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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 defect: A case report

Zohaib Akram a, Naveed A. Khawaja b, Haroon Rashid c, Fahim Vohra d,*

a Department of Restorative , 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 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 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 was good with no apparent purpose of EMD is to develop a layer of new 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 (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. Follow up and maintenance plaque, accretions and root surface irregularities. Root surface was then conditioned with saturated solution of tetracycline- Oral hygiene instructions were provided to the patient. Patient HCl for 2 min (100 mg tetracycline-HCl/1 ml of sterile distilled was instructed not to brush teeth in the surgical area and to use water). A sulcular incision was made at the site of recession, gluconate mouthrinse (0.12%) for 60 s twice which was extended horizontally into the adjacent interdental daily for 10 days. Patient was instructed to avoid muscle trac- areas slightly coronal to the tooth’s CEJ. The horizontal inci- tion and trauma to the treated area for the first 3 weeks. After sions were connected to vertical releasing incisions both three weeks, a modified brushing technique was advised in mesially and distally involving adjacent teeth. A full thickness order to minimize apically directed trauma to the soft tissue flap was elevated in an apical direction exposing the alveolar around the surgical site. Throughout the treatment, recall visits plate of bone until the mucogingival junction (MGJ). The for prophylaxis treatment were arranged at 1, 3, 5, 8, 12, 16 periosteum was released and blunt dissection into the vestibu- and 32 weeks. lar lining mucosa was performed to eliminate tension to help Healing was uneventful. At 5th week, the gingiva at the sur- re-position the flap coronal at the level of CEJ. The interdental gical site was still edematous (Fig. 5). Only erythema could be papillae of the adjacent teeth were not involved (Fig. 2). observed along the border of attached gingiva which improved The donor site for the sub-epithelial connective tissue graft at 8th week of follow-up. At 4 months and 8 months postoper- was palatal to the bicuspid region of the same subject. Donor atively, the amount of attached gingiva was approximately palatal tissue was harvested as follows: a horizontal incision 3 mm, and the gingiva was firmly attached. Probing depth at was placed in the palate 3 mm from the free gingival margin, the mid buccal site was less than 1 mm and attachment level and two parallel internal vertical incisions, one superficial gain of 4 mm with free gingival margin which was located less and one deep, were made and connected mesially and distally. than 1 mm apically to the apical border of the CEJ (Fig. 6). The underlying connective tissue of a thickness of 1–1.5 mm and a length of 3 mm was released at its base and removed. 3. Discussion The CTG was soaked in for 5 min in EMDb while the wound was closed with simple interrupted 3-0 silk sutures. The The aim of this case report was to present a predictable proce- exposed root surface was conditioned with 24% ethylenedi- dure by using EMD along with subepithelial CTG for the treatment of Class II Miller recession caused by tooth-brush trauma. Multiple causes have been proposed for localized

Figure 2 Full thickness flap excluding interdental papilla elevated. Figure 3 Graft shaped to fit the recipient site. 150 Z. Akram et al.

Figure 6 4 months postoperative. Probing depth at mid buccal site was 1 mm and free gingival margin was located 1 mm apical to CEJ. Figure 4 Graft secured to the papilla on both sides using continuous sling suture 5-0 vicryl. Procedures involving connective tissue grafts are successful when they attain adequate vascularization from the neighbor- ing blood vessels through which the grafted tissue gets its nour- ishment.43 Therefore in this clinical case report, the main idea was to preserve the blood supply of the connective tissue graft as much as possible. In addition, successful grafting and root surface coverage is critically affected by the quality of root sur- face.44 A desired root surface can be achieved by eliminating the heavy smear layer, which is essential to provide access for collagen attachment around the available root surface before applying EMD.44 Therefore, in the presented case report, 24% EDTA¥ gel solution was used for 2 min to condi- tion the root surface prior to surgical procedure. Application of EMD was utilized in order to achieve regen- eration of cementum and clinical attachment gains in the pre- sented case report. In a study by Mellonig45 a mucogingival defect was repaired using a CTG with and without the use of Emdogain, with surgical site presentation at 2 and 4 weeks follow-up. The graft tissue was harvested from the palate and gave acceptable results with reduction in probing pocket depth and gain in attachment loss. In addition, application of EMD alone resulted in periodontal regeneration involving new bone Figure 5 5th week postoperative. Edema and erythema at the deposition, cementum formation, and periodontal ligament gingival margin. regeneration.45 Similarly, Heijl29 reported that recession defect when treated with EMD alone forms a new cementum layer gingival recession including, orthodontic treatment, , with collagen fibers covering more than half of the defect area high frenal attachment and poor restorations.37–40 Tooth around the root surface. Moreover, in a study by Silvestri46 the brush trauma has been associated with gingival recession in histology of a 6 mm gingival recession defect revealed 3 mm particular with the use of a stiff brush and brushing frequency gain in keratinized tissue as well as 2 mm gain in clinical attach- of 3 or more per day.41 In order to prevent further soft and ment. The treatment regime in the study by Silvestri46 was also hard tissue defects, the patient in this case report was a combination of subepithelial CTG with the application of instructed to brush twice daily, using a soft brush. Overall EMD and demonstrated the formation of a new layer of cemen- management was aimed to minimize risk during the surgical tum, new bone and periodontal ligament attachment tethered procedure and to ensure uneventful healing along with patient into the newly formed cementum.46 Besides having the advan- comfort. The case showed coverage of the root surface and a tage of forming a new layer of cementum around the root sur- gain in clinical periodontal attachment in response to the face, EMD also serves to produce keratinization of the tissues application of EMD with CTG. The purpose of CTG in this around the surgical wound.47 These clinical gains of EMD, sup- case was two folds. Firstly, to regain apico-coronal attachment port the clinical outcome achieved in the presented case report, loss and secondly, to overcome the narrow zone of attached further cementing the efficacy of CTG in combination with gingiva.34,42 EMD in the treatment of recession defects. Management of a localized gingival recession defect 151

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