635

Gingival Coverage of Iatrogenically

Denuded Labial Bone Resulting from
Thermal Trauma

Ui-Won Jung, DDS, PhD1

Chang-Sung Kim, DDS, PhD2
Seong-Ho Choi, DDS, PhD3
Sungtae Kim, DDS, PhD4
Damage to periodontal tissue as a result of thermal injury often causes severe
gingival recession and denuded alveolar bone. In this case report, two patients
undergoing gingival coverage of iatrogenically denuded labial bone associated
with the maxillary central incisor and the lateral incisor are presented. The first
patient had gingival necrosis and labial alveolar bone exposure on the maxillary
left central incisor and was referred from a local dental clinic. The patient had
undergone root canal treatment 2 weeks previously. The gingival necrosis was
assumed to be caused by a heated plugger. The denuded root surface was
immediately covered by a laterally positioned flap over a connective tissue graft
obtained from the palate. The gingival margin and overall appearance were
symmetrically in harmony with those of the adjacent teeth. Another patient with
the same symptoms and dental history was treated using the same procedure.
Normal periodontal architecture was successfully reconstructed and maintained.
In the cases presented, laterally positioned flap coverage over a subepithelial
connective tissue graft was successfully applied to cover thermally injured bone
and the root surface. (Int J Periodontics Restorative Dent 2013;33:635639.
doi: 10.11607/prd.1024)

Associate Professor, Department of Periodontology, Research Institute for Periodontal

Regeneration, College of Dentistry, Yonsei University, Seoul, South Korea.
2Associate Professor, Department of Periodontology, Research Institute for Periodontal
Regeneration, College of Dentistry, Yonsei University, Seoul, Korea.
3Professor, Department of Periodontology, Research Institute for Periodontal Regeneration,
College of Dentistry, Yonsei University, Seoul, Korea.
4Assistant Professor, Department of Periodontology, School of Dentistry and Dental
Research, Seoul National University, Seoul, Korea; Formerly, Assistant Clinical Professor,
Department of Prosthodontics, College of Dentistry, Yonsei University, Seoul, Korea.
1

Various heated instruments such

as heat pluggers, spreaders, and
ultrasonic devices can indirectly
cause thermal injury to the surrounding tissue structures via heat
conduction through the dentin and
bone. It has been reported that
increases in temperature of over
10C can cause irreversible degenerative changes to the bone and
attachment apparatus.14 Incorrect
use of an ultrasonic device elevates
the temperature within the root
canal, which may lead to severe
burning of the surrounding tissues.
In such cases, the damaged teeth
often need to be extracted, with
subsequent and concomitant severe bone atrophy.
In this case report, two patients
who presented with iatrogenically
denuded labial bone resulting from
thermal injury by a heated plugger
during endodontic treatment and
were treated successfully using a
gingival coverage procedure are
discussed.

Correspondence to: Prof Sungtae Kim, Department of Periodontology, School of Dentistry

and Dental Research, Seoul National University, Seoul, South Korea 110-768;
fax: 82-2-744-0051; email: kst72@snu.ac.kr.
2013 by Quintessence Publishing Co Inc.

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636
Figs 1a and 1b Patient 1. Clinical photograph and standard
periapical radiograph taken at the patients first visit (2 weeks after
thermal injury). (a) Note the severe gingival recession with inflammation and exposure of the labial alveolar bone on the maxillary left
central incisor. (b) Internal root resorption and thin residual dentin
was also present.

Fig 1c After elevation of a fullthickness flap, the exposed bone

area was removed and reshaped.

Fig 1d Connective tissue was

obtained from the left palate.

Fig 1e Trimmed connective tissue positioned on the denuded

area and immobilized by sutures.

Fig 1f Overlying flap positioned laterally on the connective tissue graft.

Fig 1g Clinical photograph

taken 1 month postoperatively.

Figs 1h and 1i Clinical photograph and standard periapical

radiograph taken 3 months postoperatively. Gingivoplasty was
performed on the right incisors
to obtain symmetry.

Case report
Patient 1

A 19-year-old woman was referred

from a local dental clinic for the
treatment of a denuded labial surface of the maxillary left central

incisor. Two weeks previously, she

had visited the local dental clinic
because of discoloration of the
tooth. Incomplete filling of the
canal presented as a radiographic
void. To correct the incomplete
root canal filling, the canal was
reopened, and vertical condensa-

tion of the preexisting gutta percha

was performed with an endodontic
heat plugger (System B, Sybron
Endo). On the same afternoon,
the patient visited the dental clinic
again because of discomfort of the
labial gingiva at the treated site.
After 2 weeks, gingival recession

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637
with denudation of the labial alveolar bone was noted, and the patient was referred to the hospital.
Intraoral clinical examination
revealed localized severe gingival
recession on the labial aspect of
the left central incisor associated
with labial alveolar bone exposure
(Fig 1a). There was a 2 4-mm
gap between the cementoenamel
junction and the alveolar bone
crest. The height of the denuded
alveolar bone was 3 mm. Internal
root resorption was observed using periapical radiography (Fig 1b).
Root coverage was performed using a subepithelial connective tissue graft on the day of the visit.
Surgical procedure
A laterally positioned flap comprising a subepithelial connective
tissue graft was used for root coverage. After papilla preservation,
consisting of a horizontal incision
and two vertical incisions, a fullthickness flap was elevated (Fig
1c). The outer surface of the denuded alveolar bone was carefully
removed using a root-planing bur.
After preparing the recipient site,
free connective tissue was obtained
from the left palatal area (Fig 1d).
The connective tissue was trimmed
and placed on the exposed root
and alveolar bone bed (Fig 1e).
The outer flap was positioned laterally to cover the grafted tissue and
was sutured with 4-0 monofilament
using the single interrupted suturing technique (Fig 1f). Sutures were
removed 10 days after surgery.
Wound healing was uneventful. The patient was recalled for
follow-up at 1 (Fig 1g) and 3

months (Figs 1h and 1i) after surgery for postoperative care. The
denuded area of the maxillary left
central incisor was completely covered up to the cementoenamel
junction at 1 month after surgery.

Patient 2

A 25-year-old woman was referred

from the Department of Advanced
General Dentistry, Yonsei Univeristy, Seoul, South Korea, for the
treatment of a denuded labial surface of the maxillary right lateral
incisor. Root canal treatment had
been performed using an endodontic heat plugger because of
hypersensitivity and secondary
dental caries at the tooth. Gingival
necrosis and exposure of the labial bone were found 10 days after
canal obturation (Figs 2a and 2b).
The denuded bone and gingival
recession did not heal spontaneously over the following 4 weeks,
and the patient was referred to the
Department of Periodontology,
Yonsei University, Seoul, South Korea. A 3-mm portion of labial bone
was exposed and gingival grafting
was performed at the first visit. The
pedicle flap at the right canine was
positioned laterally to cover the
subepithelial connective tissue obtained from the left palate (Figs 2c
to 2f). The general surgical protocol was the same as that described
for patient 1.
Normal periodontal architecture, including 5 mm of keratinized
gingiva, was successfully reconstructed and maintained up to the
4-month follow-up (Figs 2g and 2h).

Discussion
The vertical condensation technique allows thermoplasticized
gutta percha to be homogeneously packed without leakage using
a heated plugger. However, the
safety of this device cannot be
guaranteed if the operator is not
aware of its correct use. Studies
evaluating temperature changes
within the root canal caused by
various devices that are used for
vertical condensation have found
that these devices can increase the
temperature of the surrounding tissue by 4C to 14C.58 Therefore,
the heated plugger used for canal
obturation may carry with it the risk
of transferring noxious heat to the
root surface, particularly if the dentin wall is thin. It is recommended
that the residual dentin thickness
be assessed at the radiographic
examination before treatment begins. If there is internal resorption
within the root or if the dentin
thickness is less than 1 mm, the risk of
heat transfer should be considered.
The timing of surgical intervention may be critical for the prognosis of the injured tooth. Cases
of thermal injury similar to those
presented have been described
previously. Gluskin et al9 reported
a case in which a tooth injured by
an ultrasonic device had to be extracted 2 days postinjury as a result
of persistent discomfort. Following
extraction of the tooth, the remaining alveolar ridge collapsed, shrank,
and was esthetically compromised.
In another case, a central incisor
was thermally injured by an ultrasonic device10 and although several

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638
Figs 2a and 2b Patient 2. Clinical photograph (above) and
standard periapical radiograph (right) demonstrating acute gingival
recession and exposure of the labial bone 10 days after canal
obturation. Note the thin dentin in the apical region.
Fig 2c Denudation of the labial bone persisted at the 5-week
recall visit following thermal injury. The patient was referred to the
Department of Periodontology, and root coverage was performed
on the day of examination.
a

b
Fig 2d Following flap reflection, the
outer surface of the exposed bone was
removed.
Fig 2e Connective tissue was placed
and immobilized on the root and the
bone.

Fig 2f A laterally positioned flap covered

the grafted connective tissue.

attempts were made to save the

tooth, it had to be extracted at 15
weeks postinjury because of the development of extreme headaches.
In both cases, the patients were not
provided with any surgical intervention for soft tissue coverage during
the follow-up period, so the involved tooth was unfortunately lost.
In the two cases described,
subepithelial connective tissue
grafting combined with removal
of any necrotic alveolar bone was
performed immediately for the in-

Figs 2g and 2h The periodontal architecture of the maxillary right lateral

incisor was symmetric with its counterpart at 4 months postoperatively.
Intact proximal bone and resolution of the apical radiolucency was noted.

jured teeth on the day of referral.

Only 2 and 5 weeks had passed
after thermal trauma for patients 1
and 2, respectively, to receive gingival grafting treatment.

when using it. In the present cases,

a laterally positioned flap was successfully applied over a subepithelial connective tissue graft for
coverage of the thermally injured
bone and root surfaces.

Conclusions
Acknowledgment
The use of a heated device during
endodontic treatment is associated
with a potentially high risk of periodontal tissue damage, and therefore, special care should be taken

This study was supported by a faculty research grant from Yonsei University College
of Dentistry in 2010 (6-2010-0100). The
authors reported no conflicts of interest related to this study.

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639
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