After her four-year maintenance phase, a patient with multiple gum recessions, Miller type 1, 2, and 3, underwent a tunnelled connective tissue graft in 2.1, 2.2 and 2.3 with emdogain to cover the root and protect the patient from increasing sensibility.

Multiple recessions, connective tissue graft, emdogain, sensibility, Miller’s classification, subepithelial connective tissue, tunnel technique with connective.

Referral

 The patient attended the clinic of D.R. Lluch (Valencia, Spain).

Patient Complaint

« The patient came to the consultation because she had generalised dental mobility, bleeding, pus, and bad breath. Moreover, he has sensibility and felt like his teeth were growing.»

History of presenting complaints

It comes because it is beginning to have sensitivity in 2.1 and 2.2. She notes that her sensitivity increased.

 Social history

Age:46 years old

Occupation: Unemployment.

Medical History:

Actual diseases: Bruxism(Bussadori et al., 2020); depression,

Past illnesses: Covid, psychosis.

Allergies: Pollen.

Tabaco history: She needs to use smokes every day; four years ago, she smoked 20 cigarettes daily.

Alcohol intake: She said that when she has a depression crisis, she drinks and increases consumption.

Family conditions: Alcoholism, drug addiction.

 Dental history

Oral hygiene technique: Adequate.

Dental visits: Frequent.

Habits: Bites her nails.

Evaluation:

 1. Health

2. Function

3. Aesthetics

The maximum aperture was 32 mm in the anterior zone.

 Attitudes Towards Previous Treatment

Challenged patient.

Treatments

phase one

1. The first step in therapy is to guide behaviour change by successfully motivating the patient to remove supragingival dental biofilm and risk factor control (alcohol and cigarettes, mainly)(Sanz et al., 2020).

To achieve this first step, it is necessary to do the following:

• Supragingival dental biofilm control and develop skills in dental biofilm removal.

• Interventions to improve the effectiveness of oral hygiene motivation and instructions.

• Adjunctive therapies for gingival inflammation.

• Interventions aimed at removing supragingival plaque and calculus, as well as possible plaque-retentive factors that impair oral hygiene practices.

• Risk factor control includes all the behavioural health change interventions eliminating/mitigating the recognised risk factors for periodontitis onset and progression (smoking cessation, improved metabolic control of diabetes, and dietary counselling and weight loss).

1. Cleaning and applying airflow are carried out.

2. Radiological diagnostic method: Periapical radiographs and orthopantomography.

3. Perio chart shows the deep pockets and soft tissue conditions:

A. CAL generalised were 2 mm in molars and 1-2 mm in anterior teeth.

B.  No bleeding and generalised plaque.

C. Thin biotype.

D. Generalised gingival recessions type 3 Miller in teeth.

E. Reduced healthy periodontium.

F. The CPITN code was 1 for the majority of her teeth.

G. Radiographic bone loss> 15% coronally.

H. She has lost teeth due to periodontitis.

I. Mobility grade 2 in most of the teeth

4. Sufficient saliva and good mobility of the tongue.

The oral mucosa is moistened, has an average colour and does not present pathologies.

5. The patient was taught the instructions and good brushing and flossing techniques. An electric toothbrush is recommended since, according to Ccahuana-Vasquez et al. (Ccahuana-Vasquez et al., 2019), 2019 reduces plaque and gingivitis compared to the manual toothbrush.

 To control plaque levels in the patients, some tablets were recommended to detect plaque after brushing. Thus, they would know if the plaque is being removed and where they need to brush better.

6. Scaling and root planning were performed; the aims for this treatment are:

A.  To reduce bleeding and the level of plaque to £25%.

B.  To reduce the depth level of the pocket under 4 mm plus BOP and any PPD > 6 mm.

C.  Keep the horizontal defect less than 2-3 mm in the furcation involved.

D. To prevent pain or bad smell.

E.  To evaluate other techniques such as regenerative or resective surgery if this treatment is unsuccessful in the periodontal revaluation carried out after four months.

7. The patient was motivated and educated about the harmful effects of tobacco and alcohol on health. It was recommended to visit pages such as the Slutta.no page, created by Helsenorge.no, for more information on quitting smoking. In addition, pinto-Filho et al. 2018(Pinto-Filho et al., 2018) conducted a cross-sectional study about alcohol and tooth loss. They found that Alcohol dependence increased 2.5 times the risk of tooth loss.

8. Sistematic revaluation was recommended after three weeks to recheck the periodontal evolution because the patient had no money, and he said that time.

8. Revision of the temporomandibular joint:

 A. The patient had not to pain when she opened her mouth; Her maximum aperture was 32 mm.

 B. The masseter and buccinator muscles are contracted on palpation, and their mobility is limited.

9. To control plaque levels in the patients, it was recommended to use some tablets to detect plaque after brushing. Thus, they would know if the plaque is being removed and where they need to brush better.

Initial OPG

Photo second quadrant

Periapical Antero- Inferior teeth

Diagnosis

1. The patient presented multiple Miller recessions (Pini-Prato, 2011) types 1: 4.4; 4.5;4.2;1.3;2.3;1.4;1.5.

Type 2: 3.4;3.5.

Type 3: 1.1;1.2;2.2;2.4;2.6

Type 4: 4.1.

•  The patient currently has a reduced healthy periodontium.

3. Bruxism(Lavigne et al., 2008).

 Teeth prognosis (Mac Guire, 1991)

The teeth have remained stable during these four years, and all have a good prognosis. However, tooth 32 has an uncertain prognosis.

Phase two

The second therapy step aims to control (reduce/eliminate) the subgingival biofilm and calculus (subgingival instrumentation). In addition to this, the following interventions may be included:

• Use of adjunctive physical or chemical agents • Use of adjunctive host-modulating agents (local or systemic) • Use of adjunctive subgingival locally delivered antimicrobials • Use of adjunctive systemic antimicrobials(Sanz et al., 2020)

1. Scaling and root planning were performed. Irrigated with 0.12% chlorhexidine.

 The aims of this treatment are:

A.  To reduce bleeding and the level of plaque to £25%.

B.  To reduce the depth level of the pocket under 4 mm plus BOP and any PPD > 6 mm.

C. Keep the horizontal defect less than 2-3 mm in the furcation involved.

D.  To prevent pain or bad smell.

E.   To evaluate other techniques such as regenerative or resective surgery or re-scaling and root planning again if this treatment is not successful in the periodontal revaluation carried out after six weeks.

3. Periodontal re-evaluation

The aims of therapy:

 No periodontal pockets >4 mm with bleeding on probing or no deep periodontal pockets ≥6 mm.

If this is not done, in that case, the third step of therapy should be considered. Some specific situations follow directly to phase three, such as tooth mobility with no antagonist.

If the treatment does not achieve the therapy endpoints,  the patient should not be placed in a supportive periodontal care (SPC) programme.(Herrera et al., 2022).

In this case, this patient, after phase two, was placed in phase three.

Because the patient had a mucogingival problem since he had some gingival recessions caused by the consumption of Snus, once the patient was stabilised, with healthy periodontal indices in terms of bleeding and plaque accumulation, once the patient had committed to stop using Snus and reduce alcohol consumption, it was explained through videos and meaningful drawings which would be the treatment to follow. It was about gaining keratinised gum around the teeth to prevent the recession from advancing further and causing the loss of their teeth in the long term (Cairo, 2017).

Phase three

If the endpoints of therapy:

No periodontal pockets >4 mm with bleeding on probing or deep pockets ≥6 mm have not been achieved; the third step of therapy should be implemented (Sanz et al., 2020).

to gain further access to subgingival instrumentation or aim at regenerating or resecting those lesions that add complexity in managing periodontitis (intra-bony and furcation lesions). It may include the following interventions(Sanz et al., 2020):

• Repeated subgingival instrumentation with or without adjunctive therapies

• Access flap periodontal surgery

• Resective periodontal surgery

• Regenerative periodontal surgery

When there is an indication for surgical interventions, these should

be subject to additional patient consent, and specific evaluation of risk factors or medical contraindications should be considered. In addition, the individual response to the third therapy step should be re-assessed (periodontal re-evaluation)(Sanz et al., 2020).

Once it was verified that the previous requirements were met, a treatment plan was designed to perform a connective tissue graft taken from the palate and its position in the area of ​​ 2.1; 2.2 to gain keratinised gingival with a tunnelled technique (What is the procedure for a connective tissue graft?).

Subsequently, ceramic or composite veneers would be made to improve aesthetics, depending on the economic capacity of the patient.

It was clearly explained to the patient that 100% root coverage would not be achieved. Instead, we would improve her sensitivity, stop her recession and improve her keratinised gum around her 2.2 teeth. At the 2.1 level, she was warned that she would gain more or less an mm of coating. Then, it will be necessary to make some aesthetic composites to improve the emergence profile and dental sensitivity. Root coverage was considered entirely achievable for Miller class I and II defects, only partially possible for Miller class III defects and not for Miller class IV defects (Miller PD, 1985).

Differential fixed treatments

1. Use as a connective tissue graft, products such as Alloderm or Mucoderm(Schmitt et al., 2016) have been shown to work in this type of retraction.

2. Make gingival fillings to treat sensibility.

It is ruled out because we would not prevent recessions from continuing to escalate.

Treatment

What is the tunnelling technique of gingival graft?

1. Once the patient has been anaesthetised, a dental cleaning has been carried out, and the airflow has been passed over the surface of the teeth, a separation of the gum surrounding the teeth is made from 2.1 to 2.6. For this, an ultra-fine tip of the scaler is used.
2. Once the resistance of the gum has been eliminated and to separate the deeper fibres, we use a Sculean microperiosteotome. We verified that the gum could reach close to the incisal third.
3. At the level of the first quadrant, we made a rectangle between 1.3 and 1.5 in the palatal gingiva, 3 mm from the gingival margin and 1.5 mm deep. Then, the free gum graft technique was performed, from which the epithelium was removed with scalpel blade No. 15.
4. Fibrin sponges were stitched together to help form a clot and prevent bleeding.
5. Some authors make a plastic splint to press the palate once the free gum tissue graft has been taken.
6. The next step is to peel off the graft. Next, it is cleaned with physiological saline. Then, the receptor area is rinsed with chlorhexidine and saline.
7. Emdogain is applied to the vestibular flap at the level of the periosteum.
8. The graft is taken from mesially from 2.1 to the level of 2.3 mesially. Then, Emdogain is applied between the connective tissue and the periosteum of the vestibular flap.
9. Subsequently, the graft is fixed in the interproximal papillae, and a suspensory suture is performed.
10. The gingival shrinkage will improve over time, with its maturity and aesthetics point after one year(Eren et al., 2016).

Options

Conveniences

1. Palatal connective tissue graft is a widely studied technique supported by the literature (Eren et al., 2016; Cairo, 2017; Zucchelli et al., 2020).

2. In this way, the recession will be prevented from advancing; it will stop, and the patient’s measures will be instilled so that the recession does not reappear.

Inconveniences

1. requires more manual dexterity than performing just a gingival filling.

2. There is a risk of cutting the palatal artery.

3. Necrosis of the palate may occur, and the pain may be quite noticeable.(Aguirre-Zorzano et al., 2017)

4. It may be that if there is any failure in the suture and placement of the graft, it is lost, and the recession increases.

 

Surgery photos

 

 Oral medication

1. Paracetamol 500 mg three times per day for three days.

2. Supplement vitamin D to try to decrease the inflammation and help the healing of the bone(Ghaly, Hart and Lawrance, 2019).

3. Oral rinses with hyaluronic acid that aid in gingiva healing(Marin et al., 2020).

 Teeth Prognosis

The forecast is good. As the recessions are thicker at the apical level, these may advance more slowly.

Periodontal re-evaluation

In the periodontal re-evaluation, the following was performed:

1. A new period chart.

2. New series of periapical radiographs.

3. Intraoral photographs.

4. Plaque-index test.

5. it was made of composite veneers in 2.4.

The aims for this treatment were completed:

A.  To reduce bleeding and the level of plaque to £25%.

B.  To reduce the depth level of the pocket to under 3-4 mm.

C.  To gain more keratinised gingiva around 2.1, 2.2, and 2.3 and to reduce the recessions.

D.  To prevent pain or bad smell.

E. The objective of motivating her and showing that smoking is terrible for her health and that alcohol consumption is harmful, I did not achieve. She continued consuming it.

The patient had to go to phase 4, where we reinforced his motivation to stop using cigarettes and drinking alcohol.

 Maintaining good dental hygiene would make her bleed less than 30%. In addition, her plaque index was that of a healthy periodontium.

Once this phase is finished, the patient will be scheduled for six months to carry out a maintenance phase. It will be assessed whether it is necessary to make more aesthetic composites or whether she has sensitivity in other teeth.

Supportive periodontal care

It aims to maintain periodontal stability in all treated periodontitis patients by combining preventive and therapeutic interventions defined in therapy’s first and second steps, depending on the gingival and periodontal status of the patient’s dentition. This step should be rendered regularly according to the patient’s needs(Herrera et al., 2022).

 In any of these recall visits, patients may need re-treatment if the recurrent disease is detected. In these situations, a proper diagnosis and treatment plan should be reinstituted. In addition, compliance with the recommended oral hygiene regimens and healthy lifestyles are part of supportive periodontal care. Finally, tooth extraction may be considered in any therapy step if the affected teeth have a hopeless prognosis(Sanz et al., 2020).

Plaque index

 

Second quadrant

Re-evaluation

The objective of the reassessment is to verify that periodontal health remains stable and that the plaque or bleeding index has not increased.

No periodontal pockets >4 mm with bleeding on probing or no deep periodontal pockets ≥6 mm.

Once the last control was carried out in 2021, the patient moved to London for work. Then, after two years, she returned to the consultation. She had undergone regenerative periodontal surgery in the first quadrant because her sensitivity had increased, and she wanted to solve it.

Unfortunately, the regeneration did not go well. Due to the type of healing, it seems they had made a coronal positioning flap. She told us that they did not take any graft.

She says that since it was done, she has had constant inflammation in the tooth; sometimes, fluid comes out of it, but it is not blood. So, we are still determining what it will be. Our treatment will be based on carefully cleaning the area in case something is impacted or a thread has not been reabsorbed and is waiting for tissue maturation.

Her treatment plan is based on waiting for the maturation of the tissues. She tells us that she will return to Valencia in the summer, so at that time, we will carry out a new assessment and plan a possible bone regeneration treatment.

Periapical X-rays

 The lesion in 1.2

Teeth prognosis

1.1 and 1.2 have an uncertain prognosis due to the lesion in the patient after periodontal surgery performed in London.

3.2: The prognosis continues to be uncertain, but the truth is that this tooth with periodontal maintenance can be in the mouth for many years.

The rest of the teeth have a good prognosis. However, at the moment, they do not have sensitivity.

The patient knows she has multiple recessions but does not want to treat them until she has to.