CASE REPORT

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Cobi Landsberg, DMD

Periodontology, Private Practice, Tel Aviv, Israel

Nitzan Fuhrer, DMD

General Practitioner, Private Practice, Tel Aviv, Israel

Correspondence to: Dr Cobi Landsberg

53 Gordon Street, Tel Aviv, Israel; e-mail: Cobi@landsberg.co.il; fax: +972 3 523 5665

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Abstract cemented into the patient’s mouth. Root

coverage procedures were implemented
Purpose: The presence of a treatable gin- using a combined connective tissue graft
gival recession in teeth ready for crown and a coronally advanced flap. No addi-
preparation requires a combined restor- tional tooth preparation and impression
ative-periodontal effort to achieve all taking were performed. After 6 months, a
biologic and esthetic goals. This needs final crown, fabricated from the previous
an ideal artificial crown proportion and a impressions, was cemented.
harmonious gingival architecture. Tradi- Results: Initially, the grafted tissue mar-
tionally, a root coverage procedure is ini- gins completely covered the root and
tially performed followed by final crown 1–2 mm of the temporary crown margins.
preparation and cementation. However, At 12 months post-surgery and 6 months
during the prosthetic phase, irritation to post-definitive crown cementation, the
the grafted delicate tissue may be fol- gingival margins slowly receded, reach-
lowed by recession and exposed crown ing the ideal position. Complete root
margins. To minimize prosthetic irrita- coverage was maintained for the next
tions, the “crown-then-graft approach” 5 years.
(CTGA) is suggested in which the root Conclusions: The CTGA may minimize
coverage procedure is performed after tissue irritation after root coverage in
final crown preparation. teeth designed for combined crown
Methods: After definitive crown prepar- preparation and root coverage proced-
ation and impression taking of the left ure, and may account for long-term mar-
maxillary incisor, an acrylic crown with ginal tissue stabilization.
flat marginal profiles was temporarily (Eur J Esthet Dent 2012;7:296–308)

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Introduction Attempts have been made to identify

factors that influence the outcome of
An important concern in dentistry is root coverage procedures.22-25 A scor-
esthetics. Harmonious and symmet- ing system, used to evaluate the esthet-
ric tooth alignment with a consistent ic outcome, depends on final color and
shape, size, and color is essential, and tissue blend.26 However, information
the importance of harmonious gingival relating to the selection of the best pro-
morphology has been emphasized.1 A cedure for each individual is still una-
problem faced by dentists and patients vailable. The choice may become more
is gingival recession of the soft tissue,2,3 confusing when the recession is com-
which can result in unfavorable esthet- bined with a cervical lesion that disrupts
ics,4 increased root caries susceptibil- the cementoenamel junction. This ne-
ity5 and dentin hypersensitivity.6 cessitates creating a less favorable sur-
Numerous surgical techniques have face (of restorative material) for gingival
been introduced to correct labial and adaptation. Different approaches that
gingival recession defects, including demonstrate various amounts of root
surgical flap procedures, such as the coverage have been proposed, such
coronally positioned flap,7-9 and the lat- as only the coronally advanced flap
erally sliding flap10. This also includes (CAF), CAF plus resin-modified glass
procedures that use graft materials ionomer or resin composite, or only the
in combination with flap operations, subepithelial connective tissue graft
such as subepithelial connective tissue (SCTG) or combined with CAF or resin-
graft,11-13 enamel matrix derivatives,12,14 modified glass ionomer. The advantage
bio-absorbable, or nonresorbable mem- of restoring the cervical lesion before
brane15 and acellular dermal matrix.13,16 implementing the root coverage pro-
These techniques have been evalu- cedure has been emphasized. A cervi-
ated in clinical studies.17,18 The depth cal restoration, if correctly planed and
of the defect has been measured pre- performed, does not have a negative
operatively and after 6 months, or at a effect on the degree of root coverage,
later follow-up examination. The results, but significantly improves the esthetic
in terms of mid-facial root coverage, outcome and reduces dental hyper-
have been expressed as the percent- sensitivity.23,24,27-32
age of the original covered defect, or In the esthetic zone, interplay be-
as the percentage of defects with com- tween the surgical and prosthetic steps
plete coverage. Mean root coverage of may become even more critical when a
70–80% is the most common. Up until tooth is designed for both root coverage
the early 2000s, complete root cover- and crown preparation. The conven-
age was achieved in about 50% of the tional approach is to first implement the
treated defects.18 However, with the root coverage procedure, and only after
development of advanced techniques marginal tissue stabilization, prepare the
and regenerative materials, a higher tooth, take impressions, and cement the
predictability (close to 95%) has been final crown. However, during tooth prep-
shown.17,19-21 aration and impression taking, irritation

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to the marginal gingiva can occur.33 This

in turn could be responsible for marginal
tissue recession and for the intracrevicu-
larly placed crown margins to become
visible within time.34-36
In this article, a different approach
is proposed to minimize tissue irritation
and recession. The final crown margins
are prepared first, followed by the final
impression for the fixed crown, place-
ment of the provisional crown, and then
implementation of the root coverage Fig 1 At presentation. Note ill-fitting crown mar-
procedure. After tissue maturation, the gins and cleft development associated with the left
provisional crown is replaced with the maxillary incisor.

final crown, without any additional tooth

preparation and impression taking. A
clinical case report is presented that
demonstrates implementation of this
“crown-then-graft approach” (CTGA).

Case report
A 35-year-old woman came to the den-
Fig 2 At presenta-
tal practice with a complaint of gingival
tion. The periapical ra-
recession and dark appearance of the diograph demonstrates
associated exposed root of the left max- normal crestal profiles.
illary incisor. She wished to reverse the
recession and to regain esthetic contour
and gingiva color. Clinical examination
revealed an ill-fitted crown with bulgy Prosthetic procedure
contours and a v-shaped recession
3 mm deep and 5 mm wide (Fig 1). The The objective was to achieve definitive
periodontal condition was healthy in the ideal tooth preparation. The buccal fin-
neighboring teeth and other parts of the ishing line was prepared ½ to 1 mm ap-
mouth. ical to the gingival line at the adjacent
Radiographic examination showed intact central incisor. Interproximally, the
physiological crestal profiles on the left finishing line was placed ½ to 1 mm in
maxillary incisor and neighboring teeth the intracrevicular region, since this area
(Fig 2). The patient was advised to re- would not be modified during surgery. A
place the old crown with a new one and minor correction was made to the axial
to have a root coverage procedure using walls to provide the necessary restora-
the CTGA. tive space that was consumed by the

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 CASE REPORT

a b

Fig 3 (a to c) The old crown is removed and the

tooth re-prepared with its labial margins located ap-
proximately ½–1 mm apical to the planned gingival
marginal line. Thereafter, the interproximal margins
are further prepared apically, and a double cord re-
traction technique is used, followed by a polyvinyl-
siloxane (PVS) (Elite HD, Zhermack, Badia Polesine,
c Italy) impression.

Fig 4 Provisional crown with its margins flat at the labial aspect. Note the location of the crown margins,
which respects the symmetry of the desired gingival line.

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buccal abrasion of the root. A double

cord (SIL Trax AS No. 7, Pascal Interna-
tional, Bellevue, WA, USA and Ultrapak
#000, Ultradent Products, South Jordan,
UT, USA) impression technique was im-
plemented (Figs 3a to 3c).
On completion of the prosthetic
procedure, a temporary crown with a
flat marginal profile was made in the
laboratory. The crown was then relined
with acrylic (Unifast Trad, Kasugai, a

Aichi, Japan), polished and temporarily

cemented (Fig 4).

Root coverage procedure

It was decided to limit the surgical field

to the involved central incisor to avoid
potential damage to the almost ideal gin-
gival contours on the neighboring teeth.
Vertical oblique incisions were made at
the mesial and distal line angles of the
b
crown, extending up to a distance of ap-
proximately 3 mm apical to the mucogin-
gival junction line. New surgical papillae
were elevated by splitting the anatomical
papillae, followed by full thickness flap
elevation up to the mucogingival line, ex-
posing the full extent of the exposed root.
Horizontal splitting incisions of the flap
were then performed to completely free
the flap from muscle attachments and the
underlying periosteum and to allow flap
coronal advancement without tension.
c
The root was planed and smoothed
Fig 5 (a to c) A triagonal flap is elevated, the
with a periodontal curette and rotatory
root planed, a connective tissue graft is placed and
diamond finishing burs up to the record- covered by the “over” coronally advanced flap.
ed presurgical level of attachment. A thin
connective tissue graft was harvested
from the palate, then placed and fixed over 1 to 2 mm of the acrylic crown mar-
to cover the exposed root surface. After gins, and was stabilized by 7-0 polyvinyl
de-epithelialization of the adjacent pa- simple sutures at the vertical line inci-
pillae, the flap was coronally advanced sions. A 6-0 polyamide (Ethilon, Ethicon,

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Fig 6 At 1 week post-surgery. The advanced flap Fig 7 At 3 weeks post-surgery, the flap margins
seems to incorporate well with the neighboring tis- have migrated slightly apically.
sues. Sutures were removed the following week.

a b

c d

Fig 8 (a to d) At 6 months post-surgery, the final crown was cemented.

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Fig 9 The cemented final

crown at 12-months follow-up.

Somerville, NJ, USA) sling suture around the patient was instructed to change to a
the tooth achieved further graft anchor- stronger (still soft) brush (Elmex, GABA,
age. No periodontal dressing was used Switzerland) for the coronally direct-
(Figs 5a to 5c). ed roll technique, and to complement
plaque control with a single tufted brush
Postoperative treatment (Paro 1003, Esro, Kilchberg, Switzer-
land), splayed and used to sweep along
Analgesics (Naproxen Sodium 275 mg the gingival line of the crowned tooth.
(Teva, Petach-Tivka, Israel), four times
daily) were prescribed for 3 days. The Initial healing phase
patient was instructed to abstain from
brushing and flossing around the surgi- At 1 week, healing appeared to be un-
cal area until suture removal (14 days), eventful (Fig 6). However, to ensure a
and to consume only soft food during mature union between the flap and
the first week. She was also instructed neighboring tissues, suture removal was
to avoid any other mechanical trauma to delayed to the following week.
the treated site. At 2 weeks, the patient At 3 weeks, the flap margins migrated
was instructed to floss and use the coro- slightly apically. Scar tissue at the verti-
nally directed roll technique with an ex- cal incision lines and some overlapping
tra soft brush (Jordan, Norway). During of the flap margins on the adjacent distal
the first 4 weeks, the patient used 0.2% papilla were noted (Fig 7).
chlorhexidine solution rinse (Tarodent,
Taro, Haita, Israel) for 1 min twice daily. Final crown placement
She was also recalled for professional
supragingival biofilm control, weekly for At 6 months, the provisional crown was
the first 4 weeks, then monthly for the replaced with the final zirconia crown
first 6 months. At 2 months post-surgery, (Lava Zirconia, 3M ESPE, Seefeld, Ger-

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Fig 10 At 18-months follow-up, the marginal gin- Fig 11 At 2½-years follow-up, note the impor-
giva have regained a normal anatomic position. tance of esthetic crown-gingival contours in a high
smile line situation.

Fig 12 At 4½-years post-surgery, a profile view Fig 13 Radiographic view demonstrating physi-
demonstrating thinned gingival margins of the left ological crestal profiles and a stable crown structure
maxillary incisor. An incisal fracture can be noted. at 4½ years post-surgery.

many), which was fabricated based on Follow-up

the pre-surgery impression. Final crown
cementation (Panavia F 2.0, Kurary At 12 months, the gingival margins ap-
Medical, Okayama, Japan) of the crown peared uneven (Fig 9), and only at 18
was done 1 month later (Figs 8a–8d). months were the esthetic anatomic con-

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tours finally recaptured, as the gingival

margins had migrated further apically
(Fig 10). At 2½ years, the gingival to-
pography at both central incisors ap-
peared almost identical, with the nearly
complete disappearance of the incision
lines (Fig 11).
At 4½ years, the patient had visited
the office to repair a fractured incisal
corner of the maxillary right incisor, at
which time healthy, nicely contoured,
but somewhat thinned gingival margins Fig 14 At 5-years follow-up, note the shadowing
were noticeable on the left maxillary inci- and minor recession of gingival margins with visible
sor (Figs 12 and 13). After 5 years, slight crown margins.

gingival marginal recession with expo-

sition of the crown margins was noted.
There was also some shadowing of the Grafted gingival tissue on a previously
gingiva, reflecting the dark root surface exposed root surface may be more sen-
underneath (Fig 14). sitive to these irritations, because it is
not as protected by well-organized and
attached fibers as the native gingiva.
Discussion Therefore, an attempt should be made
to improve the quality of the grafted tis-
In the presence of a normal periodon- sue and to minimize tissue trauma dur-
tium, most of the intracrevicularly placed ing crown preparation by using the most
crown margins may become visible biocompatible restorative materials, and
due to gingival recession, between 1 to composing the most suitable oral hy-
10 years after crown cementation.34,35 giene program for the patient.
In many clinical situations this unde- A coronally advanced flap com-
sired outcome is related to overt viola- bined with sub-epithelial connective
tion of the biological width,37,38 ill-fitted tissue graft is the preferred proced-
crown margins,39 plaque-induced gin- ure to improve the quality of the gin-
givitis,40 or self-inflicted injuries, such gival tissue. This so-called “bilaminar
as toothbrush abuse.41,42 However, technique,” which proved effective in
even in the hands of an expert clin- the mean reduction of recession and
ician, there are “silent” mechanical33,43 frequently with complete root cover-
and chemical44-46 irritations that may age, also demonstrated a gain in both
be introduced to the most coronal part buccolingual and apico-coronal width
of the attachment apparatus during of the keratinized gingiva. A wide and
crown preparation, impression taking thick gingiva may have the capacity
and crown cementation, which could to mask darkened non-vital roots and
result in immediate or late gingival mar- become less prone to recession due
ginal recession. to mechanical, chemical, or bacterial

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irritations.19,21,32,47-50 In this respect, it studies or case reports on complete root

may be assumed that if a more dense coverage in crown restored teeth can
fibrotic grafted tissue been used in the be found in the literature. This is in con-
presented case, the less likelihood that trast to the numerous studies that dem-
thinning of the graft with gingival shad- onstrate high predictability of complete
owing and recession would occur. Ac- root coverage in non-restored teeth or in
cording to the authors’ observations in teeth with cervical lesions. This dispar-
this case, it may be assumed that the ity may be explained by the unavoid-
delay in the root coverage procedure, able prosthetic originated interferences
to after final crown preparation and im- to the healed grafted gingiva, and the
pression taking, was beneficial in de- difficulty with establishing a biologically
creasing the potential irritations to the stable, irritation-free gingivo-crown in-
grafted tissue. terface.
It could be further speculated that The CTGA was designed to down-
an additional postponement of the root grade this difficulty by choosing an “out-
coverage procedure to a point where of-the-box” sequence of the involved
the final crown had already been ce- procedures when treating such cases.
mented, would prove even more effec- Undoubtedly, further investigation is
tive in eliminating potential irritations needed to validate the CTGA as a pre-
to the grafted gingiva, and perhaps in dictable and efficient approach, espe-
achieving improved, long-lasting es- cially in cases in which predetermination
thetic results. To date, and to the best of the maximum root coverage level may
of the authors’ knowledge, no long-term be difficult.

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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
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