Mucogingival Defect and Crown Margin Decision
A 34-year-old woman is referred for a 3 mm buccal recession on tooth 13 with a 1 mm band of attached gingiva and a high frenal attachment. She reports sensitivity to cold and is concerned about aesthetics. The tooth has a Class V composite restoration placed 2 years ago that is now visible at the gingival margin. Probing depth is 2 mm with no bleeding, and there is no interproximal attachment loss. She brushes with a hard toothbrush and reports using a horizontal scrub technique. She has no medical contraindications and does not smoke. She asks whether she needs a graft and whether the composite should be replaced.
1. What is the diagnosis and what are the key factors determining whether a graft is indicated?
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This is a localized buccal recession with reduced attached gingiva and a high frenal pull, with no interproximal attachment loss. The key factors are the amount of attached gingiva, the recession depth, the frenal attachment, and the patient's symptoms and aesthetics. A 1 mm band of attached gingiva with a high frenum is a risk factor for progression and makes hygiene uncomfortable. However, the presence of a Class V restoration at the margin complicates the decision: a graft may improve the gingival phenotype and cover the root, but the restoration margin may limit the achievable coverage and could be exposed again. The first step is to address the traumatic brushing technique, because without that, any graft is at risk. A graft is reasonable if symptoms persist or if the phenotype is thin, but the restoration should be evaluated for replacement or recontouring before or during the procedure. The judgment is to treat the cause first, then reassess the need for grafting.
2. How would you sequence the restorative and surgical decisions, and what would you tell the patient about outcomes?
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Sequence: first, correct the brushing technique and reassess in 4-6 weeks; if sensitivity and recession persist, plan a connective tissue graft or similar procedure. The composite should be assessed for marginal fit and aesthetics; replacing it before grafting may improve the final result, but if the graft is expected to cover the margin, the restoration may need to be redone afterward. I would explain that root coverage is predictable for a single tooth with no interproximal loss, but complete coverage is not guaranteed, especially with a restoration at the margin. I would also explain that the high frenum may need to be addressed and that the graft does not replace the need for atraumatic hygiene. The decision is a judgment call about whether to restore first or graft first, and I would favor addressing hygiene and the restoration margin before surgery to avoid compromising the graft.