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• Root Preparation

• Root coverage complications

• Soft Tissue Ridge Augmentation (Pontic Site Prep)

• Papilla management

Root Preparation

What is root preparation and what are the different categories? What materials are traditionally used for this? Does this work the same for animal studies and human studies? When is root preparation warranted?

1. Zucchelli G et al: Hand and ultrasonic instrumentation in combination with root –coverage surgery: A comparative controlled randomized clinical trial. J Periodontol 2009 Apr; 80(4):577-85

2. Bertrand PM, Dunlap RM: Coverage of deep, wide gingival clefts with free gingival autografts: root planing with and without citric acid demineralization. Int J Perio Restor Dent 8(1):65-67, 1988.

3. Bouchard P1, Nilveus R, Etienne D. Clinical evaluation of tetracycline HCl conditioning in the treatment of gingival recessions. A comparative study. J Periodontol. 1997 Mar;68(3):262-9.

4. Cheng YF, Chen JW, Lin SJ, Lu HK. Is coronally positioned flap procedure adjunct with enamel matrix derivative or root conditioning a relevant predictor for achieving root coverage? A systemic review. J Periodontal Res. 2007 Oct;42(5):474-85.

How is root coverage affected by existing restorations? What might you need to do with an existing restoration? What should you discuss with your restoring dentist (if the restoration has not been placed yet)?

1. Lucchesi JA, et al. Coronally positioned flap for treatment of restored root surfaces: a 6-month clinical evaluation. J Periodontol. 2007 Apr;78(4):615-23.

2. Santamaria M et al. Coronally positioned flap plus resin-modified glass ionomer restoration for the treatment of gingival recession associated with non-carious cervical lesions: A randomized controlled clinical trial. J Periodontol 2008 Apr; 79(4):621-8

How would a microscope possibly improve perio plastic surgery? What kind of instruments are needed to facilitate this smaller, more delicate procedure?

1. Francetti L eta L. Microsurgical treatment of gingival recession: A controlled clinical study. Int J Periodontics Restorative Dent. 2005 Apr; 25(2):181-8

2. Bittencourt S, et al. Surgical microscope may enhance root coverage with subepithelial connective tissue graft: a randomized-controlled clinical trial. J Periodontol. 2012 Jun;83(6):721-30.

What are some limiting factors for root coverage? What should you discuss with a patient before attempting root coverage? Are there things the patient can do to possibly improve the outcome? Are there any complications you might want to be aware of when doing root coverage?

1. Gray JL. When not to perform root coverage procedures. J Periodontol 71:1048-1050,2000.

2. Esteibar JR, et al. Complete root coverage of Miller Class III recessions. Int J Periodontics Restorative Dent. 2011 Jul-Aug;31(4):e1-7.

3. Chambrone et al: The influence of tobacco smoking on the outcomes achieved by root-coverage procedures: A systematic review. J Am Dent Assoc. 2009; Mar; 140(3):294-306

4. Erley K et al: Gingival recession treatment with connective tissue grafts in smokers and non-smokers. J Periodontol 2006;Jul; 77(7):1148-55

5. Silva C et al: Coronally positioned flap for root coverage: Poorer outcomes in smokers J Periodontol 2006 Jan; 77(1)81-7

6. Silva CO, de Lima AF, Sallum AW, Tatakis DN. Coronally positioned flap for root coverage in smokers and non-smokers: stability of outcomes between 6 months and 2 years. J Periodontol. Sep;78(9):1702-7. 2007

7. Vastardis S., Yukna R.: Gingival/soft tissue abscess following subepithelial connective tissue graft for root coverage: Report of three cases. J Periodontol 2003 Nov; 74(11):1676-81

When would soft tissue augmentation be warranted other than for root coverage? How stable is this procedure over time? What are the differences in harvest and site prep from root coverage or increasing keratinized tissue?

1. Seibert JS: Reconstruction of deformed partially edentulous ridges, using full thickness onlay grafts: Part I. Technique and wound healing. Compend Cont Educ Dent 4:437 -453, 1983

2. Seibert JS: Reconstruction of deformed partially edentulous ridges, using full thickness onlay grafts: Part II. Prosthetic/periodontal interrelationships. Compend Cont Educ Dent 4: 549 – 562, 1983

3. Seibert J, Cohen D. Periodontal considerations in preparation for fixed and removable prosthodontics. Dent Clin North Am 1987;31(3):529-555

4. Seibert JS, Louis JV. Soft tissue ridge augmentation utilizing a combination onlay-interpositional graft procedure – A case report. Int J Perio Rest Dent 16:311-321,1996

5. Langer B, Calgna L. The subepithelial connective tissue graft. J Prosthet Dent 1980; 44(4):363-367

6. Langer B, Calagna L. The subepithelial connective tissue graft. A new approach to the enhancement of anterior cosmetics. Int J Periodontics Restorative Dent 1982; 2 (2): 23-30

7. Orth C. A modification of the connective tissue graft procedure for the treatment of type II and type III ridge deformities. Int J Periodontics Restorative Dent 1996; 16(3):267-278

8. Harris R. Soft tissue ridge augmentation with an acellular dermal matrix. Int J Periodontivcs Restorative Dent 2003; 23(1):87-92

9. Abrams L. Augmentation of the deformed edentulous ridge for fixed prosthesis. Compend Contin Educ Dent 1980; 1 (3):205 – 214

10. Scharf D. Tarnow: Modified roll technique for localized alveolar ridge augmentation. Int J Periodontics Restorative Dent 1992; 12(5):415-425

11. Seibert J., Salama H. Alveolar ridge preservation and reconstruction. Periodontl 2000; 1996; 11:69-84

12. Allen EP. Use of mucogingival surgical procedures to enhance esthetics. Dent Clin North Am 1988:32(2):307-330

13. Akcali A, et al. Soft tissue augmentation of ridge defects in the maxillary anterior area using two different methods: a randomized controlled clinical trial. Clin Oral Implants Res. 2014 Apr 10.

What are some classifications for papilla height/contour? What anatomic features are we concerned with when trying to predict papilla height? How might this affect our treatment plans? What are some techniques to try to reconstruct the papilla? How predictable is this?

1. Nordland WP, Tarnow DP. A classification system for loss of papillary height. J Periodontol 69:1124-1126, 1998.

2. Jemt, T. Regeneration of gingival papillae after single-implant treatment. International

Journal of Periodontics and Restorative Dentistry 1997 (17) , 326 –333.

1. Tarnow DP, et al. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol. 1992 Dec;63(12):995-6.

2. Takei H, Yamada H, Hua T. Maxillary anterior esthetics: Preservation of the interdental papilla. Dent. Clin. North Am. 33(2): 1989

3. Azzi R, Etienne D, Carranza F. Surgical reconstruction of the interdental papilla. Int J Perio Rest Dent 18:466-473, 1998.

4. Blatz MB, Hürzeler MB, Strub JR. Reconstruction of the lost interproximal papilla–presentation of surgical and nonsurgical approaches. Int J Periodontics Restorative Dent. Aug;19(4):395-406. 1999 Review.

5. McGuire MK, Scheyer ET. A randomized, double-blind, placebo-controlled study to determine the safety and efficacy of cultured and expanded autologous fibroblast injections for the treatment of interdental papillary insufficiency associated with the papilla priming procedure. J Periodontol. Jan;78(1):4-17. 2007

How is management of the papilla around implants different than around teeth? How might this affect the prosthetic treatment plan?

1. Salama H, Salama MA,et al. The Interproximal height of Bone: A Guidepost to Esthetic Strategies and Soft Tissue Contours in Anterior Tooth Replacement. 2003 update of 1998 Pract Periodontics Aesthet Dent (saved on T drive)

2. Tarnow, D et al: The effect of inter-implant distance on the height of inter-implant bone crest. J Periodonto 71:546-549, 2000 (from LR 161)

3. Tarnow D et al: Vertical Distance from the Crest of Bone to the Height of the Interproximal Papilla. J Periodntol 2004; 75:1242-1246 (from 161)

4. Zetu, L., Wang. H-L: Management of inter-dental / inter –implant papilla. J Clin Peridotnol 2005; 32:831-839 (from LR 161)

5. Chow YC, Wang HL. Factors and techniques influencing peri-implant papillae. Implant Dent. 2010 Jun;19(3):208-19. (saved on T drive)

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What is root preparation and conditioning and what are the different categories? What materials are traditionally used for this? Does this work the same for animal studies and human studies? When is root preparation warranted?

Zucchelli 2009         ARTICLE

P:To compare the effectiveness, in terms of root coverage, of hand and ultrasonic root instrumentation in combination with a coronally advanced flap (CAF) for the treatment of isolated-type recession defects.

M+M:Randomized controlled split-mouth clinical study. 11 subjects (18-40 years old). Study inclusion criteria: Miller Class I isolated recession defects (greater than or equal to 3mm in depth) of similar depth in the contralateral quadrant of the upper jaw; presence of identifiable CEJ; greater than or equal to 1 mm KG apical to the root exposure; periodontally and systemically healthy; no contraindications for periodontal surgery and not taking medications known to interfere with periodontal tissue health or healing; and no periodontal surgery on the involved sites. Subjects smoking >10 cigarettes/day were excluded. Immediately prior to surgery, bilateral defects were randomly assigned by coin toss, to the test group- ultrasonic piezoelectric and the control group- curette root instrumentation. All recessions were treated with a CAF surgical technique using trapezoidal incision. Sutures were placed and post op instructions were given. Post-op after 6 months.

R: Root coverage: 95.4% in the control group and 84.2% in the test group, and complete root coverage: 82% in the control group and 55% in the test group– with no NSSD between the two groups. CAL gains were clinically significant in both groups (3.36 +/- 0.92 mm in the control group and 2.90 +/-0.70 mm in the test group). The increase in KG was SS in both groups (0.55 +/- 0.52 mm in the control group and 0.36 +/- 0.67 mm in the test group), but no NSSD between them.

BL: Hand and ultrasonic root instrumentation, in combination with CAF, for the treatment of the isolated-type of recession defect were equally effective in terms of root coverage and CAL gain. More expanded and longer-terms studies are required to confirm such results and to evaluate the efficacy of ultrasonic treatment for demineralized/softened root surfaces.

Bertrand 1988ARTICLE

P:To evaluate the effect of citric acid in the treatment of deep, wide clefts with FGGs biometrically and with intrapatient controls.

M+M: 8 pts (all male, 20-56 yrs old), healthy, non-smokers with 0 pairs of adjacent or bilateral deep, wide clefts. Underwent initial therapy: SRP and OHI. Cleft measured pre-op and 3 months post-op w/ Detch probe to the 0.1 mm. Vertical dimension was from CEJ to FGM, and horizontal was width at CEJ.

2 groups (experimental and control): both treated with root planning w/ hand curettes, experimental treated w/ cotton pellets soaked in citric acid for 5 minutes, then recipient bed prepared creating butt joints and PTF reflected, 3-5mm apical, foil template prepared, thick FGG (2mm or thicker) excised from palate by sharp dissection, margins trimmed to be butt joints, and graft sutured to recipient site. Donor site treated with pressure , packed with Gelfoam, and covered by palatal stent. Nine days after surgery dressing and sutures removed.

R:NSSD for mean cleft coverage b/w control and experimental groups.

Range of coverage for control sites: 39% – 94%; Mean percentage of coverage: 66%

Range of coverage for experimental sites: 53% – 94%; Mean percentage of coverage: 74%

Mean overall coverage: 70%

BL:FGG to cover deep, wide clefts success did not depend on application of citric acid.

Bouchard 1997         ARTICLE     tetracycline root conditioning

BG:TTC have been found to be effective against a wide range of perio pathogens, potentially inhibit CT breakdown by inhibiting neutrophil collagenase, inhibit bone resorption in vitro at concentrations which are compatible with clinical situations, and increase collagen formation in osteoblasts, and enhance perio regeneration.

P:To determine the clinical effect of topical applications of TTC-HCL versus citric acid (CA) in root conditioning as an adjunct to the modified subepithelial graft procedure for root coverage.

M&M:All pts had a MOL of at least 80%. 30 class I and II recs in non-molar tth in 30pts were tx with a modified CT graft procedure (CT graft covered completely with CAF. 15 recs in the test goup were treated with TTC (50 mg/ml: capsule with 250mg powder dissolved in 5mL syringe filled with sterile water) for 5 minutes, and the control group received CA for 3 minutes. No systemic antibiotics given to either group. Clinical parameters were measured at baseline and 6 months. Smokers were included and present in both groups. Pts that smoked > 10 cigs/day were excluded from the study.

R:All pts had an uneventful healing period. NSSD between groups. Mean RC was 79% for test and 84% for the CA group. In the test group, 6/15 recs had complete RC vs 8/15 in the control. The gingiva thickened in all cases.

BL:TTC and CA have similar effects for RC performed with CT grafts.

Cr: It would be nice to have a group without any root conditioning to verify if the treatments are actually effective, although a study comparing CA vs no CA with the same procedure was recently performed (at this point in time).

Cheng 2007        ARTICLE            Emdogain for root coverage

Purpose: To assess the efficacy of EMD and root conditioning on the root coverage with coronally advanced flap .

Materials and methods:Meta-analysis, studies by the end of October 2005. Inclusion criteria: studies in English, done in human subjects, Miller Class I and II recessions more than 2mm, treatment with coronally positioned flap (CPF), coronally positioned flap + chemical root surface conditioning or coronally positioned flap and EMD, randomized controlled trial, controlled clinical trial or case series report with at least 6- to 12-month interval between the initial and final measurements and baseline and final measurements of buccal recession depth.

Histological studies, studies with insufficient data or semilunar coronally positioned flap were excluded.

The quality of the studies was assessed by two reviewers based on the adequacy of the method of randomization, existence of blinding of the examiners for the variable type of treatment and the existence and treatment of lost cases.

Results: 7 studies were included for CPF and 11 for CPF. Of those 3 studies used tetracycline for root conditioning and 1 study used EDTA.

Clinical attachment level: At 6 months the gains in CAL were 2.42±0.70mm in the CPF group and 2.22±0.36 in the CPF +root conditioning and 4.01±0.77mm in the CPF +EMD group. At 12 months the mean gain were 1.69±0.15mm, 3.10±0.00mm and 3.61±0.50mm respectively. CPF +EMD showed SSD results in 6 and 12 months than the other two groups. At 12 months differences were statistically significant among all groups. At 6 months differences between CPF and CPF+ root conditioning groups were not SSD.

Keratinized tissue: At 6 months the gains in keratinized tissue were -0.04±0.37mm in the CPF group, 0.14±0.47mm in the CPF + root conditioning group and 0.59±0.29mm in the CPF + EMD group. At 12 months the gains were 0.10±0.41mm, 0.30±0.00mm and 0.61±0.14mm. CPF + EMD showed better results that were SSD in both 6 and 12 months. NSSD between CPF and CPF + root conditioning.

Probing depth: PDs at 6 and 12 months were less than 2mm. 1.04±0.38mm in the CPF group, 1.09±0.14mm in CPF + root conditioning and 1.16±0.15mm in the CPF + EMD. At 12 months the mean values for the groups were 0.98±0.02mm1.4±0.00mm and 1.41±0.33mm.

Gingival recession depth: CPF + EMD decreased from 3.910.35mm to 0.62±0.36mm at 6 months and 0.72±0.40mm at 12 months. In the CPF recession depth decreased from 3.36±0.36mm to 0.8±0.42mm at 6 months and 1.37±0.04mm at 12 months. In the CPF + root conditioning recession depth decreased from 3.62±0.29mm to 1.17±0.25mm at 6 months and to 1mm at 12 months. All differences were SSD except the difference between CPF and CPF and root conditioning at 6 months.

Root coverage percentage: The CPF and CPF + root conditioning resulted in root coverage percentage ranging from 55-75%. The CPF + EMD technique resulted in 71.7-95.1% root coverage.

Conclusion: Root coverage manipulated by the coronally positioned flap with or without root conditioning was unpredictable. Results can be modified by adding EMD to increase significantly the clinical outcomes of gingival recession.

How is root coverage affected by existing restorations? What might you need to do with an existing restoration? What should you discuss with your restoring dentist (if the restoration has not been placed yet)?

Lucchesi 2007ARTICLE

Purpose:To evaluate clinically the treatment of gingival recession associated with non-carious cervical lesions “NCCL” (abrasion, abfraction or erosion) by resin modified glass ionomer cement or microfilled resin composite (MCR) plus coronally positioned flap at 6 months following surgery.

Materials and methods:

• 59 pts healthy patients= 39 pts miller class 1 + NCCL , 20 pts miller class 1 + no NCCL

• 3 groups:

  • Group 1(control): root exposure with out NCCL treated with a CPF,

  • Groups 2: root exposure with NCCL treated with RMGI (resin modified glass ionomer) plus a CPF

  • Group 3: root exposure with NCCL treated with MRC (microfilled resin composite) restoration plus CPF.

• PI, BOP,PD, recession reduction, CAL, keratinized tissue height, keratinized tissue thickness, percentage of root coverage, percentage of restored root coverage were all measured at baseline, 3 and 6 months. Acrylic stents were made to take the measurements.

Results:

• Mean root coverage at 6 months was 80.83% for group 1, 71.99% for group 2 and 74.18% for group 3. No SSD between any of the groups at any time.

Conclusion:

• All treatments showed root coverage improvement without damage to the periodontal tissue, supporting the use of CPF for treatment of root surfaces restored with RMGI or MRC as being effective over a 6-month period.

Santamaria 2008             ARTICLE

P:To evaluate the treatment of recession associated with non-carious cervical lesions by a CPF or in combination with a RMGI.

M&M: 19 patients with bilateral class I buccal recessions associated with non-carious cervical lesions were selected. Recession defects were randomly selected to receive either a CPF or a CPF with a RMGI. BOP, PD, Recession, CAL, non-carious lesion height, and dentin sensitivity were measured at baseline, 45 days and 2,3,6 months postop.

R:Both groups showed SS gains in CAL and soft tissue coverage. The difference between the groups were NSSD for BOP, PD, CAL and keratinized thickness at 6 months. The % of original lesion coverage was 56% for the CPF plus RMGI and 59% for CPF alone (NSSD). The estimated root coverage for CPF plus RMGI was 88%, and for CPF was 97%. There was a more decrease in sensitivity with the CPF plus RMGI group compared to CPF.

C:Both procedures produced similar results at 6 months. There was a more reduction in sensitivity when a RMGI was used.

How would a microscope possibly improve perio plastic surgery? What kind of instruments are needed to facilitate this smaller, more delicate procedure?

Francetti 2005             ARTICLE

P: to verify whether the use of a surgical microscope in the surgical treatment of gingival treatment of gingival recession could improve the outcome in terms of root coverage and final tissue appearance in esthetic area compared with traditional periodontal surgery

M: 24 cases of gingival recession were treated. criteria were: 1) buccal recession 2-5mm in the esthetic area. 2) no loss of interdental bone or soft tissue (Miller class I and II), 3) plaque control.

12 procedures were performed with the aid of a surgical microscope (test group), whereas the other 12 pts were treated without the microscope (control group).

2 weeks after OHI phase, the variables measured recession depth (REC), PD, CAL, and KG at baseline and 12 months following surgery. Pictures were taken pre and 12 months post-op.

Test group– minimally invasive surgical technique with a surgical stereomicroscope and microsurgical instruments. the following treatment were preformed: 6 CAF + CTG/ 1 CAF + GTR/ 4 CAF + CTG + EMP, and 1 semilunar flap.

Control group-conventional instruments were used w/o surgical microscope. the following treatment were preformed: 9 CAF + CTG, 1 CAF + GTR and 2 CAF.

Post-op: 7 and 15 days, then 1, 4, 7, 10, and at 12 mouths REC, PD, CAL, KG were measured.

3 examiners separately evaluated pre and post-op pictures of the final cases on a scale from 1-3 (1=unsatisfactory, 2=good, 3=excellent) , focussing on esthetic parameters (scarring, gingival margin, and papillae appearance).

R: All parameters were improved from baseline to 12 mouths in both groups, except NSD in PD. Outcome of the test group showed major improvement over the control, but NSD could be detected. Mean defect coverage at 12 months was 86% (test) and 78% (control), NSSD (P=.330) mainly because of the low number of cases. complete coverage was 58.3% (test) and 33.4% (control), with a residual recession ranging between 0 and 1 mm.

Qualitative esthetic evaluation showed 1)high concurrence among examiners, 2)significantly better scarring and marginal profile in the test group, and 3) NSD in papillae appearance. 

C: Pt who underwent microsurgery had better results in terms of both success and predictability compared to those treated by conventional surgery.Further investigations with a larger database are needed.

D: Traditional surgery should be limited to areas of less esthetic importance, such as the mandibular anterior or posterior region.

Cr: Failures are completely unrelated to either the surgeon’s ability or techniques used. the failures may simply be related to the pt’s lack of compliance post-op or other unpredictable events, irrespective of the use of the microscope.

Bittencourt 2012            ARTICLE

P:To compare root coverage (RC), post-op morbidity, and esthetic outcomes of the SCTG technique with or wo the use of a microscope.

M&M:Split mouth study with 24 pts (13 males and 11 females) with bilateral Miller class recession I and II, >2mm in canines or premolars. Initial therapy with plaque control and non-traumatic brushing techniques were given. Treatment method was randomly designated to receive tx with SCTG with (test group) or wo microscope (control group). Periodontal clinical parameters were evaluated by a calibrated examiner at baseline, 6 and 12 months. Surgeries were performed by one clinician, the only difference in the technique between the groups was the use of the microscope. Duration of the surgery was recorded. Post-op morbidity was evaluated by an analog visual scale. Pt satisfaction was evaluated with a questionnaire.

R:Average RC after 12 months for test group: 98% control group: 88.3%. Complete RC test group: 87.5% control group: 58.3%. For all parameters except recession height, there was an improvement in the final examination but wo difference bw tx. Patient satisfaction test group: 100% control group: 79.1%. Post op morbidity: No difference bw groups. Duration test group: 60 min control group: 54 min.

C:The use of the microscope showed additional clinical benefits in the tx of recessions.

What are some limiting factors for root coverage? What should you discuss with a patient before attempting root coverage? Are there things the patient can do to possibly improve the outcome? Are there any complications you might want to be aware of when doing root coverage?

Gray 2000           ARTICLE

P:To review the risk factors and other considerations that may influence a clinician’s decision not to perform a root coverage procedure in patients with good health.

D:First step is to identify risk factors. Risk factors that cannot be modified or corrected are contraindications. The following are risk factors:

Loss of interproximal bone: Miller Class III and IV defects.

Tobacco use: Smoking is a risk factor that may contribute to the failure of all mucogingival surgical procedures. Smoking contributes to periodontal destruction and impedes healing after surgery. A patient who smokes and has had an undesirable outcome is a poor candidate for further procedures. Each clinician must decide whether or how to treat patients who smoke. Smokeless tobacco is also a risk factor for recession.

Oral hygiene: Improper oral hygiene technique cause much of the recession that requires surgical correction. Unless patients can be successfully re-educated, attempts at root coverage may be unsuccessful. This includes improper tooth pick use and fingernail biting. It should be noted that some areas of recession are difficult to clean, and root coverage is sometimes a valid indication for root coverage procedures.

Anatomic features: May contribute to recession, especially when alveolar bone is thin. Often occurs in prominent or malpositioned teeth. Other factors are shallow vestibules and effects of orthodontics/orthagnathic surgery.

Indications vs. Contraindications: Three indications are inadequate gingival width, esthetic concerns, and root hypersensitivity. Contraindications include 1) limitations due to esthetics and anatomy (high smile lines), 2) cervical restorations, and 3) patient expectations.

BL:Not all sites and not all patients are suitable candidates for surgery. Careful patient interviews and examinations are necessary to determine who is unsuitable for treatment.

Esteibar 2011            ARTICLE

P:To assess factors that are involved in complete root coverage (CRC) in class III Miller recessions.

M&M:Retrospective study. 121 Class III recessions in 50 patients that were treated for periodontal disease. Non -smokers were included. Pre-sx variables: tooth undergoing treatment, sex, age, interproximal bone loss, recession width and depth, integrity of interproximal soft tissue. Surgical variables: surgical technique used and graft thickness. Post-sx variable: creeping attachment. All recessions were treated with free gingival grafts (FGG), or subepithelial connective tissue graft (SCTG) or connective tissue double pedicle technique. All patients followed the same post-surgical medical care, amoxicillin 500mg, ibuprofen, 0.12% CHX for 6 weeks after the procedure, evaluation was performed at weeks 1, 2,4, 8 and 12 post-surgery.

R:47.11% of Class III recessions obtained complete root coverage. Τhe Langer technique was the most frequently used procedure out of the three employed. Νo differences in the final result were observed among the procedures. With regard to creeping attachment hardly any differences were observed between the group that attained CRC (35%) and the one that did not (33%). In cases where the integrity of the interproximal soft tissue was preserved, a graft of more than 2 mm in thickness was used, recession width was 3 mm or less, and bone loss, as measured on the radiograph, was not above 3 mm, the success rate was 100%. Αll cases treated under these circumstances achieved CRC.

CON:Complete root coverage is possible in some Class III recessions.

Chambrone 2009                ARTICLE

P:To evaluate the effect of tobacco smoking on clinical outcomes achieved by periodontal plastic surgery

procedures in the treatment of recession-type defects. Systematic review asking the question: “Does tobacco smoking influence the outcome measures achieved by root coverage procedures?”

M+M:Medline, EMBASE, and Cochrane Central Register of Controlled Trials were searched for RCT’s, controlled clinical trials, and case series that involved at least 6 months follow-up. They looked for studies that compared outcome measures achieved by smokers and nonsmokers after they went periodontal plastic surgery procedures for treatment of gingival recession. Inclusion criteria: Miller class I or II recession, recorded smokers vs non-smokers, 18 years or older, at least smoked 10 cigs/day. Outcome measures: change in recession, CAL, KT, % of sites having complete root coverage, and mean root coverage.

R:632 studies were identified in initial search, only 7 studiesincluded. Subepithelial CTG provided SS more root coverage and clinical attachment gain for nonsmokers than for smokers. Nonsmokers exhibited more sites with complete root coverage than smokers. NSSD with regard to CPFs in non-smokers vs smokers.

BL:Smoking negatively influences the treatment of gingival recession.

CR:In M+M authors mention ADM, FGG, and GTR. Reasons for exclusion were given (articles didn’t meet search criteria) , but would have been nice to have it in the review.

Erley 2006            ARTICLE

P:To determine whether cigarette smoking affects wound healing of subepithelial connective tissue grafts (CTG).

M+M:17 healthy patients (16 M, 1 F; 27-45 years old) with a total of 22 recession defects, Miller Class I or II of 2 mm or more on non-molar teeth. Pts classified as smokers if they had10 or more cigarettes per day. OHI given to all pts and surgery not performed until MOL of 80%. Clinical paramaters (recession, KG, relative attachment level, PD, BOP, and PI) were documented at baseline and 3 and 6 months post-op using a stent. Cotinine concentration in saliva was also recorded to confirm patient’s self reported smoking history and help quantify cigarette consumption by pt. All patients received CAF with a CTG with a procedure similar to the classic Langer technique, except that a FTF elevated and the epithelium from the donor tissue was removed. All surgeries completed by same operator. Statistical analysis completed.

R:SSD in recession depth between the two groups. At 6 months post-op, smokers group healed with was 1.0 mm recession depth, while non-smokers had a recession depth of 0.2 mm. Percentage of coverage was 98.3% for non-smokers versus 82.3% for smokers. 80% of non-smokers had complete root coverage vs 25% of smokers. This was also related to Cotinine levels. No difference in KT increase.

BL:Smoking has a significant negative effect on root coverage procedures using CAF+CTG. Smokers need to consider stopping or reducing smoking for best results with CTG.

Cr: no intraexaminer calibration performed

Silva 2006             ARTICLE

Purpose: To evaluate the effect of smoking on CPF outcomes in the treatment of Miller Class I gingival recession defects.

Materials and methods:20 healthy subjects (11 males and 9 females, average age 34.5 years). 10 were smokers (smoking at least 10 cigarettes/day for at least 5 years prior to the beginning of the study) and 10 were non smokers. Smokers with lesser tobacco exposure or former smokers were excluded. Participants had one Class I Miller defect on upper canine or premolar, 2-3mm in depth. Periodontally and systemically they were healthy and they had no occlusal interferences.

Initial therapy was performed one month prior to the beginning of the study. At baseline and throughout the study bleeding and plaque index were used to monitor oral hygiene and gingival health. Standardized measurements for PD, CAL, recession depth (RD), keratinized tissue (KT) were recorded at baseline and 6months post-op, to the nearest 0.2mm. Prior to flap elevations exposed roots were instrumented and conditioned with TTC. Trapezoidal full thickness coronally and partial thickness apically flap was elevated, advanced coronally and sutured, after papillae were de-epithelialized.

Results:

• All patients tolerated the procedure well, no complications. Bleeding and plaque indices were kept below 20%. Teeth of interest were free of plaque and inflammation prior to surgery, during and at the end of the study.

• No changes in baseline data between groups.

• In smokers recession depth decreased 1.9mm and average root coverage was 69.3% and complete coverage was obtained in no case.

• In non-smokers recession depth decreased 2.32mm and average root coverage was 91.3%. Complete root coverage was achieved in 5 cases.

• At 6 months RD was significantly greater in the smokers group.

Conclusion:CPF provided benefits for both groups. However cigarette smoking negatively impacted residual recession, % root coverage and frequency of complete root coverage.

Silva 2007                  NO ARTICLE

Purpose: To evaluate the influence of cigarette smoking on the long-term outcomes of coronally positioned flaps (CPF) in the tx of Miller class I gingival recessions.

Materials and methods:

• 20 healthy subjects with Miller class I recessions involving a maxillary canine or premolar were selected.

• Ten of the subjects were smokers ( >10 cigarettes/day) and 10 had never smoked. Recessions were treated with CPFs and the pts were scheduled weekly for the first 4 weeks, then monthly until 6 months, and subsequently once every 6 months until the end of the study for professional plaque control.

• Measurements (performed with a Florida probe) were recorded at baseline, 6, 12 and 24 months. Pts were showed a coronally directed roll technique for brushing to avoid traumatic brushing.

Results:

• PD was the only parameter that remained constant during the evaluation period.

• Recession increased in smokers from 6-24 months (0.84-1.28mm) and in non-smokers (0.22-0.5mm). The difference between smokers and non-smokers in recession was SS after 2 years.

• There was NSSD between groups with respect to quantity of keratinized tissue or CAL (which decreased in both groups between 6 and 24 months.

• None of the smokers had complete root coverage at any point in time during the study.

• From the 5 non-smokers (50%) that had achieved complete root coverage at 6 months, only 2 still presented 100% root coverage after 2 years.

• No study participant lost 1mm of the initial root coverage during the 24-month follow-up.

BL: The 2-year stability of CPF is less than desirable, especially in smokers.

Vastardis 2003                ARTICLE

P:To report 3 cases of complications after the use of a SCTG to cover recessions that occurred following the initial healing phase.

D:

All pts received a coronally positioned flap with SCTG graft.

The clinical outcome of the root coverage procedure was not affected by these infections.

The authors contribute the etiology of the cysts being from suture material left behind or epithelium that was not adequately removed from the graft.

Case 1: Seven weeks after the SCTG graft, the pt came for a maintenance appt and reported minimal swelling in the area of the graft. A sinus tract was identified. A gutta-percha point was inserted in the tract and did not lead to the apices of the teeth, which were tested and were vital. The tract was curetted with HI and the granulation tissue was removed. Three weeks later, the area completely healed and no recurrence of the abscess has been noted for 9 months.

Case 2: One week after the graft was placed (dressing was used) the sutures were removed and #5 had an area of the flap with a perforation. Antibiotics were not prescribed after the sx. When the pt came for the second post-op visit one week later, they reported that the area felt “strange.” There was a diffuse swelling with purulence under the flap that was red and sensitive to the touch. The teeth did not have any periapical pathology. Amoxicillin 500mg t.i.d. x 7 days was given to the pt. One week later she was symptom free and the treated area was healing normally.

Case 3: The grafting was performed and no Abx was given and Coe-Pak was placed.

One week after sx the healing was WNL. One month later, a swelling was noticed in the mucosa apical to tooth #12. Adjacent teeth tested vital and there was no periapical pathology. The area was drained with a single incision in the mucosa and curetted. Minimal suppuration was seen, but a caseous material was noted, which was hypothesized to be remaining polyglactin 910 suture. The area was left unsutured to drain. The pt was given amoxicillin 500mg t.i.d. x 7 days. The pt has been followed for 6 months and there has been no recurrence of the abscess. The area is symptom free and healing well.

BL: These abscesses do not affect the over-all outcome of root coverage if they are treated in a conventional manner.

When would soft tissue augmentation be warranted other than for root coverage? How stable is this procedure over time? What are the differences in harvest and site prep from root coverage or increasing keratinized tissue?

Seibert 1983               ARTICLE

P: To describe the principles, sx techniques, wound healing, and prosthetic procedures involved in reconstructing deformed edentulous ridges withfull thickness onlay grafts

M&M:

Classification:

Class I: Buccolingual loss of tissue with normal ridge height in an apico-coronal dimension

Class II: Apico-coronal loss of tissue with normal ridge width in a buccolingual dimension

Class III: Combination buccolingual and apico-coronal loss of tissue resulting in loss of normal height and width

• When preparing the recipient site, we should sacrifice as little supracrestal CT as possible within the gingival/ridge/palate recipient site. To ensure that all epithelial extensions are removed, the plane of dissection should be made approx. 1mm deep. A slightly deeper pth of incision may be required where fissures or clefts extend into the underlying lamina propia.

• Extreme caution is advised when the recipient sites are over anatomic bony defects such as a cleft palate case or maxillary sinus. The conventional FGG measures 0.75 – 1.25mm thick. Nutrients are diffused by plasma leaking into the area from damaged and undamaged capillaries at the periostium/deep CT interface.

• When a large graft is required, it is not unusual to harvest a full-thickness graft from the palate including fat and glandular submucosal tissues. In contrary to the classic article by Sullivan and Atkins, the authors feel that the fat and glandular tissue found in the submucosal layer of the palate does not act as a barrier to diffusion or vascularization.

• Thick grafts have: greater primary contraction, less secondary contraction, the best resistance to functional stress, are less assured to “take.” In this study the authors noted very little shrinkage of the grafts (primary or secondary).

• Once the recipient bed is prepared and the graft is harvested, a series of parallel cuts is made deep into the exposed lamina propria (perpendicular to the ridge) of the defect area in hopes to atraumatically injure the larger blood vessels and promote them to send capillary shoots into the graft more rapidly.

• It is advisable for the surgical assistant to hold the graft in place while the surgeon sutures it into place. The sutures should not be placed too close to the borders of the graft and a deep “bite” should be taken into the underlying CT to avoid the sutures pulling out during the healing process.

• The pontic teeth of the provisional bridge must be ground so that they make only light contact with the surface of the graft. Pressure from the pontic teeth or flange may inhibit revascularization of the graft.

• The palate takes about 2 weeks to heal when a partial thickness graft is harvested (it takes about 4-5 weeks with the full-thickness graft). The pts are instructed to not brush the site for a week and (if applicable) to not remove their RDPs for 24 hours after the procedure. If a second stage augmentation procedure is necessary, it is scheduled approximately 6 weeks after the initial procedure.

Seibert-2 1983                ARTICLE

P: To describe prosthetic and periodontal interrelationships involved in reconstructing deformed partially edentulous ridges with full thickness onlay grafts

Discussion: Objectives of the prosthodontist or generalist must be clearly defined and communicated to the periodontist.

Pros and perio factors:

1. Lip line: Resting lip line, lip line during speech, high smile lip line.

2. Type and extend of deformity.

3. Arch form.

4. Tooth form: Size and length of teeth.

5. Teeth position: Protruding contour of the teeth, midline of teeth, “root eminence”.

6. Relationship of the pontics to the abutment teeth and gingiva: Axial position of the pontics, embrasures, emergence form and profile from the gingiva (modified ridge-lap, ovate pontic design), color of the gingiva, surface characteristics (like scars and clefts).

Ovate pontics are recommended in high smile pts, but sufficient B-L ridge thickness should be achieved. The “socket” is made into the healed graft site and must be place midway b/w the labial and lingual ridge surface, and midway b/w the adjacent papillae. If the ridge is not sufficiently wide in B-L dimension, a modified “socket” can be made from the labial surface only. If the healed ridge