GTR IN MANAGEMENT OF GINGIVAL RECESSION.

Abstract.

One of the most common esthetic concerns associated with the periodontal tissues is gingival
recession. Gingival recession is the exposure of root surfaces due to apical migration of the
gingival tissue margins; gingival margin migrates apical to the cementoenamel junction.
Although it rarely results in tooth loss, marginal tissue recession is associated with thermal and
tactile sensitivity, esthetic complaints, and a tendency toward root caries. This paper reviews
etiology, classification, consequences, and the available surgical procedures, focusing on value
of GTR in management of gingival recession.
Introduction.
Gingival recession is defined as an apical displacement of gingival margins from the
cementoenamel junction (CEJ), which results in root exposure (1). The distance between the CEJ
and gingival margin gives the level of recession. Gingival recession can be caused by periodontal
disease, accumulations, inflammation, improper flossing, aggressive tooth brushing, incorrect
occlusal relationships, and dominant roots. These can appear as localized or generalized gingival
recession. Recession can occur with or without loss of attached tissue. Gingival recession may
effect in accentuated sensitivity because of the exposed dentin, it can be assessed by an
appearance of a long clinical tooth and varied proportion of the teeth when compared with
adjacent teeth.
Etiology.
1. Calculus. Association between gingival recession with supragingival and subgingival calculus
can be noted because of inadequate access to prophylactic dental care (2).
2. Tooth Brushing. Khocht et al. showed that use of hard tooth brush was associated with
recession (3).
3. High Frenal Attachment. This may impede plaque removal by causing pull on the marginal
gingival (4).
4. Position of the Tooth. Tooth which erupts close tomucogingival line may show localised
gingival recession as there may be very little or no keratinized tissue (5).
5. Tooth Movement by Orthodontic Forces. The movement of tooth such as excessive
proclination of incisors and expansion of the arch expansion are associated with greater risk of
gingival recession (6).
6. Improperly Designed Partial Dentures. The partial dentures which have been maintained or
designed which causethe gingival trauma and aid in the plaque retention have the tendency to
cause gingival recession (7).
7. Smoking. The people who smoke have more gingival recession than nonsmokers. The
recession sites were found on the buccal surfaces of maxillary molars, premolars, and
mandibular central incisors (8).
8. Restorations. Subgingival restoration margins increase the plaque accumulation, gingival
inflammation, and alveolar bone loss (9).
9. Chemicals. Topical cocaine application causes gingivalulcerations and erosions (10).

Classification.
Several classifications have been proposed in literature to facilitate the diagnosis of gingival
recessions. They are as follows:
• Sullivan and Atkins (1968)
• Mlinek (1973)
• Liu and Solt (1980)
• Bengue (1983)
• Miller (1985)
• Smith (1990)
• Nordland and Tarnow (1998)
• Mahajan (2010)
• Cairo et al. (2011)
• Rotundo et al. (2011)
• Ashish Kumar and Masamatti (2013)
• Prashant et al. (2014).
Most widely accepted classification is MILLER (1985)
Class I: Marginal tissue recession, which does not extend to the mucogingival junction (MGJ).
There is no periodontal loss (bone or soft tissue) in the interdentalarea, and 100% root coverage
can be anticipated.
 Class II: Marginal tissue recession, which extends to or beyond the MGJ. There is no
periodontal loss (bone or soft tissue) in the interdental area, and 100% root coverage can be
anticipated
Class III: Marginal tissue recession, which extends to or beyond the MGJ. Bone or soft tissue
loss in the interdental area is present or there is a malpositioning of the teeth, which prevents the
attempting of 100% of root coverage. Partial root coverage can be anticipated. The amount of
root coverage can be determined presurgically using a periodontal probe.
Class IV: Marginal tissue recession, which extends to or beyond the MGJ. The bone or soft
tissue loss in the interdental area and/or malpositioning of teeth is so severe that root coverage
cannot be anticipated.
Root coverage.
Root coverage is one of the most important components of periodontal plastic surgeries.
Currently, numerous surgical techniques are proposed for root coverage. These procedures are as
follows (10) :
1) Pedicle soft tissue grafts
 Rotational flaps :
 Laterally positioned flap
 Double papilla flap.
 Advanced flaps :
 Coronally positioned flap
 Semilunar flap.

2) Free soft tissue grafts

 Non – submerged graft :
 One stage [ free gingival graft ]
 Two stage [ free gingival graft + coronally positioned flap ]
 Submerged graft :
 Connective tissue graft + laterally positioned flap
 Connective tissue graft + double papilla flap
 Envelope technique.

3) Additive treatments
 Root surface modification agents
 Enamel matrix proteins
 Guided tissue regeneration
 Non resorbable membrane barriers
 Resorbable membrane barriers.
 GUIDED TISSUE REGENERATION IN GINGIVAL RECESSION.

The Guided Tissue Regeneration is a technique used in dentistry that aims at tissue and
bone regeneration, or to repair damaged tissue. It is based on the perception that tissues, for the
most part, are capable of self – reconstitution if appropriate conditions are provided. GTR
therapy which was introduced in the 1980s, have been widely used to regenerate lost tissues from
periodontal disease.

Classification of membranes.

MINABE in 1991.

1. Non absorbable.
 Biocompatible porous material possessing two unique microstructure.
 Open microstructure of its collar which is design to retard or inhibit the
apical proliferation of epithelium through contact inhibition.
 Occlusive membrane which acts as a barrier to the gingival connective tissue
and underlying root surfaces.
 Include :
- e – PTFE
Titanium reinforced expanded polytetrafluoroethylene.
- Nuclepore and Millipore filters
- Silicon barriers
- Sterilized rubber dam.
2. Resorbable.
The search for resorbable membranes has included trials and tests with
numerous materials and
- Collagen from different species such as bovine, porcine
( BLUMENTHAL et AL 1987 )
- Cargile membrane derived from caecum of an ox
- Polylactic acid
- Vicryl
 - Synthetic skin ( biobrane )
FLANARY et al 1991
- Freeze dried dura matter.

Resorbable membrane marketed in the US:

 OsseoQuest ( Gore ) , a combination of polyglycolic acid, polylactic acid,

trimethylene carbonate, that resorbs at 6 – 14 months.
 BioGuide ( Osteohealth ) , a bilayer porcine – derived collagen.
 Atrisorb ( Block Drug ) , a polylactic acid gel.
 BioMend ( Calcitech ) , a bovine Achilles tendon collagen that resorbs in 4 –
18 weeks.

GOTTLOW in 1993.

 First generation ( non –resorbable )

 Second generation ( resorbable )
 Third generation ( resorbable with growth factor )

First generation membrane includes :

 Millipore filter
 Expanded polytetrafluoroethylene membrane [ e- PTFE ] GORE – TEX.
 Nucleopore membrane
 Rubber dam
 Ethyl cellulose
 Semi permeable silicon barrier.
The first generation membranes developed were non resorbable and required a second surgery
for membrane removal some weeks later. The need for second surgical procedure hindered the
utilization of the original barrier membranes, which led to the development of resorbable
membranes.

Second generation membrane includes :

  Collagen – Biomend, Periogen, Paroguide, Biosite, Tissue guide.

Commercialy available collagen membranes include :

• Biomend - Collagen Type I membrane of bovine origin

-Resorbs in 4-8 weeks

• Bioguide – Collagen Type I and Type III of porcine origin

-Resorption time is 24 weeks
• Ossix plus - Type I porcine collagen
- Maintain barrier functionality for 4-6 months
- Good handling properties and adaptation

• Biosorb membrane - Type I bovine collagen

-Resorbs in 26-38 weeks

 Polylactic acid membrane - Guidor, Vicryl, Atrisorb, Resolut, Epiguide, Biofix.

 Vicryl mesh
 Cargile membrane
 Oxidized cellulose membrane.

Disadvantages of resorbable membranes include :

- Lack of space making ability compared to non resorbable membranes.

- Unpredictable degradation profile
- Risk of disease transmission.

Third generation membrane includes :

 Barrier membranes with Antimicrobial activity

 Barrier membranes with Bioactive Calcium Phosphate incorporation
 Barrier membranes with Growth Factor release
PDGF, IGFI, basic fibroblast growth factor (FGF-2) , TGF-1 , BMP-2, -4, -7 and -12,
and enamel matrix derivative (EMD).
Platelet rich fibrin (PRF) membrane
 Amniotic membranes (AM).

GTR MEMBRANES USED IN GINGIVAL RECESSION.

1. Collagen: These absorbable barrier membranes inhibit migration of epithelial cells,
promote the attachment of new connective tissue, are not strongly antigenic and prevent
blood loss by promoting platelet aggregation leading to early clot formation and wound
stabilization. They also facilitate primary wound closure via fibroblast chemotatic
properties.
2. Antibacterial substances were incorporated to reduce the bacterial contamination of
regenerating wound (11). 25%wt of metronidozale benzoate incorporated into the layer
interfacing with epithelial tissue (PLA:GEL+MET) showed reduced bacterial growth and
biofilm formation(12). It was demonstrated that incorporation of amoxicillin or
tetracycline into various GTR membranes may enhance the attachment of periodontal
ligament cells in the presence of oral pathogens streptococcus mutans and
Aggregatibacter Actinomycetemcomitans (A.a) (13).

3. Amnion membrane allograft : It is a bioresorbable freeze dried irradiated membrane

derived from human amnion tissue which is the innermost layer of fetal membrane and is
composed of a single epithelial layer, a thick basement membrane, and an avascular
stroma. Amnion membrane is one such example. It was first used by Davis 1910(14). It
facilitates epithelization, preserves the normal epithelial phenotype, decreases
inflammation, promotes angiogenesis, and decreases scar formation(15).
Amnion contains a variety of specialized proteins such as fibronectin, laminin, proteoglycans and
collagen type IV, V, and VII. It not only provides matrix for cellular migration and proliferation
but also enhances the wound healing process. It has been reported to be nonimmunogenic to
reduce inflammation, reduce scar tissue, has antibacterial properties, reduces pain at the site of
application and act as a natural biological barrier.[13] Amnion membrane has revealed the
presence of various growth factors in the membrane epithelium. Amnion membrane is also
readily obtainable in large amounts, and its preparation and storage are relatively low in cost.[14]

4. L – PRF : Leucocyte-Platelet Rich Fibrin (L-PRF) is a new biomaterial developed by

Choukroun et al. (2001). It is a second generation of platelet concentrates, widely used to
accelerate healing of hard and soft tissues mainly in dentistry. L-PRF is a fibrin network
containing cytokines, structural glycoproteins (fibronectin), and glycosaminoglycans
(heparin and hyaluronic acid). These biochemical components have well known effects
on wound healing processes (Toffler et al., 2009; Dohan Ehrenfest et al., 2010). Among
its advantages over traditional PRP (Platelet Rich Plasma), L-PRF preparation is easy and
low cost because it does not require bovine thrombin, calcium chloride, anticoagulant or
biochemical modifications (Toffler et al.). L-PRF protocol allows platelet aggregation
and cytokines release in a fibrin clot. It can be used directly as a clot or after it´s
 compression as a resistant membrane (Toffler et al.; Dohan Ehrenfest et al.). Whole blood
is placed into glass tubes without anticoagulant and centrifuged immediately. In a few
minutes the absence of anticoagulant allows sample platelets activation and coagulation
cascade initiation. A fibrin clot is obtained and removed from the tube. The L-PRF is
placed on a special box (PRF box) and covered with the compressor. This produces an
autologous fibrin membrane of constant thickness, which remains hydrated for several
hours. Platelets are a rich source of polypeptide growth factors that can promote wound
healing (Danielsen et al., 2008). Although platelets and leukocyte cytokines play an
important role in L-PRF biology, fibrin matrix that supports them constitutes a decisive
factor for the real therapeutic potential of this biomaterial (Toffler et al.).

5. Chitosan : it is he deacylated deriviative of chitin, which is widely used as food

preservative. Chitin is a linear polysaccharide consisting of beta (1-4) linked 2 –
 acetamido – 2 – deoxy – D – glucopyranose and 2 –amino – 2- deoxy – D –
glucopyranose. It is routinely derived from the N – deacetylation of chitin from
the exoskeleton of marine crustaceans. It exhibits antibacterial and antifungal
activity. The membrane is composed of densely packed Chitosan with optimum
handling characteristics. A hybrid memrane containing collagen and Chitosan
has been developed by the Central Institute of Fisheries Technology (CIFT) ,
Kochi, Kerala, which can be used as a barrier membrane.
6. Calcium sulphate : The use of calcium sulfate as a graft/barrier may act as a binder,
facilitating healing, and preventing loss of grafting material. It is well documented that
calcium sulfate acts as a barrier, is tissue compatible, and does not interfere with the
healing process.(16) As a barrier, it prevents the colonization of the defect by gingival
cells, allowing selective repopulation of the defect by periodontal ligament cells. Calcium
sulfate is biocompatible, and it completely resorbs within 4–10 weeks, depending on the
vascularity of the grafted site.(17).

CONCLUSION.
Gingival recession is highly prevalent worldwide. It increases the risk for root caries and can
interfere with patient comfort, function and esthetics. Progressive gingival recession also
increases the risk of tooth loss secondary to clinical attachment loss. Although mitigating the
causes of gingival recession decreases its incidence and severity, implementing practical
management and prevention strategies in a clinical setting can be challenging. Identification of
susceptible patients and evaluating them for the presence of modifiable risk exposures are
essential first steps in developing action plans for appropriate interventions. This paper reviews
the GTR membranes used in gingival recession. GTR procedure has been widely employed in
periodontal practice and established as a basic technique in periodontal regenerative medicine
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