Management of severe gingival recession using a double papilla connective tissue graft: A 2-year follow-up case study.

backgroundThis case study presents the treatment of a 7 mm deep and 5 mm wide RT1 gingival recession on the mandibular left canine in a 30-year-old systemically and periodontally healthy female, with the defect being associated with a self-injurious habit.

methodsFollowing counseling, self-injurious habit cessation, and oral hygiene reinforcement, a double papilla flap (DPF) plus subepithelial connective tissue graft (SCTG) procedure (DPF+SCTG) was performed. After de-epithelialization of the gingival margin, horizontal and vertical incisions were made, and a partial-thickness DPF was elevated. The SCTG was placed at the cementoenamel junction level and covered by the DPF.

resultsNearly complete root coverage was achieved, with recession depth reduced to 1 mm and keratinized tissue width increased from 1 mm to 6 mm. Ultrasound imaging confirmed successful graft integration and thick gingiva. At 2-year follow-up, creeping attachment was observed after the patient discontinued the self-injurious habit, despite a prior recurrence that had caused additional trauma. The successful surgical outcome resulted in patient satisfaction, plaque control improvement, and prevention of further recession, benefiting the ongoing orthodontic treatment.

conclusionsDPF+SCTG is an effective approach for treating an isolated deep and wide RT1 recession, providing long-term benefits, particularly when combined with behavior modification in patients with self-injurious habits. KEY POINTS: Technique choice and patient behavior management: The combination of double papilla flap and subepithelial connective tissue graft effectively achieved significant root coverage and increased keratinized tissue width in a patient with self-injurious habit. However, patient behavior management was crucial in preventing recurrence. Long-term stability and creeping attachment: Despite a relapse due to the patient's habit, the thickened gingiva facilitated natural healing through creeping attachment, reinforcing the importance of both surgical intervention and behavioral modifications in maintaining long-term stability. Ultrasound for non-invasive monitoring: Ultrasound imaging confirmed successful graft integration and determined tissue thickness, highlighting its potential as a non-invasive periodontal healing monitoring tool. PLAIN LANGUAGE SUMMARY: Gum recession is a common condition where the gum tissue pulls away from the teeth, exposing the roots and making them more prone to damage. This report describes the treatment of a 30-year-old woman who had severe gum recession on her lower left canine tooth, caused by her long-term habit of scratching the gums with her fingernail. To restore the lost tissue and protect the tooth, a double papilla flap (a surgical technique that moves nearby tissue) along with a connective tissue graft (transplanted tissue from the roof of the mouth) was used. Over 2 years, the recession was reduced by almost 90%, and the tissue over the tooth became healthier and stronger. Although her habit caused some recession to return, the thickened tissue allowed for natural healing once she controlled her habit again. This case highlights how proper surgical technique selection and execution, combined with patient behavior changes, can successfully treat severe gum recession. It also demonstrates how ultrasound imaging can be used as a non-invasive tool to monitor soft tissue healing over time.