International Journal of Clinical Case Reports 2017, Vol.7, No.2, 4-8
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Tooth malpositioning;
High frenal attachment; and
Uncontrolled orthodontic movements (Wennström, 1996; Tugnait and Clerehugh, 2001)
Gingival recession is, also, commonly seen as an outcome of various periodontal therapies delivered to treat
periodontal disease. The treatment of gingival recession is based on the assessment of etiological factors and the
amount of tissue involved. The removal of etiological factors should be the preliminary part of management of
patient with gingival recession. Re-examination of gingival status has to be done before proceeding with surgical
root coverage procedure. Surgical root coverage procedure is indicated in the anterior region where esthetics is the
prime concern. Gingival recession can be of two types; generalized, usually seen in patients with poor oral
hygiene and localized, related to traumatic factors involving only few teeth and/or, a group of teeth. Generalized
recession may be seen involving interproximal areas where as the localized type is usually seen involving buccal
areas (Miller, 1987; Maynard, 2004). Miller proposed a classification for recession defects based on the position
of gingival margin to the mucogingival junction and the height of interdental papilla and interdental bone adjacent
to the site of defect. (Table 1) (Miller, 1985) Depending upon this classification the treatment planning can be
decided (Maynard, 2004).
Table 1 Miller’s classification of gingival recession defects (1985)
Class
Description
Class I
Recession within attached gingiva. No loss of interdental bone and soft tissue papillae covering interdental bone at full
height.
Class II
Recession extending to and/or, beyond the mucogingival junction. No loss of interdental bone and soft tissue papillae
covering interdental bone at full height.
Class III Recession extending to and/or, beyond the mucogingival junction. Loss of interdental bone but interdental bone height
coronal to apical extent of recession defect. Reduction in height of the soft tissue papillae covering interdental bone.
Class IV Recession extending to and/or, beyond the mucogingival junction. Loss of interdental bone apically to the recession
defect. Gross flattening of interdental papillae.
2 Case Reports
A 28 years old male patient reported to the Department with the complaint of spacing between his upper front
teeth which was increasing since last 5-6 months. While performing intraoral examination, a midline diastema of
about 5 mm was noticed and 11 mm periodontal pocket was seen in relation to the mesiobuccal aspect of the
maxillary right central incisor (Figure 1). There were no signs of trauma from occlusion but the tooth was Grade I
mobile. The overall oral hygiene of the patient was good without any periodontal destruction of other teeth. The
radiographic examination with intra-oral periapical radiograph (IOPAR) revealed vertical bone loss in relation to
the mesial aspect of maxillary right central incisor (Figure 2). After a detailed history and clinical examination, the
case was diagnosed as chronic localized periodontitis. After phase I therapy of scaling and root planning, surgical
management was planned. After anesthetizing the region adequately, two semilunar incisions were placed in
continuation on both the central incisors (Figure 3). The incisions were continued as crevicular incisions from
buccal to the palatal aspect of the central incisors and the flap along with the interdental papilla was reflected
towards the palatal surface with its base attached to the palatal mucosa (Figure 4). The exposed root surface was
thoroughly planed and the intra-osseous defect was curetted. After complete debridement of the root surface, the
defect was filled with a DFDBA graft material and covered by resorbable GTR membrane (Figure 5). The flap
was sutured with 3-0 silk suture material (Figure 6) and covered with a periodontal dressing. Post-operative
instructions were given along with suitable medications. Sutures were removed after 1 week of surgery. At 2
month post-operative review, it was observed that the area showed gingival recession of about 5mm along the
right central incisor extending up to mucogingival junction (Figure 7). On the selected day after establishing
adequate anesthesia, the gingival margin in relation to the left central incisor was de-epithelialized. Later, a pouch
was created in the region with defect up to the mucogingival junction for the placement of connective tissue graft
(CTG). The exposed root surface was smoothened to remove any irregularities and necrotic cementum while root
