A gingival cul-de-sac following a root coverage procedure with a subepithelial connective tissue submerged graft

Background: The subepithelial connective tissue graft (SCTG) used as a submerged graft in combination 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 marginal tissue recessions. However, even with a successful 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 thickness 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 postoperatively. 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 cavity by making an incision on the facial gingiva, along the axis of the probe, through to the lumen. The gingival 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 significantly improved and no sign of recurrence was noted up to 4 years later. Conclusions: The existence of a cyst cannot be verified 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 complete elimination of the pathosis relatively hard to achieve by a "superficial" gingivoplasty procedure.