"Crown-then-Graft": A Novel Approach to Optimize Teeth for Crown Placement and Root Coverage Procedures. A 5-year Case Report

Purpose: The presence of a treatable gingival recession in teeth ready for crown preparation requires a combined restorative-periodontal effort to achieve all biologic and esthetic goals. This needs an ideal artificial crown proportion and a harmonious gingival architecture. Traditionally, a root coverage procedure is initially performed followed by final crown preparation and cementation. However, during the prosthetic phase, irritation to the grafted delicate tissue may be followed by recession and exposed crown margins. To minimize prosthetic irritations, the "crown-then-graft approach" (CTGA) is suggested in which the root coverage procedure is performed after final crown preparation. Methods: After definitive crown preparation and impression taking of the left maxillary incisor, an acrylic crown with flat marginal profiles was temporarily cemented into the patient's mouth. Root coverage procedures were implemented using a combined connective tissue graft and a coronally advanced flap. No additional tooth preparation and impression taking were performed. After 6 months, a final crown, fabricated from the previous impressions, was cemented. Results: Initially, the grafted tissue margins completely covered the root and 1-2 mm of the temporary crown margins. At 12 months post-surgery and 6 months post-definitive crown cementation, the gingival margins slowly receded, reaching the ideal position. Complete root coverage was maintained for the next 5 years. Conclusions: The CTGA may minimize tissue irritation after root coverage in teeth designed for combined crown preparation and root coverage procedure, and may account for long-term marginal tissue stabilization.