Free gingival grafts for the treatment of gingival recession

Abstract Free gingival grails can be utilized, alone or in combination with a coronally positioned flap, for the prevention and the treatment of gingival recession. The graft can be placed directly over the denuded root, as first described by Sullivan & Atkins (1968). This technique will provide adequate results, especially in cases with relatively little recession. After placing a free gingival graft in such an area, one can often observe bridging and or creeping attachment. In the case of bridging, some of the grafted tissue will remain vital over the avascular zone, i.e. the root. Creeping attachment is the result of coronal migration of the grafted gingiva and will take place during the years following surgery. Bridging and creeping are most likely to occur in cases of narrow recession where the grafts had been placed directly over the denuded zone. In a second type of surgical procedure, an enlargement of the attached gingiva is first obtained through the graft. The area of recession is later covered by a coronally positioned flap. Several cases are presented which illustrate the results obtained with this procedure. In children, when there is insufficient attached gingiva. it is often desirable to place grafts before orthodontic therapy. In the prevention or treatment of gingival recessions, four possibilities may be considered: 1)no treatment, 2)placement of a graft to prevent recession, 3)stabilizing an existing recession. 4)attempt to cover the denuded root.     

Creeping attachment of free gingival grafts. A five-year follow-up study

The purpose of this study was to observe the results subsequent to placing free gingival grafts in ten patients with areas of gingival recession less than 3 mm in width. The grafts were placed directly over the recession and were observed for a period of 5 years. In all cases, the attached gingiva increased and the recession halted and in no instance was the recession greater after surgery. One month after grafting, the phenomenon of bridging was measurable in four cases. The mean coverage, obtained principally by creeping attachment, was about 70%. Among the ten cases some coverage was seen in all patients and resulted in the improvement in the periodontium, functionally and esthetically. On the basis of this study, one could conclude that the coverage obtained when placing a free gingival graft directly over a narrow recession is advantageous. The coverage of the recession however is not always complete nor always predictable.     

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。     

Analysis of modified laterally positioned flap

The aim of this study was to investigate the effects of the covering of denuded root surfaces by the use of modified laterally positioned flap (MLPF) and application of supersaturated citric acid of pH 1. The following measurements were carried out: the width of attached gingiva, attachment of epithelium level, gingival recession, and plaque and gingival indices. The surface area of the exposed root was also measured. All measurements were made before MLPF and one, three, six and twelve months after the treatment. The average surface area of the gingival recession before surgery was 15.75 mm2 and one year after the treatment 4.20 mm2. This means that 73.30% of the denuded surfaces were covered. After the application of MLPF there was a statistically significant decrease of dental plaque index values and of gingival index values. The epithelium attachment was on the coronal level. Gingival recession was significantly decreased. The width of attached gingiva was statistically increased. It can be concluded that MLPF after the application of citric acid is a useful surgical procedure in the covering of denuded root surfaces.     

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.     

INFLUENCE OF CROWN SHAPE ON ROOT COVERAGE THERAPY

Objectives:

The aim of this study was to evaluate the influence of the crown shape on the outcomes of root coverage procedures.

Material and methods:

Eighty patients with Miller class I gingival recessions in maxillary canines or premolars were selected. The recession areas were treated using the subepithelial connective tissue grafting. The following clinical parameters were analyzed: crown length (CL) and width (CW), recession height and width, probing depth, clinical attachment level, width and thickness of the keratinized tissue and percentage of root coverage achieved. These measurements were recorded at baseline and 6 months after the surgical procedure. The CW/CL ratio was calculated for each tooth and the median obtained (0.83). Patients were then ranked into two groups, according to the shape of the tooth with gingival recession: Group A – square crown shape (CW/CL values above 0.83) and Group B – long and narrow crown shape (CW/CL values below 0.83).

Results:

No statistically significant differences (p>0.05) were found between groups in any of the clinical parameters at baseline. After 6 months, both groups presented improved clinical outcomes for all parameters analyzed compared to baseline (p>0.05). The mean percentages and standard deviations of root coverage achieved in Group A and Group B was 91.37 (16.75) and 85.49 (23.55), respectively (p>0.05).

Conclusions:

Crown shape did not influence the root coverage obtained with the subepithelial connective tissue graft technique.     

Unique creeping attachment after autogenous gingival grafting: case report

This case report describes a unique creeping attachment that developed mesiobucally on a deep, wide recession (3 mm) and extended along the remaining buccal recession (2 mm) of a maxillary first molar with a full-crown gold restoration subsequent to autogenous gingival grafting. Complete coverage of the root by this degree of creeping attachment on a restored multirooted tooth has not previously been reported in the dental literature.     

Connective tissue grafting on resin ionomer in localized gingival recession

BACKGROUND: One of the main objectives of periodontal reconstructive surgery is the coverage of exposed roots that occur due to gingival recession. On some occasions, where a caries, root resorption, or amalgam restoration exists on the exposed root surface, the treatment planning becomes more complex. This case report describes the use of a subepithelial connective tissue graft (SCTG) on a resin ionomer-restored root surface to treat gingival recession that is complicated with the above-mentioned handicaps. METHODS: An amalgam restoration and carious lesion were removed following full-thickness flap reflection, and the cavity was restored with glass ionomer cement. An SCTG was placed onto the restoration, and the flap was coronally positioned. A porcelain crown restoration was performed 9 months after surgery. RESULTS: At 3-, 6-, and 9-month follow-ups, probing depths were reduced and gain in attachment level was obtained with no clinical signs of inflammation in gingiva. Monthly periodontal controls revealed that creeping attachment had occurred on the restoration during the follow-up periods. CONCLUSION: This single case report serves as a good example to show that SCTG can be successfully performed to treat gingival recession associated with a glass ionomer-restored root surface.     

Root coverage with free gingival autografts--a clinical study.

AIM: To assess the percentage of root coverage with autogenous free gingival grafts. MATERIALS & METHODS: Ten non-smoking patients with Miller's class I or class II recessions were included in the study. The clinical parameters such as recession depth, recession width, probing pocket depth, clinical attachment level and width of the keratinized gingiva were recorded at the baseline, at the end of 1 month, 3 months, and 6 months after the surgical procedure. Autogenous free gingival grafts harvested from the palatal mucosa were used to cover the denuded roots. RESULTS: Four out of ten sites showed 100% root coverage. A mean percentage of 80.3% of root coverage was achieved.     

A comparison of two techniques for attaining root coverage.

This study compared the relative success of soft tissue coverage of denuded roots by two surgical procedures: Autogenous free gingival graft (FGG) and a 2-stage coronally-positioned flap (CPF). Eight patients who had bilateral areas of gingival recession were selected. The areas of recession treated were Class I or II according to Miller's classification and caused either an esthetic problem or root sensitivity. The defects were randomly assigned to surgical procedures in each subject. In the FGG, the root surfaces were root planed, conditioned with a saturated citric acid solution, and an adjacent recipient site was prepared surgically. A thick palatal graft was then sutured to the recipient site. In the CPF, an initial autogenous free gingival graft was surgically placed in a recipient site just apical to the root recession. After 1 month of healing, the gingiva was coronally positioned to the level of the CEJ. Standardized photographs were obtained presurgically, at 2 weeks, and at 1 and 3 months. Reduction of areas of exposed root surface and distances from CEJ to gingival margin were computed. Data analysis did not demonstrate a significant difference in success between FGG and CPF at 3 months. Maximum decrease of exposed root surfaces occurred at 2 weeks postsurgically with both procedures and then some recession of each type of graft occurred. The mean distance of the exposed root surfaces decreased from 2.136 mm to 1.301 mm and from 2.187 mm to 1.400 from baseline to 3 months for the FGG and CPF respectively.     

A longitudinal evaluation of varying widths of attached gingiva

32 patients with bilateral areas of inadequate attached gingiva on the facial surface of homologous contralateral teeth have been followed for 6 years. Treatment consisted of scaling, root planing, oral hygiene and maintenance at 3- to 6-month intervals or as needed to control inflammation. A free gingival graft was placed on one side (experimental), while the other side served as the unoperated control. Areas of inadequate attached gingiva on control sides, to include those with recession and no attached gingiva, did not demonstrate additional recession or further loss of attachment. Gingival inflammation and plaque were significantly reduced. On experimental sides, the dimension of keratinized and attached gingiva increased and was stable over 6 years. Areas which began with recession and no attached gingiva exhibited a reduction in recession and gain in clinical attachment following the placement of a gingival graft. Examination of patients who had discontinued participation in the study for a period of 5 years revealed a re-establishment of gingival inflammation on the control sides associated with additional recession. Similar changes were not observed in areas treated by a free graft. The findings demonstrate that it is possible to maintain periodontal health and attachment through control of gingival inflammation despite the absence of attached gingiva.     

Subepithelial connective tissue grafts for the coverage of denuded root surfaces: a clinical report.

AIMS AND OBJECTIVES: The aim of this study is to determine the effectiveness of subepithelial connective tissue grafts (SCTG) in the coverage of denuded roots. MATERIALS AND METHODS: A total of 16 sites with > or =2 mm of recession height were included in the study for treatment with SCTG. The clinical parameters, such as recession height, recession width, width of keratinized gingiva, probing pocket depth, and clinical attachment level were measured at the baseline, third month, and at the end of the study [sixth month]. The defects were treated with a coronally positioned pedicle graft combined with connective tissue graft. RESULTS: Out of 16 sites treated with SCTG, 11 sites showed complete (100%) root coverage; the mean root coverage obtained was 87.5%. There was a statistically significant reduction in recession height, recession width, and probing pocket depth. There was also a statistically significant increase in the width of keratinized gingiva and also a gain in clinical attachment level. The postoperative results were both clinically and statistically significant ( P 0.05). CONCLUSION: From this study, it may be concluded that SCTG is a safe and effective method for the coverage of denuded roots.     

Subpedicle connective tissue graft versus free gingival graft in the coverage of exposed root surfaces A 5-year clinical study

Abstract The authors compared the clinical results obtained in gingival recession correction treatment using free gingival and bilaminar connective subpedicle grafts. 35 patients were treated with free gingival grafts (Group A) and 35 with subpedicle grafts (Group B). Class I and II Miller gingival recessions were chosen for treatment by the 2 procedures. The degree of gingival recession (GR), keratinized tissue (KT) and the exposed root surface area (ERSA) were measured preoperatively and again 5 years post-surgery. Bilaminar connective grafting showed better results in reducing the amount of GR while both techniques significantly increased the width of KT (p>0.05). The mean % of root coverage obtained in patients in group A was 53.19%±21.48, whereas for the group B. 85.23%±17.86 of exposed root surface was covered post surgical intervention (p<0.001). In group A. only 3 patients (8.75%) showed a complete resolution of gingival recession after treatment, whereas in group B. 17 subjects (48.57%) presented with complete coverage. On the basis of these results, the authors conclude that the subpedicle graft promises better results in the coverage of exposed root surfaces when compared with the free gingival graft.     

Relative connective tissue graft size affects root coverage treatment outcome in the envelope procedure

BACKGROUND: This study investigated the correlation between the connective tissue graft size and the percentage of root coverage. METHODS: Fifteen patients with Miller Class I or II recession defects (one tooth/defect per patient) were treated using an envelope connective tissue graft procedure. Clinical parameters including gingival recession depth (RD), clinical attachment level (CAL), keratinized tissue width (KW), and the probing depth (PD) were measured. Visible denuded area (VDA) and graft tissue area (GTA) were indirectly measured in mm2 using computer software. Graft tissue thickness (GTT) and graft tissue width (GTW) were also measured. All clinical parameters and VDA were recorded at baseline and 3 and 6 months. The RD, CAL, KW, PD, and VDA were evaluated by Friedman test. The correlation between the percentage of root coverage (PRC) and factors related to graft size were determined by Spearman rank correlation and nonparametric regression analysis. RESULTS: The percent of root coverage at 3 and 6 months postoperatively was statistically significantly associated with the GTA:VDA ratio (P<0.01); it did not correlate with GTA, GTT, or RD, and was inconsistently correlated to GTW and VDA. In patients who had 100% root coverage, the GTA:VDA ratio ranged between 10.92:1 and 21.95:1; in patients with <100% root coverage, the ratio was between 4.54:1 and 11.06:1. CONCLUSION: The GTA:VDA ratio should be at least 11:1, which is a significant factor for optimal root coverage result in the envelope procedure.     

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.     

Comparative clinical study of a subepithelial connective tissue graft and acellular dermal matrix graft for the treatment of gingival recessions: six- to 12-month changes

Different techniques have been proposed for the treatment of gingival recession. This study compared the clinical results of gingival recession treatment using a subepithelial connective tissue graft and an acellular dermal matrix allograft. Seven patients with bilateral Miller class I or II gingival recession were selected. Twenty-six recessions were treated and randomly assigned to the test group. In each case the contralateral recession was assigned to the control group. In the control group, a connective tissue graft in combination with a coronally positioned flap was used; in the test group, an acellular dermal matrix allograft was used as a substitute for palatal donor tissue. Probing depth, clinical attachment level, gingival recession, and width of keratinized tissue were measured two weeks prior to surgery and at six and 12 months post-surgery. There were no statistically significant differences between the groups in terms of recession reduction, clinical attachment gain, probing pocket depth, and increase in the width of the keratinized tissue after six or 12 months. There was no statistically significant increase in the width of keratinized tissue between six and 12 months for either group. Within the limitations of this study, it can be suggested that the acellular dermal matrix allograft may be a substitute for palatal donor tissue in root coverage procedures and that the time required for additional gain in the amount of keratinized tissue may be greater for the acellular dermal matrix than for the connective tissue procedures.     

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.     

Gingival dimensions after root coverage with free connective tissue grafts

Abstract. Traumatic injury in the presence of a thin and narrow zone of gingival tissue may lead to gingival recession. Especially in class I and II recessions, root coverage may be accomplished with connective tissue grafts. In order to prevent recurrent recession, altering gingival dimensions width and thickness might be of advantage. In the present study, dimensions of gingiva were followed for 1 year after root coverage with connective tissue grafts. The study population consisted of 18 patients with a total of 28 class I or II recessions. Gingival width and depth of the recession were measured with a caliper, and thickness of the marginal tissue with an ultrasonic device. Periodontal probing depth was determined with a pressure-controlled electronic probe. Mean (±sd) recession depth at baseline was 3.l±l.4 mm. After 12 months, coverage amouted to 74±30%. Width of gingiva rose from 2.1±1.0 mm to 3.2±1.4 mm. whereas thickness was increased from 0.8±0.3 mm to 1.5±0.7 mm, on average. No significant alteration of periodontal probing depth was observed but a mean gain of clinical attachment of 1.7± 1.1 mm was ascertained. In a multiple regression analysis, recession depth and presence of the recession in the maxilla, but not tooth type significantly influenced relative root coverage (R²-=0.34, p <0.01). Attachment gain after surgery depended on baseline attachment loss and was negatively influenced by smoking. The present results point to the possibility of doubling gingival thickness after root coverage with connective tissue crafts.     

运用脱细胞真皮基质或结缔组织移植物治疗多发性相邻牙龈退缩的Meta分析

目的 应用Meta分析方法评估运用脱细胞真皮基质或自体结缔组织移植物治疗多发性相邻牙龈退缩的差异性。 方法 根据纳入和排除标准在4个英文电子数据库中筛选随机对照试验,检索日期截止至2022年4月20日,主要结局指标为角化牙龈组织宽度、退缩深度、探诊深度、临床附着水平、完全根面覆盖和根面覆盖美学评分。 结果 共纳入7项随机对照试验,术后12个月后,对照组结缔组织移植物较试验组脱细胞真皮基质能增加角化牙龈组织宽度［MD=-0.28（-0.47,-0.08）,P=0.006］、降低牙龈退缩深度［MD=0.23（0.12,0.35）,P<0.000 1］和提高完全根面覆盖［RR=0.80,95%CI（0.69,0.93）,P=0.003］;探诊深度、临床附着水平和根面覆盖美学评分差异无统计学意义。 结论 多发性相邻牙龈退缩治疗后,结缔组织移植物在增加角化牙龈组织宽度、降低牙龈退缩深度和提高完全根面覆盖方面具有优势,但脱细胞真皮基质由于手术简便并有相似的效果亦有临床应用价值。     

Harvesting technique using a mucotome and modified surgical procedure for root coverage with enamel matrix derivatives with and without a connective tissue graft

The aim of this clinical study was to evaluate the coverage of gingival recession defects with enamel matrix derivatives (EMD) with or without a connective tissue graft (CTG). Twenty-five patients (16 female, 9 male) from 16 to 58 years of age (mean: 32.2; SD: 11.2) with 92 gingival recessions (Miller Class I and II) and with at least 4.0 mm of clinical attachment loss were treated with a modified surgical technique for root coverage by CTG with EMD (45 recession defects) or EMD only (47 recession defects). Vertical recession depth, probing depth, clinical attachment level, dehiscence depth, width of keratinized gingiva (vertical), and recession coverage were recorded before surgery (baseline) and at 12 and 24 months. The average presurgical recession depth was 4.4 mm (SD: 1.3) with EMD and CTG versus 3.2 mm (SD: 1.1) with EMD only. Both treatment modalities led to a significant decrease in recession and a gain in attachment. Mean root coverage 12 months postoperatively was 92.7% (SD: 13.5) (EMD and CTG) versus 96.3% (SD: 11.5) (EMD only). Compared to the mean root coverage of recession after 24 months, the change was not significant. The results confirmed that the applied modified surgical techniques are safe and predictable, with better clinical outcomes at the donor and recipient sites.