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Table of Contents
CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 29-32

Interdisciplinary approach for the treatment of multiple adjacent recession type defects


1 Department of Periodontics, Government Dental College and Research Institute, Bangalore, India
2 Department of Periodontics, Krishnadevaraya College of Dental Sciences, Bangalore, India
3 Department of Conservative Dentistry and Endodontics, Bangalore Institute of Dental Sciences, Bangalore, India
4 Department of Conservative Dentistry and Endodontics, AECS Maruthi Dental College, Bangalore, India

Date of Web Publication25-Oct-2013

Correspondence Address:
S Janitha
Department of Periodontics, Government Dental College and Research Institute, Bangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.120525

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   Abstract 

Multiple adjacent recession type defects in the dentition of an individual are routinely encountered in the clinical practice, and hence present a challenge for management. If left untreated or unmonitored, they can be detrimental to periodontal or dental health. Patient esthetic demands have become so stringent that root-coverage procedures carried out should provide soft-tissue anatomy comparable to and indistinguishable from adjacent tissue. A combination of semilunar flap and veneers was used to treat such a kind of defect in a 45-year-old female patient complaining of unsightly and long appearing teeth since 4 years. The present case report demonstrates that the semilunar flap can be an effective treatment for the management of multiple recession defects affecting adjacent teeth. This surgical technique resulted in 100% root coverage of all the anterior teeth except 22 at 10-month post-treatment examination. Further, follow-up is required to evaluate the stability of this treatment.
Clinical relevance to interdisciplinary dentistry

  1. Biologic width violation is one of the contributing factors for gingival recession.
  2. Multiple adjacent recession type defect with altered pink to white ratio in the esthetic zone is a challenge for management.
  3. Altered pink to white ratio in such cases may be treated with a combination of semilunar flap and veneers.
  4. Team approach needed to decide on the location of the gingival margin and veneer margin to create ideal, stable dentogingival relationships.

Keywords: Biologic width, periodontal plastic surgery, semilunar flap


How to cite this article:
Janitha S, Prabhu K S, Raghu R, Srinivasan R. Interdisciplinary approach for the treatment of multiple adjacent recession type defects. J Interdiscip Dentistry 2013;3:29-32

How to cite this URL:
Janitha S, Prabhu K S, Raghu R, Srinivasan R. Interdisciplinary approach for the treatment of multiple adjacent recession type defects. J Interdiscip Dentistry [serial online] 2013 [cited 2019 Aug 17];3:29-32. Available from: http://www.jidonline.com/text.asp?2013/3/1/29/120525


   Introduction Top


Recession is the exposure of root surface due to apical migration of the gingival margin. Its etiology is multifactorial, with biologic width violation being one of the causes. Recession can cause deterioration in the esthetic appearance, dentin hypersensitivity, root caries and inability to perform proper oral hygiene procedures. Surgical root coverage [1] is indicated when esthetics is the prime concern and periodontal health is good. The semilunar incision was introduced in Oral Surgery more than a century ago by Partsch in 1898. Tarnow in 1986 reported the semilunar coronally repositioned flap (SCRF) for the treatment of gingival recession in areas with minimal probing depth and with an adequate band of keratinized gingiva. [2] Occasional case reports [3] have been documented in the literature to show its clinical applicability with newer modifications in incision design, suturing, [4] use of microsurgical techniques [5] and adjunctive use of root conditioners. [6] Although this technique has been recommended for multiple teeth, to the best of our knowledge there are no previous reports of the technique being used in more than two teeth (long flap). A combined interdisciplinary approach using periodontal therapy and ceramic veneers was used to manage the esthetically challenging case reported here.


   Case Report Top


A 45-year-old female patient from Singapore reported to our private clinic with unsightly and long appearing teeth for 4 years. She was systemically healthy, a non-smoker on regular dental care and had a stable periodontium. On clinical examination, the patient had 8-year-old direct composite veneers on the labial surfaces of 11, 12, 13, 21, 22, and 23, the margins of which were exposed and stained. The adequacy of the patient's oral hygiene was noted during the intraoral examination. The biotype was visually determined to be thick with an adequate band of keratinized gingiva. The maxillary anterior teeth showed Miller's class I recession defects [Figure 1] with altered pink to white ratio. The depth of the maxillary buccal vestibule was also found to be adequate. Oral prophylaxis was performed 2 weeks prior to the root-coverage procedure. All the maxillary anterior teeth exhibited 2 mm of recession on the facial surfaces except the maxillary left lateral incisor, which had a recession depth of 3 mm. Since the normal biologic width was established by periodontal remodeling, surgical reestablishment of the biologic width was not planned. At the time of the surgery, the denuded root surfaces of the maxillary anterior teeth intended for root coverage were thoroughly planed. Next, a continuous semilunar incision was made using a scalpel with a 15c blade [Figure 2], 5-6 mm parallel to the margin of the gingiva and extending from the distal surface of right maxillary canine to the distal surface of the maxillary left canine. For better blood supply, the semilunar incisions were extended into the alveolar mucosa so that the apical portion of the flap could be positioned over periosteum and not the dehisced root surface, which is avascular. All interproximal portions of the semilunar incisions remained ≥2 mm from the tips of the papilla to permit optimal perfusion of blood to the repositioned tissue. Sulcular incisions were made extending up to the semilunar incision to elevate a partial thickness flap that was coronally repositioned [Figure 3]. The passive tissue was held against the teeth using moist gauze with slight pressure for 10 min.
Figure 1: Pre-operative view

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Figure 2: Semilunar incision

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Figure 3: Immediate post-operative view

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A periodontal pack was placed to protect the tissues from trauma. The patient was instructed to have a soft diet and asked to avoid biting into any food using the surgically treated teeth for 2 weeks. The patient was also informed not to brush at the surgical site for 2 weeks and to avoid intrasulcular brushing for 2 months. Analgesics were prescribed to alleviate pain along with a chlorhexidine rinse twice daily starting the day before the surgery and terminating 2 weeks post-operatively and the patient was recalled after 10 days.

Healing was found to be uneventful without any complication. On the first visit at 10 days, the tissues appeared red and swollen, and the flap appeared to be in the same coronal position established after compressing the tissue during surgery. At 2 months, the gingiva had healed adequately regaining its original color, contour, and texture in the new position [Figure 4]. A noticeable faint scar at the level of the incision was also observed. The existing degraded composite veneers were ground until enamel was exposed and the teeth were re-prepared. Impressions were made and new ceramic veneers were fabricated, which completely restored the esthetics [Figure 5]. Post-operative examination of the patient 10 months revealed stable periodontium.
Figure 4: Two-month post periodontal view

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Figure 5: Ten-month post-operative view

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The esthetic outcome achieved was evaluated by root coverage esthetic score (RES) system [7] [Table 1]. Each tooth was scored individually, [Table 2] and the mean score was 9 (range 6-10) indicating 90% satisfactory esthetic outcome.
Table 1: Root coverage esthetic score system

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Table 2: Root coverage esthetic scores

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   Discussion Top


Gingival recession is seldom localized to a single tooth. More frequently, gingival recession affects a group of adjacent teeth. The choice of treatment for Multiple adjacent recession type defects involving two or more adjacent teeth should be based on a variety of factors, such as anatomic structures (size of the defect, width of keratinized tissue adjacent to the defect, amount of connective tissue available from the donor site, the depth of the vestibular fornix and mucogingival phenotypes), the number of adjacent teeth to be treated, anticipated level of discomfort during healing, cost, time required, simplicity and the need for more than one surgical procedure to treat the entire recession site. [8],[9],[10],[11]

The SCRF technique proposed by Tarnow in 1986 involves making a semilunar incision parallel to the free gingival margin of the facial tissue and repositioning it coronally over the denuded root. The semilunar flap design does not involve the complete undermining of adjacent papilla and thus, avoids the vascular disadvantages of the traditional coronally repositioned flap when attempting the root coverage of maxillary teeth. The semilunar flap is a simple technique that does not require a second surgical site such as the Free Gingival Graft or the Connective Tissue Graft. In this technique vertical releasing incisions are avoided so as not to damage the blood supply to the flap, this is of paramount importance in root coverage procedures, where the stabilization of the surgical margin is critical to the success of the surgery. Furthermore, the vertical releasing incisions often result (after healing) in an unesthetic visible scar. Other advantages are derived from the split thickness flap elevation, which avoids accidental exposure of bone while coronally displacing the flap. In fact, more thickness is provided for that portion of the flap residing over the previously exposed root surfaces and thus better opportunity to achieve root coverage. A thin fibrin clot formed immediately after application of pressure is enough to hold the tissue in place, avoiding the placement of technically demanding sutures. The other advantages include patient compliance and a satisfactory esthetic outcome. The esthetic outcome evaluated by the RES system showed favorable esthetic results in terms of color match, contour, soft-tissue texture (semilunar scar was not visible in the smile window), gingival margin (only 22 showed partial root coverage) and location of mucogingival junction. This technique however has a few limitations. It cannot be used in patients with a high smile line, thin gingival biotype, and in the mandibular region. This surgical technique used along with new veneers offered good esthetics since both the pink as well the white components of the smile was addressed. The decision to replace the existing discolored and chipped composite veneers with ceramic veneers helped to enhance the esthetic result. The choice of ceramic veneers was based on its excellent biocompatibility with the adjacent gingival tissues and the unmatched esthetics. Long-term follow-up is necessary to evaluate the stability of the results achieved.


   Conclusion Top


The present case report demonstrates that the semilunar flap can be an effective treatment for the management of multiple recession defects affecting adjacent teeth. This surgical technique resulted in 100% root coverage of all the anterior teeth except 22 at 10-months post-treatment examination. Further, studies are required to prove its benefits in comparison to other technique.

 
   References Top

1.Bouchard P, Malet J, Borghetti A. Decision-making in esthetics: Root coverage revisited. Periodontol 2000 2001;27:97-120.  Back to cited text no. 1
    
2.Tarnow DP. Semilunar coronally repositioned flap. J Clin Periodontol 1986;13:182-5.  Back to cited text no. 2
    
3.Sorrentino JM, Tarnow DP. The semilunar coronally repositioned flap combined with a frenectomy to obtain root coverage over the maxillary central incisors. J Periodontol 2009;80:1013-7.  Back to cited text no. 3
    
4.Haghighat K. Modified semilunar coronally advanced flap. J Periodontol 2006;77:1274-9.  Back to cited text no. 4
    
5.Bittencourt S, Del Peloso Ribeiro E, Sallum EA, Sallum AW, Nociti FH Jr, Casati MZ. Comparative 6-month clinical study of a semilunar coronally positioned flap and subepithelial connective tissue graft for the treatment of gingival recession. J Periodontol 2006;77:174-81.  Back to cited text no. 5
    
6.Bittencourt S, Ribeiro Edel P, Sallum EA, Sallum AW, Nociti FH Jr, Casati MZ. Root surface biomodification with EDTA for the treatment of gingival recession with a semilunar coronally repositioned flap. J Periodontol 2007;78:1695-701.  Back to cited text no. 6
    
7.Cairo F, Rotundo R, Miller PD, Pini Prato GP. Root coverage esthetic score: A system to evaluate the esthetic outcome of the treatment of gingival recession through evaluation of clinical cases. J Periodontol 2009;80:705-10.  Back to cited text no. 7
    
8.Carvalho PF, da Silva RC, Cury PR, Joly JC. Modified coronally advanced flap associated with a subepithelial connective tissue graft for the treatment of adjacent multiple gingival recessions. J Periodontol 2006;77:1901-6.  Back to cited text no. 8
    
9.Chambrone LA, Chambrone L. Subepithelial connective tissue grafts in the treatment of multiple recession-type defects. J Periodontol 2006;77:909-16.  Back to cited text no. 9
    
10.Chambrone L, Lima LA, Pustiglioni FE, Chambrone LA. Systematic review of periodontal plastic surgery in the treatment of multiple recession-type defects. J Can Dent Assoc 2009;75:203a-f.  Back to cited text no. 10
    
11.Zucchelli G, Mele M, Mazzotti C, Marzadori M, Montebugnoli L, De Sanctis M. Coronally advanced flap with and without vertical releasing incisions for the treatment of multiple gingival recessions: A comparative controlled randomized clinical trial. J Periodontol 2009;80:1083-94.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2]



 

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