CLINICAL AND RESEARCH REPORT

The Treatment of Gingival Recession

Associated with Deep Corono-Radicular
Abrasions (CEJ step) – a Case Series
Giovanpaolo Pini-Prato, Carlo Baldi, Roberto Rotundo, Debora Franceschi, Leonardo Muzzi

The present case series study illustrates two different mucogingival techniques for treating gingi-
val recessions associated with deep dental abrasions. The therapeutic strategies depend on the
depth of the abrasion measured at the mid most coronal point at the CEJ level (CEJ step). When
the CEJ step was <1 mm, a connective tissue graft associated with an extremely positioned coro-
nal flap was performed. In case of a CEJ step ≥1 mm, a double connective tissue graft with an
extremely positioned coronal flap was used. The dental abrasions and/or CEJ were not me-
chanically treated in either situation. One year later, the results showed a recession reduction of
97.5%, with complete root coverage obtained in 82% of sites, and dental hypersensitivity re-
duction obtained in 5 out of the initial 7 sites. There were no new cases of dental hypersensi-
tivity at the end of follow-up period as a consequence of the treatment. This case series report
shows that optimal clinical results in terms of complete root coverage of gingival recessions as-
sociated with deep cervical abrasions can be achieved by performing an appropriate surgical
procedure without removing dental tissue.

Key words: gingival recession, connective tissue graft, abrasion

Cervical dental caries and/or abrasions are often the abrasion, eliminating sharp edges and planes
associated with gingival recessions. These lesions the CEJ in order to position the flap and/or graft,
can be treated with either restorative or periodon- with maximum adaptability to the tooth surface
tal approaches. There are various periodontal ap- preventing dead tracts underneath (Holbrook and
proaches for treating gingival recessions associat- Ochsenbein, 1983).
ed with carious cervical lesions (Matter, 1979; In any event, if the root coverage after treatment is
Fourel, 1982; Miller, 1983; Pini Prato et al, incomplete, grinding the abrasion or planning the
1992; Goldstein et al, 2002) that make it possi- CEJ can lead to increased hypersensitivity. In order
ble to achieve excellent clinical results both in to prevent this further hypersensitivity and to avoid
terms of root coverage and cosmetic effects. unnecessary removal of dental tissue, especially in
The literature, however, contains little information patients who do not present initial dental hyper-
on periodontal treatment of gingival recessions as- sensitivity, it may be appropriate not to use me-
sociated with cervical dental lesions. The abra- chanical techniques such as grinding on the abra-
sions can involve the root, with deep steps at the sion or CEJ prior to mucogingival surgery for root
cemento-enamel junction, or both the root cemen- coverage.
tum and the enamel. In this latter situation there are Bilaminar techniques have contributed to better
often marked steps at the CEJ level (Fig. 1). This is prognoses in the treatment of gingival recessions.
often associated with dental hypersensitivity Furthermore, recent studies have reported the im-
which, along with cosmetic problems, is an indi- portance of some factors related to the surgical
cation for mucogingival surgery for root coverage technique that are useful for achieving a better
(Wennström 1993, 1996). When using the sur- percentage of root coverage. In particular, the
gical approach, the periodontist generally grinds pedicle flaps used to cover the connective tissue

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grafts must be very relaxed, that is without tension, • At baseline (T0), before surgery, the following
thick, extremely coronally advanced and passive- variables were measured at the mid-buccal
ly adapted to cover the CEJ completely (Pini Prato point of the involved tooth: deepest point of the
1999, 2000; Baldi 1999). On the basis of this cervical abrasion (CEJ step) (Fig. 2), recession
recently acquired knowledge, the aim of this case depth (RecT0), width of keratinized tissue (KTT0),
series is to present the surgical strategies applied probing depth (PDT0), distance between incisal
to successfully treat gingival recession associated margin and gingival margin (IMGMT0).
with deep cervical abrasions. Clinical attachment level was also calculated
(CALT0=RecT0+PDT0).
• Immediately after surgery (T1): the distance
MATERIALS and METHODS between incisal margin and gingival margin
(IMGMT1) was measured.
• One year after surgery (T2): recession depth
Study Population
(RecT2), width of keratinized tissue (KTT2), prob-
Twelve patients aged between 26 and 40 years ing depth (PDT2), distance between incisal
(4.2±), 5 males and 7 females, of Caucasian margin and gingival margin (IMGMT2) were
race and of middle economic level were consecu- measured, clinical attachment level (CALT2), re-
tively enrolled for this study. Seventeen sites were cession reduction (Rec Red=RecT0 – RecT2),
selected for treatment. One patient contributed 6 p e r c e n -
recession defects. Three subjects were smokers tage of root coverage (%RC=RecRed/RecT0
(>10 cigarettes per day). All the patients were se- x 100), complete root coverage (CRC), PD
lected among individuals referred from a private difference (PDdiff =PDT0–PDT2), CAL difference
practice and treated by a single periodontist with (CALdiff =CALT0–CALT2), KT difference (KTdiff =
over ten years of clinical experience. All the pa- KTT0–KTT2), were calculated. Root sensitivity
tients were informed about the study design and (SensT2) was also evaluated.
signed an appropriate consent form.
Surgical Procedures
Inclusion Criteria
All 17 recessions were treated by bilaminar tech-
The following entry criteria were used to select the nique (connective tissue graft+coronally advanced
population and the sites: 1) non-compromised sys- flap). Before surgery, all patients received oral hy-
temic health and no contraindications for peri- giene instructions to eliminate habits related to the
odontal surgery; 2) presence of maxillary buccal etiology of the recession. No root planing or
recessions (≥2 mm) classified as Miller’s class I grinding were performed in any case and the ex-
and II; 3) presence of deep abrasion (≥0.5 mm); posed root abrasion was only polished (Fig. 3).
4) tooth vitality; 5) no periodontal surgical treat- Under local anesthesia, an intrasulcular incision
ment of the involved sites during previous 24 was made with a surgical blade2 on the buccal
months; 6) Full mouth plaque scores <20% and aspect of the involved tooth. This incision was hor-
Full mouth bleeding score <20%; and 7) absence izontally extended mesio-distally to dissect the buc-
of plaque and bleeding on probing at the select- cal aspect of the adjacent papillae avoiding the
ed sites. gingival margin of the adjacent teeth. Two oblique
releasing incisions were made from the mesial
and distal extremities of the horizontal incisions be-
Data Collection
yond the mucogingival junction. A full-thickness
Gender, age, smoking habits, type of tooth, flap was raised with a periosteal elevator3 to-
Miller’s class, and dental sensitivity (yes or no) wards the mucogingival junction. Then a partial-
were recorded for all patients. The measurements thickness dissection was done apically toward the
were taken using a periodontal probe1 and 4X marginal bone crest, leaving the underlying pe-
magnification lens. riosteum in place. A mesio-distal and apical dis-
2 B.P. 15c, Hu-Friedy, Chicago, IL.
1 PCP UNC 15, Hu-Friedy, Chicago, IL. 3 P24G, Hu-Friedy, Chicago, IL.

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Fig. 1 A gingival recession associ- Fig. 2 The cervical abrasion is Fig. 3 Before surgical treatment the
ated with deep cervical abrasion. measured with a periodontal probe abrasion was treated by means
at the deepest mid coronal point. prophy paste. No scaling and root
planing of the root were ever per-
formed.

section parallel to the vestibular lining mucosa was ly advanced flap was released from tension
performed to release residual muscle tension and and sutured over the cemento-enamel junction,
facilitate the passive coronal displacement of the covering the underlying connective tissue grafts
flap. The papillae adjacent to the involved tooth (Figs. 10–18).
were de-epithelialized. No periodontal dressings were applied in either
Two different techniques were used according to case.
the depth of the step:
a. Step <1 mm: the connective tissue graft was
Post-surgical Care
positioned and sutured with resorbable sutures
to cover the entire exposed root, and extended Immediately following surgery, use of ice packs
laterally over the de-epithelialized connective was recommended for 3 hours. All patients were
tissue. The coronally advanced flap was re- instructed to discontinue tooth-brushing, avoid
leased to eliminate tension and sutured over trauma around the surgical site and reduce smok-
the cement-enamel junction, covering the un- ing. A 0.12% chlorhexidine digluconate rinse was
derlying connective tissue graft (Figs. 4–9). prescribed (4 x 60 seconds) daily for the first 10
b. Step ≥1 mm: two connective grafts were used days, and nimesulide (100 mg twice daily) was
to compensate the severe abrasion. The first recommended for pain.
was positioned to cover the abrasion com- The sutures were removed after 10 days. All the
pletely without extending laterally, and without patients were instructed to clean the surgical sites
being sutured. The second graft was posi- with a cotton pellet soaked in a 0.12% chlorhexi-
tioned on top of the first and was extended lat- dine digluconate, 4 times daily for 10 days. Three
erally to reach the adjacent connective tissue. weeks after surgery, the patients were instructed to
This graft was sutured to the periosteum with re- resume mechanical tooth cleaning of the treated
sorbable sutures. In this case too, the coronal- areas using a soft toothbrush and a careful roll

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Fig. 4 Technique A. Patient #4 Gingival recession asso- Fig. 5 The connective tissue graft is positioned and
ciated with deep abrasion (<1 mm) on left maxillary cus- sutured.
pid.

Fig. 7 The coronally advanced flap is sutured coronally

to the CEJ, covering the connective tissue graft.

Fig. 6 The extremely relaxed flap is easily displaced

coronally, reaching the cemento-enamel junction (CEJ).

Fig. 8 Healing after 1 year: the gingival margin lies in

correspondence of CEJ and complete root coverage was
achieved.

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a b

Fig. 9 Same case as figure 3 before (a) and after treatment (b). Note the optimal aesthetic result.

technique. All patients were recalled for control

and prophylaxis after 1, 2, 3 and 4 weeks and,
subsequently, once a month, until the final exami-
nation (1 year) (Figs. 8–9 and 17–18).

RESULTS

The results are reported in Table 1 and 2. Twelve

patients, 3 of whom were smokers, with 17 re-
cessions on 11 canines, 4 premolars and 2 mo-
lars – all upper teeth – were included in this study.
Twelve recessions that presented an abrasion with Fig. 10 Technique B. Patient #10. Deep cervical abra-
a depth of <1 mm were treated with a coronally sion (1.5 mm) on left first maxillary molar. The coronal
advanced flap with connective tissue graft margin of the abrasion is located coronally to the CEJ ex-
(Technique A), while 5 recessions with abrasions tending within the enamel. Severe dental hypersensitivity
was present in this case.
of ≥1 mm were treated with coronally advanced
flap and double connective tissue grafts
(Technique B). At baseline, 7 teeth were reported

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Fig. 11 A full-split thickness flap was elevated. Fig. 12 The primary connective tissue graft harvested
from the palate was positioned to fill completely the
deep abrasion. No suture was used.

Table 1 Individual patient data at baseline

Patient Gender Age Smoke Tooth Miller’s SensT0 RECT0 PDT0 CALT0 KTT0 IMGMT0 IMCEJ CEJ
cl Step

1 M 29 NO 23 2 NO 5.0 0.5 5.5 1.0 19.0 14.0 1

2 M 34 NO 13 1 NO 3.0 0.5 3.5 1.0 17.0 14.0 0.5
3 F 26 NO 13 2 Yes 3.0 1.0 4.0 4.0 13.0 10.0 0.5
4 F 35 Yes 23 2 Yes 4.0 1.0 5.0 3.0 14.0 10.0 1
5 M 40 Yes 13 2 NO 6.0 0.5 6.5 1.0 19.0 13.0 0.5
6 F 35 Yes 13 1 Yes 4.0 0.5 4.5 4.0 14.0 10.0 0.5
7 F 38 NO 24 1 Yes 2.5 1.5 4.0 2.0 10.0 7.5 0.5
8 F 39 NO 25 1 Yes 2.5 1.0 3.5 3.0 10.0 7.5 0.5
9 M 36 NO 23 2 NO 6.0 2.0 8.0 2.0 15.0 9.0 1
10 M 30 NO 16 2 NO 3.0 1.0 4.0 4.0 10.0 7.0 1.5
15 1 NO 3.0 2.0 5.0 4.0 11.0 8.0 1.5
13 1 NO 4.0 1.0 5.0 4.0 15.0 11.0 1.5
26 1 NO 3.0 1.0 4.0 5.0 10.0 7.0 2
25 1 NO 3.0 1.0 4.0 3.0 10.0 7.0 1.5
23 1 NO 2.5 1.0 3.0 5.0 13.5 11.0 1
11 F 27 NO 23 2 Yes 3.0 1.0 4.0 5.0 15.0 12.0 1
12 F 33 NO 23 1 Yes 4.0 1.0 5.0 3.0 15.0 11.0 0.5
Mean 33.5 3.6 1.0 4.6 3.2 13.6 9.9
S.D. 4.2 1.1 0.4 1.2 1.4 3.1 2.4

SensT0: dental sensitivity; RecT0: recession depth measured at the mid-point of buccal surface; PDT0: probing depth meas-
ured at the mid-point of buccal surface; CALT0: clinical attachment level calculated as RecT0+PDT0; KTT0: keratinized tissue
measured as distance between gingival margin and mucogingival junction; IMGMT0: distance between incisal margin
and gingival margin; CEJ step: depth of abrasion measured at the deepest mid-point of buccal surface.

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Fig. 13 The secondary connective tissue graft was pre- Fig. 14 The secondary connective tissue graft is posi-
pared. tioned and covers the primary graft.

Table 2 Individual patient data immediately after surgery (T1) and after 1 year (T2) data at baseline

Patient CTG IMGMT1 GM1 SENST2 RECT2 PDT2 CALT2 KTT2 IMGMT2 % RC

1 1 12.5 1.5 NO 0.5 1.0 1.5 1.5 14.5 90

2 1 13.0 1.0 NO 0.0 0.5 0.5 1.0 14.0 100
3 1 9.0 1.0 NO 0.0 1.0 1.0 4.0 10.0 100
4 1 9.0 1.0 NO 0.0 0.5 0.5 3.0 10.0 100
5 1 12.0 1.0 NO 0.5 1.0 1.5 3.0 13.0 83
6 1 9.0 1.0 13 0.0 1.0 1.0 4.0 10.0 100
7 1 6.0 1.5 NO 0.0 1.0 1.0 2.0 7.5 100
8 1 5.0 2.5 NO 0.5 0.5 1.0 2.0 8.0 100
9 1 7.5 1.5 NO 0.0 3.0 3.0 2.0 9.0 100
10 2 6.0 1.0 NO 0.0 1.5 1.5 4.0 7.0 100
2 7.0 1.0 NO 0.0 1.5 1.5 5.0 7.0 100
2 9.0 2.0 NO 0.0 1.0 1.0 4.0 11.0 100
2 6.0 1.0 NO 0.0 1.5 1.5 5.0 6.0 100
2 6.0 1.0 NO 0.0 2.0 2.0 4.5 7.0 100
1 10.0 1.0 NO 0.0 1.0 1.0 4.0 11.0 100
11 1 11.0 1.0 NO 0.0 0.5 0.5 4.0 12.0 100
12 1 10.0 1.0 Yes 1.0 0.5 1.5 4.0 11.0 75
Mean 0.1 1.1 1.3 3.3 9.9
S.D. 0.3 0.6 0.6 1.2 2.6
CTG: number of layers of connective tissue graft used for the bilaminar technique; IMGMT1: distance between incisal
margin and gingival margin immediately after surgery; GM1.

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Fig. 15 A resorbable suture was used to stabilized the Fig. 16 The flap is sutured coronally to the most coronal
two grafts. margin of the abrasion.

Fig. 17 Healing 1 year after: the gingival recession

associated with the deep abrasion was completely
covered.

as hypersensitive.
At the conclusion of the procedure, the flaps were DISCUSSION
always sutured to the CEJ, coronally or in any
event, more coronally with respect to the coronal Gingival recessions are often associated with den-
margin of the abrasion. One year after surgery, tal abrasions at the cervical level of varying mag-
the mean initial recession was reduced from nitude creating a step between the enamel and
3.6±1.1 mm to 0.1±0.3 mm; probing depth from cementum. In these cases, in order to adapt the
1.0±0.4 mm to 1.1±0.6 mm; CAL from 4.6±1.2 coronally advanced flap to the tooth surface or to
mm to 1.3±0.6 mm; and KT from 3.2±1.4 mm to the underlying connective tissue graft (when using
3.3±1.2 mm. Mean root coverage was 97.5%. the bilaminar approach), and to cover the CEJ,
Complete root coverage was achieved in 14 out practitioners tend to grind and eliminate the abra-
of 17 sites. sion. This, however, further diminishes the dental
Tooth sensitivity was reduced from 7 to 2 teeth. tissue, and if root coverage is incomplete leads to
After 1 year there were no reports of new sensi- the onset/increase of dental hypersensitivity.
tivity developing in any of the treated teeth. The aim of this study is to propose two strategies
Descriptive statistical analyses with the individual for treating gingival recession associated with
patient data at baseline (T0), after surgery (T1), dental abrasions without having to removal dental
and 1 year after surgery (T2), are shown in Tables tissue using bilaminar mucogingival techniques.
1 and 2. The choice of the technique is based on the as-

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Fig. 18 Same case as figure 10 before (a) and after treatment (b). Notice the optimal aesthetic result. Dental hypersensi-
tivity disappeared.

sessment of the abrasion depth (CEJ step). not a single case of new hypersensitivity.
For steps with a depth of <1 mm, the technique In conclusion, the present case series illustrates that
was to apply a connective tissue graft over the it is indeed possible to treat gingival recessions as-
abrasion, extending laterally and apically over the sociated with severe dental abrasions and
recipient site, associated with a pedicle flap posi- achieve excellent clinical results with two appro-
tioned as coronally as possible. Recent studies priate strategies, and without having to eliminate
have shown that the further the flap is coronally additional dental tissue.
advanced, the greater the root coverage (Pini
Prato 1999).
For steps with a depth of ≥1 mm, the procedure REFERENCES
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