Dr Francesca Daye See-Santos presents a coronally-advanced flap with subepithelial connective tissue graft to address periodontal attachment loss due to aggressive toothbrushing.
A 45-year-old female came to the periodontics department of the University of the East-Manila, complaining about how her maxillary canines appear longer than before. The patient has an unremarkable past medical history and no known vices such as smoking or alcoholism.
Upon intraoral examination, several dental caries and non-carious cervical lesions (NCCL) were observed. The patient was currently wearing upper removable prosthesis and admits of aggressive toothbrushing on her remaining natural teeth.
Deep NCCL restorations have been done to some of her posterior teeth, while surgical root coverage procedure was discussed to be done on her maxillary canines. Patient’s labial probing depths in millimetres were 2, 2, 2 (distal to mesial) and gingival margins were +2, +5, +1 (distal to mesial). Clinical attachment loss computed was as 4mm on mesial, 7mm at midroot and 3mm on distal.
As per gingival recession classification by Cairo et al., where interdental clinical attachment loss is measured, the patient’s gingival recession on the right maxillary canine is classified as Recession Type 2 (RT2). RT2 is characterised by the interproximal attachment loss being less than or equal to the buccal attachment loss (Figs. 1a-d).
After disinfection with chlorhexidine mouth rinse, supraperiosteal infiltration on labial and palatal was performed and the exposed root of tooth 13 was scaled and planed using 2R/2L universal curette. Local anaesthesia given was 2% Lidocaine HCl with 1:100,000 epinephrine.
The recipient site was prepared by making a trapezoidal partial-thickness flap with two vertical incisions mesiodistally with the use of a 15c blade (Fig. 2). A sterile strip of aluminium foil is used as a template for harvesting donor tissue and bleeding points were done (Fig. 4a). The planned donor connective tissue was characterised by an epithelial cuff covering half of the harvested tissue and is to be placed coronally at the recipient site.
Using a 15c blade, a partial thickness horizontal incision was made 6mm apical to the gingival margin in the palate, then another horizontal incision at full thickness was made 3mm apical to the palatal gingival margin. It is followed by a full thickness vertical incision mesiodistally approximating the width and length of the necessary graft.
A primary partial-thickness flap (1.5-mm thick) was prepared toward the centre of the palate, parallel to the palatal gingiva so that the underlying connective tissue is exposed. The connective tissue graft reflected, and was brought toward the centre of the palate (and separated from the bone using a surgical blade 15. An absorbable haemostatic gel was placed on the palatal surgical site to control bleeding (Figs. 4a-c).
At the recipient site, smear layer was removed on exposed root surface with tetracycline solution on a piece of cotton, left for three minutes, and washed thoroughly. The connective tissue graft was positioned at the recipient site with the thin border of epithelium coronal to cemento-enamel junction (CEJ).
Interrupted sutures using Vicryl 5-0, 3/8 reverse cutting 12mm needle was placed on the interdental papilla to secure the graft in place, followed by multiple periosteal sutures at the edges of the graft for stability. An interdental concavity suture was done to prevent dead space formation under the graft. The partial thickness flap was displaced coronally to cover the graft as much as possible and is secured with sutures (Figs. 5a-c). Lastly, several interrupted sutures were placed on the palatal donor site to hold the blood clot as well as the haemostatic gel (Fig. 4c).
Post-operative instructions for bleeding, wound care, diet and oral hygiene were given. Over-the-counter analgesics were prescribed and patient was dismissed with minimal bleeding on both surgical sites. Patient was instructed to avoid warm or hot food and beverages, place cold compress only 20 mins of every hour for the first day, avoid chewing in the surgical site, avoid brushing on the area for the first few days, have a cold, soft diet, drink plenty of fluids, and gently gargle 10ml of undiluted 0.12% Orahex Mouthrinse for 30 seconds, twice a day for two weeks.
The patient was informed to come back for follow-up check-up after seven days for review and to remove necessary sutures if needed (Fig. 6).
About the author