Journal Club On Subepithelial Connective Tissue GraftAssociated with Apicoectomy andRoot-End Fillings in the Treatment ofDeep Localized Gingival Recession withApex Root Exposure

2. Subepithelial Connective Tissue Graft
Associated with Apicoectomy and
Root-End Fillings in the Treatment of
Deep Localized Gingival Recession with
Apex Root Exposure: Case Report
Sergio Kahn, André Medina et al
IJPRD 2009;29.
Shilpa Shivanand
II MDS

3. Introduction
• Marginal tissue recession may result in esthetic
complaints, especially in those with a high smile line, and
may lead to dental hypersensitivity as well.
• Since the 1950s, free and pedicle gingival grafts have
been greatly used for treating gingival recession.
PD Miller 1985

4. • Because of Miller gingival recession classification,
and development of other appropriate techniques
that make use of subepithelial connective tissue
grafts, gingival recession treatments have resulted in
more predictable outcomes, especially with respect
to Class I and II sites, in the absence of interproximal
bone loss.
Langer B, Langer L 1985

5. • Deep gingival recession may lead to exposure of the
root apex. In such cases, endodontic treatment,
associated with dental apicoectomy, may be
combined with root coverage surgery.
• Various materials have been used in apicoectomies
and in root-end fillings, such as amalgam, glass
ionomer, and mineral trioxide aggregate (MTA).
Torabinejad M 1995

6. Aim
• The following case report examines a case of deep,
localized gingival recession with a root apex exposure
that was treated with both a subepithelial connective
tissue graft (SCTG) and apicoectomy with root-end
filling using MTA.

7. Case Description
• .
• A 25-year-old man
attended the
Periodontics Clinic at
the Central Army
Odontoclinic to
investigate gingival
recession associated
with the maxillary right
lateral incisor.
• The patient was in good
health, had no history
of systemic diseases,
and did not smoke

8. • Upon examination, the
patient was found to
have a deep and narrow
Miller Class II gingival
recession, with an 11-
mm vertical extension
all the way to the root
apex.
• Additionally, whenever
the patient smiled, the
esthetic problem
became apparent.

9. • Radiographic
examination showed
radiopaque material in
the root canal, which
suggested earlier
endodontic treatment.

10. • The patient reported a history of dental trauma that
had taken place 8 years earlier.
• The patient not only feared losing the tooth but was
also looking for an esthetic solution to the problem.
• To treat the problem, an SCTG was recommended in
conjunction with a dental apicoectomy using MTA
root-end filling.

11. Surgical Procedure
• Prior to surgery, the patient was provided with oral
hygiene instructions, supragingival scaling, and root
planing.
• On the appointed surgical day, the patient was given
a single dose of 8 mg dexamethasone to minimize
postoperative edema.
• Mepivacaine (2%) with 1:100,000 epinephrine was
used for anesthesia.

12. • Two divergent, oblique
incisions were made
with a 15C blade on the
mesial and distal sides
of the recession,
extending to the
alveolar mucosa.

13. • Two partial thickness
flaps, one mesial and
one distal, were
dissected beyond the
alveolar mucosa,
eliminating any tension
that might hinder the
free movement of the
flaps.

14. • The mesial and distal flaps were positioned over the
root to ensure that they would remain in place
without tension.
• If there was any residual tension, the flaps were
extended apically to relieve such tension.
• The apical lesion was removed and the most apical
portion of the root was cut with a 702 tungsten
carbide bur.

15. • The exposed root was scaled with McCall 13/14 and
Gracey 1/2 curettes (Hu-Friedy) and planed with a
finishing bur. The root end filling was performed with
MTA.

16. • The root end filling was performed with MTA.
• The recipient site was measured with a 15-mm
periodontal probe to estimate the amount of tissue
required for grafting.
• The length of the graft had to equal the distance
between the center of the distal papilla and that of
the mesial papilla.

17. • The SCTG was removed
from the palate in the
region between the
canine and the first
molar with a 15C
double-blade scalpel
measuring 1.5 mm
between blades.
• The epithelial band of
the graft was removed
and discarded.
• The graft was placed in
the recipient site and
sutured with 6-0 Vicryl.

18. • The flaps were sutured together and placed over the
graft with a suspensory suture using 5-0 Vicryl.
• The palate was sutured with 4-0 silk.

19. • Following surgery, the patient was instructed to take
a single dose of 8 mg dexamethasone and analgesic
medication (500 mg dipyrone) and to rinse with
0.12% chlorhexidine digluconate solution twice a day
for 7 days.
• One week later, the sutures were removed from the
palate.
• Two weeks later, the sutures were removed from the
grafted area.

20. • Postoperative maintenance was provided weekly for
the first 3 months after surgery and once a month for
the remainder of the year.
• After 1 year, the recession was seen to have
diminished from 11 mm to 1 mm.
• The probing depth did not exceed 1 mm.

21. • Radiographs showed
radiopacity in the
periapical area,
suggesting complete
repair in this region.
• A porcelain veneer was
used to improve the
esthetic appearance.
• This site has now been
followed for 30 months,
with stable conditions.

22. Discussion
• Gingival recession may cause serious esthetic
problems for patients, especially when patients have
a high smile line.
• Various surgical techniques aimed at solving this
problem have been proposed as treatment.
• The most successful of these techniques is root
coverage with a subepithelial connective tissue graft.
Roccuzzo M et al 2002

23. • In the current case, the presented gingival recession
was a deep narrow Miller Class II type involving root
apex exposure, making this a complex case to treat.
• The vertical extension of the recession limited the
surgical possibilities, ruling out coronally positioned
flap for root coverage.

24. • Because studies have shown better results for root
coverage with SCTGs, the clinicians decided to
associate this graft with a double pedicle flap, as was
initially proposed by Nelson and later by Harris.
• After 12 months, a reduction from 11 mm to 1mm in
gingival recession was noted, with 91% root
coverage, a result that can be achieved by the use of
this technique, according to Harris.

25. • At the end of the treatment, the probing depth was
1.0 mm.
• No bleeding on probing was observed, and an
adequate band of keratinized tissue was seen.
• In addition, acceptable esthetic tissue contour and
coloration were provided to the patient, so that the
treatment could be characterized as successful.

26. Conclusion
• This report serves as a good example of how a
subepithelial connective tissue graft can successfully
be used in association with mineral trioxide
aggregate for the treatment of localized Miller Class
II gingival recessions with root apex exposure.

27. Critical evaluation
• Sample size  low

28. CROSS REFERENCE

29. The connective tissue with partial thickness double
pedicle graft: the results of 100 consecutively-treated
defects. Harris RJ, JOP 1994.
• Obtaining predictable root coverage has been a goal
of periodontal therapy for some time. The
connective tissue with partial thickness double
pedicle graft has been shown to produce predictable
esthetic root coverage. The purpose of this study was
to examine the results of the surgical technique on
100 consecutively treated defects. The procedure
produced a mean root coverage of 97.7%. Root
coverage of 100% was obtained 89% of the time.
With this technique, esthetic root coverage can be
accomplished in a predictable manner.

30. The Subpedicle Connective Tissue Graft A Bilaminar
Reconstructive Procedure for the Coverage of
Denuded Root Surfaces. Stephen WN, JOP 1987.
• The subpedicle connective tissue graft, is a bilaminar graft
that is composed of a free connective tissue graft and an
overlying pedicle graft. By overlaying grafted free connective
tissue with a pedicle, the otherwise compromised section of
free graft which covers a denuded root surface is supplied by
plasmatic circulation from capillaries in the vascular portion of
the pedicle allowing it to survive.In this report 29 teeth were
treated and monitored for as long as 42 months. In the group
with advanced recession of 7 to 10 mm, there was an average
of 88% coverage. The subpedicle graft created a healthy,
functional, and esthetic result that appeared resistant to
further breakdown.