Root coverage in deep recessions with apex involvement: Long-term case study

Teeth with deep gingival recessions (GRs) associated with apex exposure present a challenging clinical scenario, often requiring a multidisciplinary approach to improve tooth prognosis. This case study presents seven RT1/RT2 deep GR (≥5 mm) associated with root apex exposure, treated with endodontic treatment, apicoectomy, and root coverage procedures.

For this retrospective study, all surgical procedures were performed using either the laterally positioned flap technique or the modified double papilla flap combined with a connective tissue graft (CTG).

After a mean follow-up period of 3.86 years (ranging from 1 to 11 years), a mean GR reduction of 7.57 mm was observed, with four cases achieving complete root coverage. No teeth required extraction during the follow-up period and the prognosis for all teeth was improved.

This case study highlights the effectiveness of treating teeth with severe mucogingival defects through root coverage surgery combined with CTG and apicoectomy.

Mucogingival procedures and interdisciplinary treatment can successfully change the tooth prognosis. Currently, there is limited information on managing teeth with a deep recession and apex involvement and even less on long-term outcomes for these cases. This case study fills these gaps, demonstrating that root coverage using an autogenous connective tissue graft combined with apicoectomy can yield successful and stable outcomes. Clinicians might consider the lateral-positioned flap or the modified double papilla flap, both of which may require specialized training and experience. However, other treatment alternatives, such as extraction and subsequent hard-and soft-tissue reconstruction, would involve more surgical procedures to rebuild all the lost tissues, increasing treatment complexity, time, and morbidity. Thus, mucogingival treatment should be prioritized as the first-line approach.

This study showed that teeth with severe gum recession, reaching the tip of the root, can be successfully treated with surgery to cover the exposed root, combined with tissue grafting and a procedure to remove the root tip. These treatments provided long-lasting results.