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Case Report
A Gingival Cul-de-Sac Following a Root Coverage
Procedure with a Subepithelial Connective Tissue
Submerged Graft
Pein-Chi Wei* and Milton Geivelis†
Background: The subepithelial connective tissue
graft (SCTG) used as a submerged graft in combina-
tion with a partial thickness advanced flap or rotated
flap is a predictable technique for achieving coverage
of the denuded root surface and/or for increasing the
width of attached gingiva in Miller’s class I and II mar-
ginal tissue recessions. However, even with a suc-
cessful result, complications may occasionally occur.
Methods: A 4-mm marginal tissue recession with an
insufficient zone of attached gingiva on the facial aspect
of a mandibular left lateral incisor (#23) was covered
with a submerged SCTG and an envelope partial thick-
ness flap. The mucogingival defect was successfully
corrected. Nevertheless, the facial gingiva, specifically
between teeth #22 (mandibular left canine) and #23,
remained bulky and was reshaped 6 months postop-
eratively. A 5-mm long gingival cul-de-sac with an
intermittent thick white discharge was detected 3
months following the gingivoplasty procedure.
Results: With a periodontal probe kept in the tract,
the lining of the cul-de-sac was exposed to the oral cav-
ity by making an incision on the facial gingiva, along
the axis of the probe, through to the lumen. The gin-
gival tissue was then removed with a rotary bur until
only a thin layer of periosteum remained. The mucosal
defect was subsequently repaired by grafting with a
non-submerged SCTG. The gingival contour was sig-
nificantly improved and no sign of recurrence was
noted up to 4 years later.
Conclusions: The existence of a cyst cannot be ver-
ified without a histological evaluation. However, the
development of a gingival cyst should be suspected
with persistent tissue bulkiness and/or emergence of
a thick white discharge from a site where a submerged
SCTG procedure was performed. In addition, the ill-
circumscribed border around the lesion makes com-
plete elimination of the pathosis relatively hard to
achieve by a “superficial” gingivoplasty procedure. J
Periodontol 2003;74:1376-1380.
* Currently, Department of Periodontics, Division of Dentistry, Lin-Kou
Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan;
previously, Department of Periodontics, Northwestern University,
Chicago, IL.
† Currently, private practice, Bartlett, IL; previously, Department of
Periodontics, Northwestern University, Chicago, IL.
1376
KEY WORDS
Cysts, gingival/etiology; gingival recession/surgery;
grafts, gingival/complications; grafts, soft tissue/
complications.
The subepithelial connective tissue graft (SCTG) has
been viewed as an effective and predictable way to
achieve coverage of the denuded root in Miller’s class
I and II marginal tissue recession cases since it was
introduced by Langer and Calagna1 in 1980 and mod-
ified by Langer and Langer2 5 years later. Reports of
complications following this procedure have been
few.3-5 Recently, a case report revealed external root
resorption approximately 1 year after surgery.5 Breault
et al.3 addressed “surgical cyst” formation under the
alveolar mucosa of tooth #24 on which an SCTG pro-
cedure had been performed 15 months earlier. Harris4
reported formation of a cyst-like lesion in the facial gin-
giva between teeth #26 and #27 13 months after an
SCTG had been placed to cover the exposed root of
tooth #27.
This report presents a case in which a persistent
bulky tissue with a thick white discharge developed
from the facial gingiva between the mandibular left
canine (#22) and the lateral incisor (#23), secondary
to an SCTG procedure used to cover the denuded root
surface of tooth #23.
CASE REPORT
A 40-year-old female patient was referred to the
Department of Periodontics at Northwestern University
Dental School for correction of an exposed root with a
minimal amount of keratinized gingiva over the facial
aspect of tooth #23. Intraoral examination showed no
active periodontal disease other than mild papilla blunt-
ing and marginal tissue recession. The most extensive
recession (4 mm) was noted on tooth #23 (Fig. 1).
The patient’s systemic condition was non-contributory.
Following a dental prophylaxis and oral hygiene
instruction, placement of an SCTG to cover the
denuded root of #23 was performed. Under local
anesthesia, after the exposed root surface was thor-
oughly planed, an envelope partial thickness flap was
elevated on the facial aspect of the affected tooth
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Figure 1.
Preoperative view of tooth #23 demonstrating 4 mm marginal tissue
recession and insufficient width of keratinized gingiva.
Figure 3.
Submerged epithelial collar-free subepithelial connective tissue graft
covered by the envelope flap.
(Fig. 2). Through a “trap door” preparation, an SCTG
without an epithelial collar was harvested from the
hard palate next to the maxillary left premolars (#12,
13) using a #15 scalpel blade. The graft was trans-
planted onto the denuded root surface and secured
to the recipient bed with 5-0 chromic gut sutures.
The SCTG was covered by the partial thickness flap
after joining the two papillae with a criss-cross sling
suture (Fig. 3).
Postoperative evaluations revealed substantial root
coverage and increased width as well as thickness of
the attached gingiva, specifically in the area between
teeth #22 and #23, where the soft tissue had a per-
sistent bulky appearance (Figs. 4 and 5). Six months
post-surgery, gingivoplasty was performed with a high-
speed diamond round bur in order to blend the area
of the graft with the adjacent tissues (Fig. 6).
J Periodontol • September 2003
Case Report
Figure 2.
Reflection of partial thickness envelope-type flap.
Figure 4.
Bulky tissue appearance at 6-week postoperative visit.
Three months after the gingivoplasty procedure
(Fig. 7A), when returning for routine periodontal main-
tenance care, the patient reported that a thick white
material was emerging from the gingiva when she
applied digital pressure to the grafted area. She expe-
rienced no discomfort or pain. On careful examination,
a pinpoint opening was identified 2.5 mm apical to the
free gingival margin of tooth #22, from which a thick
white material was expressed when slight pressure was
applied. A narrow, mesially directed cul-de-sac could
be traced with a periodontal probe to a horizontal depth
of 5 mm in the thickness of the gingiva (Fig. 7B).
In order to accurately locate and completely excise
the gingival cul-de-sac, a horizontal incision was made
through to the lumen with the periodontal probe kept
in position as a guide. Nothing other than bleeding
was observed. To remove any epithelial rests and/or
glandular tissue remaining in the connective tissue
Wei, Geivelis 1377