Subepithelial connective tissue grafts in the treatment of gingival recessions. A comparative study of 2 procedures

Root surface biomodification in periodontal therapy: Biological rationale and clinical applications

Regenerative periodontal therapy aims to form new cementum, periodontal ligament, and alveolar bone, all sealed by gingival tissue. The root surface acts as the wound margin during this regeneration process. Root surface biomodification (root conditioning/root decontamination), therefore, seems instrumental in promoting surface decontamination and enhancing tissue attachment by removing the smear layer, exposing collagen fibrils, and facilitating blood clot formation and stabilization. This review attempted to provide an all-encompassing, evidence-based assessment of the role of root surface biomodification in regenerative periodontal therapy, particularly in intrabony defects, furcation defects, and root coverage procedures. The reviewed evidence suggested that root conditioning agents, whether used independently or in conjunction with bone graft materials, biological agents, membranes, or connective tissue grafts, do not offer any clinical advantage regarding clinical attachment gain. Thus, integrating chemical methods with the mechanical root instrumentation process does not necessarily contribute to superior clinical outcomes.

Use of a hybrid soft tissue autograft for gingival phenotype modification lingual to mandibular incisors

Presence of adequate dimensions of keratinized/attached gingiva (KT/AG) and gingival thickness (GT) is considered necessary to maintain optimal periodontal health and long-term stability of gingival margin. Gingival phenotype modification therapies to increase these two dimensions (GT and KT/AG) on the buccal aspect of teeth have been widely reported, but the literature on lingual gingival augmentation is scarce. The purpose of this paper is to report the outcomes of a case treated with an envelope flap combined with a hybrid soft tissue autograft (subepithelial connective tissue graft with an epithelial collar) for phenotype modification of gingiva lingual to mandibular incisors presenting with thin gingiva (<1 mm) and lack of AG in tooth # 31 and 42. At 12 months follow-up, a substantial gain in KT, AG and GT along with partial root coverage was achieved.

Multiple coronally advanced flap with a selective use of connective tissue graft: A 3-year prospective clinical and histological study

BACKGROUND

The purpose of the present study was to prospectively evaluate the 3-year changes in the gingival dimensions following multiple coronally advanced flap (MCAF) with selective use of connective tissue graft (CTG). In addition, the secondary aim was to histologically identify the factors related to phenotype changes.

METHODS

Twenty patients treated with MCAF and site-specific application of a CTG were available for the 3-year follow-up. Outcome measures included complete root coverage (CRC), recession reduction, keratinized tissue width (KTW), marginal tissue thickness changes, and primary flap position. Biopsies were harvested at one of the sites treated with the adjunct of CTG. All sections were stained with hematoxylin and eosin, Masson trichrome, Verhoeff-van Gieson, tenascin, and alcian blue stain for semiquantitative evaluation.

RESULTS

At 3 years, CRC was detected in 86% of sites treated with MCAF alone and 81% of sites treated with MCAF + CTG. The 47% of sites treated with MCAF + CTG presented an apical shift of primary flap from its original position. Linear regression showed a significant association between KTW change and the initial KTW in MCAF-treated sites, while both initial KTW and position of primary flap were statistically significantly associated factors with KTW changes in the MCAF + CTG group. In all the biopsies examined, there is always a marked and clear separation between the connective tissue of the gingival flap and the palatal connective tissue of the graft.

CONCLUSIONS

The selective use of CTG is an effective treatment for multiple gingival recessions. Only a limited increase in KTW can be expected in a bilaminar technique if, during the healing phases, the connective tissue is maintained completely covered.

Comparison of chorion allograft and subepithelial connective tissue autograft in the treatment of gingival recession- A randomized controlled clinical trial

Background

To compare the clinical outcomes of subepithelial connective tissue graft and chorion membrane along with coronally advanced flap in the treatment of gingival recession.

Methods

A total of 12 patients with 24 sites showing isolated bilateral Miller's class I and II gingival recessions were randomly allocated into two treatment sites. One site, connective tissue graft, (n = 12 sites) while on the contra-lateral site, chorion membrane (n = 12 sites) was used with coronally advanced flap. Clinical parameters: probing depth, recession depth, recession width, width of keratinized gingiva, relative attachment level, thickness of keratinized gingiva were recorded at the baseline, 3 months, and 6 months. The amount of root coverage was evaluated after 6 months.

Results

Statistically significant differences were observed between test and control sites in terms of recession depth, recession width, width of keratinized gingiva and thickness of keratinized gingiva at 6 months. The test sites presented 66.17 ± 18.85% and the control site showed 87.17 ± 18.33% of root coverage at 6 months.

Conclusion

Very limited amount of recession coverage with chorion membrane and did not serve as an alternative to connective tissue graft.

Trial registration

CTRI/2017/12/010964.

Treatment of Multiple Adjacent Class I and Class II Gingival Recessions by Modified Microsurgical Tunnel Technique and Modified Coronally Advanced Flap Using Connective Tissue Graft: A Randomized Mono-center Clinical Trial

Background

Complete and uneventful recession coverage should be the aim of gingival recession treatment. Systematic reviews have said that coronally advanced flap with connective tissue graft (CTG) is the gold standard for gingival recession treatment. Minimally invasive procedures with optical magnification allow minimal tissue manipulation and precise adaptation of wound edges helping in faster and uneventful healing, thus bringing about a satisfactory clinical and patient outcome. Thus, the following study compares the clinical- and patient-related outcomes of modified microsurgical tunnel technique (MMTT) and modified coronally advanced flap (MCAF) using CTG in the coverage of multiple adjacent Miller's class I and II gingival recessions.

Materials and Methods

Gingival recession patients were selected and were assigned randomly to either MMTT+CTG or MCAF+CTG. Clinical parameters were evaluated at 1, 3, and 6 months. Patient's satisfaction level was assessed by measuring root coverage esthetic score, hypersensitivity, and morbidity. The statistical analysis was performed using commercially available software SPSS version 14. Descriptive statistics were expressed as mean±standard deviation for each parameter. Intragroup comparison was done by using the paired T-test. Intergroup comparison was done using the independent Student's T-test. The significance level was set at P = 0.05.

Results

MMTT+CTG showed a statistically significant greater clinical- and patient-related outcome.

Conclusion

MMTT+CTG, being a closed procedure, preserves the blood supply, helps in faster healing, and does not compromise the esthetics. All these lead to decreased morbidity and increased patient satisfaction which makes MMTT a superior technique than the conventional procedure in gingival recession treatment.

Connective Tissue Graft with or without Enamel Matrix Derivative for Treating Gingival Recession Defects: A Systematic Review and Meta-Analysis

OBJECTIVES

The aim of this systematic review is to compare the root coverage outcomes of using a connective tissue graft (CTG) with and without the application of enamel matrix derivative (EMD).

METHODOLOGY

An electronic search was performed up to July 2020 in 4 databases, including Ovid MEDLINE, EMBASE, Web of Science and Cochrane Central. Human clinical studies with data on comparing outcomes of root coverage using CTG with and without the application of EMD were included. Meta-analyses for the recorded parameters were performed and the weighted mean difference (WMD) between the 2 groups and 95% confidence interval (CI) were reported.

RESULTS

Nine clinical studies were selected for inclusion in this review. The WMD of clinical attachment level gain was 0.78 mm (95% CI of 0.23-1.34 mm, P = .005) and the WMD of recession depth reduction was 0.28 mm (95% CI of 0.06-0.51 mm, P = .01), favoring the CTG + EMD approach. However, the comparisons for the percentage of complete root coverage and mean root coverage between the 2 approaches were not statistically significant.

CONCLUSION

Although the use of a CTG with and without the application of EMD in root coverage procedures achieved a similar percentage of complete root coverage and mean root coverage, the addition of EMD to CTG may improve the outcome of recession depth reduction and clinical attachment level gain.

Soft tissue grafting with the tunnel technique in the mandibular anterior: Myths and realities

OBJECTIVE

To address the myths and realities of soft tissue grafting with the tunnel technique in the mandibular anterior region.

MATERIALS AND METHODS

Myths associated with use of the tunnel technique for soft tissue grafting in the mandibular anterior region are identified and examined. Explanations for the misunderstandings are presented and documented with case examples and evidence from scientific studies.

RESULTS

Six myths are described and the realities are presented.

CONCLUSIONS

This report demonstrates that the tunnel technique can be successfully used in the mandibular anterior region in the presence of anatomic features thought to favor the use of more invasive surgical methods.

CLINICAL SIGNIFICANCE

Soft tissue grafting in the mandibular anterior region has complicating anatomical features including a strong frenal attachment, shallow vestibule and thin tissue. These features may be successfully managed with a free gingival graft, but that procedure results in an uncomfortable experience for the patient. The tunnel technique, especially when combined with an acellular dermal matrix, dramatically improves the patient experience and esthetic outcome without compromising the clinical outcome.

Oral Soft Tissue Grafting

The presence of healthy soft tissue at the tooth and implant interface correlates to long-term success and stability in function and esthetics. Grafting procedures utilizing various techniques can be performed during any stage of the implant or restorative therapy. Materials of autogenous, allogeneic, and xenogeneic sources are available for oral soft tissue grafting. This article describes the classifications of soft tissue defects, treatment modalities, and materials used to enhance soft tissue quality and quantity and to achieve optimal esthetics and function around teeth and implants.

Creeping attachment: A literature review

OBJECTIVE

Mucogingival surgery has been widely applied in clinics. An interesting phenomenon after mucogingival surgery is the coronal migration of gingival margin, which is described as "creeping attachment." The goal of this review is to summarize the characteristics, significance, mechanism, and manifestation of the creeping attachment after mucogingival surgery and to describe the factors associated with its occurrence.

OVERVIEW

A total of 82 relevant articles were included in the literature review. The characteristics and significance of the creeping attachment after mucogingival surgery were analyzed. The mechanism of the creeping attachment was explored. Different manifestations of and factors associated with creeping attachment were summarized.

CONCLUSIONS

Creeping attachment may occur to obtain additional root coverage after the healing of various mucogingival surgeries. However, this coverage is not always complete nor entirely predictable.

CLINICAL SIGNIFICANCE

Creeping attachment plays an important role in the prognosis of mucogingival surgeries. This review will help clinicians get a thorough recognition and understanding of this phenomenon.

44-year journey of palatal connective tissue graft harvest: A narrative review

Connective tissue graft (CTG) is considered the gold standard for soft-tissue correction and augmentation surgeries, but involves a secondary donor area and its associated complications. The techniques to harvest CTG have undergone a large number of modifications over a period of 44 years since the time it was introduced by Edel in 1974 to increase the width of keratinized gingiva. This review compiles all the techniques of graft harvest from the palate and their modifications which have been introduced in the last 44 years till date. This review is based on systematic reviews, comparative human studies, and case reports describing any new technique of graft harvest. Publications till April 2018 were selected and further reviewed. In addition, specific related journals and books were searched upon. In order to minimize the pain, bleeding, and morbidity associated with donor site, several researchers proposed harvesting of the connective tissue by means of different techniques, each precisely different from others in terms of design, incisions, and procedure of harvest. Although the latest techniques are minimally invasive with reduced incision lines, less compromised blood supply, accelerated healing, and no sloughing of the overlying flap, they are technique sensitive which requires higher expertise to execute.

Impact of connective tissue graft thickness on surgical outcomes: A pilot randomized clinical trial

BACKGROUND

The aim of this study was to compare thick versus thin connective tissue grafts (CTG) for the treatment of gingival recession, over a 3-month period.

METHODS

Forty-two CTG procedures were performed on single tooth Miller Class I or II recession defects at either premolar or anterior sites in 30 individuals. Procedures were randomized (1:1 ratio) to CTG thickness of 1 or 2 mm (parallel group design). Primary outcomes were the change in the width of the zone of keratinized tissue and the amount of root coverage achieved 3 months postoperatively at the recipient site. Secondary outcomes included change in the thickness of keratinized tissue at 3 months and patient-reported outcomes, such as pain, bleeding, and swelling at both the recipient and donor sites at 1 week, 2 weeks, 1 month, and 3 months.

RESULTS

No significant differences were found between the two groups for any of the primary or secondary outcomes. Mean root coverage achieved was 2.1 ± 0.2 mm in the 1-mm thick group and 2.5 ± 0.2 mm in the 2-mm thick group (P = 0.33). Keratinized tissue width was increased by 2.2 ± 0.2 mm in the 1-mm thick group and by 2.7 ± 0.3 mm in the 2-mm thick group (P = 0.18). Keratinized tissue thickness was increased by 1.0 ± 0.1 mm and by 1.2 ± 0.1 mm in the 1- and 2-mm thick groups, respectively (P = 0.09).

CONCLUSION

Within the current study limitations, our results suggest that similar root coverage and increase in the width and thickness of keratinized tissue can be achieved at 3 months whether a 1- or 2-mm thick CTG is used.

Root coverage procedures for treating localised and multiple recession-type defects

BACKGROUND

Gingival recession is defined as the oral exposure of the root surface due to a displacement of the gingival margin apical to the cemento-enamel junction and it is regularly linked to the deterioration of dental aesthetics. Successful treatment of recession-type defects is based on the use of predictable root coverage periodontal plastic surgery (RCPPS) procedures. This review is an update of the original version that was published in 2009.

OBJECTIVES

To evaluate the efficacy of different root coverage procedures in the treatment of single and multiple recession-type defects.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 12) in the Cochrane Library (searched 15 January 2018), MEDLINE Ovid (1946 to 15 January 2018), and Embase Ovid (1980 to 15 January 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 January 2018). No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) only of at least 6 months' duration evaluating recession areas (Miller's Class I or II ≥ 3 mm) and treated by means of RCPPS procedures.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, data extraction and risk of bias assessment were conducted independently and in duplicate. Authors were contacted for any missing information. We expressed results as random-effects models using mean differences (MD) for continuous outcomes and odds ratios (OR) for dichotomous outcomes with 95% confidence intervals (CI). We used GRADE methods to assess the quality of the body of evidence of our main comparisons.

MAIN RESULTS

We included 48 RCTs in the review. Of these, we assessed one as at low risk of bias, 12 as at high risk of bias and 35 as at unclear risk of bias. The results indicated a greater reduction in gingival recession for subepithelial connective tissue grafts (SCTG) + coronally advanced flap (CAF) compared to guided tissue regeneration with resorbable membranes (GTR rm) + CAF (MD -0.37 mm; 95% CI -0.60 to -0.13, P = 0.002; 3 studies; 98 participants; low-quality evidence). There was insufficient evidence of a difference in gingival recession reduction between acellular dermal matrix grafts (ADMG) + CAF and SCTG + CAF or between enamel matrix protein (EMP) + CAF and SCTG + CAF. Regarding clinical attachment level changes, GTR rm + CAF promoted additional gains compared to SCTG + CAF (MD 0.35; 95% CI 0.06 to 0.63, P = 0.02; 3 studies; 98 participants; low-quality evidence) but there was insufficient evidence of a difference between ADMG + CAF and SCTG + CAF or between EMP + CAF and SCTG + CAF. Greater gains in the keratinized tissue were found for SCTG + CAF when compared to EMP + CAF (MD -1.06 mm; 95% CI -1.36 to -0.76, P < 0.00001; 2 studies; 62 participants; low-quality evidence), and SCTG + CAF when compared to GTR rm + CAF (MD -1.77 mm; 95% CI -2.66 to -0.89, P < 0.0001; 3 studies; 98 participants; very low-quality evidence). There was insufficient evidence of a difference in keratinized tissue gain between ADMG + CAF and SCTG + CAF. Few data exist on aesthetic condition change related to patients' opinion and patients' preference for a specific procedure.

AUTHORS' CONCLUSIONS

Subepithelial connective tissue grafts, coronally advanced flap alone or associated with other biomaterial and guided tissue regeneration may be used as root coverage procedures for treating localised or multiple recession-type defects. The available evidence base indicates that in cases where both root coverage and gain in the width of keratinized tissue are expected, the use of subepithelial connective tissue grafts shows a slight improvement in outcome. There is also some weak evidence suggesting that acellular dermal matrix grafts appear as the soft tissue substitute that may provide the most similar outcomes to those achieved by subepithelial connective tissue grafts. RCTs are necessary to identify possible factors associated with the prognosis of each RCPPS procedure. The potential impact of bias on these outcomes is unclear.

Periodontal Flap Surgery along with Vestibular Deepening with Diode Laser to Increase Attached Gingiva in Lower Anterior Teeth: A Prospective Clinical Study

BACKGROUND

Chronic periodontitis in lower anterior teeth results in rapidly progressive gingival recession (GR), loss of alveolar bone, decreased vestibular depth (VD) with consequential tooth mobility, and tooth loss. Treatment option for such cases in this esthetically important area of the oral cavity includes extraction followed by implants for which sufficient bone height and mucogingival complex are a prerequisite. Henceforth, an attempt was made to prolong the life of lower anterior teeth and postpone the need for implants by the treatment of chronic periodontitis with periodontal flap surgery followed by vestibular deepening in single surgical procedure.

MATERIALS AND METHODS

In this clinical, prospective study, conventional periodontal flap surgery was done on 74 sites in lower anterior teeth in 16 patients with attachment loss >5 mm due to chronic periodontitis. Vestibular deepening with diode laser at (wavelength - 810 nm, output power: 0.5-7 W, continuous wave, contact mode) was done after suturing the flap. All the clinical parameters: GR, pocket depth (PD), clinical attachment loss (CAL), width of keratinized gingiva, width of attached gingiva, and VD were assessed preoperatively after Phase I therapy and 6 months postoperatively.

RESULTS

At all the 74 sites, there was highly significant gain in attached gingiva, keratinized gingiva, and VD (P ≤ 0.001). Highly significant reduction in PD (P ≤ 00.001), significant reduction in attachment loss (P ≤ 0.01) but no significant reduction in GR (P = 0.897) was observed.

CONCLUSIONS

The combination of periodontal flap surgery with vestibular deepening with diode laser may be a suitable cost-effective treatment option to prolong the life of periodontally involved lower anterior teeth. The surgical technique can postpone the need for extraction of teeth along with all the intangible benefits of periodontal therapy.

Root coverage of a wide anterior mucogingival defect with epithelial embossed connective tissue graft and its evaluation using root coverage esthetic scores

New and innovative surgical techniques are necessary to help the clinician ensure the best results and satisfy patient's expectations. One such periodontal problem that has been challenging to the dental practitioners and impacts the oral health quality of life of patients has been gingival recession. When present anteriorly where esthetics is a major concern, patient centric parameters too become paramount. Root coverage esthetic score (RES) evaluation helps to keep the patient outcomes in mind. This case reports the successful treatment of a wide anterior mucogingival defect using epithelial embossed connective tissue graft which was evaluated for the first time using RES.

Periodontal soft tissue root coverage procedures: a systematic review from the AAP Regeneration Workshop

BACKGROUND

This paper aims to create a "bridge" between research and practice by developing a practical, extensive, and clinically relevant study that translates evidence-based findings on soft tissue root coverage (RC) of recession-type defects to daily clinical practice.

METHODS

This review is prepared in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement based on the proposed focused questions. A literature search with no restrictions regarding status or the language of publication was performed for MEDLINE and EMBASE databases up to and including June 2013. Systematic reviews (SRs), randomized clinical trials, controlled clinical trials, case series, and case reports evaluating recession areas that were treated by means of RC procedures were considered eligible for inclusion through the three parts of the study (part I, an overview of the base of SRs; part II, an alternative random-effects meta-analyses on mean percentage of RC and sites exhibiting complete RC; and part III, an SR of non-randomized trials exploring other conditions not extensively evaluated by previous SRs). Data on Class I, II, III, and IV recessions, type of histologic attachment achieved with treatment, recipient- and donor-site anatomic characteristics, smoking-related outcomes, root surface conditions, tooth type and location, long-term effectiveness outcomes, unusual conditions that may be reported during conventional daily practice, and patient-centered outcomes were assessed as well.

RESULTS

Of the 2,456 potentially eligible trials, 234 were included. Data on Class I, II, III, and IV gingival recessions, histologic attachment achieved after treatment, recipient- and donor-site anatomic characteristics, smoking-related outcomes, root surface conditions/biomodification, tooth type and location, long-term effectiveness outcomes and unusual conditions that may be reported during conventional daily practice, and patient-centered outcomes (i.e., esthetic, visual analog scale, complications, hypersensitivity, patients perceptions) were assessed. Subepithelial connective tissue (CT)-based procedures and coronally advanced flap plus acellular dermal matrix grafts, enamel matrix derivative, or collagen matrix led to the best improvements of recession depth, clinical attachment level (CAL) gain, and keratinized tissue (KT). Some conditions, such as smoking and use of magnification, may affect RC outcomes.

CONCLUSIONS

All RC procedures can provide significant reduction in recession depth and CAL gain for Miller Class I and II recession-type defects. Subepithelial CT graft-based procedures provided the best outcomes for clinical practice because of their superior percentages of mean and complete RC, as well as significant increase of KT.

Comparative clinical evaluation of laterally positioned pedicle graft and subepithelial connective tissue graft in the treatment of Miller's Class I and II gingival recession: A 6 months study

AIM

The purpose of the study was to compare clinical outcomes of laterally positioned pedicle graft (LPPG) and subepithelial connective tissue graft (SCTG) for treatment of Miller's Class I and II gingival recession defects, at the end of 6 months.

MATERIALS AND METHODS

Sixty Miller's Class I or II gingival recession defects (≥3 mm) (n = 30 each) on the labial aspect of anterior teeth were treated by either of the above techniques. Clinical parameters including recession depth (RD), width of keratinized gingiva (WKG), percentage of root coverage (%RC), and complete RC were recorded at baseline and 6 months postoperatively. Data were recorded and statistical analysis was done for both intergroup and intragroup.

STATISTICAL ANALYSIS USED

Paired t-test intragroup and Student's t-test intergroup.

RESULTS

In LPPG, RD decreased from 4.9 ± 0.99 mm to 1.1 ± 0.3 mm and WKG increased from 0.7 ± 0.87 to 4.5 ± 0.86 mm at 6 months, while in SCTG, RD decreased from 4.67 ± 1.12 mm to 0.46 ± 0.68 mm and WKG increased from 1.1 ± 0.99 to 5.33 ± 0.72 mm at 6 months postoperatively. The values of the soft tissue coverage remained stable for 6 months.

CONCLUSIONS

Highly significant and effective soft tissue coverage was obtained by both techniques. LPPG resulted in effective soft tissue coverage for isolated deep narrow defects while SCTG in isolated and multiple, deep narrow and wide defects.

Clinical evaluation of expanded mesh connective tissue graft in the treatment for multiple adjacent gingival recessions in the esthetic zone

BACKGROUND

Multiple approaches have been used to replace lost, damaged or diseased gingival tissues. The connective tissue graft (CTG) procedure is the golden standard method for root coverage. Although multiple sites often need grafting, the palatal mucosa supplies only a limited area of grafting material. To overcome this limitation, expanded mesh graft provides a method whereby a graft can be stretched to cover a large area. The aim of this study was to evaluate the effectiveness and the predictability of expanded mesh CTG (e-MCTG) in the treatment of adjacent multiple gingival recessions.

MATERIALS AND METHODS

Sixteen patients aged 20-50 years contributed to 55 sites, each site falling into at least three adjacent Miller's Class 1 or Class 2 gingival recession. The CTG obtained from the palatal mucosa was expanded to cover the recipient bed, which was 1.5 times larger than the graft. Clinical measurements were recorded at baseline and 3 months, 12 months postoperatively.

RESULTS

A mean coverage of 1.96 mm ± 0.66 mm and 2.22 mm ± 0.68 mm was obtained at the end of 3(rd) and 12(th) month, respectively. Twelve months after surgery a statistically significant increase in CAL (2.2 mm ± 0.68 mm, P < 0.001) and increasing WKT (1.75 ± 0.78, P < 0.001) were obtained. In 80% of the treated sites, 100% root coverage was achieved (mean 93.5%).

CONCLUSIONS

The results of this study demonstrated that multiple adjacent recessions were treated by using e-MCTG technique can be applied and highly predictable root coverage can be achieved.

Root surface modifiers and subepithelial connective tissue graft for treatment of gingival recessions: a systematic review

BACKGROUND AND OBJECTIVE

Many techniques and flap designs have been used to treat gingival recession by root coverage, but subepithelial connective tissue graft (SCTG) seems to be the gold standard procedure. In an attempt to improve the healing process and increase the success rate of root coverage, some authors have used root modifiers, including different root conditioners, lasers, EMD, recombinant human growth factors and platelet-rich plasma (PRP). The aim of this systematic review was to evaluate the effects of root biomodification in clinical outcomes of gingival recessions treated with SCTG.

MATERIAL AND METHODS

Studies reporting SCTG associated with any form of root surface biomodification for root coverage of gingival recessions (Miller Class I and Class II) were considered as eligible for inclusion. Studies needed to have data of clinical outcomes in a follow up of at least 6 months. Screening of the articles, data extraction and quality assessment were conducted independently and in duplicate.

RESULTS

None of the products evaluated (citric acid, EDTA, PRP, lasers and EMD) showed evident benefits in clinical outcomes. Test and control groups presented similar outcomes related to root coverage and periodontal parameters, with no statistical differences between them. The exception was root biomodification with the neodymium-doped yttrium aluminium garnet (Nd:YAG) laser, which impaired root coverage and had a detrimental effect on clinical outcomes.

CONCLUSION

Based on the present clinical data, the use of root surface modifiers to improve clinical outcomes in gingival recessions treated with SCTG is not justified. More in vivo studies, and randomized clinical trials with larger sample sizes and extended follow up, are necessary.

Clinical evaluation of subepithelial connective tissue graft and guided tissue regeneration for treatment of Miller's class 1 gingival recession (comparative, split mouth, six months study)

OBJECTIVES

The present study aims to clinically compare and evaluate subepithelial connective tissue graft and the GTR based root coverage in treatment of Miller's Class I gingival recession.

STUDY DESIGN

30 patients with at least one pair of Miller's Class I gingival recession were treated either with Subepithelial connective tissue graft (Group A) or Guided tissue regeneration (Group B). Clinical parameters monitored included recession RD, width of keratinized gingiva (KG), probing depth (PD), clinical attachment level (CAL), attached gingiva (AG), residual probing depth (RPD) and % of Root coverage(%RC). Measurements were taken at baseline, three months and six months. A standard surgical procedure was used for both Group A and Group B. Data were recorded and statistical analysis was done for both intergroup and intragroup.

RESULTS

At end of six months % RC obtained were 84.47% (Group A) and 81.67% (Group B). Both treatments resulted in statistically significant improvement in clinical parameters. When compared, no statistically significant difference was found between both groups except in RPD, where it was significantly greater in Group A.

CONCLUSIONS

GTR technique has advantages over subepithelial connective tissue graft for shallow Miller's Class I defects and this procedure can be used to avoid patient discomfort and reduce treatment time. Key words:Collagen membrane, comparative split mouth study, gingival recession, subepithelial connective tissue graft, guided tissue regeneration (GTR).

Esthetic root coverage with double papillary subepithelial connective tissue graft: a case report

Patients today have become excessively concerned about esthetics. These esthetic concerns of patients have become an integral part of periodontal practice. Gingival recession is an esthetic problem that can be successfully treated by means of several mucogingival surgical approaches, any of which can be used, provided that the biologic conditions for accomplishing root coverage are satisfied with no loss of soft and hard tissue height interdentally. There are currently different techniques for root coverage which include pedicle grafts, free gingival grafts, connective tissue grafts, and guided tissue regeneration (GTR). This paper reports a case in which a new double papillary connective tissue graft technique has been used in the treatment of gingival recession.

Six year follow-up of a root coverage procedure on a lower molar tooth with lateral pedicle flap

Loss of periodontal attachment and subsequent recession is one of the most common deformities that affects the periodontium. Gingival recession is a muco-gingival defect, which is commonly treated for esthetic and physiologic reasons. Adequate thickness of attached gingiva and root coverage is essential in restored teeth for proper masticatory function as well as for oral hygiene maintenance. Various root coverage procedures Nill have been proposed to correct recession defects, including coronally advanced flap and lateral pedicle flap (LPF). A case report is presented dealing with the treatment of a gingival recession on a mandibular molar tooth using LPF with a 6-year follow-up.

Clinical evaluation of alloderm for root coverage and colour match

BACKGROUND

Predictable root coverage and good colour match are the major therapeutic end points in the treatment of gingival recession. Alloderm has been used as a substitute to connective tissue graft, but its colour match in populations with a high degree of melanin pigmentation has not been extensively studied. The aim of this study was to evaluate the effectiveness of an Acellular dermal matrix graft for root coverage procedures and to objectively analyze the post-operative esthetics using a Visual Analog Scale (VAS).

MATERIALS AND METHODS

Both male and female patients were selected, aged 20-50 years presenting with aesthetic problems due to the exposure of recession defects when smiling. A total of 14 patients contributed to 15 sites, each site falling into Miller's class I or class II gingival recession.

RESULTS

A total of 15 sites were treated and a mean coverage of (85.56±21.70 and 83.33±21.82%) was obtained at the end of 3(rd) and 12(th) month respectively. A mean VAS score of 7.93±1.03 and 8.13±0.99 (3(rd) and 12(th) month) and 5.73±0.70 and 6.87±0.83 (3(rd) and 12(th) month) was obtained when the colour match recorded by the patients and an independent observer, respectively.

CONCLUSION

The study showed that acellular dermal matrix graft (alloderm) may be successfully used to treat gingival recession, as adequate root coverage may be predictably obtained. The grafted areas underwent melanization from the 6(th) month onwards and complete blending with the adjacent sites was obtained at 1 year.

Mucogingival surgery: where we stand today

Mucogingival problems are developmental and acquired aberrations in the morphology, position, and/or the amount of gingiva surrounding teeth. According to an academic report by American Academy of Periodontology, mucogingival therapy should be advocated for gingival augmentation and to create adequate vestibular depth in areas with insufficient attached gingiva. This paper provides an overview on mucogingival surgical procedures from its inception to the current time.

Root coverage in class I gingival recession defects, combining rotated papillary pedicle graft and coronally repositioned flap, using a micro surgical approach: A clinical evaluation

Background:

The purpose of this case study was to evaluate the success and predictability of a rotated papillary pedicle graft in combination with the coronally advanced flap using surgical loupe (2.5X magnification) for the treatment of Miller's class I gingival recession.

Materials and Methods:

Fifteen systemically healthy patients with isolated gingival recession underwent the procedure. The probing depth, percentage root coverage, width of the keratinized gingiva and the gain in clinical attachment, papilla width, papilla height, area of the papilla at the donor site, were recorded at baseline, 3 months and 12 months.

Results:

All parameters except probing pocket depth, significantly improved from baseline to 12 months. The mean recession defect of 2.67 ± 0.03 mm present at baseline reduced to 0.13 ± 0.35 mm at the end of the 3^rd months and stabilized at 0.27 ± 0.59 mm at 12 months. The mean reduction in recession depth was 2.40 ± 0.03 mm at the end of the study. Complete recession coverage was obtained in 13 of the 15 (87%) of the cases treated with a mean percentage recession coverage at 12 months being 86 ± 35.19%. The gain in the width of the keratinized gingiva was 1.33 ± 0.13 mm at the end of the study. There was no postoperative morbidity from where the graft was harvested at the end of the study period.

Conclusion:

The use of magnification in mucogingival surgery resulted in achieving a high degree of success and predictability as well as an excellent esthetic outcome.

Root surface biomodification with an Er:YAG laser for the treatment of gingival recession with subepithelial connective tissue grafts

BACKGROUND/AIM

Root surface biomodification has been used to treat gingival recession and periodontitis. The principle for this procedure is that removing the smear layer from the root surfaces exposes collagen fibers, which leads to improved healing. Clinical studies generally have failed to find any improvement in clinical parameters when using such agents. The aim of this study was to evaluate and compare the outcome of gingival recession therapy using the subepithelial connective tissue graft (SCTG) with or without Er:YAG laser application for root surface biomodification.

MATERIALS AND METHODS

Twenty-four teeth in 12 patients with Miller class I and II recession were treated with SCTG with (test group) or without (control group) the application of an Er:YAG laser (2 Hz, 60 mJ/pulse, 40 s, with air spray). Clinical attachment level (CAL), recession depth (RD), recession width (RW), and probing depth (PD) were measured at baseline and 6 months postsurgery.

RESULTS

There were no significant differences between test and control groups (p > 0.05). Postoperatively, significant root coverage, gains in CAL, and highly significant increases in the RW were observed in both groups. For test and control groups, the average root coverage was 80% and 86%, respectively (p > 0.05), and complete root coverage was 75% and 67%, respectively.

CONCLUSIONS

The present study showed that root surface conditioning with an Er:YAG laser does not enhance the results achieved when SCTG was performed alone.

Root surface biomodification with Nd:YAG laser for the treatment of gingival recession with subepithelial connective tissue grafts

BACKGROUND/AIM

Root surface biomodification has been used to treat gingival recession and periodontitis. The principle for this procedure is that removing the smear layer from the root surfaces exposes collagen fibers, which leads to improved healing. Clinical studies generally have failed to find any improvement in clinical parameters when using such procedures, however. The aim of this study was to evaluate and compare the outcome of gingival recession therapy using the subepithelial connective tissue graft (SCTG) with or without Nd:YAG laser application for root surface biomodification.

MATERIALS AND METHODS

Thirty-four teeth in 17 patients with Miller Class 1 and 2 recession were treated with SCTG with (test group) or without (control group) the application of Nd:YAG laser (1 W, 10 Hz, 100 mj, 60 s, 1064 nm). Clinical attachment level (CAL), recession depth (RD), recession width (RW), and probing depth (PD) were measured at baseline and six months postsurgery.

RESULTS

Both treatments yielded significant improvements in terms of RD and RW decrease and CAL gain compared to baseline values. For test and control groups, the average root coverage was 33% and 77%, respectively (p < 0.05), and the complete root coverage was 18% and 65%, respectively (p < 0.05). The control group showed a greater reduction in RD and RW compared with the test group (p < 0.05).

CONCLUSIONS

The use of Nd:YAG laser as a root surface biomodifier negatively affected the outcome of root coverage with the SCTG.

[Prosthetic and surgical options in the rehabilitation of the after-effects of alveolar clefts]

The question of final-phase treatment and prosthetic rehabilitation is posed for the young adult patient who has followed a program of surgical, orthopedic, and orthodontic work aimed at achieving a functional, aesthetic balance. When a toothless space has been maintained or recreated between the proximal teeth of each fragment, two solutions are at hand for the expert odontologist: implantology, or traditional joint prosthesis. Four problems are evoked here to describe the difficulties related to this therapeutic decision: confrontation of the banks, residual osseous defect, teeth bordering the cleft, and the odontologist's role in the overall responsibility for the patient. The choice of the final surgical and prosthetic context induces a multifactor analysis, and must be integrated early on, as part of a multidisciplinary therapeutic strategy. Psychological acceptance is thereby favored, along with the rational search for a durable, aesthetic result.

Treatment of gingival recession

Gingival recession is an intriguing and complex phenomenon. Recession frequently disturbs patients because of sensitivity and esthetics. Many surgical techniques have been introduced to treat gingival recession, including those involving autogenous tissue grafting, various flap designs, orthodontics, and guided tissue regeneration. This article describes different clinical approaches to treat gingival recession with emphasis on techniques that show promising results and root coverage.