case_images: PMC10522425_01
case_images: Front view (a) and lateral view (b) of the deep gingival recessions on the mandibular central incisors.
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case_images: fig1
case_images: The initial intraoral picture (Figure 1) showed that the two mandibular central incisors had crowns.
case_images: Front view (a) and lateral view (b) of the deep gingival recessions in the mandibular central incisors 50 days after initial presentation and immediately before surgery.
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case_images: fig2
case_images: The wound was allowed to heal for another 50 days before implementing the recession repair surgery (Figure 2).
case_images: The step-by-step preparation of the tunnel flap for 33-43 (a-i), the harvest of DGG (j-l), and the insertion of DGG into the tunnel flap and suturing (m-p).
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case_images: fig3
case_images: France), mechanical treatment of the denuded root surface was conducted with the curette (Younger-Good 7/8, Hu-Friedy, USA) (Figures 3(a) and 3(b)). For the deep recessions on the two mandibular central incisors, intrasulcular incisions were introduced carefully to the bone surface sparing the papilla area (Figure 3(c)). With the gingival recession area as the access, a full-thickness mucoperiosteal separation laterally and apically to beyond the MGJ was performed on the facial aspect of the mandibular left canine to right canine with a microsurgical elevator (PPA-ELA, Hu-Friedy, USA) (Figure 3(d)). Specially, care was taken to elevate the gingival band between the two mandibular central incisors in full thickness, but unfortunately, it teared off easily at the apical part (Figure 3(e)). The gingival band was then cautiously deepithelized to be kept under the graft later (Figure 3(f)). Afterwards, the tunnel dissection was further extended apically in partial-thickness with a 15c blade (Medicon, Germany) (Figure 3(g)) and a Modified Orban Knife (Hu-Friedy, USA). With the relative deep flap detachment apically and the continuous severing of the periosteum when commencing partial-thickness flap detachment, the tunnel flap could be coronally advanced to a great extent without tension (Figure 3(h)). The prepared accepting site was shown in Figure 3(i), and the length of the DGG graft needed was estimated to be 30 mm (Figure 3(j)). A free gingival graft (FGG) of 30 x 10 mm2 in size and about 2-2.5 mm in thickness was harvested from the left palate (Figure 3(k)). DGG (Figure 3(l)). DGG was then inserted through the gingival recession site on tooth 31 and 41 into the tunnel flap easily, aligned facial to teeth 33-43, and positioned to the crown margin levels (Figures 3(m) and 3(n)). A great part of the graft, about 9 mm in height, was exposed due to the difficulty in tension release (Figures 3(o) and 3(p)).
case_images: The follow-up intraoral view showed the healing process of the recipient site after (a) 1 day, (b) 2 days, (c, d) 15 days, and (e) 9 months.
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case_images: fig4
case_images: The first 2-day follow-up displayed an early wound healing with minimal edema and no infection for the recipient site (Figures 4(a) and 4(b)). At day 15 after surgery, the exposed part of the graft showed ischemic necrosis with a yellowish color (Figure 4(c)). After removing the suture and the superficial necrotic tissue, it was found that the deeper layer of the graft achieved an ideal healing (Figure 4(d)).
case_images: (a) The donor site immediately after surgery. The follow-up intraoral view showed the healing process of the donor site after (b) 2 days, (c) 15 days, and (d) 9 months.
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case_images: fig5
case_images: For the donor site, immediately after the surgery, a blood clot was formed on the palatal wound with the help of the collagen matrix (Figure 5(a)). After two days, there was minimal edema and no sign of infection, and a yellowish pseudomembrane was observed (Figure 5(b)). After 15 days of healing, the wound achieved a near complete closure (Figure 5(c)). The 9-month follow-up showed that the donor site healed well with minimal scar, and no discomfort was reported by the patient (Figure 5(d)).