This case report describes progressive root resorption that occurred after treatment of a deep gingival recession using scaling and root planing, tetracycline root conditioning, and connective tissue grafting. At 20 months post-operatively, external root resorption was observed without symptoms. Root resorption is an uncommon complication that can occur despite initially achieving the desired outcome of treating recession and creating healthy periodontal tissues. Tetracycline root conditioning may cause late root resorption, so this risk should be considered when developing treatment plans.

2. Progressive Root Resorption Associated
with the Treatment of Deep Gingival
Recession. A Clinical Case
Norma Cizza, Dario Migues, IJPRD 2013;30:619–25.
Shilpa Shivanand
III MDS

3. INTRODUCTION
• Gingival recession is a common pathology causing esthetic
problems, sensitivity, root caries in the cementum, and must
be treated with mucogingival surgical procedures to improve
esthetics, reduce recession progress, and avoid
hypersensitivity.
• The subepithelial connective tissue technique is well
documented and extremely predictive for solving esthetic
problems and reestablishing the gingival tissues around a
recession via long junctional epithelium formation or
periodontal tissue regeneration.
Langer B, Langer L 1985, Harris RJ et al.

4. • Restored root surfaces should also be included in the surface
to be covered by the connective tissue graft, since eliminating
the restoration allows adjunct periodontum to rebuild after
the restoration’s removal.
McGuire MK et al 1996.
• Root surface conditioning with chemical agents, citric acid,
and tetracycline is used to improve biologic compatibility of
the root with periodontal cells and enhance connective tissue
grafting, although the results are controversial.
Ben-Yehouda et al 1997.

5. AIM
• The aim of this report is to present a patient with a buccal
recession treated by scaling and root planing, tetracycline root
conditioning, and connective tissue grafting.
• Results were satisfactory, though root resorption appeared as
a late complication 20 months postoperatative.

6. CASE REPORT
• The patient was a 52-year-old woman who was a healthy
nonsmoker and attended the authors’ dental office because
of gingival recession at the maxillary left canine and an
overhanging restoration.
• Preoperative clinical and radio graphic images were taken.
Preoperative
clinical and
radio graphic
images showing
a buccal
recession and an
overcontoured
Class V
restoration.

7. • After periodontal examination, generalized chronic adult
periodontitis was diagnosed.
• Oral hygiene instructions were given to the patient, the
restoration at the canine site was polished, and scaling and
root planing were performed.
• One month after the initial therapy, a clinical reevaluation was
carried out.

8. • Considering the mesial and distal gingival tissue lost and the
recession depth, the recession was classified as Miller Class III,
which predicts partial root coverage.
• The proposed treatment consisted of subepithelial connective
tissue grafting and root conditioning with a tetracycline
solution.
Clinical reevaluation 1
month
after the initial therapy. A
Miller Class III
recession was
determined.

9. • Before surgery, baseline data were registered.
• The buccal aspect of the recession height at the canine was 7
mm, the width of the keratinized tissue was 0.5 mm, and the
probing depth was 2 mm.
Baseline data were
obtained
before the surgical
procedure.

10. • The Class V restoration was removed under local anesthesia
up to the cementoenamel junction by scaling and root
planing.
• This procedure was performed before flap raising, both
smooth and supragingival, to preserve any existing connective
tissue attachment.
• The recession area was treated topically with a 100 mg
tetracycline/mL saline solution for 3 minutes, rinsed, and then
dried.

11. • A trapezoidal partial-thickness double-pedicle flap was raised,
passing through the mucogingival junction.
• Pedicles were joined with 4.0 sutures (Ethicon).
Double-pedicle
graft and
subepithelial
connective tissue
grafting.

12. • A 2.5-mmwide subepithelial connective tissue graft was
harvested from the palate without epithelium removal and
was sutured over the recession defect.
• The flap was sutured without stress over the graft, leaving the
epithelium collar uncovered.
• Gingivoplasty at the mesial and distal papillae related to the
defect was performed to prepare a recipient bed.
Flap repositioning and suturing
was completed without stress over
the connective tissue graft. The
exposed epithelium graft and
sutured mesial and distal papillae
can be seen.

13. Post-op instructions
• Postoperative care consisted of 0.12% chlorhexidine rinses
twice a day for 3 weeks; amoxicillin was also prescribed (1.5 g
a day for 5 days).
• Sutures were removed 10 days later.
• Healing was uneventful.

14. • After 6 months, new parameters showed 2 mm of recession
measured at the level of the cementoenamel junction, 3.5
mm of keratinized tissue, and a probing depth of 2 mm.
After 6 months, new
parameters
showed 5 mm of
recession coverage and
3.5 mm of keratinized
tissue.

15. • Twelve months later, an additional 1.5-mm recession was
observed, most likely a result of aggressive brushing at the
affected site.
• New oral hygiene instructions were given and all other
parameters remained stable.
12 month
follow-up
showed
1.5-mm
increase in
recession
height at
canine as well
as at the other
teeth, most
likely a result
of aggressive
brushing.

16. • Twenty months postsurgery, external root resorption was
noted without any symptoms.
• Tooth extraction and implant placement were proposed to the
patient, but she decided to wait.
Root resorption
seen via
transparent
gingiva at 20
months.

17. • Four months later (2 years postsurgery), resorption evolution
was appreciated both clinically and through radiography.
Clinical photograph
and radiograph
showing the
posttreatment
recession at 22 and
24 months,
respectively.

18. • Before extraction and guided bone regeneration, a flap was
raised to observe the resorption.
Exploratory flap raised prior to
tooth extraction and guided
bone regeneration.
Root resorption is evident at
the buccal, mesial, and distal
aspects of the affected tooth.

19. DISCUSSION
• After a satisfactory result in a Miller Class III patient treated
with a connective tissue graft and tetracycline solution,
external root resorption occured 20 months posttreatment.
• Resorption after regeneration treatment is an uncommon
complication that can occur in spite of having achieved the
desired goal of treating the recession and creating good
health conditions for the periodontal tissues.
• It is difficult to predict, diagnose, and treat.
Heithersay GS

20. • An explanation for this unusual outcome is that the epithelial
cells could have migrated in an apical direction.
• Therefore, the epithelium acts as a protective barrier against
resorption.
Karring T, Nyman S, Lindhe J 1984
• Resorption occurs in an environment where different
periodontal tissues compete for marginal healing.
• Cell mechanisms for identifying dental tissues as foreign
structures are unknown, and they induce resorptive cell
activation.
Carnio J et al 2003

21. • There is enough published information claiming connective
tissue grafts as a reliable and predictable technique to obtain
healthy compatible gingival tissues.
• This is why it is believed that the graft material is not related
to root resorption.
• Several publications have reported that root conditioning is
not beneficial since results do not improve the clinical
outcome.
Caffesse et al 2000, Nagata et al 2005.

22. • Cervical resorption can be produced by epithelial cervical
attachment damage from a chemical agent.
Ne R et al 1999
• There are few reports available on resorption cases related to
regeneration techniques for periodontal defects and gingival
recessions resulting from root conditioning with tetracycline
solution or citric acid.

23. • A periodontal defect treated only with tetracycline showed
resorption after 3 years, as reported by Ben-Yehouda.
• Cury et al recently reported on a clinical case of root
resorption 2 years after periodontal defect treatment with a
bioabsorbable membrane and tetracycline.
• Carnio et al published a report on a patient treated with a
connective tissue graft and citric acid that presented
resorption 2 years later.

24. CONCLUSION
• The buccal recession reported here was treated with a
connective tissue graft and tetracycline solution. The
resorption appeared 20 months after treatment.
• Analysis of the published studies in the literature demonstrate
that resorption is a late complication, generally 1 year
posttreatment, and therefore time is an important factor to
be considered.
• It is suggested that tetracycline root conditioning probably
causes root resorption in long-term evaluations.
• Therefore, this must be considered by the practitioner when
developing the treatment plan.

25. CROSS REFERENCE

26. I. External root resorption following partial thickness
connective tissue graft placement: a case report.
Hokett SD et al, JOP 2002.
• We report an unusual case of external root resorption (ERR)
that developed in a 37yearold black male approximately 1
year following routine partial thickness connective tissue graft
surgery.
• The lesion was accessed via flap surgery, thoroughly root
planed, and the mucoperiosteal flap replaced.
• The site healed uneventfully and the patient has been closely
observed for over 1 year without symptoms or recurrence of
the resorptive lesion and the affected tooth remained vital.

27. • Clinicians performing partial thickness connective tissue grafts
should be alert to the possible occurrence of root resorption
over extended periods of time.
• The authors speculate that retention of the donor periosteum
with placement on the recipient dentin and root
biomodification may limit the resorptive response following
connective tissue graft procedures to treat tooth root
recession.

28. II. Potentials for root resorption during periodontal
wound healing.
Karring T, Nyman S, Lindhe J, Sirirat M, JCP 1984.
• The present study was undertaken to examine whether
(1) the process of resorption, which invariably affects
periodontitis involved reimplanted roots facing bone or
gingival connective tissue during healing, is a transient
phenomenon and,
(2) root resorption can be prevented by permitting
downgrowth of epithelium along the root surface.

29. • A total of 24 teeth in 2 monkeys was subjected to
experimental periodontal tissue breakdown by the placement
of elastic ligatures around the teeth.
• The ligatures were left in situ until about 50% of the
supporting tissues had been lost.
• Following removal of the ligatures, the teeth were extracted
and the denuded portions of the roots were scaled and
planed.

30. • The crowns of the teeth were resected and the root canals
filled with guttapercha.
• The roots were subsequently implanted into sockets prepared
in the jaw bone in such a way that each root was embedded
in bone except for a portion which was in contact with gingival
connective tissue.
• 1 month prior to sacrifice of the animals, the cut surface of
the coronal part of the roots was exposed by removal of the
covering soft tissue. The epithelium was thereby allowed to
migrate into the wound.

31. • Implantation of the roots was scheduled to provide healing
periods of 1, 2, 3, 4, 8, 12, 16, 20 and 24 weeks before
exposure of the roots.
• The histologic examination of the implant specimens
disclosed that replacement resorption was a progressive
process which eventually resulted in the elimination of the
transplanted roots.
• It was possible to prevent root resorption in this model by
permitting apical downgrowth of epithelium along the root
surface during the initial phase of healing.

33. Introduced by Waienberg in 1964
Modified by Cohen and Ross,1968
Indications
When interdental papilla adjacent to receded area is sufficient wide
AG on approximating teeth is insufficient to cause lateral displacement
Advantages
Risk of loss of bone is less as interdental bone is more resistant
Papilla usually supply greater width of AG
Reasons for failure
Inadequate suturing
Double papillae Laterally positioned flap

35. Harvesting the graft from the donor
site
• Two parallel incisions,
perpendicular to the long axis of
the teeth, are made in the palate,
close to the CEJ (Langer & Langer
1985).
• Two vertical releasing incisions
help dissect the superficial flap
and free the subepithelial
connective tissue graft .
• Once the graft is harvested, the
success rate of the procedure
does not appear to be influenced
by removing the epithelial collar
from the graft (Bouchard et al.
1994).
SCTG
The trapdoor enabling the
retrieval of the connective tissue
graft.

36. Primary incision. Make a horizontal incision with a
partial-thickness flap 3-5 mm apical to the gingival
margin in the palate (preparation of primary flap).
Secondary incision. Make a secondary incision 1-2 mm
coronal to the primary horizontal incision line. This incision,
which is perpendicular to the surface of the gingiva, should
extend to the bone.
Make a vertical incision mesiodistally approximating the width
and length of the necessary graft.
Prepare a primary partial-thickness flap (1.5-mm thick) toward
the center of the palate, parallel to the palatal gingiva. Expose the
underlying connective tissue.
Subepithelial connective tissue graft

37. Root Biomodification
• The application of bio-chemical agent to the root surface
directs the movement of specific biomodulators, triggering
variety of responses from cellular component of healing site,
which could play essential role in regeneration….. (Terranova
et al 1995)
Root Conditioning –
• Urist, Frank et al, Register & Burdick (1971- 1980)…. root
conditioning is demineralization and detoxification of root
surface.

38. Purpose of Root surface
biomodification – (Lindhe)
• To remove smear layer following mechanical debridement.
• Demineralization of the root surface (citric acid)
• Selective removal of hydroxyapatite and exposure of the
collagenous matrix of the root surface. (EDTA)
• Local delivery of antimicrobial compound. (tetracycline HCL )

39. Purpose of Root surface
biomodification – (Lindhe)
• Inhibition of collagenolytic activity. (tetracycline HCL)
• Enhancing cellular response. (migration and attachment of
cells)
• Preventing epithelial down growth Improving retention of
different biomolecules to exposed collagen.
• Expressing a cementoblast phenotype for colonizing cells.

40. Materials for root conditioning
• Physical methods include root conditioning by lasers.
• Chemical methods include use of various chemicals like bile
salts, citric acid (ph 1 , disadv: acidic ph) , tetracycline 0.5%
solution at a PH of 3.2  100mg/ml, EDTA 24 %
Ethylenediaminetetracetic acid PH 6.7 for 15 seconds (Biora),
detergents, phosphoric acid and glycoproteins like fibronectin.

41. • Citric acid…. enhances new attachment or
reattachment and regeneration by
– Removal of smear layer (Polson et al, 1984)
– Root detoxification (Aloe et al, 1975)
– Exposure of root collagen and opening of dentinal
tubules (Polson et al, 1984)
– Demineralization prior to cementogenesis (Register,
1975)
– Initial clot stabilization (Wikesjo et al, 1991)
Citric acid

42. – Enhanced fibroblast growth and stability (Boyko etal,
1980)
– Attachment by direct linkage (Stahl and Tarnow, 1985)
with or without cementogenesis.
– Prevention of epithelial migration along the denuded
roots (Polson et al 1983)
– Accelerated healing and new cementum formation after
surgical detachment of the gingival tissues and
demineralization of the root surface by means of citric
acid. (Register & Burdick)
Citric acid

43. • Time of application. (1min & 4min) tried Trombelli et al
1995...
• 1 min.... Smooth surface with many tubule openings
partially occluded by debris
• 4 min .... Three dimensional network of intertubular and
peritubular collagen fibrils.
Root conditioning with tetracycline

44. Mode of application
• Burnish with cotton pellets saturated with solution of
tetracycline HCL.
• Quantity of tetracycline HCL. (10mg/ ml, 100, 400,) 100
mg/ml should be preferred.
• Shorter application times should be preferred. (Seymour et al
1995)
• Tetracycline of HCL + Fibronectin. No additional benefit was
observed. (Alger et al 1990).

45. Mode of application
• It can be used as a 0.5% solution at a PH of 3.2 and is
applied for 5 minutes.
• One study showed >100 mg/ml may enhance fibroblast
attachment. (dose dependent)
• In another in vitro study Trombelli et al 1995 showed longer
application should be preferred.
• Results are inconsistent.

46. EDTA
• EDTA etching has been found to provide a surface more
suitable for periodontal healing compared to root planing only
or following root planing and etching with citric acid or
phosphoric acid
• 24 % Ethylenediaminetetracetic acid PH 6.7 for 15 seconds
(Biora)
• Usually provided with Emdogain.
• It removes smear layer and facilitates adherence of Emdogain

47. HEALING PATTERNS OF PERIODONTAL WOUND
The downgrowth of epithelial cells (EC) results in long junctional
epithelium.
The proliferation of connective tissue (CT) may result in
connective tissue adhesion and root resorption.
The predominance of bone cells (BC), may result into root
resorption, ankylosis though this is relatively uncommon in
humans when compared with animal models, or both.
With the ingress of periodontal ligament (PDL) and perivascular
cells from the bone, a regenerated periodontium with new
cementum develop.
There are 4 healing patterns of periodontal wound ( the four
possible cell types that predominate the wound site)

48. SOME IMPORTANT DEFINITIONS
Healing of a wound by tissue that does not fully restore
the architecture or function of the part. (AAP, Glossary of
periodontal terms,).
Repair simply restores the continuity of the diseased
marginal gingiva and reestablishes a normal gingival sulcus
at the same level on the root as the base of the
preexistent periodontal pocket.
This process called healing by scar, arrests bone
destruction without necessarily increasing bone height.
REPAIR

49. Regeneration :
Continuous physiologic process
Is the growth and differentiation of new cells and
intercellular substances to form new tissues or parts.
Regeneration takes place by growth from the same type of
tissue that has been destroyed or from it’s precursor. This
is termed as wear and tear repair.

50. Reattachment :
The term has been used in past to refer to the
restoration of the marginal periodontium.
Reunion of epithelial and connective tissues with
root surfaces and bone from which they have been
removed in the course of treatment, such as occur after
an incision or injury. It should not be confused with new
attachment.

51. New attachment
It is the embedding of new periodontal ligament fibers into
new cementum and the attachment of the gingival epithelium
to a tooth surface previously denuded by disease.
Reattachment; Repair in the areas of the roots
not previously exposed to the pocket