Coronally positioned flap procedures with or without a bioabsorbable membrane in the treatment of human gingival recession

Coronally positioned flap with or without acellular dermal matrix graft in the treatment of Class I gingival recessions: a randomized controlled clinical study

BACKGROUND

The aim of this study was to clinically evaluate the treatment of Class I gingival recessions by coronally positioned flap with or without acellular dermal matrix allograft (ADM).

METHODS

Thirteen patients with comparable bilateral Miller Class I gingival recessions (> or = 3.0 mm) were selected. The defects were randomly assigned to one of the treatments: coronally positioned flap and acellular dermal matrix (ADM group) or coronally positioned flap alone (CPF group). The clinical parameters included: probing depth (PD), clinical attachment level (CAL), recession height (RH), recession width (RW), height of keratinized tissue (HKT), thickness of keratinized tissue (TKT), plaque index (PI), and gingival index (GI). The measurements were taken before the surgeries and after 6 months.

RESULTS

The mean baseline recession was 3.4 mm and 3.5 mm for ADM group and CPF group, respectively. After 6 months, both treatments resulted in significant root coverage (P < 0.01), reaching an average of 2.6 mm (76%) in the ADM group and 2.5 mm (71%) in the CPF group. The difference in recession reduction between treatments was not statistically significant. There were no statistically significant differences between the treatments in PD, CAL, RH, RW, and HKT. However, the mean TKT gain was 0.7 mm for the ADM group and 0.2 mm for the CPF group (P < 0.01).

CONCLUSION

It can be concluded that both techniques could provide significant root coverage in Class I gingival recessions; however, a greater keratinized tissue thickness can be expected with ADM.

Expanded Mesh Connective Tissue Graft for the Treatment of Multiple Gingival Recessions

BACKGROUND

The connective tissue graft procedure is an effective method to achieve root coverage. Although multiple sites often need grafting, the palatal mucosa supplies only a limited area of grafting material. The expanded mesh graft provides a method whereby a graft can be stretched to cover a larger area. The aim of this study was to determine the effectiveness and the predictability of expanded mesh connective tissue graft (e-MCTG) in the treatment of multiple gingival recessions.

METHODS

Fifty-two buccal gingival recessions were treated in 10 systemically healthy patients. Fifteen recession treated operation sites with at least three adjacent Miller Class I and/or II recessions were performed. The connective tissue graft obtained from the palatal mucosa was expanded to cover the recipient bed, which was 1.5 times larger than the graft. Clinical measurements recorded at baseline and 12 months postoperatively included gingival recession depth (RD), gingival recession width (RW), percentage root coverage (RC), probing depth (PD), width of keratinized tissue (KT), and clinical attachment level (CAL).

RESULTS

Twelve months after surgery, a statistically significant gain in CAL (3.2 +/- 0.8 mm, P < 0.001) and increase in KT (1.2 +/- 0.4, P < 0.001) were assessed. In 80% of the treated sites, 100% RC was achieved (mean 96%).

CONCLUSIONS

The results of this study demonstrated that the use of e-MCTG technique allowed the treatment of multiple adjacent recessions with adequate wound healing and highly predictable root coverage. This procedure can be applied favorably in treating multiple gingival recessions in one surgery.

Treatment of gingival recession using a collagen membrane with or without the use of demineralized freeze-dried bone allograft for space maintenance

BACKGROUND

Studies utilizing collagen membranes for guided tissue regeneration (GTR)-based root coverage procedures have reported promising results. However, creating and maintaining space underneath the membrane remains a challenge. Therefore, the purpose of this clinical trial was to determine whether the addition of bone graft (i.e., demineralized freeze-dried bone allograft [DFDBA]) significantly affects the outcome of collagen membrane GTR-based root coverage procedures.

METHODS

Twenty patients participated. One Miller's Class I or II recession defect per patient was treated with a collagen membrane covered by a coronally positioned flap. Half of the patients also had DFDBA placed under the membrane. Clinical parameters recorded included: recession depth, recession width, width of keratinized tissue, clinical attachment level, and probing depth, measured to the nearest 0.5 mm. Presurgery and postsurgery (6-month) data were compared using Student's paired t test for parametric data and the Wilcoxon matched pairs test for non-parametric data.

RESULTS

Guided tissue regeneration with collagen (COLL) and collagen + DFDBA (COBA) both resulted in statistically significant (P <0.05) reductions in recession depth (2.1 +/- 0.9 mm and 2.5 +/- 0.5 mm), recession width (1.5 +/- 1.7 mm and 2.2 +/- 1.6 mm), increase in keratinized tissue (0.7 +/- 0.8 mm and 1.2 +/- 1.0 mm), and gain of clinical attachment level (2.1 +/- 1.0 mm and 3.0 +/- 1.0 mm), when comparing 6-month data to baseline. Mean root coverage was 68.4 +/- 15.2% with COLL and 74.3 +/- 11.7% with COBA. However, there were no statistically significant differences between groups for recession depth, recession width, width of keratinized tissue, clinical attachment level, and probing depth.

CONCLUSIONS

Both techniques are effective in attaining root coverage. Although root coverage tended to be better with the addition of DFDBA, the difference was not statistically significant. Further studies with a larger sample size are needed to determine whether adding DFDBA to GTR-based procedures using collagen membranes is of any benefit.

A Multicenter Comparative Study of Two Root Coverage Procedures: Coronally Advanced Flap With Addition of Enamel Matrix Proteins and Subpedicle Connective Tissue Graft

BACKGROUND

Free grafts, pedicle flaps, and barrier membranes have been used to cover exposed root surfaces. The aim of the present study was to evaluate the clinical efficacy of a coronally advanced flap procedure with the additional use of enamel matrix protein derivative (EMD) to treat gingival recession and to compare it to the subpedicle connective tissue graft procedure (CTG).

METHODS

The study was conducted in six different periodontal clinics. Miller Class I or II buccal recession type defects in the anterior or premolar teeth were treated in 70 consecutive patients, 30 with EMD and 40 with CTG. At baseline and 6 and 12 months post-surgical treatment, vertical recession defect, defined as the distance from cemento-enamel junction to gingival margin; width of keratinized tissue; and probing depth were recorded and the percentage of coverage of the original defect was calculated. Statistical analyses consisted of t-test, analysis of variance, and analysis of covariance.

RESULTS

At 6 months, percent of root coverage was 77.4% +/- 11.92% in EMD and 84.1% +/- 11.97% in CTG (statistically significant at P = 0.024). At 12 months, percent of root coverage in EMD was 71.7% +/- 16.14% and 87.0% +/- 12.22% in CTG; again, differences between groups were statistically significant (P < 0.001). Differences between the 6- and 12-month vertical recession defect and percent of root coverage recordings within each group were also statistically significant.

CONCLUSIONS

The connective tissue graft procedure was superior to the coronally positioned flap with the addition of enamel matrix proteins derivative in percentage of coverage and increase in width of keratinized tissue. The EMD procedure is a predictable treatment for root coverage that is relatively easy to perform and presents low patient morbidity, and is appropriate especially where a substantial increase in the width of keratinized tissue is not of prime importance.

Cigarette Smoking and the Periodontal Patient

Evidence from cross-sectional and case-control studies in various populations demonstrates that adult smokers are approximately three times as likely as non-smokers to have periodontitis. The association between smoking and attachment loss is even stronger when the definition of periodontitis is restricted to the most severely affected subjects. Smokers have a diminished response to periodontal therapy and show approximately half as much improvement in probing depths and clinical attachment levels following non-surgical and various surgical modalities of therapy. Implant failures in smokers are twice those of non-smokers, with a higher failure rate in the maxillary arch accounting for the majority of the difference. Tobacco-induced alterations in microbial and host factors contribute to these deleterious effects of smoking on the periodontium. In longitudinal studies, the rate of periodontal disease progression is increased in smokers, but decreases to that of a non-smoker following tobacco cessation. Likewise, recent non-smokers respond to periodontal therapy in a manner similar to patients who have never smoked. Data regarding the impact of smoking on periodontal status included in this review will be helpful to dental health professionals as they counsel their patients regarding tobacco use. The role of dental health professionals in tobacco cessation is discussed, including the use of the five A's: ask--identify tobacco users; advise--advise them to quit; assess--evaluate the patient's readiness to quit; assist--offer assistance in cessation; and arrange--follow up on the patient's cessation efforts. The addition of pharmacotherapy to behavioral therapy, including nicotine replacement therapy and bupropion, can increase cessation rates. The most popular form of nicotine replacement therapy is the patch, and its use has been shown to double cessation rates compared to behavioral therapy alone. Use of bupropion in combination with nicotine replacement therapy may be particularly helpful for heavy smokers or smokers who have experienced multiple failed attempts at cessation. The American Academy of Periodontology Parameters of Care include tobacco cessation as a part of periodontal therapy, and the 2000 Surgeon General's Report on Oral Health in America encourages dental professionals to become more active in tobacco cessation counseling. Doing so will have far-reaching positive effects on our patients' oral and general health.

The Clinical Effect of Acellular Dermal Matrix on Gingival Thickness and Root Coverage Compared to Coronally Positioned Flap Alone

BACKGROUND

The primary aim of this randomized, controlled, blinded, clinical investigation was to compare the coronally positioned flap (CPF) plus an acellular dermal matrix (ADM) allograft to CPF alone to determine their effect on gingival thickness and percent root coverage.

METHODS

Twenty-four subjects with one Miller Class I or II buccal recession defect of > or = 3 mm were treated with a CPF plus ADM or a CPF alone. Multiple additional recession sites were treated with the same flap procedure, and all sites were studied for 6 months. Tissue thickness was measured at the sulcus base and at the mucogingival junction of all teeth, with an SDM ultrasonic gingival thickness meter.

RESULTS

For the ADM sites, mean initial recession of 3.46 mm was reduced to 0.04 mm for defect coverage of 3.42 mm or 99% (P < 0.05). For the CPF group, mean initial recession of 3.27 mm was reduced to 1.08 mm for defect coverage of 2.19 mm or 67% (P < 0.05). The difference between ADM and CPF groups was statistically significant (P < 0.05). Marginal soft-tissue thickness was increased by 0.40 mm (P < 0.05) for the ADM group, whereas the CPF group remained essentially unchanged. Keratinized tissue was increased for the ADM group by 0.81 mm (P < 0.05), whereas the CPF group increased by 0.33 mm (P > 0.05). No additional root coverage was gained due to creeping attachment between 2 and 6 months for either group.

CONCLUSIONS

Treatment with a CPF plus an ADM allograft significantly increased gingival thickness when compared with a CPF alone. Recession defect coverage was significantly improved with the use of ADM.

Surgical Therapies for the Treatment of Gingival Recession. A Systematic Review

BACKGROUND

A variety of soft tissue augmentation procedures directed at root coverage have been documented in the literature utilizing autogenous or allogenic soft tissue grafting or guided tissue regeneration (GTR).

RATIONALE

The purpose of this systematic review was to assess the literature regarding the efficacies of various surgical gingival augmentation procedures relative to clinical and patient-oriented outcomes.

FOCUSED QUESTION

What is the effect of surgical therapy for root coverage in patients with gingival recession compared with other treatment modalities or baseline values?

SEARCH PROTOCOL

PubMed and the Cochrane Oral Health Group Trials Register were searched to identify human studies in English investigating the therapeutic use of a soft tissue surgical procedure to treat gingival recession. Searches were performed for articles published by April 2002.

SELECTION CRITERIA

Initial screening of identified abstracts accepted all studies evaluating surgical intervention of gingival recession. Independent review by 2 reviewers evaluated full-text reports regarding study characteristics. Only those studies determined to be randomized clinical trials (RCTs) were included in the final analysis. DATA ANALYSIS AND COLLECTION: Outcome measures included changes in root coverage, clinical attachment levels (CAL), probing depth (PD), and width of keratinized tissue (KT). The only data suitable for meta-analysis were comparisons of the efficacy of connective tissue grafts with GTR.

MAIN RESULTS

1. Thirty-two articles (total study population: 687) met the criteria for RCTs: 11 (population: 286) related to various autogenous soft tissue augmentation procedures; 18 (population: 360) to GTR; and 3 (population: 41) to allogenic soft tissue augmentation. 2. Meta-analysis identified greater gains in both root coverage and keratinized tissue width for connective tissue graft procedures compared to GTR. 3. No other data were compatible with meta-analysis.

REVIEWERS' CONCLUSIONS

1. Soft tissue augmentation procedures are effective means of obtaining root coverage. 2. Connective grafting techniques appear to have an advantage over GTR. 3. There is a need for further efficacy studies and for investigation of these procedures relative to patient-oriented outcomes such as esthetics, root sensitivity, and postoperative morbidities.

Guided Tissue Regeneration-Based Root Coverage: Meta-Analysis

BACKGROUND

The goal of guided tissue regeneration-based root coverage (GTRC) is to repair gingival recession via new attachment formation. Numerous clinical trials have been conducted utilizing the concept of GTR to promote root coverage. Most GTRC studies have had relatively small sample sizes and have not utilized power calculations to determine appropriate sample size; therefore, it is difficult to draw strong conclusions from them. Hence, the purpose of this study is to combine data from currently available GTRC studies and to use meta-analysis to determine whether GTRC provides significantly improved clinical outcomes compared to conventional periodontal plastic surgical approaches for the treatment of marginal tissue recession.

METHODS

Studies were identified that used GTR approaches to treat gingival recession from January 1990 to October 2001. Information from each study was entered into a database. Data were analyzed according to the following criteria: GTRC versus conventional mucogingival surgery (CMGS); membrane type; root conditioning; pretreatment recession depth; adjunctive use of bone replacement graft (BRG); and source of funding. Studies were ranked independently, and mean data from each were weighted accordingly. Meta-analysis was performed using the weighted means for each group. Paired t tests were used to determine statistical significance between each pair of groups.

RESULTS

Forty papers were included for analysis. GTRC resulted in an average of 74% recession depth reduction, 41% complete root coverage, 3 mm AL gain, and 1 mm KG gain. Both GTRC and CMGS produced significant (P < 0.05) improvement compared to baseline measurements. Compared to GTRC, CMGS resulted in significantly (P < 0.05) increased KG (2.1 mm vs. 1.1 mm), root coverage (81% vs. 74%), and percentage of defects with complete root coverage (55% vs. 41 %). Use of absorbable membranes, root conditioning, shallow pretreatment recession (< 4 mm), and corporate sponsorship all resulted in significantly (P < 0.05) improved percentages of sites with complete root coverage but had no effect on other parameters.

CONCLUSIONS

Based on this meta-analysis, guided tissue regeneration-based root coverage can be used successfully to repair gingival recession defects. Conventional mucogingival surgery, however, resulted in statistically better root coverage, width of keratinized gingiva, and complete root coverage.

Periodontal plastic surgery for treatment of localized gingival recessions: a systematic review

BACKGROUND

The evidence for the efficacy of periodontal plastic surgery (PPS) in the treatment of recession defects has not yet been systematically evaluated. The objective of this review was to systematically review the efficacy of PPS in achieving root coverage in the treatment of localized gingival recession. The following surgical procedures have been considered in this review: guided tissue regeneration (GTR), free gingival graft (FGG), connective tissue graft (CTG), and coronally advanced flap (CAF).

METHODS

Randomized and controlled trials, as well as case series of at least 6 months' follow-up, were searched. Data sources included electronic databases and hand-searched journals. Screening, data abstraction and quality assessment were conducted independently and in duplicate.

RESULTS

Regarding recession reduction, a limited but statistically significant greater benefit was found for CTG compared with GTR (weighted mean difference: 0.43 mm, 95% CI: 0.62-0.23). No differences were found comparing either GTR with CAF or resorbable versus non-resorbable GTR barriers. Gain in attachment was also similar for each of the three comparisons. Analysis of single arms of trials and case series demonstrated that PPS can have a marked improvement on clinical parameters but heterogeneity was often high and only partly explained by initial defect depth.

CONCLUSIONS

Overall, PPS was effective in reducing gingival recessions with a concomitant improvement in attachment levels. Even though no single treatment can be considered superior to all the others, CTG was statistically significantly more effective than GTR in recession reduction. Further research is needed to identify the factors most associated with successful outcomes.

Evidence-based mucogingival therapy. Part 1: A critical review of the literature on root coverage procedures

BACKGROUND

Systematic reviews of the literature are an increasingly important tool for providing evidence-based guidance to the practitioner. This review article and a companion paper deal with the surgical coverage of exposed root surfaces, but their aim is to promote a more up-to-date way of writing and publishing scientific articles in this field. This article presents the published data about surgical root coverage in table form and its aim is to identify updated minimum standards for data presentation.

METHODS

Manual and computer-assisted searches were conducted to find the articles published on this topic during the 30-year period from 1970 to 2000. Articles that described the surgical procedure and reported at least the number of treated recessions and the duration of the follow-up, including case series, controlled studies, and randomized trials were selected and data were arranged in tables.

RESULTS

Only 90 of the 290 articles that dealt with root coverage met the entry criteria; 25 of these were found only through manual searching. The overall clinical outcomes of different techniques appear to be satisfactory, but the published evidence is of little help in deciding which procedure is best suited for each clinical situation. Only a more homogeneous way of collecting and reporting clinical data and especially outcome measures will allow for an effective reanalysis which could help in everyday clinical decision making. Perhaps studies should be carried out and presented keeping in mind that the published results of sound clinical studies will, sooner or later, be reviewed and compared with other studies.

CONCLUSION

A standard format with minimum requirements for data collection and presentation should be established and imposed by international journals in order to provide readers and researchers with more useful information.

Treatment of gingival recession

BACKGROUND

Gingival recession is an intriguing and complex phenomenon. Patients frequently are disturbed by recession owing to sensitivity and esthetics. Many techniques have been introduced to treat gingival recession, including connective tissue grafting, or CTG; various flap designs; orthodontics; and guided tissue regeneration, or GTR. The authors reviewed human clinical studies to assess which techniques provided optimal results.

TYPES OF STUDIES REVIEWED

The authors reviewed controlled clinical trials to assess the outcome of gingival grafting. They also included histological studies in this article to elucidate the type of healing after those procedures were performed.

RESULTS

The studies showed that the combination of CTG and coronally positioned flaps yielded a higher percentage of root coverage compared with other techniques. When GTR using bioabsorbable or nonbioabsorbable membranes was compared with CTG, the studies were inconclusive. Some studies found that GTR was as effective as CTG, while the others found that CTG was superior.

CLINICAL IMPLICATIONS

Gingival grafting to treat recession is a predictable and reliable periodontal procedure.

Comparative clinical study of guided tissue regeneration with a bioabsorbable bilayer collagen membrane and subepithelial connective tissue graft

BACKGROUND

During the last decade, there have been great strides in the treatment of gingival recession defects, especially with subepithelial connective tissue graft and guided tissue regeneration (GTR) procedures. Gingival recession represents a significant concern for patients. It is necessary to choose the most appropriate procedure in order to obtain more root coverage while avoiding clinical disadvantages. The purpose of this randomized clinical trial was to evaluate the use of a bioabsorbable bilayer collagen membrane with GTR compared to a connective tissue graft in the treatment of gingival recession defects.

METHODS

Twenty patients each contributing a pair of Miller Class I or II buccal gingival recessions were treated. In each pair, one recession was randomly assigned for treatment with GTR using a bioabsorbable bilayer collagen membrane and the other treated with subepithelial connective tissue graft (CTG). Clinical measurements taken at baseline (D0) and 3 and 6 months post-treatment included recession depth (RD), recession width (RW), probing depth (PD), and clinical attachment level (CAL).

RESULTS

Data were analyzed using the non-parametric Wilcoxon matched pair test. All results were statistically significant. Both treatments resulted in a significant gain of root coverage (P<0.0001), amounting to an average of 2.80 mm at 3 months in the GTR group and 3.34 mm in the CTG group. At 6 months, the decrease of the mean RD remained statistically significant: 2.70 mm (74.59% root coverage) in the GTR group and 3.19 mm (84.84% root coverage) in the CTG group. The mean RW also decreased from 4.48 mm at D0 to 2.42 mm at 6 months in the GTR group, and from 4.38 mm at D0 to 1.35 mm at 6 months in the CTG group, representing a percentage of coverage of 45.98% and 69.18%, respectively. Mean CAL gain obtained between D0 and 6 months with the GTR procedure and CTG was 3.31 mm and 3.09 mm, respectively, and was significant within groups. At 3 and 6 months, the differences in the results for RD, CAL, and RW were not statistically significant between the 2 groups. However, the difference was significant for PD at 3 and 6 months.

CONCLUSIONS

The results suggest that a bioabsorbable bilayer collagen membrane can be used in the GTR treatment of human buccal recession defects, with no statistically significant differences between this procedure and connective tissue grafts.