Treatment of multiple recession-type defects in a young patient with esthetic demands

Treatment of gingival recession has become an important therapeutic issue due to the increasing number of cosmetic demands from patients. Frequently, gingival recessions affect groups of adjacent teeth. In order to optimize the esthetic result all the contiguous recessions should be treated at the same time. The purpose of this article is to compare some techniques of root coverage in a patient with Miller class 1 recessions. A mean of 80% of root exposure was covered using the free gingival graft and free connective tissue graft with repositioned flap compared to 67% using coronally positioned flap over a connective tissue graft. In conclusion, partial root coverage and gingival augmentation with a good esthetic appearance were obtained by a one-step connective tissue graft procedure.     

Simultaneous application of combination of three surgical techniques for treatment of gingival recession: a case report

The treatment of Miller class III gingival recession is considered a challenge in periodontal practice, and among the different techniques used, autogenous connective tissue graft has shown the most favorable results. In some cases, more than one procedure may be necessary. In this case report, we describe the simultaneous application of a combination of three techniques (the tunnel technique, a connective tissue graft and a laterally positioned flap) to treat a Miller class III gingival recession localized in the lower anterior region. Twelve months after surgical procedures, partial root coverage, favorable esthetic results and a gain in clinical attachment level were observed, with no periodontal pockets or bleeding on probing.     

Pocket elimination surgery with simultaneous connective tissue graft. A case report with 3-year follow-up

BACKGROUND, AIMS: The purpose of the present case report was to present 2 ways of treating recession in a periodontal patient combined with regular pocket elimination surgery. The techniques used enabled the operator to reduce the number of surgical sessions and clinically evaluate the 3-year coverage of gingival recessions using a subpedicle connective tissue graft. METHODS: Surgery consisted of pocket elimination procedures to treat adult periodontitis as a way to harvest connective tissue to be placed in the areas of recession. The grafted tissue was covered by the primary flap or left uncovered in a pouch, according to 2 different techniques described in the literature. RESULTS: In this case, we observed that, with this approach, we were successful in reducing the number of surgical session as well as achieving objective and subjective goals of therapy in treated areas.     

A promising periodontal procedure for the treatment of adjacent gingival recession defects

Various clinical reports on the reconstruction of gingival recession defects have been published in the past decade. Several techniques have been used to achieve root coverage, including creation of free gingival grafts, laterally positioned flaps or semilunar coronally positioned flaps, as well as guided tissue regeneration and connective tissue grafting. This article focuses on the importance of connective tissue grafting, combined with a recent approach known as the tunnel procedure, in managing gingival recession defects with a single operation. This procedure originated in 1985 with an envelope design and a subepithelial connective tissue graft for single gingival recession defects and is used today for coverage of multiple adjacent gingival recession defects. Histological evaluation of such connective tissue grafts demonstrates periodontal regeneration in human subjects. Clinical trials have yielded good results, including early tissue healing because of increased blood supply, good esthetic results, excellent patient cooperation and avoidance of secondary periodontal plastic surgery. These benefits underline the appropriateness of this technique, which improves the success rate of connective tissue grafting and increases the amount of root coverage.     

种植体周围的牙龈退缩及自体软组织移植治疗的研究进展

牙龈退缩是临床上较为常见的一种症状.牙龈退缩引起的牙周组织缺损会导致一定的美学风险,在前牙美学区种植修复中往往造成较严重的美学并发症.细菌感染、牙周生物型、修复体设计等均会对牙龈退缩造成影响.牙龈退缩的手术治疗有很长的历史,其中自体软组织移植,包括游离龈移植和上皮下结缔组织移植,是较为可靠的方法.本文针对这两种自体软组...     

Histologic observation of soft tissue acquired from maxillary tuberosity area for root coverage

BACKGROUND: The palatal area has been the major donor site for obtaining connective tissue for root-coverage procedures. This study evaluated the long-term outcome of using a gingival cuff from the maxillary tuberosity area as a donor site for root coverage procedures. METHODS: Case 1: A 26-year-old female patient complaining of tooth hypersensitivity and gingival recession on the maxillary left canine was treated with root coverage using a pouch technique. A connective tissue graft was obtained from the gingival cuff of the maxillary tuberosity area. An additional gingivectomy was performed at 3 months after surgery to trim the bulk of the grafted tissue. Regular recall check-up visits, including oral hygiene maintenance, occurred every 6 months. The patient was followed for 35 months after surgery. Case 2: A 24-year-old female patient with a chief complaint of tooth hypersensitivity and multiple areas of gingival recession in the maxilla was treated with a pouch and semilunar technique. The patient was treated with the same surgical protocol as in case 1. The patient was followed for 31 months after surgery. RESULTS: Full coverage was achieved in both cases with uneventful healing. The gingival biotype changed from a thin scalloped biotype to a thick flat biotype, and the overall color match was successful. The histologic findings of case 1 revealed good adaptation of the grafted tissue with continuous epithelial lining into the recipient site. The grafted tissue remained consistently stable with no change in the probing depths. CONCLUSION: The long-term evaluation of root coverage with a gingival cuff of the maxillary tuberosity area showed it to be an easier method than obtaining the graft from palatal masticatory mucosa, with a highly predictable prognosis.     

Periosteal pedicle graft for the treatment of gingival recession: A viable alternative to sub-epithelial connective tissue graft

Treating gingival recessions is important to satisfy the functional and aesthetic needs of the patients. Among various available techniques to treat gingival recessions, the subepithelial connective tissue graft technique is still considered to be the best despite its inherent disadvantages. The recent innovation utilising periosteum as a pedicle graft to treat gingival recession defects has drawn considerable attention and may provide a viable alternative to subepithelial connective tissue graft.     

Expanded mesh connective tissue graft for the treatment of multiple gingival recessions

BACKGROUND: The connective tissue graft procedure is an effective method to achieve root coverage. Although multiple sites often need grafting, the palatal mucosa supplies only a limited area of grafting material. The expanded mesh graft provides a method whereby a graft can be stretched to cover a larger area. The aim of this study was to determine the effectiveness and the predictability of expanded mesh connective tissue graft (e-MCTG) in the treatment of multiple gingival recessions. METHODS: Fifty-two buccal gingival recessions were treated in 10 systemically healthy patients. Fifteen recession treated operation sites with at least three adjacent Miller Class I and/or II recessions were performed. The connective tissue graft obtained from the palatal mucosa was expanded to cover the recipient bed, which was 1.5 times larger than the graft. Clinical measurements recorded at baseline and 12 months postoperatively included gingival recession depth (RD), gingival recession width (RW), percentage root coverage (RC), probing depth (PD), width of keratinized tissue (KT), and clinical attachment level (CAL). RESULTS: Twelve months after surgery, a statistically significant gain in CAL (3.2 +/- 0.8 mm, P < 0.001) and increase in KT (1.2 +/- 0.4, P < 0.001) were assessed. In 80% of the treated sites, 100% RC was achieved (mean 96%). CONCLUSIONS: The results of this study demonstrated that the use of e-MCTG technique allowed the treatment of multiple adjacent recessions with adequate wound healing and highly predictable root coverage. This procedure can be applied favorably in treating multiple gingival recessions in one surgery.     

Re-epithelialization of a palatal connective tissue graft transplanted in a non-keratinized alveolar mucosa: A histological and biochemical study in humans

This study was undertaken to evaluate the type of tissue obtained after transplantation of a connective tissue graft, from the same palatal donor site, into a non-keratinized oral mucosa in humans. In 6 human volunteers, a thick palatal epithelio-connective tissue graft was excised, split into two thinner grafts (a thin epithelio-connective tissue graft and a connective tissue graft) and transplanted into controlateral areas lacking keratinized gingiva. The biopsies, excised 3 months post-operatively, were examined using routine histology, immunofluore-scence techniques with different anticy to keratin antibodies and biochemical techniques with non-equilibrium two-dimensional gel electrophoresis. The results show that the epithelio-connective tissue grafts display the histological and biochemical characteristics of keratinized gingiva, whereas the connective tissue grafts expressed features belonging both to keratinized and non-keratinized gingival tissues. It is concluded that the deep palatal connective tissue does not have the full potential to induce non-keratinized epithelial cells to keratinize and that a gingival or palatal connective tissue graft without its overlying epithelium is not likely to yield genuine attached gingiva.     

牙周膜龈手术的临床应用Ⅰ:自体组织的应用

近年来,随着口腔科学的迅速发展,牙周病学方面的新技术和新材料也层出不穷.膜龈手术已在包括牙周再生、牙周美容、种植、正畸等方面得到了越来越广泛的应用.膜龈手术主要包括:1)带蒂软组织瓣术,可以覆盖暴露的牙根表面,也可以结合游离结缔组织移植术达到覆盖根面的治疗效果;2)游离牙龈移植术,不但可以重建附着龈,还可以保护牙齿健康,防止牙龈退缩;3)结缔组织移植术,是治疗牙龈退缩最常用的术式.本文主要以笔者多年的临床经验为基础,采用手术临床照片结合简要文字的方式,介绍常见的各种膜龈手术的适应证、优缺点和临床应用,以使口腔医师能更好地了解并掌握该技术.     

牙周膜龈手术的临床应用Ⅰ：自体组织的应用

近年来,随着口腔科学的迅速发展,牙周病学方面的新技术和新材料也层出不穷。膜龈手术已在包括牙周再生、牙周美容、种植、正畸等方面得到了越来越广泛的应用。膜龈手术主要包括：1）带蒂软组织瓣术,可以覆盖暴露的牙根表面,也可以结合游离结缔组织移植术达到覆盖根面的治疗效果;2）游离牙龈移植术,不但可以重建附着龈,还可以保护牙齿健康,防止牙龈退缩;3）结缔组织移植术,是治疗牙龈退缩最常用的术式。本文主要以笔者多年的临床经验为基础,采用手术临床照片结合简要文字的方式,介绍常见的各种膜龈手术的适应证、优缺点和临床应用,以使口腔医师能更好地了解并掌握该技术。     

Treatment of multiple adjacent gingival recessions with the tunnel subepithelial connective tissue graft: a clinical report

This article describes a surgical periodontal plastic procedure for the coverage of multiple adjacent gingival recessions. This surgical technique is based on the construction of a tunnel under the gingival tissue by means of a sulcular incision beyond the mucogingival line without raising the papillae. A large connective tissue graft obtained from the palatal mucosa is introduced through this tunnel, covering the adjacent gingival recessions. A suturing technique to allow this graft to slip through the tunnel under the gingival tissues and to secure and stabilize the graft covering the recessions is described. Twelve-month postoperative results are presented from 21 teeth that were treated with this technique: 100% root coverage was achieved in 66.7% of the recessions treated, with a mean root surface coverage of 91.6%. This study suggests that the use of this surgical procedure allows the treatment of multiple adjacent recessions in a single procedure with adequate early healing and highly predictable root coverage results.     

Root coverage in isolated gingival recessions using autograft versus allograft: a pilot study

BACKGROUND: Different surgical techniques have been used to treat gingival recessions. This preliminary study compared clinical findings for the treatment of isolated gingival defects using a coronally positioned flap associated with a subepithelial connective tissue graft or an acellular dermal matrix graft. METHODS: Ten subjects with bilateral and comparable Miller Class I or II defects were selected. The defects were > or =3.0 mm deep and were assigned randomly to the test group, which was treated with a coronally positioned flap associated with an acellular dermal matrix, or to the control group, which was treated with a coronally positioned flap associated with a subepithelial connective tissue graft. Probing depth (PD), clinical attachment level (CAL), gingival recession depth (GRD), and width (KT) and thickness (GT) of the keratinized tissue were assessed at baseline and 6 months after the surgery. RESULTS: Mean root coverage was 50% in the test group (representing a gingival margin shift of 2.1 +/- 0.99 mm) and 79.5% in the control group (representing a gingival margin shift of 3.5 +/- 1.20 mm). These results were statistically different on intra- and intergroup comparisons (P <0.05). Between-group comparisons revealed statistically significantly greater gains in CAL, GRD, and GT in the control group (P < or =0.05); no differences were found for PD or KT (P > or =0.05). CONCLUSIONS: The coronally positioned flap associated with a subepithelial connective tissue graft or an acellular dermal matrix graft was effective in root coverage. However, the coronally positioned flap associated with a connective tissue graft provided a more favorable clinical outcome. More expanded studies are needed to confirm the present findings.     

Epithelial inclusion cyst after free gingival graft: a case report

There have been few case reports of cystic lesions occurring after gingival grafting. There are three reports of this type of sequela after connective tissue grafting, but this is the first known case of a cystlike lesion developing secondarily to a free gingival graft procedure. The bulky tissue, which had developed under the previously grafted area, was properly excised under local anesthesia. The small specimen removed was sent for histologic analysis. A new gingival graft was performed immediately after the lesion enucleation, as the cystic lesion had dislocated the earlier graft. The surgical wound healed uneventfully, and no recurrence was seen 18 months later The microscopic sections showed a cystic cavity lined with an orthokeratinized, hyperplastic, stratified squamous epithelium covered with fibrous connective tissue. The development of a cystlike lesion following a free gingival graft is, to date, an unpublished event. The fact that most cystic lesions appear in the mandibular lateral incisor-canine-first premolar area deserves further consideration.     

A preliminary comparative study of the guided tissue regeneration and free gingival graft procedures for adjacent facial root coverage.

OBJECTIVE: The purpose of this study was to compare the clinical efficacy of guided tissue regeneration with expanded polytetrafluoroethylene membranes to that of free gingival graft for treatment of adjacent facial gingival recession. METHOD AND MATERIALS: Eight adjacent gingival recession sites with Miller class I or II defects containing at least a maxillary or mandibular canine were selected in 6 patients. Four recession sites in 3 patients were treated with guided tissue regeneration, and the other 4 sites in the remaining 3 patients were treated with free gingival graft. Probing depth, gingival recession, attachment level, width of keratinized gingiva, and root coverage were recorded before surgery (baseline) and 6 months and 1 year postoperatively. RESULTS: Statistically significant improvements were found for gingival recession, attachment level, and root coverage from baseline to 6 months and 1 year postoperatively in both groups. Both procedures produced the same average reduction in gingival recession, gain in attachment level, and amount of root coverage after 1 year. Probing depths did not differ between groups throughout the study. The width of keratinized gingiva was significantly greater in the grafted group than in the guided tissue regeneration group. CONCLUSION: Both procedures produced the same average amount of root coverage, reduction in gingival recession, and gain in clinical attachment. The guided tissue regeneration procedure provided a better esthetic appearance without any difference in gingival color or architecture in cases of adjacent facial gingival recession.     

A clinical comparison of two gingival extension procedures.

In recent years the free gingival autograft and the periosteal separation procedure have emerged as the periodontal treatment techniques most favoured for gingival extension without marginal correction. Previous investigators reporting separately on both techniques have demonstrated varying relapse rates, and while the periosteal separation procedure is regarded as more traumatic, the free gingival graft technique has the disadvantage of leaving a granulating wound in the palate as a possible source of postoperative pain. The present study was undertaken to compare the two procedures by assessing postoperative relapse at 2, 4, 12 and 24 weeks and evaluating pain experience during the first week after surgery. With the free gingival graft a mean shrinkage of 17·4 per cent occurred over 24 weeks, although this was offset by creeping reattachment coronal to the wound margin. The periesteal separation procedure produced a mean loss of 47·5 per cent of the original extension and a tendency towards gingival recession. With the latter technique pain was significantly greater at the 4- and 8-hour postoperative intervals.     

The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces

A mucogingival grafting procedure has been developed to cover denuded root surfaces. This procedure, the subpedicle connective tissue graft, is a bilaminar graft that is composed of a free connective tissue graft and an overlying pedicle graft. By overlaying grafted free connective tissue with a pedicle, the otherwise compromised section of free graft which covers a denuded root surface is supplied by plasmatic circulation from capillaries in the vascular portion of the pedicle allowing it to survive. In this report 29 teeth were treated and monitored for as long as 42 months. In the group with advanced recession of 7 to 10 mm, there was an average of 88% coverage. The subpedicle graft created a healthy, functional, and esthetic result that appeared resistant to further breakdown. The subpedicle graft is indicated when a single surgical procedure is desired that will predictably cover denuded root surfaces when there is inadequate keratinized gingiva available for a pedicle graft and where the prognosis is poor for root coverage with a free gingival graft.     

Surgical treatment of localized gingival recessions using coronally advanced flaps with or without subepithelial connective tissue graft

Background

A coronally advanced flap with subepithelial connective tissue graft is the gold standard surgical treatment of gingival recessions, since it offers a higher probability of achieving complete root coverage compared with other techniques. However, optimum short- and middle-term clinical results have also been obtained with coronally advanced flaps alone. The aim of the present study was to evaluate the results obtained by the surgical treatment of localized gingival recessions using coronally advanced flaps with or without subepithelial connective tissue graft.

Material and Methods

The reduction of recession height was assessed, together with the gain in gingival attachment apical to the recession, and total reduction of recession, in a comparative study of two techniques. Twenty-two gingival recessions were operated upon: 13 in the control group (coronally advanced flap) and 9 in the test group (coronally advanced flap associated to subepithelial connective tissue graft).

Results

After 18 months, the mean reduction of recession height was 2.2 ± 0.8 mm in the control group and 2.3 ± 0.7 mm in the test group, with a mean gain in gingival attachment of 1.3 ± 0.9 mm and 2.3 ± 1.3 mm, respectively. In percentage terms, the mean reduction of recession height was 84.6 ± 19.6% in the control group and 81.7 ± 17.8% in the test group, with a mean gain in gingival attachment of 20.5 ± 37.4% and 184.4 ± 135.5%, respectively.

Conclusions

Significant reduction of gingival recession was achieved with both techniques, though the mean gain in gingival attachment (in mm and as a %) was greater in test group. Key words:Gingival recession, coronally advanced flap, subepthelial connective tissue graft.     

Effect of connective tissue graft orientation on root coverage and gingival augmentation

The present study was undertaken to assess the width of keratinized tissue and root coverage achieved when orienting the superficial surface of a connective tissue graft toward either the gingival flap or the root surface. Sixteen pairs of bilateral gingival recessions (Miller Class I and II) in 13 subjects were divided into two groups. In each subject, one side received a connective tissue graft with its superficial surface facing the gingival flap, while the contralateral side received a connective tissue graft with its superficial surface facing the root surface. Plaque Index, Gingival Index, probing depth, gingival recession, and relative clinical attachment level were recorded at baseline and 3 months postoperative. Root length was measured on periapical radiographs to calculate the percentage of actual root coverage. ANOVA was used to detect significant differences between the two treatment groups. The results indicated that surface orientation of a connective tissue graft has no significant effect on the clinical outcome of either root coverage or gingival augmentation.     

Exostosis following a free gingival graft

BACKGROUND: There have been few cases reported of exostoses following a free gingival graft. In 1980, a free gingival graft was placed on the facial level of 33-34, developing over the years a significant enlargement. In 1999, since the patient felt progressively uncomfortable with the enlarged area, its surgical reduction was proposed. METHOD: Under local anesthesia, the hard tissue developed under the previously-grafted area, was significantly reduced. The specimen, together with a fragment of the covering soft tissue, was sent for histological analysis. RESULTS: The surgical wound healed uneventfully, and the patient was satisfied with the results. The histology showed the presence of mature bone surrounded by a dense connective tissue, whereas the gingival tissue showed acanthosis and fibrosis. CONCLUSION: The development of exostoses following a free gingival graft can be considered an unpredictable, albeit infrequent side-effect of this procedure. The fact that most of these exostoses appear in the cuspid-premolar area, deserves further consideration.