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

Levels of smoking and outcome measures of root coverage procedures: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis was performed to investigate if there was a significant association between the number of cigarettes smoked per day and the results of root coverage procedures.

METHODS

Electronic search was performed through PubMed, Web of Science, Embase, and Scopus until January 2023. Studies were included if evaluated the outcomes of periodontal plastic surgery procedures for the treatment of gingival recession in smokers. Statistical evaluation was conducted using random-effects method to analyze the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CI).

RESULTS

From a total of 4494 references, 15 studies were considered relevant to be included in this study. The results showed that 44.39% sites had complete root coverage (CRC) at 6 months (non-smokers: 54.06%, < 10 cigarettes/day: 48%, 10-20 cigarettes/day: 19.56%, ≥ 20 cigarettes/day: 50%). Mean root coverage at 6 months were as follows: non-smokers: 74.94% ± 16.71%, < 10 cigarettes/day: 84.20% ± 2.24%, 10-20 cigarettes/day: 75.30% ± 14.69%, ≥ 20 cigarettes/day: 68.75% ± 26.51%. A significant difference was revealed between non-smokers and individuals who smoked 10-20 cigarettes/day in terms of CRC at 6 months: OR = 0.15 (95% CI = 0.03 to 0.71; P = .017). However, no significant difference was detected comparing 10-20 and ≥ 20 cigarettes/day.

CONCLUSION

As there was not enough data available, any definitive conclusions about the connection between an increase in the amount of cigarettes consumed per day and the results of root coverage procedures could not be reached. Further research is required with comparative studies involving individuals who smoke varying numbers of cigarettes.

Intra-marrow penetrations and root coverage outcomes: a systematic review

BACKGROUND

Intra-marrow penetrations (IMPs) have been performed during guided tissue regeneration (GTR) procedures with reported clinical benefits. The aim of this systematic review was to investigate the use and effect of IMPs during root coverage procedures.

METHOD

A broad search for human and animal studies was performed on PubMed, Cochrane Database of Systematic Reviews and Cochrane Central Registry of Controlled Trials and Web of Science, following a registered review protocol (PROSPERO). All prospective study designs, case series and case reports on gingival recession treatment (follow-up ≥ 6 months) that employed IMPs were included. Root coverage, complete root coverage prevalence, and adverse effects were recorded, and risk of bias was assessed.

RESULTS

Of 16,181 screened titles, 5 articles (all of them human studies) met inclusion criteria. All studies (including two randomized clinical trials) treated Miller class I and II recession defects, using coronally advanced flap with IMPs alone or in conjunction with GTR protocols. Therefore, all treated defects received IMPs and no studies compared protocols with and without IMPs. Outcomes were indirectly compared with existing root coverage literature. Mean root coverage was 2.7 mm and 68.5% at 6.8 months (median: 6 months, range 6-15 months) for sites treated with IMPs.

CONCLUSION

IMPs are rarely used during root coverage procedures, have not been associated with intra-surgical or wound healing adverse effects and have not been investigated as independent factor. Future clinical studies are needed to directly compare treatment protocols with and without IMPs and investigate the potential benefits of IMPs for root coverage.

Evaluation of PRF Membrane with Coronally Advanced Flap with and without Vertical Releasing Incisions for the Treatment of Gingival Recessions

AIM

The aim of the current study was to compare the esthetic results for subjects with Miller Class I and II gingival recession (GR) abnormalities using platelet-rich fibrin (PRF) membrane with coronal advanced flaps (CAFs) with and without vertical releasing incisions (VRIs; the envelope-type flap and the flap with VRIs).

MATERIALS AND METHODS

Seven defects from each of the test and control groups made up of fourteen defects total. In the test group, PRF + CAF was performed without VRI, while in the control group, VRI was used. Gain in root coverage was the main result, with secondary results including papillary bleeding index (PBI), plaque index (PI), relative gingival margin level, relative attachment level, probing pocket depth, recession depth, width of keratinized gingiva (WKG), and gingival thickness. After 3 months of therapy, a clinical evaluation was conducted.

RESULTS

No significant difference was observed between the two groups in terms of recession reduction (2.08 ± 0.5 vs 1.91 ± 0.66 mm), clinical attachment level (CAL) gain (2.08 ± 0.5 vs 1.91 ± 0.66 mm), and increase in WKG (2.66 ± 0.88 vs 2.58 ± 0.51 mm) for test and control groups, respectively.

CONCLUSION

For the treatment of GR, both groups are efficient. However, the CAF + PRF without VRI group showed higher patient compliance and lower postoperative morbidity.

CLINICAL RELEVANCE

The PRF membrane with CAF with or without VRI provide effective treatment option for GR. CAF + PRF without VRI is easy to perform and has less postoperative complications.

Comparative efficacy of coronally advanced flap with and without guided tissue regeneration in the management of gingival recession defects: A split-mouth trial

Background

The gingival recession causes tooth sensitivity, poor esthetics, and tooth mobility in severe cases. Scientific documentation revealed effective root coverage (RC) and increased keratinized tissue heights acquired with the coronally advanced flap (CAF) for multiple recession defects.

Objectives

This research evaluates and compares the efficacy of CAF procedures with and without Type I collagen bio-absorbable membrane in guided tissue regeneration (GTR) in the treatment of Miller's Class I and II gingival recession.

Materials and Methods

A total of 30 sites from 15 patients were selected for the study after fulfilling the presurgical phase of treatment. The chosen sites were randomly allocated into Group A CAF and Group B (CAF + Resorbable GTR membrane). The clinical variables such as plaque index, gingival index, recession depth (RD), recession width (RW), width of keratinized gingiva (WKG), clinical attachment level (CAL), and surface area of the defect were recorded at the baseline and 6 months postoperatively.

Results

Both therapies resulted in a notable gain in RC with a mean of 73.13% and 71.60%, respectively, but it was not statistically significant when compared between the groups. Both the RD and RW were significantly reduced from baseline to 6 months postoperatively. Although there was a gain in WKG and CAL in both experimental sites, no significant difference was observed between both the groups.

Conclusion

Although there are several RC procedures, CAF furnishes a foreseeable, straightforward, and appropriate perspective for treating Miller's Class I and II recessions. Integrating this approach with placing a bio-absorbable membrane does not seem to improve the results following surgical treatment of such defects. However, both groups showed the potential advantage of achieving RC.

Novel Surgical Approach for Root Coverage Using Coronally Advanced Flap in Conjunction With Transposition of Periosteal Pedicle Graft

INTRODUCTION

Gingival recession is a complex phenomenon with multifactorial etiology. It is defined as the apical migration of the soft tissue margin beyond the cemento-enamel junction, thereby exposing the root surface. It results in the destruction of both soft and hard tissues.

CASE PRESENTATION

Three patients with buccal gingival recession defects underwent surgical treatment consisting of transposition of a periosteal pedicle in conjunction with the coronally advanced flap (CAF) technique. As the cambium layer of the periosteum has greater osteoblastic potential than the fibrous layer, this study considered juxtaposing of the cambium layer directly onto the denuded root surface. A 9-month review demonstrated satisfactory: root coverage; gain in clinical attachment, reduction in probing depth; and increase in width of keratinized gingiva with a good color match and minimal scarring.

CONCLUSION

Within the limits of the study, this CAF technique, in conjunction with the cambium layer of periosteum, showed a significant amount of root coverage.

Modified coronally advanced flap design in management of isolated gingival recession: Saddle flap technique

Saddle flap technique, a modified coronally advanced flap approach for isolated gingival recession management was introduced and assessed in terms of clinical efficacy and patient satisfaction. A total of 10 systemically healthy subjects with isolated gingival recession defect (Miller Class I and II) were enrolled in the study. The primary endpoint measure was patient satisfaction in terms of esthetics and percentage root coverage. The secondary outcome measures comprised clinical attachment level change, gingival thickness variation, width of keratinized tissue alteration, and postoperative healing. At 1 year postoperative, 80% of the treated sites achieved 100% root coverage. Based on clinical results, saddle flap technique could be considered as one of the possible treatment options for isolated gingival recession with good esthetic and patient satisfaction.

Root coverage with coronally advanced flap:6-year follow-up

AIM

The aim of this study was to evaluate the long-term stability of root coverage without a regular control programme after coronally advanced flap (CAF) procedures in isolated gingival recessions.

MATERIAL AND METHODS

Recession defects were treated with CAF using microsurgery technique. Probing depth, clinical attachment level, keratinized gingival width, plaque index, papilla bleeding index, recession depth, recession width and root surface area was evaluated at baseline, and then postoperative 6-month and 6-year follow-up sessions. Percentages of root coverage and complete root coverage rates were also calculated.

RESULTS

In total, 12 defects in 12 patients of the 36 defects in 30 patients were available for analysis at the 6-year follow-up examination (66.7% of the initial sites could be reached). Percentage of mean root coverage was 95.06% at 6-month and 69.27% at 6-year and the difference was statistically significant (P < 0.05). Complete root coverage rate decreased from 75% (at 6-month) to 50% (at 6-year), but the difference was not statistically significant (P > 0.05).

CONCLUSION

Within the limits of this long-term follow-up study, there seems to be a rather high risk for relapse after root coverage with CAF possibly due to the lack of regular recalls and persistent traumatic tooth brushing habits.

[Vestibular incision subperiosteal tunnel access with connective tissue graft for the treatment of Miller classI and II gingival recession]

OBJECTIVE

To evaluate the clinical outcomes of vestibular incision subperiosteal tunnel access (VISTA) with connective tissue graft (CTG) in the treatment of Miller classes I and II localized gingival recession.

METHODS

Ten patients with 10 Miller classes I and II localized gingival recessions were enrolled in the study. All defects were equal to or above 2 mm in recession depth. All the patients received treatment with VISTA+CTG. Their clinical parameters, including recession depth (Rec), recession width (RW), keratinized tissue width (KT), clinical attachment loss (CAL), probing depth (PD) were recorded and compared before surgery and 6 months later. The mean root coverage (MRC) and complete root coverage (CRC) were calculated at the end of 6 months. A visual analogue scale (VAS) was used to estimate the patients' discomfort during the operation and during the 2 weeks post-operation. Patient-based aesthetic satisfaction 6 months after surgery was evaluated by a VAS.

RESULTS

The mean Rec was (2.65±0.82) mm at baseline, and (0.35±0.58) mm after 6 months. The VISTA+CTG treatment resulted in an improvement of (2.30±0.98) mm in recession depth (P<0.001). MRC was 86.67%±21.94% and CRC reached 70% at the end of 6 months. KT increased (0.90±1.22) mm (P<0.05). Aesthetic satisfaction on the patients' level was 8.30 based on VAS (0=unsatisfied, 10=extremely satisfied). The patients' discomfort during the operation and 2 weeks post operation were 2.40 and 4.30 (0=no pain, 10=extreme pain). Furthermore, clinical outcomes showed no statistically significant difference between the gingival biotypes, and between the teeth positioned in maxillary and in mandibular.

CONCLUSION

VISTA+CTG could be an effective treatment for Miller classes I and II localized gingival recession. Clinical outcomes indicated decrease in recession depth and width, and increase in width of keratinized tissue. Patients suffered little pain during the operation and 2 weeks post-operation of healing and accessed good aesthetic satisfaction. VISTA+CTG could be an option for the treatment of Miller classes I and II localized gingival recession.

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.

Comparative efficacy of placental membrane and Healiguide™ in treatment of gingival recession using guided tissue regeneration

Background

Guided tissue regeneration-based root coverage has emerged as a promising treatment modality in the treatment of gingival recession. A variety of nonresorbable and bioresorbable membranes have been successfully used. Among resorbable membranes, collagen has been extensively studied. Recently, a third generation barrier membrane derived from placenta has been introduced for periodontal regeneration.

Aim

The objective of the present study is to clinically compare the efficacy of placental membrane (Amnion) and collagen membrane (Healiguide) for the treatment of gingival recession.

Materials and Methods

Twelve patients having isolated bilateral gingival recession defects were included in the study and were divided into two groups randomly. Group I were treated by coronally positioned flap and amnion membrane and Group II were treated by coronally positioned flap and collagen membrane (Healiguide)™. Clinical parameters, including dental plaque index (PI), gingival index (GI), gingival recession depth, probing pocket depth, clinical attachment level, and gingival biotype, were recorded before surgery at baseline and then reevaluated at 3 and 6 months postoperatively.

Statistical Analysis

Nonparametric test, i.e., Wilcoxon Signed-Ranks Test was used in the present study. Significance was reported at 95% confidence level.

Results

The results of the present study revealed statistically no significant difference (P > 0.05) in dental PI improved, GI and probing pocket depth in both groups. Significant reduction in gingival recession defects and gain in clinical attachment level was observed in both the groups. Intergroup comparison of gingival recession defects and clinical attachment level yielded nonsignificant differences. However, a statistically significant increase (P < 0.05) in gingival tissue thickness was observed in Group II as compared to Group I.

Conclusion

Both membranes are equally efficacious in the treatment of gingival recession. More gingival tissue thickness (gingival biotype) enhancement was observed in sites treated with collagen membrane.

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.

Amnion and Chorion Allografts in Combination with Coronally Advanced Flap in the Treatment of Gingival Recession: A Clinical Study

BACKGROUND

Guided tissue regeneration (GTR) based root coverage using different allograft membranes has been utilized to correct gingival recession defects with promising results. Amnion and chorion allograft membranes of alternative origin derived from human placental tissue has been advocated in the treatment of gingival recession. However, chorion membrane has been used in combination with amnion membrane no study has compared these allograft membranes in the treatment of gingival recession. Therefore, the purpose of this study was to clinically evaluate and compare the efficacy of amnion membrane and chorion membrane in combination with coronally advanced flap in the treatment of gingival recessions.

MATERIALS AND METHODS

Twelve systemically healthy patients having at least 2 bilateral Miller's Class I or Class II gingival recession were recruited and coronally advanced flap was performed with amnion membrane or chorion membrane. Clinical parameters such as gingival Index, plaque index, length of the recession, width of the recession, width of keratinized gingiva, relative attachment level were evaluated at baseline, 3 and 6 months post-surgery.

RESULTS

The mean decrease in length of recession (LR) for Chorion site was 2.00±1.54mm and amnion site was 1.58±1.14mm. The gain in attachment level for amnion site was 2.17±1.53mm and for chorion site was 1.58±1.22mm. The total mean percentage of root coverage was 34% for chorion site and 22% for amnion site.

CONCLUSION

Both amnion membrane and chorion membrane has shown to be versatile allograft material to be used in the treatment of root coverage.

Comparative evaluation of envelope type of advanced flap with and without type I collagen membrane (NEOMEM™) in the treatment of multiple buccal gingival recession defects: A clinical study

BACKGROUND

The aim of this study is to compare and evaluate the clinical outcome of the envelope-type of coronally advanced flap (CAF) alone versus envelope type of coronally advanced flap plus type I collagen membrane (NEOMEM) in the treatment of multiple buccal gingival recessions, using the split mouth study.

MATERIALS AND METHODS

Ten patients in the age group of 20-50 years showing bilateral gingival recessions were treated. The defects in each patient were randomly assigned as Group A, which were treated with the envelope type of CAF, and those in Group B were treated with envelope type of CAF along with the Type I collagen membrane (NEOMEM). The recession depth (RD), probing depth (PD), clinical attachment level (CAL), and width of the keratinized tissue (KT) were measured at baseline, at three and six month intervals.

RESULTS

Forty-six Miller's class I and II gingival recessions were treated. In the CAF + Type I collagen membrane (NEOMEM)-treated (Group B) sites the baseline gingival recession was 2.34 ± 0.48 mm, while in the CAFtreated (Group A) sites it was 2.52 ± 0.84 mm. Both the treatments resulted in significant recession depth reduction (P < 0.001), but the reduction was significantly greater (P < 0.01) for Group B than Group A. The probing depth changes were significant (P < 0.01) for both groups, but the difference was nonsignificant. Similarly, a significant gain of CAL was seen in Group B (2.23 ± 0.75 mm, P < 0.001) as well as in group A (1.60 ± 0.86 mm, P < 0.001) showing a significant difference (P < 0.01) between the two groups. The width of keratinized tissue was also significantly (P < 0.001) increased in both groups, but the increase was significantly greater (P < 0.001) in group B (2.30 ± 1.06 mm) than in group A (1.21 ± 0.67 mm).

CONCLUSION

The envelope type of CAF along with Type I collagen membrane (NEOMEM) was more effective than envelope type of CAF alone, in producing root coverage in multiple gingival recession defects, associated with gain in CAL as also in the width of KT.

Evaluation of the efficacy of 100% Type-I collagen membrane of bovine origin in the treatment of human gingival recession: A clinical study

BACKGROUND

Various treatment modalities have been devised for gingival recession, which is one of the most common signs of periodontal disease. The present study evaluates the efficacy of bioresorbable 100% type I collagen membrane of bovine origin in the treatment of human gingival recession.

MATERIALS AND METHODS

Twenty cases of Miller's class I or class II localized gingival recession defects on the facial surface were treated with 100% type I collagen membrane of bovine origin in conjunction with coronally positioned flap. Pre-operative and post-operative assessments were performed with respect to probing pocket depth, clinical attachment level and clinical recession at 12, 24 and 36 weeks. The data thus collected were analyzed statistically.

RESULTS

Statistically significant improvement based on Student's t test was found in all the three clinical parameters.

CONCLUSION

Bioresorbable 100% type I collagen membrane of bovine origin has given inspiring results in the treatment of human gingival recession defects, thereby justifying the use of this material wherever indicated.

Shallow localized gingival recession defects treated with modified coronally repositioned flap technique: A case series

OBJECTIVES

Various coronally repositioned flap (CRF) techniques have been proposed for coverage of gingival recession defects. Although CRF has several modifications all of them needs vertical or oblique external releasing incisions for treatment of localized gingival recession defects. The aim of present article was to evaluate the effectiveness of a modification of the new CRF procedure without any releasing incision for treatment of shallow localized gingival recession defects.

CONCLUSION

Shallow localized gingival recession defects can be treated with modified coronally repositioned flap technique successfully.

Coronally advanced flap and combination therapy for root coverage. Clinical strategies based on scientific evidence and clinical experience

During the past three decades, several surgical techniques have been proposed to treat single and multiple gingival recessions. Evidence indicates that coronally advanced flap-based approaches result in the best clinical results. Among all the different techniques, the use of a graft under a coronally advanced flap results in the best short- and long-term outcomes in terms of root coverage and gain in keratinized tissue. The use of a coronally advanced flap + connective tissue graft would appear to be the best choice for root coverage. However, harvesting a graft from the palate adds morbidity, surgical chair-time and requires increased surgical skills. A potential alternative could be the use of enamel matrix derivatives under a coronally advanced flap, and this achieves similar clinical outcomes and is less invasive, but adds economic costs to the treatment. Evidence shows that a coronally advanced flap alone in many instances results in complete root coverage and is stable over time. A coronally advanced flap is less invasive for the patient, requires less chair-time and probably less surgical skill. It would therefore be desirable to use a coronally advanced flap approach when indicated. It has been hypothesized that a coronally advanced flap approach alone could be successfully applied when the residual gingiva is thick and wide, although existing evidence does not support this hypothesis in full. Accordingly, the adjunctive use of a graft or enamel matrix derivatives could be restricted to sites at which there is thin and narrow residual gingiva.

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.

Root coverage procedures for the treatment of localised 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 periodontal plastic surgery (PPS) procedures.

OBJECTIVES

To evaluate the effectiveness of different root coverage procedures in the treatment of recession-type defects.

SEARCH STRATEGY

The Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE and EMBASE were searched up to October 2008. The main international periodontal journals were handsearched. There were no restrictions with regard to publication status or language of publication.

SELECTION CRITERIA

Only randomised controlled clinical trials (RCTs) of at least 6 months' duration evaluating recession areas (Miller's Class I or II > 3 mm) and that were treated by means of PPS procedures were included.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Authors were contacted for any missing information. Results were expressed as random-effects models using mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals.

MAIN RESULTS

Twenty-four RCTs provided data. Only one trial was considered to be at low risk of bias. The remaining trials were considered to be at high risk of bias. The results indicated a significant greater reduction in gingival recession and gain in keratinized tissue for subepithelial connective tissue grafts (SCTG) compared to guided tissue regeneration with resorbable membranes (GTR rm). A significant greater gain in the keratinized tissue was found for enamel matrix protein when compared to coronally advanced flap (0.40 mm) and for SCTG when compared to GTR rm plus bone substitutes. Limited 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 the treatment of localised recession-type defects. In cases where both root coverage and gain in the keratinized tissue are expected, the use of subepithelial connective tissue grafts seems to be more adequate. Randomised controlled clinical trials are necessary to identify possible factors associated with the prognosis of each PPS procedure. The potential impact of bias on these outcomes is unclear.

Treatment of gingival recession with coronally advanced flap procedures: a systematic review

BACKGROUND

The treatment of buccal gingival recessions is a common requirement due to aesthetic concern or root sensitivity. The aim of this manuscript was to systematically review the literature on coronally advanced flap (CAF) alone or in combination with tissue grafts, barrier membranes (BM), enamel matrix derivative (EMD) or other material for treating gingival recession.

MATERIAL AND METHODS

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 and hand-searched journals. The primary outcome variable was complete root coverage (CRC). The secondary outcome variables were recession reduction, clinical attachment gain, keratinized tissue gain, aesthetic satisfaction, root sensitivity, post-operative patient pain and complications.

RESULTS

A total of 794 Miller Class I and II gingival recessions in 530 patients from 25 RCTs were evaluated in this systematic review. CAF was associated with mean recession reduction and CRC. The addition of connective tissue graft (CTG) or EMD enhanced the clinical outcomes of CAF in terms of CRC, while BM did not. The results with respect to the adjunctive use of acellular dermal matrix were controversial.

CONCLUSIONS

CTG or EMD in conjunction with CAF enhances the probability of obtaining CRC in Miller Class I and II single gingival recessions.

Is coronally positioned flap procedure adjunct with enamel matrix derivative or root conditioning a relevant predictor for achieving root coverage? A systemic review

BACKGROUND AND OBJECTIVE

This study is a systemic review of coronally positioned flap, coronally positioned flap+chemical root surface conditioning, or coronally positioned flap+enamel matrix derivative (EMD) for the treatment of Miller class I and II gingival recession.

MATERIAL AND METHODS

All studies available through the Medline database by the end of October 2005 were used. Each study provided mean clinical attachment level, keratinized tissue, probing pocket depth, gingival recession depth and root coverage percentage before and after treatment with coronally positioned flap alone, coronally positioned flap+chemical root surface conditioning, or coronally positioned flap+EMD. Effectiveness was evaluated by comparing the weighted mean average in gingival recession depth, probing pocket depth, clinical attachment level, keratinized tissue and root coverage percentage achieved with the three treatments.

RESULTS

Seven studies for the coronally positioned flap+EMD group, four studies for the coronally positioned flap+chemical root surface conditioning group, and seven studies for the coronally positioned flap group were retrieved for this weighted mean analysis. The results of clinical attachment level, gingival recession depth, and root coverage percentage in the coronally positioned flap+EMD group were statistically significantly better than the changes in the coronally positioned flap and coronally positioned flap+chemical root surface conditioning group at 6 and 12 mo (p<0.001). There was no significant difference at the 6-mo comparison among clinical attachment level, keratinized tissue, probing pocket depth, and gingival recession depth, except in the root coverage percentage for coronally positioned flap and coronally positioned flap+chemical root surface conditioning groups.

CONCLUSION

The results suggest that root coverage by the coronally positioned flap and coronally positioned flap+chemical root surface conditioning procedures were unpredictable but became more predictable when the coronally positioned flap procedure was improved by the modification of adding EMD.

Coronally Positioned Flap for Root Coverage in Smokers and Non-Smokers: Stability of Outcomes Between 6 Months and 2 Years

BACKGROUND

Smoking adversely affects the short-term outcomes of coronally positioned flap (CPF) root coverage procedures, but the long-term stability of this procedure in smokers has not been studied. The objective of this study was to evaluate the effect of smoking on the long-term outcomes of CPF in recession treatment.

METHODS

CPF was used to treat a Miller Class I defect in a maxillary canine or premolar in 10 current smokers (> or =10 cigarettes daily for > or =5 years) and 10 non-smokers (never smokers). At baseline and 6, 12, and 24 months, clinical parameters, including probing depth (PD), clinical attachment level (CAL), recession depth (RD), and width of keratinized tissue (KT), were determined.

RESULTS

Intragroup analysis showed that CPF failed to maintain the gingival margin at the initially achieved position. RD significantly increased in smokers (from 0.84 +/- 0.49 to 1.28 +/- 0.58 mm) and in non-smokers (from 0.22 +/- 0.29 to 0.50 +/- 0.41 mm) between 6 and 24 months. Further analysis showed that 50% of smokers and 10% of non-smokers lost between 0.5 and 1.0 mm of root coverage in the same period. Intergroup analysis showed that smokers had significantly greater residual recession (P = 0.001) at 24 months. Both smokers and non-smokers lost CAL and experienced decreases in KT.

CONCLUSIONS

The long-term stability of CPF outcomes is less than desirable, particularly in smokers. Two years after a CPF procedure, smokers have significantly greater residual recession compared to non-smokers both statistically and clinically.

A two-year prospective study of coronally positioned flap with or without acellular dermal matrix graft

AIM

Evaluation of the treatment of gingival recessions with coronally positioned flap with or without acellular dermal matrix allograft (ADM) after a period of 24 months.

METHODS

Thirteen patients with bilateral gingival recessions were included. The defects were randomly assigned to one of the treatments: coronally positioned flap plus ADM or coronally positioned flap alone. The clinical measurements were taken before the surgeries and after 6, 12 and 24 months.

RESULTS

At baseline, the mean values for recession height were 3.46 and 3.58 mm for the defects treated with and without the graft, respectively (p>0.05). No significant differences between the groups were observed after 6 and 12 months in this parameter. However, after 24 months, the group treated with coronally positioned flap alone showed a greater recession height when compared with the group treated with ADM (1.62 and 1.15 mm, respectively--p<0.05). A significant increase in the thickness of keratinized tissue was observed in the group treated with ADM as compared with coronally positioned flap alone (p<0.05).

CONCLUSIONS

ADM may reduce the residual gingival recession observed after 24 months in defects treated with coronally positioned flap. In addition, a greater gingival thickness may be achieved when the graft is used.

Comparative Study of Two Root Coverage Procedures: A 24-Month Follow-Up Multicenter Study

BACKGROUND

Treatment alternatives to cover exposed root surfaces include free grafts, pedicle flaps, and barrier membranes. This 24-month follow-up study clinically evaluated the long-term effect of a coronally advanced flap procedure with the additional use of enamel matrix derivative (EMD) to treat gingival recession versus the subpedicle connective tissue graft (CTG) procedure.

METHODS

Miller Class I or II buccal recession-type defects in the anterior teeth or premolars in 65 patients (28 in EMD and 37 in CTG groups) were treated in several centers. At baseline and 12 and 24 months post-treatment, vertical recession defect (VRD), height of keratinized tissue (HKT), and probing depth (PD) were recorded, and the percentage of root coverage (PRC) of the original defect was calculated. Student t test, analysis of variance, and analysis of covariance were used for statistical analyses.

RESULTS

At 12- and 24-month evaluations, PRC was 73.2% (SD=15.58%) and 76.9% (SD=16.77%) in the EMD group and 86.8% (SD=12.48%) and 84.3% (SD=13.32%) in the CTG group, respectively (P<0.001). Differences between groups were statistically significant (P=0.002). Baseline HKT was 1.07 mm (SD=0.66 mm) in the EMD group and 1.65 mm (SD=0.92 mm) in the CTG group. At 12 and 24 months, values were 1.75 mm (SD=0.59 mm) and 2.25 mm (SD=0.52 mm) in the EMD group and 4.24 mm (SD=0.89 mm) and 4.05 mm (SD=0.94 mm) in the CTG group, respectively. Differences in HKT were statistically significant within (EMD: P<0.001; CTG: P=0.017) and between (P<0.001) groups.

CONCLUSIONS

Both treatments proved clinically successful. CTG treatment showed a higher percentage of root coverage and HKT increase. EMD is a valuable, long-term effective treatment alternative to achieve root coverage together with an increase in HKT.

Coronally Positioned Flap for Root Coverage: Poorer Outcomes in Smokers

BACKGROUND

Gingival recession is significantly more common among smokers, while the relative outcome of various root coverage procedures in smokers, compared to non-smokers, is debatable. The objective of this study was to evaluate the influence of cigarette smoking on the outcome of coronally positioned flap (CPF) in the treatment of Miller Class I gingival recession defects.

METHODS

Ten current smokers (> or = 10 cigarettes daily for at least 5 years) and 10 non-smokers (never smokers), each with one 2- to 3-mm Miller Class I recession defect in an upper canine or bicuspid, were treated with CPF. At baseline and 6 months, clinical parameters, probing depth (PD), clinical attachment level (CAL), recession depth (RD), and apico-coronal width of keratinized tissue (KT) were determined.

RESULTS

Intragroup analysis showed that CPF was able to reduce RD and improve CAL in both groups (P <0.05). Intergroup analysis demonstrated that smokers presented greater residual RD at 6 months and lower percentage of root coverage (69.3% versus 91.3%; P <0.05). No smokers obtained complete root coverage compared to 50% of non-smokers (P <0.05).

CONCLUSIONS

Within the limits of the present study, it can be concluded that CPF provides benefits for both smokers and non-smokers in terms of root coverage of shallow Miller Class I recession defects. However, cigarette smoking negatively impacts the clinical outcomes, specifically residual recession, percent root coverage, and frequency of complete root coverage.

Oral reconstructive and corrective considerations in periodontal therapy

This paper was prepared by the Research, Science and Therapy Committee of the American Academy of Periodontology. It is intended to provide information for the dental profession and other interested parties. The purpose of this paper is to provide a general overview of oral reconstructive and corrective procedures used in periodontal therapy. It is not intended to be a comprehensive review of this subject.

Coronally positioned flap procedures with or without a biodegradable membrane in the treatment of human gingival recession. A 6-year follow-up study

BACKGROUND

Short-term data have indicated that treatment of gingival recession type defects by coronally positioned flap procedures with or without biodegradable membranes may result in similar treatment outcome. The aim of this study was to compare 12-month and 6-year follow-up results for these two treatment approaches.

METHODS

Twenty patients with buccal bilateral Miller Class I or Class II gingival recession defects in cuspids or bicuspids were treated randomly by coronally positioned flap alone (20 sites) or in combination with a biodegradable membrane (20 sites). Clinical measurements at baseline, 6, 12 months and 6 years included apical extent of gingival recession, width of the defect at the cemento-enamel junction (CEJ), width of keratinized tissue, as well as attachment level and probing depth. Eleven patients were available for the 6-year evaluation.

RESULTS

At 12 months (20 sites), both treatments resulted in significant gain of root coverage (p<0.001), stable probing depth, and increased attachment level (p<0.001). The 6-year evaluation (11 sites) showed a significant gain of root coverage for the non-membrane group only (p<0.05). No significant between-group differences were detected for any other treatment variable regardless of smoking status (p>0.05). Compared with baseline, the 6-year results showed that seven membrane sites gained root coverage, three were unchanged and one lost root coverage. For the 11 non-membrane sites, eight gained root coverage, and three were unchanged. The five membrane and the 10 non-membrane sites exhibiting complete root coverage at 6 months were reduced to two and one, respectively, at the 6-year evaluation.

CONCLUSIONS

The coronally positioned flap procedure offers a simple and reliable treatment alternative as a root coverage procedure in Class I and Class II recession type defects. Placement of a biodegradable membrane underneath the flap does not seem to improve neither the short- nor the long-term results. Long-term outcome stability seems to be critically dependent on a continuous follow-up program with re-instruction in non-traumatic brushing habits.

Coronally Advanced Flap: The Post-Surgical Position of the Gingival Margin Is an Important Factor for Achieving Complete Root Coverage

BACKGROUND

An assessment of the factors affecting the clinical outcome of root coverage procedures may be useful in clinical decision making. The aim of this study is to investigate whether the post-surgical location of gingival margin relative to the cemento-enamel junction (CEJ) can influence the recession reduction (RecRed) and complete root coverage (CRC) following coronally advanced flap procedure (CAF).

METHODS

Sixty patients, aged between 22 and 57 years, 15 males and 45 females, each showing maxillary buccal recessions (> or =2 mm) identified as Miller's Class I were consecutively enrolled. All the defects were treated by CAF procedure from 2000 to 2003 by a single operator with more than 20 years of clinical experience. Age, gender, smoking habits, and type of tooth of each patient were recorded. In addition, the following clinical data were measured or computed: recession depth, width of keratinized tissue, probing depth, distance between incisal margin (IM) and CEJ, dental hypersensitivity, clinical attachment level, distance between IM and gingival margin (IMGM), distance between IM and mucogingival junction (IMMG), and the location of gingival margin relative to the CEJ following CAF procedure (GM(1)). A multiple linear regression, and a logistic linear regression analyses were performed.

RESULTS

The recession depth at baseline (Rec(T0)) and the location of the gingival margin after suturing (GM(1)) are positively correlated to recession reduction. Complete root coverage appeared to be influenced by GM(1): the more coronal the level of the gingival margin after suturing (GM(1)), the greater the probability of CRC.

CONCLUSION

The location of the gingival margin relative to the cemento-enamel junction following CAF procedure seems to affect CRC.

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.