111. Esthetics : Recession                                     

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Etiology and Treatment (Root coverage):

• Free Gingival Graft

• Root coverage and increasing keratinized tissue

• Coronally Positioned Flaps

• Laterally positioned Flaps

Discussion Topics

What is(are) the known or suspected cause(s) of recession? Do you consider recession a pathologic or physiologic process? How do we classify recession? Is recession progressive? What is it’s relationship to the underlying bone?

1. Loe H, Anerud A, Boysen H. The natural history of periodontal disease in man: prevalence, severity, and extent of gingival recession. J. Periodontol 63: 489-495, 1992

2. Joshipura K, Kent R, Depaola P. Gingival recession: Intra-oral distribution and associated factors. J Periodontol 1994;65:864-870

3. Serino G, Wennström JL, et al. The prevalence and distribution of gingival recession in subjects with a high standard of oral hygiene. J Clin Periodontol. 1994 Jan;21(1):57-63.

4. Hujoel PP, Cunha-Cruz J, Selipsky H, Saver BG. Abnormal pocket depth and gingival recession as distinct phenotypes. Periodontol 2000. 39:22-9;2005

5. Rajapakse P et al: Does tooth brushing influence the deveopment and progression of non-inflammatory gingival recession? A systematic review. J Clin Periodontol 2007; Dec; 34(12)1046-61

6. Kapferer I, Benesch T, Gregoric N, Ulm C, Hienz SA. Lip piercing: prevalence of associated gingival recession and contributing factors. A cross-sectional study. J Periodontal Res. 2007 Apr;42(2):177-83.

7. Pires IL, Cota LO, Oliveira AC, Costa JE, Costa FO. Association between periodontal condition and use of tongue piercing: a case-control study. J Clin Periodontol. 2010 Aug 1;37(8):712-8. Epub 2010 Jun 17.

8. Endo, Rees, Hallmon, Kono, Kato: Self –inflicted gingival injuries caused by excessive oral hygiene practices. TexDentJ 2006 Dec; 123(12):1098-104

9. Miller PD. A classification of marginal tissue recession. Int J Perio Restor Dent 5:9 - , 1985

10. Lost C. Depth of alveolar bone dehiscences in relation to gingival recession. J Clin Periodontol 11:583-589, 1984.

11. Zimmer, Seifi-Shirvandeh: Changes in gingival recession related to orthodontic treatment of traumatic deep bites in adults: J Orafac Orthop; 2007 May; 68(3): 232-44

12. Closs L et al: Gingival margin alterations and the pre-orthodontic treatment amount of keratinized gingvia: Braz oral Res 2007 Jan – Mar: 21(1)58-63

What is the relationship of keratinized tissue and recession? Are patients who are lacking keratinized tissue more likely to develop recession? Are recessions on teeth with limited KG more likely to progress?

13. Maynard JG Jr, Wilson RD. Physiologic dimensions of the periodontium significant to the restorative dentist. J Periodontol. 1979 Apr;50(4):170-4.

14. Wennström J, Lindhe J. Role of attached gingiva for maintenance of periodontal health. Healing following excisional and grafting procedures in dogs. J Clin Periodontol. 1983 Mar;10(2):206-21.

15. Miyasato M, Crigger M, Egelberg J. Gingival condition in areas of minimal and appreciable width of keratinized gingiva. J Clin Periodontol. 1977 Aug;4(3):200-9.

What is the theory behind a free gingival graft? How does it heal? In which situations is a free gingival graft appropriate? Describe the technique you prefer for a Free Gingival Graft. Is there any difference if attempting to increase keratinized tissue vs covering recession? What are the drawbacks or complications of a free gingival graft?

16. Sullivan HC et al. Free autogenous gingival grafts. I. Principles of successful grafting. Periodontics. (1968)

17. Miller PD: Root coverage using the free soft tissue autograft following citric acid application. III. A successful and predictable procedure in areas of deep-wide recession. Int J Perio Restor Dent. 5(2):15-37, 1985.

18. Miller PD: Root coverage with the free gingival graft. Factors associated with incomplete coverage. J. Periodontol. 58:674-681, 1987.

19. Matter J. Creeping attachment of free gingival grafts - A five year follow-up study. J. Periodontol. 51:681-685, 1980

20. Agudio, G Nieri, M, Rotundo R., Cortellini P, Pini Prato G.: Free gingival grafts to increase keratinized tissue: A retrospective long-term evaluation (10-25 years) of outcomes. J Periodontol 2008 Apr; 79 (4):587 – 94 (ADD Erratum in : J Periodontol 2008 Jul 79(7):1312)

21. Freeman E: Development of the dentogingival junction of the free graft. A histologic study. J.Perio Res. 16:140-146, 1981.

22. Pasquinelli K. The histology of new attachment utilizing a thick autogenous soft tissue graft in an area of deep recession; A case report. Int J Perio Res Dent 1995; 15: 249-57.

What are the differences in recipient site preparation? Is there a difference in making a full thickness or split thickness site? What would you expect to see in the healing?

23. Dordick B, Coslet JG, Seibert JS. Clinical evaluation of free autogenous gengival grafts placed on alveolar bone. Part I. Clinical predictability. J Periodontol. 1976 Oct;47(10):559-67.

24. James WC, McFall WT Jr. Placement of free gingival grafts on denuded alveolar bone. Part I: clinical evaluations. J Periodontol. 1978 Jun;49(6):283-90.

What is a pedicle graft? What are the different ways this can be utilized to cover recession? How have the classic descriptions been modified over time? What is the role of citric acid? How does this type of procedure heal? How does this healing compare to the free gingival graft? How stable are these grafts?

25. Grupe H, Warren RF. Repair of gingival defects by a sliding flap operation. J Periodontol 27:92-95, 1956.

26. Grupe HE. Modified technique for sliding flap operation. J Periodontol 37:491-495, 1966

27. Smukler H, Goldman HM : Laterally repositioned "stimulated" osteoperiosteal pedicle grafts in the treatment of denuded roots - a preliminary report. J. Periodontol. 50:379-383, 1979.

28. Robinson RE. Utilizing an edentulous area as a donor site in the lateral repositioned flap. Periodontics 2:79- , 1964.

29. Caffesse R, et. al. Lateral sliding flaps with and without citric acid. Int J Perio Restor Dent 7(6):43-57, 1987.

30. Caffesse RG, Kon S, Castelli WA, Nasjleti CE : Revascularization following the lateral sliding flap procedure. J. Periodontol. 55:352-358, 1984

31. Common J, McFall WT : The effects of citric acid on attachment of laterally positioned flaps. J.Periodontol. 54:9-18, 1983.

32. Cohen DW, Ross S : The double papillae repositioned flap in periodontal therapy. J Periodontol 39:65-70, 1968.

33. Ross S, Crosetti H, Gargiulo A : The double-papillae flap - An alternative. I. Fourteen years in retrospect. Int J Perio Restor Dent 6(6):47-59, 1986.

Is the coronally positioned flap considered a pedicle graft? How useful is this technique to cover recession? Are there limitations to this technique? Histologically, how does this compare with lateral sliding or the double papillae flap? What are some modifications of this technique?

34. Bernimoulin JP, Luscher B, Muhlemann HR: Coronally repositioned periodontal flaps. J. Clin. Periodontol. 2:1-13, 1975.

35. Allen EP, Miller PD: Coronal positioning of existing gingiva: short term results in the treatment of shallow marginal tissue recession. J. Periodontol. 60:316-319, 1989.

36. Harris R, Harris A. The coronally positioned pedicle graft with inlaid margins: A predictable method of obtaining root coverage of shallow defects. Int J Perio Rest Dent 1994;14:229-241

37. Baldi C, Pini-Prato G, et al. Coronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage? A 19-case series. J Periodontol. 1999 Sep;70(9):1077-84.

38. Lucchesi JA, Santos VR, Amaral CM, Peruzzo DC, Duarte PM. Coronally positioned flap for treatment of restored root surfaces: a 6-month clinical evaluation. J Periodontol. Apr;78(4):615-23. 2007

39. Gottlow J, Nyman S, Karring T, Lindhe J: Treatment of localized gingival recessions with coronally displaced flaps and citric acid. An experimental study in the dog. J. Clin. Periodontol. 13:57-63, 1986.

40. Zucchelli G, Sanctis D. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol 71:1506-1514, 2000.

41. Zucchelli G, Mele M, et al. Coronally advanced flap with and without vertical releasing incisions for the treatment of multiple gingival recessions: a comparative controlled randomized clinical trial. J Periodontol. 2009 Jul;80(7):1083-94.

42. Tarnow DP: Semilunar coronally repositioned flap. J. Clin. Periodontol. 13:182-185, 1986.

Are there any techniques to increase keratinized tissue without a pedicle or a free flap? What are the requirements for this?

43. Carnio J, Camargo P, Passanezi: Increasing the apico-coronal dimension of attached gingival using the modified apically repositioned flap technique: A case series with a 6 month follow-up J Periodontol 2007Sep 78(9):1825-30

What is(are) the known or suspected cause(s) of recession? Do you consider recession a pathologic or physiologic process? How do we classify recession? Is recession progressive? What is it’s relationship to the underlying bone?

Loe 1992         ARTICLE
P: To describe the initiation, pattern of development, and progression of gingival recession in Norwegian and Sri Lankan population.
M&M: Data presented in this study on recession was obtained through parallel longitudinal studies of periodontal disease in man conducted in Norway between 1969-1988, and in Sri Lanka between 1970-1990. The Norwegian group consisted of 565 male high school and non-dental, non-medical university students and junior faculty between 17 and 30+ years of age. Norwegian patients reported seeing their dentist on at least an annual basis, owning a toothbrush and brushing their teeth daily. The Sri Lankan group (tea laborers) consisted of 480 male that were healthy but they had never received any dental care or any type of instruction on dental care. Gingival recession was measured on the 4 surfaces of all teeth (except 3rd Molars) from the exposed CEJ.
R: Norwegian group: In exams of 20year old subjects, 63% presented recession (between 1-3mm). It was confined almost entirely, to the buccal aspects of the maxillary and mandibular bicuspids and molars. Gingival recession was found in about 75% of 30year old men, still mainly on the buccal surfaces (13% had rec 1-2mm, 2% had rec 3-7mm). IPx surfaces were still unaffected. In the exams of men between 46 and 50 years old, more than 90% had 1 or more sites with gingival recession (26% on buccal surfaces and 4% IPx, 22% of the buccal rec was between 1-2mm and 4% between 3-5mm)
Sri Lankan Group: 29% of men 18 to 19 years old had recession, mainly confined to the buccal surfaces and did not exceed 4mm. By 30 years, 90% had recession on buccal, lingual and IPx surfaces. By age 40 approximately 100% had recession - 2/3 of which showed recession between 1-2mm and 1/3 between 3-9mm. 32% of the lingual surfaces showed recession. At 50 years, recession occurred in all teeth types and surfaces with 70% on the buccal, 40% in the IPx, and 50% on the lingual. 50% of the recession measured between 3-9mm.
For both groups the distribution of recession was bilaterally symmetrical.
Conc:
In both groups prevalence and severity of gingival recession increased with age
Gingival recession is something common in both patients with good OH -dental care and in patients with poor OH - no dental care.
Severity and extent of gingival recession was higher in tea laborers
Several factors determine the initiation and development of recession

Joshipura, 1994         ARTICLE

P: To assess the role of poor oral hygiene and forceful tooth-brushing as risk factors for recession.

M+M: 298 subjects (42-67 years old) with at least 1 tooth with >1mm recession examined. Oral hygeine index (debris: 0= no debris; 1=debris covering up to a third of the tooth or extrinsic stains; 2=debris covering more than a third to less than two-thirds of the tooth surface; 3=debris covering more than two-thirds of the surface; supragingival calculus: 0=no calculus; 1=up to a third of the tooth surface; 2=one third to two-thirds of the tooth surface; 3= more than two-thirds of the surface or a continuous band around the tooth), and GI measured . Analyses were performed on buccal surfaces.

R: Analysis of variance on subject means for buccal recession showed both calculus and presence of buccal root surfaces with abrasion to be significantly associated with recession after adjusting for age and gender.

59% of subjects had buccal abrasion.

Males had more recession.

Recession increased with age.

Premolars had high amount of recession and abrasion and low levels of calculus.

Molars had high levels of calculus and low levels of abrasion.

BL: OH probably plays an important role on recession in molars (due to poor OH), and abrasion in PMs (due to forceful brushing). Subjects with poor OH are likely to have more recession due to periodontal disease; patients who brush with excess vigor have recession due to trauma; tooth profile can also effect recession especially when associated with these two.

Serino 1994            ARTICLE
P: To evaluate the prevalence and the development/progression of attachment loss and gingival recession (rec) in a pts with good OH (PI < 30%, BOP < 10%). An additional aim is to study the realationship between ALoss and gingival recession.
M&M: Multi-center study (12 clinics) in Sweden with 225 pts on regular dental care included. Based on age, 4 cohorts were generated: 18-29, 30-41, 42-53, 54-65. All subjects had a baseline exam, and then another exam at 5 and 12yrs. The exam included PI, GI, PD, PALoss, and rec. FMX was taken at the different exams to determine periodontal bone support.
R: PALoss (>2mm ALoss on buccal surface) per age group: 18-29 (19%), 30-41 (52%), 42-53 (66%), 54-65 (76%).
Rec at baseline overall was 25%. Over 12 yrs, rec increased in all groups from: 18-29 (7 -> 19%), 30-41 (25 -> 33%), 42-53 (33 -> 44%), 54-65 (40 -> 46%). 33% of unaffected sites at baseline showed rec 12 yrs later, and 87% of sites showing rec at baseline displayed an increase in rec from baseline at 12 yrs. Maxillary molars and PM and mand incisors and PM were the most commonly affected at both at baseline and the 12-yr examination. Of the pts <30 yrs of age, 44% displayed rec. Of the pts >41pts of age > 90% displayed rec.
Buccal sites with 3mm of ALoss were associated with rec 67% of the time, while 98% of sites with PALoss of 4mm or more had rec. Only 3% of sites with buccal PALoss of 2mm displayed rec. By including the interproximal PALoss, interprox bone level, and OH parameters as explanatory variables, 58% of the variance of the dependent variable (buccal rec) could be explained.
Only 16% of tth with an intact interproximal periodontium had buccal rec. Tth with 3mm PALoss and 3mm interprox bone loss had rec 68% of the time.
D: Some buccal loss of attachment does not necessarily result in recession. Since rec is prevalent in subjects with very good OH and intact interprox periodontium, it is unlikely that perio dz can account for rec. In fact, rec was uncommon unless the buccal site and had at least 3mm of ALoss.
BL: Buccal rec was a frequent finding, the proportion of pts with rec increased with age, prevalence and incidence of rec within dentition showed different patterns depending on age, sites with rec showed susceptibility of additional rec, loss of approximal periodontal support was associated with rec at the buccal surface.

Hujoel 2005         ARTICLE
Purpose: To distinguish destructive periodontal disease from periodontal atrophy and explore criteria to define when pockets are abnormal.
Discussion: Periodontal atrophy: the gums retain a very health aspect, are free of pain and inflammation and yet will gradually recede. Destructive periodontal disease: presence of deepened periodontal pockets and underlying bone loss.
Treatment and economics: 90% of the periodontal procedures would be eliminated if periodontal pocketing disappeared. First, due to the insurance guidelines requiring pockets deeper than 4mm. Secondly, because the rationale behind most (not all) periodontal procedures is the elimination of deep pockets. Economic implications of abnormal pocket depth suggest that its incidence should be tracked as a distinct clinical entity.
Etiology: Osteoporosis, aging , continuous eruption, aggressive oral hygiene procedures and anatomic periotypes have been suggested as potential causes of periodontal atrophy.
Smoking and diabetes are considered the primary driver of destructive periodontal disease.
The biologic basis for claiming that both phenotypes are the result of plaque is mostly supported by assumption for the periodontal atrophy, since no such evidence have been presented over the last 30 years.
The anthropologic and comparative medicine features of destructive periodontal disease and periodontal atrophy are different. Studies of 23 different population groups around the world suggest that age related alveolar bone loss is a normal physiologic process, an observation which is at odds with current thinking that any attachment loss is pathologic and the result of an inflammatory process caused by plaque.
Authors believe that if pocket-free recession (periodontal atrophy) is labeled a destructive periodontal disease, we will end-up with the “anomalous situation” of being close to 100% of individuals with signs of chronic periodontitis.
Is periodontal atrophy a disease? Attachment loss is almost universal after the age of 30 and increases with age. Wear-and-tear of aging affects every organ system in the human body. It appears logical that periodontal atrophy is a normal age-related process.
Abnormal periodontal pockets: Currently all definitions of periodontal diseases are arbitrary, which should be cause for alarm. Normative values may be superior to arbitrary values. These values can be based on parametric or nonparametric percent of cut-off values.

Diagnoses based on these values though are irrelevant to underlying factors (diabetes, smoking) and can become disconnected from clinical realities (tooth loss, periodontal abscesses, difficulty chewing). Destructive periodontal disease is a complex disease with too much natural variability to allow a successful definition based on arbitrary or normative values. The most attractive diagnosis is the therapeutic diagnosis. A person is screened for the disease only if the diagnosis lease to better outcomes. Critical PDs are the example of therapeutic reference values in periodontitis, although the shortcoming is that no evidence exists that short term changes in attachment levels relate to clinically relevant outcomes such as tooth loss.

Conclusion: Destructive periodontal disease and periodontal atrophy are two phenotypes with distinct clinical features. Different lines of evidence suggest that the two phenotypes have distinct etiologies, prognosis and are treated differently. The current custom of labeling both phenotypes as one and the same disease, chronic periodontitis, merely because they both exhibit attachment loss, needs to be re-evaluated. This will involve evaluating whether periodontal atrophy should be labeled as a disease.

Rajapakse 2007:         ARTICLE
Purpose: The aim of the systematic review was to search for the best available evidence to evaluate potential role of tooth brushing in the initiation and progression of non-inflammatory, localized gingival recession.
Materials and methods:
The focused question of the review was” Do factors associated with tooth brushing predict the development and progression of non-inflammatory gingival recession in adults?”
The search covered six electronic database b/w Jan 1996-July 2005. Hand searching included searched of J Perio, J of Clin perio, J of Perio Reas.
Results:
29 papers were read and 18 texts were eligible for inclusion. One was RCT (Level I evidence) and 17 were observational/cross-sectional study (Level III evidence).
IN RCT, author concluded that the toothbrushes significantly reduce the recession on buccal surface of the tooth over 18 months.
Of remaining 17 studies, 2 concluded that there is no relationship b/w tooth brushing frequency and recession.
8 studies concluded with an association b/w brushing frequency and recession.
No study concluded the potential risk factor like duration, force, frequency of changing of tooth brushes, and brushing technique or the confounding factors like age, biotype, crowding, ortho TX was controlled.
None of the observational studies satisfied all the specified criteria for quality appraisal.
Conclusion:
1. Data supporting the association b/w brushing and recession are inconclusive
2. Tooth brushing factors that have been associated with the development and progression of the recession are frequency, technique, force, and hardness of the bristles.
3. The limited evidence of one RCT suggests that the tooth brushing either powered or manual and with standardized instructions in tooth brushing technique may reduce the severity of recession. Important conclusions to remember

Kapferer I  2007            ARTICLE

Purpose: To assess the prevalence and severity of periodontal and dental complications with the contributing factors of gingival recession associated with labial piercing.

M&M: A cross sectional study was performed on 100 (14-28yrs) patients with lower-lip studs. The test and control groups were matched according to the gender, age and smoking status. Clinical examination included plaque and bleeding indices, probing depth, recession, clinical attachment level, width of keratinized gingiva, periodontal biotype, frenula attachment, evaluation of hard tissues, trauma from occlusion, stud features, radiographs and photographs of the lower front teeth.

R: NSSD was observed in the mean probing depth, plaque control, and bleeding on probing of the test group compared to the controls. No significant correlations were observed with the prevalence of buccal recessions a the distribution of periodontal biotype between groups. Amount of buccal recession (occluso-apical and mesio-distal) and avg width of keratinized gingiva were significantly higher in test group compared to the controls. Localized periodontitis was recorded in 4% of test subjects. There were no significant associations between piercing and abnormal tooth wear. Time since piercing and the position of the stud in relation to the cemento–enamel junction were significantly associated with the prevalence of buccal recessions.

BL: Labial piercing was found to be significant factor in the development of the buccal recession in the mandibular anterior teeth. Narrow width of keratinized gingiva is associated with higher amounts of buccal recession.

Pires 2010            ARTICLE

P: Cross sectional study to evaluate the periodontal status and risk factors for gingival recession in individuals with tongue piercings.
M: 60 individuals w tongue piercing and 120 w/o were examined from schools and universities in Brazil b/t 13 and 28 y/o, entire sampling was taken from low socioeconomic status. recorded PD, CAL, plaque index, BOP, recession and tooth fracture
R:The case group presented with a higher prevalence and severity of recession when compared to the control group. The prevalence of recession in the anterior lingual mandibular region was associated with the use of piercings, male gender and BOP.
Recession in the lingual of anterior mandible region presence: case: 55% control: 10%
case: 23% had 1-2mm
13% had 3mm
18% had  4mm
control: 10% had 1-2mm
BL: Use of tongue piercings has a strong association with gingival recession in ant lingual mandibular area.
Side note: prevalence of periodontitis for case: 11.7 and control 4.2
localized severe (either man or max: 6.7 and control 1.77
36.7% reported swelling and infection/inflammation
20% reported fractured teeth

Endo ‘06             NO ARTICLE
Case series: Self inflicted gingival injuries caused by excessive oral hygiene practices
Categorized as Non-plaque induced gingival lesion. Physical injuries are classified as: Accidental, Iatrogenic (acute and self-limiting) and Self-inflicted (SI) (chronic). SI can be deliberate injuries usually associated with emotional disturbances. In kids SI are due damage with their fingernails and in adults due excessive oral hygiene practice. SI can cause: ulcers, erosions, retractions, hyperkeratosis, CAL and destruction of teeth.

Case I
Female pt, 1-month history of pain and bleeding on the buccal gingiva. Marginal gingiva was rolled, horizontal groove in the base of the papilla, linear ulcer #28, white plaque like changes in papilla and marginal gingiva. Brushed teeth 30 min a day due fear to loose more teeth with hard nylon toothbrush (TB), no toothpaste and horizontal motion. Dx: Excessive and improper tooth brushing. Instruction: Use soft TB, 2 min, twice a day. Signs disappear within 2 weeks.

Case II
Female pt, 3-month history of pain in the gingiva. Horizontal erythematous groove in the base of the papilla, abrasion, white plaque like changes in papilla detach with contact. History of 6 Rx for depression and dry mouth. Brushed teeth 30 min a day/ 3 times because she felt mouth uncomfortable. She used TB and no toothpaste. Dx: Excessive and improper toothbrushing. Instruction: Brush 2 min, twice a day. Use salivary substitute (biotene). Signs disappear within 1 week.

Case III
Female pt, 1 year hx of painful gingiva in ant mand teeth, loss of tip of papilla. Lesions similar to NUG, lingual ant had lobulated appearance, recession, gingival clefts, white plaque changes, v-shaped gingival recessions present. Good medical hx. Pt was concerned with periodontal disease. Pt used interproximal brush (IB) around 2 hours a day (she inserted back and forward 100 times in each space b/w teeth, 3 times a day). Dx: Gingival trauma. Instructions: Stop use of IB, use medium TB twice a day for 2 min. Gingival cleft and white plaque lesion disappeared by follow up 1 month later. Lingual gingival enlargements disappeared as well.
Conclusion:
Due fear of periodontal disease, these 3 pts practiced excessive tooth brushing. It is important to interview the pts about their oral hygiene practices and ask them to show you. Saliva function as a “blanket” that protects the soft tissue. Pts with xerostomia need to be aware of possibility of tissue damage. Salivary substitute may be beneficial for them. Abrasion of teeth may be related to toothpaste. No interproximal abrasion in any teeth was noticed on case #3.

Miller,1985            ARTICLE

P: to classify marginal tissue recession.

Disc:

Class I: Marginal tissue recession which does not extend to the MGJ. No bone loss in interdental area & 100% root coverage is expected.
Class II: Marginal tissue recession which extends to or beyond the MGJ. No bone loss in interdental area & 100% root coverage expected.
Class III: Marginal tissue recession which extends to or beyond MGJ. Bone or soft tissue loss in interdental area is present or there is malpositioning of teeth which prevents the attempting of 100% root coverage. Partial coverage is expected.
Class IV: Marginal tissue recession to or beyond MGJ. Bone or soft tissue loss in interdental area &/or malpositioning of teeth is so severe that root coverage cannot be anticipated.
Root coverage is considered to be 100% if the marginal tissue after complete healing is at CEJ & sulcus depth is 2mm or less and there is no BOP.
Root coverage is either primary, which occurs immediately following grafting, or secondary, which is known as “creeping attachment.”

Lost, 1984            ARTICLE

P: To assess the relationship between bony dehiscence and gingival recession.
M&M: Periodontal flap surgery was performed in 50 recession areas, 113 affected teeth, in 27 patients (mean age 25.6 years), and pre-operative and intra-operative dehiscence measurements were taken (most apical portion of dehiscence to most apical portion of CEJ). All recessions met the following criteria: located facially, intact interdental papillae adjacent to area of recession, no interproximal bone loss, absence of tooth mobility, absence of periodontal pockets and no or minimal gingival inflammation.
R: Mean recession and dehiscence depth were 2.67mm and 5.43mm respectively. The difference between these measurements – 2.76mm – consists of 0.82mm sulcus depth, 0.63mm epithelial attachment and 1,22mm connective tissue attachment. Of the 113 examined teeth, 16 presented markedly greater distance (4-7.5mm) between the gingival margin and the alveolar bone crest. A correlation between dehiscence depth and type of tooth could not be found, but the 1/3 of these 16 teeth presenting 4mm or more between dehiscence depth and recession were lower canines.
C: In average, a recession depth of 1mm is exceeded by 2.8mm towards the apex of the alveolar bone dehiscence. Almost identical with the value reported by Gargiulo (2.73mm). Each 1mm increase in recession depth involves an average of .98mm in the alveolar bone dehiscence.

Zimmer, 2007            ARTICLE

P: To study the effect of orthodontic intrusion on trauma-induced recessions
M+M: 12 patients (8F, 4M; average age 38 years) with >6 mm overbite, and recession on at least one incisor caused by direct trauma from contact with opposing dentition. Five had Class 2 Div1 and seven had Class 2 Div2. 6 patients had history of periodontal treatment. All patients received fixed appliances and were treated by intrusion, one patient was taken out of the study due to recurrence of periodontitis, all were on a 6 week maintenance schedule. 41 teeth in total had recession, measured clinical crown lengths intra-orally, on casts and on photographs with an electronic precision sliding gauge. PDs were also measured. Teeth without trauma served as controls.
R: Four teeth excluded due to signs of incisal edge abrasion. At the end of treatment the clinical crown measurement of teeth with recession had SS decreased by an average of -2.05 mm (max decrease was –3.2 mm, the min decrease was –0.9 mm; no increases were observed). The average change in teeth without recession defects was NSS and 0.02 mm (range of -1.2 to +2.4). No changes in PDs noted.
BL: Orthodontic treatment is effective in reducing recession caused by trauma from deep overbite, and in teeth without trauma it can improve gingival marginal contour

Closs 2007             ARTICLE
P: To associate the amount of keratinized gingiva present in adolescents prior to orthodontic treatment to the development of gingival recessions after the end of treatment.
M&M: Retrospective study. The sample consisted of the intra-oral photographs and orthodontic study models from 209 Caucasian patients with a mean age of 11.20 +/- 1.83 years on their initial records and 14.7 +/- 1.8 years on their final records (28 days or more after removal of their appliances). Patients were either Angle Class I or II and were submitted to non-extraction orthodontic treatment. The spacing or crowding in the lower anterior teeth could not exceed 4mm. Gingival recession was evaluated by visual inspection of the lower incisors and canines as seen in the initial and final study models and intra-oral photographs. The amount of recession was quantified using a digital caliper and the observed post-treatment gingival margin alterations were classified as unaltered, coronal migration of the gingival margin or apical migration of the gingival margin. The width of the keratinized gingiva was measured from the mucogingival line to the most apical point of the gingival margin at the center of the facial aspect of the teeth on the pre-treatment photographs.
R: The teeth that developed gingival recession and those that did not have their gingival margin position changed did not differ in relation to the initial amount of keratinized gingiva (3.00 +/- 0.61 and 3.5 +/- 0.86 mm, respectively). Paradoxically, teeth that presented a coronal migration of the gingival margin had a smaller initial amount of keratinized gingiva (2.26 +/- 0.31 mm).
C: The mean amount of initial keratinized gingiva did not predispose lower incisors and canines to gingival recession
CR-What matters more is the direction of the ortho movement: if labially, outside of natural alveolar house, recession will occur.

What is the relationship of keratinized tissue and recession? Are patients who are lacking keratinized tissue more likely to develop recession? Are recessions on teeth with limited KG more likely to progress?

Maynard 1979             ARTICLE
Purpose: To present the physiologic dimensions of the periodontium significant to the restorative dentist.
Discussion: Physiologic dimensions have been classified as superficial physiologic, crevicular physiologic and subcrevicular physiologic.
Intracrevicular margins are the ones placed into the gingival crevice and are different than subgingival margins that can extent into the junctional epithelium and connective tissue, which causes gingivitis that may progress to periodontitis.
Superficial physiologic dimension extends from MGJ to gingival margin. If there is insufficient attached gingiva restorative procedures may result in apical migration of marginal tissue and attachment apparatus. In these cases preprosthetic surgery should be considered. Adequate band of KG is fundamental to successful restorative dentistry with intracrevicular margins. 2mm of free gingiva and 3mm of attached are required. Thickness of gingiva should also be evaluated. If the probe is visible through the free gingival margin, width should be increased.
When marginal tissue recession is present prior to the restoration two stage approach (increase in KG – root coverage) should be performed.
Normal depth of gingival crevice is 0 to 3-4mm. To prepare a tooth for intracrevicular margin a minimum depth of 1.5-2mm should be present. If it less than that junctional epithelium will be traumatized during restorative procedures. After periodontal surgery restorative procedures should be delayed for at least 6 weeks. Margins of restorations should not be rough and poorly adapted because that will result in mechanical irritation and plaque retention.
Subcrevicular physiologic dimensions are on average 0.97mm for JE and 1.07mm for connective tissue according to Gargiulo, Wentz and Orban, and violation of these could cause periodontal disease.
Trauma from occlusion will cause reversible mobility in healthy periodontium. If inflammation is caused because of the restorations, it will result in more rapid periodontal destruction.
Conclusion: The first and most basic objective of restorative dentistry is preservation of the teeth. Function, comfort and esthetics are also considered and margins are intracrevicular although it is widely accepted that the best option is supragingival. Daily observation of the three physiologic dimensions permits the therapist to restore teeth with minimal injury to the periodontium.

Wennstrom & Lindhe, 1983            ARTICLE

Purpose: Evaluate the effect of plaque infection on gingiva w or w/o AG and with different height of the attachment apparatus.
Materials and methods:
Created 4 different dentogingival units in 7 dogs to determine differences in resistance to inflammation
1. Normal  nonoperated , KG present
2. Normal  excised KG and allowed reformation Narrow KG, no AG, n. height of supp. app.
3. Periodontal breakdown – excised – ungrafted. Narrow KG, no AG, low height of supp. app
4. Periodontal breakdown  grafted. KG present, AG, low height of supp. app
They allowed plaque to accumulate for 40 days
Clinical exam at day 0, day 20 & day 40 (PI, GI, Gingival Exudate, PD, AL, GM, AG)
2 dogs randomly chosen for biopsy and sacrifice to perform histology prior to plaque accumulation.
Results:
Gingiva regenerated postexcision and postgrafting is clinically and histologically similar to normal gingiva.
Unit w/no AG had FG w/ thinner B-L & keratin layer.
3. After 40d of plaque accumulation, there was NSD btw dentogingival units regarding size and apical extension of infiltrated portion of CT or GCF.
4. FG unit supported by alveolar mucosa is not more susceptible to inflammation than a FG unit supported by a wide zone of AG.
BL: The presence or not and the width of AG has an effect on the clinical evaluation of inflammation of the gingival but no effect in a histologic level. Supports Miyasato; Contradicts Lang & Loe, Bowers.
Cr- is 40 days long enough? This supports the clinical observation of teeth with little or no AG remaining in a steady state for years.

Miyasoto 1977            ARTICLE

P: To evaluate gingival conditions in areas of minimal and appreciable width of KG.
M&M: 250 dental, dental hygiene and dental assisting students and dental faculty were screened. 16 subjects were selected, age 19-39. 6 of them had one lower PM with a width of KG ≤1mm and a PM with width of KG ≥ 2mm on the opposite side (contralateral pair). The remaining pts had width of KG ≤ 1mm on one PM and ≥2mm on another PM on the same side (unilateral pair). Subjects with high frenum attach were excluded. Measured GE, GI, sulcus depth, PI, AG. The 6 pts with contralateral pairs were used for experimental gingivitis study- asked to cease OH and were re-examined at 4,7,11,14,18,21,25 days and measured GE, PI, and GI.
R: Mean width of KG were 0.7mm and 2.3mm for the study pairs. None of the teeth with minimal KG (≤1mm) had any amount of attached gingiva. 0/16 showed presence of plaque on mid buccal surface, 2/16 with min width of KG showed sigs of GI/color change/swelling. No areas showed BOP in either ≤1mm or ≥2mm KG. NSSD between the groups for GE. For the experimental gingivitis, there was a gradual and similar increase in plaque and GE for both groups. Not until day 25 did buccal areas show signs of inflammation, 6/6 areas with KG ≤ 1mm showed inflammation and 4/6 areas of ≥2mm KG showed inflammation.
C: Gingiva with ≤1mm of KG and ≥2mm of KG only exhibit minute amounts of gingival exudate, which correlated with lack of clinical signs of inflammation for both types of marginal gingiva. After the 25 day experimental gingivitis, there was only a gradual increase in PI. There was no diff in GE in areas with min or appreciable KG. This may indicate that areas of min width of KG are no more prone to the development of plaque-induced inflammatory changes than areas of appreciable width of KG.
BL: Over the 25 day period, there was in increase in plaque and GI and clinical inflammation, with no apparent difference between the areas with minimal or appreciable width of KG.

What is the theory behind a free gingival graft? How does it heal? In which situations is a free gingival graft appropriate? Describe the technique you prefer for a Free Gingival Graft. Is there any difference if attempting to increase keratinized tissue vs covering recession? What are the drawbacks or complications of a free gingival graft?

Sullivan 1968            ARTICLE

P: report our observation on free gingival grafting and to attempt to correlate the surgical principles previously developed in plastic surgery to the conditions encountered in periodontal
Recipent site:
The most important is the capacity of the recipient bed to form capillary outgrowths for vascularization of the graft.
Adequate hemostasis. Bleeding site will separate the graft and form a hematoma.

Procedure for recipient site preparation:
Allow adequate time for hemostasis – control bleeding.
Epithelium, CT, and muscle fibers are sharply dissected down to the periosteum.
Donor site:
Edentulous ridge
Avoid visible postextraction scars, decreased vascularity
Attached gingiva
Limited, not suitable when inflamed and hyperplastic. Requires reshaping.
Palatal mucosa (most common)
Submucosa should be removed wit ha scalped before grafting, it will act as a barrier both to diffusion and vascularization.
Greater palatine foramen/vessels – may limit the surgical site.
Grafts types: Full thickness and intermediate or thick split thickness gingival grafts.
Thicker graft will undergo greater immediate contraction upon detachment from the donor area (higher elastic fiber in the graft)
Secondary contraction is caused by cicatrization of the tissue, which unites the graft and its base.
A thick graft on a rigid bed offers maximum resistance to cicatrix contraction and thus will undergo little secondary contraction.
Graf survival is enhanced by decreasing the amount of lamina propria in the graft. Thinner graft can be more easily maintained by diffusion and is easier to vascularize.
However, thicker graft is indicated in area where greater functional demands are anticipated (it’s resistance to functional stress)
Procedure for Donor site preparation:
A tin foil or wax template may be made on the recipient bed.
Atraumatic removal of donor tissue is the most important aspect.
An access incision is made at a 45 degree angle adjacent to the outline of the graft. This assists the surgeon in achieving the desired graft thickness.
The donor tissue is placed in the recipient bed as soon as possible to min trauma and dehydration.
Immobilization of the graft (VERY IMPORTANT)
in area lacking vestibular depth at the recipient site – this condition may be corrected by performing a vestibular extension in conjunction with preparing the recipient site.
The steps in immobilization
Suturing:
The graft is stretched to conform to the recipient bed. This tension counteracts primary contraction and aids in vascularization by reopening the graft’s collapsed vessels.
Minimal number of sutures is used (author used 5-0 teflon-coated Dacron suture with an atraumatic needle)
Formation of a fibrin clot.
After suturing, Pressure is exerted against the graft for 5 mins to displace blood under it. Fibrin clot anchors the graft to its bed, allow rapid penetration by capillaries, and act as a matrix through which metabolites and waste products diffuse.
Placement of the rubber dam – functions as a sliding film btw the dressing and the graft (reduces the shearing forces that prevent vascularization.
Dressing – maintains a positive pressure on the the graft and aids in its immobilization.
Stages of a graft “Take”
Plasmic circulation – diffusion of the graft from its host bed and occurs most efficiently through the fibrin clot.
Vascularization – capillary proliferation (end of 1^st day) -> extended into the graft (2-3^rd day) ->circulation (3^rd day) -> adequate blood supply (8^th day)
Organic union (4-5^th day) – a fibrous attachment is complete by the 10^th day.
Post-Op care
Recipient site:
The first 6 days – the pt is instructed to minimize facial movement.
Do not remove the dressing before the 6^th day.
If infection is present, remove hematoma formation or infection- redress for an additional 5 days.
Donor site:
Protected by a dressing until it has epithelized.
Thinner split-thickness grafts heal faster
Full thickness require primary closure or coverage.
Problems and possible limitation
The capacity of the recipient bed to form capillary outgrowths, hemostasis of the recipient bed, atraumatic handling of tissue, rapid vascularization of the graft, adequate immobilization during healing, and proper post-op care.

Miller ‘85            ARTICLE

Purpose: To measure the root coverage using a free soft tissue autograft following citric acid (CA) application.
M&M: 100 consecutive marginal tissue recession on 49 females and 9 males. Width of the recession was constant (around 3mm), but depth (marginal tissue recession + PD) was very variable 2-14mm. Control group was discontinued after recession and sensitivity were present 10 days post op in 3 control pts. Technique: CA solution of pH1 mixed with anhydrous CA crystals (15 min allowed for dissolution) were used in combination to make the CA super-saturated. CA on a cotton pellet was used to “burnished” the root surface. The cotton was change 2-3times a min, and the area was “burnished “for 5min. CA was flushed with abundant water. After CA application incisions were made. The horizontal incision in made in the interdental papilla at the level of CEJ. Vertical incisions made at prox line angles of adjacent teeth. Retracted tissue was completely excised. Care was taken to maintain intact periosteum. Graft was removed from the donor site using a “dry” foil pattern. Most (but not all) of the submucosa (glandular and adipose tissue) is removed by sharp dissection. The inner surface of the graft was as smooth as possible. Thus avoiding “dead space”. Resorbable sutures were used on each papilla after positioning the butt joint of the graft close to the butt joint of the papilla. 2 additional interrupted sutures were placed in each corner of the graft and into the periosteum. Coe-pak and adhesive “dry” foil was placed for 2w. Criteria: 100% root coverage (RC) was considered when gingival margin was at CEJ, PD 2mm and no BOP. RC was considered primary if it was found at 10w post-op or secondary if obtained after 10w. If RC was not 100% at 10w, a recall visit at 1y was performed to see if 100% RC could be obtained by a secondary RC. Class I recession were included only when were next to a class II or III, if had been isolated grafting wouldn’t be needed.
Results: 100% RC is attainable only in class I and II. In class I and II 100% RC was obtained in 71 of 79 sites 90%, partial in 4 of 79 (5%) and no RC in 4 of 79 sites (5%). Averaged of overall gain was 3.79mm and of probing attachment gain 4.54mm. Class I recession: 100% RC on all 13 sites. Class II: 100% RC on 58 of 66 sites (88%). Only 1 tooth need RCT after therapy (it had 5mm recession, 6mm PD, hx of ortho tx and vitality was not performed bf sx.
BL: Complete RC can be successful and predictable using soft tissue graft and the right concentration of citric acid as a one stage procedure.
Ctq: Some sites need a 2^nd stage for complete RC. No control groups.

Miller 1987            ARTICLE

Summary: Complete root coverage has been defined according to the following criteria:
A) The soft tissue margin must be at the CEJ. B) There is clinical attachment to the root. C) Sulcus depth is <2mm D) No BOP. Failing to address certain factors can result in incomplete root coverage.
Factors associated w/ incomplete coverage:
1. Improper classification of marginal tissue recession. First step in predicting is classifying recession.
2. Inadequate root planing, not creating anatomy conducive to root coverage.
3. Failure to treat the planed roots w/ Citric Acid. Surface changes after conditioning w/ CA include widening of the dentinal tubules, removal of the smear layer, accelerated healing w/ accelerated re-attachment, inhibition of epithelial migration, and the formation of a CT attachment. Do this prior to preparing recipient site as CA causes coagulation of blood.
4. Improper prep of the recipient site. The horizontal incision must be made at the level of the CEJ. If the incision is made apical to the CEJ, complete root coverage should not be contemplated. Author recommends creation of a butt joint margin in the papilla to enhance circulation to the coronal aspect of the graft. Vertical incisions should be made at the line angles of adjacent teeth. Recipient site should be prepared a minimum of 3 mm apical to the recession.
5. Inadequate size of the interdental papillae. The broader and thicker the interdental papilla, the greater the blood supply to the coronal aspect of the graft and the easier the suturing.
6. Improperly prepared donor tissue. The undersurface of the graft should be flat and smooth w/ the graft having the same type of butt joint margins as those created in the papilla.
7. Inadequate graft size (too much better than too little) / Inadequate graft thickness (thicker better).
8. Dehydration of the graft. Place graft immediately on a bleeding recipient bed to minimize dehydration.
9. Inadequate adaptation of graft to root and remaining periosteal bed. Failure to stabilize graft.
10. Excess or prolonged pressure in adaptation of sutured graft.
11. Reduction of inflammation prior to grafting. A bleeding papilla may enhance circulation to the coronal margin of the graft.
12. Trauma to graft during initial healing. Examples include: loose dressing, excessive edema, or stretching or manipulating the lips, and incising foods that can loosen dressing. Give adequate post op instructions.
Excessive smoking. 100% correlation b/w failure to obtain root coverage and heavy smoking (in excess of 10 cigs/day). Heavy smokers should refrain from smoking during the 1st 2 post-op wks.

Matter, 1980*         ARTICLE

Background: creeping attachment is a post-op migration of the free gingival margin in a coronal direction covering partially or totally a previously denuded root.
P: To report creeping attachment subsequent to placing a free gingival graft in areas of narrow recession, over a 5 year follow-up period.
M&M: 10 patients (9 Females, 1 Male), age 25-45. Isolated narrow recessions, <3 mm in width. After OHI and initial therapy measured 1) recession 2) width of exposed root surface at the level of the CEJ. The recipient bed was extended several millimeters on each side and epithelium was removed by sharp dissection. Root instrumented, coronal margin of graft sutured at the level of CEJ. Dressing for 7 days. At 1 month, 1 year and 5 years photographs and clinical measurements were taken.
R/Disc: In all cases, attached gingiva increased and recession stopped. Coverage of recessions mainly by Creeping Attachment. Bridging noted in 4 cases. Creeping Attachment occurred between 1 month and 1 year; between 1-5 years, no creeping attachment was observed. Mean coverage obtained was ~ 70%. .
Another study is quoted for the amount of creeping attachment. According to Bell creeping attachment occurred during a period of 1 year after the surgery with an average of 0.890.46mm.

Agudio, 2008            ARTICLE

P: To evaluate changes in the amount of keratinized tissue (KT) and in the position of the gingival margin after free gingival graft procedures over a period of 10 to 25 years.
M+M: 103 subjects presenting with 224 sites completely lacking attached gingiva associated with gingival recessions were treated in a private practice. The experimental sites were treated with FGGs. The grafts were positioned at the presurgical level of the gingival margin or in a submarginal position. Clinical variables, including recession depth, amount of KT, and probing depth (PD), were measured at baseline (T0), 1 year after surgery (T1), and at the end of the follow up period (10 to 25 years) (T2) and analyzed using descriptive statistics and multilevel models.
R: At 1 year after surgery (T1), overall in the experimental sites the recession associated with the lack of KT was reduced 0.8 mm (shift coronally), the mean amount of KT was increased 4.2 mm, and the mean PD remained stable.
At the end of follow-up (T2), an additional reduction in mean gingival recession was observed was 0.6 mm (shift coronally), the mean amount of KT was reduced slightly with respect to the 1-year measurement by -0.7mm, and mean PD remained stable.
BL: Gingival augmentation procedures performed in sites with an absence of attached gingiva associated with recessions provide an increased amount of KT associated with recession reduction over a long period of time.

Freeman, 1981             ARTICLE
P: To investigate the histology of the dento-gingival junction formed from FGG placement.
M&M: 4 monkeys received FGG secured with cyanoacrylate (no sutures), covered with dressings and acrylic stints. Sacrificed d at 1, 2, 3, 4, 5, 6 weeks post op. Formalin was perfused and areas prepared for histological evaluation.
R: 2 weeks –epithelium migrated to tooth from facial aspect of graft; had wide intercellular spaces in “disturbed” connective tissue;
4 weeks – inflammation in connective tissue resolved, lamina propria matured; epithelium keratinized; At the tooth surface: Connective tissue seen against the tooth was inflamed and dento-gingival junction formed over this; sulcular epithelium not keratinized; junctional epithelium had wide intercellular spaces. This remained virtually unchanged for the rest of the experiment.
C: It is suggested that the use of the FGG be seriously questioned. This tissue does not provide a more effective barrier to antigens of plaque than the dento-gingival junction normally found (the authors just state this because they feel this way).
BL: The dentogingival junction developed from FGG grafts consisted of non-keratinized epithelium supported by “disturbed” connective tissue.
Cr: Explains the histological aspect of FGGs in monkeys, but it does not prove that this tissue is not as effective as normal dentogingival junction tissue. No mention of any OH measures given to monkeys.

Pasquinelli 1995             ARTICLE
Purpose: To present a case report detailing the histology of attachment between the root surface and a thick autogenous epithelial and connective tissue graft.
Case report: 40-year old female with 6mm of recession on mandibular left premolar and 5mm of recession on mand left canine. PDs were about 2mm. After root instrumentation, root surfaces were etched with tetracycline solution for 3min. Partial thickness flap was created and a 1.5mm thick FGG was taken from the palate. Graft was placed at the level of the CEJs and extended 3mm to the extent of recession in all directions. Periodontal dressing was placed for 7 days. Ten weeks later canine had 0 recession and premolar 0.5mm. Several month laters pt decided to undergo ortho treatment and the premolar was extracted with the surrounding tissues and histology was performed.
Results: Pre-op recession was 6mm and post-op histologically 1mm. Length of junctional epithelium was 2.6mm. Newly formed bone was found 5mm from the CEJ with a zone of osteoblasts extending 0.4mm coronally. The amount of new bone was 4mm.
Most coronal evidence of new cementum with perpendicular connectivce tissue fibers was seen 4.4mm apical to the CEJ.
New connective tissue attachment was 4.4mm.
Conclusion:5mm of root coverage in an area of 6mm recession (83%)
2.6mm of epithelium
4.4mm new attachment
4mm new bone
No new cementum was found in areas where all the old cementum had been removed from the root.


What are the differences in recipient site preparation? Is there a difference in making a full thickness or split thickness site? What would you expect to see in the healing?

Dordick 1976             ARTICLE

Purpose: to study if it is more appropriate clinically to place the graft tissue on denuded bone in order to obtain fixed attached base rather than a mobile periosteal base.

Materials and methods

• 60 cases requiring free autogenous gingival grafts. The indications for grafting included inadequate zones of attached gingiva and/or gingival crevices that could be probed to the mucogingival junction.

• 2 groups, Group A had intermediate split thickness free autogenous grafts from palate placed on a recipient bed of denuded alveolar bone. Group B had a similar donor placed on a clinically acceptable bed of “periostium” and/or CT.

• Cases were followed up from 7 days up to 1 year in some cases.

Results/Conclusion

• All 60 grafts were clinically successful including the 30 in denuded bone.

• There was statistically no difference between the pain levels in group A and B, although the grafts placed on denuded bone were slightly more comfortable

• Healing lag existed in the grafts placed in denuded bone. On patients with bilateral grafts A and B Type B seemed to be several days behind in the healing during the first 2 weeks then it caught up by the third week.

• Less operative postop swelling and better hemostasis on type B

• More than one half (17/30) of the type A (denuded bone) exhibited mobility by 6 months, in either antero-posterior, or apico-coronal or both, while none of the grafts placed on denuded bone moved. 

• No infections or sequestrations were noted in any case

James 1978     Part I-Clinical Evaluations             ARTICLE
P: To study the placement of FGGs on denuded bone
M&M: 14 pts ages 27-56 yo who needed 6 or more extractions and removable prosthesis were included in this study. OHI were given and patients needed to be at 20% or below plaque score before surgery. All patients received initial therapy before surgery. Each patient was treated on the L side of mandible by placement of a FGG on denuded bone and 12/14 pts had a FGG on retained periosteum on the R side of the mandibular anterior region. (One FGG was placed on a recipient bed with half denuded bone and half on retained periosteum). To ensure removal of all periosteal fibers the bone was thoroughly scraped with a back action chisel producing a bleeding response from the subjacent marrow spaces. The graft was tattooed with india ink to measure shrinkage.
R: All surgical sites for up to 24 weeks demonstrated graft “take” and lack of clinical graft mobility on both control and experimental graft sites. Clinical measurements suggested a 1.5-2 fold increase in shrinkage of grafts placed over periosteum when compared to grafts placed on denuded bone- which was most significant from the 1 to 12 week post op healing interval. Control and experimental grafts both had an increase post-op tissue thickness. Subjective evaluation of post op pain suggested no differences between the surgical techniques.
BL: Clinically, a FGG on denuded bone is a reliable and feasible method for treatment of a lack of attached gingiva in selected cases with a sufficient thickness of pre-operative alveolar bone.


What is a pedicle graft? What are the different ways this can be utilized to cover recession? How have the classic descriptions been modified over time? What is the role of citric acid? How does this type of procedure heal? How does this healing compare to the free gingival graft? How stable are these grafts?

Grupe 1956              ARTICLE
P: To demonstrate the repair of gingival defects by sliding flap Operation
Incisions are made on each side of the defect (Fig 1, A&B), removing only inflamed margin and extending straight downward to a level slightly below the base of the defect then connecting with a horizontal incision at the base (Fig1, C)
Make another incision at the distance of one papilla distal to the defect (Fig 1, D), not on the crest of a papilla, as far as may be necessary to provide adequate mobility to the flap.
By sharp dissection, the alveolar mucosa is separated from the underlying soft structures, so that the alveolar bone is not exposed.
Place the free movable flap in the position of the defect and suture.
Surgical pack is placed



Post-op instruction
Refrain from unnecessary speech or manipulation of the lip
72 hours liquid diet
Uncover the wound and remove sutures in 3 days.
All edges of the wound surface are cauterized with 30% trichloroacetic acid and immediately rinsed with warm water
Re-pack for a period of 12 – 16 days.
Do not probe for a period of 60 days


Grupe ‘66             ARTICLE
Purpose: Described the modified technique for sliding flap operation
Technique: In cases where amount of fibrous gingiva is sufficient, retain the marginal gingiva to its attachment to tooth and bone. Place a horizontal incision apical to the gingival sulcus. The remaining steps are as described in his previous article related to this technique. Case I: Recession tooth #22. Sx was performed; small recession under CEJ was observed 7d post-op. At 10 months post-op gingival margin was more coronal than at 7d post-op (it may be explained by “creeping attachment” as described by Goldman). Case II: Recession #24, technique as described above. Small area of root exposure below CEJ at 11d. Case III: Recession #25, after sx a inadequate repair was seen at the donor site at 5w, it was assumed horiz incision may have invaded the gingival sulcus.
Conclusion: This technique conserves the marginal gingiva coronal to the donor flap. Influence of the frenulum on mucogingival problems should be emphasized.


Smukler, 1979             ARTICLE
P: A preliminary report on favorable results being achieved with laterally repositioned “stimulated” osteoperiosteal pedicle grafts in the treatment of denuded roots.

D:Surgical prerequisites: All patients must demonstrate the desire and ability to maintain good plaque control and present regularly for professional cleaning and monitoring. All cases selected for treatment must exhibit radiographically and clinically adequate and healthy interproximal bone. Sufficient keratinized gingiva must also be available in areas adjacent to the denuded root to be grafted. Be careful in areas where labial plates are thin, and dehiscences or fenestrations may be anticipated.
“Stimulated osteoperiosteal” pedicle flaps: 17-21 days following initial preparation mentioned above, the tissue will be at its peak regenerative capacity. The recipient site is prepared according to the method outlined by Ruben, Goldman, and Janson. The root surface should be completely clean and can be confirmed with an application of disclosing solution. The PDL area surrounding the denuded root is fully exposed. Flap design is either a single or double pedicle or a Goldman modification of the mucoperiosteal flap preparation. The Goldman modification consisting of a partial thickness flap in the area two teeth lateral to the recipient site, and continuing the same incision to full thickness “osteoperiosteal” depth in the actual donor area. At repositioning, the osteoperiosteal portion will be adapted to the recipient area and the partial thickness portion to the donor area. Properly prepared and elevated mucoperiosteal flaps are thick, freely mobile, and have on their undersurfaces microscopic bony spicules with a “feel” of course sand paper.
BL: In order for successful coverage of denuded roots to be accomplished, correctly applied fundamental biological principles must be considered in the choice and utilization of the surgical modality.

Robinson 1964,             No ARTICLE
P: To describe a modification of Grupe’s procedure, in which an edentulous area can serve as a donor site for the laterally repositioned flap.
DISC:
Indication: Lack of attached gingiva and recession on single tooth adjacent to edentulous area.
Procedure: A canine tooth with marked recession and inadequate zone of attached gingiva is treated. Square fashion incision is made on the mesial (1), the distal (2) and a joining incision in made at the base of these two incisions in the alveolar mucosa. Immediately above this a portion of the alveolar bone is exposed. The exact location depends on the amount of bone loss on the buccal surface. At this point refinement of the root surface should be done. A fourth incision is made on the edentulous ridge occlusal to the mucogingival line. The last incision (5) is cut parallel to the first 2 incisions. Before these two incisions are made it must be determined that sufficient mature tissue is obtained from the donor site and that there is an adequate base to ensure the blood supply. It is best to cut a larger piece of tissue from the donor site than is needed and also to angle the incision number 5 off mesially. Next step is undermining the flap at donor site. With sharp dissection the tissue is incised to a sufficient width to maintain its vitality, but not so much as to denude bone or to have the donor tissue balky. Donor tissue is laterally repositioned over the exposed bone and sutured to the tissue distal to incision 2. A periodontal pack is placed and changed in one week. After 6 months areas can be probed forcefully and appeared healthy with adequate zone of AG, good architecture and no alveolar mucosal pull.



Caffesse, 1987             ARTICLE
P: To compare the amount of root coverage and KG obtained by lateral sliding flap with and without citric acid conditioning.
M+M: 25 patients (17-79 years old) with 28 localized gingival recession defects on facial aspect of mandibular anterior teeth. Initial visit: SRP and OHI. Measurements recorded: recession, PD, KG, clinical attachment, PI, and GI. Measurements taken pre-op, 1, 3, and 6 months post-op. Patients randomly assigned to lateral sliding flap without citric acid treatment or lateral sliding flap with citric acid treatment. Citric acid was applied for three minutes with a cotton pellet. Pellets were changed every 30 seconds to avoid dilution of the acid.
R: Lateral sliding flap with citric acid group: SSD improvement in recession (5mm at baseline to 1.84 mm at 180 days), clinical attachment (7 mm from CEJ at baseline to 3.31 mm from CEJ at 180 days), and width of KG (0.71 mm at baseline to 3.46 mm at 180 days).
Soft tissue coverage of 60.8 % (4.69 mm initial to 1.84 mm at 180 days).

Lateral sliding flap without citric acid: SSD improvement in recession (4.23 mm at baseline to 1.85 at 180 days), sulcus depth (2.43 mm at baseline to 1.29 mm at 180 days), clinical attachment (6.66 mm below CEJ at baseline to 3.14 mm below CEJ at 180 days), and width of KG (0.21 mm at baseline to 3.21 mm at 180 days).
Soft tissue coverage of 56.3 % (4.23 mm initial to 1.85 mm at 180 days).

Comparing the results of the two techniques, there were NSSD in terms of root coverage, PD, CA gain and width of KG. OH and gingival inflammation improved for both techniques up to 6 months post-op. Level of CA gain and root coverage was significantly less in patients with poor OH in both techniques.
BL: Lateral sliding flap revised technique provides satisfactory root coverage of localized gingival recessions with or without citric acid. Gain in clinical attachment was not enhanced by citric acid treatment.

Caffesse, 1984             ARTICLE
P: To evaluate the revascularization of the lateral sliding flap procedure in monkeys.
M&M: 2 young adult Rhesus monkeys were used for the study. Weekly prophylaxis was performed throughout the experiment. 14 artificial defects on incisors, premolars and molars were created by raising a flap and removing a 5 x 7 mm of buccal alveolar bone. The defects were left untreated for 2 months. FT lateral sliding flaps were performed to cover the recessions. The animals were killed, providing specimens at 1, 9, 14, 21, 28 and 35 days after surgery. A combined solution of Pelikan carbon black and 10% buffered formalin was perfused through the external carotid arteries to evaluate revascularization. Block sections were fixed in 10% formalin and then decalcified in EDTA. Histological evaluation was performed.
R:
Clinically: Some recession developed up to 14 days POT, but remained stable thereafter. By 28 days the flap appeared normal in color.
Histologically: At 1-3 days post-op, a network of perfused vessels was seen marginally and the flap was well adapted to the tooth surface and the tissue bed with a thin blood clot interposed. At 14 days, there was an irregular sulcular epithelium with minimum inflammatory infiltrate. By 21 days, a definite vascular network was reestablished and CT fibers run parallel to the tooth. Vascularization was completely reestablished by 28 days, which grew from the displaced flap, surrounding periodontal membrane and tissue. The new connection of the tissues to the root involves both CT attachment and LJE.
40-50% coverage is CT, 60-60% LJE
BL: 1) By 21 days, a definite vascular network is reestablished in the surgical area, 2) The vessels in the flap maintain their patency after surgery and contribute to healing, 3) Anastomoses at the surgical interface are reestablished with capillaries arising from the recipient soft tissue bed, bone marrow and periodontal membrane, 4) vessels from the periodontal membrane contribute significantly to the re-establishment of the vascular network, 5) the new connection of the tissues to the root involves both CT attachment and LJE.



Common 1983             ARTICLE
Purpose: To evaluate clinically and histologically the repair occurring at the root surface following citric acid demineralization.
Materials and methods: Five patients scheduled for extraction for 4 mandibular incisors. On the recipient site soft tissue was removed, a notch was created at the apical extent of the alveolar bone, distance from CEJ to the notch and a laterally positioned flap was used to cover the root. Citric acid was applied for two minutes with cotton pellets and the area was then cleaned with a moist gauze. On the control tooth citric acid was not applied to the tooth. Dressing was placed for one week. The areas were allowed to heal for 1, 2 weeks, 1, 3 and 5 months and block sections were obtained.
Results: All ten flaps were classified clinically as successful laterally positioned flaps. In general greater root surface coverage appeared to be associated with the test teeth although recession was generalized in all 4 incisors and no significant information could be gained. Greater mobility of control flaps was observed for the 2-week, 1-month and 5-month specimen. Application of citric acid did not appear to delay healing of soft tissues and patients had no subjective complaints.
Histologically moderate to heavy collection of lymphocytes and plasma cells were observed in all 10 specimens. All specimens except the ones of 1 week, exhibited long epithelial attachment extending to the reference notch. The 1-month control specimen was the only one that exhibited connective tissue attachment adjacent to the notch.
New cementum was observed at 1-, 3-, and 5-month specimens of test group. 3- and 5-month specimens had parallel collagen fibers.
Conclusion: Citric acid demineralization enhances or accelerates connective tissue attachment and cementogenesis during the laterally positioned flap procedure, through 5 months of healing.

Cohen 1968             ARTICLE
Purpose: To discuss the double papillae repositioned flap.
Discusion:
Indication: for the double papillae repositioned flap: gingival recession where interdental papillae destruction not present.
Advantages over laterally positioned flap:
1) Minimal exposure of periodontium at interdental donor sites.
2)Wound healing at interdental areas less susceptible than buccal plates to permanent damage after exposure. Healing more rapid with less exposure
3) Less tension on flap, single flap not pulled from one root to cover another
4) Each papilla has own blood supply
5) Greater AG at interdental position and tissue generally thicker, less chance for necrosis.
Technique:
Initial prep of recipient area: SRP, tooth movement in necessary, OHI, temporary stabilization, definitive occlusal adjustment and elimination of local environmental factors
A "V" shaped tissue wedge removed from recipient site provides fresh wound for approximation.
Donor site oblique vertical incisions at line angles extended to alveolar mucosa. Partial thickness papillary flaps.
Cutback incisions in direction of movement to negate tension. Position graft at or coronal to CEJ with suspensory suture. Sc/RP and dressing change at 1 week.
Author's clinical experience indicates 85% success in denuded root repair.



Ross 1985             NO ARTICLE
P: To reemphasize the indications, objectives, and techniques of the double papillae repositioned flap.
Indications: The double papillae respositioned flap is indicated where there has been recession of the labial or lingual gingiva but when the destruction of the interdental papillae on either side of the denuded area either has not occurred or is minimal. Incorrect tooth brushing and aberrant tooth position are primary causes of recession. Wound healing studies indicate that the interdental alveolar process is much less susceptible to permanent damage after surgical exposure than either the labial or lingual plates of bone. The double papilla flap utilizes the adjacent interdental tissues rather than the buccal and lingual tissue and this minimized the possibility of a permanent deformity at the donor site. The exposure of the underlying tissues is kept to a minimum, reducing the postoperative sequelae. Due to the minimal repositioning of tissues, there is a reduction in tension and pull. Each papillae retains it’s own blood supply. Interdental papillae are usually thicker than the radicular buccal and lingual gingiva and offer sufficient donor tissue. They are easier to suture and chance of flap necrosis is reduced.
Technique: First, etiology needs to be addressed before correcting a mucogingival problem. Review and correction of tooth brushing habits, root debridement and any necessary change in tooth position (if tooth is mal-positioned it needs to be corrected first).
-Initial V-shaped beveled incision is made in the area of the deformity to eliminate marginal tissue and provide a fresh wound surface for approximation of the two papillae
-Surface of one papillae is beveled so that it exposes a CT surface, the other papilla is treated with a reverse bevel so that the two connective tissue surfaces will be matched
-Donor site is prepared using vertical incisions at the line angles of adjacent teeth, which extend to the mucosa and done in an oblique manner so the base of the graft is wider than margin
-if papilla is large, can cut off the tips of the papillae
-split thickness incision is made, leaving CT and periosteum on the interdental alveolar process
-two interdental flaps are positioned passively, sutured in coronal direction with 5.0 plain gut sutures and a suspensory suture in the tip of papillae. Graft is placed slightly coronal to the CEJ, finger pressure for 2 mins to adapt the soft tissue and eliminate any dead space.
-dressing is placed, 1 week follow up
Discussion: The double papillae procedure is a predictable treatment for covering denuded root surfaces. The authors also state that using citric acid for root preparation can enhance the success of this procedure.

Is the coronally positioned flap considered a pedicle graft? How useful is this technique to cover recession? Are there limitations to this technique? Histologically, how does this compare with lateral sliding or the double papillae flap? What are some modifications of this technique?


Bernimoulin 1975             ARTICLE
P: To illustrate the coronally repositioned periodontal flap technique of the graft, post-op results after 1, 6, 12 months. 2 steps operation was preformed 1) creation of new attached ginigva by FGG, 2) 2 months after graphting, elevation and coronal repositioning of the flap containing the graft
M: 20 procedures with coronal flap repositioning were performed on 41 teeth with gingival recessions in 13 young adults. The amount of gingival recession and the clinical gingival sulcus depth were measured pre-operatively and 1, 6 and 12 months after surgery; the amount of osseous dehiscence was measured during surgery. Technique: 2 vertical incisions bordering the papillae to the recession area and connected with a reverse bevel scalloped incision along the gingivial margin were made, a mucoperiostal flap was then elevated to expose root surfaces and alveolar bone dehiscences. With curettes, the denuded root surfaces were scaled gently. The base was separated from the periosteum with undermining incisions. The flap was pulled coronally and sutured. First, lateral borders of the flap were sutured, then the papillary sutures were placed. Flap was firmly adapted to its seat with gauze and finger pressure for several min. perio pack was not applied.
R: No significant differences were found among reduction values of gingival recession by reattachment 1, 6 and 12 months post-operatively. Although a significant correlation was found between the degree of gingival recession preoperatively and 1 month post-operatively, non was found between the amount of alveolar bone dehiscence and gingival recession 1 month post-operatively.
BL: NSD between reattachement values 1, 6 and 12 months post-op. the surgical result remained stable. Creeping attachment didn’t take place compared to a FGG

Allen and Miller ‘89             ARTICLE
Purpose: To show short term results in the treatment of shallow marginal tissue recession with coronally positioning of existing gingiva.
Methods: 37 sites in 28 pts with class I recession, minimum 3mm KG, adequate thickness of “minimum” 1mm and no loss of interdental bone. Pt had to be concerned either by esthetics or sensitivity. Recession (CEJ-gingival margin) and PD were measured at 3 and 6months. Pt was seen post-op at 2 and 4weeks. Sx technique: Root was prepared (cementum was removed), citric acid was applied to the root surface. Then, vertical incisions were made lateral to the recessed area and extended to the alveolar mucosa. Sulcular incision closed to the periosteum until reach a split thickness flap. Gingivoplasty in the papilla was performed just to form a bed for the coronally position flap. Suturing the vertical incisions was done first. The 1^st puncture was in the flap margin and the 2nd punctured on the attached gingiva more coronally (distant equal to the vertical height of the recession). At last, the interproximal suture was placed. Dressing and cyanoacrylate were used. No brushing during 2 weeks (just a cotton swab).
Results: Prior to sx: Recession ranged from 2.5-4mm (average 3.25mm), sulcus depth (SD) 1-3mm (averaged 3.25mm). At 3 month: Recession mean was 0.08mm, SD mean was 1.26mm. Overall root coverage gain (ORCG) was 3.17mm. At 6 months: Recession mean: 0.07mm and SD 1.43mm. ORCG was 3.18mm. At 3 and 6months gingival margin was at or coronal of CEJ in 31 of 37 sites. At 6 months 5 of 37 sites had 1mm recession. Overall root coverage at 6 months was 97.8% coverage of root exposure. Initial sensitivity reported in 16 sites, at 3 months only in 2 sites and at 6 months absent in all sites.
BL: Coronally positioning is a conservative and successful approach for 4mm or less gingival recessions.

Harris, 1994             ARTICLE
P: To examine the predictability of the coronally positioned pedicle graft with butt joints and inlaid margins, in conjunction w/ tetracycline root conditioning, to treat shallow Class 1 defects.
M&M: 18 patients (16 men, 2 women) referred for treatment of 20 isolated Class 1 recession areas. Mean age of 31.1 years. Each site had estimated gingival thickness of at least 1 mm. All teeth vital and restoration free in area to be covered. No molars included. All patients in good general health with no contraindications to periodontal surgery. Measurements were taken and rounded to nearest 0.5 mm: gingival recession depth, gingival recession width, PD, width of keratinized tissue, preoperative sensitivity, supragingival plaque, and BOP. Patients were not excluded because they smoke. Phase 1 completed. All patients received loading dose of NSAID 1 hr pre-op and as needed for pain post-op. Exposed root was planed and conditioned with a tetracycline solution.
1) Vertical incisions placed generally where the exposed CEJ met the gingival margin on either side of the defect perpendicular to the gingival surface to produce a butt joint.
2) Partial thickness flap was reflected by sharp dissection as close to the periosteum as possible and continued to appoint where it can be repositioned to cover exposed root surface.
3) Secondary vertical incisions are made at the most occlusal point of the papillae adjacent to defect that bisect the interproximal tissue, extending apically until it met the primary vertical incision (also a butt joint).
4) The result is a recipient area with butt joints designed so that the pedicle graft would inlay into the recipient area.
5) Pedicle flap sutured w/ 5-0 gut suture using a modified sling suture and interrupted sutures.
6) Thin layer of isobutyl cyanoacrylate dressing was applied and the area covered with periodontal dressing. Chlorhexidine was prescribed for 4 wks and advised not to brush in the area. Dressing removed at 1 wk. Pts were seen at 1,2,4, and 8 weeks. Pts were placed on 2-3 month recall. Final measurements taken between 5 and 57 weeks.
R: Complete root coverage obtained in 95% of the cases. SS reduction in mean recession depth (2.15 mm to 0.03 mm) and mean recession width (3.0 mm to 0.1 mm). Mean root coverage was 98.8% of exposed root surface. 6 of the patients were smokers and complete root coverage was obtained. Mean probing depth change was 0.5 mm which was statistically significant but not clinically significant.
BL: Coronally positioned pedicle graft with inlaid margins is an effective and predictable method of obtaining root coverage in shallow Class 1 defects even in instances where you have less than 3 mm keratinized tissue.

Baldi et al 1999,             ARTICLE
P: To determine if the thickness of flap can influence the recession reduction following coronally advanced flap (CAF) surgery.
M&M: 19 patients (6M/13F), 25-57 years, 5/19 smokers, 16 maxillary and 3 mandibular recession were treated with CAF. Isolated buccal recessions (2mm) classified as Miller Class 1 and Class 2. All patients received OHI. All surgical procedures were performed by one operator. Root surface was planed to reduce root convexity, intrasulcular incision was performed on the buccal aspect of the involved tooth. This incision was horizontally extended to the adjacent papilla avoiding the gingival margin of the adjacent teeth. Two oblique releasing incisions were carried out from the mesial and distal extremities of the horizontal incisions beyond the mucogingival junction (MCJ). A trapezoidal FTF was raised towards the MCJ. Partial thickness dissection was performed apically. The thickness of the flap was measured by another operator with a modified Iwansson gauge at the distance between MCJ and base of the flap. The papillae we de-epithelialized. The flap was then coronally displaced and adapted to cover the CEJ. Sutures were placed. After surgery, all patients were recalled for control and professional prophylaxis once a week during the first month and monthly up to the third month. Clinical parameters (REC, PD, CAL, KG) at baseline and at 1,2,3,4 weeks and 2 and 3 months after sx.
R: Mean initial recession depth was 30.9mm. Mean flap thickness was 0.70.2mm. 3months later mean recession depth was 0.60.6 and mean recession reduction was 2.40.7mm. Mean root coverage was 8217%. Significant association between recession reduction and both the thickness of the flap and the initial recession depth. All sites with flap thickness greater than 0.8mm showed complete root coverage. Sites with flap thickness less than 0.8mm showed partial coverage.
CON: Flap thickness is a significant predictor of the clinical outcome of root coverage of shallow gingival recessions treated with CA



Lucchesi, 2007                 ARTICLE
P: To evaluate clinically the treatment of gingival recession associated with non-carious cervical lesions “NCCL” (abrasion, abfraction or erosion) with resin modified glass ionomer cement or microfilled resin composite and coronally postioned flap at 6 months following surgery.
M+M: 59 pts (44F, 15M, 23-65 years old), non-smokers and healthy. Prospective, parallel and randomized clinical design. Each subject assigned to one of 3 groups. All subjects had Miller Class I recessions.
Group 1 (control, n=20): root exposure without NCCL treated with a CPF.
Group 2 (test, n=20): root exposure with NCCL treated with RMGI (resin modified glass ionomer) plus a CPF.
Group 3 (test, n=19): root exposure with NCCL treated with MRC (microfilled resin composite) restoration plus a 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.
Two weeks after restorative procedures, CPF surgery was done.
R: The mean root coverage:
Group 1: 80.83% +/- 21.08% at 3 and 6 months.
Group 2: 72.99% +/- 17.02% at 3 months, and 71.99% +/- 18.69% at 6 months.
Group 3: 75.50% +/- 16.40% at 3 months, and 74.18% +/- 15.02% at 6 months.
The difference between test groups was NSS at any time.



BL: NSSD in root coverage improvement between any of the groups, supporting the use of CPF for treatment of root surfaces restored with RMGI or MRC as being effective over a 6-month period.
CR: Control recessions were not associated with non-carious cervical lesions like the test groups.

Gottlow, 1986             ARTICLE
P: To examine whether citric acid (CA) conditioning of the exposed root increases the amount of new CTA after txt of localized gingival recession with coronally displaced flaps (CPFs).
M&M: 3 beagle dogs. Ging recessions were surgically created at B surf of canines, PM & molars with a notch (N1) placed in the buccal root surface at the bone level. After 6 mo of plaque accumulation, 6 teeth were ext for histo. Remaining teeth had a second notch prepared at the gingival margin, then surgery. B & L flaps were raised & exposed root had SRP and removal of cementum. 2^nd notch at level of bone. ½ of the teeth were txt w/ CA (pH1 for 3 min) and the other ½ were used as controls. Flaps were advanced then sutured to cover root completely. Brushing was performed daily as well as topical application of CHX 0.2% gel post-operatively. Dogs were sacrificed at 3 months then histo exam.
R: A total of 17 CA-treated teeth and 16 non-CA treated teeth were included. At the time of Sx, experimental teeth had avg dehiscence of 5.9 mm, control had 5.5 mm. Both experimental and control had ~1.4 mm retraction of the ging margin at sacrifice. New cementum had formed in both coronal to notch, with new attachment (2.2 mm in test, 2.1 mm in control) forming on all test and control roots and in some, extended to a position coronal to the pre-Sx level of the gingival margin. Both groups had 0.4 mm of newly formed bone. Newly formed cementum with inserting collagen fibers was seen in the bottom of the defect with NSD between control or experimental in any parameter.
BL: CA conditioning did not produce additional new attachment when CPF is used to cover ging recession.


Zucchelli 2000             ARTICLE
Purpose: To evaluate with respect to root coverage the effectiveness of a new surgical approach to the coronally advanced flap procedure for the treatment of multiple recession – type defects in patients with esthetic demands.
Materials and methods: 22 patients (18-34 years old) with esthetic problems due to exposure of recession during smiling. No medical history and no periodontal support in tooth surfaces other than the ones showing recession. At least two adjacent sites with recession, Miller Class I or II. Coronally directed roll technique was prescribed for teeth with recession in order to minimize tooth-brushing trauma. Recession, PD and AL were measured at baseline and 1 year post-op.

Technique: Modified design of the envelope flap was performed. Horizontal incision extending one tooth from each side to be treated is performed and consists of oblique submarginal incision in the interdental areas and continues with intrasulcular incisions at the recession site. Surgical papilla mesial to the flap midline was dislocated apically and distally comparing to the anatomic papilla and the distal one to a more apical and mesial position. Flap is raised with a split-full-split approach. Apical to the root full thickness flap was raised to provide that critical part of the flap with more thickness. Previously exposed root surfaces were instrumented. Remaining anatomic papillae were de-epithelialized. Dissection into the vestibular lining mucosa was performed to eliminate muscle pull.
When advancing the flap coronally the surgical papilla will rotate towards the end of the flap. The surgical papilla located mesial to the midline of the flap will rotate to mesial-coronal direction and the one located distal of the midline will rotate in a distal –coronal direction.
Sling sutures were performed and a horizontal double mattress more apically to reduce lip tension on the marginal portion of the flap.
No brushing and use of Chx for 14 days, and sutures were removed at that time. Prophy at 1, 3, 5 weeks and every 3 months until the final examination (12 months).
Results: 22 patients with 73 teeth with recession.


On average 97% of root surface initially exposed was covered after 1 year.
88% of surfaces showed complete root coverage
73% of patients showed complete root coverage.
Absence of a wide zone of KG was not a limitation. Good results were obtained even with amount of KG (1mm or less).
Conclusion: This technique is a new approach to the coronally advanced flap andis very effective for the Tx of multiple gingival recession.


Zucchelli 2009             ARTICLE
Purpose: to compare the root-coverage and esthetic outcome of two different approaches using the CAF for the treatment of multiple gingival recessions: the envelope type flap and the flap with vertical releasing incisions (VRI’s)
Materials and methods
32 subjects with esthetic complaints due to exposure of multiple gingival recession type defects when smiling
Inclusion criteria: multiple miller class I and II recession defects on adjacent teeth in the same quadrant, identifiable CEJ, presence of 1 or more mm of KG.
Patients received SRP, OHI. Clinical measurements Recession depth (RD), PD, CAL, height of KG were taken 1 week before and 1 year after surgery.
Control groups received CAF with VRI’s vs experimental envelope type CAF.
Results
The overall chair time was shorter for the envelope type CAF
Complete root coverage was achieved in 77.7% of controls vs 89.3% of tests defects.
The odds of obtaining complete root coverage were 3.76 times better with the envelope type CAF.

Conclusions
CAFs with or without VRI’s are equally effective in providing a consistent reduction in the baseline recession and gain CAL
Envelope CAF is associated with increase probability of achieving complete coverage and greater increase in buccal keratinized tissue height.
Patient satisfaction was very high with both treatments with no differences between them.

Tarnow 1986
P: To describe the semilunar coronally repositioned flap.
D: Indications for this procedure are when there is gingival recession with minimal labial sulcus depth present. There should be an adequate zone of KG- if there is not , it should be created 2 months prior with a FGG. Approx 2-3mm of root coverage can be obtained with this procedure.
Initial plaque control (SRP) 2 weeks prior to surgery. Root plane exposed root surfaces to be covered. Semilunar incision is made parallel to the free gingival margin of the facial tissue and coronally position it over the denuded root.

Advantages include: no tension on the flap, no shortening of the vestibule, papillae mesial and distal to the tooth being treated remain cosmetically unchanged, no sutures are needed b/c lack of tension to the tissue being coronally positioned.
 

Are there any techniques to increase keratinized tissue without a pedicle or a free flap? What are the requirements for this?

Carnio 2007
P: A case series to clinically evaluate the modified apically repositioned flap (MARF) and how effective it is to increase the apico-coronal dimension of attached gingival over multiple adjacent teeth
M&M: 37 areas in 33 pts, treatment of 2-5 teeth in each patient. Age 18-73, 4 pts smoked. Inclusion criteria: presented w/ 0.5-2.0 mm attached gingiva, physiologic sulcus depth, gingival tissues free of clinical inflammation, and absence of bony dehiscence (bone sounding immediately prior to surgery). Measurements taken baseline and 6 months post op.
MARF surgical technique: single horizontal incision w/in KG ~0.5 mm coronal to MGJ. Tissue coronal to this incision was left alone. M-D, extended at least one-half tooth in both directions around area needing gingival augmentation (no vertical release). Partial thickness flap elevation as apically as necessary, then suture apically positioned flap to periosteum. Finger pressure for 3-5 min to maintain flap to underlying periosteum. Perio dressing on exposed area, CHX and Ibuprofen for pain control.
R: SSD augmentation of apico-coronal dimension of keratinized tissue and attached gingiva. Mean KG was 2.20 mm preop and 4.28 mm post op, Mean AG was 1.0 mm preop and 3.14 mm post op. NSD in PD pre or post op. Recession decreased from 0.82mm preop to 0.75 mm post op, little clinical significant. Esthetically, no difference in clinical appearance at 6 months PD in treated area did not change.
BL: For patients who have minimum PD, no bony dehiscence, and at least 0.5-2.0 mm KG who need increased attached gingiva, this modified ARF is a good technique to use that is esthetic and eliminates a palatal donor site.