Esthetic Reconstruction of Soft Tissue Dehiscence with Subepithelial Connective Tissue Graft: A Case Report

INTRODUCTION

Soft-tissue dehiscence in the esthetic zone presents significant clinical challenges, including root exposure, dentinal hypersensitivity, and compromised esthetics. These defects may also impair plaque control and increase the risk of root caries.^[1] Achieving stable gingival contours requires accurate diagnosis and appropriate surgical intervention.

Subepithelial connective tissue grafting (SCTG) is considered the gold standard for soft-tissue augmentation due to its ability to increase tissue thickness, provide predictable root coverage, and achieve superior color match.^[2] Recent evidence has also highlighted its role in enhancing peri-implant mucosal stability and long-term tissue health.^[3] This case report describes the management of a localized gingival recession defect using SCTG in combination with a coronally advanced flap (CAF). This case highlights the effectiveness of a subepithelial connective tissue graft combined with a coronally advanced flap in the management of localized gingival recession in the esthetic zone.^[1,2] The increase in soft-tissue thickness achieved through SCTG is a critical factor contributing to the long-term stability and predictability of root coverage outcomes, particularly in patients with a thin gingival phenotype.^[3,4] However, the periodontal diagnosis in this case requires careful consideration. The presence of a 7 mm probing depth is not typical for Cairo RT1 recession and indicates a component of localized attachment loss. This underscores the importance of comprehensive clinical evaluation, including clinical attachment level assessment, to ensure accurate diagnosis and appropriate treatment planning.^[5,6] Previous randomized controlled trials comparing SCTG with deepithelialized grafts have reported comparable postoperative morbidity, with SCTG demonstrating advantages in terms of enhanced tissue thickness and marginal stability.^[7,8] Despite its predictability, complications such as epithelial proliferation have been reported, emphasizing the need for careful postoperative monitoring.^[9]Donor-site morbidity, including palatal abscess formation and suture-related complications, has also been documented.^[10] To minimize such risks, modified graft harvesting techniques have been proposed. Zazou et al. described an in situ deepithelialization method that reduces surgical time and graft handling.^[1] Furthermore, long-term studies have demonstrated stable peri-implant mucosal outcomes with SCTG in combination with laterally positioned flaps.^[11] In the present case, the absence of complications may be attributed to meticulous flap design, adequate graft stabilization, and tension-free wound closure. The favorable esthetic outcome reinforces SCTG as a dependable technique for recession coverage, particularly in patients with high esthetic demands.

However, the findings should be interpreted with caution due to the single-case design, lack of histological evaluation, and relatively short follow-up period. Further longitudinal studies are required to confirm long-term stability.

CASE REPORT

A 24-year-old male patient reported to the Department of Periodontology with the chief complaint of gingival recession in the maxillary premolar region for the past year, associated with increased root visibility during smiling. The patient had no systemic illness or any significant findings. There was no history of orthodontic treatment or parafunctional habits. The patient reported the extraction of the maxillary canine in the second quadrant two years earlier.

An intraoral periapical radiograph was obtained to evaluate the underlying cause of the soft-tissue defect associated with tooth 24. Clinical examination revealed a 2-mm buccal gingival recession on the facial aspect of tooth 24, associated with a thin gingival phenotype. The probing depth was 7 mm at the mesio-buccal site with bleeding on probing. The clinical attachment level was 7 mm at the same site. The width of keratinized tissue was ~2 mm, and the gingival phenotype was clinically assessed as thin. Radiographic assessment revealed a buccal bone plate defect in relation to tooth 24.

Based on the clinical findings, the defect was provisionally classified as Cairo RT1 recession. However, the presence of a 7 mm probing depth is not characteristic of cairo recession Type 1 (RT1) recession and suggests an associated component of localized attachment loss. This necessitates careful interpretation of the defect, as it may represent a combined recession and periodontal involvement rather than an isolated mucogingival defect. After discussing all available treatment options, the patient opted for esthetic correction using a subepithelial connective tissue graft combined with a CAF.

DISCUSSION

This case highlights the effectiveness of a subepithelial connective tissue graft combined with a coronally advanced flap in the management of localized gingival recession in the esthetic zone.^[1,2]

The increase in soft-tissue thickness achieved through SCTG is a critical factor contributing to the long-term stability and predictability of root coverage outcomes, particularly in patients with a thin gingival phenotype.^[3,4]

However, the periodontal diagnosis in this case requires careful consideration. The presence of a 7 mm probing depth is not typical for Cairo RT1 recession and indicates a component of localized attachment loss. This underscores the importance of comprehensive clinical evaluation, including clinical attachment level assessment, to ensure accurate diagnosis and appropriate treatment planning.^[5,6]

Previous randomized controlled trials comparing SCTG with de-epithelialized grafts have reported comparable postoperative morbidity, with SCTG demonstrating advantages in terms of enhanced tissue thickness and marginal stability.^[7,8] Despite its predictability, complications such as epithelial proliferation have been reported, emphasizing the need for careful postoperative monitoring.^[9] Donor-site morbidity, including palatal abscess formation and suture-related complications, has also been documented.^[10]

To minimize such risks, modified graft harvesting techniques have been proposed. Zazou et al. described an in situ deepithelialization method that reduces surgical time and graft handling.^[1] Furthermore, long-term studies have demonstrated stable peri-implant mucosal outcomes with SCTG in combination with laterally positioned flaps.^[11]

In the present case, the absence of complications may be attributed to meticulous flap design, adequate graft stabilization, and tension-free wound closure. The favorable esthetic outcome reinforces SCTG as a dependable technique for recession coverage, particularly in patients with high esthetic demands. However, the findings should be interpreted with caution due to the single-case design, lack of histological evaluation, and relatively short follow-up period. Further longitudinal studies are required to confirm long-term stability [Figure 1-7].

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Figure 1: Preoperative

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Figure 2: Reflection of split thickness flap

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Figure 3: Preparation of the donar site using the trap door approach for harvesting graft

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Figure 4: Approximation of the donar site using 3-0 BBS . BBS: Braided black silk

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Figure 5: Placement of harvested graft in the recipient site

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Figure 6: Approximation of the recipient site using 3-0 BBS. BBS: Braided black silk

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Figure 7: Postoperative

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CONCLUSION

The combination of a CAF with a subepithelial connective tissue graft provided predictable root coverage, enhanced tissue thickness, and satisfactory esthetic outcomes. The unique aspect of this case lies in the management of a gingival recession defect associated with increased probing depth and underlying bone dehiscence, highlighting the importance of accurate diagnosis and meticulous surgical execution in achieving optimal clinical results.