CASE REPORT

Rebuilding Anterior Dental Esthetics: Interdisciplinary Treatment of an

Iatrogenically Induced Marginal Tissue Recession
B. Arzu Alkan,* A. Erdem Yagan,* and Kerem Kilic†

Introduction: Root canal perforation during endodontic therapy is one of the most commonly encountered clinical
situations that necessitates interdisciplinary therapy.
Case Presentation: This case report presents the use of periodontal and prosthodontic teamwork to treat severely
deteriorated anterior esthetics caused by an iatrogenically induced marginal tissue recession defect.
Conclusion: In the case of deterioration of anterior dental esthetics, an interdisciplinary approach can successfully
restore both esthetics and function, as observed in this case report. Clin Adv Periodontics 2015;5:160-164.
Key Words: Connective tissue; esthetics, dental; gingival recession; surgery, plastic.

Background to root perforation. A case report by Harris10 described the

Clinical dental experience plays a pivotal role in improving
the quality of patient care and satisfaction. However,
iatrogenic injuries during dental treatments may occur in
daily practice.1-7 Root canal perforation during endodon-
tic therapy is one of the most commonly encountered
clinical situations that necessitates an interdisciplinary
therapy in some severe cases. Although size and location
of the perforation, its immediate sealing, and prevention
of infection are the main factors that affect the success of
endodontic therapy,8 the biotype of the gingiva, the amount
of exposed root surface, and the material used for sealing
the perforation are additional critical determinants that
need to be considered from a periodontal point of view.2,6,8
In some cases, prosthetic rehabilitation is mandatory as
a complementary phase of the therapy for the final clinical
outcome. There are some reports on the treatment of such
cases. Sonoda et al.9 performed controlled orthodontic
tooth extrusion to treat marginal tissue recession secondary
* Department of Periodontics, Faculty of Dentistry, Erciyes University,
Kayseri, Turkey.
† of the tooth, resulting in an acute marginal tissue recession.
Department of Prosthodontics, Faculty of Dentistry, Erciyes University.
Submitted September 10, 2012; accepted for publication December 28,
2013
doi: 10.1902/cap.2014.120098
successful treatment of an endodontically induced root
perforation and marginal tissue recession by using an
amalgam restoration and connective tissue (CT) with a
partial-thickness double pedicle graft, respectively.
This case report describes an interdisciplinary approach
used to restore anterior esthetics lost as a result of iatro-
genic trauma during endodontic treatment of a maxillary
incisor.
Clinical Presentation
In July 2010, a 45-year-old female was referred to the De-
partment of Endodontics, Faculty of Dentistry, Erciyes
University, Kayseri, Turkey, with the complaint of severe
pain in the maxillary right central incisor and poor esthetic
appearance attributable to a fractured incisal edge of the
neighboring left central incisor. On clinical and radio-
graphic examination, the tooth was diagnosed as having
irreversible pulpitis, and endodontic therapy was initiated
by an undergraduate student. During the preparation of the
access cavity searching for the pulp chamber, the coronal
root third was accidentally perforated at the labial surface
Root canal treatment was completed over 1 week in two
sessions, and the perforation site was sealed with a tempo-
rary filling material‡ (Fig. 1). The patient was referred to
‡
Cavit G, 3M ESPE, Seefeld, Germany.

160 Clinical Advances in Periodontics, Vol. 5, No. 3, August 2015


FIGURE 1 Radiograph of the maxillary central incisors immediately after
root canal filling.
the Periodontology Department for consultation 7 days after
root perforation and completion of root canal therapy.
Clinical periodontal examination revealed a 5-mm-deep
and 3-mm-wide marginal tissue recession measured at
the level of the cemento-enamel junction (CEJ) and z1
mm of enamel loss at the maxillary right central incisor.
Measurements of mid-labial probing depth (PD) and amount
of keratinized and attached gingiva were 1, 5, and 4 mm, re-
spectively, at the maxillary right central incisor. There was no
radiographic or clinical evidence of bone loss and soft tissue
existed in the adjacent interproximal regions.
Case Management
Oral informed consent was obtained from the patient prior to
treatment. The Miller11 Class I marginal tissue recession (Fig. 2)
was treated with subepithelial CT graft (SCTG) preceded by the
simultaneous root surface restoration using a glass ion-
omer cementx on the day of consultation. After local anes-
thesia, a split-thickness flap was reflected by using a no.
15C blade‖ to create a pouch-like recipient bed to expose
the root surface and the bony margins (Fig. 3). No vertical
incisions were made. A rubber dam was placed for isolation
of the operative field. Minimal root preparation was per-
formed to flatten the margins of the perforation. A resin
ionomer restoration was placed following the manufacturer’s
Alkan, Yagan, Kilic
C A S E R E P O R T
FIGURE 2 Preoperative view 7 days after root perforation. A Miller11 Class
I recession defect occurred during the preparation of the access cavity.
FIGURE 3 A pouch-like recipient bed prepared for the SCTG.
instructions to cover the entire defect. A flame-shaped bur was
used to maintain a smooth root surface, and the surgical site
was irrigated by using a sterile saline solution. The SCTG was
harvested from the inner surface of a mucoperiosteal flap raised
at the palatal premolar-molar region. Mattress and sling sutures
crossing over the SCTG were used for the immobilization and
tight adaptation of the soft-tissue graft to the root surface
(Fig. 4). A 5-0 polyglactin 910{ suture was used for this purpose,
and the donor area was closed with 4-0 silk# suture material. The
patient was advised not to brush the treated site for 21 days. The
patient was placed on 15 mL 0.12% clorhexidine gluconate
twice daily for 3 weeks, and an analgesic (275 mg naproxen so-
dium, one tablet three times daily) and an antibiotic (625 mg
amoxicillin, one tablet twice daily) were prescribed for 2 and
7 days, respectively. The sutures at the recipient and donor sites
were removed 10 days after surgery. Follow-up visits were per-
formed at 2, 4, 6, 8, and 12 weeks and at 5 months after surgery.
Clinical Outcomes
Total root coverage was obtained, but 1 mm of glass ion-
omer cement at the mid-labial enamel surface was evident
x
Prime-Dent, Prime Dental Manufacturing, Chicago, IL.
‖
15C Bisturi, Lawton, Fridingen, Germany.
{
san, Istanbul, Turkey.
Vicryl (Pegelak, 5-0, 16 mm, 3/8 inches), Dog
#
Silk (4-0, 16 mm, 3/8 inches), Dogsan.
Clinical Advances in Periodontics, Vol. 5, No. 3, August 2015 161
C A S E R E P O R T

FIGURE 6 Preparation of the maxillary right and left central incisors for
FIGURE 4 SCTG sutured into the recipient bed by mattress (black arrow)
porcelain veneer restorations.
and sling (white arrow) sutures.

FIGURE 7 Clinical view 5 months post-surgery.

FIGURE 5 Eight weeks after surgery. Note the small area of glass ionomer
cement at the gingival margin of the maxillary right central incisor.

TABLE 1 Clinical Periodontal Measurements at the Maxillary Right Central Incisor

Baseline* 5 Months Post-Surgery

Clinical Periodontal Measurements Mesial Mid-Labial Distal Mesial Mid-Labial Distal

PD (mm) 2 1 2 2 1 2

RD (mm) 0 5 0 0 0 0

WKT (mm) 11 5 4 11 10 4
RD ¼ recession depth; WKT ¼ width of KT.Ć
* Seven days after root perforation.

(Fig. 5). The mid-labial PD was the same as that of the base-
line at final examination, and the width of keratinized tis-
sue (KT) reached 10 mm (Table 1). Five months after
surgery, the patient was referred to the Prosthodontics
Department for the restoration of the maxillary central
incisors using porcelain veneers (Figs. 6 and 7).
Discussion
Endodontic claims are the most frequently filed malprac-
tice claims in dentistry, and it is reported that errors fre-
quently occur during instrumentation and root canal
filling.12 Root perforation mostly occurs during access
opening, as seen in this case report. The location of the per-
foration is the overriding factor in the decision-making
process. Although perforations coronal to the crestal bone
can frequently be managed non-surgically, apical third and
critical crestal zone perforations may necessitate a surgical
intervention.13 The root perforation in the present patient
starts on the enamel 1 mm coronal to the CEJ and extended
5 mm along the root surface, resulting in an acute marginal
tissue recession.
Regardless of the surgical technique performed to cover
the exposed root surface, the restoration material of choice
is important and should meet some criteria. In this context,
glass ionomer cement is insoluble in oral fluids and bio-
compatible with soft and hard tissues. Additionally, it
releases fluoride, which may positively affect bacterial pla-
que chemistry.14,15

162 Clinical Advances in Periodontics, Vol. 5, No. 3, August 2015 Interdisciplinary Approach to Repair Anterior Esthetics
 C A S E R E P O R T

Successful treatment outcomes in terms of root coverage
were reported in some cases.16,17 Although a histologic ex-
amination could not be performed for ethical reasons in the
present case, it was reported that epithelium and CTadhere
to the resin ionomer when placed in a subgingival environ-
ment.14 To the best of the authors’ knowledge, no study
exists on the long-term stability of either the veneer adapta-
tion over the glass ionomer or the glass ionomer subgingivally
over time. The use of glass ionomer cement in combination
with root coverage procedures appear in the literature in some
case reports.2,6,9,16
For the management of soft tissue esthetics before any
restorative treatment, an SCTG procedure was considered
as a treatment option. A width of 5 mm of KT was present
mid-labially apical to the gingival margin. Indeed, this
amount of KT was quite enough to cover the SCTG com-
pletely by a double papilla pedicle or coronally positioned
flap. However, a high frenum attachment extending
corono-apically just in the proximity of recession borders
could have jeopardized the immobilization of any pedicle
flap used to cover the graft. Therefore, the SCTG was
placed into the pouch-like recipient bed prepared by
split-thickness flap. No problem occurred with the survival
of the CT graft. Total root coverage was maintained at 5
months after surgery. Excellent color match of the ve-
neers with the neighboring teeth satisfied both the patient
and the clinicians and restored anterior esthetics.
In conclusion, dental practitioners will continue to be
faced with endodontic perforations as a result of anatomic
variations, technical deficiency, or simply a clinician’s in-
sufficient knowledge, skill, and experience performing
the procedure. Whatever the cause is, saving the tooth is
the first mission of the clinician. In the case of the deterio-
ration of anterior dental esthetics, an interdisciplinary ap-
proach can successfully restore both esthetics and function,
as described this case report. n

Summary
Why is this case new information? j Follows a multidisciplinary treatment approach
j Involves treatment steps in a complex malpractice case

What are the keys to successful j Communication among dental professionals from different
management of this case? specialties

What are the primary limitations to j Size and location of the root perforation
success in this case? j Operator skill
j Timing of when the procedure occurs

Acknowledgment CORRESPONDENCE:
Dr. B. Arzu Alkan, Erciyes University, Faculty of Dentistry, Department of
The authors report no conflicts of interest related to this Periodontics, 38039 Melikgazi, Kayseri, Turkey. E-mail: arzualkan@
case report. erciyes.edu.tr.

Alkan, Yagan, Kilic Clinical Advances in Periodontics, Vol. 5, No. 3, August 2015 163
C A S E R E P O R T
References
1. Löe H. Reactions to marginal periodontal tissues to restorative
procedures. Int Dent J 1968;18:759-778.
2. Walters JD, Rawal SY. Severe periodontal damage by an ultrasonic
endodontic device: A case report. Dent Traumatol 2007;23:123-127.
3. De Bruyne MA, De Moor RJ, Raes FM. Necrosis of the gingiva caused
by calcium hydroxide: A case report. Int Endod J 2000;33:67-71.
4. Lombardi T, Kuffer R, Dubrez B. Polishing-paste-induced silica
granuloma of the gingiva. Dermatology 2001;203:177-179.
5. Ozcelik O, Haytac MC, Akkaya M. Iatrogenic trauma to oral tissues.
J Periodontol 2005;76:1793-1797.
6. Rawal SY, Claman LJ, Kalmar JR, Tatakis DN. Traumatic lesions of the
gingiva: A case series. J Periodontol 2004;75:762-769.
7. Lim KF. Latex elastic-induced periodontal damage: A case report on the
subsequent orthodontic management. Quintessence Int 1996;27:685-690.
8. Fuss Z, Trope M. Root perforations: Classification and treatment
choices based on prognostic factors. Endod Dent Traumatol 1996;12:
255-264.
9. Sonoda CK, Panzarini SR, Poi WR, Pedrini D, Saito CT, Pinheiro JJ.
Integrated clinical treatment of gingival recession secondary to root
perforation: Case report. Quintessence Int 2009;40:723-727.
indicates key references.
164 Clinical Advances in Periodontics, Vol. 5, No. 3, August 2015
10. Harris RJ. Treatment of an endodontic perforation with a restoration
and a root coverage gingival graft. J Periodontol 1995;66:646-652.
11. Miller PD Jr. A classification of marginal tissue recession. Int J
Periodontics Restorative Dent 1985;5(2):8-13.
12. Givol N, Rosen E, Taicher S, Tsesis I. Risk management in endodontics.
J Endod 2010;36:982-984.
13. Regan JD, Wıtherspoon DE, Foyle DM. Surgical repair of root and
tooth perforations. Endod Topics 2005;11:152-178.
14. Dragoo MR. Resin-ionomer and hybrid-ionomer cements. Part II:
Human clinical and histologic wound healing responses in specific
periodontal lesions. Int J Periodontics Restorative Dent 1997;17:
75-87.
15. Scherer W, Dragoo MR. New subgingival restorative procedures with
Geristore resin ionomer. Pract Periodontics Aesthet Dent 1995;7(Suppl.
1):1-4.
16. Alkan A, Keskiner I, Yuzbasioglu E. Connective tissue grafting on resin
ionomer in localized gingival recession. J Periodontol 2006;77:1446-
1451.
17. Santamaria MP, Ambrosano GM, Casati MZ, Nociti Júnior FH, Sallum
AW, Sallum EA. Connective tissue graft plus resin-modified glass
ionomer restoration for the treatment of gingival recession associated
with non-carious cervical lesion: A randomized-controlled clinical trial.
J Clin Periodontol 2009;36:791-798.
Interdisciplinary Approach to Repair Anterior Esthetics