Guided tissue regeneration in human gingival recessions. A 10-year follow-up study

OBJECTIVE: The aim of the present study was to evaluate the changes of the mucogingival complex of guided tissue regeneration (GTR)-treated gingival recession defects over a 10-year follow-up. METHODS: The study population consisted of 20 patients, 11 males and nine females, mean age: 44.3+/-10.4 years, each contributing one recession defect treated with a polytetrafluoroethylene membrane. Eight patients were smokers at the time of surgery and at 10 years post-surgery. Recession depth (RD), probing depth clinical attachment level (CAL), and width of keratinized gingiva (KG) were assessed immediately before surgery, at 6 months, 4 years and 10 years post-surgery. RESULTS: RD was 0.9+/-0.6 mm at 6 months, 1.0+/-1.3 mm at 4 years and 1.3+/-1.6 mm at 10 years. CAL amounted to 1.9+/-1.0 mm at 6 months and shifted to 2.2+/-1.4 and 2.6+/-1.6 mm at 4 years and 10 years, respectively. KG significantly increased following surgery and remained stable thereafter. At 10-year examination, no significant changes from 4-year evaluation were observed. Differences in periodontal parameters between smokers and non-smokers were not statistically significant. CONCLUSION: In conclusion, the results of the present study failed to demonstrate changes over time in the clinical outcome achieved following GTR procedure in gingival recession defects over a period between 4 and 10 years post-surgery.     

Healing response of gingival recession defects following guided tissue regeneration procedures in smokers and non-smokers

Abstract This retrospective study evaluated healing response in gingival recession defects following guided tissue regeneration (GTR) in smokers. 22 systemically healthy patients who had been treated for deep (4 mm), buccal. Miller's class I or II gingival recession defects with ePTFE membranes were included. Patients were regarded as smokers if they smoked more than 10 cigarettes/day at the time of surgical procedure. Occasional and former smokers were excluded. 9 patients (6 male, mean age 29 years) were smokers, while 13 patients (4 male, mean age 35 years) were non smokers. Clinical parameters, recorded pre surgery and at 6 months post surgery. included defect-specific plaque (DPI) and bleeding on probing (BoP) scores, recession depth (RD). probing depth (PD). clinical attachment level (CAL). and keratinized tissue width (KG). Extent of membrane exposure (ME) and newly formed tissue (NFT) gain were assessed at membrane removal. Statistical analysis revealed no significant differences between smokers and non-smokers in demographic and pre surgery defect characteristics. DPI and BoP scores were similar pre surgery and remained almost unchanged thorough out the observation interval in both groups. ME was significantly greater in smokers (2.6±1.4 mm) than in non smokers (1.3±0.6 mm). NFT gain was 2.8±1.0 mm in smokers and 3.6±1.4 mm in non-smokers, the difference being not statistically significant. Smokers showed significantly less RD reduction and root coverage (2.5±1.2 mm and 57%, respectively) compared to non-smokers (3.6±1.1 mm and 78%, respectively). In conclusion, the results indicate that treatment outcome following GTR in gingival recession defects is impaired in cigarette smokers.     

Gingival recession treatment: guided tissue regeneration with bioabsorbable membrane versus connective tissue graft

BACKGROUND: Gingival recession represents a significant concern for patients and a therapeutic problem for clinicians. Several techniques have been proposed to achieve root coverage. The purpose of this randomized clinical trial was to evaluate the effect of a guided tissue regeneration (GTR) procedure in comparison to connective tissue graft (CTG) in the treatment of gingival recession defects. METHODS: Twelve patients, each contributing a pair of Miller Class I or II buccal gingival recessions, were treated. In each patient one randomly chosen defect received a poly(lactic acid)-based bioabsorbable membrane, while the paired defect received a CTG. Clinical recordings included oral hygiene standards and gingival health, recession depth (RD), recession width (RW), probing depth (PD), clinical attachment level (CAL), and keratinized tissue width (KT). RESULTS: Mean RD statistically significantly decreased from 2.5 mm presurgery to 0.5 mm with GTR (81% root coverage), and from 2.5 mm to 0.1 mm with CTG (96% root coverage), at 6 months postsurgery. Prevalence of complete root coverage was 58% for the GTR group and 83% for the CTG group. Mean CAL gain was 2.0 mm for the GTR group and 2.2 mm for the CTG group. No statistically significant differences between treatment groups were observed for changes in RD, RW, PD, CAL, and KT. CONCLUSIONS: Treatment of human gingival recession defects by means of either GTR or CTG results in clinically and statistically significant improvement of the soft tissue conditions of the defect when pre- and post-treatment measurements were compared. Although differences between CTG and GTR in mean root coverage and prevalence of complete coverage consistently favored the CTG procedure, the differences in measurements were not statistically significant.     

Comparison of 2 clinical techniques for treatment of gingival recession.

BACKGROUND: In early case studies, use of a collagen barrier as a guided tissue regeneration (GTR) material has shown particular promise in procedures aimed at root coverage. The similarities between collagen membrane and subepithelial connective tissue graft (SCTG) have made collagen membrane an attractive and a possible alternative material for root coverage. The purpose of this randomized clinical trial was to compare these 2 techniques, SCTG versus a GTR-based procedure (GTRC), for root coverage/recession treatment. METHODS: Sixteen patients with bilateral Miller's Class I or II (gingival recession > or = 3.0 mm) recession defects were treated either with SCTG or GTRC using a newly designed collagen membrane. Clinical parameters monitored included recession depth (RD), clinical attachment level (CAL), probing depth (PD), width of keratinized gingiva (KG), attached gingiva (AG), and recession width (RW), each measured at the mid-buccal area to the nearest 0.5 mm. Measurements were taken at baseline and 6 months. A standard mucogingival surgical procedure was performed. Data were reported as means +/- SD and were analyzed using the paired t test for univariate analysis and restricted/residual maximal likelihood (REML)-based mixed effect model for multivariate analysis. RESULTS: No statistically significant differences were observed in RD, CAL, KG, and AG between test and control groups at either time period. However, SCTG showed significantly more residual PD and more RW gain when compared to GTRC at 6 months. Both treatments resulted in a statistically significant (P < 0.05) reduction of recession defects (2.5 mm and 2.8 mm), gain of CAL (2.8 mm and 2.3 mm), reduction of RW (1.9 mm and 2.7 mm), and increase of KG (0.7 mm and 1.1 mm) and AG (0.7 mm and 0.5 mm) for GTRC and SCTG, respectively, when comparing 6-month data to baseline. Mean root coverage of 73% (collagen membrane) and 84% (subepithelial connective tissue graft) was achieved. CONCLUSIONS: The 2 techniques are clinically comparable. Use of a modified collagen membrane to attain root coverage may alleviate the need for donor site procurement of connective tissue.     

Comparative clinical study of guided tissue regeneration with a bioabsorbable bilayer collagen membrane and subepithelial connective tissue graft

BACKGROUND: During the last decade, there have been great strides in the treatment of gingival recession defects, especially with subepithelial connective tissue graft and guided tissue regeneration (GTR) procedures. Gingival recession represents a significant concern for patients. It is necessary to choose the most appropriate procedure in order to obtain more root coverage while avoiding clinical disadvantages. The purpose of this randomized clinical trial was to evaluate the use of a bioabsorbable bilayer collagen membrane with GTR compared to a connective tissue graft in the treatment of gingival recession defects. METHODS: Twenty patients each contributing a pair of Miller Class I or II buccal gingival recessions were treated. In each pair, one recession was randomly assigned for treatment with GTR using a bioabsorbable bilayer collagen membrane and the other treated with subepithelial connective tissue graft (CTG). Clinical measurements taken at baseline (D0) and 3 and 6 months post-treatment included recession depth (RD), recession width (RW), probing depth (PD), and clinical attachment level (CAL). RESULTS: Data were analyzed using the non-parametric Wilcoxon matched pair test. All results were statistically significant. Both treatments resulted in a significant gain of root coverage (P<0.0001), amounting to an average of 2.80 mm at 3 months in the GTR group and 3.34 mm in the CTG group. At 6 months, the decrease of the mean RD remained statistically significant: 2.70 mm (74.59% root coverage) in the GTR group and 3.19 mm (84.84% root coverage) in the CTG group. The mean RW also decreased from 4.48 mm at D0 to 2.42 mm at 6 months in the GTR group, and from 4.38 mm at D0 to 1.35 mm at 6 months in the CTG group, representing a percentage of coverage of 45.98% and 69.18%, respectively. Mean CAL gain obtained between D0 and 6 months with the GTR procedure and CTG was 3.31 mm and 3.09 mm, respectively, and was significant within groups. At 3 and 6 months, the differences in the results for RD, CAL, and RW were not statistically significant between the 2 groups. However, the difference was significant for PD at 3 and 6 months. CONCLUSIONS: The results suggest that a bioabsorbable bilayer collagen membrane can be used in the GTR treatment of human buccal recession defects, with no statistically significant differences between this procedure and connective tissue grafts.     

Factors affecting the outcomes of coronally advanced flap root coverage procedure

BACKGROUND: The coronally advanced flap (CAF) has been used to treat gingival recession. However, the final outcomes (percentage of root coverage) vary from case to case. Hence, the purpose of this study was to analyze the factors that may affect the results of CAF root coverage procedures. METHODS: Twenty-three systemically healthy patients (mean age, 43.8 +/- 11.9 years) each with one Miller's Class I buccal recession defect were included. Baseline clinical parameters included recession depth (RD), recession width (RW), gingival thickness (GT), width of keratinized tissue (WKT), clinical attachment level (CAL), probing depth (PD), plaque index (PI), and gingival index (GI). CAF root coverage procedures were performed to correct the recession defects. Patients were followed at 2, 4, 12, and 24 weeks post-surgery, at which time wound healing index (WHI) and other measurements were recorded. RESULTS: The mean baseline RD was 2.9 +/- 0.4 mm; RW, 3.4 +/- 0.6 mm; WKT, 2.7 +/- 1.3 mm; and GT, 1.1 +/- 0.3 mm. At mid-buccal, the mean CAL was 4.5 +/- 0.8 mm. Six months after surgery, the average RC was 82.3% +/- 24.7%; RD, 0.5 +/- 0.7 mm; RW, 0.4 +/- 0.9 mm; WKT, 3.2 +/- 0.9 mm; and GT, 1.5 +/- 0.5 mm. At mid-buccal, the mean CAL was 1.8 +/- 1.1 mm. From baseline to the 6-month follow-up, the changes of RC, RD, RW, WKT, GT, and CAL showed statistical significance (P < 0.05). Fourteen patients achieved 100% RC. The mean RC in partial coverage cases was 54.8% +/- 16.8%. Analysis revealed that an initial GT thicker than 1.2 +/- 0.3 mm was associated with complete root coverage at the 6-month follow-up (P < 0.05). CONCLUSIONS: CAF is a predictable procedure to treat Miller's Class I mucogingival defects. Initial GT was the most significant factor associated with complete root coverage.     

Root coverage: comparison of coronally positioned flap with and without titanium-reinforced barrier membrane

BACKGROUND: Various surgical procedures have been proposed as effective treatment methods for recession defects. The purpose of this study was to evaluate the clinical outcome of root coverage comparing the coronally positioned flap (CPF) with and without guided tissue regeneration (GTR) using a titanium-reinforced expanded polytetrafluoroethylene barrier in paired gingival recession defects. METHODS: Procedures were performed in 10 patients having bilateral buccal recession defects > or = 2.0 mm on maxillary canines and first premolars. Mucoperiosteal flaps were raised and root surfaces were scaled, planed, and conditioned. Randomly assigned sites received either GTR + CPF or CPF treatment. Clinical parameters measured at baseline and at 6 months after the procedure included gingival recession depth (GRD), clinical attachment level (CAL), probing depth (PD), keratinized gingival width (KGW), and alveolar crest level (ACL). RESULTS: GRD decreased from 3.4 +/- 0.6 mm to 1.9 +/- 1.2 mm with GTR (45% root coverage) and from 3.3 +/- 0.4 mm to 1.3 +/- 0.7 mm with CPF (60% root coverage). The difference in GRD decrease between procedures was significant. CAL, KGW, and PD differences between procedures were not significant. ACL mean gain was significant (1.0 +/- 0.6 mm in the GTR group and 0.2 +/- 0.3 mm in the CPF group; P < 0.05). CONCLUSIONS: Both GTR and CPF procedures result in root coverage. The amount of root coverage obtained with CPF was greater than that observed with GTR, although GTR resulted in significantly greater ACL gain.     

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.     

Resorbable barrier and envelope flap surgery in the treatment of human gingival recession defects

Abstract. The present case report evaluates the treatment outcome following mucogingival surgery combined with a bioresorbable barrier in gingival recession defects in humans. A total of 11 buccal, Miller Class I or II, gingival recession defects in 6 patients were consecutively treated. The exposed root surface was ultrasonically scaled and conditioned with a tetracycline HCI solution (10 mg/ml) for 4 min. A buccal full/split thickness envelope flap was then elevated, and a bioresorbable matrix barrier was positioned to completely cover the exposed root surface and surrounding bone margins. A flap was then positioned at or slightly coronal to its original position. In all cases, a variable amount of membrane was intentionally left uncovered on the exposed root surface. Clinical recordings, assessed presurgery and at 6 months postsurgery, included defects-specific plaque and gingival scores, recession depth (RD), probing depth (PD), clinical attachment level (CAL) and keratinized tissue width (KT). Immediately postsurgery, and at weeks 1, 2, 4, 6 and 8 postsurgery, the location of gingival margin or granulation tissue covering the previously exposed root surface was recorded, as well as the extent of barrier exposure. Statistical analysis showed that RD decreased from 2.3±0.2 mm presurgery to 0.8±0.5 mm at 6 months postsurgery ( p =0.001), representing a mean root coverage of 65% (range: 40–100%). CAL gain paralleled RD reduction (l.5±0.5 mm: p=0.0009), while KT showed a slight increase (0.3±0.6 mm) at 6 months postsurgery. Results indicate that clinical improvement of gingival recession defects may be achieved by means of a barrier-supported envelope technique. The bioresorbable matrix barrier represented an effective scaffold to support the reconstruction of the mucogingival unit.     

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.     

Treatment of gingival recessions by combined periodontal regenerative technique, guided tissue regeneration, and subpedicle connective tissue graft. A comparative clinical study

BACKGROUND: Many surgical techniques have been shown to be effective in correcting gingival recessions by covering the exposed root with soft tissue; however, the thickness of the gingival tissue over the root surface probably plays an important role in preventing the recurrence of tissue recession. The aim of the present study was to compare the results of a mucogingival bilaminar technique (BT), guided tissue regeneration (GTR), and a combined periodontal regenerative technique (CPRT) in achieving root coverage and increasing the gingival thickness 1 year after surgical treatment. METHODS: In 45 systemically healthy, non-smoking patients aged 33.6 +/- 4.3 years with no periodontal pockets >4 mm, a Miller's Class I or II gingival recession was treated for root coverage: 15 patients underwent BT (connective tissue with partial-thickness double pedicle graft), 15 GTR by a bioabsorbable membrane, and 15 CPRT by a collagen membrane and collagen-incorporated hydroxyapatite. Before and 1 year after surgical treatments, the following clinical parameters were recorded: gingival recession (GR), probing depth (PD), clinical attachment level (CAL), keratinized tissue width (KT), and gingival thickness (GT); the percentage of root coverage was also calculated and the data were statistically analyzed. RESULTS: All 3 techniques yielded significant improvements in terms of GR decrease, CAL and KT gain, and GT increase compared to baseline values. Mean root coverage was 90.0%, 81.01%, and 87.12% in BT, GTR, and CPRT groups, respectively. Complete root coverage was observed in 60%, 40%, and 53.3% of subjects from the BT, GTR, and CPRT groups, respectively. No significant differences were observed among the 3 techniques in GR or CAL improvements; however, BT produced a significantly (P<0.01) greater increase of KT, and BT and CPRT groups showed a significantly (P<0.01) greater increase of GT compared to the GTR group. CONCLUSIONS: BT, GTR, and CPRT successfully treated gingival recession defects, obtaining comparable percentages of root coverage, but BT and CPRT created a thick gingival tissue significantly greater than that achieved with GTR.     

Treatment of intrabony defects with enamel matrix proteins or bioabsorbable membranes. A 4-year follow-up split-mouth study.

BACKGROUND: Treatment with enamel matrix proteins (EMD) and guided tissue regeneration (GTR) with bioabsorbable membranes has been shown to promote periodontal regeneration; however, until now, there were only limited data on the long-term clinical results following these regenerative techniques. Therefore, the aim of the present study was to present the 4-year results following treatment of intrabony defects with EMD or guided tissue regeneration (GTR). METHODS: Twelve patients, each displaying one pair of intrabony defects located contralaterally in the same jaw, were randomly treated with EMD or with GTR by means of bioabsorbable membranes. The following clinical parameters were evaluated at baseline, at 1 year, and at 4 years after treatment: plaque index (P1), gingival index (G1), bleeding on probing (BOP), probing depth (PD), gingival recession (GR), and clinical attachment level (CAL). The primary outcome variable was CAL. No statistically significant differences between the groups were found at baseline. Power analysis to determine superiority of EMD treatment showed that the available sample size would yield 70% power to detect a 1 mm difference. RESULTS: The sites treated with EMD demonstrated mean CAL change from 9.8 +/- 2.0 mm to 6.4 +/- 1.6 mm (P<0.001) and to 6.8 +/- 1.8 mm (P<0.001) at 1 and 4 years, respectively. No statistically significant differences were found between the CAL mean at 1 and 4 years postoperatively. The sites treated with GTR showed a mean CAL change from 9.8 +/- 2.3 mm to 6.6 +/- 1.7 mm (P<0.001) at 1 year and to 6.9 +/- 1.8 mm (P<0.001) at 4 years. The CAL change between I and 4 years did not present statistically significant differences. No statistically significant differences in any of the investigated parameters were observed at 1 and 4 years between the treatment groups. CONCLUSIONS: It was concluded that the CAL gain obtained following treatment with EMD or GTR can be maintained over a 4-year period.     

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.     

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.     

Surgical guided tissue regeneration treatment of advanced periodontal defects: a 5-year follow-up study

OBJECTIVES: To study the 5-year outcome of combined use of guided tissue regeneration (GTR) barriers and bovine bone in advanced periodontal defects. MATERIAL AND METHODS: In each of 24 patients, one defect was surgically exposed, debrided, filled with bovine bone, and covered with a bioresorbable barrier. Re-examinations were made after 1, 3, and 5 years. RESULTS: Average full-mouth plaque scores (FMPS) were 14.5% at baseline and 10.7%, 9.8%, and 18.9% after 1, 3, and 5 years, respectively. Mean probing pocket depth (PPD) was 10.0 mm at baseline. Mean PPD reduction was 5.2 mm after 1 year, 5.6 mm after 3 years, and 5.3 mm after 5 years. Mean gingival recession was 1.0 mm after 1 year, 1.6 mm after 3 years, and 1.3 mm after 5 years. Mean gain in clinical attachment level (CAL) was 4.2 mm at the 1-year, 4.1 mm at the 3-year, and 4.3 mm at the 5-year examination. Smoking significantly influenced CAL change at all re-examinations. FMPS were significantly correlated with radiographic defect depth at the 5-year examination and CAL with smoking and FMPS at the 3-year examination. CONCLUSION: Advanced periodontal defects can be successfully treated with the combined use of GTR barriers and bovine bone to substantially reduce PPD and achieve a stable, long-term gain of CAL.     

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.     

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.     

The Role of Smoking and Gingival Crevicular Fluid Markers on Coronally Advanced Flap Outcomes

Background: This study evaluates possible effects of smoking on the following: 1) biochemical content in gingival crevicular fluid (GCF) samples from sites of gingival recession and saliva; and 2) clinical outcomes of coronally advanced flap (CAF) for root coverage. Methods: Eighteen defects in 15 patients were included in each of the smoker and non‐smoker groups. Baseline cotinine, basic fibroblast growth factor, vascular endothelial growth factor, platelet‐derived growth factor, interleukin (IL)‐8, IL‐10, IL‐12, tumor necrosis factor‐α, matrix metalloproteinase (MMP)‐8, MMP‐9, and plasminogen activator inhibitor‐1 levels were determined in GCF and saliva samples. CAF with microsurgery technique was applied. Plaque index, papilla bleeding index, recession depth (RD), recession width (RW), and root surface area were evaluated at baseline and postoperative months 1, 3, and 6. Probing depth, clinical attachment level (CAL), and keratinized gingival width (KGW) was recorded at baseline and month 6. Percentage of root coverage and complete root coverage were calculated at postoperative months 1, 3, and 6. Results: All biochemical parameters were similar in the two groups apart from the definite difference in salivary cotinine concentrations (P = 0.000). Compared with the baseline values, RD, RW, CAL, and root surface area decreased, and KGW increased, with no significant difference between the study groups. CAL gain, percentage of root coverage, and complete root‐coverage rates were similar in the study groups. Conclusion: Similar baseline biochemical data and comparably high success rates of root coverage with CAF in systemically and periodontally healthy smokers versus non‐smokers suggest lack of adverse effects of smoking on clinical outcomes.     

The effect of platelet-rich plasma on the coronally advanced flap root coverage procedure: a pilot human trial

BACKGROUND: Coronally advanced flap (CAF) has been shown to effectively treat gingival recession. Platelet-rich plasma (PRP), containing autologous growth factors, has been shown to promote soft tissue healing. Therefore, the purpose of this study was to evaluate the effects of PRP in combination with CAF. METHODS: Twenty-four systemically healthy patients participated in this study. A single Miller's Class I buccal recession defect per patient was treated. These patients were randomly assigned into CAF or PRP + CAF groups. Clinical parameters included recession depth (RD), recession width (RW), gingival thickness (GT), width of keratinized tissue (WKT), clinical attachment level (CAL), probing depth (PD), plaque index (PI), wound healing index (WHI), and gingival index (GI). PRP was prepared from whole blood drawn prior to surgery and applied to root surfaces. Patients were followed at 2, 4, 12, and 24 weeks post-surgery. RESULTS: Twenty-three patients completed the study. The RD at 24 weeks was significantly reduced from 2.9 +/- 0.5 to 0.5 +/- 0.6 mm in the CAF group (P < 0.05) and from 2.8 +/- 0.2 to 0.5 +/- 0.7 mm in the PRP + CAF group (P < 0.05). The mean root coverage was 83.5% +/- 21.8% in the CAF group and 81.0% +/- 28.7% in the CAF + PRP group (P > 0.05). Fourteen out of 23 patients (60.9%) experienced 100% root coverage at the 24-week postoperative follow-up. CONCLUSION: Based on the results of this pilot study, the application of PRP in CAF root coverage procedure provides no clinically measurable enhancements on the final therapeutic outcomes of CAF in Miller's Class I recession defects.     

Effect of platelet-rich plasma on the healing of intrabony defects treated with an anorganic bovine bone mineral and expanded polytetrafluoroethylene membranes

BACKGROUND: Regenerative periodontal therapy with a combination of platelet-rich plasma (PRP) + an anorganic bovine bone mineral (ABBM) + guided tissue regeneration (GTR) has been shown to result in significantly higher probing depth reductions and clinical attachment level gains compared to treatment with open flap debridement (OFD) alone, ABBM alone, or GTR alone. However, there are no data evaluating to what extent the use of PRP may additionally enhance the clinical outcome of the therapy compared to treatment with ABBM + GTR. This study aimed to clinically evaluate the effect of PRP on the healing of deep intrabony defects treated with ABBM and GTR by means of a non-resorbable expanded polytetrafluoroethylene (ePTFE) membrane. METHODS: Twenty-four patients with advanced chronic periodontal disease and displaying one intrabony defect were randomly treated with a combination of either PRP + ABBM + GTR or ABBM + GTR. The following clinical parameters were evaluated at baseline and at 1 year after treatment: plaque index (PI), gingival index (GI), bleeding on probing (BOP), probing depth (PD), gingival recession (GR), and clinical attachment level (CAL). The primary outcome variable was CAL. RESULTS: No differences in any of the studied parameters were observed at baseline between the two groups. Healing was uneventful in all patients. At 1 year after therapy, the sites treated with PRP + ABBM + GTR showed a reduction in mean PD from 8.6 +/- 1.7 mm to 3.1 +/- 1.3 mm (P <0.001) and a change in mean CAL from 10.3 +/- 1.4 mm to 5.7 +/- 1.6 mm (P <0.001). In the group treated with ABBM + GTR, mean PD was reduced from 8.8 +/- 1.7 mm to 3.1 +/- 1.0 mm (P <0.001), and the mean CAL changed from 10.4 +/- 2.6 mm to 5.9 +/- 1.8 mm (P <0.001). In both groups, all sites gained > or =3 mm of CAL. CAL gains > or =4 mm were measured in 83% (i.e., in 10 of 12 defects) of the cases treated with PRP + ABBM + GTR and in 92% (i.e., in 11 of 12 defects) treated with ABBM + GTR. No statistically significant differences in any of the studied parameters were observed between the two groups at 1-year reevaluation. CONCLUSION: Within its limits, the present study has shown that, at 1 year after regenerative therapy in periodontal intrabony defects, optimal clinical results were obtained with ABBM + GTR with a non-resorbable barrier, with or without the addition of PRP.