Root coverage with apical tunnel approach using propolis as a root conditioning agent: A case report with 2-year follow-up and review of the literature

Abstract

Objectives: One of the main challenges in performing root coverage is patient discomfort and donor site morbidity. This case report presents a minimally invasive apical tunnel surgical technique, with propolis for root conditioning, to correct gingival recession defects without harvesting donor grafts, flap elevation, or sutures. Propolis is a natural anti-infective, anti-inflammatory, and antioxidant agent.

Material and methods: A 58-year-old woman with no significant medical history was presented for root coverage of her upper left canine and first premolar with recession type (RT)1A (+). Propolis was used as a root conditioning agent to promote soft tissue coverage via an apical tunnel approach. During the apical tunnel approach, a small apical hole was made 6 mm below the mucogingival junction, and the mucosa and associated attached gingiva was away from the tooth so the flap could be repositioned coronally. Collagen matrix was used as a soft tissue graft material.

Results: At the 2-month, 6-month, 8-month, and 2-year follow-up, complete root coverage was achieved for both teeth. No bleeding on probing was noticed nor recurrent GRs at the treated sites.

Conclusion: Without incisions, donor site reflection, or flaps, the apical tunnel approach can be successfully used to cover the exposed roots. Additionally, propolis is a potential root conditioning agent during soft tissue graft procedure due to its anti-inflammatory and antioxidant properties.

Keywords: apical tunnel approach; gingival recession; propolis; root coverage.

Figure 1

Probing depth (PD) was 1 mm in the midfacial region for both teeth without any bleeding on probing (a, b). The recession height was 4 mm in tooth #11 (a) and 2 mm in tooth #12 (b), and the width of keratinized tissue (WKT) was 2 mm for both teeth (a–c). A preoperative periapical radiograph was taken, the affected teeth showed no signs of interproximal radiographic bone loss as well as no interproximal attachment loss (d). Only a slight amount of gingival inflammation was seen, along with rolled marginal gingiva and blunted interdental papillae. First, scaling and root planing was performed to prepare the teeth for phase II treatment (e). Local anesthetic infiltration was performed and applied propolis paste using a cotton pellet to condition the roots for 3 min (f). Then pierced an apical hole of 4 mm above the mucogingival junction (MGJ) apical to the recession defect (g). The gingiva then pushed downward until it is coronal to cementoenamel junction, using a curved Orban's knife and tunneling tools to loosen gingival tissues. Full‐thickness splitting was accomplished, resulting in free mobile gingiva (h, i). To help and hold the gingiva in its coronal position, one‐piece of CenoMembrane, an allograft collagen matrix (size: 10 × 10 mm, thickness: 0.6–0.9 mm, CenoBiologics Ltd–Tissue Engineering, United Kingdom) was divided into small strips and placed through the hole to the interdental papillae, as illustrated in (j). To keep the gingiva in its new position, gentle digital pressure was applied for 3 min. Propolis was then reapplied to the gingiva for an additional 3 min. The 2 months (k), 6 months (l), 8 months (m), and 2 years (n) follow‐ups showing complete root coverage. The pocket depth was 2 mm for both teeth #11 and #12 during all follow‐up visits (k–n). WKT of both affected teeth increased to 3 mm and remained the same during all follow‐ups (k–n). Post‐op peri‐apical X‐ray taken at the 2 years follow‐up showed no bone level change when compared to baseline (o).