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.     

Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 1: Comparison of clinical parameters

BACKGROUND: Recession defects around teeth have been treated with a variety of surgical techniques. Most of the literature suggests that the subepithelial connective tissue graft has the highest percentage of mean root coverage with the least variability. Previous studies have demonstrated that enamel matrix derivative (EMD) has the ability to improve clinical parameters. The purpose of this study was to compare the clinical efficacy of enamel matrix derivative placed under a coronally advanced flap to subepithelial connective tissue placed under a coronally advanced flap in patients with recession type defects. METHODS: Twenty patients with incisors or premolars presenting with a facial recession of > or = 4 mm in contralateral quadrants of the same jaw were treated; 17 patients completed the study. One tooth in each patient was randomized to receive either a coronally advanced flap with a subepithelial connective tissue graft (control) or a coronally advanced flap with EMD (test). Clinical parameters measured at baseline and at 6, 9, and 12 months included amount of recession; width at the coronal extent of the gingival defect; width of keratinized tissue; probing depth; clinical attachment level; inflammation score; plaque score; plaque index; alveolar bone level; tissue texture and color; and patient perception of pain, bleeding, swelling, and sensitivity. RESULTS: Results for both the test and control groups were similar for all measured clinical parameters with the exception of early healing, self-reported discomfort, and the amount of keratinized tissue obtained. The coronally advanced flap with EMD was superior to the subepithelial connective tissue graft with regard to early healing and patient-reported discomfort, whereas the subepithelial connective tissue graft demonstrated greater amount of keratinized tissue during the 12-month evaluation period. However, both the test and control showed a significant increase in the amount of keratinized tissue at 9 and 12 months compared to baseline. No significant difference in the amount of root coverage was found between the test and control groups (n = 19; P = 0.82). On average, a gain of 4.5 mm (range 4 to 8 mm) tissue covering the previously exposed root surfaces was achieved with both treatment groups. The average percentages of root coverage for control and test groups were 93.8% and 95.1%, respectively. One hundred percent root coverage was obtained 89.5% of the time with the coronally advanced flap with EMD and 79% of the time with the subepithelial connective tissue graft. CONCLUSION: Based on the results of this investigation, the addition of EMD to the coronally advanced flap resulted in root coverage similar to the subepithelial connective tissue graft but without the morbidity and potential clinical difficulties associated with the donor site surgery.     

牙龈退缩根面覆盖治疗1例

目的 牙龈退缩常常导致根面敏感、菌斑控制不良和牙龈美学等问题,影响患者的口腔健康和颜面美观。本病例采用根面覆盖术治疗牙龈退缩,以改善患者牙齿敏感问题。诊治经过：手术采用冠向复位瓣联合结缔组织移植瓣双层技术治疗退缩类型（recession type,RT）为1类的牙龈退缩。结果 术后2周,受区龈缘略水肿;术后12个月复诊,龈缘位置趋于稳定,根面覆盖率达100%,角化龈宽度及临床附着水平增加。患者无牙齿敏感、系带牵拉和瘢痕形成等不适症状,牙龈美学效果良好。结论 冠向复位瓣联合结缔组织移植瓣双层技术治疗RT 1类牙龈退缩效果良好,不仅能够获得完全根面覆盖、牙龈美学效果良好,而且增加了术区角化牙龈的宽度和临床附着水平。     

富血小板纤维蛋白辅助治疗牙龈退缩的临床效果及患者满意度评价

目的 评价和比较冠向复位瓣术单独或联合应用富血小板纤维蛋白（platelet rich fibrin,PRF）治疗Miller Ⅰ类或Ⅱ类牙龈退缩的临床效果及患者满意度。方法 临床上选取Miller Ⅰ类或Ⅱ类牙龈退缩且有意愿进行手术治疗的患者30例,分为试验组（冠向复位瓣术联合PRF）、对照组（冠向复位瓣术）。在术前、术后3个月、术后6个月记录牙周探诊深度、角化龈宽度、牙龈退缩深度以及根面覆盖率,分析2组的临床疗效,患者填写满意度调查表,并进行分析。结果 试验组和对照组在术后3、6个月检查临床指标牙龈退缩深度、角化龈宽度较术前明显好转,差异有统计学意义（P<0.05）;术后3、6个月,试验组和对照组2组间角化龈宽度比较,差异有统计学意义（P<0.05）;术后3、6个月,2组间牙周探诊深度、牙龈退缩深度、根面覆盖率比较均无统计学差异(P>0.05);术后3、6个月时,2组中的牙周探诊深度与术前相比,差异无统计学意义(P>0.05);试验组患者的满意度显著高于对照组,差异有统计学意义(P<0.05)。结论 本研究结果进一步证实了这两种方法对MillerⅠ、Ⅱ类牙龈退缩的治疗均有效,辅助应用PRF可增加术后角化龈宽度,并提高患者满意度。     

Coronally Advanced Flap Alone or With Connective Tissue Graft in the Treatment of Single Gingival Recession Defects: A Long‐Term Randomized Clinical Trial

Background: Numerous surgical approaches for the treatment of single gingival recession (GR) defects are documented in the literature. The aim of this 5‐year, split mouth–design, randomized clinical trial was to evaluate the effectiveness of coronally advanced flap (CAF) alone versus CAF with connective tissue graft (CAF+CTG) in the treatment of single Miller Class I and II GR defects. Methods: Thirty‐seven patients with 114 bilateral, single Miller Class I and II GR defects were treated with CAF on one side of the mouth and CAF+CTG on the other side. Clinical measurements (GR length [REC], keratinized tissue width [KT], complete root coverage [CRC], and percentage of root coverage [PRC]) were evaluated before surgery and after 6, 12, 24, and 60 months. Results: There was a significant reduction of REC and increase of KT after surgery in both groups. CAF+CTG showed significantly better results for all evaluated clinical parameters in all observed follow‐up periods. Miller Class I defects showed better results in terms of REC, CRC, and PRC, whereas Miller Class II showed better results in KT, both in favor of CAF+CTG. Miller Class I defects showed better results than Miller Class II GR defects regardless of the surgical procedure used. Conclusions: Both surgical procedures were effective in the treatment of single Miller Class I and II GR defects. The CAF+CTG procedure provided better long‐term outcomes (60 months postoperatively) than CAF alone. Long‐term stability of the gingival margin is less predictable for Miller Class II GR defects compared to those of Class I.     

Coronally positioned flap with or without acellular dermal matrix graft in the treatment of Class I gingival recessions: a randomized controlled clinical study

BACKGROUND: The aim of this study was to clinically evaluate the treatment of Class I gingival recessions by coronally positioned flap with or without acellular dermal matrix allograft (ADM). METHODS: Thirteen patients with comparable bilateral Miller Class I gingival recessions (> or = 3.0 mm) were selected. The defects were randomly assigned to one of the treatments: coronally positioned flap and acellular dermal matrix (ADM group) or coronally positioned flap alone (CPF group). The clinical parameters included: probing depth (PD), clinical attachment level (CAL), recession height (RH), recession width (RW), height of keratinized tissue (HKT), thickness of keratinized tissue (TKT), plaque index (PI), and gingival index (GI). The measurements were taken before the surgeries and after 6 months. RESULTS: The mean baseline recession was 3.4 mm and 3.5 mm for ADM group and CPF group, respectively. After 6 months, both treatments resulted in significant root coverage (P < 0.01), reaching an average of 2.6 mm (76%) in the ADM group and 2.5 mm (71%) in the CPF group. The difference in recession reduction between treatments was not statistically significant. There were no statistically significant differences between the treatments in PD, CAL, RH, RW, and HKT. However, the mean TKT gain was 0.7 mm for the ADM group and 0.2 mm for the CPF group (P < 0.01). CONCLUSION: It can be concluded that both techniques could provide significant root coverage in Class I gingival recessions; however, a greater keratinized tissue thickness can be expected with ADM.     

Modified coronally advanced flap associated with a subepithelial connective tissue graft for the treatment of adjacent multiple gingival recessions

BACKGROUND: The clinical choice of the appropriate surgical technique aiming at root coverage relies, among other factors, on the number of adjacent gingival recessions. This study aimed to clinically evaluate the effectiveness and the predictability of root coverage at adjacent multiple gingival recessions using a modified coronally positioned flap associated with the subepithelial connective tissue graft. METHODS: Ten non-smoking, healthy subjects (five men and five women; mean age, 28.7 years) presenting 29 Class I or II adjacent multiple gingival recessions were enrolled. Each patient was treated using a modified coronally advanced flap associated with the subepithelial connective tissue graft. Probing depth (PD), clinical attachment level (CAL), recession depth (RD), and width of keratinized tissue (KT) were measured at baseline and 6 months later. The Student t test was used to compare treatment outcomes through time. RESULTS: The results revealed significant CAL gain (mean gain +/- SD, 1.97 +/- 0.94 mm; P <0.0001), RD decrease (2.03 +/- 0.78 mm; P <0.0001), and KT increase (1.31 +/- 1.23 mm, P <0.0001). The average root coverage was 96.7%, and complete root coverage was found at 93.1% of the defects. Nine of the 10 patients (90% of the patients) experienced complete root coverage. CONCLUSIONS: The modified coronally advanced flap associated with the subepithelial connective tissue graft was effective and predictable to produce root coverage at multiple adjacent gingival recessions associated with gain in the CAL and in the width of KT.     

Enamel matrix derivative and coronal flaps to cover marginal tissue recessions

BACKGROUND: Correcting recession defects is one of the goals of periodontal therapy, and the efficacy and predictability of the various techniques are important considerations for both patients and clinicians. Several reports have examined the outcome of gingival recession treatment by means of coronally positioned flaps (CPF) and enamel matrix derivative (EMD). The purpose of this study was to clinically evaluate the use of EMD in association with CPF to cover localized gingival recessions compared to CPF alone. METHODS: Twenty-two patients with Miller Class I or II gingival recessions >2 mm were included. One recession from each patient was treated in the study. Two treatments were randomly assigned: coronally positioned flap with EMD (test) and coronally positioned flap alone (control). Clinical parameters measured at baseline and 1, 6, and 12 months included gingival index, plaque index, probing depth, clinical attachment level, vertical and horizontal recession, and width of keratinized gingiva. RESULTS: At 12 months, both treatment modalities showed significant root coverage, gain in clinical attachment, and gain in width of keratinized gingiva (P <0.05). Vertical recessions were reduced from 2.68 +/- 1.63 mm to 0.36 +/- 0.60 mm in the test group and from 2.31 +/- 1.52 mm to 0.90 +/- 0.95 mm in the control group. Horizontal recessions decreased from 4.27 +/- 2.06 mm to 0.77 +/- 0.87 mm in the test group and from 3.68 +/- 1.91 mm to 1.72 +/- 1.31 mm in the control group. Changes in keratinized gingiva went from 3.81 +/- 1.95 mm to 4.63 +/- 2.15 mm in the test group and from 3.31 +/- 1.81 mm to 3.27 +/- 1.80 mm in the control group. When both treatments were compared at 12 months, there was a significant difference in vertical tooth coverage and gain in keratinized gingiva in favor of the experimental group (P <0.05). The average percentage of root coverage for test and control groups was 88.6% and 62.2%, respectively. CONCLUSIONS: The coronally positioned flap alone or with EMD is an effective procedure to cover localized gingival recessions. The addition of EMD significantly improves the amount of root coverage.     

上皮下结缔组织移植术治疗正畸后牙龈退缩1例

［摘要］ 牙龈退缩是正畸治疗常见的并发症,目前对于牙龈退缩的治疗主要是根面覆盖。报告1例正畸后牙龈退缩的患者,经过上皮下结缔组织移植术联合冠向复位瓣,取得了理想的根面覆盖,角化龈宽度及牙龈厚度增加,达到良好的临床效果。     

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.     

Subepithelial connective tissue grafts in the treatment of multiple recession-type defects

BACKGROUND: There is little documentation regarding the treatment of multiple recession-type defects. The objective of this study was to evaluate the results obtained with a connective tissue graft placed under a coronally advanced flap for the treatment of multiple gingival recessions. METHODS: Twenty-eight patients, with at least two recession defects affecting adjacent teeth, were treated with a combination of a connective tissue graft and a coronally advanced flap. At baseline, the following measurements were recorded: 1) recession depth; 2) probing depth; 3) clinical attachment level; and 4) width of keratinized tissue. At 6 months post-surgery, all clinical measurements were repeated. RESULTS: The mean root coverage from baseline to 6 months post-surgery results was 96%. Complete root coverage was achieved in 20 (71%) of the 28 defects. The mean recession depth decreased from 3.84 +/- 1.50 mm to 0.14 +/- 0.23 mm. Statistically significant improvements were found for all clinical parameters from baseline to 6 months (P <0.01). Patients with maxillary recessions recorded statistically superior outcomes than patients with mandibular recessions. CONCLUSIONS: The results of the present study demonstrated that the connective tissue graft associated with a coronally advance flap is an effective procedure to cover multiple gingival recessions, especially in defects localized in the maxillary arch. However, further investigation focusing on the effects of this root coverage procedure in mandibular sites is necessary.     

A multicenter comparative study of two root coverage procedures: coronally advanced flap with addition of enamel matrix proteins and subpedicle connective tissue graft

BACKGROUND: Free grafts, pedicle flaps, and barrier membranes have been used to cover exposed root surfaces. The aim of the present study was to evaluate the clinical efficacy of a coronally advanced flap procedure with the additional use of enamel matrix protein derivative (EMD) to treat gingival recession and to compare it to the subpedicle connective tissue graft procedure (CTG). METHODS: The study was conducted in six different periodontal clinics. Miller Class I or II buccal recession type defects in the anterior or premolar teeth were treated in 70 consecutive patients, 30 with EMD and 40 with CTG. At baseline and 6 and 12 months post-surgical treatment, vertical recession defect, defined as the distance from cemento-enamel junction to gingival margin; width of keratinized tissue; and probing depth were recorded and the percentage of coverage of the original defect was calculated. Statistical analyses consisted of t-test, analysis of variance, and analysis of covariance. RESULTS: At 6 months, percent of root coverage was 77.4% +/- 11.92% in EMD and 84.1% +/- 11.97% in CTG (statistically significant at P = 0.024). At 12 months, percent of root coverage in EMD was 71.7% +/- 16.14% and 87.0% +/- 12.22% in CTG; again, differences between groups were statistically significant (P < 0.001). Differences between the 6- and 12-month vertical recession defect and percent of root coverage recordings within each group were also statistically significant. CONCLUSIONS: The connective tissue graft procedure was superior to the coronally positioned flap with the addition of enamel matrix proteins derivative in percentage of coverage and increase in width of keratinized tissue. The EMD procedure is a predictable treatment for root coverage that is relatively easy to perform and presents low patient morbidity, and is appropriate especially where a substantial increase in the width of keratinized tissue is not of prime importance.     

Long-term outcome following treatment of multiple Miller class I and II recession defects in esthetic areas of the mouth

BACKGROUND: Multiple recession defects can be successfully treated using envelope-type coronally advanced flaps. The aim of the present study was to evaluate the long-term (5 years) stability of clinical outcomes achieved with the surgery and the association between patient variables and long-term stability. METHODS: Seventy-three Miller Class I and II gingival recessions affecting 22 young, systemically healthy subjects were treated with coronally advanced flaps with no releasing incisions. All patients were instructed to perform a coronally directed roll technique to minimize the toothbrushing trauma to the gingival margin. The clinical reevaluation was made 1 year after the surgery. At this point, 13 patients took part in a supportive periodontal care program consisting of oral hygiene instructions, control of toothbrushing technique, and professional tooth cleaning every 4 months. The remaining nine patients did not participate and received only sporadic care by general dentists. At 5 years post-surgery, all patients were reexamined. RESULTS: At the 5-year examination, 94% of the root surfaces initially exposed due to gingival recession were still covered with soft tissue, and 85% of the treated recession defects showed complete coverage. Complete root coverage in all recessions was maintained in 15 out of 22 patients (68%). The long-term stability of the soft-tissue margin in the treated sites was significantly influenced by the patient's regular participation in the recall program and the susceptibility to gingival recession in other areas of the mouth. A statistically significant increase of keratinized tissue (0.80 +/- 0.64 mm) was observed between the 1- and 5-year observation visits, and the average increase of keratinized tissue between the baseline and the 5-year follow-up amounted to 1.38 +/- 0.90 mm. This increase was significantly affected by the baseline keratinized tissue (KT) and recession (REC) depth: in particular, the 5-year increase in the amount of keratinized tissue was greater in sites with a greater recession depth and lower amount of keratinized tissue at baseline. CONCLUSIONS: 1) The successful root coverage results obtained with the coronally advanced flap for multiple recession defects were well maintained over the 4-year observation period. 2) Negative patient characteristics such as a lack of compliance with a supportive care program and individual susceptibility to gingival recession were significantly associated with the recurrence in gingival recession. 3) The increase in keratinized tissue height that followed the coronally advanced flap procedure may be attributed to the tendency of the mucogingival line to regain its genetically determined position.     

Laterally moved, coronally advanced flap: a modified surgical approach for isolated recession-type defects

BACKGROUND: Various modifications of the laterally sliding flap have been proposed to reduce the risk of gingival recession at the donor tooth site, but the reported root coverage predictability was quite low. The goal of the present study was to evaluate the effectiveness with respect to root coverage of a modified surgical approach of the laterally moved flap procedure for the treatment of an isolated type of recession defect. METHODS: One hundred and twenty (120) isolated gingival recessions (Miller Class I or II) with specific features of the keratinized tissue lateral to the defects were treated with a new approach to the laterally moved flap. The main surgical modifications consisted of the coronal advancement of the laterally moved flap and the different thickness during flap elevation. Clinical evaluation was made 1 year after the surgery. RESULTS: At the 1-year examination, 97% of the root surface was covered with soft tissue and 96 defects (80%) showed complete root coverage. A statistical and clinically significant increase of keratinized tissue was observed. These favorable results were accomplished with no change in the position of gingival margin or in the height of gingival tissue at the donor tooth/site. CONCLUSIONS: The laterally moved, coronally advanced surgical technique was very effective in treating isolated gingival recessions. It combined the esthetic and root coverage advantages of the coronally advanced flap with the increase in gingival thickness and keratinized tissue associated with the laterally moved flap. The ideal gingival conditions must be present lateral to an isolated recession defect in order to render the proposed surgical technique an highly effective and predictable root coverage surgical procedure.     

A comparative study of root defect coverage using an acellular dermal matrix with and without a recombinant human platelet-derived growth factor

Background: The objective of this case series is to compare root defect coverage results and healing responses of bilateral recession defects treated with acellular dermal matrix (ADM) with and without recombinant human platelet‐derived growth factor (rhPDGF). Methods: Seventeen patients with 40 bilateral gingival recession defects were compared. Each defect was ≥2 mm and treated with ADM and a coronally advanced flap. Using split‐mouth design, the control‐side ADM was hydrated in sterile saline, whereas the test‐side ADM was hydrated in rhPDGF. The patients were evaluated at 1 week, 1 month, 3 months, and 6 months. Standardized measurements were taken preoperatively at 3 and 6 months. Healing was clinically assessed at 1 week and 1 month post‐surgically. Results: Both test and control groups showed significant gain in root defect coverage over the 6‐month period for all individuals, with the test group showing a 69.0% gain and the control group showing a 76.7% gain. Patients divided into Miller Class I and Class III defects were also found to have a significant gain in root defect coverage over 6 months. The test group showed 84.1% gain, and the control group showed 84.7% gain for Miller Class I defects. For Miller Class III defects, the test group showed 51.5% gain, and the control group showed a 60.8% gain. One week after surgery, 35% of the test group showed better healing, whereas 15% of the control group showed better healing. One month after surgery, 20% of the test group showed better healing, whereas 15% of the control group showed better healing. Conclusion: Based on the results of this case series, there were no statistically or clinically significant differences in root defect coverage, keratinized tissue, clinical attachment level, or clinical healing for treatment of root recession with a coronally advanced flap and ADM with and without rhPDGF.     

Coronally advanced flap combined with a subepithelial connective tissue graft using full- or partial-thickness flap reflection

Background: Although the use of a subepithelial connective tissue graft (SCTG) in conjunction with a coronally advanced flap (CAF) is a widely performed periodontal procedure, the creation of a partial‐thickness flap can incur a risk of perforation or overthinning of the flap itself. Therefore, the aim of the present trial is to compare the efficacies of partial‐ and full‐thickness flap reflections combined with an SCTG. Methods: Twenty patients with Miller Class I or II defects (52 teeth) were selected, and teeth with defects were randomly assigned to the test group (25 teeth) for a CAF and SCTG using a full‐thickness flap reflection or to the control group (27 teeth) for a CAF associated with an SCTG and partial‐thickness flap reflection. The probing depth (PD), gingival recession (GR), and width of the keratinized tissue (KT) were assessed at baseline and 6 months after surgery. Results: The mean root coverage was 97% in the test group (mean reduction in GR: 2.27 ± 1.15 mm) and 95% in the control group (mean reduction in GR: 1.68 ± 0.74 mm). The gain in KT was 0.46 ± 1.47 mm in the test group and 0.49 ± 1.3 mm in the control group, the PD ranged from 1.33 to 1.55 mm in the test group and from 1.31 to 1.64 mm in the control group; no statistically significant difference was found between the two groups for all of these parameters (P >0.05). Conclusions: The elevation of a full‐ or partial‐thickness flap did not appear to influence the amount of KT or the percentage of root coverage achieved post‐surgically. More expanded studies are needed to confirm the present findings.     

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.     

Sling and tag suturing technique for coronally advanced flap

The coronally advanced flap (CAF), either by itself or combined with other soft tissue grafts, provides predictable root coverage. However, it is a major challenge to suture and secure the flap coronally and stabilize its position over the entire healing period. Thus, the purpose of this study was to introduce a modified incision design and a suturing technique (sling and tag [SAT]) to enhance the results of CAF for root coverage. Ten patients with Miller Class I gingival recession defects (> or = 2.5 mm) were treated. Clinical parameters assessed included recession depth (RD), recession width (RW), clinical attachment level (CAL), probing depth (PD), gingival tissue thickness (GT), and keratinized gingiva width (KGW). Measurements were taken at baseline and 6 months and 1 year later. The paired t test was used to compare presurgical and postsurgical results. Statistically significant (P < .05) reductions in RD (2.6 +/- 0.5 mm) and RW (2.9 +/- 0.9 mm) were observed at 1 year. An average of 93.0% +/- 14.8% root coverage was achieved. In addition, a statistically significant CAL gain of 3.3 +/- 1.0 mm was obtained. No statistically significant differences were found in PD and KGW before and after therapy. The newly introduced flap design and SAT suturing technique may enhance the results of CAF for root coverage.     

A 3-year longitudinal evaluation of subpedicle free connective tissue graft for gingival recession coverage

BACKGROUND: The purpose of this study was to longitudinally evaluate, over a 3-year period, the reduction of gingival recession through use of a subepithelial free connective tissue graft placed under a coronally advanced partial-thickness pedicle flap. METHODS: Twenty-one buccal recession defects (mean 3.67 mm; range 3 to 4.5 mm; Miller Class I, II, and III) in 15 patients were treated using this technique. Amount of gingival recession (GR), clinical attachment loss (CAL), and width of keratinized gingiva (WKG) were followed for 3 years after surgery. The measurements were performed at presurgery, and 1, 3, 6, 12, 18, 24, and 36 months postsurgery. RESULTS: GR decreased from 3.67 +/- 0.58 mm at baseline to 0.33 +/- 0.43 mm at 36 months, representing a reduction of 3.33 mm, corresponding to 91.28% mean root coverage. CAL was significantly decreased at 36 months from 5.26 +/- 0.77 mm to 2.14 +/- 0.57 mm. At 36 months, 3.12 mm of attachment gain was obtained. WKG significantly increased after 36 months (1.95 mm). GR, CAL, and WKG had the most positive outcomes at 12 months and were maintained at stable levels throughout the 36-month observation period. CONCLUSIONS: These results indicate that the connective tissue graft with a partial thickness coronal advancement pedicle is a predictable method for root coverage and, provided that optimal maintenance care is provided, the clinical outcomes gained by this technique can be well maintained.     

Root coverage using the coronally positioned flap with or without a subepithelial connective tissue graft

BACKGROUND: Various surgical techniques have been proposed for treating gingival recession. This randomized clinical trial compared the coronally positioned flap (CPF) alone or in conjunction with a subepithelial connective tissue graft (SCTG) in the treatment of gingival recession. METHODS: Eleven non-smoking subjects with bilateral and comparable Miller Class I recession defects were selected. The defects, at least 3.0 mm deep, were randomly assigned to the test (CPF + SCTG) or control group (CPF alone). Recession depth (RD), probing depth (PD), clinical attachment level (CAL), width of keratinized tissue (KT), and gingival/mucosal thickness (GT) were assessed at baseline and 6 months postoperatively. RESULTS: Recession depth was significantly reduced 6 months postoperatively (P<0.05) for both groups. Mean root coverage was 75% and 69% in the test and control groups, respectively. There were no significant differences between the two groups in RD, PD, or CAL, either at baseline or at 6 months postoperatively. However, at 6 months postoperatively, the test group showed a statistically significant increase in KT and GT compared to the control group (P<0.05). CONCLUSIONS: The results indicate that both surgical approaches are effective in addressing root coverage. However, when an increase in gingival dimensions (keratinized tissue width, gingival/mucosal thickness) is a desired outcome, then the combined technique (CPF + SCTG) should be used.