Abstract

The purpose of this case report is to present treatment of a patient with multiple  gingival recession  using  different periodontal plastic surgical techniques (connective tissue graft, free gingival graft and coronally advanced flap) . A 17 year old female patient referred to our clinic for therapy with aesthetic problems, hypersensitivity. After the clinically examination, multiple gingival recession was observed. Female patient has two recession defects at maxilla, 23,14 and seven reccession defects at mandibula 31,32,33,34,41,43,44. After initial treatment  the defects were treated with  free gingival graft and connective tissue graft.  Clinical examination was performed at first month after each operation  and sixth months after last operationIt was observed that application of the connective tissue graft and free gingival graft has been succesfull for multiple gingival recession treatment. Treatment also helped to resolve hypersensitivity and achieved satisfaction of the patient’s aesthetic concerns.

Introductıon:

Gingival recession is characterized by the root surface being exposed due to the migration of gingival margin to apical to the cemento enamel junction. . Gingival recession is associated with many etiological factors. These include inflammatory periodontal disease, traumatic toothbrushing, inadequate attached gingival size and iatrogenic factors . Gingival recessions are successfully treated with various periodontal plastic surgery procedures. The ultimate purpose of these plastic periodontal surgical procedures is to coverage the exposed root surface and achieve optimal aesthetic results . The main indications for root coverage procedures are aesthetic care, root hypersensitivity, prevention of cervical abrasion and root caries, improvement of restorative results and facilitating plaque control. There are many periodontal plastic surgery procedures in the treatment of gingival recessions

Free gingival grafting (FGG), connective tissue grafts (CTG), coronally advanced flaps (CAF), and a combination of CTG, CAF and guided tissue regeneration (GTR) have been introduced with a high degree of predictability in Miller Class I and II recession defects . Coronally advanced flaps is considered the gold standard treatment when combined with connective tissue graft . In addition the success of free gingival grafting has been proven to increase the keratinized tissue width.

The purpose of this case report is to present treatment of a patient with multiple gingival recession using connective tissue graft and free gingival graft.

Case Report:

A 17 year old female patient referred to our clinic for therapy with aesthetic problems and hypersensitivity. After the clinically examination, multiple gingival recession was observed. She had a history of dental trauma and traumatic toothbrushing . Female patient has two recession defects at maxilla (tooth number 23 and 14), and seven reccession defects at mandibula (tooth number 31,32,33,34,41,43,44)( Figure 1 ). The depth of the pocket was no more than 3 mm in the recession areas.

After initial treatment the defects were treated with free gingival grafts (FGG) and connective tissue grafts (CTG) (Figure 2-6). Recipient areas were prepared and CTG and FGG were harvested from the palate. For recurrent surgeries in the palate; after three months, after the keratinized tissue has increased, a second surgical procedure was performed, The CTG was removed from the palate using the single-incision palatal harvest technique referred to by Lorenzana and Allen . Grafts sutured in recipient areas using 7.0 resorbable sutures (WEGO-PGLA, Foosin Medical Supplies, UK). The recipient and donor areas was allowed to healing by Coe-Pak (GC America Inc, IL, USA). The patient was told about the postoperative recommendations, analgesics and mouthwash were prescribed. The sutures and periodontal dressing removed at the tenth day after each operation.

  1. Clinic examination was performed at first month after each operation and sixth months after last operation ( Figure 7 ) . It was observed that application of the connective tissue graft and free gingival graft has been succesfull for multiple gingival recession treatment. No complications were observed during the healing period. We observed increased attached gingival level at mandibula, especially in regions with inadequate attached gingiva. The results indicated that the  FGG  allows for a gain in the keratinized tissue level and the  CTG  allows for root coverage with decreased  recession  level.Clinic examination was performed at first month after each operation and sixth months after last operation ( Figure 7 ). It was observed that application of the connective tissue graft and free gingival graft has been succesfull for multiple gingival recession treatment. No complications were observed during the healing period. We observed increased attached gingival level at mandibula, especially in regions with inadequate attached gingiva. The results indicated that the FGG allows for a gain in the keratinized tissue level and the CTG allows for root coverage with decreased recession level.

Discussion:

  1. Multiple recession defects in the dentition of an individual are routinely encountered in clinical practice and as such present a challenge for management. Periodontal plastic surgical procedures aim to restore both gingival esthetics as well as function in these defects. The selection of one surgical technique over another depends on several factors, some of which are related to the type or character of the defect and others that are related to patients wishes .Multiple recession defects in the dentition of an individual are routinely encountered in clinical practice and as such present a challenge for management. Periodontal plastic surgical procedures aim to restore both gingival esthetics as well as function in these defects. The selection of one surgical technique over another depends on several factors, some of which are related to the type or character of the defect and others that are related to patients wishes .

FGG application to widen the keratinized tissue and to obtain root coverage is an important development in esthetic periodontal surgery. In addition, high level keratinized tissue was obtained in this case with FGG and this tissue was thickened and achieved a high level of success for subsequent surgery. However, it has been reported that there are limitations on volume, color, scaling, aesthetic integrity and surface properties. Advantages of CTG are that it is highly predictable, it has abundant blood supply both from inside the flap and from the periosteum–connective tissue side, and the wound is closed at the palatal donor site after harvest of CTG . The main disadvantage of CTG technique is the need for donor tissue resulting in postoperative pain and the need for a large amount of tissue in the treatment of multiple recessions . This case report supports the fact that root coverage and keratinized tissue increase are achieved with FGG and CTG procedures.

According to the literature, the CTG, FGG, and CAF, according to the systematic reviews in recent years, provide a gain in the attachment level with the reduction in gingival recession. According to another systematic review, it was reported that the CTG procedure provided the most appropriate level of keratinized tissue width and root coverage .

Conclusion:

This is based on the data of this case and current scientific literature, both connective tissue grafts and free gingival grafts can provide successful results to certain cases in the treatment of gingival recessions.

  1. Consent: Written informed consent was obtained from all of patients for publication of this case reports and clinical images.Consent: Written informed consent was obtained from all of patients for publication of this case reports and clinical images.