Journal of the International Academy of Periodontology 2017 19/1: 10–14

Root Coverage of Palatal Recession Using

Epithelial Embossed Connective Tissue: A
Case Report
Avita Rath1, Bennete Fernandes1, Priyadarshini H R1, Smriti
Varma2, Aravind Kumar Pavuluri3

1
Faculty of Dentistry, SEGi University, Petaling Jaya, Selangor,
Malaysia; 2Private Practice, Dubai, UAE; 3Department of Peri-
odontics, St. Joseph Dental College and Hospital, Duggirala,
Eluru, Andhra Pradesh, India

Abstract
Labial and buccal gingival recession is a common finding in the adult population, which
can occur due to various factors. When present, it can lead to an unesthetic appearance
and can cause hypersensitivity. However, very limited literature is available regarding
the incidence of palatal gingival recession. Many times it goes unnoticed during routine
clinical examinations. Although there are no esthetic concerns in these regions, recession
can cause sensitivity and pose a technical challenge in surgical correction because of
poor accessibility and visibility. This case reports the treatment of a single palatal reces-
sion defect using an epithelial embossed connective tissue graft. The 12-month follow-
up of the case showed significant root coverage (93.6%) and decreased sensitivity. The
advantage of the harvested graft was that the connective tissue was not exposed, as it
was tucked into the underlying flap, and the mucosal contour was maintained.

Key words: palatal/gingival recession, connective tissue grafts, periodontal

plastic surgery

Introduction that failed to show complete root coverage with the

conventional technique. However, little has been done
Gingival recession occurs due to the apical migration of when it comes to palatal recession, making it reasonable
the gingival margin from the cementoenamel junction to assume that not much importance has been given to
(CEJ), which leads to exposure of root surface. It is often these types of cases to date. There are many factors that
associated with unpleasing esthetics, root hypersensitiv- can complicate treating palatal recession defects owing
ity and attachment loss (Pradeep et al., 2012). Successful to the type of tissue in this region, which makes pedicle
coverage of exposed roots for esthetics and functional flaps or any other regenerative procedures difficult to
reasons has been the objective of various mucogingival perform (Harris, 2001). This case report demonstrates
surgeries (Shubham et al., 2015, Chan et al. 2015). Ac- successful coverage of a palatal recession using an
cording to the proceedings from the 2014 American epithelial embossed connective tissue graft, suggesting
Academy of Periodontology Regeneration Workshop, new avenues to treat palatal defects.
buccal root coverage may be attained through the ap-
plication of various surgical techniques (Tatakis et al.,
Case presentation
2015), the gold standard being the classic subepithelial
connective tissue graft (Langer and Langer, 1985). Re- A 35-year-old male patient reported to the dental clinic
cently, a modification to the procedure was described by with the chief complaint of hypersensitivity in an upper
Sterrett in 2008 to deal with large mucogingival defects left posterior tooth for the preceding 6 months. The
patient was systemically healthy and was a non-smoker.
His dental history revealed that he had used desensitizing
toothpaste for 2 months, but there was no improvement.
Correspondence to: Bennete Fernandes, Faculty of Dentistry, SEGi Additionally, he expressed his inability to maintain oral
University, No. 9 Jalan Teknologi, Taman Sains PJU5, 47810 Kota hygiene in that area.
Damansara, Selangor, Malaysia. E-mail: [email protected]

© International Academy of Periodontology

 Rath et al.: Root coverage of palatal recession 11

Intra-oral examination showed fair oral hygiene, ent site was prepared under local anesthesia. A sulcular
mild gingival inflammation with no pockets or loss of incision was made on the palatal aspect of the involved
attachment on any teeth other than 26. Detailed peri- tooth. A submarginal incision of 0.5 mm was used at
odontal examination revealed 6 mm of recession on the the interdental areas to retain the proximal tissues within
palatal surface of 26, with a probing pocket depth of 3 the confines of the interdental space. The incision was
mm and attachment loss of 9 mm (Table 1). There was extended to the distal and mesial papillae of the adjacent
no loss of papillary height and no non-carious cervical teeth, respectively. Sharp dissection of a partial-thickness
lesion in relation to 26 (Figure 1). Further radiographic flap extended 4 mm laterally and apically, forming an
examination revealed about 1 mm of interdental bone envelope flap. Dissection was such that the periosteum
loss in the region. Hence, it was diagnosed to be a case was retained on the bone. This preparation technique
of chronic gingivitis with localized periodontitis. by Raetzke (1985) resulted in a recipient pouch at the
treatment site (Figure 2).
Table 1. Comparison of pre- and post-operative
measurements of clinical parameters
Pre- Post- Change
operative operative in mm
Recession 6 0.5 5.5
depth (mm)

Probing 3 1 2
depth (mm)

Clinical 9 1.5 7.5

attachment
level (mm)

Figure 2. Incisions made and envelope pouch created.

The previously prepared tinfoil template was placed

on the palatal region of 14 and 15. The primary incision,
which was a scalloped sub-marginal incision, was made
in between the above teeth (Figure 3). Subsequently, a
crestal incision was extended to the distal and mesial
papilla of 14 and 15, respectively. A split-thickness dis-
secting incision, extending more than 3 mm apical and
lateral to the primary incision, was made to undermine
and define the extent of the donor graft. To free the
tissue from the donor site, a secondary incision was
made perpendicular to the palate at the outer periphery
Figure 1. Pre-operative view of palatal recession, tooth
of the graft. The entire graft was separated from the
26 (primary figure).
underlying bone and removed (Figure 4).
The graft was tucked into the envelope pouch, with
Case management the “embossed epithelium” completely covering the
recession defect (Figure 5). A simple suturing technique
After thorough evaluation of the site, which showed (4-0 silk suture) was used to secure the tissues and graft
about 1 mm bone loss, and the fact that palatal tissue together on each side (Figure 6). Likewise, the palatal area
could not be advanced to cover the defect owing to its was sutured and the previously prepared stent cover-
non-stretchable nature, the decision to treat the area ing the donor area alone was placed after periodontal
with an epithelial embossed connective tissue graft dressing.
(EECTG) was made. The treatment plan was thor- Postoperative pain and edema were controlled with
oughly explained to the patient and informed written ibuprofen. The patient was instructed not to brush his
consent was obtained before initiation of the therapy. teeth in the treated area and was asked to rinse with a
Thorough scaling and root planing was done 4 weeks chlorhexidine mouthrinse (0.2%) for three times a day
prior to the surgery. A template was prepared by placing for 1 minute for one week. The periodontal dressing
tinfoil on the defect to replicate the exact dimensions, and sutures were removed two weeks after the surgery.
which were about 6 mm by 6 mm in size. The recipi-
12 Journal of the International Academy of Periodontology (2017) 19/1

The patient was instructed to clean the area with a soft (Figure 7). The final evaluation was done at 12 months
end-tufted brush and a cotton-tipped applicator dipped in postoperatively. The clinical measurements were
chlorhexidine and also to avoid hard foods and chewing recorded (Table 1). There was 1.5 mm of recession
in the area. He was recalled once every 6 weeks for the and a probing depth of 1.0 mm, representing a 5.5
next 12 months. mm gain in root coverage (93.6%) and 7.5 mm gain
in attachment level (Figure.8). The thermal sensitivity
Clinical outcomes had decreased to the point that it no longer bothered
the patient. Additionally, there was visible gain in the
There appeared to be 100% root coverage and a com-
papillary volume.
plete survival of the graft 2 weeks post-operatively

Figure 3. Outline of graft on the donor site. Figure 6. Sutures placed.

Figure 4. Epithelial embossed graft. Figure 7. Two-week post-operative view, tooth 26.

Figure 5. Epithelial embossed connective tissue graft Figure 8. One-year post-operative view, tooth 26.
tucked into the envelope flap over the recession defect
(primary figure).
 Rath et al.: Root coverage of palatal recession 13

Discussion probing. The results appeared better at 2 weeks post-

operatively than at the final evaluation. However, the
A wide variety of periodontal plastic surgical procedures decrease in the amount of root coverage was insignifi-
have been described to correct mucogingival problems cant and there could be several possible explanations
and to cover denuded root surfaces (Richardson et al., for it. Trauma to the area is the most likely explanation.
2015) However, little has been presented to show root This trauma may have occurred with mastication, oral
coverage of a palatal root surface. In this case report, hygiene efforts, or other causes. The histologic evidence
though there was not 100% root coverage, the 5.5 mm of any kind of regeneration was not available, but based
root coverage (93.6%) was clinically significant and was on the results of Rosetti et al. (2013) there is a possibility
considered a success over a period of 12 months. Similar that some regeneration may have occurred.
results were presented in treatment of palatal recessions There may be limited indications for treating palatal
by Harris (2001) and Deepa et al. (2013). recessions (Wilcko et al., 2005). Inability to reposition
Sub-epithelial connective tissue graft (SECTG) the tissue in the area would make either a pedicle graft,
was first introduced by Langer and Langer (1985) and guided tissue regeneration, or an acellular dermal matrix
modified by Harris (1992), Allen (1994) and Bruno graft impractical, thus making SECTG or any of its vari-
(1994). It combines the advantages of the pedicle flap ations a more successful technique for these kinds of
procedure and guarantees a double blood supply from cases (Wennstrom, 1996). Despite the slight loss of root
both the overlying pedicle flap and the underlying coverage, the patient and clinician were satisfied with
periosteum. Other advantages of connective tissue the result. Because the true benefit of these treatment
grafts are the good color match with neighboring soft procedures is also about stability, long-term follow up
tissues and a less invasive palatal wound, as well as long- periods are required to validate these treatment modali-
term results in terms of root coverage (Bruno, 1994) ties (Hamdan et al., 2009).
However, technically this procedure can be difficult
owing to the nature of palatal tissue, which makes its
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