PMC5485303_01
Patient with multiple Miller class II gingival recessions, on the vestibular face of the upper and lower teeth.
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Asuncion, Paraguay, presenting high sensitivity in the anterior teeth and a longer aspect compared to the other ones. A clinical exam was carried out and multiple Miller's recessions class II was identified, in the vestibular phase in the upper and lower teeth (Figure 1).
(a) Blood collection. (b) Blood stocking tubes. (c) Centrifugation. (d) Platelet-rich fibrin membranes.
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Before the surgical procedure, a 40 ml venous blood collection was withdrawn from the patient (Figure 2(a)). The blood was stored in four tubes of 10 ml each (BD Vacutainer Serum, NJ, USA) (Figure 2(b)) and the samples were centrifuged at 2700 rpm for 12 minutes (Benchtop Low Speed Centrifuge DT5-6A, Hunan, China) (Figure 2(c)), to obtain the L-PRF clot, which was positioned and compressed on a sterile metallic surface in order to obtain the membrane shape (Figure 2(d)).
(a) Scraping and root smoothing. (b) Smear with tetracycline.
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Immediately, the exposed roots were cleaned up through scraping and root smoothing with periodontal curettes (Figure 3(a)); subsequently, they were treated and demineralized with tetracycline smear of 500 mg and dissolved in 10 ml of saline solution, using cotton during three minutes to remove the smear layer (Figure 3(b)).
(a) Intrasulcular incisions and conservation of the interdental papillae. (b) Mucoperiosteal tunnel to release the partial thickness flap.
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Using a scalpel blade 15C, intrasulcular incisions were taken in internal bezel in the vestibular face of the teeth 14-13-12-11-21-22-23-24, aiming to create an envelope of partial thickness, extending sideways until the distal of the second premolars and apically until overrunning the mucogingival line, including the interdental papilla without tearing them (Figure 4(a)). Afterwards, with the support of the periodontal tunnel makers (Hu-Friedy, Ipanema, RJ, Brazil), a mucoperiosteal tunnel was created to release the flap and the coverage of the recessions of each quadrant (Figure 4(b)).
(a) Demarcation of the graft area on the donor site. (b) Removal of the subepithelial connective tissue.
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SCTG's recipient-site and then transferred to the region of the right side palate, delineating the graft in the donor site. Subsequently, the incisions were made: a perpendicular paracrestal incision along the teeth axis, at 3 mm from the palatine gingival contour, preserving the biological distance of the surrounding teeth (trap technique) (Figure 5(a)). A SCTG of around 24 mm x 7 mm and 2 mm of thickness was obtained and removed by using a fine extractor (Figure 5(b)).
(a) Inserted graft on the recipient site. (b) Graft positioned on the recipient site.
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Thereafter, the graft was inserted and positioned (Figure 6(a)) covering the recessions in the recipient site in anteroposterior direction (Figure 6(b)); a light pressure was performed in the graft/flap complex with gauze for eight minutes in order to have a minimum clot thickness; besides, the stabilization of the SCTG was performed with suspensory and vertical mattress sutures (Figure 7), using nylon fiber 4-0 (Ethicon, Johnson & Johnson, Sao Jose dos Campos, SP, Brazil), in close contact with the periosteum.
Stabilization and suture of the subepithelial connective tissue.
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Thereafter, the graft was inserted and positioned (Figure 6(a)) covering the recessions in the recipient site in anteroposterior direction (Figure 6(b)); a light pressure was performed in the graft/flap complex with gauze for eight minutes in order to have a minimum clot thickness; besides, the stabilization of the SCTG was performed with suspensory and vertical mattress sutures (Figure 7), using nylon fiber 4-0 (Ethicon, Johnson & Johnson, Sao Jose dos Campos, SP, Brazil), in close contact with the periosteum.
(a) Insertion of platelet-rich fibrin on the palate. (b) Simple suture on the donor site.
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In the donor area of the palate, L-PRF membranes were inserted (Figure 8(a)), and, afterwards, simple sutures were performed by using nylon fiber 4-0 (Ethicon, Johnson & Johnson, Sao Jose dos Campos, SP, Brazil) to favor closure by primary intent (Figure 8(b)).
(a) Platelet-rich fibrin membranes. (b) Application of platelet-rich fibrin membranes on the recipient-site.
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To the right side, using a pair of modified tweezers, a plenty of L-PRF membranes were inserted and adapted, around 5 mm x 3 mm and 2 mm of thickness in each exposed root surface to recover the recessions (Figures 9(a) and 9(b)), which were obtained from clots resulting from centrifugation.
Stabilization and suture of the platelet-rich fibrin membranes.
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The flap was positioned in coronal direction and maintained by suspensory and vertical mattress sutures in each tooth involved in the process (Figure 10).
Stabilized mucogingival tissue with satisfactory appearance 45 days after the root coverage surgery.
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The healing procedure came naturally and, after 45 days, a significant repairing and regeneration of the collagen fibers in the entire superior arch, great thickness and great quality of the mucogingival tissue, and satisfactory appearance were observed (Figure 11).