factors must be taken into account, which may necessitate giving tooth brushing instruction, prevent bruxism, or correction of tooth malposition by orthodontic treatment. Periodontal plastic surgery becomes an option if 155

2 156 Egawa M et al. no improvement is observed through such measures 8), and a connective tissue graft is often indicated in such cases. This procedure can be also used to augment the width of vestibular and ridge. However, in cases of multiple recession or recession extending beyond the muco-gingival junction (MGJ), a complete root coverage is not possible 7), and the data are limited on the long-term outcome in this situation. Here, we report a case of gingival recession requiring a connective tissue graft to improve esthetics, hypersensitivity, and plaque control. Case Presentation Written informed consent was obtained from the patient and her mother for inclusion in this report. 1. Baseline examination In June 2014, a 17-year-old girl was referred to the Clinic of Conservative Dentistry at the Tokyo Dental College Chiba Hospital with the chief complaint of gingival recession in the mandibular incisor region. The patient was systemically healthy. She had been receiving orthodontic treatment commencing in On completion of active orthodontic treatment in 2013, she noticed gingival recession a b Fig. 1 (a) Oral view at first visit (baseline, June, 2014), (b) Enlarged view

3 Connective Tissue Graft for Recession 157 Fig. 2 Periodontal examination at baseline BOP; bleeding on probing in the mandibular incisor area and together with hypersensitivity in that region. She had also been treated for caries several times, but not in the cervical area of the mandibular incisors, and experienced anemia on a few occasions. The patient was a non-smoker. She was preparing for entrance examinations to college, and her oral esthetic problems seemed to be compounding the stress. Generally, plaque accumulation and gingival inflammation was minimal (Fig. 1a). Pronounced gingival recession and discoloration of the exposed root were observed in #31, and minor recession was present in #32, 41, and 42 (Fig. 1b). Tooth #31 showed a probing depth (PD) of 6 mm at the mid-labial site (Fig. 2). No sign of tooth fracture was noted. The other teeth had a PD of 3 mm. Bleeding on probing (BOP) was noted in some regions including the mandibular incisors. The level of plaque control as assessed according to the O Leary Plaque Control Record (PCR) 9) was 24%. As for occlusion, no premature contact was observed in #31 and other teeth. No balancing contact was observed. Radiographic examination revealed minor loss of marginal bone in the interproximal area of the central incisors (Fig. 3). Enlargement of the periodontal ligament space was also noted. 2. Diagnosis The clinical diagnosis was localized chronic Fig. 3 Radiographic view at baseline periodontitis. Gingival recession in tooth #31 was judged to be Miller Class II 7). 3. Treatment plan 1) Initial periodontal therapy This comprised: (1) plaque control, including instruction on appropriate tooth brushing methods; and (2) quadrant scaling and root planing (SRP). 2) Reevaluation 3) Periodontal surgery

4 158 Egawa M et al. a b c d Fig. 4 During surgery (a) Harvested graft tissue, (b) Preparation of recipient site, (c) Placement of graft tissue and flap closure, (d) Placement and suturing of collagen sheet at donor site. Periodontal plastic surgery involving a connective tissue graft by a modified Langer technique 1). 4) Reevaluation 5) Maintenance or supportive periodontal therapy Clinical Procedures and Outcomes An effort was made throughout to establish good communication with the patient to minimize her level of anxiety. 1. Initial periodontal therapy Following evaluation of the patient s selfcare measure, tooth brushing instruction was given. A modified Stillman method was recommended for #31 to minimize brushing pressure and prevent further recession. Careful SRP was performed on #31 using a mini-curette. 2. Periodontal plastic surgery At reevaluation, PD at the mid-labial site in #31 was reduced to 3 mm, and no BOP was observed. The gingival thickness of the donor palate site was mm. Local anesthesia was given to the maxillary left palate and a connective tissue graft containing gingival epithelium harvested. The harvested graft tissue was trimmed to cover the exposed roots of #31, 32, 41, and 42 (Fig. 4a). A partial thickness flap extending between the mandibular canines was raised to prepare the recipient site. Less than one third of the labial bone relative to the root length was present in #31 (Fig. 4b). Scaling and root planing was then performed. After trial of the donor tissue at the recipient site, it was fixed in position with a sling suture. The flap was then placed over the graft and fixed by another sling suture. More sutures were applied to the periosteum to maintain stability at the donor site during lip movement or tension (Fig. 4c). The donor site was subsequently covered with a collagen sheet (Terudamis R, Olympus Terumo Biomaterials, Tokyo, Japan) (Fig. 4d). The patient was instructed not to brush the surgical site, but to use an antimicrobial oral rinse instead for 2 weeks postoperatively. Figure 5 shows the oral view at 1 week postopera-

5 Connective Tissue Graft for Recession 159 Fig. 5 Oral view at 1 week postoperatively Fig. 6 Oral view at 2 weeks postoperatively Fig. 7 Oral view at 3 months postoperatively tively. Discoloration of the graft margin and reddening of the margin of the donor site were evident. The sutures were removed after 2 weeks. Surface irregularity was observed at the site of the graft (Fig. 6). The donor site still showed some reddening, but this gradually decreased and disappeared after 4 weeks. At 3 months postoperatively, the surface irregularity and bleeding at the gingival margin of the recipient site became less pronounced (Fig. 7), indicating that healing was progressing. At 6 months postoperatively, irregularity of the labial gingiva still remained, and minor recession (approximately 0.5 mm) was observed in #31 (Fig. 8). The donor palatal area showed complete healing. The patient and her mother indicated satisfaction with the treatment outcome. It was decided, however, that careful monitoring of the graft site needed to be continued.

6 160 Egawa M et al. Fig. 8 Oral view at 6 months postoperatively Discussion In this case, an attempt was made to improve esthetics in the mandibular incisor area. At her first visit, the patient complained of compromised esthetics due to gingival recession and was concerned about potential tooth loss. After consultation, she became very cooperative. She was about to take college entrance examinations and needed to concentrate on her studies, but this oral problem was inflicting a great deal of stress on her. Her parents even started to regret the fact that they had recommended orthodontic treatment to her. With gingival recession, the root surface becomes exposed, compromising esthetics, inducing dentinal hypersensitivity and the risk of caries. Once a root becomes exposed and loses periodontal ligament, spontaneous recovery of alveolar bone and gingiva cannot be expected. Periodontal plastic surgery involving a connective tissue graft is one solution in such cases. To harvest an adequate thickness of connective tissue (approximately 1.5 mm), the thickness of the palatal gingival needs to be more than mm 14). In the present case, the thickness at the donor site was approximately 4 mm, and was therefore sufficient. A relatively large amount of connective tissue was harvested and grafted between the mandibular canines to increase the width and thickness of the attached gingiva, with the hope of preventing further gingival recession in the incisor area. Aging, inappropriate tooth brushing, periodontitis, periodontal surgery, or occlusal trauma can cause gingival recession. Many studies have reported that orthodontic treatment can induce gingival recession, and there have been many reports on this 16). Excessive orthodontic force or displacement to an inappropriate tooth position beyond the boundary of the alveolar bone can result in gingival recession 2,18). The exact cause of gingival recession in the present case is unclear. Orthodontic treatment in this patient involved extraction of the first premolars. Alignment of the mandibular incisors was achieved by moving the teeth lingually. The risk of gingival recession after such a procedure is generally lower than that where labial movement is involved. It is unlikely that inappropriate brushing would result in marked gingival recession in one particular tooth. Moreover, no significant problem was observed with regard to occlusion, and no premature contact was found in #31 after orthodontic treatment. It is possible that #31 had dehiscence or fenestration, and orthodontic treatment and inflammation due to compromised plaque control may have contributed to loss of attachment. This might also be the reason for the localized deep pocket found in #31. The lack of connective tissue attachment may have contributed to loss of attachment in response to plaque accumulation. In some cases, corrective orthodontic treatment followed by root coverage treatment can minimize the recurrence of gingival recession 5). It was reported that orthodontic treatment alone improved gingival recession in a case where

7 Connective Tissue Graft for Recession 161 occlusal trauma was the primary cause 10). In the present case, the patient and her parents did not wish for further orthodontic treatment. Therefore, the gingival recession was treated by periodontal plastic surgery only. The patient s gingival tissue and labial bone plate were very thin, and the width of the attached gingiva was limited. It was classified as Type IV according to the classification by Maynard and Wilson 6), which presents the risk of recurrence 4). At 6 months postoperatively, the gingiva in #31 showed minor recession (0.5 mm), but the patient and her mother seem to be satisfied with the result. The patient has now been placed on a recall system. At each visit, a detailed explanation of the surgical site is given. In addition to oral hygiene instruction, occlusion is checked for potential occlusal trauma. We are continuing to carefully monitor the periodontal condition and provide meticulous professional care. In recent years, many treatment modalities for root coverage have been developed, including regenerative therapies 11,13,15,20). It is necessary to develop more predictable and less invasive procedures. Acknowledgements We thank the dental hygienists at Tokyo Dental College Chiba Hospital for their periodontal care. We report no conflicts of interest regarding this case report. References 1) Bruno JF (1994) Connective tissue graft technique assuring wide root coverage. Int J Periodontics Restorative Dent 14: ) Karring T, Nyman S, Thilander B, Magnusson I (1982) Bone regeneration in orthodontically produced alveolar bone dehiscences. J Periodontal Res 17: ) Krishna Prasad D, Sridhar Shetty N, Solomon EG (2013) The influence of occlusal trauma on gingival recession and gingival clefts. J Indian Prosthodont Soc 13: ) Lang LP, Löe H (1972) The relationship between the width of keratinized gingiva and gingival health. J Periodontol 43: ) Machado AW, MacGinnis M, Damis L, Moon W (2014) Spontaneous improvement of gingival recession after correction of tooth positioning. Am J Orthod Dentofacial Orthop 145: ) Maynard JG Jr, Wilson RD (1980) Diagnosis and management of mucogingival problems in children. Dent Clin North Am 24: ) Miller PD Jr (1985) A classification of marginal tissue recession. Int J Periodontics Restorative Dent 5: ) Miller PD Jr, Allen EP (1996) The development of periodontal plastic surgery. Periodontol : ) O Leary TJ, Drake RB, Naylor JE (1972) The plaque control record. J Periodontol 43: ) Pini-Prato G, Cozzani G, Magnani C, Baccetti T (2012) Healing of gingival recession following orthodontic treatment: a 30-year case report. Int J Periodontics Restorative Dent 32: ) Pini Prato G, Tinti C, Vincenzi, G, Magnani C, Cortellini P, Clauser C (1992) Guided tissue regeneration versus mucogingival surgery in the treatment of human buccal gingival recession. J Periodontol 63: ) Rajapakse PS, McCracken GI, Gwynnett E, Steen ND, Guentsch A, Heasman PA (2007) Does tooth brushing influence the development and progression of non-inflammatory gingival recession? A systematic review. J Clin Periodontol 34: ) Roccuzzo M, Lungo M, Corrente G, Gandolfo S (1996) Comparative study of a bioresorbable and a non-resorbable membrane in the treatment of human buccal gingival recessions. J Periodontol 67: ) Sato N (1997) Periodontal Surgery: a clinical atlas, p.371, Quintessence, Tokyo. (in Japanese) 15) Sculean A, Cosgarea R, Stähli A, Katsaros C, Arweiler NB, Brecx M, Deppe H (2014) The modified coronally advanced tunnel combined with an enamel matrix derivative and subepithelial connective tissue graft for the treatment of isolated mandibular Miller Class I and II gingival recessions: a report of 16 cases. Quintessence Int 45: ) Slutzkey S, Levin L (2008) Gingival recession in young adults: occurrence, severity, and relationship to past orthodontic treatment and oral piercing. Am J Orthod Dentofacial Orthop 134: ) The Japanese Society of Periodontology (Eds) (2013) Glossary of Periodontal Terms 2013,

8 162 Egawa M et al. p.48, Ishiyaku Publishers, Tokyo. (in Japanese) 18) Thilander B, Nyman S, Karring T, Magnusson I (1983) Bone regeneration in alveolar bone dehiscences related to orthodontic tooth movements. Eur J Orthod 5: ) Tugnait A, Clerehugh V (2001) Gingival recession its significance and management. J Dent 29: ) Wennström JL, Zucchelli G (1996) Increased gingival dimensions. A significant factor for successful outcome of root coverage procedures? A 2-year prospective clinical study. J Clin Periodontol 23: Correspondence: Dr. Atsushi Saito Department of Periodontology, Tokyo Dental College, Misaki-cho, Chiyoda-ku, Tokyo , Japan atsaito@tdc.ac.jp