A 29-year-old female patient with a general state of health came to the Master's Degree in Orthodontics at the U.C.M. (Unicipality bom Periense de Madrid).
The patient presented multiple gingival recesses in the three upper jaw sixths.
He had received orthodontic treatment a few years ago.
The patient was especially concerned about the aesthetics of his gums, but he also reported dentin sensitivity problems.
The recesses presented were Miller class II.
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Her oral hygiene level was good, but her technique was modified in favor of a softer brushing using the Stillman technique.
He was motivated to receive treatment.
In a first appointment, a medical history was taken and prophylaxis was given to the patient in the whole mouth one week later.
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In the first stage, sex fixation was decided to place a connective tissue graft using Langer's technique (12).
Once the local anesthetic was administered (Lidocaine 2% 1:100,000), a horizontal incision was made at the limit angle to the illustrative 15. The papillae were respected together with a liberating incision in the distal line.
Partial thickness flap was separated until a few millimeters of mucogingival line was exceeded.
At level 13, liberating incision was avoided due to esthetic compromise, instead the papilla was not separated and a partial thickness envelope was created by the mesial part.
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The graft was taken on the same side to circumscribe the bloody area to the right side and improve patient comfort during the postoperative period.
A palatal incision from 16 to 13 was performed with a mesial liberating incision to access the connective tissue graft by means of the trampilla technique. A connective graft with a length of 25 mm and a length of 14 mm was obtained 13.
The donor site was sutured with 4 ceros Supramid® suture.
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The graft was sutured in the receptor area using resorbable sutures, in the areas to be covered by the flap, anchored to the periosteum and remaining connective tissue undisserted in the flap.
To achieve greater graft recovery with the flap, several incisions were made at the bottom of the vestibule.
Once released, it was sutured at the level of the papillae.
Analgesics and acetaminophen were prescribed for 4 days (Ibuprofen 600 every 8 hours and paracetamol 1 g every 12 hours).
It was recommended not to brush this area for 2 weeks and apply 0.12% chlorhexidine to Spray on the graft receptor area 3 times/day.
No surgical cement was used.
The patient suffered moderate discomfort during the first three days, despite the medication, at the level of the palate.
The sutures at the level of the palate were removed one week later and those of the receiving area were removed two weeks later.
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The patient came two weeks after the first surgery to treat the third sex.
In this sex setting, it was decided to perform a coronal replacement technique described by G. Zucchelli and M. Devices (13).
However, when the mucosa was deemed to be too thick a connective tissue graft was preferred.
Local anesthetic was administered, submarginal oblique incisions were made in the intermarginal zones together with an intrasurcular incision in the recession area.
The papillae were denuded to leave the underlying connective tissue exposed so as to suture our flap at this level by displacing it coronally.
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A 15 mm graft of connective tissue of the palate on the same side was taken, in this case a single horizontal incision was made in the premolar area and first molar to access the graft harvest.
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The donor site was sutured with Supramid® of four ceros, the graft was placed with absorbable suture SSA® of six ceros and the flap was repositioned coronally with Supramid® sutures.
Analgesics and acetaminophen were prescribed for 4 days (Ibuprofen 600 every 8 h and paracetamol 1 g every 12 h).
This time, the patient reported no discomfort during the postoperative period.
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After both interventions, the patient had a remaining 2 mm recession at level 22.
It was decided to perform an envelope technique described by P. Raetzke (14).
Local anesthetic was administered and the sachet was prepared with a partial thickness incision in the recession area without liberators and without flap reflection.
A micro scalpel provided the dimension of the receiving area and the technique to be performed.
The connective tissue graft was taken from the palate on the left side with a horizontal incision from 26 to 27.
The donor area and the graft were sutured with Supramid® six ceros suture.
