Single-stage regenerative approach for persistent RT3 gingival recession following orthodontic improvement of tooth position.

Abstract

Background: Management of gingival recession type 3 (RT3) defects remains a clinical challenge due to interproximal attachment loss and soft tissue deficiency. This case report describes a regenerative strategy for a malpositioned anterior tooth presenting with severe recession.

Methods and results: Following orthodontic alignment to correct the tooth position, a single-stage regenerative surgery was performed using the entire papilla preservation technique (EPPT) combined with a modified connective tissue graft (m-CTG) wall and adjunctive biologically active regenerative materials, including enamel matrix derivative, recombinant human basic fibroblast growth factor-2, plasma rich in growth factors, and deproteinized bovine bone mineral. This multidisciplinary approach resulted in successful root coverage, significant clinical attachment gain, and increased keratinized tissue width. Clinical and radiographic outcomes remained stable, with high esthetic satisfaction achieved over a 30-month follow-up period.

Conclusions: A strategic combination of orthodontic therapy and periodontal regeneration using EPPT and m-CTG wall technique may offer a clinically favorable treatment approach for managing complex RT3 recessions in the esthetic zone.

Key points: This case presents an integrated approach with orthodontic alignment and the entire papilla preservation technique and a m-CTG wall to treat severe recession type 3 gingival recession. Favorable outcomes were attributed to the synergistic effect of correcting the tooth position and the stability provided by the m-CTG wall, which contained the regenerative materials within the non-contained defect. Despite significant improvements in root coverage and attachment levels, complete regeneration of the interdental papilla remains biologically limited by the extent of underlying interproximal bone loss.

Plain language summary: Severe gum recession with interdental bone loss (recession type 3 [RT3]) is highly challenging to treat, particularly when the affected tooth is also malpositioned. This case report describes a 28-year-old woman with an upper front tooth presenting persistent RT3 recession following orthodontic correction of its position. A single-stage surgery was performed to restore both gum and bone defects simultaneously. The surgeon used a minimally invasive tunneling technique to access the defect without cutting the delicate tissue between the teeth, preserving blood supply and wound stability. A palatal gum graft was inserted to cover the exposed root and thicken the surrounding tissue. To stimulate regeneration, three biological agents-for attachment regeneration, bone formation, and wound stabilization-were combined with a bone substitute to fill the defect. At 30 months, the root was successfully covered, gum width increased significantly, and the bone remained stable. This case demonstrates that combining orthodontic alignment with a tissue-preserving surgical technique, a gum graft, and targeted biological agents can achieve lasting results in complex recession cases.