Clinical context and challenges of root coverage

The treatment of gingival recessions using the coronally advanced flap (CAF) remains a clinical challenge where flap stability and the immobile maintenance of the blood clot are decisive for therapeutic success. Although the conventional sling and tag suturing technique is recognized for its ability to stabilize flap margins, it involves tissue perforations that can compromise local vascularization and exacerbate the postoperative inflammatory response. For the practitioner, the challenge consists in finding a balance between the tension necessary for stability and the preservation of papillary microcirculation.

Objective and hypothesis of the case study

This case report documents the management of a 30-year-old patient presenting with multiple RT1-type recessions in the upper left quadrant, with a depth of 3 mm for tooth 22 and 2 mm for teeth 23 and 24. The specific objective of this study is to describe a modification of the conventional sling and tag suturing technique to optimize papilla adaptation during a coronally advanced flap combined with a connective tissue graft. The hypothesis tested is that this technical variant constitutes a less invasive approach allowing for complete root coverage while ensuring superior marginal stability and increased vascularization compared to traditional suturing methods.

Case study protocol

This clinical case report, conducted according to CARE guidelines, details the management of a 30-year-old healthy, non-smoking patient presenting with multiple gingival recessions in the upper left quadrant.

• Sample and site: The teeth involved (22, 23 and 24) presented type 1 recessions (RT1) with a detectable cemento-enamel junction (CEJ). The recession depth was 3 mm for tooth 22, and 2 mm for teeth 23 and 24. Each site initially presented 2 mm of keratinized tissue (KT).
• Surgical procedure: After prior root planing, the treatment combined a coronally advanced flap (Zucchelli technique) with a de-epithelialized connective tissue graft.
• Suturing technique: Wound closure was performed using a modification of the conventional "sling and tag" suturing technique, using a 5-0 polyamide monofilament.
• Post-operative follow-up: The protocol included the administration of nimesulide (100 mg every 12 hours for 3 days) and chlorhexidine 0.12% mouthwashes (twice a day for one week). Brushing at the surgical site was suspended for 3 weeks.
• Evaluation: Sutures were removed at 14 days. Final evaluation of clinical results (recession depth, KT and clinical attachment level) was performed at 7 months postoperatively using a UNC-15 periodontal probe.

Analysis of Initial Periodontal Parameters

The case report describes the management of a 30-year-old patient, non-smoker and in good systemic health, consulting for root hypersensitivity and aesthetic discomfort. Clinical examination revealed multiple type 1 gingival recessions (RT1) at teeth 22, 23, and 24. All teeth presented a detectable cemento-enamel junction without root steps.

Surgical Outcome and Healing

The procedure relied on a coronally advanced flap (CAF) combined with a de-epithelialized connective tissue graft. The surgical site closure was ensured by a modification of the "sling and tag" suture technique, designed to optimize flap stability and preserve papillary vascularization.

The final clinical results demonstrate total therapeutic success: complete root coverage was achieved for the three treated teeth. The surgical approach allowed for effective management of mucogingival defects while meeting the patient's aesthetic requirements. Qualitatively, the suture variant used promoted precise tissue adaptation and adequate blood clot immobilization, key elements for treatment predictability.

Stability and vascularization: the balance found?

Beyond the aesthetic success achieved in this 30-year-old patient, this clinical case raises a central question in periodontal plastic surgery: how to maximize flap stability without compromising its vascularization? The total success of root coverage on teeth 22, 23, and 24 (all classified as RT1) suggests that the modification of the "sling and tag" suture effectively addresses this challenge. By reducing tissue perforations while ensuring precise adaptation of the papillae, the practitioner preserves the blood supply, a critical factor for the survival of the subepithelial connective tissue graft (SCTG).

The major interest of this technique lies in its ability to maintain the blood clot immobile, a pillar of healing. While the literature, notably Tavelli's work on cadavers, already validated the superior stability of the conventional sling and tag, this variant seems to offer a less invasive approach. The reduced tissue trauma induces a lower postoperative inflammatory response, a significant advantage for patient comfort and healing kinetics.

Clinical limitations and perspectives

Let's be clear: we are looking at a unique case report (n=1). Although the clinical results are convincing for 2 to 3 mm recessions, this study does not allow for the generalisation of the technique's efficacy to more complex cases or extremely thin biotypes. The precision of the surgical procedure, performed here by a single operator, remains a determining variable.

Summary of results

This case report demonstrates complete root coverage (100%) at 7 months for multiple RT1-type recessions (initial depth of 2 to 3 mm) in a 30-year-old patient. The use of a modified "sling and tag" suture allowed for securing the coronally advanced flap and the connective tissue graft while optimizing tissue healing through a reduction in surgical trauma.

In concrete terms, for the practitioner:

• Optimize vascularization: this technical variant reduces tissue perforations at the papillae level, which limits postoperative inflammation and preserves the blood supply necessary for connective tissue graft integration.
• Secure flap stability: by transfixing the de-epithelialized anatomical papilla and anchoring the knot at the vestibular level, you ensure total immobility of the blood clot and the flap during the critical healing phase.
• Manage multiple recessions: prioritize this approach to achieve precise and uniform papillary adaptation, offering a more tissue-friendly alternative than the conventional suturing technique.

Technical lexicon

Coronally Advanced Flap (CAF): Surgical root coverage technique consisting of moving the flap in a coronal direction. In this study, it is used with a connective tissue graft to treat multiple recessions.

Modified "sling and tag" suture: A variant of a transfixing suture technique secured by a knot. This modification aims to improve flap stability and vascularization while minimizing tissue trauma during papillary closure.

Type 1 Recession (RT1): Clinical classification of a gingival defect where the cemento-enamel junction (CEJ) is detectable, but without loss of interdental tissues or presence of a root step.

De-epithelialized connective tissue graft: Harvesting of subepithelial connective tissue from which the epithelial layer has been removed, used here in combination with the flap to optimize clinical results.

Cemento-Enamel Junction (CEJ): Anatomical landmark corresponding to the junction between the tooth enamel and cementum, used as a reference to measure recession depth and clinical attachment level.

Keratinized Tissue (KT): Band of gingival tissue measured from the free gingival margin to the mucogingival junction. The patient initially presented with 2 mm of KT under each recession.

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