Unique Creeping Attachment After Autogenous Gingival Grafting: Case Report
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C LINICAL P RACTICE Unique Creeping Attachment after Autogenous Gingival Grafting: Case Report • Francisco J. Otero-Cagide, DDS, Dip Perio • • M. Fermín Otero-Cagide, DDS, Dip Perio • Abstract This case report describes a unique creeping attachment that developed mesiobucally on a deep, wide recession (3 mm) and extended along the remaining buccal recession (2 mm) of a maxillary first molar with a full-crown gold restoration subsequent to autogenous gingival grafting. Complete coverage of the root by this degree of creeping attachment on a restored multirooted tooth has not previously been reported in the dental literature. MeSH Key Words: gingiva/physiology; gingiva/transplantation; wound healing © J Can Dent Assoc 2003; 69(7):432–5 This article has been peer reviewed. utogenous gingival grafting or epithelialized free be adapted in intimate contact with the recipient site. Later, gingival grafting is a well-established pure muco- Miller10 presented a classification of recession defects based gingival procedure for increasing the width of on the position of marginal tissue recession in relation to A 1 2 attached gingiva. Since its introduction in 1963, the the mucogingival junction and the level of interproximal procedure has proven reliable in increasing attached gingiva tissues (Table 1). With the modified technique proposed by and stopping progressive gingival recession. Also, long-term Miller, root coverage is more predictable and more success- stability (up to 4 years) of these treatment outcomes has ful with Class I and II defects, whereas only partial coverage been demonstrated.3 can be expected with Class III defects. Root coverage in Although root coverage is not a primary goal of autoge- Class IV defects should not be expected. Successful root nous gingival grafting, it may occur, in cases of narrow coverage was found to depend mainly on bridging and recession (< 3 mm), as a result of bridging, whereby some partly on creeping.10 of the grafted tissue remains vital over the avascular zone This case report describes a unique creeping attachment of the root.4 Some root coverage may also result from that developed mesiobucally on a deep, wide recession another mechanism known as creeping attachment, which (3 mm) and extended along the remaining buccal recession was described by Goldman and Cohen5 as the postopera- (2 mm) of a maxillary first molar with a full-crown gold tive migration of the gingival marginal tissue in a coronal restoration subsequent to autogenous gingival grafting. To direction over portions of a previously denuded root. the authors’ knowledge, this degree of creeping attachment Creeping attachment has been reported by several clinicians on a restored multirooted tooth has not previously been and is apparently best observed on mandibular anterior reported in the dental literature. teeth with narrow recessions.6–8 This phenomenon can be detected 1 to 12 months after graft surgery with an average Case Report coverage of about 1 mm.8 During a periodontal examination of a 45-year-old man In 1982, Miller9 proposed a modification of the at the Dental Clinic of the College of Dentistry, University conventional technique for autogenous gingival graft of Saskatchewan, in 1995, it was found that there was an surgery for root coverage. This modification used a thicker inadequate band of gingiva on the facial aspect of the graft (2 mm) positioned over a carefully planed root surface maxillary first and second molars, and the mesiobuccal root that had been previously conditioned with citric acid. With of the first molar had a recession of 3 mm apicocoronally detailed suturing marginally and apically, the graft could and 3 mm mesiodistally. The remaining buccal aspect had 432 July/August 2003, Vol. 69, No. 7 Journal of the Canadian Dental Association Unique Creeping Attachment after Autogenous Gingival Grafting 2 mm of recession. A full-crown gold restoration had been to this treatment plan, and therapy was initiated with placed 6 years before. There was mild to moderate gingival instructions for plaque control, followed by scaling and root inflammation marginally. The recession defect was classi- planing. fied as Class II mesiobuccally and Class I distobuccally Surgical Procedure (according to the Miller classification). There was no loss of During the surgical appointment, after local anesthesia interdental bone or soft tissue (Figs. 1a and 1b). had been achieved, the exposed root was planed thoroughly The patient’s medical history was noncontributory, and with a Gracey 7-8 curet, followed by burnishing a tetracy- he had no complaints or discomfort. Since appearance was line hydrochloride solution (125 mg/mL) over the root not a concern, it was decided to treat the site by Miller’s with a cotton tip for 3 minutes. The area on the first molar technique for autogenous gingival grafting to achieve root that was to receive the gingival graft was prepared by coverage, particularly for the mesiobuccal root of the first creation of a partial-thickness flap according to Miller’s molar, and also to increase the attached gingiva. As a full- techniques; the graft tissue (approximately 2 mm in thick- crown restoration was planned for the second molar, it was ness) was obtained from the palatal side at the level of the recommended that the patient undergo autogenous gingi- right premolars and first molar. The graft was sutured in val grafting of this tooth during the same surgical appoint- place by means of interrupted sutures (5-0 polyglycolic acid ment, to increase the attached gingiva. The patient agreed sutures) at the coronal and apical corners. A basting-type of suture was also used, to obtain good adaptation of the graft Table 1 Classification of recession defects to the recipient site. A conventional autogenous gingival 10 proposed by Miller graft (approximately 1 mm thick) was placed on the Class of prepared recipient site of the second molar and was immo- defect Description bilized with cyanoacrylate. A non-eugenol periodontal I Marginal tissue recession does not extend to dressing was applied to both donor and recipient sites. The mucogingival junction patient received routine postsurgical instructions, including No loss of interdental bone or soft tissue a 0.12% chlorhexidine mouth rinse twice daily along with II Marginal tissue recession extends to or 400 mg ibuprofen 4 times daily for 7 days. One week after beyond mucogingival junction the surgical procedure, the patient reported no major prob- No loss of interdental bone or soft tissue lems, although survival problems were evident for the graft III Marginal tissue recession extends to or over the mesiobuccal root of the first molar (Fig. 2). beyond mucogingival junction Loss of interdental bone or soft tissue occurs Healing of the grafted sites was assessed weekly for the first apical to the cementoenamel junction, but 3 weeks after surgery. At the 12-week evaluation there was coronal to apical extent of marginal tissue a gain in attached gingiva around the first molar, but no recession root coverage had been achieved at the mesiobuccal root IV Marginal tissue recession extends beyond (Fig. 3). The patient had no complaints about the treat- mucogingival junction ment outcome, and oral hygiene was reinforced at this Loss of interdental bone extends to level apical to extent of marginal tissue recession appointment. It was recommended that he proceed with his restorative plan and continue regular periodontal Figure 1a: Preoperative view of the maxillary right first molar of a Figure 1b: Preoperative radiographic view. There is no loss of 45-year-old man shows a deep, wide recession mesiobuccally interproximal bone. (3 mm), with inadequate attached gingiva. Distobuccal recession (2 mm) is also evident, but there is no loss of interdental soft tissue. Journal of the Canadian Dental Association July/August 2003, Vol. 69, No. 7 433 Otero-Cagide, Otero-Cagide Figure 2: Evaluation 1 week after surgery. A portion of the gingival Figure 3: Appearance of the site 12 weeks after graft procedure. A gain graft overlying the mesiobuccal root suffered necrosis, and root in attached gingiva is evident, but root coverage of the mesiobuccal coverage was not achieved. root was unsuccessful. Figure 4a: Treated area 5 years after surgery. Impressive creeping Figure 4b: The gingiva exhibits resistance to probing and probing attachment has resulted in complete root coverage. depth is minimal. developed, which entirely covered the previously denuded root of the first molar. The marginal tissue felt well attached and probing depth was minimal. A full-crown gold restora- tion had been placed over the second molar (Figs. 4a and 4b). The patient was referred back to the fixed prosthodon- tic clinic for assessment of the fractured porcelain at the margin of the crown on the second premolar and for reassess- ment of the margins of the crown on the first molar (Fig. 4c). Discussion Only a few cases of creeping attachment after gingival grafting have been reported in the dental literature and these cases have usually involved unrestored mandibular Figure 4c: Radiographic appearance of interproximal bone 5 years after surgery. Bone levels are good. A full-crown restoration has been anterior teeth in young adults.6–8 Only one case has been placed on the second molar. The margins of the crown on the first reported in which bilateral creeping attachment resulted in molar were to be reassessed in the fixed prosthodontic clinic. root coverage of extensive, wide recessions on the maxillary maintenance. He was seen at the periodontal clinic a couple cuspids after autogenous gingival grafting (in a 39-year-old of times for maintenance, but no information was recorded patient).11 Matter and Cimasoni6 described 5 factors that about the grafted sites until 5 years after the surgery, when seemed to have a definite influence on creeping attachment: it was noticed that an impressive creeping attachment had width of the recession, position of the graft, interproximal 434 July/August 2003, Vol.