1132_IPC_AAP_553092 3/1/02 2:44 PM Page 340

Case Report
Formation of a Cyst-Like Area After a Connective Tissue
Graft for Root Coverage*
Randall J. Harris

Background: Many techniques have been devel- Obtaining predictable and esthetic root coverage
oped to obtain root coverage. There have been few has become an important part of periodontal therapy.
complications reported with these techniques. This Many techniques have been shown to be effective in
case report chronicles the development of a cyst-like obtaining root coverage. Autogenous masticatory
area after a connective tissue partial-thickness dou- mucosa grafts (free gingival grafts), pedicle grafts,
ble pedicle graft was used to obtain root coverage. guided tissue regeneration, and acellular dermal
Methods: The root coverage procedure was per- matrix grafts have all been shown to be effective.1,2
formed as previously reported. Postoperatively, in the However, the use of a connective tissue graft com-
surgical area, the patient developed occasional bined with an overlying pedicle graft (subepithelial
swelling. It was possible to express a white material connective tissue graft) is probably the most com-
from the area. A biopsy was taken to determine the monly used root coverage procedure. Multiple clini-
cause of the clinical findings. cal studies1 have shown predictable and esthetic root
Results: Histological evaluation revealed the devel- coverage results with many variations on the original
opment of a cyst-like area. subepithelial connective tissue graft proposed by
Conclusion: The development of cysts does not Langer and Langer.3
seem to be a common event. However, this case report Potential complications involved with the use of
demonstrates that they are a possible complication subepithelial connective tissue grafts have been
of root coverage procedures. J Periodontol 2002;73: examined. Reiser et al.4 reported on the anatomy of
340-345. the donor area. This knowledge is important to pre-
vent damage to the vasculature and nerves in the
KEY WORDS
area. Studer et al.5 measured the thickness of poten-
Cysts/etiology; gingival recession/surgery; grafts, tial palatal donor sites. Selection of sites of sufficient
gingival/complications; grafts, soft tissue/ thickness is important to prevent sloughing of palatal
complications. tissues after the graft is taken. Jahnke et al.6 reported
high rates of sloughing when vertical incisions were
used to obtain connective tissue grafts. Harris7 com-
pared palatal sloughing when 2 different graft har-
vesting techniques were used. Additionally, Harris et
al.8 reported on complications and the severity of
complications associated with 500 subepithelial con-
nective tissue grafts. This included pain, bleeding,
swelling, infections, and other complications.
Ouhayoun et al.9 reported on the development of
a cyst-like space in the epithelial projections in 2 of
7 samples evaluated. These projections were found
at the junction of the connective tissue graft and the
overlying gingival flap. In their study, they compared
connective tissue grafts where the epithelium was
either chemically or surgically removed. One of the
cyst-like spaces occurred with each treatment. The
development of these cyst-like areas, according to
the authors, seemed to be related to epithelium grow-
ing between the connective tissue graft and the over-
lying flap. Since these cyst-like spaces occurred with
* Private practice, Reno, NV. connective tissue grafts with both chemically and sur-

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Case Report
gically removed epithelium, the cause of these cyst-
like spaces did not seem to be epithelium possibly
remaining with the connective tissue graft.
This case report presents a case that developed a
cyst-like space which did not seem to be associated
with an epithelial projection.
CASE REPORT
The patient was a 27 year-old female. She was a
non-smoker in good health, with no contraindications
for periodontal surgery. She was referred for treat-
ment of a recession defect on the buccal aspect of
#27. The area was sensitive to cold and difficult for
the patient to clean adequately. Periodontal evalua-
tion revealed no other areas requiring treatment.
The clinical measurements at #27 were recorded Figure 1.
with a conventional Williams style probe. All mea- Preoperative tooth #27.
surements, evaluations, and surgery were done by
the author. The measurements were rounded to the
nearest 0.5 mm. The marginal recession depth (reces-
sion) was 4.5 mm, the probing depth was 2.0 mm,
and there was 1.0 mm of keratinized tissue in the
area of the recession defect. There was no bleeding
on probing at #27. Clinical measurements are pre-
sented in Table 1. Figure 1 shows tooth #27 prior to
the grafting procedure.
The possible treatment options were discussed with
the patient. A connective tissue with partial-thick-
ness double pedicle graft was selected to treat the
recession defect. An informed consent form was
signed by the patient.
The procedure was performed as previously
described.10 Anesthesia was obtained, and the exposed
root surface was root planed and treated with a tetra- Figure 2.
cycline solution (125 mg tetracycline/1 cc of saline) Incisions.
for 2 minutes. Incisions were made to create the dou-
ble pedicles and recipient bed (Fig. 2). A partial- joined with two 5-0 gut sutures. A connective tissue
thickness dissection was used to reflect the double graft was obtained by using a scalpel with parallel
pedicles and create a recipient bed for the connec- blades.† The epithelial border was excised and dis-
tive tissue graft (Fig. 3). The double pedicles were carded. The connective tissue graft was sutured into
the bed preparation with 5-0 gut sutures (Fig. 4). The
Table 1. double pedicles were sutured over the connective tis-
sue graft with 5-0 gut sutures (Fig. 5). Isobutyl cyano-
Clinical Measurements (mm) acrylate‡ and a periodontal dressing§ were applied.
Routine postoperative instructions were given.
Preoperative Postoperative The patient was seen at 2 weeks postsurgery. The
Recession 4.5 0 dressing was removed and postoperative instructions
were given. A follow-up appointment was scheduled
Probing depth 2.0 1.0 in 4 weeks; however, the patient left the area and
Attachment level 6.5 1.0
† Harris Double Blade Graft Knife, H & H Company, Ontario, CA.
Keratinized tissue 1.0 5.0 ‡ Iso-Dent, Ellman International, Hewlett, NY.
§ Barricaid, Dentsply, LD Caulk Division, Milford, DE.

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Case Report

Figure 3. Figure 4.
Reflection of partial-thickness pedicle. Connective tissue graft sutured over defect.

Figure 5. Figure 6.
Pedicle sutured over connective tissue graft. Postoperative 13 months (arrows indicate where white material
could be expressed).

there was no contact with her until 13 months post-

operative. At that point, she presented with a chief After obtaining anesthesia, a 3.0 mm punch biopsy
complaint of white discharge from the area mesial to was taken from the area where the discharge was
the original recession defect (Fig. 6). According to the seen. The biopsy was placed in 10% formalin and
patient, the area with the discharge seemed to swell processed for histological evaluation. The bulkiness
occasionally. Additionally, she was concerned that was reduced with diamond burs and gingivectomy
the overall result seemed bulky. There was no pain knives (Fig. 7).
or sensitivity in the area. Complete root coverage Six sections were evaluated. Figure 8 shows a rep-
was obtained. There was a probing depth of 1.0 mm resentative section. The external surface was cov-
on the buccal aspect of #27 and 5.0 mm of kera- ered by parakeratinized, stratified, squamous epithe-
tinized tissue. It was possible to express a small lium with reactive hyperplasia and anastomosing rete
amount of a thick white material from the area ridges. There was mild basal cell hyperplasia. Deep
between #26 and #27. to the surface, there was epithelium lining a cystic
The decision was made to biopsy the area and do space or invagination. Figure 9 shows a higher mag-
a gingivoplasty to decrease the bulkiness of the result. nification (×100) of this area. The epithelium was

342 Cyst-Like Formation After Connective Tissue Grafting Volume 73 • Number 3