CLINICAL RESEARCH

Combined Orthodontic
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Giovanni Zucchelli, DDS, PhD
Associate Professor, Department of Periodontology, University of Bologna, Bologna, Italy

Serena Incerti Parenti, DDS,

Visiting Professor, Department of Orthodontics, University of Bologna, Bologna, Italy

Gino Ghigi, MD
Associate Professor, Department of Radiology, University of Bologna, Bologna, Italy

Giulio Alessandri Bonetti, MD, DDS

Assistant Professor, Department of Orthodontics, University of Bologna, Bologna, Italy

Correspondence to: Prof Giovanni Zucchelli

Department of Oral Sciences, University of Bologna, Via San Vitale 59, 40125 Bologna, Italy;
Tel: +39 (051) 2088125; Fax: +39 (051) 225208; e-mail: giovanni.zucchelli@unibo.it

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ZUCCHELLI ET AL

Abstract

provements in the root coverage prognosis due to the resolution of root malposi-

In this article, the interdisciplinary man-

tion and de novo formation of keratinized

agement of an isolated-type recession

tissue apical to the root exposure (I Miller

defect in a severely compromised man-

class gingival recession). A subepithelial

dibular incisor of a young post-orthodon-

connective tissue graft was performed

tic patient is described. The prognosis

as a root coverage surgical procedure.

of root coverage surgery was very ques-

Clinical examination 1 year after surgery

tionable and unpredictable due to the

revealed complete root coverage, good

severe root malposition (III Miller class

color blending with adjacent soft tis-

gingival recession). The treatment plan

sue and an increase in facial gingival

consisted of: (1) interproximal enamel

thickness.

reduction to gain space within the den-

Successful periodontal and esthetic out-

tal arch, (2) orthodontic repositioning of

comes can be accomplished after the

the root of the affected tooth within the

combined orthodontic-periodontal treat-

alveolar bone and (3) root coverage mu-

ment of a severely mucogingivally com-

cogingival surgery.

promised tooth.

Clinical re-evaluation 7 months after xed

orthodontic treatment revealed major im-

(Eur J Esthet Dent 2012;7:266280)

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CLINICAL RESEARCH

Introduction

gingiva at baseline and, overall, to the

type of orthodontic tooth movement.7-9

In orthodontics, the desire to improve

It is presumed that excessive movement

dento-facial

been

of teeth beyond the cortical bone may

found to be the primary motivation for

cause alveolar dehiscence, thus predis-

patients seeking orthodontic care.1-3

posing to future recession in the pres-

appearance

has

Esthetics regards macroscopic as-

ence of inadequate plaque control and/

pects, such as the face, the smile, the

or traumatic mechanical factors.10-16

occlusion

aspects

This may be the result of inadequate

such as the gingiva.4-6 All these features

and

microscopic

treatment planning, particularly in bor-

are inter-related and the clinician should

derline cases where proclination of the

critically evaluate each of them in the

mandibular incisors as a part of the

decision-making process, thus select-

orthodontic treatment is considered as

ing the best treatment plan in order to

an alternative to tooth extraction.

optimize each component of dento-

The resulting exposure of the root surface to the oral environment by an apical

facial appearance.
As a result, clinicians have tended to

shift of the gingival margin with respect

move away from treatment planning en-

to the cementoenamel junction (CEJ),17

tirely based on static morphologic fea-

occurring more frequently in the man-

tures gained from lateral cephalometric

dibular incisor region where a thin labial

radiograph and plaster study casts, to-

bone plate and gingival tissue are pre-

wards a greater emphasis on the static

sent,11,12 even if not esthetic, may lead

and dynamic clinical examination of

to sensitivity and root caries.

the face. Moreover, in addition to the

This case report describes the diag-

traditional dental and facial evaluation

nosis and treatment of an isolated-type

in three dimensions (transverse, anter-

recession defect in a severely compro-

oposterior, and vertical), the orthodon-

mised mandibular incisor of a young

tist now must think in terms of the fourth

post-orthodontic patient.

dimension:

time.5

The goal of enhance-

ment of the overall patients dento-facial

appearance requires the clinician to

Case report

understand the effect of the orthodontic

therapy as related to growth, maturation

A 21-year-old female of Caucasian ori-

and aging of the hard and the soft tis-

gin, in good general medical health,

sues, both facial and

gingival.5

was referred to the Department of Perishould

odontology for evaluation of a tooth 32

receive the emphasis they deserve in

affected by a gingival defect (Fig 1a).

the selection of different treatment ap-

The patient had xed orthodontic appli-

proaches (for example, dental arch ex-

ances in both arches between 12 and 15

pansion versus tooth extraction), since

years of age. She was also wearing a lin-

the health of the gingival tissues during

gual retainer, bonded from canine to ca-

and after the active treatment period is

nine at the mandibular arch (Fig 1b). The

related to the quantity and quality of the

intraoral clinical examination revealed

Periodontal

considerations

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ZUCCHELLI ET AL

a
Fig 1

Baseline intraoral clinical examination: a) anterior mandibular teeth; b) occlusal clinical view: buc-

cal dislocation of the root of tooth 32; c) cone-beam computed tomography (CBCT), axial view: note the
root apex of tooth 32 is outside the limits of the alveolar bone.

a
Fig 2

Baseline periodontal examination of tooth 32 with gingival defect: a) facial aspect; b) periapical

radiograph; c) lateral view; d) CBCT sagittal view: note the absence of the labial cortical plate.

an occlusal sagittal molar relationship

ical to the CEJ (Fig 2a). The most ap-

of Angle Class I, a moderate mandibu-

ical extension of the recession extended

lar crowding and an anomalous bucco-

beyond the mucogingival line (III Miller

lingual inclination of teeth 31, 32, and

class gingival recession).18 The clinical

33. A particular root prominence of tooth

examination revealed a buccal probing

32 with respect to the neighboring teeth

pocket depth of 3 mm apical to the root

was present (Fig 1ac).

exposure, thus the clinical attachment

loss at the buccal surface was 10 mm.

Baseline periodontal examination

No attached gingiva and keratinized

tissue remained apical to the root expo-

A gingival recession was found on the

sure, while areas of simil-inammatory

labial surface of the buccally dislocated

tissue (red, highly vascularized tissue)

root of tooth 32, extending 7 mm ap-

were present, positioned distally to the

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CLINICAL RESEARCH

root exposure. This area was not associ-

plaque control. Gentle subgingival scal-

ated with plaque accumulation and did

ing with an ultrasonic device, polishing

not bleed after supercial probing; nev-

of the crowns and of the root exposure at

ertheless 3 mm of probing pocket depth

tooth 32 were performed. After 2 weeks,

was measurable in the buccal-lingual

a signicant improvement in plaque con-

direction. Bleeding was present when

trol with disappearance of clinical signs

deep probing the pockets apically and

of inammation at the tooth with gingival

distally to the root exposure.

recession and at the neighboring teeth

Mesial and distal interdental papil-

was demonstrated. Swelling resolution

lae of tooth 32 almost completely lled

and calculus removal led to the clinical

the embrasure spaces up to the contact

appearance of unesthetic black trian-

points. Some plaque and calculus accu-

gles at the interdental space, which

mulation was present at the interdental

were very unsatisfactory for the patient

space and at the lingual aspect of all

(Fig 3a and b).

teeth comprised between right and left

The peculiarity of a different axial in-

mandibular canines. Minor signs of in-

clination of tooth 32 as compared with

ammation, swelling and bleeding upon

adjacent incisors, together with the sito-

supercial probing, but no pathological

specicity of the gingival lesion led to

probing pocket depths were demonstra-

the hypothesis that a traumatic mech-

ble at the interdental papillae.

anical factor, together with the lingual

Radiographic examination revealed

bonded retainer preventing any crown

that the interdental bone level was al-

movement, could have displaced the

most intact (Fig 2b). Minor bone loss

root of the affected tooth.

was demonstrable at the facial bone

After careful interrogation of the pa-

crest. Cone-beam computed tomog-

tient, no apparent etiological cause was

raphy (CBCT) in the axial view showed

clear: no chronic habits or signs of nail-

that the root of tooth 32 was outside the

biting were detected;19-22 no occlusal

labial alveolar plate, and the canine

interferences, high muscle attachment,

root was almost out of the lingual alveo-

frenal pull, lip piercing, nor signs of

lar plate (Fig 1c). Both the clinical lat-

tooth brushing trauma were present.7,10

eral view and the CBCTs sagittal view

It was therefore speculated that the de-

showed the absence of the labial corti-

scribed gingival lesion may have reect-

cal plate (Figs 2c and d).

ed a pre-existing defect or an acquired

one, either created or worsened by an

Diagnosis

incorrect diagnosis or an incorrect biomechanical tooth movement during the

The patients medical history was unre-

past orthodontic treatment. Anyway, in

markable; she did not take any medica-

the absence of any pre-treatment di-

tions known to interfere with periodontal

agnostic records, it was impossible to

tissue health or healing, and she was a

make a proper differential diagnosis

non-smoker. Oral hygiene was not good.

among possible causative factors.

A prophylaxis appointment was sched-

The patients main complaint and

uled to improve patient motivation and

concern was losing the tooth, since her

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ZUCCHELLI ET AL

Fig 3

Clinical aspect after oral hygiene prophilaxis: a) frontal view; b) lateral view.

general dentist judged the affected inci-

The

sor as a hopeless tooth and ascribed the

were explained to the patient and the

situation to an orthodontists mistake.

combined orthodonticperiodontal ap-

In these circumstances, the risk of

different

treatment

alternatives

proach was chosen.

medico-legal litigation was very high

and, after careful consultation between

Treatment

a second orthodontist and the periodontist, two treatment options were consid-

After retainer removal, an interdental

ered: (1) the extraction of the affected

stripping

mandibular incisor followed by ortho-

on the mandibular incisors and a xed

dontic therapy to close the space and

orthodontic treatment was initiated at

solve the crowding; and (2) interproxi-

the mandibular arch aiming to reposi-

mal enamel reduction (the so-called

tion the root of tooth 32 in the alveolar

stripping procedure) to gain space

bone (Fig 4a). Following 7 months, the

within the dental arch to orthodontically

correct axial inclination of all mandibu-

reposition the root of tooth 32 in the al-

lar incisors was reached (Fig 4b). At that

veolar bone to improve the prognosis of

time, the patient underwent a further

the subsequent root coverage mucogin-

periodontal examination.

procedure

was

performed

gival surgery.

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a
Fig 4

b
a) Interdental stripping procedure; b) 7 months after xed orthodontic treatment: frontal view of

anterior mandibular teeth.

Post-orthodontic periodontal

The clinical examination (Figs 5a and

examination

b) revealed a buccal probing depth of

1 mm apical to the root exposure, with

The gingival recession on the labial sur-

clinical attachment loss amounting to

face of tooth 32 extended 5 mm apically

6 mm at this site. No buccal-lingual

to the CEJ. Its most apical extension did

pocket depth was probable lateral to

not reach the mucogingival line (I Miller

the root exposure and less than 1 mm

class gingival recession) and a healthy

of attached gingiva remained apical to

1.5 mm-high apical and 2 mm-high lat-

the root exposure. Mesial and distal in-

eral keratinized tissue band was demon-

terdental papillae were intact: they lled

strable around the root exposure.

the embrasure spaces up to the contact points and no pathological probing

pocket depths were present.
A

new

oral

hygiene

motivation

recall visit was performed and proper

instructions on the correct use of a soft
toothbrush were given to the patient. An
apical-coronal directed (from the soft
to the hard tissue) roll tooth-brushing
technique was prescribed.

Surgical procedure
Improvements after orthodontic therapy
a

at the gingival affected site (Figs 5a and

b) enabled a very predictable and es-

Fig 5

Periodontal examination after orthodontic

treatment. Note the do novo formation of keratinized

thetic root coverage surgical procedure

tissue apical and lateral to the root exposure: a)

to be performed. The surgical technique

frontal view; b) lateral view.

(Figs 6a6e) adopted to treat the gingival

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ZUCCHELLI ET AL

Fig 6

Surgical procedure: a) trapezoidal incisions; b) muscle isolation between the deep and supercial

split thickness incisions c) sito-specic muscle removal; d) periostium exposure apical to the root exposure
and root planning; e) disepithelization of interdental anatomic papillae and suture of the connective tissue
graft. Note that the graft does not cover the most apical extension of the root exposure.

recession was a bilaminar technique,

The ap was elevated with a split-full-

consisting of a trapezoidal coronally ad-

split approach: the soft tissues com-

vanced ap covering a connective tissue

prised between the two horizontal inci-

graft positioned at the level of the CEJ.

sions, and the most apical extension of

The reason for this choice was to join

the root exposure (surgical papillae),

the esthetic advantages of the coronally

were elevated split-thickness.

ap23 with

the increase in gin-

The keratinized tissue apical to the

gival thickness and long term stability of

root exposure was elevated full-thick-

the bilaminar procedure.24,25 In the man-

ness up to the buccal bone crest. The

dibular incisors, the vestibulum depth is

periostium elevator was inserted in the

low and the muscle pull is quite strong.

gingival sulcus apical to the root expo-

In this situation, there is some post-sur-

sure. No intrasulcular incision (with the

gical tension on the coronally displaced

blade) was performed apical to the gin-

soft tissue margin, and it is easier for the

gival recession. This was avoided to not

patient to traumatize it. The presence

thin the marginal keratinized tissue of

of the connective tissue graft below the

the ap that is critical for the success of

ap may prevent the post-surgical con-

the root coverage procedure.

advanced

traction of the ap marginal tissue, and

Once the buccal bone crest was ex-

increase the buccal gingival thickness

posed, ap elevation continued the par-

and the vestibulum depth, allowing for

tial thickness in order to coronally ad-

an easier patient maintenance phase.

vance the ap. Two different incisions

The trapezoidal ap (Fig 6a) consist-

were performed: one deep incision,

ed of: two horizontal incisions (extended

(with the blade parallel to the bone) that

3 mm each in the mesial-distal direc-

detached all muscle insertions from the

tion) performed at a distance from the

periostium, and one supercial (with

tip of the anatomic papilla equal to the

the blade parallel to the external lining

depth of the recession (plus 1 mm) and

mucosa) that separated the ap from the

two beveled vertical releasing incisions

muscle. That portion of the lip muscle,

which extended into alveolar mucosa.

isolated by the two incisions, was physi-

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CLINICAL RESEARCH

cally removed (Figs 6b and 6c) and

ap elevation, withdrawal of connective

only the periostium was left to protect

tissue graft and complete closure of the

the buccal bone lateral and apical to

palatal wound with the access ap), de-

the bone dehiscence (Fig 6d). This was

rive from this approach:

done in order to reduce tension on soft

(1) lower depth of the withdrawal and

tissue margin of the coronally displaced

thus less bleeding during the surgery

ap and to retard muscle reinsertion in

and less pain/discomfort for the pa-

the rst healing period. It was the super-

tients in the postoperative course;26

cial incision and muscle removal that

(2) the most stable connective tissue (im-

allowed for the adequate coronal ad-

mediately below the epithelium) with

vancement of the ap.

no (or very limited) fatty and glandu-

The root surface was mechanically

lar tissues is used for the graft;

treated with the use of curettes. Only that

(3) the possibility to obtain different

portion of the root surface with loss of

thickness along the graft during the

clinical attachment (gingival recession

disepithelization procedure: greater

and probing pocket depth) was instru-

in the central portion covering the

mented. Root planing was terminated

root and lower peripheral areas cov-

when a clean and hard root surface was

ering the vascular beds.

obtained (Fig 6d). Chemical treatment of

the root was obtained with 24% ethyl-

The only drawback of this procedure

ene-diaminetetraacetic acid (EDTA) gel

was the secondary intention palatal

left in situ for 2 mins. This eliminated the

wound healing. Nevertheless the use

smear layer from the dentin tubules and

of equine-derived collagen (Gingistat;

improved blood clot adhesion to the ex-

Acteon, Mount Laurel, NJ, USA) to pro-

posed root.

tect the palatal wound and the reduced

dimensions and thickness of the with-

Connective tissue graft

drawal allowed for an absolutely pain-

harvesting procedure

less palatal postoperative course. After

1 week, an almost complete re-epitheli-

At the time of the palatal anesthesia, the

zation of the wound area was observed.

presence of a very thin bromucosa (epi-

After disepithelization with the blade, the

thelium and connective tissue) and thick

thickness of the connective tissue graft

fatty and glandular submucosa was real-

was 0.7 mm.

ized. This prompted the clinician to har-

The connective tissue graft was po-

vest a free gingival graft that was sub-

sitioned at the level of the CEJ and

sequently disepithelized with the use of

anchored at the base of the anatomic

the blade. The mesiodistal length of the

papillae with two interrupted 7-0 PGA re-

free gingival graft was 9 mm, the apical

sorbable sutures (Fig 6e). The presence

coronal dimension was 5 mm and the

of keratinized tissue in the covering ap

thickness was 1 mm. Numerous advan-

enabled the placement of a small graft

tages, with respect to the other connec-

in the apical-coronal dimension, with no

tive tissue harvesting procedures (con-

need to cover the CEJ, nor the periostium

sisting in primary split-thickness access

below the bone dehiscence (Fig 6e).

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ZUCCHELLI ET AL

Fig 7

a) Apical sutures anchored to the periostium and coronal sling suture; b) ap sutures: frontal view;

c) ap sutures: lateral view; d) ap sutures: occlusal view; e) clinical healing 4 weeks after surgery.

The remaining buccal soft tissue of the

and stabilized every surgical papilla

anatomic interdental papillae was dis-

over the interdental connective tissue

epithelized (Fig 6e) with microsurgical

bed (Fig 7c). At the end of the surgery,

scissors to create connective tissue

the marginal tissue of the ap resided

beds to which the surgical papillae of

2 mm coronal to the CEJ (Fig 7d). This

the covering ap were sutured.

was done to compensate post-surgical

The

suture

of

the

covering

ap

soft tissue shrinkage.

(Figs 7a7e) started with two interrupted sutures anchored to the periostium,

Post-surgical plaque control

performed in the most apical extension of the mesial and distal releasing

The patient was instructed not to brush

incisions. These sutures made it pos-

the teeth in the treated area, and to rinse

sible to replace the vestibulum depth

with chlorhexidine solution (0.12%) three

and reduce lip tension on the marginal

times a day for 1 minute. Fourteen days

portion of the ap (Fig 7a). Then, the

after the surgical treatment, the sutures

suture of the ap proceeded coronally,

were removed. Healing was uneventful

with other interrupted sutures, each of

and no discomfort, pain or bleeding was

them directed from the ap to the ad-

reported by the patient.

jacent buccal soft tissue, in the apical-

Plaque control in the surgically treat-

coronal direction. After these sutures

ed area was maintained by chlorhex-

the most marginal portion of the cover-

idine rinsing for an additional 2 weeks.

ing ap was stable in its coronal pos-

After this period, the patient was again

ition without disrupting forces acting

instructed in mechanical tooth clean-

on it at the time of the nal suture. This

ing of the treated tooth region using a

last suture was a sling suture anchored

soft toothbrush and a roll-tooth-brushing

around the lingual cingulum of the treat-

technique. The patient was recalled for

ed tooth (Figs 7b7d) This suture was

prophylaxis 1, 3 and 5 weeks after su-

permitted a precise adaptation of the

ture removal and, subsequently, once

marginal keratinized tissue of ap on

every 3 months until the nal examin-

the convexity of the crown of the tooth

ation (12 months).

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CLINICAL RESEARCH

a
Fig 8

Periodontal examination 3 months after surgery: a) frontal view of anterior mandibular teeth; b)

particlular of tooth 32; c) lateral view: note the increase in buccal soft tissue thickness.

a
Fig 9

b
Periodontal examination 1 year after surgery. Anterior mandibular teeth: a) frontal view and b)

occlusal view.

Four weeks after surgery, the orthodon-

1 mm and 2 mm of attached keratinized

tic appliance was removed and a lin-

tissue was present at its buccal aspect.

gual mandibular retainer was bonded

A clinical re-evaluation made 1 year

from canine to canine to ensure control

after surgery showed stability in root

of tooth position.

coverage (Fig 9a). The soft tissue margin resided coronal to the CEJ of tooth

Post-surgery periodontal

32, 2 mm of attached keratinized tissue

examinations

was present at its buccal aspect and

buccal probing depth remained shallow

The clinical examination revealed that

(1 mm). The increase in buccal gingival

complete

been

thickness was demonstrable when pull-

surgery

ing the lip retractor as a white-pink area

(Figs 8a8c). The soft tissue margin still

apical to the marginal keratinized tissue.

resided 1 mm coronal to the CEJ of tooth

The mucogingival junction was well

32, buccal probing depth was less than

aligned, good color blending with the

achieved

root

coverage

3 months

had

after

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ZUCCHELLI ET AL

Fig 10

Particular of tooth 32: a)

frontal view; b) lateral view. Note

the increase in vestibulum depth
and in buccal soft tissue thickness; c) periapical radiograph.

Fig 11

At 1 year CBCT: a) axial

view: the root apex of tooth 32 is

now within the limits of the alveolar bone. b) Sagittal view: buccal
bone is now covering the apical
half the root exposure of tooth 32.

adjacent soft tissue was achieved and

inside the labial alveolar plate (Fig 11a),

no scars or signs of graft exposure were

while the sagittal view demonstrated the

detectable.

re-appearance of the labial cortical plate

The vestibulum depth was re-estab-

for half of the root extension (Fig 11b).

lished. The occlusal view shows the

increase in soft tissue thickness at the
buccal aspect of tooth 32 that works

Discussion

well with that of adjacent healthy teeth

(Figs 9b, 10a and b).

It has been thoroughly documented that

The periapical radiograph showed an

an alveolar bone dehiscence acts like

intact interdental bone with no signs of

a locus minoris resistentia for develop-

bone loss (Fig 10c).

ing soft tissue defects in the presence

The CBCT axial view showed that

of bacterial plaque and/or mechanical

tooth 32 was well aligned with the ad-

trauma, such as improper tooth brush-

jacent teeth and the root was located

ing techniques or chronic habits, partic-

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CLINICAL RESEARCH

ularly in thin gingival biotype.7,27-29 The

ing the crowding while achieving a not

inadequacy in alveolar bone may be a

optimal and indistinguishable outcome

consequence of specic anatomic con-

in terms of esthetics and function of the

ditions including ectopic tooth position

occlusion. Moreover, the following xed

within the dental arch or abnormal tooth

orthodontic therapy to close the space

shape,30 but also created or worsened

could have been prolonged.

by uncontrolled orthodontic movement

It was decided to follow the second

of teeth outside the alveolar plate.7,13-15

treatment option, which appeared to be

In the present case report, the pos-

more a conservative treatment from bio-

sible role of an excessive proclination

logic, esthetic and medico-legal points

of the mandibular incisors as a part

of view, since the severely compromized

of the orthodontic therapy was widely

tooth would have been maintained thus

questioned but, in the absence of any

satisfying the patients chief complaint,

pre-treatment diagnostic records, it re-

no asymmetric tooth extraction was re-

mained unclear. The patient was greatly

quired and a brief xed orthodontic ther-

concerned about the risk of losing her

apy was necessary.

mandibular incisor after many years of

The presence of root malposition

treatment and she was particularly an-

(III Miller class) would have limited the

gry with her previous orthodontist. It

amount of root coverage. Its orthodon-

was in fact speculated that the bone

tic resolution (I Miller class), improved

dehiscence affecting tooth 32 might

the prognosis and allowed for complete

have been created or more probably

root coverage to be achieved. Moreo-

worsened by an incorrect diagnosis or

ver, when a buccally displaced root

biomechanical control during the past

is moved lingually into a more proper

orthodontic treatment.

position within the alveolar bone under

In these circumstances, the presence

optimal plaque control, the gingival di-

of a severely periodontally compro-

mensions on the labial aspects will in-

mised mandibular incisor had different

crease both in the buccal-lingual and

implications from biologic, esthetic, and

coronal-apical dimensions.7 All clinical

medico-legal points of view. The differ-

changes, at the gingival affected site,

ent treatment alternatives included: (1)

after orthodontic treatment were of criti-

tooth extraction and orthodontic space

cal importance for achieving successful

closure, or (2) stripping and orthodontic

esthetic and periodontal outcomes after

repositioning of tooth root within the al-

mucogingival surgery and for reducing

veolar bone followed by a surgical root

the patient post-surgical discomfort.

coverage procedure. They both repre-

The absence of keratinized tissue apical

sented highly demanding procedures

and lateral to the root exposure would

from a psychological standpoint, since

have obliged the periodontist to use a

the patient would have been forced to

gingival graft as a root coverage pro-

undergo a further xed orthodontic treat-

cedure, a very unpredictable surgical

ment. The rst treatment option involved

procedure, especially in the presence

the asymmetric extraction of the affected

of wide root dehiscence. The presence

tooth in the mandibular arch, thus solv-

of keratinized tissue apical to the gin-

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ZUCCHELLI ET AL

gival recession allowed for the use of a

val approach also improved with respect

bilaminar approach, which is the most

to the esthetics of the gingival tissues of

predictable root coverage surgical pro-

the neighboring teeth since a good soft

cedure.24 The loss of clinical attachment

tissue prole was obtained and, after the

both in the apical-coronal (10 mm) and

orthodontic stripping procedures in the

buccal-lingual directions would have

mandibular incisor region, the papillae

necessitate to harvest from the palate

lled the interdental spaces up to the

a very big and thick gingival graft. On

contact points with no exposure of inter-

the contrary, the gain in clinical attach-

dental black triangles.

ment (4 mm) after orthodontic therapy

together with the formation of a 1.5 mmhigh band of healthy keratinized tissue

Conclusion

apical to the root exposure allowed for

the use of a very thin (0.7 mm) and small

A deep isolated-type recession defect

(9 mm wide and 5 mm high) connective

associated with root malposition in a

tissue graft, thus limiting the postopera-

young post-orthodontic patient required

tive patient discomfort. Generally the es-

thetic outcome after free gingival graft is

approach. The orthodontic root reposi-

very unpleasant, due to the incomplete

tioning within the limits of the alveolar

root coverage and poor color bleeding

bone was the key factor for achieving

of the treated site, the white-scar ap-

successful esthetic and periodontal out-

pearance of the grafted area and the

comes after subsequent mucogingival

dis-alignment of the mucogingival line.

surgery. Recognizing that orthodontic

On the contrary the bilaminar technique,

tooth repositioning will increase the pre-

consisting of a coronally advanced ap

dictability of the mucogingival surgical

covering a connective tissue graft posi-

procedures should make the clinician

tioned at the level of the CEJ, was able

very cautious before extracting a com-

to provide the best esthetic outcomes.

promized tooth, even with severe base-

The combined orthodonticmucogingi-

line periodontal conditions.

combined

orthodontic-periodontal

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