root coverage.pdf

8/14/2019 Root Coverage.pdf

1/24

Periodontology 2000, Vol. 27, 2001, 97120 Copyright C Munksgaard 2001Printed in Denmark All rights reserved

PERIODONTOLOGY 2000ISSN 0906-6713

Decision-making in aesthetics:root coverage revisitedPHILIPPE BOUCHARD, J ACQUES M ALE T & A LAIN BORGHETTI

Over the years, numerous surgical techniques havebeen introduced to correct labial, gingival recessiondefects. Aesthetic concerns are usually the reason toperform these procedures. Clinical studies haveevaluated many of the techniques. The depths of thedefects have been measured before surgery and at afollow-up examination after 6 months or later. Re-sults in terms of mid-surface root coverage havebeen expressed in millimeters and as the percentageof original defect that has been covered. Also, per-centage defects with complete coverage have oftenbeen reported.

The results of available studies have been evalu-ated (30, 117, 119). Mean root coverage for thetreated patient groups ranges from around 50% toclose to 100% of the original defect depth. Mean rootcoverages of 7080% seem most common. Completeroot coverages have been achieved in about 50% of

the treated defects. These results were conrmed by our own updated review and compilation of data

Table 1. Mean percentage of root coverage in Class I and Class II defects: summary of data fromcomparative and non-controlled case studies. Selection criteria: 6-month minimum follow-up, at least10 patients per group, initial recession depth data available

Number Number Maximum Mean initialof of Number Number length of recession Mean % of selected study of of studies depth in mm root coverage

Procedure studies groups patients teeth in months (range) (range)

Rotational aps a 6 8 121 127 36 3.9 (3.15.0) 66 (4182) Advanced aps b 6 7 119 244 96 3.7 (3.34.1) 77 (5598)Submerged grafts rotational aps c 5 5 137 170 18 3.9 (3.34.9) 83 (7097) coronally positioned ap d 11 13 246 281 60 4.0 (3.05.6) 82 (5299)Envelope e 4 4 50 64 48 2.9 (2.53.4) 83 (8087)Guided tissue regeneration techniquesNonresorbable membrane f 10 10 201 201 48 5.0 (3.36.3) 76 (5487)Resorbable membrane g 7 8 98 104 12 4.25 (3.15.8) 74 (4892)

Selected studies:a 24, 25, 33, 40, 98, 123.b 2, 64, 67, 91, 113, 118c 15, 16, 46, 48, 88.d 16, 17, 19, 20, 49, 61, 78, 93, 116, 118, 125.e 4, 58, 72, 86.f 58, 83, 89, 90, 107, 108, 109, 111, 112, 125.g 17, 48, 49, 63, 89, 116, 125.

97

from the literature (Tables 1, 2). There seems to beno clear difference in the effectiveness of the varioustechniques using these methods of evaluation.

Previous research has focused on evaluations andcomparisons of various techniques. Few attemptshave been made to identify factors of importance forsuccess or failure. Therefore, the clinician receiveslittle guidance from the literature in decision-making on the individual case. In addition, results have only been assessed bymillimeter and percentage data. Theoverall aesthetic outcome also depending on nalcolor and tissue blend of the grafted area has notbeen systematically evaluated. It has merely been re-marked upon using general terms such as aesthet-ically pleasing and good aesthetic results. This lack of information adds to the difculties in the selectionof best procedure for the individual case.

At this stage, thus, decision-making for root cover-

age procedures can only partly be based upon scien-tic evidence. Therefore, this chapter also focuses on


2/24

Bouchard et al.

Table 2. Mean percentage of teeth with complete root coverage in Class I and Class II defects:summary of data from comparative and non-controlled case studies. Selection criteria: 6-monthminimum follow-up, at least 10 patients per group, initial recession depth data available

Maximum % teeth withNumber Number length of complete rootof selected of study Number Number studies in coverage

Procedure studies* groups of patients of teeth months (range)

Rotational aps

Advanced aps a 6 7 119 244 96 45 (984)Submerged grafts rotational aps b 2 2 84 110 6 89.5 (8990)** coronally positioned ap c 8 8 205 223 60 56 (5088)Envelope d 4 4 50 64 48 53 (4262)Guided tissue regeneration techniquesNonresorbable membrane e 6 6 84 84 48 33 (047)Resorbable membrane f 5 5 64 70 12 44 (872)

*The numbers of studies in this table are reduced compared to Table 1, since the percentage of defects with complete coverage has not always beenreported.**One operator performed all procedures.Selected studies:a 2, 64, 67, 91, 113, 118.b 46, 48.c 19, 20, 49, 61, 78, 116, 118.d 4, 58, 72, 86.e 58, 89, 90, 107, 111, 125.f

48, 49, 89, 116, 125.

the unknowns overall aesthetic outcome and fac-tors of relevance for successfull results of the individ-ual case. It should be realized that many opinionsand recommendations presented here are primar-ily and by necessity based on our personal clin-ical experiences. Nevertheless, we feel that carefuldecision-making prior to root coverage procedures will enhance the success rate for these efforts.

Table 3. Root coverage techniques

Pedicle soft tissue graftsO Rotational aps

Laterally positioned apDouble papilla ap

O Advanced apsCoronally positioned apSemilunar ap

Free soft tissue graftsO Nonsubmerged graft

One stage (free gingival graft)Two stage (free gingival graft coronally positioned

ap)O Submerged grafts

Connective tissue graft laterally positioned apConnective tissue graft double papilla apConnective tissue graft coronally positioned ap

(subepithelial connective tissue graft)Envelope techniques

Additive treatmentsO Root surface modication agentsO Enamel matrix proteinsO Guided tissue regeneration

Nonresorbable membrane barriersResorbable membrane barriers

98

Root coverage techniques

Currently, numerous surgical techniques are pro-posed for root coverage (Table 3).

Pedicle soft tissue grafts

Soft tissues adjacent to the recession area are posi-tioned over the defect.

Rotational aps

The displacement is a lateral movement of rotation. At rst it was described as the lateral sliding ap

Fig. 1. Schematic drawing of laterally positioned ap tech-nique


3/24

Decision-making in aesthetics: root coverage revisited

Fig. 2. A . Shallow-narrow recession de-fect. The base of the cleft is located inthe alveolar mucosa (Miller Class II).Gingival augmentation is needed tocover the prosthetic margin. B . In-creased dimension of the gingiva; 27months post-treatment following lat-erally positioned ap.

(38). The procedure was then improved, and named:the laterally positioned ap (39, 99) (Fig. 1, 2). Theoblique rotational ap (80), the rotation ap (79)and the transpositioned ap (9) are modicationsin incision design. When the lateral movement isboth mesial and distal to the defect, the rotationalap is called a double papilla ap (26) (Fig. 3).

Advanced aps

The displacement is a vertical movement in a co-ronal direction. The semilunar ap (102) differs fromthe coronally positioned ap (2, 47, 67, 91, 118) inthe incision design and in the placement of sutures(Fig. 4, 5).

Fig. 4. Schematic drawing of semilunar ap technique

99

Fig. 3. Schematic drawing of double papilla ap technique

Fig. 5. Schematic drawing of coronally positioned aptechnique


4/24

Bouchard et al.

Fig. 6. Schematic drawing of nonsubmerged graft tech-nique

Fig. 7. Schematic drawing of subepithelial connectivetissue graft technique.

Free soft tissue grafts

Soft tissues are transferred from an area distant tothe recession to cover the defect. The graft can benonsubmerged: that is, placed on the surface of therecipient bed; or submerged, when the graft is com-pletely or partially covered by the ap.

100

Nonsubmerged grafts

The epithelialized soft tissue graft is commonly named free gingival graft (13, 14, 54, 56, 66, 69, 110)(Fig. 6). A two-step procedure has also been de-scribed (12, 24, 50, 59, 104). First, gingival augmenta-tion is achieved by a free gingival graft. Secondly,

after the graft has healed, a coronally positioned apis performed to cover the recession defect.

Submerged grafts

The subeptithelial connective tissue graft combinesa free connective tissue graft with pedicle soft tissuegrafts (Fig. 7). Numerous modications have beendescribed in the literature.

To cover the graft, laterally positioned aps (73,88) or double papilla aps (15, 45, 46, 48) havebeen proposed. However, a coronally positionedap is most commonly used (17, 19, 36, 60, 61, 78,93, 116, 118, 125). Horizontal incisons have beensuggested to avoid vertical releasing incisons (23,49, 57) (Fig. 8, 9). An envelope technique with (72)or without (86) vertical incisions has been alsoproposed (Fig. 10). A modication of the envelopetechnique, the tunnel approach, has been de-scribed for combined treatment of adjacent re-cessions (3, 4, 122) (Fig. 11, 12).

Initially, partially epithelialized connective tissuegrafts were used; the epithelial border of the graft was not excised, but left coronal to the border of theap. In order to enhance the esthetic results, it hasbeen suggested to remove the epithelial collar andcompletely immerse the graft under the ap (19, 20)(Fig. 13, 14).

Fig. 8. Schematic drawing of submerged graft technique with horizontal incisions.


5/24


Fig. 9. A . Moderate-wide recession defect on the maxillary mesial and distal to the defect. C. A connective tissuecanine (Miller Class I). No gingival augmentation is re- graft, without epithelial band, is placed beneath the ap.quired. B . Preparation of the recipient site. Two horizontal D. The embedded graft is secured by the coronally posi-incisions are made at the cementoenamel junction level, tioned ap. E . 2 years post-surgery.

Additive treatments

In order to improve the biological link between theroot surface and the covering soft tissues, additivetreatments have been explored.

Root surface modication agents

Chemical biomodication has centered on the useof citric acid (2, 13, 14, 19, 25, 45, 56, 57, 59, 62, 69,

101

74, 110) and tetracycline hydrochloride (20, 23, 4547, 49, 111). It has been recommended to rub theroots with pH 1 citric acid for 3 min or with tetracy-cline HCl (50125 mg/ml for 35 min).

Enamel matrix proteins

Enamel matrix proteins gel is applied onto root sur-faces previously conditioned for 2 min with a 24%EDTA containing gel (42).


6/24

Bouchard et al.

Fig. 10. Schematic drawing of the envelope technique

Fig. 11. Schematic drawing of the tunnel approach. Thegraft is pulled through the tunnel with a suture.

Guided tissue regeneration

A membrane barrier is placed beneath a coronally positioned ap to cover the area of the recession.

Nonresorbable membrane barriers

Expanded polytetrauoroethylene membrane bar-riers were rst used (81, 106108, 112). To provide aspace between the membrane and the root, a teon

suture in mesiodistal direction through the mem-brane (81, 88, 125), a gold frame bent under themembrane (108), or the use of miniscrews (90) wassuggested. Specially designed titanium-reinforcedexpanded polytetrauoroethylene membrane bar-riers have also been tested (58, 109).

Resorbable membrane barriers

Various absorbable biomaterials for guided tissue re-generation devices have been used in the compo-

102

sition of membrane barriers. Polylactic acid and cit-ric acid ester (17, 35, 36, 48, 49, 63, 82, 88, 115, 125),polylactic-polyglycolic acid copolymer (116), polyg-lactin 910 (28, 85), and collagen (96, 101, 124) havebeen subjected to clinical evaluation (Fig. 15).

Healing events affecting aestheticoutcome

From a periodontal standpoint, Egelberg initiatedthe basic principles of wound healing in 1987 (29).More recently, periodontal wound healing was em-phasized and reviewed by Wikesj & Selvig (121). Al-though the healing pattern in recession defects issomewhat different from intrabony or furcation de-fects, the biological principles of healing remain thesame. Surgical guidelines can be deduced from theseprinciples (Table 4).

Histocompatibility

Root surface cementum of a recession defect isusually contaminated by exposure to the oral en-vironment. The longer the roots have been exposed,the more the surface changes (95). As yet, no clinicalstudy has explored the inuence of the duration of

Table 4. Surgical guidelines related to biologicalprinciples of healing in root coverage procedures

Histocompatibility Decontamination of exposed root surfaces VascularizationCareful surgical manipulation of the soft tissuesGraft larger than the coronal width of the recession

defectLateral extension of the vascular bed according to the

surface area of the defect Vertical incisions over a vascular bedNo sutures over the root surface Wound stability No graft mobility Passive adaptation of the covering ap onto the

recession defect3 to 5 minutes nger pressure on the operated areaSuture removal after 10 to 14 daysNo brushing or chewing on the operated area for 3 weeks Wound contractionCoronal margin of the ap secured up to or beyond the

cementoenamel junction Wound asepsisNo periodontal dressing Postoperative anti-infective care program

0.12% chlorhexidine rinse, twice daily during the rst 2 weeks

Application of chlorhexidine gel onto theoperated area for another 2 weeks


7/24


Fig. 12. A . Deep-wide recession defects (Miller Class II).Gingival augmentation is needed. B . A tunnel is createdunder the papillae. C . A connective tissue graft is shapedand trimmed to t the recipient site. D. The graft is se-cured by the ap. The coronal portion of the graft is leftoutside the border of the facial ap. E . Four months post-surgery.

root exposure for the outcome of root coverage pro-cedures.

The removal of the biolm on the exposed portionof the root appears to be of importance for healing (77). It now appears that previously suggested exten-sive root attening is not required. Thus, gentle rootplaning must render the root surface free from mi-crobial plaque (32). Root reduction before rootcoverage therapies is only indicated for anatomicalreasons, such as root prominence, or caries removal(119). Recently, the results of a comparative study suggest that root planing is not necessary in shallow recession defects treated with coronally positioned

103

ap (84). Polishing the exposed root surface resultedin similar clinical outcome.

Vascularization

In root coverage procedures, the avascular surfaceof the root presents a challenge for wound healing.Blood supply following ap operations will have tocome from the areas bordering the recession de-fect and from the pedicle (70). The healing of non-submerged graft primarily depends on the restora-tion of collateral circulation from the periostealconnective tissue bed bordering the defect. Thus,


8/24

Bouchard et al.

Fig. 13. Schematic drawing of submerged graft technique without epithelial collar

the size of the defect relative to the connectivetissue bed determines the survival of nonsub-merged graft (75, 100).

A recent case-series indicates that ap thicknessis associated with frequency of complete root cover-age in coronally positioned ap procedures (10). Thethinner the soft tissues, the more difcult the pro-cedure and higher the risk of postoperative necrosis. When tissues are thin, particular attention should bepayed to ensure a large vascular bed.

Clinical studies have also demonstrated that thethickness of the graft plays a major role in graft sur-vival (14, 69). Submerged grafts maximize soft tissuesurvival by providing a double blood supply from theoverlying ap and the periosteal connective tissuebed.

Wound stability

It has been demonstrated that the initial adhesion of the clot to the root surface is of critical importancein the healing process (120). A thin clot promotestensile strength and stability of the wound. The sur-gical technique and the early postoperative periodare the keystones to achieving successful root cover-

age. It is our personal experience that failures pri-marily occur within the rst week after surgery.

Wound contraction

Wound contraction is a major event occurring dur-ing the formation of granulation tissue. In large wounds, 510% reduction can be observed (11). Un-desirable postoperative recession can be avoided by suturing the ap 1 to 2 mm coronal to the cemento-enamel junction.

104

Wound asepsis

In addition to mechanical disruption of the wound,persistent inammation and/or infections may af-fect the healing process. The postoperative care pro-gram should be based on infection control using topical antimicrobial agents. Systemic antibiotic

therapy might be reserved for membrane procedures(97). We rarely use periodontal dressings (18). They may increase local temperature, humidity and stag-nation, favoring the development of bacterial bi-olms (21). It should be added, however, that thereare no clinical studies available evaluating differentpostoperative procedures.

Aesthetic evaluation of outcomePatients own evaluation

It is the patient, not the surgeon, who primarily should judge the success of root coverage pro-cedures. Thus, a key metric should be patient satis-faction. For other conditions, such qualitative out-come is usually measured by Visual Analog Scales,other scores or questionnaires. Surprisingly, this hasnot been part of the available literature. A system forpatients own evaluation, adapted to root coverageprocedures, is highly needed and should be includedin future research.

Professional evaluation As mentioned above, defect coverage by soft tissuein millimeters and percentages has so far been themain outcome variables in clinical studies. However,in terms of aesthetics, the percentage of teeth withcomplete root coverage seems more important andshould be considered as a prerequisite for success.Furthermore, comparative data have been based on

Fig. 14. A . Moderate-narrow/wide recesion defects on the

canine and the rst premolar (Miller Class I). Gingivalaugmentation is not required. The patients concern is es-thetic although recessions are in a non-visible area.B . After preparing the recipient site, the graft is removedfrom the palate. C . Connective tissue wedge with an easily identied epithelial collar. D. The small band of epithel-ium is excised. E. Wound edges at the donor site are su-tured. F. The connective tissue graft is placed over the de-nuded root surface, and secured up to the cementoenamal junction. Note that a single mesial vertical releasing in-cision is made. G . The ap is coronally positioned in orderto completely immerse the graft. H . Three years post-surgery.


9/24


105


10/24

Bouchard et al.

a central vertical linear measurement taken in mm

in the area of recession. This measurement cannotfully estimate the aesthetic success of the procedurebecause of two reasons: (1) a single measurementdoes not accurately reect the shape and the area of residual recession; (2) the visual aspect of the graftand surrounding tissues is not taken into account.

Thus, success criteria should not only be basedupon the amount of root coverage but also upon thecosmetic integration of the operated zone within themouth. Attention needs to be payed to additionalfactors (Fig. 16). In a comparative study on root

106

coverage, we attempted to evaluate aesthetic results

(19). Impressions and photographs of the recessions were made preoperatively and 6 months later. Eachphotograph was magnied on a screen. The photo-graphs and the impressions were examined andcompared by two independent examiners who wereblind to the given treatment. The evaluation of theaesthetic results was scored using a three-step scale:good, moderate or poor. Concordance betweenexaminers was assessed by a kappa test. The exam-iners were asked to score an overall impression of the surrounding tissues, not just the amount of root


11/24


Fig. 15. A . Moderate-wide recession defect on a maxillary ditioned with a solution of 50 mg/ml tetracycline HCL for 5canine (Miller Class III). B . The cervical abrasion may minutes. F. Two vertical releasing incisions are made. G.createadequate space foringrowthof periodontal ligament The membrane is secured up to the cementoenmal junc-tissue. C. A guided tissue regeneration technique is chosen tion. H . The ap is sutured over the membrane. I . Thirty usinga biodegradable membrane barrier (Guidor A ). D . The months post-surgery. Root coverage is limited to the heightroot surface is gently planed. E. The defect area is con- of contour of the interproximal tissue.

surface that was covered. Table 5 indicates the fourrelevant factors taken into account by the panel of examiners to score a global aesthetic impression.

Hopefully, a system like this, one and the same anduniversally used, can soon be agreed upon and regu-larly included in clinical studies.

Decision-makingPatient evaluation

Patient psychology

In 1987, the denition of cosmetic surgery of the American Society of Plastic and Reconstructive Sur-

107

Table 5. Professional evaluation factors foraesthetic outcome of root coverage procedures

Degree of root coverage

Color match of the tissues Alveolar mucosaPre-existing keratinized tissuesGingival graftSoft tissue appearanceLack of hypertrophic scars or brosisMatching volume and textureLocation of the mucogingival line


12/24

Bouchard et al.

Fig. 16. Top

. Episodes of necrotizing gingivitis resulting inrecession defects on the canine, rst and second bicuspid.Bottom . 2 years post-treatment following submergedgraft. Patients expectation matches surgeons ability. Bothare satised with the results. Aesthetic criteria of successare fullled.

geons, accepted by the American Medical Associ-ation in June 1989, was the following: Cosmeticsurgery is performed to reshape normal structures of the body in order to improve the patients appear-ance and self-esteem. Thus, the end goal of aes-thetic surgery is to boost self-esteem (37). Thismeans that aesthetic procedures deal with psycho-analytic and social behavior.

Gingival recession is often a source of anxiety topatients. So far, no psychological instrument in theeld of aesthetic dentistry has been developed toidentify the patient prole. Nevertheless, infor-mation collected during the consultation can reveala psychological prole that may jeopardize patientsatisfaction.

O Noncompliant patients should be considered atrisk. Compliance is needed for success of rootcoverage. Long-term, the patient has to modify hisor her hygiene habits in order to avoid marginalinammation and minimize toothbrushing trauma (31) (Fig. 17). Success decreases with poorplaque control (25). Short-term, the fragile inter-face between the root surface and the soft tissuesduring the days following the operation requiresstrict compliance with postoperative instructions.

O Gingival recessions can be the visible sign of on-

108

going periodontitis. If so, the periodontal diseasemust be rst treated. Usually, patients with on-going periodontitis seeking for aesthetic concernsare not good candidates for root coverage pro-cedures (34). There is a discrepancy between aes-thetic expectation and the likelihood of furthergingival recession as part of the periodontal heal-

ing process.O An unsatised patient already subjected tomultiple aesthetic procedures should be sus-pected of never being satised. The demand forrepeated surgery can be, in fact, a sign of psycho-pathology (polysurgical addiction).

O Patients presenting factitious gingival ulcerationshould be carefully evaluated prior to root cover-age procedures. Self-inicted periodontal injuriescan be related to mental disorders (92) such asMunchausens syndrome (51) or dysmorphophob-ia. Based on information from the American Psy-chiatric Association (6), when this behavior per-sists for 4 weeks or longer, it may refer to mental

Fig. 17. A . Multiple Class II recessions associated withmechanical trauma (29-year-old man from Togo). B . Pieceof soft wood used by the patient as a toothbrush. Any sur-gical attempt aiming at covering the recessions will failuntil oral hygiene habits are modied.


13/24


Fig. 18. In a social smile, most patient displays eightmaxillary teeth. In full laugh, the exposure can extend tothe mesial portion of the rst maxillary molar.

disorders. It can be deducted that at least a 1-month observation period is necessary prior to adecision to surgically correct factitial defects.

O The cosmetic zone, as experienced by the patient,may be not limited to the smile (Fig. 14). It de-pends on the patients perception of his body. A rm request for aesthetic root coverage procedurein nonvisible areas should be discussed.

O Aesthetic demands for treatment of shallow ClassI recessions should be carefully analyzed. Even if the percentage of complete root coverage is highin this defect category, the surgeon should keepin mind that the more aesthetic the demand, themore difcult it is to satisfy the patient.

Risk factors

Little is known about various characteristics of thepatients relative to the results. Only one attemptseems to have been made (46) but, as has been sug-gested, the high degree of success of this study (89%of complete root coverage) may explain that the pa-tient characteristics evaluated were not related to theresults (30). For example, there is no informationabout the inuence of gender and age of the patients

on the success rates. A recent study suggests an association between

smoking and gingival recession in subjects present-ing minimal or no periodontal disease (41). However,evaluations of the impact of smoking on the out-come of root coverage procedures are contradictory.In two studies using free soft tissue graft, the resultsdo not seem to be affected by tobacco consumption(46, 110). This is in contrast to one study using freeconnective tissue graft (71), and two studies using guided tissue regeneration techniques (114, 125);

109

where smokers showed less root coverage. However,in view of the growing number of studies demon-strating a negative effect of tobacco consumption onperiodontal wound healing (30, 105), it seemsreasonable to consider smoking a risk factor.

The smile line also needs to be considered. Nor-mally, the cosmetic zone is limited to the maxilla.

The position of the lip line relative to the gingivalline determines the amount of gingival exposure (65)(Fig. 18). Patients presenting a gummy smileshould be carefully evaluated before root coverageprocedures. The surgical challenge is great, becausethe smile will expose the entire operated zone. Thesepatients may require orthodontics and orthognaticsurgery to improve the lip line.

Fig. 19. Schematic drawing of Miller classication (68). A . Class I: Marginal tissue recession does not extend tothe mucogingival junction. No loss of interdental bone orsoft tissue. Class II: Marginal tissue recession extends toor beyond the mucogingival junction. No loss of interden-tal bone or soft tissue. B . Class III: Marginal tissue re-cession extends to or beyond the mucogingival junction.Loss of interdental bone or soft tissue is apical to thecementoenamel junction, but coronal to the apical extentof the marginal tissue recession. Class IV: Marginal tissuerecession extends beyond the mucogingival junction. Lossof interdental bone extends to a level apical to the extentof the marginal tissue recession.


14/24

Bouchard et al.

Defect evaluation

So far, only case reports indicate that the loss of interdental papillae may be partially resolved in iso-lated defects by grafting procedures (8, 44). The lack of hard tissue support jeopardizes any attempt to llthe interproximal area. Thus, the commonly used

Millers classication (68) remains a convenient toolfor prognosis evaluation (Fig. 19) (Table 6). However,this classication has some limitations.

O The position of the tooth and the alveolar ridgeare not taken into account. Recessions in teeth ina labial position may require orthodontic treat-ment prior to surgical procedures.

O The size of the defect in both vertical and horizon-tal dimensions must be considered. As a rule of thumb, the literature classies the defects as shal-low ( 3 mm), moderate (3 to 5 mm) or deep ( 5mm). On average, clinical studies indicate a defect width of 4.5 mm. A 5-mm width should be viewedas wide. It is to be assumed that the larger therecession area, the less root coverage should beexpected.

O The residual depth of the vestibule also seems tobe of importance for the selection of procedures.

Choice of technique

In periodontal plastic surgery, the choice of pro-cedure is based on the four cardinal principles of any surgery: success, reproducibility, lack of mor-bidity and economy. Basically, the easier the tech-nique the more reproducible it is, since the needfor technical skill of the surgeon is reduced. A skillfully performed operation is 75% decision-

Table 6. Prognosis for root coverage related todefect morphology

Class I and IIInitial recession depth 5 mm Favorable prognosis: complete root coverage can beachieved.Initial recession depth 5 mm Uncertain prognosis: limited number of teeth will show complete root coverage.Class IIIPoor prognosis: no tooth will present complete rootcoverage.Class IV No root coverage can be anticipated.

110

making and 25% dexterity (27). Cosmetic surgery remains highly dependent on the skill of the oper-ator, and technological advances should be viewed with this in mind (53). Sophisticated proceduresmay lead to postsurgical complications that canimpair aesthetic outcomes. Time-consumption andincreased fees are also factors to consider in the

selection of procedure. In fact, both are linked.This implies the choice of a single-step procedure without additive treatments, which increase dur-ation and cost of the operation. In coverage of ex-posed roots, a questionnaire has revealed single-step surgery to be the patients choice (89).

The description of the subepithelial connectivetissue graft technique by Langer & Langer in 1985represents a breakthrough in the coverage of ex-posed root surfaces (60). Submerged grafts are now the reference for prospective comparative studies onthe use of various root coverage techniques (Table7).

The surgeons choice will be based on the con-dence he has of his own ability to match the out-comes of the clinical trials. Table 1 and 2 summarizedata from clinical studies on the effect of variousroot coverage procedures. The results of nonsub-merged grafts are not included since they have beenextensively reviewed previously (30, 117, 119). Dueto differences between protocols, these tables mustbe carefully interpreted. Nevertheless, the mean per-centages express a trend, which can be taken intoaccount by the clinician.

Interestingly, wide ranges of results are observedfor submerged grafts as well as for the other tech-niques. These variations suggest limited reproducib-ility of procedures that require high surgical skills.They conrm the clinical opinion that these tech-niques are operator-sensitive.

Dated procedures

Nonsubmerged grafts are no longer justied in thecoverage of recession defects for aesthetic purposes.

The procedure is uncomfortable for the patient be-cause of the denuded palatal donor site, and thematch with the surrounding tissues is unpredictable.

The double papilla ap also seems to be a datedtechnique. Use of elaborate sutures is time-consum-ing. The procedure requires surgeons dexterity. Su-tures placed over the avascular root surface may leadto postoperative cleft complications that may impairesthetic results. Similarly, there seems to be littleclinical advantage in using double pedicle ap tocover connective tissue grafts.


15/24


T a b l e 7 . P r o s p e c t i v e c o m p a r a t i v e s t u d i e s o n t h e u s e o f s u b m e r g e d g r a f t s v e r s u s v a r i o u s r o o t c o v e r a g e p r o c e d u r e s

I n i t i a l

M e a n

L e n g t h o f r e c e s s i o n

M e a n %

% t e e t h w i t h

i n c r e a s e

D e f e c t

N u m b e r o f

N u m b e r s t u d y

d e p t h

o f r o o t

c o m p l e t e r o o t i n g i n g i v a l

A u t h o r

S t u d y d e s i g n

c l a s s

p a t i e n t s

o f t e e t h

( m o n t h s )

( m m )

c o v e r a g e c o v e r a g e *

h e i g h t ( m m )

N o n s u b m e r g e d g r a f t s

S b o r d o n e e t a l . (

9 3 )

S u b e p i t h e l i a l c o n n e c t i v e t i s s u e g r a f t

I o r I I

1 2

1 2

1 2

4 . 2

5 2 S

F r e e g i n g i v a l g r a f t

I o r I I

1 2

1 2

4 . 5

1 1

J a h n k e e t a l . (

5 7 )

C o n n e c t i v e t i s s u e g r a f t ( e n v e l o p e t e c h n i q u e )

I a n d I I

9 w i t h

9

6

2 . 8

8 0 S

5 6

3 . 0 N S


I a n d I I

p a i r e d d e f e c t s

9

2 . 9

4 3

1 1

3 . 0

P a o l a n t o n i o e t a l . (

7 8 )


I a n d I I

3 5

3 5

6 0

3 . 4 3

8 5 S

4 8 . 5

2 . 8 1 N S


I a n d I I

3 5

3 5

3 . 1 1

5 3

8 . 5

3 . 6 6

A d v a n c e d a p

W e n n s t r m & Z u c c h e l l i


I

3 5

5 8

2 4

4 . 0

9 8 N S

8 8

2 . 8 S

( 1 1 8 )

C o r o n a l l y p o s i t i o n e d a p

3 2

4 5

4 . 1

9 7

8 0

1 . 1

G u i d e d t i s s u e r e g e n e r a t i o n p r o c e d u r e s w i t h n o n - r e s o r b a b l e b a r r i e r m e m b r a n e

R i c c i e t a l . (

8 8 )


I a n d I I

1 8

1 2

4 . 9

7 7 N S

2 . 1 S

G o r e - T e x

c o r o n a l l y p o s i t i o n e d a p

1 8

5 . 9

8 1

2 . 3

J e p s e n e t a l . (

5 8 )


I a n d I I

1 5 w i t h p a i r e d 1 5

1 2

2 . 5

8 7 N S

4 7

2 . 5 N S

G o r e - T e x t i t a n i u m r e i n f o r c e d

d e f e c t s

1 5

3 . 3

8 7

4 7

1 . 5


G u i d e d t i s s u e r e g e n e r a t i o n p r o c e d u r e s w i t h r e s o r b a b l e b a r r i e r m e m b r a n e

H a r r i s ( 4 8 )

C o n n e c t i v e t i s s u e g r a f t

d o u b l e p a p i l l a a p

I

1 0

1 0

6

3 . 7

9 7 N S

9 0

3 . 1 S

G u i d o r


I

1 0

1 0

3 . 7

7 5

6 0

0 . 4

H a r r i s ( 4 9 )


I a n d I I

1 2

1 9

6

3 . 6

9 5 N S

7 4

2 . 1 S

G u i d o r


I a n d I I

1 2

1 8

3 . 6

9 2

7 2

0 . 1

Z u c c h e l l i e t a l . (

1 2 5 )


I a n d I I

1 8

1 8

1 2

5 . 6

9 3 . 5

S

6 6

3 . 1 S

G u i d o r


I a n d I I

1 8

1 8

5 . 8

8 6 S

3 9

0 . 7 S

G o r e - T e x


I a n d I I

1 8

1 8

5 . 7

8 0 . 5

N S

2 8

0 . 6 N S

T r o m b e l l i e t a l . (

1 1 6 )


I a n d I I

1 2 w i t h

1 2

6

3 . 0

8 1 S

5 0

1 . 8 S

R e s o l u t


I a n d I I

p a i r e d d e f e c t s 1 2

3 . 1

4 8

8

0 . 8

B o r g h e t t i e t a l . (

1 7 )


I

1 4 w i t h

1 4

6

3 . 8 5

7 6 N S

2 . 0 3 S

G u i d o r


I


4 . 3

7 0

0 . 4 2

M l l e r e t a l . (

7 2 )


I a n d I I

1 3

1 4

6

2 . 5

8 0 S

6 2

1 . 2 4 N S

G u i d o r


I a n d I I

9

1 4

3 . 0

4 5

1 1

1 . 1 4

S : s i g n i c a n t s t a t i s t i c a l d i f f e r e n c e b e t w e e n t r e a t m e n t s

. N S : n o t s i g n i c a n t . *

S t a t i s t i c a l c o m p a r i s o n s h a v e n o t b e e n u s e d f o r t h i s p a r a m e t e r b e c a u s e o f t h e s t u d i e s r e v i e w e d .

111


16/24

Bouchard et al.

Table 8. Decision-aid model for root coverage surgery (Class I and II defects)

Shallow residual vestibule depth Deep residual vestibule depth

No gingival augmentation Gingival augmentation No gingival augmentation Gingival augmentationDefect size(mm) Narrow 5 Wide 5 Narrow 5 Wide 5 Narrow 5 Wide 5 Narrow 5 Wide 5

Shallow 3 Semilunar ap or coronally positioned ap Connective tissue graft envelope*

Moderate 35

Connective tissue graft envelope*

Coronally Connective Connective tissue graft

positioned tissue graft coronally positionedap coronally po- apsitionedap**

Deep 5 Connective tissue graft envelope* Connective tissue graft Connective tissue graftcoronally positioned ap envelope

*Laterally positioned ap may be used for single recession.**Completely submerged.

Table 9. Mean increase in gingival height in mm in Class I and Class II defects: summary of data from

comparative and non-controlled case studies. Selection criteria: 6-month minimum follow-up, at least10 patients per group, initial recession depth data available

MaximumNumber Number length of Mean increaseof selected of study Number Number studies in in height

Procedure studies groups of patients of teeth months (range)

Rotational aps a 5 7 107 113 9 3.16 (2.74.0) Advanced aps b 4 5 72 152 96 0.4 ( 0.41.3)Submerged grafts rotational aps c 5 5 137 170 18 2.8 (2.13.3)Coronally positioned ap d 9 11 224 248 60 1.8 (0.63.1)Envelope e 4 4 50 64 48 2.4 (1.23.5)Guided tissue regeneration techniquesNonresorbable membrane f 9 9 145 145 48 0.9 (0.01.9)

Resorbable membraneg

7 8 98 104 12 0.5 (

0.42.0)Selected studies:a 25, 33, 40, 98, 123.b 67, 91, 113, 118.c 15, 16, 46, 48, 88.d 16, 17, 19, 20, 49, 78, 116, 118, 125.e 4, 58, 72, 86.f 58, 83, 89, 90, 107, 109, 111, 112, 125.g 17, 48, 49, 63, 89, 116, 125.

Current procedures

Decision-aid model for soft tissue grafts

It is our opinion that the operators choice in clinicalpractice could be limited to use of pedicle soft tissuegrafts and submerged connective tissue grafts. Theapplication of these two techniques should be basedupon various aspects of the anatomy of the individ-ual defect site. In Table 8 we propose a decision-aidmodel that considers the size of the defect to betreated, the need for gingival augmentation, and theresidual depth of the vestibule in a effort to achievebest possible overall aesthetic result.

112

Size of the defect

The semilunar ap, easy to perform, is highly repro-ducible in shallow recession defects when gingivalaugmentation is not needed. In Class I moderate de-fects, similar degrees of root coverage have been re-ported with coronally positioned ap and sub-merged graft. Nevertheless, less favorable results were observed in defects presenting an initial re-cession depth 5 mm (118). With reference to thehealing events described above, it is reasonable toassume that moderate recessions should be treated with coronally positioned aps, whereas submerged


17/24


Fig. 20. A . A mandibular canine and a premolar with deeprecession defects and extensive abrasion. B . 1 year post-treatment following subepithelial connective tissue graft.Complete root coverage is achieved. However, the aes-thetic evaluation is classied as moderate due to the softtissue appearance. A gingival groove marks the border of the epithelial band of the graft, which was left coronal to

the ap margin.

graft procedures seem to be needed for wide and/ordeep defects.

Envelope procedures without vertical releasing in-cisions should be preferred over other techniques asthey prevent any unappealing postoperative scarlines. Tunnel approach allows multiple recessions tobe treated in one session. At the donor site, a long wedge of tissue must be pulled out. To avoid the risk

of cyst formation, the epithelium of the graft to becovered by the interdental gingiva must be carefully excised.

Need for gingival augmentation

Some increase in gingival height is found following all root coverage procedures (Table 9). However, ro-tational aps and submerged grafts provide more in-crease than advanced aps and membrane tech-niques. Connective tissue grafts combined with co-

113

ronally positioned ap show somewhat lowerincrease in gingival height than envelope pro-cedures.

When partially submerged grafts are used, a gingi-val groove is often formed between the coronal bor-der of the ap and the epithelial band of the graft(Fig. 20). This tends to affect the aesthetic result.

Histologically, deep epithelial projections are foundat the junction between the gingival ap and thetransplanted connective tissue (76) (Fig. 21). Thus, when increased gingival height is not required, theepithelial collar of the connective tissue should beexcised, and the graft completely covered by the ap.However, a surgical cyst has been reported 15months post-surgery following this technique (22).Care must be taken to completely remove the epi-thelial collar of the graft. Hurtzeler & Weng have de-scribed a surgical approach at the donor site, whichdoes not include harvesting the epithelial border of the graft (55) (Fig. 22).

Increased gingival thickness is observed with sub-merged connective tissue grafts (49) and can poss-ibly be doubled (71). An increase in gingival thick-ness may be advantageous at sites with subgingivalrestorations (119). Deep cervical abrasions shouldalso be considered. Connective tissue grafts may bebest suited to avoid the collapse of the ap onto the

Fig. 21. Twelve-month biopsy of a subepithelial connectivetissue graft. A long epithelial projection into the connec-tive tissue marks the border between the ap (bottom)and the graft (top). Hematoxylin and eosin. Originalmagnication 110. Laboratoire de Recherche UPRES-A 7052 CNRS.


18/24

Bouchard et al.

Fig. 22. Schematic drawing illustrating the surgical pro-cedure at the donor site. In this case, the graft is removed without the epithelial collar.

root surface, and to provide better restoration of thesoft tissue morphology.

Laterally positioned aps can be proposed to in-crease the gingival height for root coverage of iso-lated recessions when neighbouring gingiva is suf-cient. In situations where an increase of gingivalheight and thickness is desirable, submerged graftsare preferred (49, 125).

Residual depth of the vestibule

The distance between the base of the recession andthe bottom of the vestibule has not yet been debatedin the literature. Excessive coronal positioning of themucogingival line as a consequence of coronally po-sitioned ap may, in a shallow residual depth, impairthe aesthetic results, even if long-term studies indi-cate that the mucogingival line tends to regain itsinitial position over time (1, 83). Furthermore, co-ronal traction of the covering soft tissues may dis-rupt the wound during the healing phase. Sub-merged grafts without coronal positioning, as de-scribed by Raetzke (86), are to be preferred. Thisenvelope technique gives less traction and provides

increased gingival height (Fig. 23).

Additive treatments

From an aesthetic viewpoint, the histological out-come of root coverage techniques might appear tobe of little importance. However, lack of bone sup-port is a major risk factor in the causation of gingivalrecession. Thus, regenerative techniques aimed atrestoring a new functional attachment apparatus with formation of cementum, periodontal ligament

114

and alveolar bone seem advantageous, even if thispossibility has not as yet been demonstrated inhumans.

Root surface modication agents

Animal and clinical studies have failed to demon-

strate that root surface modication agents improvethe mean percentage of root coverage (5, 30). How-ever, recent clinical studies still use root surface con-ditioning (20, 48, 49, 58, 72, 116). As demonstratedby our compilation of data, few prospective com-parative studies have explored the clinical effect of decalcifying agents (Table 10). The lack of differencebetween groups can also be interpreted as an in-ability of root surface modication agents to inducea clinical effect, which would reach statistical sig-nicance. However, the use of citric acid or tetracy-cline hydrochloride may be justied as a means toremove the instrumentation smear layer.

Enamel matrix proteins

Histological ndings indicate that the application of enamel matrix proteins in treatment of recession-type defects may result in the formation of a new attachment apparatus (43, 94). A 6-month case seriesindicates mean recession coverage of 81% following the use of enamel matrix proteins in conjunction with a coronally positioned ap (52). These resultsneed to be conrmed by further studies.

Guided tissue regeneration

It appears that resorbable membranes should beused for guided tissue regeneration, since the clinicaloutcome is similar to that following nonresorbablemembranes (Table 1), and a second surgical pro-cedure for membrane removal is not needed.

However, over the years it has become our im-pression that it is questionable whether membranetechniques offer any benets over submerged grafts,

which overall seem more preferable and can be usedin all situations considered for membrane methods. A number of reasons can be advocated.

O The mean percentages of root coverage and teeth with complete root coverage indicate more favor-able results with submerged graft techniques(Tables 1, 2).

O When membranes are used, infection risk during the healing period is high (97). Adverse side ef-fects as foreign body reaction have recently been


19/24


20/24

Bouchard et al.

T a b l e 1 0

. C o m p a r a t i v e 6 - m o n t h s t u d i e s o n t h e u s e o f r o o t s u r f a c e m o d i c a t i o n a g e n t s

N u m b e r

I n i t i a l

M e a n

o f t e e t h

L e n g t h o f r e c e s s i o n

M e a n %

% t e e t h w i t h

i n c r e a s e

D e f e c t

N u m b e r o f

i n e a c h

s t u d y

d e p t h

o f r o o t

c o m p l e t e r o o t i n g i n g i v a l

A u t h o r

S t u d y d e s i g n

c l a s s

p a t i e n t s

g r o u p

( m o n t h s )

( m m )

c o v e r a g e c o v e r a g e

h e i g h t ( m m )

C a f f e s s e e t a l . (

2 5 )

L a t e r a l l y p o s i t i o n e d a p

c i t r i c a c i d

I o r I I

1 4

1 4

6

5 . 0

6 1

2 . 8

L a t e r a l l y p o s i t i o n e d a p

I o r I I

1 4

1 4

4 . 2

5 6

3 . 0


1 1 2 )

G o r e - T e x


I o r I I

8 w i t h

8

6

4 . 4

6 0

0

0 . 9

G o r e - T e x


I o r I I

p a i r e d d e f e c t s

8

4 . 5

6 7

1 2 . 5

1 . 1

t e t r a c y c l i n e H C l

b r i n e b r o n e c t i n e

( T i s s u c o l A )


1 1 3 )



I a n d I I

1 1 w i t h

1 1

6

3 . 4

5 5

1 8

0 . 5



I a n d I I


3 . 8

6 5

9

0 . 4

b r i n e b r o n e c t i n e ( T i s s u c o l A )

B o u c h a r d e t a l . (

2 0 )


I a n d I I

1 5

1 5

6

4 . 1

8 4

5 3

0 . 9

c i t r i c a c i d

I a n d I I

1 5

1 5

3 . 9

7 9

4 0

1 . 0



N o s t a t i s t i c a l l y s i g n i c a n t d i f f e r e n c e b e t w e e n a n y o f t h e c o m p a r e d t r e a t m e n t s

.

116

reported (103). Frequent postoperative examina-tions and antibiotic regimens increase patient dis-comfort.

O Complications, when they occur, are more dif-cult to correct following guided tissue regenera-tion. The bioabsorption process of the materialduring the healing phase makes it impossible to

remove resorbable membranes. Consequently,postoperative infections mostly turn into dra-matic aesthetic outcomes, leading to additionalcorrective procedures.

O Membrane techniques appear to be sensitive tothe thickness of the covering tissues. The meanresidual recession has been found to be threetimes higher when nonresorbable membranes areused in a thin soft tissue area ( 1 mm) than when tissues are thick (7). A signicant differencebetween the use of absorbable membrane andconnective tissue grafts has been reported inmean root coverage whith thin overlying tissues:26.7% and 95.9%, respectively (48).

O Submerged graft may allow lower fees.

Long-term follow-ups after submerged grafts andother nonmembrane procedures show stability of initial results (66, 78, 83, 91). We feel that this cir-cumstance, together with the lack of data to demon-strate enhanced new attachment following guidedtissue regeneration, provide no preference for mem-brane techniques. Thus, from a clinical perspective,even if tissue match following guided tissue re-generation is good, nonmembrane techniques areour preference for root coverage in aesthetics. Never-theless, the possibility of enhanced formation of new bone following use of membranes should be kept inmind.

Concluding remarks

This chapter has emphasized that, in aesthetics, theselection of surgical techniques for root coverage

should not only consider the results evaluated by millimeter and percentage data. Clinical trialsshould include methods for patients own evaluationas well as professional evaluation of the overall aes-thetic outcome.

In decision-making, evaluation of general patientcharacteristics and evaluation of various aspects of the anatomy at the individual defect site need to beconsidered.

New procedures should be developed to improvecomplete root coverage in Class I and Class II re-


21/24


cession defects. They should be simplied to ensurea wider reproducibility and to decrease the costbenet ratio. Progress in the creation of gingival pap-illae in Class III and Class IV recession defects is de-sirable.

Further research is needed to evaluate the inu-ence of soft and hard tissue attachment to the root

on the stability of the results.

References

1. Ainamo A, Bergenholtz A, Hugoson A, Ainamo J. Locationof the muco-gingival junction 18 years after apically reposi-tioned ap surgery. J Clin Periodontol 1982: 19 : 4952.

2. Allen EP, Miller PD. Coronal positioning of existing gingiva:short term results in the treatment of shallow marginaltissue recession. J Periodontol 1989: 60 : 316319.

3. Allen AL. Use of the supraperiosteal envelope in soft tissue

grafting for root coverage. I. Rationale and technique. Int JPeriodontics Restorative Dent 1994: 14 : 216227.

4. Allen AL. Use of the supraperiosteal envelope in soft tissuegrafting for root coverage. II. Clinical results. Int J Peri-odontics Restorative Dent 1994: 14 : 302315.

5. American Academy of Periodontology. Consensus report.Mucogingival therapy. Ann Periodontol 1996: 1: 705.

6. American Psychiatric Association. Diagnostic and statisti-cal manual of mental disorders. 4th edn. Washington, DC: APA, 1994: 466469.

7. Anderegg CR, Metzler DG, Nicoll BK. Gingiva thickness inguided tissue regeneration and associated recession at fa-cial furcation defects. J Periodontol 1995: 66 : 397402.

8. Azzi R, Etienne D, Carranza F. Surgical reconstruction of

the interdental papilla. Int J Periodontics Restorative Dent1998: 18 : 466473.

9. Bahat O, Handelsman M, Gordon J. The transpositionalap in mucogingival surgery. Int J Periodontics RestorativeDent 1990: 10 : 473482.

10. Baldi C, Pini Prato GP, Pagliaro U, Nieri M, Saletta D, MuzziL, Cortellini P. Coronally advanced ap procedure for rootcoverage. Is ap thickness a relevant predictor to achieveroot coverage? A 19-case series. J Periodontol 1999: 70:10771084.

11. Bartold PM, Narayanan AS. Biology of the periodontal con-nective tissues. Carol Stream, IL: Quintessence, 1998: 62.

12. Bernimoulin JP, Ly schezr B, Mhlemann HR. Coronally re-positioned periodontal ap. Clinical evaluation after one

year. J Clin Periodontol 1975: 2: 113.13. Bertrand PM, Dunlap RM. Coverage of deep wide gingival

clefts with free gingival autografts: root planing with and without citric acid demineralization. Int J Periodontics Re-storative Dent 1988: 8: 6577.

14. Borghetti A, Gardella JP. Thick gingival autograft for thecoverage of gingival recession: a clinical evaluation. Int JPeriodontics Restorative Dent 1990: 10 : 216229.

15. Borghetti A, Louise F. Controlled clinical evaluation of thesubpedicle connective tissue graft for the coverage of gingi-val recession. J Periodontol 1994: 65 : 11071112.

16. Borghetti A, Durand B, Louise F. La greffe conjonctive dansle recouvrement des re cessions gingivales. Evaluation de

117

deux techniques. J Parondontol Implantol 1997: 16: 369379.

17. Borghetti A, Glise JM, Monnet-Corti V, Dejou J. Compara-tive clinical study of a bioabsorbable membrane and sub-epithelial connective tissue graft in the treatment of humangingival recession. J Periodontol 1999: 70 : 123130.

18. Bouchard P, Etienne D. La cicatrisation parodontale. J Paro-dontol Implantol 1993: 12 : 227236.

19. Bouchard P, Etienne D, Ouhayoun JP, Nilve us R. Subepith-elial connective tissue grafts in the treatment of gingivalrecessions. A comparative study of two procedures. J Peri-odontol 1994: 65 : 929936.

20. Bouchard P, Nilve us R, Etienne D. Clinical evaluation of te-tracycline HCl conditioning in the treatment of gingival re-cessions. A comparative study. J Periodontol 1997: 68 : 262269.

21. Bourne GH. Nutrition and wound healing. In: Glynn LE,ed. Tissue repair and regeneration. Amsterdam: Elsevier/North Holland Biomedical Press, 1981: 212241.

22. Breault LG, Bilman MA, Lewis D. Report of a gingival sur-gical cyst developing secondarily to a subepithelial con-nective tissue graft. J Periodontol 1997: 68 : 392395.

23. Bruno JF. Connective tissue graft technique assuring wideroot coverage. Int J Periodontics Restorative Dent 1994: 14 :126137.

24. Caffesse RG, Guinard EA. Treatment of localized gingivalrecession. IV. Results after three years. J Periodontol 1980:510 : 167170.

25. Caffesse RG, Alspach SR, Morrison EC, Burgett FG. Lateralsliding aps with and without citric acid. Int J PeriodonticsRestorative Dent 1987: 7: 4357.

26. Cohen D, Ross S. The double papillae ap in periodontaltherapy. J Periodontol 1968: 39 : 6570.

27. Darzi A, Smith S, Tafnder N. Assessing operative skill. BMJ1999: 318 : 887888.

28. DeSanctis M, Zucchelli G. Guided tissue regeneration witha resorbable barrier membrane (Vicryl) for the manage-ment of buccal recession: a case report. Int J PeriodonticsRestorative Dent 1996: 16 : 435441.

29. Egelberg J. Regeneration and repair of periodontal tissues.J Periodontal Res 1987: 22 : 233243.

30. Egelberg J. Periodontics. The scientic way. Synopses of clinical studies. 3rd edn. Malmo: OdontoScience, 1999: 562.

31. Egelberg J. Oral hygiene methods. The scientic way. Syn-opses of clinical studies. 3rd edn. Malmo: OdontoScience,1999: 119.

32. Egelberg J. Current facts on periodontal therapy. Q&A. 1stedn. Malmo: OdontoScience, 1999: 62.

33. Espinel MC, Caffesse RG. Comparison of the results ob-tained with the lateral positioned pedicle sliding ap-re-vised technique and the lateral sliding ap with a free gin-gival graft technique in the treatment of localized gingivalrecession. Int J Periodontics Restorative Dent 1981: 1: 3037.

34. Etienne D, Azzi R, de la Rufnie ` re S, Bouchard P. Esthe tiqueet traitement des parodontites. Conside rations sur la re -cession gingivale. J Parodontol Implantol 1995: 14: 153167.

35. Genon P, Genon-Romagna C, Gottlow J. Traitement des re -cession gingivales par la re gene ration tissulaire guide e: bar-rie re re sorbable. J Parodontol Implantol 1994: 13 : 289296.

36. Genon-Romagna C, Genon P. Traitement cosme tique desrecessions gingivales. Comparaison entre la greffe conjonc-tive enfouie et la re generation tissulaire guide e. J Parodon-tol Implantol 1995: 14 : 135146.


22/24

Bouchard et al.

37. Gilman SL. Creating beauty to cure the soul. Durham: DukeUniversity Press, 1998: 141.

38. Grupe J, Warren R. Repair of a gingival defect by a sliding ap operation. J Periodontol 1956: 27 : 290295.

39. Grupe J. Modied technique for the sliding ap operation.J Periodontol 1966: 37 : 491495.

40. Guinard EA, Caffesse RG. Treatment of localized gingivalrecessions. III. Comparison on results obtained with lateralsliding and coronally repositioned aps. J Periodontol 1978:49 : 457461.

41. Gunsolley JC, Quinn SM, Tew J, Goos CM, Brooks CN,Schenkein HA. The effect of smoking on individuals withminimal periodontal destruction. J Periodontol 1998: 69:165170.

42. Hammarstrm L. Enamel matrix, cementum developmentand regeneration. J Clin Periodontol 1997: 24 : 658668.

43. Hammarstrm L, Heijl L, Gestrelius S. Periodontal re-generation in a buccal dehiscence model in monkeys afterapplication of enamel matrix proteins. J Clin Periodontol1997: 24 : 669677.

44. Han TJ, Takei HH. Progress in gingival papilla reconstruc-tion. Periodontol 2000 1996: 11 : 6568.

45. Harris RJ. The connective tissue and partial thicknessdouble pedicle graft: a predictable method of obtaining root coverage. J Periodontol 1992: 63 : 477486.

46. Harris RJ. The connective tissue with partial thicknessdouble pedicle graft: the results of 100 consecutively-treated defects. J Periodontol 1994: 65 : 448461.

47. Harris RJ, Harris AW. The coronally positioned pedicle graft with inlaid margins: a predictable method of obtaining rootcoverage of shallow defects. Int J Periodontics RestorativeDent 1994: 14 : 22824.

48. Harris RJ. A comparative study of root coverage obtained with guided tissue regeneration utilizing a bioabsorbablemembrane versus the connective tissue with partial-thick-ness double pedicle graft. J Periodontol 1997: 68 : 779790.

49. Harris RJ. A comparison of 2 root coverage techniques:guided tissue regeneration with bioabsorbable matrix stylemembrane versus a connective tissue graft combined witha coronally positioned pedicle graft without vertical in-cisions. Results of a series of consecutive cases. J Peri-odontol 1998: 69 : 14261434.

50. Harvey PM. Surgical reconstruction of the gingiva. II. Pro-cedures. N Z Dent J 1970: 66 : 4252.

51. Heasman PA, MacLeod I, Smith DG. Factitious gingival ul-ceration: a presenting sign of Munchausens syndrome? JPeriodontol 1994: 65 : 442447.

52. Heinz B, Jepsen K, Arjomand M, Jepsen S. Enamel matrix derivative in the treatment of periodontal recession de-fects. J Periodontol Acad Rep 1999: 70 : 235236.

53. Hoeyberghs JL. Cosmetic surgery. BMJ 1999: 318 : 512516.54. Holbrook T, Ochsenbein C. Complete root coverage on the

denuded root surace with a one-stage gingival graft. Int JPeriodontics Restorative Dent 1983: 3: 927.

55. Hrzeler MB, Weng D. A single-incision technique to har-vest subepithelial connective tissue grafts from the palate.Int J Periodontics Restorative Dent 1999: 19 : 278287.

56. Ibbott CG, Oles RD, Laverty WH. Effects of citric acid treat-ment on autogenous free graft coverage of localized re-cession. J Periodontol 1985: 56 : 662665.

57. Jahnke PV, Sandifer JB, Gher ME, Gray JL, Richardson AC.Thick free gingival and connective tissue autografts for rootcoverage. J Periodontol 1993: 64 : 315322.

118

58. Jepsen K, Heinz B, Halben J, Jepsen S. Treatment of gingivalrecession with titanium reinforced barrier membranes ver-sus connective tissue grafts. J Periodontol 1998: 69: 383391.

59. Laney JB, Saunders VG, Garnick JJ. A comparison of twotechniques for attaining root coverage. J Periodontol 1992:63 : 1923.

60. Langer B, Langer L. Subepithelial connective tissue grafttechnique for root coverage. J Periodontol 1985: 56: 715720.

61. Levin RA. Covering denuded maxillary root surfaces withthe subepithelial connective tissue graft. CompendiumContin Educ Dent 1991: 12 : 568577.

62. LiuWJ, Solt CW. A surgical procedure forthe treatment of lo-calized gingival recession in conjunction with root surfacecitric acid conditioning. J Periodontol 1980: 51: 505509.

63. Matarasso S, Caero C, Coraggio F, Vaia E, de Paoli S.Guided tissue regeneration versus coronally repositionedap in the treatment of recession with double papillae. IntJ Periodontics Restorative Dent 1998: 18 : 444453.

64. Marggraf E. A direct technique with a double lateral bridg-ing ap for coverage of denuded root surface and gingivaextension. Clinical evaluation after 2 years. J Clin Peri-odontol 1985: 12 : 6976.

65. McGuire MK. Periodontal plastic surgery. Dent Clin North Am 1998: 42 : 411465.

66. Michaelides PL, Wilson SG. An autogenous gingival grafttechnique. Int J Periodontics Restorative Dent 1994: 14:112125.

67. Milano F. A combined ap for root coverage. Int J Peri-odontics Restorative Dent 1998: 18 : 544551.

68. Miller PD. A classication of marginal tissue recession. IntJ Periodontics Restorative Dent 1985: 5: 914.

69. Miller PD. Root coverage using the free soft tissue autograftfollowing citric acid application. III. A successful and pre-dictable procedure in area of deep-wide recession. Int J

Periodontics Restorative Dent 1985: 5: 1537.70. Mrmann W, Cianco SG. Blood supply of human gingivafollowing periodontal surgery. A uorescein angiographicstudy. J Periodontol 1977: 48 : 681692.

71. Mller HP, Eger T, Schorb A. Gingival dimensions after rootcoverage with free connective tissue grafts. J Clin Peri-odontol 1998: 25 : 424430.

72. Mller HP, Stahl M, Eger T. Root coverage employing anenvelope technique or guided tissue regeneration with bi-oabsorbable membrane. J Periodontol 1999: 70 : 743751.

73. Nelson SW. The subpedicle connective tissue graft. A bi-laminar reconstructive procedure for the coverage of de-nuded root surfaces. J Periodontol 1987: 58 : 95102.

74. Oles RD, Ibbott CG, Laverty WH. Effects of citric acid treat-

ments on pedicle ap coverage of of localized recession. JPeriodontol 1985: 56 : 259261.

75. Oliver RG, Le H, Karring T. Microscopic evaluation of thehealing and re-vascularization of free gingival grafts. J Peri-odontal Res 1968: 3: 8495.

76. Ouhayoun J-P, Khattab R, Serfaty R, Feghaly-Assaly M, Sa- waf MH. Chemically separated connective tissue grafts:clinical application and histological evaluation. J Peri-odontol 1993: 64 : 734738.

77. Page RC, Offenbacher S, Schroeder HE, Seymour GJ, Korn-man KS. Advances in the pathogenesis of periodontitis:summary of developments, clinical implications and futuredirections. Periodontol 2000 1997: 14 : 216248.


23/24


78. Paolantonio M, di Murro C, Cattabriga A, Cattabriga M.Subpedicle connective tissue graft versus free gingival graftin the coverage of exposed root surfaces. A 5-year clinicalstudy. J Clin Periodontol 1997: 24 : 5156.

79. Patur B. The rotation ap for covering denuded root sur-faces. A closed wound technique. J Periodontol 1977: 48:4144.

80. Pennel BM, Higgison JD, Towner TD, King KO, Fritz BD,Salder JF. Oblique rotated ap. J Periodontol 1965: 36 : 305309.

81. Pini Prato GP, Tinti C, Vincenzi G, Magnani C, Cortellini P,Clauser C. Guided tissue regeneration versus mucogingivalsurgery in the treament of human buccal gingival re-cession. J Periodontol 1992: 63 : 918928.

82. Pini Prato GP, Clauser C, Magnani C, Cortellini P. Re-sorbable membranes in the treatment of human buccal re-cession. A nine-case reports. Int J Periodontics RestorativeDent 1995: 15 : 258267.

83. Pini Prato GP, Clauser C, Cortellini P, Tinti C, Vincenzi G,Pagliaro U. Guided tissue regeneration versus mucogingivalsurgery in the treament of human buccal recessions. A 4-year follow-up study. J Periodontol 1996: 67: 1216223.

84. Pini Prato GP, Baldi C, Pagliaro U, Nieri M, Saletta D, Ro-tundo R, Cortellini P. Coronally advanced ap procedurefor root coverage. Treatment of root surface: root planing versus polishing. J Periodontol 1999: 70 : 10641076.

85. Rachlin G, Koubi G, Dejou J, Franquin JC. The use of aresorbable membrane in mucogingival surgery. Case series.J Periodontol 1996: 67 : 621626.

86. Raetzke PB. Covering localized areas of root exposure em-ploying the envelope technique. J Periodontol 1985: 56:397402.

87. Register A, Burdick F. Accelerated reattachment with ce-mentogenesis to dentin, demineralized in situ . II. Defectrepair. J Periodontol 1976: 47 : 497505.

88. Ricci G, Silvestri M, Tinti C, Rasperini G. A clinical/statisti-cal comparison between the subpedicle connective tissuegraft method and guided tissue regeneration technique inroot coverage. Int J Periodontics Restorative Dent 1996: 16 :538545.

89. Roccuzzo M, Lungo M, Corrente G, Gandolfo S. Compara-tive study of a bioabsorbable and non-resorbable mem-brane in the treatment of human buccal gingival re-cessions. J Periodontol 1996: 67 : 714.

90. Roccuzzo M, Buser D. Treatment of buccal gingival re-cessions with ePTFE membranes and miniscrews: surgicalprocedure and results of 12 cases. Int J Periodontics Re-storative Dent 1996: 16 : 356365.

91. Romanos GE, Bernimoulin J-P, Marggraf E. The double lat-

eral bridging ap for coverage of denuded root surface:longitudinal study and clinical evaluation after 5 to 8 years.J Periodontol 1993: 64 : 683688.

92. Sandhu HS, Sharma V, Sidhu GS. Role of psychiatric dis-orders in self-inicted periodontal injury: a case report. JPeriodontol 1997: 68 : 11361139.

93. Sbordone L, Ramaglia L, Spagnuolo G, De Luca M. A com-parative study of free gingival and subepithelial connectivetissue grafts. Periodontal Case Rep 1988: 10 : 812.

94. Sculean A, Donos N, Reich E, Brecx M, Karring T. Healing of recession-type defects following treatment with enamelmatrix proteins or guided tissue regeneration. A pilot study in monkeys. J Parodontol Implantol 2000: 19 : 1220.

119

95. Selvig KA, Zander HA. Chemical analysis and microradio-graphy of cementum and dentin from periodontally dis-eased human teeth. J Periodontol 1962: 33 : 303310.

96. Shieh A-T, Wang H-L, ONeal RB, Glickman GN, MacNeilRL. Development and clinical evaluation of a root cover-age procedure using a collagen barrier membrane. J Peri-odontol 1997: 68 : 770778.

97. Slots J, MacDonald ES, Nowzari H. Infectious aspects of periodontal regeneration. Periodontol 2000 1999: 19 : 164172.

98. Smuckler H. Laterally positioned mucoperiosteal pediclegrafts in the treatment of denuded roots. A clinical andstatistical study. J Periodontol 1976: 47 : 590595.

99. Stafleno H. Management of gingival recession and rootexposure problems associated with periodontal disease.Dent Clin North Am 1964: March : 111120.

100. Sullivan HC, Atkins JH. Free autogenous gingival grafts. I.Principles of successful grafting. Periodontics 1968: 6:121129.

101. Tal H. Subgingival acellular dermal matrix allograft for thetreatment of gingival recession: a case report. J Peri-odontol 1999: 70 : 11181124.

102. Tarnow DP. Semilunar coronally positioned ap. J ClinPeriodontol 1986: 13 : 182185.

103. Tatakis DN, Trombelli L. Adverse effects associated withbioabsorbable guided tissue regeneration device in thetreatment of human gingival recession defects. A clinico-pathologic case report. J Periodontol 1999: 70 : 542547.

104. Tennenbaum H, Klewansky P, Roth JJ. Clinical evaluationof gingival recession treated by coronally repositionedap technique. J Periodontol 1980: 51 : 686690.

105. Thomson MR, Garito ML, Brown FH. The role of smoking in periodontal disease: a literature review. Periodontal Abstr J West Soc Periodontol 1993: 41 : 510.

106. Tinti C, Vincenzi G. The treatment of gingival recession with guided tissue regeneration procedures by means of

Gore-Tex membranes. Quintessence Int 1990: 6: 465468.107. Tinti C, Vincenzi G, Cortellini P, Pini Prato GP, Clauser C.Guided tissue regeneration in the treatment of human fa-cial recession. A 12-case report. J Periodontol 1992: 63:554560.

108. Tinti C, Vincenzi GP, Cocchettto R. Guided tissue re-generation in mucogingival surgery. J Periodontol 1993:64 : 11841191.

109. Tinti C, Vincenzi G. Expanded polytetrauoroethylene ti-tanium-reinforced membranes for regeneration of muco-gingival recession defects. A 12-case report. J Periodontol1994: 65 : 10881094.

110. Tolmie PN, Rubins RP, Buck GS, Vagianos V, Lanz JC. Thepredictability of root coverage by way of free gingival

autografts and citric acid application: an evaluation by multiple clinicians. Int J Periodontics Restorative Dent1991: 11 : 261271.

111. Trombelli L, Schincaglia G, Checchi L, Calura G. Com-bined guided tissue regeneration, root conditioning, andbrin-bronectin system application in the treatment of gingival recession. A 15-case report. J Periodontol 1994:65 : 796803.

112. Trombelli L, Schincaglia GP, Scapoli C, Calura G. Healing response of human buccal gingival recessions treated with ePTFE membranes. A retrospective report. J Peri-odontol 1995: 66 : 1422.

113. Trombelli L, Scabbia A, Wikesj UME. Fibrin glue appli-


24/24

Bouchard et al.

cation in conjunction with tetracycline root conditioning and coronally positioned ap procedure in the treatmentof human gingival recession defects. J Clin Periodontol1996: 23 : 861867.

114. Trombelli L, Scabbia A. Healing response of gingival re-cession defects following guided tissue regeneration pro-cedures in smokers and non-smokers. J Clin Periodontol1997: 24 : 529533.

115. Trombelli L, Scabbia A, Tatakis DN, Checchi L, Calura G.Resorbable barrier membrane and envelope ap surgery in human gingival recession defects. A case report. J ClinPeriodontol 1998: 25 : 2429.

116. Trombelli L, Scabbia A, Tatakis DN, Calura G. Subpedicleconnective tissue graft versus guided tissue regenerationprocedure with bioabsorbable membrane in the treat-ment of human gingival recession defects. J Periodontol1998: 69 : 12711277.

117. Wennstrm JL. Proceedings of the 1996 World Workshopin Periodontics. Ann Periodontol 1996: 1: 667701.

118. Wennstrm JL, Zucchelli G. Increased gingival dimen-sions. A signicant factor for successful outcome of rootcoverage procedures? A 2-year prospective clinical study.J Clin Periodontol 1996: 23 : 770777.

119. Wennstrm JL, Pini Prato GP. Mucogingival therapy. In:Lindhe J, ed. Clinical periodontology and implant den-tistry. 3rd edn. Munksgaard: Copenhagen, 1997: 550596.

120. Wikesj UME, Nilveus RE, Selvig KA. Signicance of early healing events on periodontal repair: a review. J Peri-odontol 1992: 63 : 158165.

121. Wikesj UME, Selvig KA. Periodontal wound healing andregeneration. Periodontol 2000 1999: 19 : 2139.

122. Zabalegui I, Sicilia A, Cambra A, Gil J, Sanz M. Treatmentof multiple adjacent gingival recessions with the tunnelsubepithelial connective tissue graft: a clinical report. IntJ Periodontics Restorative Dent 1999: 19 : 199206.

123. Zade RM, Hirani SH. A clinical study of localized gingivalrecession treated by lateral sliding ap. J Indian Dent As-soc 1985: 57 : 1926.

124. Zahedi S, Bozon C, Brunel G. A 2-year clinical evaluationof a diphenylphosphorylazide-cross-linked collagenmembrane for the treatment of buccal gingival recession.J Periodontol 1998: 69 : 975981.

125. Zucchelli G, Clauser C, De Sanctis M, Calandrello M. Mu-cogingival versus guided tissue regeneration proceduresin the treatment of deep recession type defects. J Peri-odontol 1998: 69 : 138145.

root coverage.pdf

Documents