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Dental Tribune Middle East & Africa Edition | 3/2017 GENERAL DENTISTRY 27 ◊Page 26 Fig 1. Initial Situation. Lower Anterior Sextant. Fig 4. Two Weeks after starting with basic treatment Fig 12. Follow up 6 months Fig 8, 9. Sub-Epithelial Connective Tissue graft Har- vested From the palate. Detail of the Connective tis- sue graft impregnated with the amelogenins (Strau- mann Emdogain). Fig 13. Follow up 6 months. Occlusal view Fig 5. Pre- Surgical situation. Lower anterior Sextant. Fig 2, 3. Post- Op situation after Basic Periodontal treatment. cession is expressed as success (i.e. the aver- age percentage of root that has been covered). The type of recession according to Miller’s classifi cation infl uences the outcome of the surgical procedure. Factors related to the surgical technique used - tissue tension, fl ap thickness - may also infl uence the treatment results (Pini Prato et al. 2000) This paper reports a clinical case of a 6 months follow up after a modifi ed coronally advanced tunnel and connective tissue graft (Subepithelial) + enamel matrix derivative proteins (Straumann Emdogain) to treat a multiple lower anterior gingival recession. Clinical case description A systemically healthy 35-year-old female pa- tient, a nonsmoker, was referred to our Clinic. Her chief complaints were root sensitivity, discomfort and pain when brushing the low- er anterior teeth. The patient underwent orthodontic treat- ment between 2003 and 2009. The symp- toms she relates started after such treatment. Upon examination, the following was ob- served on lower anterior sextant: Miller’s class II gingival recession in tooth #31 that showed a 2,5mm width and 4mm depth; Class I #41,32 showing 2 mm x 2mm. Localized gingival infl ammation and tartar accumulation in the root surface #31, 41, Thin periodontal biotype, Lack of attached gingiva. (Figure 1) Diagnosis and suggested treatment plan was explained in detail to the patient: basic periodontal therapy and periodontal plastic surgery - Modifi ed coronally advanced tun- nel technique (MCAT) in this case (Zuhr et al. 1999, Aroca et al. 2010, Sculean et al. 2014, 2015) + connective- tissue graft and enamel matrix derivative proteins. Other grafting material options such as xenografts and al- lografts were discussed. The basic therapy included: Instructing the patient regarding den- tal plaque control, tartar removal(Fig. 2,3), prophylaxis and use of a soft toothbrush and of the necessary interproximal cleaning de- vices for each sector. This therapy lasted four sessions, once a week and the results can be seen in Figure 5. The surgical technique selected was a tunnel- ling technique (MCAT) + connective tissue graft harvested from the palate. This surgical approach has the advantage of not incising into or refl ecting many of the papillae within the surgical site, thereby minimizing the risk of losing papilla height in critical areas. The surgical procedure was performed under Fig 6, 7. Preparation of the recipient site according to the tunneling technique Fig 10, 11. Post- Op Situation after 14 days. Prior to su- ture removal. Good tissue blending and colour were observed Fig 14. Comparative initial to 6 months situation local anesthesia. Scaling and root planning was performed at all teeth scheduled for root coverage. Thereafter, a mucoperiosteal fl ap was raised using several tunneling knives be- yond the mucogingival junction, maintain- ing interdental papillae intact, thus creating a tunnel fl ap (Figs 6,7). The tunnel was then extended apically and laterally in a split fl ap, sectioning and releasing all attached muscle and collagen fi bers from the inner aspect of the fl ap. After gentle undermining but not disruption of the interdental papillae, the tunnel fl ap was mobilized so as to allow complete coronal tension-free advancement. Root conditioning using EDTA 24% 2 minutes (PrefGel) and enamel matrix derivative pro- teins (EMD) was performed. A sub-epithelial connective tissue graft (SCTG) was taken from the palate. The single- incision technique was used to remove the graft (Fig. 8,9) and soaked in EMD for 5 min- utes. The donor area was sutured with suture 5/0 Seralon. The SCTG was introduced into the recipient site and fi xed using 7-0 and 6-0 Prolene su- ture. This surgical approach has the advantage of not incising into or refl ecting many of the papillae within the surgical site, thereby minimizing the risk of losing papilla height in critical areas. The patient was instructed to take Ibuprofen 600mg 30 min before surgery, 6 hours after and every 12 hours as necessary during the following days and to use mouth-rinse (0.12% chlorhexidine digluconate) twice a day for 15 days. Sutures in the donor area were removed after 1 week and all the rest 14 days after the procedure. The patient was followed up weekly during the fi rst month and monthly up to the third month. Healing was uneventful. The patient did not report pain or major discomfort dur- ing the postoperative period. The color of the tissues was homogeneous 2 weeks following the surgical procedure (Fig. 10,11). Six months after the treatment, gingiva stability and thickness seem adequate, which shows good hygiene of the sector and gingival tissue sta- bility achieved with the graft. (Fig. 12, 13) Conclusions Successful treatment outcomes requires the analysis of all the etiological factors. Basic periodontal therapy is fundamental when treating gingival recession. Appropriate oral hygiene techniques should be implemented. In cases where the recession causes aesthetic concerns or root hypersensitivity, surgical treatment should be recommended. Subepi- thelial connective tissue grafts are the gold standard in periodontal plastic surgery as they modify tissue thickness, increase kerati- nized gingiva and improve root coverage. The MCAT can lead to predictable recession coverage of single and multiple recessions. Periodontal maintenance is essential to avoid infl ammatory events which might increase recession recurrence. References 1.Chambrone, L. Rationale for the Surgical Treatment of Single and Multiple Recession- Type Defects, In: Chambrone, L. Evidence Based Periodontal and Peri Implant Plastic Surgery, 1st Ed, Springer, 2015: 45-146. 2. Wennströ m JL, Zucchelli G. Increased gin- gival dimensions. A signifcant factor for suc- cessful outcome of root coverage procedures? A 2-year prospective clinical study. J Clin Peri- odontol, 1996; 23: 770- 777. 3.Bueno, L; Chambrone, L. Management of multiple recessions type defects after Ortho- dontic erapy: A clinical case report based of Scienti c Evidence, Clinical Advanced of Peri- odontology; 2015; 10: 1- 14 4. Sukekava F, Araujo MG, Pustiglioni FE, Lima LA. Root coverage procedures for the treat- ment of localized recession-type defects: a Cochrane systematic review. J Periodontol 2010; 81:452-78. 5. Tatakis DN. Periodontal soft tissue root cov- erage procedures: A systematic review from the AAP Regeneration Workshop. J Periodon- tol 2015, 86 (2 Supplement):S8-S51. 6. Richardson CR, Allen EP, Zabalegui I, Zadeh HH, Tatakis DN. Periodontal soft tissue root coverage procedures: Practical applications from the AAP Regeneration Workshop. Clin Adv Periodontics 2015; 5:2-10. 7. Miller, PD. A classi cation of marginal tissue recession. Int J Periodontol Rest Dent, 1985; 5: 9-13. 8. Bueno, L; Ferrari, R; Shibli, J. Tratamiento de recesiones y defectos mucogingivales medi- ante injertos de tejido conjuntivo en piezas dentarias e implantes. Odontoestomatologí a, 2015; XVII (25): 35-46. 9 Molnár B1, Aroca S, Keglevich T, Gera I, Win- disch P, Stavropoulos A, Sculean A. Treatment of multiple adjacent Miller Class I and II gin- gival recessions with collagen matrix and the modifi ed coronally advanced tunnel tech- nique.Quintessence Int. 2013 Jan;44(1):17-24. 10. Sculean A, Cosgarea R, Stahli A, et al. The modifi ed coronally advanced tunnel com- bined with an enamel matrix derivative and subepithelial connective tissue graft for the treatment of isolated mandibular Miller Class I and II gingi- val recessions: a report of 16 cas- es. Quintessence Int 2014;45:829–835. 11. Hurzeler, M; Weng, D. A single incision technique to harvest subepithelial connec- tive tissue grafts from the palate. Int. J. Peri- odontics Restorative Dent, 1999, 19, 279-287. 12. Aroca S, Molnar B, Windisch P, et al. Treat- ment of multiple adjacent Miller class I and II gingival recessions with a Modifi ed Coronally Advanced Tunnel (MCAT) technique and a collagen matrix or palatal connective tissue graft: a randomized, controlled clinical trial. J Clin Periodontol 2013;40:713–720. Dr. Laura Delgado Rodriguez Periodontist Primarily graduating from the University Alfonso X el Sabio, Madrid with a degree in Dentistry, Laura also has a Master’s Degree in Periodon- tics and Implant Dentistry at the University of Catalunya. Alongside these accolades, she attained an advanced course in Implant Dentistry and Prosthodontics from Loma Linda in the USA and a Diploma in Aesthetics Dentistry from the University of Gotemburg. After almost a decade working in Madrid, Spain, my husband and I embraced the exciting challenge of moving to Dubai, and I was fortunate enough to join the amazing team at Dr. Roze & Associates Dental Clinic – allowing me to work with passion, every day. In my spare time, I enjoy traveling, dancing and going to the beach. I also love spending time in Dubai with my family, my husband and my son.”