Progressive Root Resorption Associatedwith the Treatment of Deep Gingival

Recession. A Clinical Case

Norma Cizza, Dario Migues, IJPRD 2013;30:619–25.

Shilpa Shivanand

III MDS

INTRODUCTION• Gingival recession is a common pathology causing esthetic

problems, sensitivity, root caries in the cementum, and must be treated with mucogingival surgical procedures to improve esthetics, reduce recession progress, and avoid hypersensitivity.

• The subepithelial connective tissue technique is well documented and extremely predictive for solving esthetic problems and reestablishing the gingival tissues around a recession via long junctional epithelium formation or periodontal tissue regeneration.

Langer B, Langer L 1985, Harris RJ et al.

• Restored root surfaces should also be included in the surface to be covered by the connective tissue graft, since eliminating the restoration allows adjunct periodontum to rebuild after the restoration’s removal.

McGuire MK et al 1996.• Root surface conditioning with chemical agents, citric acid,

and tetracycline is used to improve biologic compatibility of the root with periodontal cells and enhance connective tissue grafting, although the results are controversial.

Ben-Yehouda et al 1997.

AIM

• The aim of this report is to present a patient with a buccal recession treated by scaling and root planing, tetracycline root conditioning, and connective tissue grafting.

• Results were satisfactory, though root resorption appeared as a late complication 20 months postoperatative.

CASE REPORT

• The patient was a 52-year-old woman who was a healthy nonsmoker and attended the authors’ dental office because of gingival recession at the maxillary left canine and an overhanging restoration.

• Preoperative clinical and radio graphic images were taken.

Preoperative clinical and radio graphic images showing a buccalrecession and an overcontoured Class Vrestoration.

• After periodontal examination, generalized chronic adult periodontitis was diagnosed.

• Oral hygiene instructions were given to the patient, the restoration at the canine site was polished, and scaling and root planing were performed.

• One month after the initial therapy, a clinical reevaluation was carried out.

• Considering the mesial and distal gingival tissue lost and the recession depth, the recession was classified as Miller Class III, which predicts partial root coverage.

• The proposed treatment consisted of subepithelial connective tissue grafting and root conditioning with a tetracycline solution.

Clinical reevaluation 1 monthafter the initial therapy. A Miller Class IIIrecession was determined.

• Before surgery, baseline data were registered. • The buccal aspect of the recession height at the canine was 7

mm, the width of the keratinized tissue was 0.5 mm, and the probing depth was 2 mm.

Baseline data were obtainedbefore the surgical procedure.

• The Class V restoration was removed under local anesthesia up to the cementoenamel junction by scaling and root planing.

• This procedure was performed before flap raising, both smooth and supragingival, to preserve any existing connective tissue attachment.

• The recession area was treated topically with a 100 mg tetracycline/mL saline solution for 3 minutes, rinsed, and then dried.

• A trapezoidal partial-thickness double-pedicle flap was raised, passing through the mucogingival junction.

• Pedicles were joined with 4.0 sutures (Ethicon).

Double-pedicle graft andsubepithelial connective tissue grafting.

• A 2.5-mmwide subepithelial connective tissue graft was harvested from the palate without epithelium removal and was sutured over the recession defect.

• The flap was sutured without stress over the graft, leaving the epithelium collar uncovered.

• Gingivoplasty at the mesial and distal papillae related to the defect was performed to prepare a recipient bed.

Flap repositioning and suturingwas completed without stress over the connective tissue graft. The exposed epithelium graft and sutured mesial and distal papillae can be seen.

Post-op instructions

• Postoperative care consisted of 0.12% chlorhexidine rinses twice a day for 3 weeks; amoxicillin was also prescribed (1.5 g a day for 5 days).

• Sutures were removed 10 days later.• Healing was uneventful.

• After 6 months, new parameters showed 2 mm of recession measured at the level of the cementoenamel junction, 3.5 mm of keratinized tissue, and a probing depth of 2 mm.

After 6 months, new parametersshowed 5 mm of recession coverage and3.5 mm of keratinized tissue.

• Twelve months later, an additional 1.5-mm recession was observed, most likely a result of aggressive brushing at the affected site.

• New oral hygiene instructions were given and all other parameters remained stable.

12 month follow-up showed1.5-mm increase in recession height atcanine as well as at the other teeth, mostlikely a result of aggressive brushing.

• Twenty months postsurgery, external root resorption was noted without any symptoms.

• Tooth extraction and implant placement were proposed to the patient, but she decided to wait.

Root resorption seen via transparentgingiva at 20 months.

• Four months later (2 years postsurgery), resorption evolution was appreciated both clinically and through radiography.

Clinical photograph and radiograph showing the posttreatmentrecession at 22 and 24 months,respectively.

• Before extraction and guided bone regeneration, a flap was raised to observe the resorption.

Exploratory flap raised prior totooth extraction and guided bone regeneration.Root resorption is evident at the buccal, mesial, and distal aspects of the affected tooth.

DISCUSSION

• After a satisfactory result in a Miller Class III patient treated with a connective tissue graft and tetracycline solution, external root resorption occured 20 months posttreatment.

• Resorption after regeneration treatment is an uncommon complication that can occur in spite of having achieved the desired goal of treating the recession and creating good health conditions for the periodontal tissues.

• It is difficult to predict, diagnose, and treat. Heithersay GS

• An explanation for this unusual outcome is that the epithelial cells could have migrated in an apical direction.

• Therefore, the epithelium acts as a protective barrier against resorption.

Karring T, Nyman S, Lindhe J 1984• Resorption occurs in an environment where different

periodontal tissues compete for marginal healing.• Cell mechanisms for identifying dental tissues as foreign

structures are unknown, and they induce resorptive cell activation.

Carnio J et al 2003

• There is enough published information claiming connective tissue grafts as a reliable and predictable technique to obtain healthy compatible gingival tissues.

• This is why it is believed that the graft material is not related to root resorption.

• Several publications have reported that root conditioning is not beneficial since results do not improve the clinical outcome.

Caffesse et al 2000, Nagata et al 2005.

• Cervical resorption can be produced by epithelial cervical attachment damage from a chemical agent.

Ne R et al 1999• There are few reports available on resorption cases related to

regeneration techniques for periodontal defects and gingival recessions resulting from root conditioning with tetracycline solution or citric acid.

• A periodontal defect treated only with tetracycline showed resorption after 3 years, as reported by Ben-Yehouda.

• Cury et al recently reported on a clinical case of root resorption 2 years after periodontal defect treatment with a bioabsorbable membrane and tetracycline.

• Carnio et al published a report on a patient treated with a connective tissue graft and citric acid that presented resorption 2 years later.

CONCLUSION• The buccal recession reported here was treated with a

connective tissue graft and tetracycline solution. The resorption appeared 20 months after treatment.

• Analysis of the published studies in the literature demonstrate that resorption is a late complication, generally 1 year posttreatment, and therefore time is an important factor to be considered.

• It is suggested that tetracycline root conditioning probably causes root resorption in long-term evaluations.

• Therefore, this must be considered by the practitioner when developing the treatment plan.

CROSS REFERENCE

I. External root resorption following partial thicknessconnective tissue graft placement: a case report.

Hokett SD et al, JOP 2002.• We report an unusual case of external root resorption (ERR)

that developed in a 37yearold black male approximately 1 year following routine partial thickness connective tissue graft surgery.

• The lesion was accessed via flap surgery, thoroughly root planed, and the mucoperiosteal flap replaced.

• The site healed uneventfully and the patient has been closely observed for over 1 year without symptoms or recurrence of the resorptive lesion and the affected tooth remained vital.

• Clinicians performing partial thickness connective tissue grafts should be alert to the possible occurrence of root resorption over extended periods of time.

• The authors speculate that retention of the donor periosteum with placement on the recipient dentin and root biomodification may limit the resorptive response following connective tissue graft procedures to treat tooth root recession.

II. Potentials for root resorption during periodontal wound healing.

Karring T, Nyman S, Lindhe J, Sirirat M, JCP 1984.

• The present study was undertaken to examine whether (1) the process of resorption, which invariably affects periodontitis involved reimplanted roots facing bone or gingival connective tissue during healing, is a transient phenomenon and, (2) root resorption can be prevented by permitting

downgrowth of epithelium along the root surface.

• A total of 24 teeth in 2 monkeys was subjected to experimental periodontal tissue breakdown by the placement of elastic ligatures around the teeth.

• The ligatures were left in situ until about 50% of the supporting tissues had been lost.

• Following removal of the ligatures, the teeth were extracted and the denuded portions of the roots were scaled and planed.

• The crowns of the teeth were resected and the root canals filled with guttapercha.

• The roots were subsequently implanted into sockets prepared in the jaw bone in such a way that each root was embedded in bone except for a portion which was in contact with gingival connective tissue.

• 1 month prior to sacrifice of the animals, the cut surface of the coronal part of the roots was exposed by removal of the covering soft tissue. The epithelium was thereby allowed to migrate into the wound.

• Implantation of the roots was scheduled to provide healing periods of 1, 2, 3, 4, 8, 12, 16, 20 and 24 weeks before exposure of the roots.

• The histologic examination of the implant specimens disclosed that replacement resorption was a progressive process which eventually resulted in the elimination of the transplanted roots.

• It was possible to prevent root resorption in this model by permitting apical downgrowth of epithelium along the root surface during the initial phase of healing.

Introduced by Waienberg in 1964 Modified by Cohen and Ross,1968Indications

When interdental papilla adjacent to receded area is sufficient wideAG on approximating teeth is insufficient to cause lateral displacement

AdvantagesRisk of loss of bone is less as interdental bone is more resistantPapilla usually supply greater width of AG

Reasons for failureInadequate suturing

Double papillae Laterally positioned flap

Harvesting the graft from the donor site• Two parallel incisions,

perpendicular to the long axis of the teeth, are made in the palate, close to the CEJ (Langer & Langer 1985).

• Two vertical releasing incisions help dissect the superficial flap and free the subepithelial connective tissue graft .

• Once the graft is harvested, the success rate of the procedure does not appear to be influenced by removing the epithelial collar from the graft (Bouchard et al. 1994).

SCTG

The trapdoor enabling the retrieval of the connective tissue graft.

Primary incision. Make a horizontal incision with a partial-thickness flap 3-5 mm apical to the gingival margin in the palate (preparation of primary flap).

Secondary incision. Make a secondary incision 1-2 mm coronal to the primary horizontal incision line. This incision, which is perpendicular to the surface of the gingiva, should extend to the bone.

Make a vertical incision mesiodistally approximating the widthand length of the necessary graft.

Prepare a primary partial-thickness flap (1.5-mm thick) towardthe center of the palate, parallel to the palatal gingiva. Expose the underlying connective tissue.

Subepithelial connective tissue graft

Root Biomodification• The application of bio-chemical agent to the root surface

directs the movement of specific biomodulators, triggering variety of responses from cellular component of healing site, which could play essential role in regeneration….. (Terranova et al 1995)

Root Conditioning –• Urist, Frank et al, Register & Burdick (1971- 1980)…. root

conditioning is demineralization and detoxification of root surface.

Purpose of Root surface biomodification – (Lindhe)

• To remove smear layer following mechanical debridement.

• Demineralization of the root surface (citric acid)

• Selective removal of hydroxyapatite and exposure of the collagenous matrix of the root surface. (EDTA)

• Local delivery of antimicrobial compound. (tetracycline HCL )

Purpose of Root surface biomodification – (Lindhe)

• Inhibition of collagenolytic activity. (tetracycline HCL) • Enhancing cellular response. (migration and attachment of

cells)• Preventing epithelial down growth Improving retention of

different biomolecules to exposed collagen.• Expressing a cementoblast phenotype for colonizing cells.

Materials for root conditioning

• Physical methods include root conditioning by lasers.

• Chemical methods include use of various chemicals like bile

salts, citric acid (ph 1 , disadv: acidic ph) , tetracycline 0.5%

solution at a PH of 3.2 100mg/ml, EDTA 24 %

Ethylenediaminetetracetic acid PH 6.7 for 15 seconds (Biora),

detergents, phosphoric acid and glycoproteins like fibronectin.

• Citric acid…. enhances new attachment or reattachment and regeneration by– Removal of smear layer (Polson et al, 1984)– Root detoxification (Aloe et al, 1975)– Exposure of root collagen and opening of dentinal

tubules (Polson et al, 1984)– Demineralization prior to cementogenesis (Register,

1975)– Initial clot stabilization (Wikesjo et al, 1991)

Citric acid

– Enhanced fibroblast growth and stability (Boyko etal, 1980)

– Attachment by direct linkage (Stahl and Tarnow, 1985) with or without cementogenesis.

– Prevention of epithelial migration along the denuded roots (Polson et al 1983)

– Accelerated healing and new cementum formation after surgical detachment of the gingival tissues and demineralization of the root surface by means of citric acid. (Register & Burdick)

Citric acid

• Time of application. (1min & 4min) tried Trombelli et al

1995...

• 1 min.... Smooth surface with many tubule openings

partially occluded by debris

• 4 min .... Three dimensional network of intertubular and

peritubular collagen fibrils.

Root conditioning with tetracycline

Mode of application

• Burnish with cotton pellets saturated with solution of tetracycline HCL.

• Quantity of tetracycline HCL. (10mg/ ml, 100, 400,) 100 mg/ml should be preferred.

• Shorter application times should be preferred. (Seymour et al 1995)

• Tetracycline of HCL + Fibronectin. No additional benefit was observed. (Alger et al 1990).

Mode of application• It can be used as a 0.5% solution at a PH of 3.2 and is

applied for 5 minutes.

• One study showed >100 mg/ml may enhance fibroblast

attachment. (dose dependent)

• In another in vitro study Trombelli et al 1995 showed longer

application should be preferred.

• Results are inconsistent.

EDTA

• EDTA etching has been found to provide a surface more suitable for periodontal healing compared to root planing only or following root planing and etching with citric acid or phosphoric acid

• 24 % Ethylenediaminetetracetic acid PH 6.7 for 15 seconds (Biora)

• Usually provided with Emdogain. • It removes smear layer and facilitates adherence of Emdogain

HEALING PATTERNS OF PERIODONTAL WOUND

The downgrowth of epithelial cells (EC) results in long junctional epithelium.The proliferation of connective tissue (CT) may result in connective tissue adhesion and root resorption.The predominance of bone cells (BC), may result into root resorption, ankylosis though this is relatively uncommon in humans when compared with animal models, or both.With the ingress of periodontal ligament (PDL) and perivascular cells from the bone, a regenerated periodontium with new cementum develop.

There are 4 healing patterns of periodontal wound ( the four possible cell types that predominate the wound site)

SOME IMPORTANT DEFINITIONS

Healing of a wound by tissue that does not fully restore the architecture or function of the part. (AAP, Glossary of periodontal terms,).

Repair simply restores the continuity of the diseased marginal gingiva and reestablishes a normal gingival sulcus at the same level on the root as the base of the preexistent periodontal pocket.

This process called healing by scar, arrests bone destruction without necessarily increasing bone height.

REPAIR

Regeneration :

Continuous physiologic process

Is the growth and differentiation of new cells and intercellular substances to form new tissues or parts.

Regeneration takes place by growth from the same type of tissue that has been destroyed or from it’s precursor. This is termed as wear and tear repair.

Reattachment :

The term has been used in past to refer to the restoration of the marginal periodontium.

Reunion of epithelial and connective tissues with root surfaces and bone from which they have been removed in the course of treatment, such as occur after an incision or injury. It should not be confused with new attachment.

New attachmentIt is the embedding of new periodontal ligament fibers into new cementum and the attachment of the gingival epithelium to a tooth surface previously denuded by disease.

Reattachment; Repair in the areas of the roots not previously exposed to the pocket