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Sub-Epithelial Connective Tissue Graft and Enamel Matrix Derivative in the Management of a Localized Gingival Recession Defect: a Case Report

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Sub-Epithelial Connective Tissue Graft and Enamel Matrix Derivative in the Management of a Localized Gingival Recession Defect: a Case Report View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector The Saudi Journal for Dental Research (2016) 7, 147–152 King Saud University The Saudi Journal for Dental Research www.ksu.edu.sa www.sciencedirect.com CASE REPORT Sub-epithelial connective tissue graft and enamel matrix derivative in the management of a localized gingival recession defect: A case report Zohaib Akram a, Naveed A. Khawaja b, Haroon Rashid c, Fahim Vohra d,* a Department of Restorative Dentistry, University of Malaya, Kuala Lumpur, Malaysia b Faculty and Senior Registrar, Department of Oral and Maxillofacial Surgery, College of Dentistry, King Saud University, Riyadh, Saudi Arabia c Department of Prosthodontics, College of Dentistry, Ziauddin University, Karachi, Pakistan d Department of Prosthetic Dental Science (SDS), College of Dentistry, King Saud University, Riyadh, Saudi Arabia Received 12 March 2015; revised 8 June 2015; accepted 25 November 2015 Available online 28 December 2015 KEYWORDS Abstract Within the past 20 years, clinicians have successfully performed mucogingival surgeries Gingival defect; to restore periodontal defects. This article describes the application of enamel matrix derivative Connective tissue graft; (EMD) in combination with connective tissue graft (CTG) for the repair of localized mucogingival Enamel matrix derivative defect. The procedure was performed to observe the clinical success of autogenous CTG in the treatment of moderate facial recession defect combined with the usage of an EMD. The manage- ment involved scaling and root planning, root surface conditioning, elevation of full-thickness flap, application of EMD, shaping and application of CTG at the recession site. Eight-month observa- tions showed root coverage of 3 mm (>75%) with attachment level gain of 4 mm and a gingival margin that was harmonious with adjacent teeth. From a clinical observation, it emerges that root coverage and soft tissue attachment is possible with the use of autogenous CTG in combination with EMD in the management of moderate gingival recession defects. Ó 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction Defects in the form, extent, and position of gingiva (mucogin- * Corresponding author. Tel.: +966 532911056; fax: +966 gival defects), can be corrected by different plastic surgery pro- 114698786. cedures collectively called mucogingival surgeries.1 Indications E-mail address: [email protected] (F. Vohra). for root coverage procedures include root sensitivity, poor Peer review under responsibility of King Saud University. esthetics, prevention of root caries and cervical abrasions due to gingival recession.2,3 In addition to soft tissue deficiency, mucogingival defects may also involve destruction of hard tissues resulting in major functional, esthetic and biological Production and hosting by Elsevier http://dx.doi.org/10.1016/j.sjdr.2015.11.001 2352-0035 Ó 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 148 Z. Akram et al. concerns.4 While root coverage helps in improving esthetics, it support is of prime importance.33 Pilloni et al.,34 in their study also facilitates proper plaque control and maintains periodon- reported topical application of EMD as a successful treatment tal health.5,6 Multiple methods are used for root coverage approach in terms of root coverage, attachment level gain and which include pedicle grafts,7 free gingival grafts,8 connective width of keratinized tissue. A review study provided evidence tissue grafts (CTG),9,10 membrane barrier guided tissue regen- of complete root coverage and long-term stability following eration technique,11 and acellular dermal matrix allografts.12,13 treatment of gingival recessions using CAF in combination Miller14 determined the level of root coverage achievable with with either SCG or EMD.35 Recent results from case series free gingival graft in the form of a classification which evalu- indicate that use of modified coronally advanced tunnel tech- ated both soft and hard tissue defects, dividing the recession nique combined with EMD and CTG may appear to lead to categories (Table 1). predictable outcome in terms of root coverage of isolated Sub-epithelial CTG procedures have been employed in the mandibular Miller Class I and II recession defects.36 management of muco-gingival defects with varying success. The aim of this case report was to clinically evaluate the Palatal donor sites15 are commonly utilized for CTG harvest- healing following the application of EMD and sub-epithelial ing, due to quality and quantity of tissue available, low esthetic CTG in the treatment of localized gingival recession defect in cost and uneventful healing. Studies16–19 have reported benefits an attempt to achieve better clinical outcomes in terms of soft of CTG including increase in keratinized tissue width, clinical tissue root coverage and gain of clinical attachment. attachment level gain; thus successful outcome of gingival recession repairs9,20–22. Studies by Tozum et al.23 and Jahnke 2. Case report et al.24 reported a greater percentage of root coverage with bet- ter outcome as a result of CTG procedure for gingival reces- 2.1. Clinical case presentation sion defects. In a recent consensus report by Tatakis et al.,25 procedures like acellular dermal matrix graft or EMD in con- A 24-year-old female was referred to the department of junction with a coronally advanced flap (CAF) and subepithe- restorative dentistry with complaint of long and un-esthetic lial CTG techniques were identified as effective repair options. mandibular incisor tooth (tooth 31). In addition, patient also The authors concluded that subepithelial CTG offers the best suffered from sensitivity to hot and cold stimulus from approx- outcome in the treatment of Miller Class I and II gingival imately 18 months at a similar site. Clinical evaluation revealed recession defects. gingival recession on the labial surface of tooth 31 extending Advancements in periodontal repair procedures have led to 3 mm apical to the cemento-enamel junction (CEJ) and a nar- the development and clinical application of enamel matrix row zone of attached gingiva (approximately 1 mm) (Fig. 1). derivative (EMD),26–31 showing significant improvements in The pocket depth on 31 was not more than 2 mm with slight clinical attachment levels in both animal and human subjects. sensitivity associated with cold revealed by vitality testing. EMD contains 90% of amelogenins, proline-rich non- There was no papillary height loss on the distal aspect of the amelogenins, tuftelin, tuft protein and serum proteins, incisor and mild loss of papillary height on the mesial aspect. extracted from young embryonic piglet tooth germs.26,32 The Plaque control and oral hygiene was good with no apparent purpose of EMD is to develop a layer of new cementum staining on teeth. There was no evidence of interdental bone around the exposed root surface, initiating migration of loss (i.e. the distance between the crestal bone and CEJ was fibroblastic cells with subsequent improvement in clinical not greater than 2 mm). The patient was a non-smoker and attachment level.27 Commercially, EMD is available as Emdo- gainÒ (Biora AB, Malmӧ, Sweden) in a gel form, which is used to treat periodontal defects by mimicking the development of root structure. Application of EMD is convenient and provides good clinical outcomes especially where periodontal Table 1 Miller’s classification of gingival recession defects. Class I Marginal tissue recession which does not extend to mucogingival junction (MGJ) and is not associated with alveolar bone loss in the interdental area. Complete root coverage is obtainable Class II Marginal tissue recession which extends to or beyond the MGJ and is not associated with alveolar bone loss in the interdental area. Complete root coverage is obtainable Class III Marginal tissue recession which extends to or beyond the MGJ and is associated with alveolar bone loss in the interdental area. Partial root coverage is obtainable Class IV Marginal tissue recession which extends to or beyond the MGJ and is associated with gross alveolar bone loss in the interdental area with exposure of more than one proximal root surface. No root coverage Figure 1 Gingival recession on the labial surface extending 3 mm apical to the CEJ and a narrow zone of attached gingiva. Management of a localized gingival recession defect 149 taking no medication with the absence of any systemic condi- aminetetraacetic acid (EDTA¥) gel solution for 2 min follow- tion or periodontal pockets associated with the gingival reces- ing the manufacturer’s instructions and thoroughly rinsed sion. The case was diagnosed to be sensitivity associated with with saline. The root surface was dried and EMD was applied. Class II Miller recession associated with traumatic tooth The graft was shaped to fit the recipient site and secured to the brushing. The goal of the treatment was to restore the appear- wound bed (Fig. 3) with a continuous sling suture using 5-0 ance of the gingiva by covering the root surface to normal ana- vicryl to the papilla on either side of the graft (Fig. 4). Silk tomic contours and to increase the zone of attached gingiva. sutures were removed after 14 days; visible portions of the vicryl suture were removed after 3 weeks. To reduce the risk 2.2. Connective tissue graft (CTG) of plaque induced inflammation the donor site was covered with a removable acrylic plate. The donor site healed by pri- Following local anesthesia application (2% lidocaine, epi- mary intention two weeks after suture removal. nephrine 1:100,000), the exposed root surface was thoroughly planed and scaled with the use of hand instruments to remove 2.3.
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