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Root coverage for gingival recession associated with orthodontic treatment
楊惠敏▲ ( Yang HM), 林承俊( Lin CJ)
戴德森醫療財團法人嘉義基督教醫院牙科 (Department of Dentistry, Ditmanson Medical Fundation Chia-Yi Christian Hospital)
Introduction
Orthodontic therapy involving movement of the incisors over the osseous envelope of the alveolar process may induce a risk of gingival
recession .Gingival recession creates an aesthetical problem, and it may be associated with dentin hypersensitivity, root caries, and cervical abrasion.
The free gingival graft (FGG) and subepithelial connective tissue graft (SCTG) are methods for root-coverage about gingival recession. FGG is
pale coloration , so it is not indicated in visible esthetic areas. Oppositely ,SCTG is associated with the advantage of color and bilaminar blood supply.
According to the results by Nelson , SCTG treated the advanced recession of 7~10 mm and reached to average of 88% coverage. 1 Therefore, SCTG
has become the gold standard for root coverage.
Case report
A 34 y/o female suffered from Miller class III gingival recession and hypersensitivity in lower anterior region, so she was referred from local
dental clinic for further treatment.(Fig 1) According to her statement, she has accept orthodontic treatment for 7 years at local dental clinic.
We planned to perform the surgery of SCTG for #31 root-coverage depending on Langer &Langer technique. After local anesthesia, we made
horizontal incision along #31 gingival margin, and combined vertical releasing incision beyond the mucogingival junction and partial thickness flap
was elevated (Fig.2 ).
SCTG was took by trapdoor technique from #24 and #25 palatal gingiva, and then two parallel incisions located from CEJ about 2~3mm in order
to get the SCTG. The thickness should be take into consideration, which is 1.5~2mm recommend by Nelson . 1 We placed a dressing
gauze(Surgicel®) into donor site , and then suture with 4-0 Vicryl to achieve hemostasis (Fig.3).
After removing #31 labial cementum and convex root surface with low-speed diamond bur, we performed root-conditioning with tetracycline.
Further, mesial and distal papilla were de-epithelial with round bur(Fig.4).
Furthermore, we placed the SCTG up to CEJ to achieve root coverage(Fig.5) and fixed the SCTG on the split flap with 4-0 Vicryl and 5-0 Nylon.
Finally we used interrupted suture and sling suture to fix the SCTG and flap on recipient site.(Fig.6)
In the healing process, patient did not complain about pain or bleeding. After 2 weeks(Fig.7) and 3 months follow-up(Fig.8), patient is satisfied
with the esthetic result and the uncomfortable symptom has been subsided.
Fig.3
Fig.2
Fig.1
Fig.4
Fig.5
Fig.6
Fig.7
Discussion
Miller’s classification of gingival recession according to : (1) the breadth and depth in relations to
the gingival margin and the remaining attached gingiva; (2)the loss of interdental papilla.2(Fig.9)
Because the interdental papilla of patient has been lost and the gingival recession was beyond the
mucogingival line till the mobile mucosa, the case is classified to Miller class III gingival recession.
The risk for development of recession defects associated with orthodontic treatment is present if
the tooth moved out of the alveolar bone housing. Two important factors should be considered : (1)the
direction of tooth movement; (2) the buccal-lingual(B-L) thickness of the gingiva.3
Facial tooth movement will incuse the follow complications included : (1) reduced B-L tissue
thickness (2)reduced height of the free gingival portion (3) increased clinical crown height. 3
Final inclination of mandibular central incisors(>95°) and free gingival-margin thickness (<0.5mm)
showed more severe recession.4 Because the predictability and the superior aesthetics are confirmed,
the SCTG technique is the gold standard for root coverage.5
Fig.8
Conclusion
Considering the relationship between orthodontic treatment and gingival health, therefore the
cooperation among patients, orthodontists, and periodontists is important. 6
Surgical periodontal treatments result in esthetic improvement, elimination of hypersensitivity and
less risk of developing root caries.7 SCTG is generally predictable and the gold standard for root
coverage. 5
Reference
1. Nelson SW. ,The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J periodontol
1987 58(2):95-102
2. Miller ,A classification of marginal tissue recession. IntJ periodontics restorative Dent. 1985;5(2):8-13
3. Jan L Wennstrom, Mucoginigval considerations in orthodontic treatment. Seminars in orthodontics. 1996 2(1): 46-54.
4. Karen Ferreira Gazel Yared, Elton Goncalves Zenobio, and welling ton Pacheco. Am J Orthod Dentofacial orthop 2006;130(6): e1-6.e8
5. Color atlas of dental medicine—Periodontology .p 419-421
6. Fatma Boke, Cagri Gazioglu, Sevil Akkaya ,and Murat Akkaya. Relationship between orthodontic treatment and ginigval health: A retrospective
study.European Journal of dentistry . 2014 8(3)
7. Alparslan Dilsiz ,and Turba Aydin. Gingival recession associated with orthodontic treatment and root coverage. J Clin Exp Dent.2010;2(I):30-3
8. Sergio Kahn, Walmir Junio de Pinho Reis Rodrigues ,and Marcos de Oliveira Barceleiro. Periodontal plastic microsurgery in the treatment of deep
gingival recession after orthodontic movement.Hindawi publishing corporation case report in dentistry .2013
9. Ama johal, Christos Katsaros, Stavros Kiliaridis,Pedro Leitao, Marco rosa, Anton Sculean, Frank Weiland and Bjorn Zachrisson , State of the science
on controversial topic: orthodontic therapy and gingival recession (a report of the Angle Society of Europe 2013 meeting). Progress in Othodontics
2013,14:16 .
Fig.9