A 49-year-old man was referred to our service for evaluation and treatment of gingival recession with root exposure (FDA, tooth 13) and a tooth with a hopeless prognosis because of root resorption (tooth 11) (Fig. 1). After comprehensive examination, no significant health problems and no contraindications for periodontal and implant surgery were detected. For tooth 13, clinical measurements and observations resulted in a diagnosis of a Miller class I recession. For tooth 11, CBCT images (Figs. 2, 3) revealed a bucco-lingual bony defect secondary to previous endodontic surgery in very close proximity to the nasopalatine canal. Although they were not the patient’s main complaint, some esthetic issues were observed in the adjacent teeth.
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Straumann® Emdogain® is one of the best documented products in oral tissue regeneration. Its excellent clinical tolerability [1,2] has been demonstrated in over two million surgical applications. Emdogain® contains enamel matrix proteins (amelogenins). When applied to the wound, these proteins form an extracellular matrix that stimulates cells and processes that are fundamental for wound healing . These properties make Emdogain® a unique solution to stimulate and accelerate the healing of wounds and regeneration of tissues.
 Clinical evaluation of wound healing following multiple exposures to enamel matrix protein derivative in the treatment of intrabony periodontal defects. Heard RH, Mellonig JT, Brunsvold MA, Lasho DJ, Meffert RM, Cochran DL. J Periodontol. 2000 Nov;71(11):1715-21.  Clinical safety of enamel matrix derivative (EMDOGAIN) in the treatment of periodontal defects. Zetterström O, Andersson C, Eriksson L, Fredriksson A, Friskopp J, Heden G,  Jansson B, Lundgren T, Nilveus R, Olsson A, Renvert S, Salonen L, Sjöström L, Winell A, Ostgren A, Gestrelius S. J Clin Periodontol 1997 Sep;24(9 Pt 2):697-704. 29. Emdogain Promotes Healing of a Surgical Wound in the Rat Oral Mucosa. Maymon-Gil T, Weinberg E, Nemcovsky C, Weinreb M. J. Periodontol. 2016 Jan 16:1-16.
For the Miller class I recession of the canine, a substantial amount of good quality keratinized tissue was observed at the gingival margin. Consequently, a coronally advanced flap approach was planned, combined with the use of Emdogain®. Regarding the central incisor, a minimally invasive extraction with immediate implant placement and immediate temporization were planned. The bony defect would be addressed using a block bone graft from the posterior mandible. Additionally, nasopalatine content removal was also considered in order to prevent future contact between the implant and that anatomic landmark. Topical application of Emdogain® was envisaged for both situations with the aim of optimizing wound healing.
After a healing period of 3 months, the prosthetic procedure was performed. In accordance with the patient’s wishes and esthetic needs, teeth 21 and 12 were also prepared (Fig. 22), and individual temporary crowns were made. A tooth-whitening procedure was also carried out (Procedure, products) in both upper and lower arches to optimize the final esthetic outcome. At the time of impression-taking, the abutment torque was confirmed and a customized impression coping was used to copy the resulting profile obtained with the temporary crown. Individual zirconia-ceramic crowns were made and permanently fitted (Figs. 23, 24).
During the first two weeks postoperatively, the patient was followed up every other day to ensure that adequate healing was taking place. Aspects related to inflammation, infection, re-epithelialization of the surgical incisions and soft tissue maturation were assessed. Satisfactory postoperative wound healing was achieved without complications. The combination of a coronally advanced flap and Emdogain® proved to be a good treatment option for this Miller class I case, which resulted in a positive outcome. Immediate implant placement with immediate temporization promoted a satisfactory initial result for the patient. Topical Emdogain® application aided in wound healing, based on the angiogenic properties previously reported by the authors themselves (Guimarães et al. 2015). Although a considerable number of surgical sites were involved at the same time, the patient was highly satisfied and reported no postoperative pain. Regarding the restorative aspects of this case, which was the patient’s main concern, a highly satisfactory esthetic result was obtained. The tooth-whitening procedure and the zirconia-ceramic crowns were key to achieving such goals, in terms of both esthetics and function.
Gingival recession cases are often challenging, especially in the context of immediate implant placement. Careful treatment planning is therefore crucial to a positive long-term outcome. Treatment combining a coronally advanced flap and Emdogain® in the case presented here permitted complete root coverage and satisfactory esthetics. Both the grafted alveolar bony defects and the nasopalatine canal content enucleation were regarded as predictable and important for long-term implant performance. Immediate implant placement and temporization to replace the central incisor provided the patient with good immediate esthetics and contributed to the preservation of the soft tissue architecture during the healing phase which, in turn, was paramount in the final restoration.
This case was realized with the support of Dr. James Carlos Nery, PhD, and Silvio Arouca, MSc.