Management of gingival recession and a surgical dehiscence with a soft tissue autograft: 4 year observation

Effect of Enamel Matrix Derivative on Collagen Guided Tissue Regeneration-Based Root Coverage Procedure

BACKGROUND

Enamel matrix derivative (EMD) has been shown to promote periodontal wound healing and/or regeneration when applied to tooth root surfaces in soft tissue dehiscence models. In addition, guided tissue regeneration (GTR)-based root coverage using collagen membrane (GTRC) has shown promising results. However, limited information is available regarding how EMD may influence GTRC outcome.

METHODS

Twenty-six patients with Miller's Class I or II gingival recession defects of 2.5 mm were recruited for the study. Subjects were randomly assigned to receive either EMD + collagen (EMDC; test group) or collagen membrane (GTRC; control group). Clinical parameters, including plaque index (PI), gingival index (GI), relative clinical attachment levels (RCAL) to the stent, recession depth (RD), recession width (RW), probing depth (PD), gingival tissue thickness (GTT), and width of keratinized gingiva (KG) were assessed at baseline, and 3 and 6 months after surgery. A repeated measure of analysis of variance (ANOVA) was used to determine differences between treatment groups and time effect.

RESULTS

Both treatments (GTRC and EMDC) resulted in a statistically significant decrease in RD and RW between baseline and 6 months (P <0.05). However, no difference was noted between treatment groups. The percent of root coverage after 6 months was 75% for GTRC and 63% for EMDC. Complete 100% root coverage was achieved in five patients in the GTRC group, compared to only one patient in the EMDC group. There was a statistically significant gain (P <0.05) in the clinical attachment level (CAL) between baseline and 6 months in both groups, as reflected on the RCAL data. No other significant differences were noted on other clinical parameters (PD, GTT, KG, GI, and PI).

CONCLUSIONS

GTR-based root coverage utilizing collagen membrane, with or without enamel matrix derivative, can be successfully used in obtaining gingival recession coverage. The application of EMD during GTRC procedures did not add additional benefit to the final clinical outcome.

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.

Langerhans cells in oral epithelium of chronically inflamed human gingivae

This study describes the histopathological features and the distribution of oral epithelial Langerhans cells in 19 gingival biopsies originating from an adult Tanzanian population characterized by very poor oral hygiene and severe gingival inflammation. Light-microscopically, all biopsies contained often large inflammatory connective tissue infiltrates, 6 of which predominantly contained plasma cells while the rest were dominated by lymphocytes. Seven specimens contained peculiar accumulations of round lymphoid and dendritic cells in the lower cell layers of the oral epithelium. These phenomena have not previously been demonstrated in human gingiva and deserve further attention in studies on the pathogenesis of periodontal diseases. Immuno-histochemical staining with OKT6, OKT4 and OKT8 antibodies showed markedly increased numbers of OKT6-positive cells in 7 specimens and clusters of OKT4- and OKT8-positive cells in the oral epithelium of 4 specimens. High numbers of OKT6-positive cells were not related to the presence of intra-epithelial, non-keratinocyte infiltrates or large connective tissue infiltrates. The variable numbers of oral epithelial Langerhans cells may therefore result from different bacterial antigens elucidating different responses or, alternatively, reflect different responses to similar plaque antigens penetrating the surface of the oral epithelium.

A histometric evaluation of the effect of citric acid preparation upon healing of coronally positioned flaps in nonhuman primates

Facial recession defects were created on maxillary canine teeth of six Macaca irus monkeys and left untreated and exposed to oral fluids for 6 to 12 weeks. Notches were placed in the exposed root surfaces at the level of the free gingival margins. Following root planing with the addition of topical citric acid application on experimental surfaces, pedicle flaps were coronally positioned over the previously exposed roots. After euthanasia, block sections representing postsurgical time periods of 0, 3, 7, 14, 21, 28 and 42 days were secured and tissues were processed for histologic evaluation. All citric acid-treated surfaces exhibited new connective tissue attachment of pedicle flaps to previously exposed areas by 14 days with transmission electron micrographs confirming beginning cementum deposition. In contrast, controls demonstrated epithelial migration to, or apical to, reference notches. Although the total number of samples available for statistical comparison was small, a two-tailed t test for correlated samples showed citric acid application did not result in enhanced clinical root coverage, but did result in significantly greater amounts of new connective tissue attachment (P less than 0.05, df = 3). Pedicle flap healing against teeth with devital pulps was identical to that seen in teeth with vital pulps, while citric acid application to root-planed surfaces of vital teeth had no observable effect upon pulpal tissues.

Free gingival grafts for the treatment of gingival recession. A review of some techniques

Free gingival grafts can be utilized, alone or in combination with a coronally positioned flap, for the prevention and the treatment of gingival recession. The graft can be placed directly on the denuded root, as first described by Sullivan & Atkins (1968). This technique will provide adequate results, especially in cases with relatively little recession. After placing a free gingival graft in such an area, one can often observe bridging and/or creeping attachment. In the case of bridging, some of the grafted tissue will remain vital over the avascular zone, i.e. the root. Creeping attachment is the result of coronal migration of the grafted gingiva and will take place during the years following surgery. Bridging and creeping are most likely to occur in cases of narrow recession where the grafts had been placed directly over the denuded zone. In a second type of surgical procedure, an enlargement of the attached gingiva is first obtained through the graft. The area of recession is later covered by a coronally positioned flop. Several cases are presented which illustrate the results obtained with this procedure. In children, when there is insufficient attached gingiva, it is often desirable to place grafts before orthodonic therapy. In the prevention or treatment of gingival recessions, four possibilities may be considered: 1) no treatment, 2) placement of a graft to prevent recession, 3) stabilizing an existing recession, 4) attempt to cover the denuded root.

Mucogingival problems and the movement of mandibular incisors: a clinical review

In recent years "mucogingival problems" have received considerable attention in the literature. This clinical review distinguishes between variations in gingival morphology having minimal attachment and frank localized pathosis. It is suggested that some cases of potential or actual mucogingival deficiencies may be improved by tooth movement. Since orthodontic and conservative periodontal therapy may induce changes in the character and level of the attached gingiva, surgical grafts may be unnecessary or at least deferable.

The sutureless free gingival graft

A technique designed to utilize the autogenous free gingival graft without the use of sutures was demonstrated. Necessary objectives were maintained but achieved without unnecessarily piercing the graft, and in less time. The only variance in results would be due to the underlying physical properties of the recipient site. This new approach to grafting avoids the cyanoacrylate from getting between the graft and recipient site, therefore acting as a foreign body. Also shown was the complete coverage of a denuded root surface by this technique using a free autogenous gingival graft. This technique enables the surgeon to achieve the results of a predictable technique (autogenous free gingival graft) even more predictably simple.

The papilla rotation flap

A new technique is described for correction of specific mucogingival defects which is designed to encourage rapid healing of the defect and donor areas. Further, this approach often yields a greater width of attached gingiva than other techniques, and is well tolerated by the patient.

Placement of free gingival grafts on denuded alveolar bone. Part I: clinical evaluations

Fourteen patients were examined and determined to lack an adequate zone of attached gingiva in the mandibular incisor region. Each patient was treated on the left side of the mandible by placement of a free gingival graft on denuded bone and 12 of the 14 patients received a free gingival graft on retained periosteum in the right mandibular anterior region. Two patients were treated on the right side by either bone denudation or periosteal bed preparation without graft placement to permit histological evaluation of wound healing under these circumstances. Grafts were retained for time intervals from 1 week to 24 weeks. All patients were evaluated clinically for graft "take", graft healing, graft shrinkage, and graft mobility.

Creeping attachment after free gingival grafts

Free gingival grafts were placed in the lower anterior vestibular region of 30 patients each of whom had a gingival recession. According to the width of the recession and to the surgical procedure, the patients were divided into four groups. Group 1 showed a "narrow" (less than 3 mm) type of recession, while Group 2 had a "wide" type. In both of these groups the graft was placed over the denuded root. In Group 3 (narrow recession) and Group 4 (wide), a collar of vestibular gingiva was left in place on the lower margin of the denuded root at the moment of grafting. Measurements and photographs taken before and 1 month after surgery, 6 months and 2 years postoperatively, showed varying degrees of root covering by the phenomenon of creeping attachment. An optimal recovery of the gingival profile was obtained in the three patients of Group 1. In the other categories of patients the creeping of the attachment apparatus was relatively small (between 0 and 33%) within the 2 years of observation. The factors which seem to have a definite influence upon the phenomenon of creeping attachment are the following: width of the recession, position of the graft, bone resorption, position of the tooth and hygiene of the patient.