Professional Documents
Culture Documents
Int J Periodontics Restorative Dent 2011 Leong
Int J Periodontics Restorative Dent 2011 Leong
© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY..
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
307
© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY..
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
308
© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY..
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
309
Identify etiology
Remove etiology
Purpose of procedure
100% root
coverage
possible Root coverage is unpredicatable
Fig 1 Decision tree for selecting a soft tissue grafting procedure. CT = connective tissue; CAF = coronally advanced flap; GTR = guided
tissue regeneration; ADM = acellular dermal matrix; KG = keratinized gingiva; LPF = laterally positioned flap; APF = apically positioned flap;
GTRC = GTR-based root coverage.
© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY..
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
310
© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY..
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
311
coverage in Miller Class I and II de- coverage for these studies.34 GTR
fects in maxillary teeth.29 procedures using both absorbable
Using GTR, sites with a tissue and nonresorbable membranes
thickness of > 0.5 mm obtained have been performed for root cov-
a mean root coverage of 95.6%; erage, with no apparent significant
at thin areas of ≤ 0.5 mm, a mean differences in treatment outcome.38
root coverage of only 26.7% was The mean root coverage has been
obtained.26 This may lead one found to be approximately 72% to
to speculate that the membrane 73%, with a 35% to 39% predict-
placed between the bone and full- ability of achieving ≥ 90% root cov-
thickness flap may have acted as erage.34,39,40 Some factors affecting
a barrier preventing blood circula- the success of root coverage in-
tion. This is especially detrimental clude the initial recession depth,41
for a thin flap. gingival thickness,25,26 and mem-
Techniques used for root cov- brane exposure.42
erage include CT grafts, FST grafts, In a recent systematic review
pedicle autografts (rotational and comparing CT grafts, ADM, and
advanced flaps), GTR, and, more GTR with absorbable membranes,
recently, acellular dermal matrix. results showed that CT grafts can
The use of a CT graft for root cov- be considered the ”gold standard”
erage has been shown to be a in treating Miller Class I and II re-
highly predictable and successful cession defects with respect to ob-
procedure. Studies have shown a taining substantial root coverage,
mean defect coverage of 84%30–32 clinical attachment, and keratinized
and a predictability of achieving tissue gain.43 Similar results in favor
≥ 90% defect coverage 68% of of CT grafts were also reported in
the time.30,33,34 The CAF is another other systematic reviews.44,45
technique often used alone or in Another factor that may influ-
combination26 with other soft tis- ence the final treatment outcome
sue grafting procedures to cover is the final position of the gingival
exposed roots. However, the re- margin. It has been demonstrated
sults can only be predictable un- that the more coronal the level of
der specified conditions27,28: Miller the gingival margin postsuturing,
Class I recession defect, shallow re- the higher the probability of achiev-
cession ≤ 4 mm, keratinized tissue ing complete root coverage.35
width ≥ 3 mm, gingival thickness ≥ Huang and Wang23 introduced a
0.8,22,24,27 and overcorrection of the ”sling and tag” technique in 2007
defect.23,35 The LPF technique has for the CAF procedure, and in the
been advocated for coverage of lo- study, the flap was repositioned cor-
calized recession defects. In gener- onally beyond the cementoenamel
al, clinical studies on humans have junction by at least 1 mm. At 1 year
reported a range of 61% to 74% postsurgery, a mean root cover-
reduction in recession depth,10,36,37 age of 93% ± 15% was obtained,
representing a mean 67% defect indicating very successful results.
© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY..
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
312
Therefore, to increase the predict- Acknowledgments 13. de Souza SL, Novaes AB Jr, Grisi DC, Taba
M Jr, Grisi MF, de Andrade PF. Compara-
ability of complete root coverage tive clinical study of a subepithelial con-
This study was supported by the Periodontal
with a CAF procedure, it is gener- nective tissue graft and acellular dermal
Graduate Student Research Fund, University matrix graft for the treatment of gingival
ally recommended that the flap be
of Michigan, Ann Arbor, Michigan. recessions: Six- to 12-month changes.
repositioned at least 1 mm beyond J Int Acad Periodontol 2008;10(3):87–94.
the cementoenamel junction. 14. Wei PC, Laurell L, Geivelis M, Lingen
MW, Maddalozzo D. Acellular dermal
If the objective of root coverage References matrix allografts to achieve increased at-
is to obtain new attachment, proce- tached gingiva. Part 1. A clinical study.
1. Friedman N. Mucogingival surgery. Texas J Periodontol 2000;71:1297–1305.
dures such as GTR-based root cov- Dent J 1957;75:358–362. 15. Harris RJ. A short-term and long-term
erage and use of tissue-engineered 2. Miller PD Jr. A classification of marginal comparison of root coverage with an
tissue recession. Int J Periodontics Re- acellular dermal matrix and a subepitheli-
or biologic agents may be consid-
storative Dent 1985;5:8–13. al graft. J Periodontol 2004;75:734–743.
ered. GTR and other techniques, 3. Miller PD Jr. Regenerative and reconstruc- 16. McGuire MK, Scheyer ET, Nunn ME,
such as root surface conditioning tive periodontal plastic surgery. Mucogin- Lavin PT. A pilot study to evaluate a tis-
gival surgery. Dent Clin North Am 1988; sue-engineered bilayered cell therapy as
procedures and root biomodifi- 32:287–306. an alternative to tissue from the palate.
cation with biologic agents (eg, 4. Proceedings of the World Workshop on J Periodontol 2008;79:1847–1856.
Periodontics. Consensus report on muco- 17. Joly JC, Carvalho AM, da Silva RC, Ciotti
enamel matrix derivatives), have
gingival therapy. Ann Periodontol 1996;1: DL, Curry PR. Root coverage in isolated
shown varying results with uncer- 702–706. gingival recessions using autograft ver-
tain predictability in obtaining new 5. Gorman WJ. Prevalence and etiology of sus allograft: A pilot study. J Periodontol
gingival recession. J Periodontol 1967;38: 2007;78:1017–1022.
attachment and root coverage.46 316–322. 18. Woodyard JG, Greenwell H, Hill M, Dris-
Histologic evidence showing re- 6. Hall WB. Pure Mucogingival Problems: ko C, Iasella JM, Scheetz J. The clinical
Etiology, Treatment and Prevention. Chi- effect of acellular dermal matrix on gin-
generation of the periodontium at
cago: Quintessence, 1984. gival thickness and root coverage com-
6 months has been shown in stud- 7. Friedman N. Mucogingival surgery. The pared to coronally positioned flap alone.
ies using EMD and certain growth apically repositioned flap. J Periodontol J Periodontol 2004;75:44–56.
1962;33:328–340. 19. Sallum EA, Nogueira-Filho GR, Casati
factors.47,48 However, more studies 8. James WC, McFall WT Jr. Placement of MZ, Pimentel SP, Saldanha JB, Nociti FH
are warranted in this area to ascer- free gingival grafts on denuded alveolar Jr. Coronally positioned flap with or with-
bone. Part I: Clinical evaluations. J Peri- out acellular dermal matrix graft in gingi-
tain the effectiveness and predict-
odontol 1978;49:283–290. val recessions: A histometric study. Am J
ability of attaining new attachment 9. Matter J, Cimasoni G. Creeping attach- Dent 2006;19:128–132.
with various biologic agents. ment after free gingival grafts. J Peri- 20. Harris RJ. Gingival augmentation with an
odontol 1976;47:574–579. acellular dermal matrix: Human histolog-
10. Guinard EA, Caffesse RG. Treatment of ic evaluation of a case—Placement of the
localized gingival recessions. Part I. Lat- graft on periosteum. Int J Periodontics
eral sliding flap. J Periodontol 1978;49:
Conclusion 351–356.
Restorative Dent 2004;24:378–385.
21. Seibert JS. Ridge augmentation to en-
11. Karring T, Cumming BR, Oliver RC, Löe hance esthetics in fixed prosthetic treat-
The decision tree proposed serves H. The origin of granulation tissue and its ment. Compendium 1991;12:548–552.
impact on postoperative results of muco- 22. Huang LH, Neiva RE, Wang HL. Factors
as a guide for clinicians to select gingival surgery. J Periodontol 1975;46: affecting the outcomes of coronally ad-
the most appropriate and predict- 577–585. vanced flap root coverage procedure.
12. Cordioli G, Mortarino C, Chierico A, J Periodontol 2005;76:1729–1734.
able soft tissue grafting procedure
Grusovin MG, Majzoub Z. Comparison 23. Huang LH, Wang HL. Sling and tag su-
to minimize unnecessary mistakes of 2 techniques of subepithelial connec- turing technique for coronally advanced
while providing the ultimate de- tive tissue graft in the treatment of gin- flap. Int J Periodontics Restorative Dent
gival recessions. J Periodontol 2001;72: 2007;27:379–385.
sired treatment outcome. 1470–1476. 24. Baldi C, Pini Prato G, Pagliaro U, et al.
Coronally advanced flap procedure for
root coverage. Is flap thickness a relevant
predictor to achieve root coverage? A
19-case series. J Periodontol 1999;70:
1077–1084.
© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY..
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
313
25. Hwang D, Wang HL. Flap thickness as a 36. Smukler H. Laterally positioned muco- 48. McGuire MK, Scheyer ET, Nevins M,
predictor of root coverage: A systematic periosteal pedicle grafts in the treatment Schupbach P. Evaluation of human re-
review. J Periodontol 2006;77:1625–1634. of denuded roots. A clinical and statistical cession defects treated with coronally
26. Harris RJ. A comparative study of root study. J Periodontol 1976;47:590–595. advanced flaps and either purified recom-
coverage obtained with guided tissue 37. Caffesse RG, Espinel M. Lateral sliding binant human platelet-derived growth
regeneration utilizing a bioabsorbable flap with a free gingival graft technique in factor-BB with beta tricalcium phosphate
membrane versus the connective tissue the treatment of localized gingival reces- or connective tissue: A histologic and
with partial-thickness double pedicle sions. Int J Periodontics Restorative Dent microcomputed tomographic examina-
graft. J Periodontol 1997;68:779–790. 1981;1:22–29. tion. Int J Periodontics Restorative Dent
27. Allen MP, Miller PD Jr. Coronal position- 38. Roccuzzo M, Lungo M, Corrente G, Gan- 2009;29:7–21.
ing of existing gingiva: Short term results dolfo S. Comparative study of a bioresorb-
in the treatment of shallow marginal tis- able and a non-resorbable membrane in
sue recession. J Periodontol 1989;60: the treatment of human buccal gingival
316–319. recessions. J Periodontol 1996;67:7–14.
28. Harris RJ, Harris AW. The coronally po- 39. Shieh AT, Wang HL, O’Neal R, Glickman
sitioned pedicle graft with inlaid mar- GN, MacNeil RL. Development and clini-
gins: A predictable method of obtaining cal evaluation of a root coverage proce-
root coverage of shallow defects. Int J dure using a collagen barrier membrane.
Periodontics Restorative Dent 1994;14: J Periodontol 1997;68:770–778.
228–241. 40. Harris RJ. GTR for root coverage: A long-
29. Cortellini P, Tonetti M, Baldi C, et al. Does term follow-up. Int J Periodontics Restor-
placement of a connective tissue graft ative Dent 2002;22:55–61.
improve the outcomes of coronally ad- 41. Pini Prato G, Tinti C, Vincenzi G, Magnani
vanced flap for coverage of single gingi- C, Cortellini P, Clauser C. Guided tissue
val recessions in upper anterior teeth? A regeneration versus mucogingival sur-
multi-centre, randomized, double-blind, gery in the treatment of human buccal
clinical trial. J Clin Periodontol 2009;36: gingival recession. J Periodontol 1992;63:
68–79. 919–928.
30. Harris RJ. The connective tissue and 42. Trombelli L, Schincaglia GP, Scapoli C,
partial thickness double pedicle graft: A Calura G. Healing response of human
predictable method of obtaining root cov- buccal gingival recessions treated with
erage. J Periodontol 1992;63:477–486. expanded polytetrafluoroethylene mem-
31. Harris RJ. A comparative study of root branes. A retrospective report. J Peri-
coverage obtained with an acellular der- odontol 1995;66:14–22.
mal matrix versus a connective tissue 43. Chambrone L, Chambrone D, Pustiglioni
graft: Results of 107 recession defects FE, Chambrone LA, Lima LA. Can subepi-
in 50 consecutively treated patients. Int thelial connective tissue grafts be consid-
J Periodontics Restorative Dent 2000;20: ered the gold standard procedure in the
51–59. treatment of Miller Class I and II recession-
32. Wang HL, Bunyaratavej P, Labadie M, Shyr type defects? J Dent 2008;36:659–671.
Y, MacNeil RL. Comparison of 2 clinical 44. Roccuzzo M, Bunion M, Needleman I,
techniques for treatment of gingival reces- Sanz M. Periodontal plastic surgery for
sion. J Periodontol 2001;72:1301–1311. treatment of localized gingival recessions:
33. Tal H, Moses O, Zohar R, Meir H, Nem- A systematic review. J Clin Periodontol
covsky C. Root coverage of advanced 2002;29(suppl 3):178–194.
gingival recession: A comparative study 45. Oates TW, Robinson M, Gunsolley JC.
between acellular dermal matrix allograft Surgical therapies for the treatment of
and subepithelial connective tissue gingival recession. A systematic review.
grafts. J Periodontol 2002;73:1405–1411. Ann Periodontol 2003;8:303–320.
34. Greenwell H, Fiorellini J, Giannobile W, 46. Cheng YF, Chen JW, Lin SJ, Lu HK. Is cor-
et al. Oral reconstructive and corrective onally positioned flap procedure adjunct
considerations in periodontal therapy. with enamel matrix derivative or root con-
J Periodontol 2005;76:1588–1600. ditioning a relevant predictor for achiev-
35. Pini Prato GP, Baldi C, Nieri M, et al. ing root coverage? A systematic review. J
Coronally advanced flap: The post-surgi- Periodontal Res 2007;42:474–485.
cal position of the gingival margin is an 47. McGuire MK, Cochran DL. Evaluation of
important factor for achieving complete human recession defects treated with cor-
root coverage. J Periodontol 2005;76: onally advanced flaps and either enamel
713–722. matrix derivative or connective tissue.
Part 2: Histological evaluation. J Peri-
odontol 2003;74:1126–1135.
© 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY..
NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
Copyright of International Journal of Periodontics & Restorative Dentistry is the property of Quintessence
Publishing Company Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print, download, or email
articles for individual use.