Introduction

In the patient candidate for the placement of dental implants soft tissue should be evaluated during the basic periodontal examination, since the width of the keratinized mucosa is important in the health of tissues surrounding the implant. An adequate band of keratinized mucosa is related to less accumulation of bacterial plaque and inflammation of the mucosa, and less pro-inflammatory mediators. In contrast, its absence may be critical especially for the control of bacterial plaque and plaque-associated mucous lesions around dental implants.¹,²

The keratinized gingiva around dental implants influences both the clinical and immune parameters of these areas. These findings are of particular importance in the esthetic aspect, where thin, narrow keratinized gingiva can lead to further gingival recession.³

This is also seen in patients with overdentures because the lack of adequate keratinized mucosa around the implants is associated with increased accumulation of bacterial plaque, gingival inflammation, bleeding at periodontal probing and mucosal recession.⁴

Increased keratinized mucosal width around implants is associated with lower mean alveolar bone loss and better soft tissue health rates.⁵

Therefore, the performance of periodontal microsurgery for the augmentation of inserted gingiva has been successfully implemented to improve the quality and amount of gingiva attached around the implants.⁶

In the case presented here, the endodontic diagnosis was pulpal necrosis with asymptomatic apical periodontitis as a result of dental trauma resulting in a lack of apical closure. These cases had traditionally been treated with long-term Ca hydroxide, with multiple dental office visits to achieve apex closure but with high prevalence of root fracture. In the 1990s the MTA (Mineral Trioxide Aggregate) emerged as an alternative, reducing the number of visits and the predisposition to root fracture of the involved tooth.⁷ MTA has been used with good results in teeth with vital pulp treatment in direct pulp capping, partial and total pulpotomy, and filling of lateral canal and furcal perforations. It has also been used for apexification as apical barrier in root canal treatment of necrotic tooth with incomplete root formation and as retro-obturation material during apical surgery.⁸,⁹

The use of MTA instead of Ca hydroxide is based on its ability to form a hard apical barrier, so it has been shown to be the appropriate material for cases of apexification.¹⁰

The following case report describes the procedure for apexification with MTA in a permanent tooth with immature apex and the periodontal surgeries carried out to address the periodontal disease of the patient.

Clinical case presentation

A 20-year-old female patient attended the dental office for orthodontic treatment but was referred to periodontal consultation due to inflammation and gingival recession in tooth #12. During the initial evaluation, periodontal probing was performed, which revealed inflammation, purulent exudate, and vestibular mucogingival deformity (gingival recession). The patient had no pathological medical history. Periodontal diagnosis was bacterial plaque-induced gingivitis and Miller’s class I gingival recession in tooth #12. Periapical radiograph was taken to complete diagnostic aids (Figure 1).

Figure 1: Initial orthodontic examination. 

The patient reported having suffered trauma at the age of 5 affecting the upper right-side teeth. At pulp vitality and percussion tests tooth #12 did not respond. Clinically, changes in crown coloration were observed in addition to gingival recession. At radiographic examination, open apex and radiolucent lesion were noted at the periapical level. Clinical and radiographic findings pointed to a diagnosis of pulpal necrosis with asymptomatic apical periodontitis. The treatment of choice was apexification with MTA (Figure 2A).

Figure 2: A) Preoperatory periapical radiograph. B) Results of periodontal phase I. C) Surgical procedure for the elimination of the retained canine and view of the immature apex. D) Final radiograph of root canal treatment. 

Based on the clinical examination, we decided to carry out the periodontal and endodontic treatment that will be explained afterward. The tooth had an unfavorable prognosis, so the initial goal of these treatments was to control the periodontal and endodontic disease, recover periodontal soft tissues to subsequently extract the tooth, and perform guided bone regeneration to place an implant later.

The treatment advantages and disadvantages were explained in detail to the patient, who agreed and signed an informed consent letter.

Root coverage procedure

Two months later, a periodontal surgery was performed to gain gingival height and thickness, where a coronal displacement was carried out plus subepithelial connective tissue graft (SCTG) application (Figure 3A).

Figure 3: A) Preparation of the recipient bed (SCTG). B) Adaptation of the subepithelial connective tissue graft. C) Scaring at 15 days after performance of root coverage. D) Clinical examination 4 months after performance of root coverage. 

The SCTG was taken from the palatine area; the adipose tissue and the underlying epithelium were removed (Figure 3B). The graft was applied at the recipient site and secured to the interdental papillae in a coronal position with suspensory sutures; later the coronal flap displacement was performed, combining 5-0 polyglycolic acid interrupted sutures with suspensory sutures.

At the end of the procedure, a periodontal dressing (Coe-pak) was placed at both surgical sites.

The patient was prescribed 600mg ibuprofen capsules and 0.12%Clorhexidine gluconate oral rinse twice a day for 2 weeks.

Two weeks after the surgery the periodontal dressing and the sutures were removed. The patient showed no postoperative complications (Figure 3C).

Results

Periodontal examinations were carried out periodically; 4 months after the second surgery, root coverage was about 90% in tooth #12. That is the reason that we decided to perform root coverage with the semilunar technique, which is indicated for small recessions with a good amount of attached gingiva (Figure 3D).

According to the clinical and radiographic follow-up performed at 6 months and at 1 year, the treatment was successful since the patient was asymptomatic and radiographically a repair of the periapical lesion was observed.

Two years after performing the procedures, soft tissue stability was observed, so at the patient’s request the placement of the implant was postponed for as long as the tooth remained functional and did not present any symptoms (Figures 4AandB).

Figure 4 A) Final photograph, examination 2 years later. B) Periapical radiograph 2 years after the end of treatment. C) Initial periodontal probing. D) Final periodontal probing. 

At probing no periodontal pocket was found and the proper insertion of the graft was corroborated by clinically comparing the initial and final periodontal examination (Figures 4CandD).

The patient was satisfied with the clinical results.

Discussion

In this clinical case the performance of various periodontal surgical procedures allowed gaining a good quantity and quality of keratinized tissue, since one of the techniques used was the application of subepithelial connective tissue graft, which significantly reduces gingival recession in comparison with the sole performance of coronally displaced flap.¹¹

Other studies have shown that the modified coronally advanced flap combined with the subepithelial connective tissue graft is effective and predictable for producing root coverage in multiple adjacent gingival recessions associated with gain in clinical insertion levels and keratinized tissue width.¹²,¹³

The coronally displaced flap procedure plus the subepithelial connective tissue graft provides better long-term results (60 months after surgery) than coronal displacement alone. The long-term stability of the gingival margin is less predictable for Miller class II gingival recession (GR) defects compared class I¹⁴ defects, although other results indicate that the treatment of Miller Class I and Class II adjacent multiple gingival recessions by using the modified coronally advanced tunnel technique and collagen matrix can result in statistically and clinically significant complete root coverage.¹⁵

Soft tissue grafting procedures are also important in areas around dental implants as they result in more favorable peri-implant health by gaining keratinized mucosa. There is improvement in bleeding rates as well and higher marginal bone levels.¹⁶ Autogenous grafts (subepithelial connective tissue graft) allow an increase in soft tissue thickness, better esthetic results, and improved gingival biotype.¹⁷-¹⁹

Considering the initial clinical and radiographic findings, the treatment of choice for the patient’s affected tooth was apexification. Several materials have been used to perform this procedure, such as Ca hydroxide, but this material has some disadvantages, such as multiple office visits over long periods of time, unpredictable results in the formation of an apical barrier, and above all, susceptibility to bacterial microfiltration and fracture.²⁰

Another widely used material is MTA. Some studies have shown its great biocompatibility, excellent sealing, and good marginal adaptation that reduces bacterial microfiltration. In addition, its use reduces significantly the long periods of treatment in comparison with the use of Ca hydroxide.

We used MTA as it has proven to be the best material to form an apical barrier in non-vital permanent teeth with open apex.²¹ Unlike other materials,MTA sets in the presence of moisture and its main component is calcium oxide, which is converted into Ca hydroxide that gives it a high pH with antibacterial effect. In addition, unlike Ca hydroxide alone, the material has good stability and low solubility.²²

As mentioned, the favorable results obtained with MTA were due to its properties, such as biocompatibility. Tawil PZ et al. showed that histologically new cementum is formed in the area of periradicular tissues. There is also a low inflammatory response with the formation of a bridge in the pulp space area. Thanks to the MTA sealing capacity it achieves a stable barrier avoiding bacterial and fluid contamination, which is an important aspect to obtain clinical success.²³

Conclusions

The case presented confirms that the use of MTA for treatment of teeth with open apex stimulates the regeneration of apical tissue. Also, the various techniques of mucogingival surgery that we used allowed us to gain or in this case to recover the soft tissues that had been lost around the patient’s tooth; it was only a matter of good diagnosis and development of a treatment plan.

Finally, we can conclude that multidisciplinary work is important to achieve success and well-being of the patient.