112. Esthetics: Recession - Root coverage                                     

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 Rapid Search Terms
CT Graft with coronally advanced flap histology of CTG healing
Raetzke’s envelope Nelson’s subpedicle
tunneling technique bilateral pedicle
Harris double pedicle anatomic requirement and technique to harvest palatal donor tissue
acellular dermal matrix Emdogain for root coverage
PRP in root coverage GTR for root coverage
growth factors and tissue engineering comparison of different methods and long term stability

 

 

 

 

 

 

 

 

 

 

 

 

Coronally Positioned Flap with......

  1. Connective tissue

  2. Allografts

  3. Emdogain

  4. PRP

  5. GTR

Discussion Topics

 

  1. What is another predictable way to increase keratinized tissue using autogenous tissue from donor site? Can this be used to cover recession? How do CT grafts heal histologically? Does this improve the outcome of a coronally advanced flap?

  1. Cortellini, P., Tonetti, M., et al: Does placement of a connective tissue graft improve the outcomes of coronally advanced flap for coverage of single gingival recessions in upper anterior teeth: A multi-center, randomized double blind clinical trial. J Clin Periodontol2009; Jan 36(1):68-79

  2. Wennstrom J, Zuchelli G. Increased gingival dimensions. A significant factor for successful outcome of root coverage procedures? A 2-year prospective clinical study. J Clin Periodontol 1996; 23:770-777.

  3. Da Silva R., Et al: Root coverage using the coronally positioned flap with or without a subepithelial connective tissue graft. J Periodontol. 2004;Mar; 75(3):413-9

  4. Bouchard P, Etienne D, Ouhayoun JP, Nilveus R. Subepithelial connective tissue grafts in the treatment of gingival recessions. A comparative study of 2 procedures. J Periodontol 1994; 65:929-93

  5. Muller H-P, Eger T, Schorb A. Gingival dimensions after root coverage with free connective tissue grafts. J Clin Perio 25:424-430,1998.

  6. Butler B: The subepithelial connective tissue graft with a vestibular releasing incision. J Periodontl 2003:74(6):893-98

  7. Harris RJ. Root coverage in molar recession: report of 50 consecutive cases treated with subepithelial connective tissue grafts. J Periodontol. 2003 May;74(5):703-8.

  8. Harris RJ. Successful root coverage: A human histologic evaluation of a case. Int J Perio Rest Dent 19:439-447, 1999.

  9. Bruno JF, Bowers GM. Histology of a human biopsy section following the placement of a subepithelial connective tissue graft. Int J Perio Rest Dent 20:225-231, 2000.

  1. What are some of the different ways to prepare a subepithelial connective tissue graft recipient site? Do all of these techniques utilize coronal advancement? Describe a. Raetzke’s envelope, b. Nelson’s subpedicle, c. Langer & Langer connective tissue graft technique, d. Allen tunneling technique, e. Zabalegui multiple recession technique, f. Blanes bilateral pedicle. G. Harris double pedicle

  1. Raetzke, P: Covering localized areas of root exposure employing the „envelope“ technique. J Periodontol 1985; 56(7):394-402

  2. Nelson SW. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol. 1987 Feb;58(2):95-102.

  3. Borghetti A, Louise F. Controlled clinical evaluation of the subpedicle connective tissue graft for the coverage of gingival recession. J Periodontol 1994; 65:1107-1112

  4. Langer B, Langer L: Subepithelial connective tissues graft technique for root coverage. J. Periodontol. 56:715-720, 1985.

  5. Allen A; Use of the supraperiosteal envelope in soft tissue grafting for root coverage: I. Rationale and technique Int J Periodontics Restorative Dent 1994:14(3):216-227

  6. Zabalegui I, Sicilia A, Cambra J, Gil J, Sanz M. Treatment of multiple adjacent gingival recessions with the tunnel subepithelial connective tissue graft: A clinical report. Int J Perio Rest Dent 19:199-206, 1999

  7. Blanes R; Allen E: The bilateral pedicle flap-tunnel technique: A new approach to cover connective tissue grafts. Int J Periodontics Restorative Dent 1999:19(5);471-480

  8. Harris RJ. Human histologic evaluation of root coverage thickness obtained with a connective tissue with partial thickness double pedicle graft. A case report. J Periodontol 70:813-821, 1999.

  1. How do we harvest connective tissue? What are the potential donor areas? What anatomical factors are we concerned with?

  1. Reiser GM, Bruno JF, et al. The subepithelial connective tissue graft palatal donor site: anatomic considerations for surgeons. Int J Periodontics Restorative Dent. 1996 Apr;16(2):130-7.

  2. Edel A. Clinical evaluation of free connective tissue grafts used to increase the width of keratinized gingiva. J Clin Periodontol. 1974(4):185–196.

  3. Harris RJ (1997) A comparison of two techniques for obtaining a connective tissue graft from the palate. Int J Periodont Restor Dent 1997. (17):260-271

  4. Hürzeler M, Weng D. A single incision technique to harvest subepithelial connective tissue graft from the palate. Int J Periodont Restor Dent 1999. (19):279–287

  1. What is Acellular Dermal Matrix? What are the different types? Can it be used for gingival recession? What are this indications and contraindications for this material? How is the material managed? How does it heal?

  1. Harris RJ. Root coverage with a connective tissue with partial thickness double pedicle graft and an acellular dermal matrix graft: a clinical and histological evaluation of a case report. J Periodontol 1998; 69: 1305 - 1311.

  2. Gapski R, Parks CA, Wang HL. Acellular dermal matrix for mucogingival surgery: a meta-analysis. J Periodontol. 2005 Nov;76(11):1814-22.

  3. De Queiroz Cortes A., Sallum A, et al: A two year prospective study of coronally positioned flap with or without acellular dermal matrix graft. J Clin Periodontol 2006 Sep; 33(9):683-9

  4. Wang HL, Romanos GE, et al. Comparison of Two Differently Processed Acellular Dermal Matrix Products for Root Coverage Procedures: A Prospective Randomized Multi-Center Study. J Periodontol. 2014 Jun 26:1-25. [Epub ahead of print]

  1. When can emdogain be used for root coverage? What are the steps to utilize this material? What are some of the drawbacks of this material?

  1. Modica F, Del Pizzo M, Roccuzzo M, Romagnoli R. Coronally advanced flap for the treatment of buccal gingival recessions with and without enamel matrix derivative. A split-mouth study. J Periodontol. 2000 Nov;71(11):1693-8.

  2. Abbas F, et al. Surgical treatment of gingival recessions using emdogain gel: clinical procedure and case reports. Int J Periodontics Restorative Dent. 2003 Dec;23(6):607-13.

  1. How effective are platelet-rich products in root coverage? Theoretically, how would this material influence soft tissue procedures? Should platelet-rich products be used alone or with other materials/procedures?

  1. Huang LH, et al. The effect of platelet-rich plasma on the coronally advanced flap root coverage procedure: a pilot human trial. J Periodontol. 2005 Oct;76(10):1768-77.

  2. Bashutski, J., Wang, H: Role of platelet-rich plasma in soft tissue root coverage procedures: A review Quintessence Int., 2008 Jun; 39(6):473-83

  3. Del Fabbro M, Bortolin M, Taschieri S, Weinstein R. Is platelet concentrate advantageous for the surgical treatment of periodontal diseases? A systematic review and meta-analysis. J Periodontol. 2011 Aug;82(8):1100-11.

  1. What is the efficacy of guided tissue regeneration for root coverage? What materials have been studied acting as a barrier membrane? Should bone graft be used with a barrier membrane to cover recession? What is its effect on soft tissue?

  1. Al-Hamdan K et al: Guided tissue regeneration based root coverage: A meta-analysis. J Periodontol. 2003 Oct; 74(10):1520-33

  2. Leknes K., Coronally positioned flap procedures with or without a biodegradable membrane in the treatment of human gingival recession. A 6-year follow-up study. J Clin Periodotnol 2005;May; 32(5):518-29

  3. Trombelli L et al: Guided tissue regeneration in human gingival recessions. A 10-year follow-up study. J Clin Periodontol 2005 Jan; 32(1):16-20

  4. Park, S Wang,H., Management of localized buccal dehiscence defect with allografts and acellular dermal matrix. Int J Periodontics Restorative Dent, 2006 Dec; 26(6):589-95

  1. How have growth factors or tissue engineering been utilized with regards to root coverage? How effective are these treatments?

  1. McGuire M et al: A pilot study to evaluate a tissue-engineered bilayered cell therapy as an alternative to tissue from the palate. J Periodontol 2008; Oct; 79(10):1847-56

  2. McGuire MK, Scheyer ET. Comparison of recombinant human platelet-derived growth factor-BB plus beta tricalcium phosphate and a collagen membrane to subepithelial connective tissue grafting for the treatment of recession defects: a case series. Int J Periodontics Restorative Dent. 2006 Apr;26(2):127-33.

  1. How do different root coverage procedures compare to one another. What is the most beneficial therapy for total root coverage? Increasing keratinize tissue? Long term stability?

  1. Greenwell H. Oral reconstructive and corrective considerations in periodontal therapy. J Periodontol. 2005 Sep;76(9):1588-600.

  2. Cairo, F, Pagliaro, U., Nieri, M. Treatment of gingival recession with coronally advanced flap procedures: A systematic review. J Clin Periodontol 2008:Sept; 35(8 Suppl):136-62

  3. Buti J, Baccini M, Nieri M, La Marca M, Pini-Prato GP. Bayesian network meta-analysis of root coverage procedures: ranking efficacy and identification of best treatment. J Clin Periodontol. 2013 Apr;40(4):372-86.

  4. Wessel J, Tatakis, D: Patient outcomes following subepithelial connective tissue graft and free gingival graft procedures. J Periodontol 2008 Mar: 79(3):425-30

  5. Paolantonio M, di Murro C, Cattabriga A, Cattabriga M. Subpedicle connective tissue graft versus free gingival graft in the coverage of exposed root surfaces. A 5-year clinical study. J Clin Periodontol 24:51-56, 1997.

  6. Bittencourt, S et al: Comparative 6-month clinical study of a semilunar coronally positioned flap and subepithelial connective tissue graft for the treatment of gingival recession. J Periodontol 2006+;Feb;77(2):174-81

  7. Mc Guire, M., Nunn, M: Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part1: Comparison of clinical parameters. J Periodontol, 2003: Agu; 75 (8):1110 – 25

  8. McGuire M., Cochran D., Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 2: Histologivcal evaluation. J Periodontol. 2003 Aug; 74(8):1126-35

  9. Paolantonio et al. Subpedicle acellular dermal matrix graft and autogenous connective tissue graft in the treatment of gingival recessions: A comparative 1-year clinical study. J Periodontol 2002 Nov; 73(11):1299-307

  10. Harris R. A short-term and long-term comparison of root coverage with an acellular dermal matrix and a subepithelial graft. J Periodontol 2004 May; 75(5):734-43

  11. Papageorgakopoulos G., Greenwel., et al. Root coverage using acellular dermal matrix and comparing a coronally positioned tunnel to a coronally positioned flap approach. J Periodontol 2008 Jun; 79(6):1022-30

  12. Shepherd, Greenwell et al: Root coverage using acellular dermal matrix and comparing a coronally positioned tunnel with and without platelet-rich plasma: A pilot study in humans. J Periodontol 2009 Mar; 80(3):397-404

  13. Borghetti A, Glise J-M, Monnet-Corti V, Dejou J. Comparative clinical study of a bioabsorbable membrane and subepithelial connective tissue graft in the treatment of human gingival recession. J Periodontol 70:123-130, 1999.

  14. Muller H-P, Stahl M, Eger T. Failure of root coverage of shallow gingival recessions employing GTR and a bioabsorbable membrane. Int J Perio Rest Dent 21:171-181, 2001.


 

What is another predictable way to increase keratinized tissue using autogenous tissue from donor site? Can this be used to cover recession? How do CT grafts heal histologically? Does this improve the outcome of a coronally advanced flap?

 

Cortellini, Tonetti, et al. 2009            ARTICLE

P: to compare the root coverage of the CAF alone with the CAF+CTG in the treatment of single Miller Class I and II gingival recessions.

M&M: Parallel-group, three-center, double-blind, randomized-controlled clinical trial. 85 patients (no untreated periodontal disease, good OH, smoking 20 cig/day, Miller class I or II buccal recession ) participated in the study. Two different modalities for root coverage were compared: CAF (control) and the CAF+CTG (test). Each patient contributed with a recession. In case of patients presenting with multiple recessions, the deepest one was selected. Early healing events were evaluated at weeks 1, 2, 3, and 4. Standrdized clinical measurements and photographs were taken at baseline, during and after surgery, and at months 3 and 6 examination visits by a blinded examiner. At baseline, a stent was fabricated, a reference point (slot) was carved on the stent at the mid- buccal area of the experimental tooth, to allow a reproducible periodontal probe positioning.

R: 9 smokers in control and 13 smokers in test group. Recession reduction was observed in all cases, with the exception of five (12%) cases treated with CPF and three (7%) cases treated with the combination. Recession reduction was greater in cases with a deeper baseline recession, and in cases treated with CPF+CTG but NSSD. SSD increase in complete root coverage (OR of 5) when using CPF+CTG vs CAF alone. The sites treated with a combination of CAF plus a graft resulted in a significantly higher number of recessions completely covered (60%) with respect to sites treated with CAF alone (37%). The odds of achieving CRC (complete root coverage) following the use of CAF+CTG were significantly greater than after the use of CAF in smokers.

Clinician variability was significant (center 2 had much less coverage with the CPF alone group than other centers). More KG with CPF+CTG at 6 months. More patients reported some pain after CPF+CTG. Pain-related VAS values were very low and there was NSSD between the two groups and among the three centers. The overall surgical chair-time was significantly shorter for CAF. Dentin sensitivity improved in both groups.

BL: Both treatments were effective in providing a significant reduction of the baseline recession and dentine hypersensitivity, with only limited intra-operative and post-operative morbidity and side effects. Adjunctive application of a CTG under a CAF increased the probability of achieving CRC in maxillary Miller Class I and II defects.



Wennstrom, 1996               ARTICLE

P: To evaluate whether an increased thickness of gingiva through use of a CTG in conjunction with a coronally advanced flap (CAF) may positively influence the treatment outcome with respect to root coverage and long term stability of the soft tissue margin during a 2 yr post-op period.

M+M: 67 healthy subjects (19-38 years old) with aesthetic (62 pts) or root hypersensitivity problems (5 pts) due to localized recession at least 3mm, Miller Class I. PD, PAL, recession, gingival height (KG), plaque, BOP recorded at baseline, 6, 12, and 24 months. Pts all had initial therapy w/ prophylaxis, OHI, and toothbrushing technique discussed (cornally directed roll technique) to minimize brushing trauma. Total of 103 recession sites, broken up into test group (n=58) that were treated w/ CTG+CAF and control group (n=45) that were treated w/ CAF alone.

R: NSSD in mean root coverage between the test and the control group at any examination

time point.


Gingival height (KG) was the only variable that showed SSD between the test and control sites at the followup examinations with a mean KG increase of 2.6mm at 6 months post-op and 2.8 mm at 12 and 24 months postop in test vs 0.4 mm KG increase at 6 months, 1.2 mm at 12 months, and 1.1 mm at 24 months.


BL: Both CTG+ CAF and CAF alone achieve similar root coverage results of Miller Class I recessions, however CTG+CAF achieves SS greater amount of KG.



Da Silva 2004               ARTICLE

P: To compare the outcome of gingival recession therapy using coronally positioned flap (CPF) alone or in conjunction with a subepithelial connective tissue graft (CTG) in a split mouth design.

M+M: Eleven pts (18-43 years old), who had bilateral greater than or equal to 3mm Class I Miller recession defects on maxillary canine or premolar teeth, presence of identifiable CEJ, periodontally and systemically healthy, no occlusal interferences and not taking medication known to interfere with periodontal tissue health or healing were enrolled in the study. Bilateral defects were randomly assigned to test group (CPF+CTG) and control group (CPF) by a coin toss. Clinical parameters (recession, PD, CAL, KG, and tissue thickness) were taken at baseline and 6 months post-op. Initial therapy included OHI and SRP 1-2 months pre-op; impressions, and casts made for fabrication of stents that were used to take the measurements. During surgery, partial thickness flap was elevated with intrasulcular incision and two vertical releasing incisions mesial and distal to the defects. Flaps were slightly coronally advanced with or without CTG (1.3mm average thickness). Both surgical procedures were performed at the same appointment. Statistical analysis was done.

R: CPF group showed SS improvement in recession, PD, and CAL. CPF + CTG showed SS improvement in all clinical parameters: recession, PD, CAL, KG, and tissue thickness. CPF group showed a 2.73 +/- .99 mm of recession reduction (68.8%) and only 1/11 defects had complete coverage. The CPF + CTG group showed a 3.16 +/- .86 mm recession reduction (75.3%) and 2/11 defects showed complete coverage.

BL: Both CPF and CPF+CTG are effective in providing root coverage in Miller Class I recession defects of >3mm, although the combined technique should be preferred if increases in gingival dimensions (KG and gingival tissue thickness) are a desired outcome



Bouchard 1994               ARTICLE

Purpose: To evaluate the clinical and esthetic effects of the subepithelial CT grafts to cover gingival recession using a traditional procedure compared to using a modified technique.

Materials and methods: 30 subjects (6 males, 24 females mean age of 37 y.o.). Pts had buccal Miller Class I or II recession, with PDs less than 3mm and were systemically healthy. Molars were not included.

The procedures performed were either subepithelial CT graft without epithelial collar plus citric acid conditioning and coronally repositioned flap (partial thickness flap)(CR group) or subepithelial CT graft with epithelial collar and no root conditioning (CTG group). In the second group the epithelial collar of the graft was not covered by the coronally advance flap of the recipient site. No surgical dressings were used. Measurements for recession were taken at 1, 2, 3, 6, 12, and 24 week and for PD, AL and KG at baseline 3 and 6 months. Plaque scores were used throughout the study to evaluate pt’s compliance. Impressions and photographs were taken pre-op and 6 months later for esthetic evaluation by 2 blinded examiners.

Result: Healing was uneventful in both groups. No SSD between two groups for PD and AL. After 6 months all the follow-up date showed improvement.

The surface of root exposure was reduced from 13.82mm2 to 2.15mm2 for CR group and from 13.67mm2 to 2.34mm2 for CTG from baseline to 6 months.

All patients were satisfied with the esthetic results.

Mean coverage of 69.2% of the central area of the root was obtained.

Conclusion: Partial root coverage and gingival augmentation with a good or moderate esthetic appearance were obtained by one-step CT graft procedures in Miller Class I and II recessions.

 


Muller, 1998               ARTICLE

Purpose: To follow the dimensions of the gingival unit for 12 months after root coverage procedures w/ CTG.

Materials and methods:

Results:

Conclusion:

 

Butler, 2003               ARTICLE

Purpose: to describe the technique of subepithelial connective tissue graft with a vestibular releasing incision.

M&M: The subepithelial connective tissue graft is harvested as a single incision technique and should be approximately 1.5 mm thick and 5-6 mm high to ensure adequate surface area. The recipient site is root planed and root conditioning with citric acid. An envelope technique is utilized. A periosteal release is made deep to allow for coronal placement of the tissue, allowing a superficial external vestibular releasing incision to be made later. The mucosal tension is released with a superficial vestibular releasing incision. A sharp blade is used, undermining and extending laterally until the flap can easily be coronally positioned. The connective tissue graft is placed with interrupted sling sutures. The papillary areas are deepithelialized at the coronal aspect. The flap is coronally positioned to close with primary coverage. Approximately 30% of the graft is left exposed facially.

Discussion/Conclusion: This technique has allowed to achieve a high degree of success both esthetically and functionally in patients with a shallow vestibule. The strongest advantage of this technique is immobilization of the graft, which helps with successful healing. Also, KG is increased in width and thickness and it achieves more KG than the acellular dermis procedure. This is due to the acellular dermis requiring full coverage of the donor tissue. Less coronal positioning is needed compared to the acellular dermis so there is a less chance for the graft to pull free. Another advantage is the esthetic color match of the gingiva and less trauma to the donor site compared to a FGG.

The most common complication are incomplete union or cleft formation in the papillae areas and a lack of attachment of the graft to the root surface which are caused from excessive tension on the flap. Also, ecchymosis and edema can occur.

 


Harris 2003                ARTICLE

P: the purpose of this study was to evaluate root coverage of molar recession defect

M: 50 pts with molar recession defect on one molar were treated with a subepithelial connective tissue graft. All pt had 1 molar recession defect al least 3mm deep (miller class I or class II defect). Furcation involvement was not greater than Class I. no medical complication. The following parameters were recorded; recession depth (RD), PD, width of KG and AL.

Technique:

R: Compete root coverage was obtained in 29/50 defects (58%).
Mean root coverage of 91.1% was obtained.

 recession depth (4.4 mm to 0.5 mm)

 PD (3.0mm to 2.3mm)

 AL loss (7.4mm to 2.8mm) – 4.6 mm mean attachment gain

 quantity of KG (0.9 mm to 3.1mm)

C: the subepithelial CT graft is an effective method to obtain root coverage of recession on molars.

Cr: the study was completed in a private practice. No blinded evaluation, pressure sensitive probes, acrylic stents for fixed reference points, examiner calibrations, or long term follow up

 


Harris,1999                ARTICLE

P: To examine histologically the results obtained with a connective tissue graft combined with a partial thickness double pedicle graft in humans.

M/M: Case report on 47y old female. Tooth #28 and #29 needed to be extracted for restorative work. #28 had 2 mm of recession and 0mm KG and #29 had 3 mm of recession on the buccal surface and 1mm KG. . Both had 2 mm probing depths on the buccal. They were treated with a partial thickness double pedicle with a connective tissue graft under it, notches at free gingival margin and at the bone level. Area was allowed to heal for 6 months and final measurements were taken. Extractions with a small collar of tissue were performed for histologic evaluation.

R: After 6 months,, #28 had no recession and #29 had 0.5 mm of recession on the buccal surface. Both had 0.5 mm probing depths on buccal surface. 2 different healing patterns were seen. The first was characterized by a long junctional epithelial attachment that extended beyond the original gingival margin (bw the GM notch and the bone notch) with minimal connective tissue adjacent to the tooth. The second pattern was a short junctional epilthelium that stopped at GM notch. In this pattern connective tissue approximates the root surface, but wo appearing to insert into the cementum. No new bone, nor new cementum were seen in any section.

B/L: The histological evaluation of this case didn’t obtain establishment of a new connective tissue attachment with fibers inserting into new bone, nor new cementum. Result would be defined as repair and not as regeneration. However, the use of this technique can produce root coverage and a successful clinical result.

 


Bruno 2000               ARTICLE

P: Case report to examine the type of attachment that can occur after root coverage of a long-standing facial recession defect w/ a subepithelial connective tissue graft.

Case Report: 56 y/o male w/ generalized, severe marginal tissue recession. Was to have all 4 first pre-molars extracted for ortho. Pt consented to subepithelial connective tissue graft and biopsy of maxillary left first premolar prior to extraction. CTG procedures were perform from canine to second premolar. Initial recession was 9 mm #11, 8 mm #12, and 6 mm #13. After 12 months recession was 1 mm #11, 2 mm #12, and 1mm #13. PD were 1-2 mm and no BOP. At 12 months #11 was extracted w/ 10 mm of the gingival tissue at site #11 including the buccal bone still attached to root. Extraction site was filled with DFDBA. Histologic sections showed some coronal apposition of new bone, cementum, and PDL at base of the defect ranging from 0.5 to 1.0 mm. Sharpey’s fibers were present inserting into newly formed bone/cementum. The majority of the exposed root surface was covered by connective tissue ranging from 3 to 5 mm.

Discussion: Histologic findings suggest that subepithelial CTG may heal by various modes of attachment to the tooth. Base of the recession defect attachment occurred by periodontal regeneration. Connective tissue attachment persisted for 1 year w/o converting to cementum and without adversely affecting the root surface. There is controversy regarding whether original root cementum is necessary for the formation of new cementum. In this case new cementum formed over original root cementum and paralleled the amount of new bone formation.

BL: Subepithelial CTG can increase gingival height and esthetics. The amount of soft tissue coverage achieved following CTG can be maintained during orthodontic movement. Histologic findings indicate various types of tissue attachment, including periodontal regeneration, may occur over a recession defect after placement of subepithelial CTG.

 


What are some of the different ways to prepare a subepithelial connective tissue graft recipient site? Do all of these techniques utilize coronal advancement? Describe a. Raetzke’s envelope, b. Nelson’s subpedicle, c. Langer & Langer connective tissue graft technique, d. Allen tunneling technique, e. Zabalegui multiple recession technique, f. Blanes bilateral pedicle. G. Harris double pedicle


Raetzke P, 1985               ARTICLE

P: To describe a new method for covering localized areas of root exposure with connective tissue grafts. The “envelope”technique.

M&M: 10 patients (6 males, 4 females), ages 16-39, 12 areas of recession were treated. After initial treatment, gingival inflammation was controlled and no pathologic pockets were present at the sites of recession. Average probing depth was 1.04mm. Additional clinical parameters obtained before and from 2-8 months after surgery included depth and width of recession, width of KG. Also, the distance from the gingival margin to the crest of the facial bone was measured pre-operatively by vertical sounding through the gingival crevice.

The surgical method consists of the following steps:

  1. A collar of tissue, its width corresponding with sulcus depth, is excised from the receded gingiva on order to remove the sulcular epithelium.

  2. The root of the involved tooth is carefully scaled and planed until its surface is smooth and hard. Citric acid is applied to its surface.

  3. Through an undermining partial thickness incision, an “envelope” is created in the tissue around the denuded root surface.

  4. In the premolar/molar region of the palate, close to the teeth, two incisions are made 1 to 2mm apart in an anterior/posterior direction. Their length should be double the width of the area of recession.

  5. A wedge of tissue is removed and its small band of epithelium excised. Epithelium may be left in the middle part of the graft which comes to lie over the exposed root.

  6. The graft is placed in the previously created envelope so that it completely covers the formerly exposed root area. Finger pressure is applied with a piece of gauze until the bleeding has stopped and the graft is firmly seated.

  7. It is then secured with a tissue adhesive, no sutures are required.

  8. The area is covered with a non-eugenol periodontal dressing for 1 weekAt the donor site, the wound edges are adapted by sutures. No further protection is necessary.


R: The average coverage was 80%. There was a significant gain of KG in every case, ranging from 2mm to 5.5mm and average 3.5mm. Probing depth at these sites was 1-2mm.

Healing at recipient site:

Discussion: Compared to other procedures used to treat localized recession, the envelope technique offers the following advantages:

Indications:

The success of the envelope technique is attributed to the favorable positioning of part of the graft, between two layers of well vascularized tissue.


Nelson, 1987            ARTICLE      (Nelson’s subpedicle)

P: To describe the subpedicle CTG.

M+M: 14 healthy pts (12-52 years old). A total of 29 teeth were treated and monitored from 6 to as long as 42 months. Pocket depths were recorded prior and following treatment.

One week following surgery, healing was evaluated and sutures removed. Each patient was shown how to perform gentle sulcular brushing with a soft toothbrush on the involved teeth.

At 3, 6, and 12 weeks post-op, a prophylaxis was performed with pumice on a ribbed cup, and the sulcular area was gently debrided with a curette. PDs were evaluated 12 weeks post-op and at subsequent 3-month SPT visits.

R:

In all three groups the subpedicle connective tissue graft produced a zone of attached gingiva that was clinically adequate without producing a pocket depth greater than 3 mm.

BL: The subpedicle graft is indicated when a single surgical procedure is desired that will predictably cover denuded root surfaces when there is inadequate keratinized gingiva available for a pedicle graft and where the prognosis is poor for root coverage with a free gingival graft.

 


Borghetti 1994               ARTICLE

P: To clinically evaluate the 1-yr coverage of gingival recs by a subpedicle CT graft according to Nelson’s technique (a free CT graft placed over the denuded surface with an overlying pedicle graft, increasing the blood supply to the graft) compared to untreated recs used as control sites and to examine PD, KT, and MGJ location changes.

M&M: 15 pairs of buccal recs were selected in 15 healthy pts. All pts agreed to have one rec treated as part of the study (test site) and the other left untreated until one year later (control site). The surgical protocol of the subpedicle CT graft with double papilla FTF flap. Rec, PD, KT, and CEJ-MGJ distance was recorded pre-op and 1-yr POT.

R: The control group showed NSSD in any of the parameters. In the test group, rec had SS decreased from 3.66mm to 1.09mm, displaying 70.5% root coverage. KT increased from 1.6mm to 4.3mm, PD had NSSD and CEJ-MGJ distance had NSSD either.

BL: The subpedicle CT graft may provide a good amount of CT coverage and a substantial increase in KT.



Langer 1985               ARTICLE

Purpose: To describe the subepithelial connective tissue graft, technique that can be used to gain total root coverage in isolated and multiple sites.

Discussion: Indications: 1. Inadequate donor site for a horizontal sliding flap, 2. Isolated wide gingival recession, 3. Multiple root exposures, 4. Multiple root exposures in combination with minimal attached gingiva and 5. Recession adjacent to an edentulous area that also requires ridge augmentation.

Technique: In the recipient site two vertical incisions at least one-half to one tooth wider than the treated area. Coronal margin of the incision is horizontal Sulcular that prevents the radicular gingiva. Interdental papillae are left intact. Partial thickness flaps are elevated. With the exception of root planning roots are not prepared in any specific manner.

In the donor site, horizontal incision is made 5-6mm from the gingival margin at the desired width (depending on the teeth that need to be covered). A second incision is made 1.5-2mm coronal to the first one and continues apically until it meets the base of the original incision and the palatal bone is scored. Vertical incision can be made on either side to facilitate the removal of CT graft and help wound closure. Connective tissue is excised and the epithelium between the two incisions. The epithelium seems to provide a smother junction with the existing epithelium. The adipose tissue is removed. It is advisable to suture the palatal flap immediately after the graft is excised. The graft is place over the denuded roots and sutured in place with either 4-0 silk or chromic gut. Partial thickness flap is placed coronally to cover as much of the graft as possible . No attempt is made to completely cover the graft as this would create an excessive pull on the vestibular fold. Dressing is placed on the recipient site. It is optional on the palate. Dressing and sutures are removed at 7 days and normal plaque control techniques are resumed. During healing period graft may appear thickened but this will lessen ver time. If not gingivoplasty may be needed.

If at least ½ to 2/3 of the graft is covered with the flap, the remaining portion will survive over the denuded root.

Percentages of root coverage were not recorded.

Marginal position of the gingiva appears stable.

Gingivoplasty may be necessary.

Tatoo or keloid-like appearance of FGGs is less common.

Palatal wound heals with less discomfort than FGG, but excessive undermining of the primary donor flap can lead to tissue necrosis.

Increase in root coverage in the cases performed by the time the article was written (56 cases in 4 years) varied from 2-6 mm.

 


Allen 1994               ARTICLE         tunneling technique

Purpose:To discuss the technique of using a supraperiosteal envelope for soft tissue grafting (tunneling) and root coverage

Discusion:

BL: In absence of perio pockets, using a supraperiosteal envelope for soft tissue grafting is a good approach for root coverage of appropriate defects. However, this is technique sensitive.





Zabalegui,1999               ARTICLE

P: To describe a surgical periodontal plastic procedure for the coverage of multiple adjacent gingival recessions.

Technique: No external incisions. Partial thickness sulcular incision, preserve the papillae by undermining the tissue coronal to the CEJ and beyond the MGJ. Graft held by M&D sutures and pulled under tunnel. Graft aided by blunt instrument. graft is sutured in place with 2 square knots. Hold for 5 min w/moist gauze. No OHI for 1st wk. 0.12CHX prescribed.

D: Indications CL I or II Miller recession (multiple) in which very early healing is needed for esthetic demands or a need to reduce the number of surgical interventions. Relative contraindications are heavy smoking, expected impaired healing response, Miller CL III or IV recession or extremely thin periodontium. Advantages: early healing. 2 weeks after treatment color matched. Difficulties of technique sensitive flap perforation difficult, establish same plane of dissection and avoiding severance of base of papilla. Micro surgical instruments recommended.

BL: Use of this technique allows treatment of multiple adjacent recessions in a single surgical procedure w/early healing and predictable coverage.



 

 

 

 

Blanes 1999                ARTICLE             bilateral pedicle

P: to describe a periodontal plastic surgery procedure where a bilateral pedicle flap and a tunnel are combined to compensate for the lack of blood supply that the tunnel technique offers in deep or wide adjacent recessions.

The Bilateral Pedicle Flap-Tunnel Technique

Recipient and donor site preparation:

D: This technique combines the use of a tunnel procedure with double lateral pedicle flaps to cover a CT graft. This approach combines the advantage of the tunnel technique with the increased blood supply and protection provided by pedicle flaps. ~95% root coverage in 6 pts

 

 

Harris, 1999                ARTICLE         double pedicle

Purpose: To histologically evaluate successfully treated root coverage with a connective tissue graft.

M&M: Case report on 38yr old female. Ridge collapse was observed in tooth #7 and 4 mm recession at the buccal aspect of # 8 with probing depth of 1mm (buccal) and 2mm KG. Exposed roots were planed with hand instruments. Tetracycline solution (125mg/1ml saline) was applied for 3 min and then rinse. Incision was made from mesial of #8, across edentulous ridge, to distal of #,6 and a vertical incision on mesial of #8. Partial thickness flap was reflected. 1.5 mm thick connective tissue graft (CTG) (ephitelial border discarded) was then sutured over the recession defect (#8) and the edentulous ridge (#7) with 5.0 gut sutures. The pedicle flap was then sutured over the CTG with the same sutures. Full root coverage was observed at 2, 4, 8, & 12 weeks post-op. At the area of defect, PD= 1mm and KG= 4mm was achieved. At 5 months post-op, the tooth was extracted due to endo problem. Tissue collar was left on tooth for histological evaluation.

Results: Histological evaluation revealed areas of regeneration with new bone, cementum, & connective tissue attachment coronal to the original gingival margin.

BL: Regeneration is possible when connective tissue graft is combined with an overlying pedicle graft to achieve root coverage.

Cr: Notches couldn't be use in this case; author used as a reference point of original gingival margin, the terminal edge of the root planning done bf the sx.



How do we harvest connective tissue? What are the potential donor areas? What anatomical factors are we concerned with?

Reiser 1996               ARTICLE

P: To describe the anatomy of the palatal donor site and to identify structures that could potentially create surgical complications.

D: The height, length, and thickness of donor tissue that can be obtained varies depending on the dimensions of the palatal vault. The greatest height can be found in the U-shaped palatal vault. The greatest length can be found in a large palate. The thickest tissue can be found from the mesial line angle of the palatal root of the first molar to the distal line angle of the canine. Thick alveolar process and/or exostosis in the molar region can limit the length and thickness of the donor site. A clinician can test thickness of the donor site by needle sounding following local anesthesia. The greater and lesser palatine nerves and blood vessels pass through the greater and lesser palatine foramina but foramina location may vary. Generally foramina can be identified apical to the third molar at the junction of the vertical and horizontal parts of the palatine bone. The neurovascular bundle may be located 7 to 17 mm from the CEJ of the maxillary premolars and molars within the bony groove. Shallow vault palates (flat) the NVB will be located more proximally to the CEJ. When the palatal vault is high (U-shaped), the NVB will be located further from the CEJ. In general more caution should be taken with a shallow (flat) palate. If a surgeon encounters bleeding from palatine vessels one should 1) apply direct pressure for 5 min, 2) place sutures proximal to the bleeding site, 3) reflect the vessel with a full thickness flap and ligate the vessel.

BL: Knowing the anatomy is mandatory to avoid surgical complications. The thickest donor connective tissue can usually be harvested from the premolar region of the palate. Contralateral side may also be simultaneously harvested to obtain sufficient donor tissue. Greater tissue availability is found with a high palatal vault versus a lower palatal vault. Watch for a thick alveolus or exostosis in the molar region. If a provider encounters serious bleeding complications remember the three steps listed above.



Edel 1974               ARTICLE

P: To determine the predictability of using free gingival connective tissue grafts in order to increase the keratinized gingiva.

M&M: 14 areas in 8 patients were treated. Inclusion criteria: KG width <2mm. Prior to surgery, scaling was performed and OHI were given. Width of KG was measured pre-op and post-op at 1,2,5,10,12 weeks and 6 months. The recipient site was prepared by making 2 vertical incisions into the alveolar mucosa, at the buccal line angle of the teeth adjacent to the area to be treated. A periosteal bed was prepared. The remaining partial thickness flap was displaced apically, but was not sutured.

Donor site

Method 1: Palatal region opposite to molar teeth served as the donor site in 6 cases. A partial thickness gingival pedicle flap was raised with his base wider that its free end. Connective tissue graft was harvested. Flap was replaced and pressure applied for 2min, flap was sutured, no dressing was placed.

Method 2: The underface of FTF was used as donor site in 6 cases. Primary incision was made to the crest of the bone along the axis of teeth close to the gingival margin. A FTF was raised and a second incision was made to thin the flap internally. Graft was obtained. Palatal flap was sutured and dressing was placed if necessary.

Method 3: A partial thickness flap was raised at the edentulous area and graft was harvested. Flap was then sutured back.

Graft was placed on the recipient bed and sutured with silk 6-0 sutures. The displaced flap was checked to ensure that it did not interfere with the graft. Dressing was placed.

Biopsy was taken from one area at 6 months.

R: In all cases the graft area and the donor site healed uneventfully where methods 2 and 3 were employed. In cases where method 1 was used, the flap degenerated to a varying degree and was associated with marked discomfort, as no dressing was applied. Mean width of graft prior to dressing placement was 5.54mm. At 6 months the mean width of KG was 4.58mm. At 6 months, the mean contraction was 28%. At 1week the surface of the graft appeared red and shiny, and was covered in parts with greyish slough. At 2 weeks the surface was completely epithelialized, by 4 weeks keratinization was evident and by 6 weeks it blended normally with the surrounding tissues.

Histology: Clear demarcation between keratinized and non-keratinized epithelium at the newly created MGJ. The keratinized epithelium showed well developed rete pegs. The collagen bundles in the connective tissue were predominantly oriented at right angles.

CON: A statistically significant increase in width of KG was achieved by free connective tissue graft. Histologically the healed tissues showed the normal characteristic of a normal keratinized tissue.

 

 

Harris, 1997               ARTICLE

P: To compare the early healing in the donor area, patient discomfort levels, and the root coverage results two graft harvesting procedures: the free gingival graft knife method and the parallel incisions method.

M+M: 26 pts (24M, 2F) divided into two groups (12M, 1F in each group). All recessions had to be 2mm or greater and were class I or class II miller classification. All pts treated with connective tissue with partial thickness double pedicle graft technique with goal of root coverage.

First group-13 pts, 19 defects (8 isolated, 11 multiple, 11 mand incisors, 1 mand canine, 4 mand PMs, 1 max canine, 2 max PMs), 3 smokers. Obtained graft with free gingival graft knife method.

Second group- 13 pts, 15 defects (11 isolated, 4 multiple, 4 mand incisors, 2 max incisors, 7 max canines, 2 maxmolars), 3 smokers. Graft harvested with parallel incisions method.

Pt were seen at 1, 2, 4, 6, and 12 weeks post-op for prophylaxis.

The donor area healing evaluated at the 1-week and 4-week post-op visit. Pts were asked to rate their discomfort level in the palate and grouped into those reporting no/minimal pain and those reporting greater than minimal pain. The surface area of the palate that appeared to be granulating in or was not completely covered by epithelium was calculated to the nearest 0.5 mm at 1 and 4 weeks ,same was done at the recipient area. Final eval done at 12 weeks.

FGG Knife method: A free gingival graft knife with the cutting shoe in a pushing direction used to elevate a partial-thickness trap door flap by pushing the knife, under control, distally across the pa late. The distal border of the fiap was allowed to remain attached to the palate. The trap door was retracted distally to permit access to the connective tissue beneath it. The knife then used in the conventional manner to cut in a pulsing motion, beginning at the distal and pulling the knife mesially. CTG was then incised and removed.

Parallell incisions method: Using a specially designed scalpel with parallel blades (Harris Double Blade Graft Knife, H & H), a pair of deep parallel incisions were made into the palate. These incisions were made palatal to the first molarto canine. The blades were 1.5 mm apart. The

intent was to keep the incisions away from the gingival margin. The incisions made with a single 10 to 12-mm-deep pass. Vertical incisions were placed at the mesial and distal end of the more external incision. A 4-0 silk suture was placed through the palatal tissue to retract the palatal tissue and to provide access to the tissue between the initial incisions. This tissue between the initial parallel incisions was to be utilized as the graft. The tissue was removed by incising the mesial, distal, and medial edges between the parallel incisions.

R: NSSD in the mean root coverage when comparing the results produced by these graft harvesting techniques (98.3% for FGG knife to 98.7% for parallel incisions).

Root coverage of 100% was obtained in 84.2% of the cases treated with the free gingival graft knife method and in 93.3 % of the cases treated with the parallel incisions method.

The parallel incisions method produced less patient discomfort, a smaller wound at 1 week post-op, a more uniform graft, and was easier to use clinically.

BL: The parallel incision method seems to fulfill more of the factors of an ideal technique to obtain a CTG than the free gingival graft knife method.

 


Hurzeler 1999               ARTICLE

P: To present a new technique for harvesting CTG

D:

-Scalpel blade is used to make a single horizontal incision to the bone 2mm form the gingival margin with a 90 degree angle

-The blade is then angled to approximately 135 degrees, and an undermining preparation toward the median is started within the first incision

-With each new movement of the scalpel along the incision line, the angle is further flattened until the blade reaches a nearly parallel position to the bone surface. No vertical incisions are to be made. The goal of this procedure is to create a partial thickness mucosal flap with a uniform thickness of 1-1.5mm.

-The underlying CTG is separated from the surrounding CTG by making incisions to bone on the mesial, distal and medial sides of the graft

-The graft can then be removed by detaching it from the bony surface with a periosteal elevator

-The donor site is sutured with horizontal suspension sutures. Collagen material can be placed in the void where the CTG has been removed to maintain the outer contour of the palatal mucosa after healing.

BL: This technique attempts to simultaneously combine the tissue gain of large grafts with unimpaired wound healing and patient comfort by primary intention healing in a single incision approach.


 


What is Acellular Dermal Matrix? What are the different types? Can it be used for gingival recession? What are this indications and contraindications for this material? How is the material managed? How does it heal?


Harris 1998                        ARTICLE

Purpose: Case report of covering recession with acellular dermal matrix.

50 yo male was referred for root coverage of #11 and #28-30. #11 treated with CT graft and pedicle flap. At 6 days post-op bleeding from the palatal wound was reported by the patient and bleeding was controlled at the dental office.

In order to avoid the palatal donor area, #28-30 were treated with an acellular, biocompatible, human connective tissue matrix. It is an allograft of human skin processed to eliminate the epithelium and all cellular components of the connective tissue and then freeze-dried. Primary incisions were made from #27-31 connecting the CEJs and were connected with intrasulcular incision. Partial thickness flap was elevated without vertical incisions and sharp dissection was continued to a point where the pedicle could cover the defect without tension. Root planning was performed and are was treated with TTC solution (125mg/cc saline). Material covered the defects and extended 3-4mm on the surrounding bone. Basement membrane of the graft does not retain the blood. CT side retains the graft. Basement membrane should be placed away from the bone according to the manufacturer, but since the healing dynamics of root coverage are different it was decided to place the basement membrane adjacent to the defects. The pedicle was then coronally positioned to completely cover the the graft and secured with 5-0 gut sutures. Dressing was applied and 100mg doxycycline twice the day of the surgery and then once every day for 2 weeks. Dressing was removed at 9 days. 3 months after the second procedure and 7 months after surgery in #11 areas were dermabrased to achieve satisfactory esthetic results and 2mm punch biopsies were obtained from the two sites.

Results: Complete root coverage was achieved in #11 and in #28, 29. 1mm of recession in #30 (4mm initial).

Final esthetics were judged to be acceptable by both the patient and the clinician. All procedures were well tolerated and the only post-op complication was the post-op bleeding from the palatal wound. Biopsies were normal with few inflammatory cells. Both areas showed similar structures. Elastin fibers were found in the deeper areas treated with acellular dermal matrix. Since these fibers are only found in the skin and not in the gingiva, they were used as a marker for the acellular dermal matrix showing it was incorporated and involved in the results.

Conclusion: Similar clinical results were obtained with the two techniques. Obvious advantage of the acellular dermal matrix was the ability to avoid the CT graft from the palate. It was 32mm long which would not be safely obtained from the palate.

It seems that acellular dermal matrix is an effective substitute for a connective tissue graft.

 


Gapski 2005                ARTICLE

Purpose: to perform a meta-analysis to evaluate 1) the efficacy of Acellular dermal matrix (ADM) tissue on percent root coverage and changes in CAL and PD versus coronally advanced flap (CAF) and Connecive Tissue grafts (CTG) and 2) the efficacy of ADM in gaining KG versus Free gingival graft (FGG) and Connective Tissue Grafts (CTG).

Materials and methods

Results

Discussion/Conclusion


De Queiroz Côrtes 2006             ARTICLE

P: Evaluate the tx of gingival recessions with coronally positioned flap with or without acellular dermal matrix allograft (ADM) over 24 months.

M&M: 13 patients with bilateral gingival recessions were included (bilateral Miller Class I buccal recessions ≥3mm in Max canines or PM). The defects were randomly assigned to one of the tx: CPF + ADM or CPF alone. Clinical measurements were taken before the sx and after at 6,12,24 months.

R: At baseline, the mean values for recession height were 3.46 and 3.58 for the defects treated w/ and w/o the graft, respectively. NSD between the groups were observed after 6 and 12 months in recession height. After 24 months, the group treated with CPF alone showed a greater recession height when compared to the group treated with ADM + CPF (1.62 vs. 1.15mm). A significant increase in thickness of keratinized tissue was observed in the group treated with ADM + CPF as compared to the CPF alone.

BL: ADM may reduce the residual gingival recession observed after 24 months in defects treated with CPF. Also, we can expect to achieve greater gingival thickness when the graft is used.

 

Wang 2014               ARTICLE
P: The purpose of this multicenter randomly controlled clinical trial was to compare 2 acellular dermal matrix (ADM) materials produced by different processing techniques, freeze-dried (FDADM) and solvent- dehydrated ADM (SDADM), in their ability to correct Miller’s Class I and II recession defects.

M: Eighty subjects from four study centers, each with a single maxillary anterior Miller’s class I or II recession defect were enrolled. Subjects were randomly assigned and treated with coronally advanced flap (CAF)+FDADM (N = 42) or CAF+SDADM (N = 38). Gingival thickness, recession depth, recession width, probing pocket depth, clinical attachment level, Gingival index, Plaque index, patient discomfort and wound healing index were recorded before surgery (Day 0), immediately post surgery (Day 1), and 2, 4, 12, 24 and 52 weeks postoperatively. The Student's t-test, Paired t-test, and Kruskal-Wallis one way ANOVA were used to analyze the data.

R: When evaluating the clinical parameters after one year, both groups showed significant (P<0.05) improvement for most of the parameters evaluated when compared to baseline (Day 0). For example, percentage of root coverage was 77.20% ± 29.10% for CAF+FDADM and 71.01% ± 32.87% for CAF+SDADM. On the other hand, no significant differences were observed between the two materials for any clinical parameter tested or for patient satisfaction except for PD on the mesial side of the defects (p=0.03) being 2.63 ± 0.63 mm for FDADM and 2.33 ± 0.57 mm for SDADM

C: Both ADM materials, freeze-dried or solvent-dehydrated, can be used successfully to correct Miller’s class I or II recession defects. There were no statistically significant differences between groups for any of the clinical parameters tested.

D: Both ADM materials yielded comparable surgical results because both have a similar collagen matrix structure, which allows easy penetration of a new vascular systems into open channels and integration into existing host tissue.

 

When can Emdogain be used for root coverage? What are the steps to utilize this material? What are some of the drawbacks of this material?

 

Modica ’00                  ARTICLE

P: To evaluate coronally advance flaps (CAF) in combination with EMD in treating buccal gingival recessions.

M+M: 12 pts in a spit mouth study with14 pairs of Miller class I and II ( 10 bilateral) (4 adjacent). One sight was randomly assigned to the test group (EMD) and the contralateral site as the control group (wo EMD). Both groups were treated the same, except the test group the EMD was applied according the manufactures instructions (EDTA 24% for max 2 min, rinse with saline and then EMD applied from the most apical to the most coronal part of the exposed root surface), flap was then repositioned coronally. Recession, CAL, KG and PD were recorded at baseline and at 6 months by a blinded and calibrated examiner.

R: The average initial REC was 3.71MM (SD +/- 1.68) for the test group, and 3.50 mm (SD +/- 1.56) for the control group (statistically homogenous). The mean root coverage was 3.6mm (SD +/- 1.55), 91.2% for the test group, and 2.71mm (SD +/- 1.20), 80.9% for the control group. NSSD. The mean CAL gain was 3.57mm (SD +/- 1.55) for the test group and 2.7mm (SD +/- 1.19) for the control group. No changes of PD and KG were found.

BL: EMD didn’t show to significantly improve the clinical outcomes of gingival recession treated by CAF.

Cr: Follow up 6 months.

 


Abbas 2003                    ARTICLE

P: Clinical procedure and outcome of surgical treatment of gingival recessions with the adjunctive use of Emdogain gel, an enamel matrix derivative bioactive material for periodontal reconstructive surgery.

M&M: 6 patients (4 men, 2 women) w/ localized gingival recessions (Miller Class I recession of at least 4 mm in depth, presence of keratinized tissue apical to the recession, and absence of clinical signs of inflammation). Selected teeth were maxillary canines with vital pulp and no Class V restorations. The following parameters were measured at baseline and 12 months: recession, PD, clinical attachment level, and amount of KG. Measurements rounded to nearest lower mm. Patients were also asked to rate esthetic result. Coronally advanced flap, as described by Wennstrom and Pini Prato, was used to achieve soft tissue root coverage. The pocket epithelium was removed mesial and distal of the recession defect and interdental papilla was deepthelialized to create a connective tissue bed. No instrumentation of the root surface was carried out. The root surface was conditioned with EDTA gel for 2 min and a sterile rinse. Emdogain gel was applied on exposed root surface. The pedicle graft was coronally advanced and secured at the level of the CEJ. Periodontal dressing was placed. Patients instructed not to brush the area for 3 weeks. Recall prophylaxis was performed at 1, 3, 6, and 12 weeks and subsequently every 3 months. At 12 months measurements were taken.

R: After 12 months the mean root coverage was 73%, mean gain of attachment was 4.0 mm, and PD reduction mean of 0.5 mm. KG was slightly increased.

BL: The coronally advanced flap in combination with the application of Emdogain gel is a predictable treatment procedure for the achievement of soft tissue root coverage and gain of clinical attachment in recession defects. RCT should be performed to confirm the above statement.

 


How effective are platelet-rich products in root coverage? Theoretically, how would this material influence soft tissue procedures? Should platelet-rich products be used alone or with other materials/procedures?

 

Huang 2005                ARTICLE

PRP is derived from concentrated platelets, allowing it to deliver a greater concentration of autologous growth factors including platelet-derived growth factor (PDGF), transforming growth factor beta (TGF-b), vascular endothelial growth factor (VEGF), insulin-like growth factor (IGF)-I, and epithelial growth factor (EGF). These native growth factors pro- mote fundamental phases of tissue repair such as mitogenesis and angiogenesis.

P: to evaluate the role of PRP in CAF(coronally advanced flap procedures).

M&M: Randomized, controlled, examiner-masked clinical trial. 24 subjects were randomly assigned to either test (PRP + CAF) or control groups (CAF). Presurgical procedures included OHI, full-mouth SRP, and occlusal adjustment as indicated. Surgical procedures as well as PRP preparations were performed by a single investigator. Inclusion criteria: 1) systemically healthy subjects, 2) non- smokers, 3)good OH, 4) maxillary or mandibular incisors, canines, or premolars with Miller’s Class I , 5) gingival thickness (GT)0.5 mm as measured 2 mm apical to the gingival margin, 6) KG2 mm and 9) recession depth (RD) 2 mm.

Clinical parameters (PD, CAL, KG, REC depth and width, gingival thickness, PI, GI and WHI (wound healing index)) were recorded. Measurements were made using a stent.

Sx: sulcular incisions on the buccal aspect of the tooth. At papillary areas, the incisions followed the outline of the papilla. The distance between the tip of the papillae and the papillary incision was equivalent to the recession depth. Two vertical releasing incisions were made at the line angles of adjacent teeth and extended into the mucosa. FTF reflected. Periosteal releasing incision at the inner aspect of the flap was made to allow coronal flap advancement without tension. Deepithelialization was performed at each papillae to provide a connective tissue bed for flap adaptation. The exposed root surface was planed. Patients in the test group then received PRP over the root surfaces. Flaps were then coronally advanced to cover the exposed root and sutured. Patients were followed at 2, 4, 12, and 24 weeks post-surgery.

R: 23 patients completed the study. No significant difference in baseline recession depth, width, KG and gingival thickness. The reduction of RD and RW 6 months after surgery was statistically significant compared to the baseline (P <0.05) in both groups.. The RD at 24 weeks was significantly reduced from 2.9 0.5 to 0.5 +0.6 mm in the CAF group (P <0.05) and from 2.8 0.2 to 0.5 0.7 mm in the PRP + CAF group (P <0.05). The mean root coverage was 83.5% 21.8% in the CAF group and 81.0% 28.7% in the CAF + PRP group (P >0.05). Fourteen out of 23 patients (60.9%) experienced 100% root coverage at the 24-week postoperative follow-up.

CON: CAF is a predictable approach to treat Miller’s Class I gingival recession. The additional application of PRP failed to improve root coverage after CAF in Miller’s Class I recession defects. However, a positive trend of PRP utilization was observed since lower GI and increased GT postoperatively were observed in this group. It is important to emphasize that this positive trend should be better observed and confirmed in studies involving a larger number of subjects. Therefore, future studies with larger sample sizes are recommended to further explore this hypothesis.

 


Bashutski, 2008                NO ARTICLE

P: To review current information on the use of PRP (Platelet-rich plasma) in soft tissue healing and root coverage procedures.

PRP: Is an increased concentration of autologous platelets suspended in a small amount of plasma after centrifugation. A small volume (about 50ml) of the patient’s blood is obtained and centrifuged at varying speeds until it separates into 3 layers: platelet-poor plasma, platelet-rich plasma and red blood cells. The PRP is isolated and stored with a citrate-based anticoagulant until the end of the surgical procedure. Immediately before application, topical bovine thrombin and 10% calcium chloride are added to activate the clotting cascade, producing a platelet gel. The whole process takes approximately 12 minutes and produces a platelet concentration of 3-5 times more than native plasma. Bioactive growth factors are released upon activation and are involved in key stages of wound healing and regeneration including chemotaxis, proliferation, differentiation and angiogenesis. Vascular endothelial growth factor and platelet-derived growth factor are the most widely characterized growth factors secreted by platelets that play important roles in angiogenesis and fibroblast cell differentiation. Theoretically PRP should improve graft adhesion, minimize micromovement, increase early wound strength and decrease inflammatory phase of wound healing.

Esthetic outcomes: A study comparing a coronally advanced flap vs. coronally advanced flap with PRP, showed a trend towards increased tissue thickness- this study lacked sufficient power to detect a SS.

In vertical incisions, scarring is limited due to increased concentrations of platelet derived growth factor and epidermal growth factor as these growth factors accelerate wound healing. Also hepatocyte growth factor has powerful antfibrotic effects, leading to wound healing to be 2 to 3 times faster.

Patient morbidity: Studies evaluating PRP for applications other than root coverage procedures have revealed that PRP cannot enhance wound healing, bone remodeling, or sinus augmentation.

Marx reported no difference in infection rates of PRP –treated bone grafts and skin wounds when compared to traditional treatment protocols.

Regeneration: Studies evaluating the ability of PRP to promote regeneration in bone showed that PRP has a low regenerative potential. However, an in vitro study showed that PRP increased the proliferation of PDL cells, caused a minor increase in gingival fibroblast growth and inhibition of keratinocyte proliferation.

Root coverage: PRP offers the advantage of accelerated wound healing. However, a randomized controlled trial study showed greater root coverage percentage for the control (CTG w/o PRP) when compared to treatment with PRP (95% vs. 80%, 83.5% vs. 81%).

BL: Preliminary reports suggest that the potential benefits of PRP in root coverage procedures may be improved esthetics, decreased patient morbidity and accelerated wound healing. Further investigation is needed, with larger sample sizes, more challenging defects, and histologic data to better determine the value of PRP as an adjunct to traditional root coverage procedures. Clinical studies are lacking, and the evidence is insufficient to support PRP use at this time.

 


Del Fabbro 2011               ARTICLE

P: To perform a meta-analysis determining whether the use of autologous platelet concentrates may affect the outcome of regenerative procedures for the tx of periodontal defects and gingival rec.

M&M: MEDLINE, EMBAS, and Cochrane Central Register of Controlled Trials, and hand searching were performed. Only RCTs included. For intrabony defects, the primary outcome variable was CAL, and the influences of GTR and study type (split-mouth vs parallel studies) were also evaluated. For rec, the outcome variables were root coverage (RC) and KT. Synthetic grafting materials for recession were included.

R: 24 studies included: 16 intrabony defects all which used PRP, 6 for rec, and 2 for furcation defects. For meta-analysis, 14 articles were used for perio defects and 4 for rec. Most of the RCTs had a split-mouth design. A significant positive effect was found when PRP was used for intrabony defects without the use of membranes (0.84mm in favor of PRP: for bone graft without membrane). However when using GTR, the PRP did not have a positive effect. NSSD of platelet concentrates was found for rec (only 1/6 studies has a SSD, 6wk follow-up). Follow-up for rec ranged from 6wks-1yr. Also, NSSD found in amount of KT. NSSD of PRP for furcations in the two articles, but both favored PRP. NSSD in study design was observed.

D: Authors feel PRP is faster and easier to use than membranes and call it more cost effective.

BL: PRP may have a positive effect in combination with graft materials, but not with GTR, for the tx of intrabony defects. NSS benefit of platelet concentrates found for the tx of rec.

 


What is the efficacy of guided tissue regeneration for root coverage? What materials have been studied acting as a barrier membrane? Should bone graft be used with a barrier membrane to cover recession? What is its effect on soft tissue?

 

Al-Hamdan 2003                ARTICLE

Purpose: 1) To define the clinical outcomes of GTR for root coverage (GTRC), 2) To quantify the mean overall expected improvement, 3) to evaluate the difference between GTRC and conventional mucogingival surgery (CMGS) and 4) to examine factor that may affect GTRC.

Materials and methods: Literature survey was conducted for articles published in English from 1/1/1990 to 10/31/ 2001. Statistical analysis was performed and weighted means and standard deviations were computed for each group considering the sample size for each study for PD, recession depth, CAL, width of KG, CAL gain, % of root coverage and % of cases with complete root coverage. 40 studies were included.

Results: GTRC resulted in significant CAL of 3.1±1.2mm and KG was increased by 1.0±0.9mm. On average it resulted in 75±11% of root coverage and complete root coverage in 42±19.8%.

GTRC vs CMGS: SSD was observed between the two groups for the percentages of root coverage and complete root coverage as well as increase in KG. No SSD for initial values between the two groups.

Absorbable vs non-absorbable membranes: SSD was observed between two groups for recession depth reduction (3.6mm for non-absorbable and 2.8mm for absorbable). Cases treated with absorbable membranes had higher percentage of complete root coverage (45% vs 35%).

Root conditioning: The root surface conditioning group on the cases treated with GTR had higher % of complete root coverage (51.7% vs 32.1%).

Bone replacement graft had no effect in the parameters evaluated. It was used in only 2 studies with a total of 41 sites.

Pretreatment recession depth: No difference between deep and shallow (less than 4mm) recessions in terms of post-treatment depth reductions, % of root coverage, PD changes and gain of KG. Gain of CAL was greater for deep recession (3.9mm vs 2.2mm) and shallow sites exhibited higher % of complete root coverage (51.2±22.1% vs 32±13%).

Study Sponsor: 9 studies were company funded 31 were not. Better root coverage was reported in company funded studies but it was no SD. The non-sponsored studies reported greater CAL gain. The sponsored studies reported higher % of complete root coverage and and had significantly less pretreatment recession depth.

CMGS significantly increased the width of KG more the GTR.

Conclusion: 1. Both methods can be used to repair gingival recession defects with good success.

2.GTR resulted in 75% root coverage with a complete coverage of 42%, 3.1mm gain of Al and 1mm increase in KG width.

 


Leknes 2005 `               ARTICLE

Purpose : to compare coronally positioned flap with or without a membrane in treating gingival recession at 12 months and 6 years follow up.

Materials and methods:

Results:

w/o membrane: 3 unchanged 8 gained (1 full coverage)

Conclusion:

 

Trombelli  2005                ARTICLE

P: To evaluate the changes of the mucogingival complex of guided tissue regeneration (GTR)-treated gingival recession defects over a 10-year follow-up.

M&M: Twenty patients (11M, 9F) had been treated with GTR procedures for Miller’s Class I or II 3 mm or deeper. Each patient contributed one recession defects. Recession depth (RD), PD, CAL, KG were measured immediately before the surgery, and 6 months, 4 years, 10-12 years post-surgery. Nine patients were smokers (considered if > 10 per day).

R:


Before Sx

6 months (mm)

4 years (mm)

10 years (mm)

RD

4.5

0.9

1.0

1.3

PD

1.5

1.0

1.2

1.4

CAL

6.0

1.9

2.2

2.6

KG

1.9

3.1

3.1

3.2



** Note: Recession defects were selected only when they had revealed RD reduction 2 mm or more and root coverage 60% or more at 6 months following GTR treatment

BL: There was no statistically significant change over time in the clinical outcome achieved following GTR procedure in gingival recession defects from 6-month to 10-year follow-up.

 


Park 2006                ARTICLE

P: To present the use of acellular dermal matrix (ADM) as a barrier membrane in reconstructing buccal dehiscences associated with simultaneous implant placement in locally deficient ridges.

M&M: Five sites in four healthy nonsmoking patients were treated with a combination of the mucogingival pouch flap technique, sandwiched layering of mineralized human cancellous allograft (inner layer, Puros cancellous bone) and milled cortical chips (outer layer, Puros cortical bone), and ADM (Alloderm) was properly trimmed to completely cover the particulate grafting material - barrier membrane. The localized one-walled defect was associated with a single missing tooth for 2 yrs.

R: Three patients encountered 2 to 4 mm of membrane exposure at 2 weeks post surgery. However, all sites were completely covered at 3 months. None of the cases exhibited implant exposure throughout the entire healing period. At the 6-month re-entry surgery, ADM-assisted guided bone regeneration achieved a mean of 86.5% height gain with 100% of threads coverage and critical bone thickness of 1.8 mm or greater, with clinical bone density equivalent to that of the native bone.

BL: Use of ADM in GBR may serve as a less technique-sensitive material

 


How have growth factors or tissue engineering been utilized with regards to root coverage? How effective are these treatments?

 

McGuire 2008                ARTICLE

B: Tissue-engineered product is purified type I bovine collagen and viable neonatal keratinocyts and fibroblasts (isolated from human foreskin). The living cells contained in the bilayered cell therapy (BCT) have shown to release cytokines involve in tissue healing. Supplied as ~7.5 cm diameter circular disk that is 0.075 cm thick on a agarose tray.

P: To compare a tissue-engineered (BCT) to traditional FGG to enhance keratinized gingiva and to evaluate wound healing b/w these therapies.

M&M: 25 subjects w/at least 2 teeth in contralateral quads needing soft tissue grafting due to insufficient zone of AG. Molars and mobile teeth excluded. No smokers or pts with systemic conditions (DM, HIV, cancer, etc). 44% were former smokers. AG and KG measured at baseline and followed for 6 months. CAL, BOP, inflammation and resistance to muscle pull were observed throughout the study. Independent examiner blinded to surgical procedure did post op evals. Biopsies from 7 subjects were taken at baseline and 6 months to evaluate the persistence of BCT cells in the subject’s tissue. Sx were done at same appt, random as to which side would receive which therapy. The same recipient preparations were made (removal of tissue, not apically positioned). FGG were ~1 mm thick for all pts.

R: Both increased band of KG, FGG had sig more KG (4.36 mm vs 2.54 mm) than BCT at 3 months and more KG (4.46 mm vs 2.4 mm) at 6 months. Both had sig increase of KG (at least 2 mm more) at 6 months; however, 100% of FGG had at least 2 mm increase, only 76% of BCT sites had at least 2 mm (96% had some increase in KG). NSD in recession or CAL, BOP or muscle pull b/w groups at 6 months. BCT sites were determined to have better color match and tissue texture than FGG sites. Patient’s were surveyed as to which technique they preferred, overall BCT reduced duration of pain and sensitivity.

BL: Possible alternative to FGG for increasing KG, still not as predictable.

 


McGuire 2006                NO ARTICLE

P: To compare recombinant human platelet-derived growth factor (rhPDGF-BB) and Betatricalcium phosphate (β-TCP) and a collagen membrane to the subepithelial CTG with a coronally advanced flap in patients with recession-type defects.

M&M: Seven patients with Miller Class II buccal gingival recession of ≥ 3 mm and gingival width ≥ 3 mm on teeth in contralateral quadrants of the same jaw. All were Caucasian nonsmokers. All teeth had ≤ 2.0 mm KG and a min. of 3 mm of recession. Occlusal adjustments were made. Each patient served as his/her control. Surgery was not scheduled until patient could demonstrate adequate supragingival plaque control. Surgery was performed on each side the same day and patients were randomly placed into two groups where the provider exposed and cleaned root surface and was treated with 1) rhPDGF-BB + β-TCP and a collagen membrane or 2) subepithelial CTG. The surgical technique used to achieve soft tissue coverage was a coronally advanced flap repositioned to the level of the CEJ. The exposed root surface was conditioned with EDTA and the rhPDGF-BB solution was applied to exposed root surfaces. A small amount of β-TCP was placed below the level of the CEJ. A membrane and sutures were then placed. The same procedure was completed on the control side with a subepithelial CTG placed over the denuded root surface (donor from the palate). Abx and analgesics were rx for management of post op infection and pain control. Post op exams were performed at 1, 2, 4, 8, 12, 16, 18, and 24 weeks. At weeks 8, 16, and 24, clinical measurements were made and perio. maint. was performed.

BL: Within the limits of this case series, the use of rhPDGF-BB + β-TCP and a collagen membrane may represent an acceptable alternative to the CTG for covering gingival recession defects. This new procedure 1) eliminates the need for the palatal donor site, 2) represents a less invasive surgery for the patient, and 3) relieves the clinician from relying on a limited supply of donor tissue.

 


How do different root coverage procedures compare to one another. What is the most beneficial therapy for total root coverage? Increasing keratinized tissue? Long term stability?

 

Greenwell 2005                ARTICLE

Periodontal reconstructive surgery consists of a variety of mucogingival procedures including root coverage, tooth exposure, crown exposure, vestibular deepening, papilla reconstruction, ridge augmentation, and ridge preservation.

There are two types of gingival recession, one due to periodontitis and the other primarily related to mechanical factors, especially toothbrushing. Recession due to periodontitis can affect all tooth surfaces and is irreversible. In contrast, facial recession due to mechanical factors is often reversible, or partially reversible, with periodontal reconstructive procedures. In general complete coverage of facial recession defects can be achieved when there is no loss of interproximal bone or soft tissue. Facial recession occurs in patients with a high level of personal and professional dental care, while chronic periodontitis, with its more generalized recession, is a disease associated with plaque and calculus. Other factors that can predispose to gingival recession include tooth malposition, bone dehiscence, thin marginal soft tissue, high frenum attachment, inflammation and dental restorative, orthodontic, or periodontal treatments. Recession increases with age and studies show a substantial increase for each decade of life.

Classification: 1) Sullivan and Atkins: shallow-narrow, shallow-wide, deep-narrow, deep-wide 2) Miller Classification: I, II, III, IV

Root coverage techniques:

  1. Laterally positioned flap technique

Indicated for isolated recession defects on mandibular teeth. The tooth adjacent to the recession defect served as the donor site for a flap that was moved laterally to cover the recession defect. The LPF technique had the disadvantage of often leaving recession at the donor site. Flap design was subsequently modified to leave the marginal tissue at the donor site intact. However, this technique was limited to sites with an adequate amount of adjacent keratinized donor tissue. Only the apical portion of the keratinized tissue was included in the flap, leaving the coronal portion intact to protect the osseous crest and gingival margin, thus preventing donor site recession. Mean defect coverage ranging from 61% to 74% with a mean for all studies of 67%. This indicates limited success with this procedure. Final root exposure ranged from 0.8 to 1.8 mm with a mean of 1.3 mm relative to mean initial recession of 3.9 mm.

  1. Thin Free Gingival Graft Technique

It was believed that free gingival grafts would survive better over the avascular root surface if they were thin, probably about 1 mm in thickness. The technique worked best on shallow, narrow defects but overall the procedure was a failure. One study attributed most of the defect coverage achieved, then known as “bridging,” not to immediate surgical results but instead to creeping attachment that occurred within 1 year. Studies show mean defect coverage ranged from 12% to 66% with a mean for all studies of 41%.

  1. Thick Free Gingival Graft Technique

The thick FGG technique utilized a graft that was at least 2 mm in thickness. Site preparation included butt joint margins between the papilla base and the graft at the level of the cemento-enamel junction to facilitate graft revascularization. The disadvantages of this procedure were a large, slow healing donor site and often an unfavorable color match. Reports show mean defect coverage ranged from 39% to 100% with a mean for all studies of 69%.

  1. Connective Tissue Graft Techniques

The subepithelial connective tissue graft (CTG) is a highly predictable procedure that lacks the esthetic disadvantages of the thick free gingival graft. Successful defect coverage can be achieved with less donor tissue since revascularization occurs from both the periosteal or osseous base and the overlying flap. This dual blood supply is responsible for the increased predictability of CTG procedures. The overlying flap ensures an excellent color match when the graft is completely covered; however, mucosal tissue will not necessarily take on a keratinized appearance. When the graft is partially exposed, the color of the exposed tissue will not necessarily match the flap, but the exposed tissue does become keratinized, thereby increasing the zone of keratinized tissue. The harvesting techniques for connective tissue produce less postoperative morbidity than for thick free gingival grafts.

Techniques:

  1. Langer: Vertical incisions, split thickness flap, CTG immobilized, flap is sutured over to cover as much graft as possible

  2. Pouch procedure: similar but no verticals, no suturing, tissue adhesive

  3. Subpedicle, double pedicle tecnhiques

  4. Tunneling

e) Free Gingival Graft/Coronally Positioned Flap Technique

Studies show mean defect coverage ranging from 57% to 98% with a mean for all studies of 84%.

The free gingival graft (FGG) followed by a coronally positioned flap (CPF) first augmented the zone of keratinized tissue using an FGG This was considered necessary to achieve successful root coverage. About 2 months later a flap was raised and coronally positioned. Flap design included new papilla tips located apical to the original tip by a distance equal to the millimeters of recession. The flap was full thickness to approximately the mucogingival junction, at which point it was split, then coronally positioned. Existing papilla were de-epithelialized, then overlaid by the newly created papilla tip. A disadvantage of this technique is that the free graft may heal as scar tissue and then be difficult to elevate. Studies show mean defect coverage ranging from 36% to 71% with a mean for all studies of 61%.

f) Coronally positioned flap

The coronally positioned flap is an old procedure in periodontics. The current surgical approach for the coronally positioned flap alone often follows the pre- viously described technique, although other variations are used.

The semilunar coronally positioned flap, is a split thickness technique that primarily involves the mid-facial tissue and utilizes an apically placed semilunar releasing incision. This procedure has advantages in many situations and is particularly useful for covering exposed crown margins. A unique full thickness CPF with a horizontal vestibular releasing incision designed to facilitate coronal positioning and to prevent flap retraction may be important in the presence of shallow vestibule where it is extremely difficult to prevent flap retraction. Another unique CPF technique, best for shallow recessions, involves oblique incisions in the papillae, which can then be rotated to facilitate coronal positioning.

Indications:1) shallow recession of 4 mm 2) Miller Class I recession 3) keratinized tissue width 3 mm and 4) gingival thickness of 1 mm

Studies show mean defect coverage ranging from 50% to 98% with a mean for all studies of 78%

g) Guided Tissue Regeneration Technique

Numerous studies of recession defect coverage utilized the principles of guided tissue regeneration (GTR) and employed either resorbable or non resorbable membranes. The membrane is sutured into place, then covered with a coronally positioned flap. Complete coverage of the membrane is preferred at the time of surgery and throughout the healing period since membrane exposure can compromise the result. An advantage of this technique is that it is theoretically possible to regenerate bone and periodontal ligament rather than just gain soft tissue coverage alone. Another advantage is that a secondary surgical site to obtain donor tissue is not needed. One report indicates that deeper recession defects respond better to GTR than shallow defects.

Bioabsorbable membranes studies show mean defect coverage ranging from 45% to 94% with a mean for all studies of 72%. For non-resorbable membranes, studies show mean defect coverage ranging from 45% to 91% with a mean for all studies of 73%.

h) Acellular Dermal Matrix Technique

The use of acellular dermal matrix (ADM) as a substitute for connective tissue when covered by a coronally positioned flap is a relatively new approach that allows coverage of multiple sites and does not require autogenous donor tissue. Used to cover an unlimited number of sites without the need for a second surgical site to obtain donor tissue. ADM is obtained from human dermis harvested and treated to remove all cells while preserving the intact structure of the extracellular matrix, including an intact vascular network. Currently, controlled studies show stable results for up to 1 year; however, additional studies are needed to confirm the long-term stability of this treatment. Studies show mean defect coverage ranging from 66% to 99% with a mean for all studies of 86%.

I) Enamel Matrix Derivative-

Enamel matrix derivative applied to a coronally positioned flap may enhance root coverage, although some studies show no advantage to its use. While this is not GTR, it may also have the potential to enhance regeneration of bone and periodontal ligament.

Studies show mean defect coverage ranging from 72% to 94% with a mean for all studies of 86%.

Factors affecting predictability:

  1. According to recent studies soft tissue thickness 0.8 mm is needed for complete coverage with a coronally positioned flap, while tissue 0.8 mm in thick- ness more often results in incomplete coverage.

  2. Adequate vascular supply is essential to achieve complete root coverage. This may be obtained from the bone, periosteum, and periodontal ligament underlying the graft and from flap tissue overlying the graft.

  3. Flap retraction will decrease the predictability of subepithelial graft or coronally positioned flap techniques. It has been clearly shown that the increased flap tension decreases the predictability of complete root coverage. It is essential that flaps are designed to be tension free so that retraction during healing will not compromise the result. Suturing techniques that will prevent or minimize flap retraction are also necessary. Another technique to prevent flap retraction is to use a tunnel type procedure that keeps the papilla intact

Histologic Evaluations of Attachment

Histologic evaluations of the attachment show long junctional epithelium, some connective tissue attachment, while others show small amounts of regeneration. The type of attachment may be dependent on the type of procedure and he proximity of the epithelium to the wound margin. Studies of root coverage tend to show healing with shallow probing depths and gain of attachment similar to the amount of defect coverage obtained. The type of attachment, therefore, may not have a significant impact on the clinical result, particularly since longer term studies of 3 years or more show that the result is stable over time for connective tissue, free gingival graft, coronally positioned flap, and non-resorbable membrane tecnhiques.

 

 

Cairo, 2008                ARTICLE

P: To systematically review the literature in order to find out the clinical benefit of adding to the coronally advanced flap (CAF) procedure: connective tissue graft (CTG) or barrier membrane (BM) or enamel matrix derivative (EMD) or acellular dermal matrix (ADM) or platelet-rich plasma (PRP) or living tissue- engineered human fibroblast- derived dermal substitute (HF-DDS) in the treatment of Miller Class I and II localized gingival recessions.

M+M: Randomized clinical trials on treatment of Miller Class I and II gingival recessions with at least 6 months of follow-up were identified. Data sources included electronic databases (MEDLINE and Cochrane Oral Health Group Trials Register) and hand-searched journals. The primary outcome variable was complete root coverage. The secondary outcome variables were recession reduction, clinical attachment level gain, keratinized tissue gain, aesthetic satisfaction, root sensitivity, post-operative patient pain and complications.

R: 67 articles selected in literature search were narrowed down to 25 studies. A total of 794 Miller Class I and II gingival recessions in 530 patients from 25 RCTs were evaluated in this systematic review.

BL: CAF is safe and predictable for root coverage. CTG or EMD in conjunction with CAF enhances the probability to obtain complete root coverage and to improve recession reduction in Miller Class I and II single gingival recessions. BM does not improve the clinical benefits of CAF alone. Contradictory results were found in when ADM was used in conjunction with CAF.

 

 

Buti 2013                ARTICLE

P: To conduct a meta-analysis of RCTs to establish a ranking efficacy and the best technique for coronally advanced flap-based root coverage procedures. (other systematic reviews were not able to compare all possible tx alternatives, to establish a ranking efficacy)

M&M: Literature search on PubMed, Cochrane libraries, EMBASE, and hand-searched journals until June 2012 was conducted to identify RCTs on treatments of Miller Class I and II recessions. Criteria included a follow-up of at least 6 months and the following procedures: CPF + CTG, barrier membrane (BM), EMD, ADM, PRP, human fibroblast derived dermal substitute (HF-DDS), collagen membrane (CM). Rec reduction, CAL change, KT, and CRC (complete root coverage) were evaluated. Studies that examined more than two sx techniques were excluded.

R: 29 studies included, but 20/29 were classified as being high risk for bias. CPF + CTG ranked highest in effectiveness for rec reduction (40% most likely the best tx) and CALgain (28% most likely best treatment). CPF + CM (69% most likely best tx) as well as CPF + CTG were the most effective for KT gain. Network inconsistency was low for all outcomes excluding CALgain. For CRC, CPF + EMD was the most effective, followed by CPF + CTG.

BL: CPF + CTG might be considered the gold standard in RC procedures. The low amount of inconsistency gives support to the reliability of the present findings.

 

 

Wessel 2008                ARTICLE

Purpose: To compare patient-based outcomes, specifically post-op pain and analgesic usage, for CTG and FGG procedures.

Materials and methods: 26 patients were recruited from the Graduate Periodontology Clinic from the Ohio State University College. Exclusion criteria were allergy to impression or acrylic stent material, severe gag reflex and inability or unwillingness to provide informed consent form.

Study was of an observational parallel-group design. Total duration was 21 days from the day of the surgical procedure. Subjects filled out a pre-op questionnaire which dealt with demographic and systemic health conditions. Post-op pain, number of analgesic pills and number of days pills were assessed using questionnaires administered at the 3-day and 3-week post-op appointments. Patients’ pos-op pain was assessed using the visual analog scale scores from 1-10 (1 minimal pain and 10 severe pain, 0 if no pain). Subjects also asked to indicate the location of pain: donor site, recipient site or elsewhere in the mouth. Palatal stents were provided in the FGG subjects. Chx 0.12% and Ibuprofen 600mg were prescribed to the patients. Statistical analysis was performed.

Results: 3/26 subjects did not complete the study. 12 CTG subjects were included and 11 subjects with FGG.

At 3 days post-op 11/12 CTG subjects and 11/11 FGG subjects had experienced post-op pain since the surgery. VAS scores were 3.5 and 4.8 respectively (NSSD). The proportion of subjects reporting pain in the palate was significantly greater for FGG (64% vs 50%).

At 3 weeks post-op 6/12 CTG reported pain (VAS mean score 1.6) and 5/11 for FGG (1.4 VAS score) (NSSD).

Pain in the palatal donor site was 90% for FGG and 50% for CTG.

CTG group took 3.2 analgesic pills total and and FGG 4.9.

Conclusion: From patient comfort perspective CTG might be the procedure of choice when FGG and CTG can meet the patient’s surgical needs.

More efficient analgesic protocols and donor wound protection may help improve postoperative protocols.

 


Paolantonio,1997               ARTICLE  

Purpose:  To evaluate the long-term clinical efficacy of Free gingival graft (FGG) vs. Subpedicle connective tissue graft (SCTG) for coverage of exposed root surfaces.

Materials and methods: 

Results: 

Gingival Recession Before Sx            After SX

Group A                     3.11 mm           1.50mm                       

Group B                      3.43mm           0.58mm                      

KG

Group A                     1.57mm             5.23mm  

Group B                       1.94mm            4.75mm        

 ERSA

Group A                      7.54mm            3.70mm     

Group B                       9.79mm            1.62mm   

Mean % coverage

Group A 53.19

Group B           85.23   

Conclusion :Both techniques offer improved root coverage with the SCTG offering slightly better results.  The authors attribute the improved results to better blood supply to the graft with the SCTG.

 


Bittencourt 2006                ARTICLE

P: RCT to compare the outcome of gingival recession therapy using the semilunar coronally positioned flap (SCPF) or the sub-epithelial connective tissue graft (SCTG).

M&M: 17 pts with bilateral Miller Class I buccal gingival recessions (≤ 4mm) in maxillary canines or premolars. The recessions were randomly assigned to receive either the SCPF or the SCTG. RH (recession height), RW (recession width), WKT (width of keratinized tissue), TKT (thickness of keratinized tissue), PD and CAL were measured at baseline and 6 months post surgery. Pt satisfaction with esthetics, root sensitivity and post op pain was also evaluated.

R: The avg percentage of root coverage for SCPF was 90.95% and SCTG was 96.1%. Complete root coverage was observed in 52.9% of SCPF pts and 76.47% of the SCTG pts. The SCTG showed a SSD in TKT. There were no significant differences between the two groups with regards to RH, RW, WKT, PD and CAL. The esthetic condition of both treatments was considered satisfactory by the patients.

BL: SCPF and SCTG were effective in providing root coverage in Miller Class I gingival recession defects where the pt presented with at least 2mm KG prior to the root coverage surgical procedure, however SCTG resulted in thicker tissue.

 

 

McGuire, 2003                ARTICLE

P: Comparison b/t Enamel Matrix Derivative (EMD) placed under a coronally positioned flap (CPF) to a CT graft with a CPF.

M&M: 17 pts with incisors or premolars w/ facial recession of ≥ 4mm in contralateral quadrants of the same jaw were used. One tooth in each patient was randomly assigned to receive a CT + CPF, and one tooth EMD + CPF. Clinical parameters were measured at baseline, 6, 9, and 12 months. Recession, width of defect, KG, PD, CAL, inflammation, plaque, and tissue color were recorded. Patients were also questioned as to their perception of pain, bleeding, swelling, and sensitivity.

R: All measured clinical parameters were similar except: EMD plus CPF was superior to CT graft with early healing and patient reported discomfort. The CT graft plus CPF was superior in gaining more keratinized tissue over 1 yr. Both showed a SS gain in KG. NSSD in amount of root coverage. Both groups averaged 4.5 mm of root coverage, and the average % of root coverage was 94% for CT graft vs 95% for EMD.

C: This study shows that using EMD with a CPF achieves similar results to CT grafts, but with less discomfort and no donor site morbidity site.

 


McGuire 2003                ARTICLE

P: Case report to assess the quality and nature of new tissue attachment (histologically) to a previously denuded root surface following treatment with coronally advanced flap with enamel matrix derivative (CAF +EMD) or a coronally advanced flap with subepithelial connective tissue graft (CAF + CTG).

M+M: One patient had two hopeless teeth (#7 and #9), with Miller Class IV recession, planned ultimately for extraction. #6 and #11 also qualified for inclusion into the study. Teeth #6 and #7 randomized received CAF + EMD and #9 and #11 were assigned to CAF + CTG, according to protocol of the previous paper; Notches at bone crest and at gingival margin were made. 6 months post-op, the two hopeless teeth were extracted with a small collar of tissue. Histological analysis was done.

R: CAF+CTG: showed a CT attachment between tooth and graft, no histologic evidence of new bone, new cementum and new PDL (regeneration) was noticed. Some root resorption observed adjacent to graft. CAF+EMD showed new cementum, organizing PDL fibers, and islands of condensing bone.

BL: These histological findings showed that EMD, had all necessary tissues for regeneration and that it works in a similar process to that of tooth development.

Crt: The histology of EMD specimens had a mucogingival flap fenestration in the area of the notches, so the notches were useless.

 


Paolantonio 2002                ARTICLE

P: To compare the results obtained by 2 bilaminar techniques (BT) using connective tissue (CT) or acellular dermal matrix (ADM) grafts to achieve root coverage (RC) and an increase in the gingival thickness (GT) at a 1 year examination after surgical treatment.

M&M: 30 healthy, non-smoking patients w/ mean age of 34.5 yrs with no perio pockets >4 mm after phase 1 treatment with a Miller Class I or II gingival recession was treated for RC. 15 patients received an autogenous connective tissue graft (CT group). The remaining 15 patients had ADM grafting. Measurements were taken at baseline and 1 year after sx treatment (GR, PD, CAL, KG, GT, and % of RC). The number of weeks needed to obtain complete healing with mature tissue appearance was also recorded.

R: Both groups had significant improvements in GR, CAL, and KG gain as compared to baseline. Mean RC was 88.80 ± 11.65% for CT and 83.30 ± 11.40% for the ADM group. Complete RC was achieved in 46.6% of patients in the CT group and 26.6% of the ADM group. NSD were observed between groups when comparing GR, CAL, and GT. The CT group produced a significant increase in KG as compared to the ADM group (P<0.001). The CT group completely healed at a faster rate when compared to ADM (6.20 ± 1.01 and 8.93 ± 1.33 weeks, P<0.001).

BL: CT and ADM grafts have similar success at treating recession defects but the CT group achieved significantly greater increase in KG and quicker complete healing. ADM offers the advantage of avoiding a second surgical site but should be avoided in cases where the goal is to achieve the maximum increase in KG.

 


Harris, 2004                ARTICLE

P: To evaluate the short- and long-term root coverage results obtained with accelular dermal matrix (ADM) and subepithelial connective tissue graft (SCTG).

M&M:

- Criteria: good health, never had root coverage procedure in area being treated, Miller Class I or II defect with at least 2 mm recession, at least 3-year follow up

- All cases treated with ADM utilized CPF

- Cases treated with SCTG utilized double pedicle graft or CPF

- Patients were seen for post-operative care at 1-2weeks, 4-6weeks, 9-16weeks, and then as needed.

-Clinical measurements (REC, PD, CAL) were recorded pre-op, 9-16 weeks post-op and at least 3 years post-op

Results:

ADM group: 25 patients (15F, 10M), 2 smokers, 57 defects

SCTG: 25 patients (16F/9M), 2 smokers, 39 defects

% Mean root (defect) coverage

Change in recession mm.

Change in KT mm.

ST

LT

ST

LT

ST

LT

ADM

93.4

65.8

3.0

2.2

1.0

0.7

SCTG

96.6

97.0

3.7

3.7

2.6

3.2

In long -term cases where multiple defects were treated with ADM, them mean root coverage was greater (70.8%) than in long -term cases where single defect was treated with ADM (50%).

BL: SCTG held up with time better than ADM. SCTG is a better procedure to produce more predictable and stable long-term root coverage results.

 

 

Papageorgakopoulos, 2008                ARTICLE

P: To compare the percentage of root coverage between a coronally positioned flap (CPF) + acellular dermal matrix (ADM) allograft to that of a tunnel technique + ADM 4 months post surgically, as well as compare the soft tissue thickness and creeping attachment.

M+M: 24 subjects (16F, 8M) with at least one site with > 3 mm Miller class I or II recession were treated and followed for 4 months.

Test group: 12 pts treated with a coronally positioned tunnel technique+ ADM.

Control group: 12 pts treated with CPF+ADM

Subjects were randomly selected to receive the test or control treatment. Baseline and 4-month data were measured.

R:

Recession

CPF+ADM

TUN+ADM

Mean gain (% coverage)

3.2 mm (95 %)

2.4 mm (78%)

Statistically significant

NSSD

Predictability of achieving > 90% coverage

83 %

50 %

Tissue thickness at sulcus base

CPF+ADM

TUN+ADM

Mean gain

0.5 mm

0.1 mm

Statistically significant

NSSD


Creeping attachment from 2 to 4 months

CPF+ADM

TUN+ADM

Mean gain

No change

0.2 mm

Statistically significant

NSSD


BL: The CPF+ ADM produced a defect coverage of 95%, whereas the tunnel technique+ADM produced only 78% coverage. This difference was considered clinically significant but was NSS.

 

 

Shepherd 2009                ARTICLE

P: To compare the percentage of recession defect coverage and tissue thickness obtained with a coronally positioned tunnel (CPT) plus an acellular dermal matrix allograft (ADM) to that of a CPT plus ADM and platelet-rich plasma (CPT/PRP) 4 months post-sx.

M&M: 18 healthy pts with a Miller Class I or II recession defect 3mm on a non-molar tooth were included. In both pts, the tissue was elevated using a split-thickness incision beyond the MGJ and extended enough to coronally position. In the control group, ADM was sutured in place at the CEJ. The same was done in the test group except the ADM was soaked in platelet-poor plasma (PPP), while platelet-rich plasma (PRP) was applied to the tunnel prior to suturing and then used over the ADM after it had been sutured. Finally, after the suturing was completed, PRP gel was placed over the entire area. Pts were seen periodically until the 4-month exam that marked the end of the study.

R: Two pts who failed to return for post-op visits were excluded from the study. Mean PD was about 1mm initially and remained essentially unchanged in both groups at 4months. The initial amount of keratinized tissue was slightly greater than 1mm and was increased by 0.4 and 0.6mm for the CPT and CPT/PRP groups respectively. The mean gingival thickness at the sulcus base in the CPT group was increased to 1.2 mm at the 4-month exam; the mean increase in the CPT/PRP group was 1.0mm. The mean recession (REC) defect at the initial exam for the CPT group was 3.6mm, which was reduced to 1mm at 4 months, for a coverage of 2.6mm or 70%. The mean REC for the CPT/PRP group at the initial exam was 3.3mm, which was reduced to 0.4mm at 4 months, for a defect coverage of 2.9mm or 90% coverage.

BL: The CPT group produced 90% mean root coverage, while the CPT/PRP group produced 70% coverage. This was NSS, but may be clinically significant.

- On average, there was a 0.3mm difference between groups in amount of defect covered

 


Borghetti 1999                 ARTICLE

Purpose: To compare subpedicle CT grafts and GTR with a biabsorbable membrane in the coverage of denuded root surfaces in pairs of defects selected in the same patients.

Materials and methods: 28 recessions in 14 patients. (11 females and 3 males, mean age 37.5). Recessions were classified as Miller Class I and were at least 2mm height (ranged between 2.5 and 5mm).

CTG: Partial thickness flap was elevated at the donor site. 1.5-2mm thick CT graft was harvested and sutured to cover the root from the CEJ to at least 3mm apical to base of the defect. Flap as positioned coronally and if the initial height of KF was poor no attempt was made to completely cover the graft.

GTR: Full thickness and more apically split thickness flap to expose at least 3mm of bone surrounding the denuded root. Absorbable membrane was placed at the level of the CEJ and secured and flap was advanced coronally.

Height of recession, CAL, height of KG, distance from CEJ to MGJ and PD were recorded at baseline and 6 months later. All measurements were assessed at the midbuccal level to the nearest 0.5mm with a calibrated probe. Statistical analysis was performed.

Results: NSSD in initial width of recession between two groups. 76% of root coverage was obtained with CTG and 70.2% for the GTR group. 4 sites had 100% root coverage in both groups. CAL gain was 2.73mm for CTG group and 2.88mm for GTR (NSSD). KG height was increased 2.03mm in the CTG group and 0.42mm in the GTR group (SSD). SSD between to groups for CEJ –MGJ distance (0.78mm decrease for CTG and 2.35 for GTR group). No SSD for PDs.

Conclusion: 1. No difference between the two techniques in the coverage of Miller Class I recessions and 2. at 6 months KG height was increase only in the CT graft group.

 


Muller 2001                 ARTICLE

Purpose: to compare the 12 month postsurgical outcome of two different modes of surgical root coverage of relatively shallow gingival recessions GTR with bioresorbable membrane and free CTG with the envelope technique.

Materials and methods

Results

BL: Miller class 1 and 2 might be more predictably treated with CTG and an envelope technique than GTR and bioresorbable membrane.

 



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