New Nigerian Journal of Clinical Research

: 2016  |  Volume : 5  |  Issue : 8  |  Page : 39--41

Subepithelial connective tissue graft with coronally advanced flap for the treatment of miller class-III gingival recession; Case report with review of literature

Mohammad Arif Khan1, Saket Banchhor2, Priyanka3, Deepti Chandra1, Vijay Krishnan4,  
1 Department of Periodontology, Career P.G. Institute of Dental Sciences and Hospital, Lucknow, Uttar Pradesh, India
2 Department of Periodontology, Rungta Collage of Dental Science and Research, Bhilai, Chattisgarh, India
3 Department of Oral and Maxillofacial Surgery, Government Collage of Dentistry, Indore, Madhya Pradesh, India
4 Department of Oral Medicine and Radiology, Career P.G. Institute of Dental Sciences and Hospital, Lucknow, Uttar Pradesh, India

Correspondence Address:
Mohammad Arif Khan
H. N. 25, Dak Bangla Road, Ghosi, Mau, Lucknow, Uttar Pradesh


Mucogingival surgery involving gingival reconstruction has become an integral part of the current periodontal practice. Gingival recession, either localized or generalized, associated with one or more surfaces, causes clinical and functional problems such as attachment loss, root exposure, poor esthetic, and poor plaque control. This case report describes a clinical case of Miller Class III gingival recession which has been successfully treated by subepithelial connective tissue graft with coronally advanced flap for complete root coverage.

How to cite this article:
Khan MA, Banchhor S, Priyanka, Chandra D, Krishnan V. Subepithelial connective tissue graft with coronally advanced flap for the treatment of miller class-III gingival recession; Case report with review of literature.N Niger J Clin Res 2016;5:39-41

How to cite this URL:
Khan MA, Banchhor S, Priyanka, Chandra D, Krishnan V. Subepithelial connective tissue graft with coronally advanced flap for the treatment of miller class-III gingival recession; Case report with review of literature. N Niger J Clin Res [serial online] 2016 [cited 2022 May 23 ];5:39-41
Available from:

Full Text


Gingival recession is defined as exposure of root surface by the apical migration of junctional epithelium (JE), leading to unaesthetic appearance and root hypersensitivity. [1]

Although several surgical procedures have been used to achieve predictable root coverage, these include pedicle grafts with or without connective tissue grafts (CTGs), free gingival autograft, CTGs, coronally advanced flaps (CAFs) alone, and CAF with CTG. [2]

Hence, the aim of the present case report was to clinically evaluate the management of root coverage (Miller Class III gingival recessions) by CAF with CTG.

 Case Report

A 25-year-old female patient reported to the Department of Periodontology, Career Post Graduate Institute of Dental Sciences and Hospital, Lucknow, Uttar Pradesh, India, with the chief complaint of receding gums of her front lower teeth [Figure 1]. Her intraoral examination revealed Class III gingival recession (according to P. D. Miller, 1985) on the front lower teeth. Patient was informed about the procedure and consent was taken.{Figure 1}

At the time of surgery, local anesthesia was administered first. A horizontal intracrevicular incision was given around 31, 41 region and extended with two vertical releasing incisions at the line angles of distal surface of 31 and 41 region [Figure 2]. Partial thickness flap was reflected to create a connective tissue bed [Figure 3].{Figure 2}{Figure 3}

Subepithelial Connective tissue graft (SCTG) was obtained from the second quadrant of palatal region [Figure 4] and placed at the recipient bed (only 31 region) and secured with 4-0 vicryl absorbable sutures [Figure 5], and then, flap was coronally advanced to cover SECG (31) and adjacen (41) exposed root for complete root coverage [Figure 6]. Donor site was immediately sutured [Figure 7] and the operated area was covered with periodontal dressing [Figure 8].{Figure 4}{Figure 5}{Figure 6}{Figure 7}{Figure 8}

Suture and periodontal dressing were removed after 7 days of surgical procedure. Healing was observed satisfactory and uneventfully. No postoperative complications were created and there were no signs of relapse at the end of 6 months [Figure 9].{Figure 9}


Several mucogingival techniques have been introduced in literature to correct gingival recessions which involve groups of adjacent teeth and is seldom localized to a single tooth; they should all be treated at the same time and obtain the best esthetic results. Subepithelial CTG (SCTG) with CAF was used for one or two adjacent gingival recession defects to obtain excellent result with color matching.

CAF has been tried with varying degrees of success to cover the multiple recession defects at the same time. Histologically, this technique leads to reformation of JE and the connective tissue attachment with minimal bone repair. Hence, the connective tissue attachment achieved by CAF alone is not stable over long periods. [3] Hence, various adjunctive agents have been used to speed up healing and also to enhance the clinical outcomes. These agents include root biomodification agents, SCTG, barrier membranes, enamel matrix derivatives, acellular dermal matrix, platelet-rich plasma, and platelet-rich fibrin. [4]

Initially, in 1963, Bjorn stated that free gingival graft (FGG) was used to compensate the inadequate width of keratinized tissue because partial root coverage was obtained with the FGG which was considered insufficient. Hence, for complete root coverage, a second procedure with an envelope technique was necessary. [5]

However, in 1968, Sullivan and Atkins described a technique for coverage of exposed root surfaces using the free gingival autogenous graft and they concluded that the graft survival over large expanses of avascular root surfaces was unpredictable and complete root coverage was rarely achieved. [6]

After that, in 1985, Langer and Langer described the SCTG technique for root coverage on both single and multiple adjacent teeth. [7] So, the advantages of SECTG with CAF has a more rapid maturation and less traumatic healing of the graft in the recipient sites due to dual blood supply obtained from the overlying flap and connective tissue graft harvested from palate that inhance graft survival rate and also provides excellent esthetic results. [8],[9],[10]

Thus, in the present case report, the use of SCTG covered by a CAF has been shown a high percentage of root coverage and adequate width of keratinized tissue.


The results of this case report favor the theory that root coverage with CTG could produce an increase in root coverage and keratinized tissue. Based on this case report, Miller Class III recession defects can be treated successfully when CTG is combined with CAF.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc 2003;134:220-5.
2Wennstrom JL. Mucogingival therapy. Ann Periodontol 1999;70:30-43.
3Lee EJ, Meraw SJ, Oh TJ, Giannobile WV, Wang HL. Comparative histologic analysis of coronally advanced flap with and without collagen membrane for root coverage. J Periodontol 2002;73:779-88.
4Cortellini P, Pini Prato G. Coronally advanced flap and combination therapy for root coverage. Clinical strategies based on scientific evidence and clinical experience. Periodontol 2000 2012;59:158-84.
5Bjorn H. Free transplantation of gingiva propria. Sven Tandlak Tidskr 1963;22:684.
6Sullivan HC, Atkins JH. Free autogenous gingival grafts. I. Principles of successful grafting. Periodontics 1968;6:121-9.
7Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20.
8Jahnke PV, Sandifer JB, Gher ME, Gray JL, Richardson AC. Thick free gingival and connective tissue autografts for root coverage. J Periodontol 1993;64:315-22.
9Harris RJ. Clinical evaluation of 3 techniques to augment keratinized tissue without root coverage. J Periodontol 2001;72:932-8.
10Rosetti EP, Marcantonio RA, Rossa C Jr., Chaves ES, Goissis G, Marcantonio E Jr. Treatment of gingival recession: Comparative study between subepithelial connective tissue graft and guided tissue regeneration. J Periodontol 2000;71:1441-7.