Pellicle and early dental plaque in periodontitis patients before and after surgical pocket elimination

OBJECTIVE

Gingival inflammation may affect the composition of the dental pellicle and initial acquisition of bacteria, which in turn could affect the healing of the periodontal pocket. The aim of this study was to examine the dental pellicle and early supragingival biofilms in periodontitis patients with an established subgingival infiltrate before and after surgical pocket elimination.

MATERIALS AND METHODS

Eleven patients with remaining pockets were selected. Samples were taken before and after surgical pocket elimination and after subsequent experimental gingivitis. Pellicle proteins were analyzed by SDS-PAGE, immunoblotting and image analysis and 4-h supragingival plaque by culturing.

RESULTS

The inflammatory status affected to a greater extent the concentration of plasma proteins than salivary proteins in the dental pellicle. The highest plasma protein concentrations were observed at remaining periodontal pockets where also the highest bacterial counts were found. The TVC was reduced on the gingival tooth surfaces (p < 0.05) after pocket elimination and increased slightly during experimental gingivitis. The finding of streptococci was highest on the incisal tooth surfaces and increased after surgery. Gram-negative anaerobes were sparse but seen more often before than after pocket elimination and on gingival than on incisal surfaces.

CONCLUSIONS

This study suggests that increased amounts of plasma proteins in the pellicle formed in the presence of remaining periodontal pockets may foster the acquisition of bacteria, including proteolytic Gram-negative species. This, in turn, results in an increased de novo plaque formation rate.

The coronally advanced flap in combination with platelet-rich fibrin (PRF) and enamel matrix derivative in the treatment of gingival recession: a comparative study

OBJECTIVE

The main objective of this study was to evaluate the clinical effectiveness of platelet-rich fibrin membrane used in combination with a coronally advanced flap (CAF) and to compare it with the use of an enamel matrix derivative (EMD) in combination with a coronally advanced flap in gingival recession treatment.

MATERIAL AND METHODS

20 split-mouth cases of maxillary anterior teeth or bicuspids presenting with Miller Class I or II gingival recession were treated with a CAF combined with a platelet-rich fibrin membrane (PRF group) or with EMD (EMD group) placed under a CAF. The following parameters were measured at baseline and at 12 months post treatment: gingival recession (GR), apicocoronal width of the keratinized tissue (WKT), and probing depth (PD).

RESULTS

Complete rot coverage in the PRF group was 65% (13 out of 20 recessions) and 60% in the EMD group (12 out of 20 recessions). GR was 4.10 ± 1.05 mm in the PRF group and 3.90 ± 1.00 mm in the EMD group at baseline, and 1.05 ± 0.45 mm in the PRF group and 1.15 ± 0.65 mm in the EMD group at 12 months. The difference observed between the tow groups at 12 months was statistically significant. Average root coverage was 70.5% in the EMD group and 72.1% in the PRF group. WKT was 1.30 ± 0.56 mm in the EMD group and 1.45 ± 0.86 mm in the PRF group at baseline, and 1.90 ± 0.81 mm in the EMD group and 1.62 ± 0.28 mm in the PRF group at 12 months. The difference observed between the two groups at 12 months was not statistically significant. Twelve-month changes in PD were not significantly different between the two groups. The pain intensity was statistically different between the two groups. The pain intensity was statistically different between groups for the first 5 days, favoring the PRF group.

CONCLUSIONS

The present study did not succeed in demonstrating any clinical advantage of the use of PRF compared to EMD in the coverage of gingival recession with the CAF procedure. The EMD group showed a higher success rate in increasing WKT than did the PRF group.

Free gingival grafts to increase keratinized tissue: a retrospective long-term evaluation (10 to 25 years) of outcomes

BACKGROUND

Gingival augmentation procedures are indicated primarily to increase an insufficient amount of gingiva and sometimes to halt the progression of gingival recession. The aim of this retrospective long-term study was to evaluate changes in the amount of keratinized tissue (KT) and in the position of the gingival margin after free gingival graft procedures over a period of 10 to 25 years.

METHODS

One hundred three subjects presenting with 224 sites completely lacking attached gingiva associated with gingival recessions were treated in a private practice. The experimental sites were treated with gingival augmentation procedures (free gingival grafts). The grafts were positioned at the presurgical level of the gingival margin or in a submarginal position. Clinical variables, including recession depth, amount of KT, and probing depth (PD), were measured at baseline (T(0)), 1 year after surgery (T(1)), and at the end of the follow-up period (10 to 25 years) (T(2)) and analyzed using descriptive statistics and multilevel models.

RESULTS

From T(0) to T(1), the gingival margin shifted coronally 0.8 mm, and KT increased 4.2 mm. From T(1) to T(2), the gingival margin shifted coronally 0.6 mm, and the overall KT decreased 0.7 mm. PD remained stable.

CONCLUSION

Gingival augmentation procedures performed in sites with an absence of attached gingiva associated with recessions provide an increased amount of KT associated with recession reduction over a long period of time.

Effect of connective tissue graft orientation on the root coverage outcomes of coronally advanced flap

The aim of the present study was the evaluation of the effect of connective tissue graft orientation on clinical outcome of root coverage procedure when applied in conjunction with coronally advanced flap. Sixteen similar bilateral recession defects--Miller's class I and II--in eight patients were treated using coronally advanced flap and connective tissue graft harvested from the palate. The defects in each patient were randomly allocated to P-teeth or P-flap groups with the periosteum contacting the tooth surface or the flap, respectively. After initial scaling and root planing, acrylic templates of the treatment sites were generated. Recession depth (RD), recession width (RW), gingival sulcular depth, clinical attachment level, length of keratinized tissue, papilla width, and percentage of root coverage were measured at baseline, 1 and 3 months postoperatively. Wilcoxon and Mann-Whitney U tests were used for analyzing the data. The reduction in RD averaged 3.68 mm in P-teeth and 3.25 mm in P-flap. RW decreased 2.68 and 2.6 mm in P-teeth and P-flap, respectively. Keratinized tissue increased an average of 1.25 mm in P-teeth and 1.31 mm in P-flap. Clinical attachment gain equaled 3.87 mm for P-teeth and 3.32 mm for P-flap. All variables exhibited significant improvement compared to baseline (P < 0.0001), but between-group differences were negligible (P > 0.05). It could be concluded that while the application of connective tissue graft with coronally advanced flap is efficient for coverage of Miller's class I and II gingival recession defects, the short-term clinical outcome of this surgical method is not affected by orientation of connective tissue graft.

A two-year prospective study of coronally positioned flap with or without acellular dermal matrix graft

AIM

Evaluation of the treatment of gingival recessions with coronally positioned flap with or without acellular dermal matrix allograft (ADM) after a period of 24 months.

METHODS

Thirteen patients with bilateral gingival recessions were included. The defects were randomly assigned to one of the treatments: coronally positioned flap plus ADM or coronally positioned flap alone. The clinical measurements were taken before the surgeries and after 6, 12 and 24 months.

RESULTS

At baseline, the mean values for recession height were 3.46 and 3.58 mm for the defects treated with and without the graft, respectively (p>0.05). No significant differences between the groups were observed after 6 and 12 months in this parameter. However, after 24 months, the group treated with coronally positioned flap alone showed a greater recession height when compared with the group treated with ADM (1.62 and 1.15 mm, respectively--p<0.05). A significant increase in the thickness of keratinized tissue was observed in the group treated with ADM as compared with coronally positioned flap alone (p<0.05).

CONCLUSIONS

ADM may reduce the residual gingival recession observed after 24 months in defects treated with coronally positioned flap. In addition, a greater gingival thickness may be achieved when the graft is used.

Clinical and radiographic evaluation of periodontal intrabony defects treated with guided tissue regeneration. A pilot study

BACKGROUND

The aim of this clinical and radiographic study was to evaluate the effect of guided tissue regeneration using a bioabsorbable barrier in the treatment of intrabony defects in humans.

METHODS

Intrabony osseous defects (2 or 3 walls) around mandibular canines and premolars were treated in 10 systemically healthy patients with ages ranging from 35 to 56 years. Prior to the surgical phase, patients were enrolled in a strict maintenance program including oral hygiene instructions and scaling and root planing (presurgical Pi and GI < 10%). Patients were seen for professional prophylaxis during the duration of the study. Clinical measurements were performed with an electronic probe at baseline and at reentry 8 months following surgical therapy. Measurements included clinical attachment levels (CAL), gingival margin levels (GML), probing depths (PD), bone defect levels (BDL), and alveolar crest level (ACL). A split mouth design was used. Quadrants were randomly assigned for treatment by GTR (experimental) or open flap debridement alone (control). Standardized radiographs were taken at baseline and at reentry. Digital images were analyzed by subtraction to assess changes in area (A) and optical density (OD). Data were evaluated using paired t test.

RESULTS

Statistically significant differences were found in both groups when comparing baseline and post-treatment values for CAL, GML, PD, and BDL (P < 0.0 1). Greater reductions in BDL and gain in A and OD were observed in the GTR group when compared to control (P < 0.01). Both therapies were effective in improving the clinical parameters assessed.

CONCLUSION

Clinical and radiographic findings from this study demonstrated more bone fill in sites treated with GTR.

Cellular dermal matrix used for root coverage: 18-month follow-up observation

The goal of this study was to evaluate the long-term stability of the root coverage results obtained with an acellular dermal matrix. The mean root coverage at 12 weeks postoperative was 91.7%. The mean root coverage at the final postoperative evaluation (mean 18.6 months) was 87.0%. This difference was not statistically or clinically significant. The root coverage results obtained with an acellular dermal matrix were predictable, esthetic, and stable over time.

Use of bone grafts for the enhancement of a GTR-based root coverage procedure: a pilot case study

The use of guided tissue regeneration (GTR) procedures for the treatment of gingival recession has shown encouraging results and is gaining clinical acceptance. However, attaining space maintenance beneath the membrane remains a problem for clinicians. Hence, the purpose of this pilot case study was to evaluate the effect of adjunctive demineralized freeze-dried bone allograft (DFDBA) placement during collagen membrane GTR-based root coverage procedures. Five patients with Miller Class I or II defects were treated with a combination of DFDBA and collagen membrane. Clinical parameters monitored include recession depth, probing attachment level, probing depth, width of keratinized gingiva, and recession width. Measurements were taken at baseline and 6 months. A statistically significant reduction in recession depth (3.1 +/- 0.7 mm) was observed at 6 months, representing 93.4% total attainable root coverage. A significant reduction of recession width (3.5 +/- 1.2 mm) after 6 months was also noted. Clinically, a statistically significant mean gain of 3.3 +/- 0.6 mm in clinical attachment and 0.8 +/- 0.9 mm in keratinized gingiva were obtained at 6 months. No statistically significant difference was found in probing depth between baseline and 6 months postoperative. Plaque and gingival indices remained low and showed no statistically significant change throughout the study period. Results from this pilot case study indicate that use of DFDBA during collagen membrane GTR-based root coverage could be beneficial.

Acellular dermal matrix allograft in the treatment of mucogingival defects in children: illustrative case report

Mucogingival defects can occur in children and are of particular concern when orthodontic treatment is indicated. The rationale for surgical intervention is predicated on the need to repair the mucogingival defect and to establish adequate thickness of attached gingiva. The free gingival graft, usually obtained from the hard palate, is often used to increase the amount of attached gingiva. The prospect of a second surgical site, and its inherent risks and complications, which may include pain, discomfort, and bleeding, is especially undesirable in children. Important to consider is the possibility that a child may not have adequate tissue thickness at the donor site. A case report is presented utilizing the alternative soft tissue graft, Alloderm, to correct a mucogingival defect prior to orthodontic treatment. Adhering to the free gingival autograft technique, an acellular dermal matrix allograft was utilized at the graft site. The patient revealed good post-operative healing, tissue vascularization, and a healthy zone of attached gingiva at the six month follow up visit. Comparable results to the conventional autograft were obtained with less surgical time, surgical sites, and discomfort to the patient.

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

BACKGROUND

Many surgical techniques have been shown to be effective in correcting gingival recessions by covering the exposed root with soft tissue; however, the thickness of the gingival tissue over the root surface probably plays an important role in preventing the recurrence of tissue recession. The aim of the present study was to compare the results of a mucogingival bilaminar technique (BT), guided tissue regeneration (GTR), and a combined periodontal regenerative technique (CPRT) in achieving root coverage and increasing the gingival thickness 1 year after surgical treatment.

METHODS

In 45 systemically healthy, non-smoking patients aged 33.6 +/- 4.3 years with no periodontal pockets >4 mm, a Miller's Class I or II gingival recession was treated for root coverage: 15 patients underwent BT (connective tissue with partial-thickness double pedicle graft), 15 GTR by a bioabsorbable membrane, and 15 CPRT by a collagen membrane and collagen-incorporated hydroxyapatite. Before and 1 year after surgical treatments, the following clinical parameters were recorded: gingival recession (GR), probing depth (PD), clinical attachment level (CAL), keratinized tissue width (KT), and gingival thickness (GT); the percentage of root coverage was also calculated and the data were statistically analyzed.

RESULTS

All 3 techniques yielded significant improvements in terms of GR decrease, CAL and KT gain, and GT increase compared to baseline values. Mean root coverage was 90.0%, 81.01%, and 87.12% in BT, GTR, and CPRT groups, respectively. Complete root coverage was observed in 60%, 40%, and 53.3% of subjects from the BT, GTR, and CPRT groups, respectively. No significant differences were observed among the 3 techniques in GR or CAL improvements; however, BT produced a significantly (P<0.01) greater increase of KT, and BT and CPRT groups showed a significantly (P<0.01) greater increase of GT compared to the GTR group.

CONCLUSIONS

BT, GTR, and CPRT successfully treated gingival recession defects, obtaining comparable percentages of root coverage, but BT and CPRT created a thick gingival tissue significantly greater than that achieved with GTR.

Human histology of new attachment after root coverage using subepithelial connective tissue graft

BACKGROUND, AIMS

Connective tissue grafts are used successfully in periodontal therapy for root coverage. However, reports on the histologic interface between the root surface and the grafted tissue have been few in number. This report describes a case study in which a subepithelial connective tissue graft was placed in a 27-year-old female on the maxillary left side.

METHODS

The graft (15 mm long, 10 mm wide, 1.5 mm thick) included palatal periosteum and was placed with the periosteal side facing the exposed bone and root surfaces.

RESULTS

15 weeks after grafting, the teeth presented with residual recessions of 1 mm, and buccal probing depths were approximately 1 mm. 14 months post-surgery, the 1st maxillary premolars on both sides were extracted for orthodontic therapy. Clinical parameters at the graft site remained as at 15 weeks. Histologic analysis of tooth #24 showed that the sulcular epithelium was keratinized; epithelium lining the dentin exhibited rete ridges projecting into the gingival connective tissue; and junctional epithelium extended over new cementum. New connective tissue attachment was also observed, including periodontal ligament.

CONCLUSION

Biological width was comparable pre- and post-surgery, indicating a real gain in attachment of 3.9 mm.

Coronally advanced flap procedure: is the interdental papilla a prognostic factor for root coverage?

BACKGROUND

This study was designed to verify if the dimension of the interdental papilla may be a prognostic factor for the clinical outcome of the coronally advanced flap (CAF) in the treatment of gingival recessions.

METHODS

Thirty-three Miller Class I recessions were treated in 33 patients using the CAF procedure. Two types of measurements were performed: 1) clinical measurements (probing depth, recession depth, width of keratinized tissue, clinical attachment level) were recorded at baseline and 3 months after surgery and 2) all recessions were photographed and transformed into computer images. A specific software allowed recording of both linear and square measurements. The following digital measurements were recorded at baseline: 1) base, height, and area of the mesial and distal papillae adjacent to the involved tooth and 2) width/depth of the recession and the area of the exposed root surface of the involved tooth. The residual recession area, if any, was recorded 3 months after surgery. The digital measurements of the height and of the area of the papilla were used in statistical analysis (multiple linear regression and logistic regression) to evaluate a possible correlation with root coverage (mm2) and/or with complete root coverage.

RESULTS

Root coverage was not significantly correlated to the papilla area (P= 0.3692) or to papilla height (P= 0.0968). The complete root coverage was not correlated to the papilla area (P= 0.3181), but it was correlated to papilla height (P= 0.0499).

CONCLUSIONS

This study indicates that the root coverage following CAF procedure is not significantly correlated to papilla dimension. However, complete root coverage is significantly more frequent in sites with lower height of the adjacent papilla.

Coronally positioned flap procedures with or without a bioabsorbable membrane in the treatment of human gingival recession

BACKGROUND

A variety of surgical techniques have been used to cover recession type defects. New data have indicated that the outcome of coronally positioned flap procedures may be augmented by supporting the flap with a membrane.

METHODS

The present study aimed at comparing the clinical outcome following treatment of localized gingival recessions by a coronally positioned flap procedure alone, or combined with a bioabsorbable membrane. Twenty patients with buccal bilateral Miller Class I or Class II gingival recessions in cuspids or premolars participated in the study. The split-mouth design, randomized selection of site treatment, and blind evaluation provided 20 sites in a membrane group and 20 sites in a non-membrane group for examination at baseline, and at 3 months and 6 months postoperatively. Clinical variables included the apical extent of the gingival recession, the width of the recession defect measured at the cemento-enamel junction (CEJ), and the width of keratinized tissue at the recession site as well as probing depth and attachment level.

RESULTS

Both treatments resulted in a significant gain (P <0.0001) of root coverage, amounting to an average of 2.3 mm in the membrane group and 2.5 mm in the non-membrane group at the 6-month evaluation. There was no significant difference between the treatments. Similarly, a significant gain of clinical attachment level was seen in the membrane (1.3 mm; P <0.001) as well as in the non-membrane (1.5 mm; P <0.0001) group, but without a significant difference between the groups. The reduction of the recession width from baseline to 6 months was significantly greater (P <0.01) for the non-membrane (2.3 mm) than for the membrane (1.4 mm) group. Probing depth changes were small and not significant for either of the treatments. When patients were grouped as smokers (8) and non-smokers (12), no significant differences were revealed for any of the response variables. Overall, among the 20 membrane sites, one showed no change while the remaining 19 gained root coverage at the 6-month examination. Five sites obtained coverage to the CEJ. Among the non-membrane sites, all gained root coverage at 6 months and 10 sites showed complete coverage to the CEJ.

CONCLUSIONS

The coronally positioned flap operation offers a predictable, simple, and convenient approach as a root coverage procedure in Miller Class I and Class II recession defects. Combining this technique with the placement of a bioabsorbable membrane does not seem to improve the results following surgical treatment of such defects.

Citric acid demineralization and subepithelial connective tissue grafts

BACKGROUND

The present study was designed to evaluate the effect, if any, of citric acid root demineralization in the outcome of subepithelial connective tissue grafts performed to cover localized gingival recessions.

METHODS

Thirty-six patients participated, each providing one gingival recession; 19 received citric acid demineralization, while 17 did not. All were treated surgically with subepithelial connective tissue grafts and followed for 6 months. At baseline and 6 months, the following parameters were recorded: plaque index, gingival index, recession height, probing depth, recession width, and amount of keratinized tissue. Data were analyzed statistically to 1) evaluate the results achieved with each procedure individually over time and 2) compare the results obtained with the 2 procedures after 6 months.

RESULTS

Results showed significant reductions in recession height after 6 months independently of whether citric acid was applied or not (2.79+/-0.79 versus 2.56+/-0.73). Similarly, recession width was significantly reduced (3.74+/-1.19 versus 3.50 +/-0.73), and the width of keratinized tissue was significantly increased (2.47+/-1.6 versus 2.3+/-1.2). No significant changes in probing depth were found (-0.16+/-0.06 versus -0.13+/-0.81). No significant differences were found when both techniques were compared in any one of the parameters analyzed (all P >0.30).

CONCLUSIONS

It is concluded that: 1) the subepithelial connective tissue graft procedure provides a satisfactory solution in the treatment of localized gingival recessions, and 2) citric acid demineralization does not affect the clinical outcome of the surgical technique.

Increasing the amount of attached gingiva using a modified apically repositioned flap

The purpose of this study is to describe a modification in the apically repositioned flap technique. Unlike the original technique, this technique preserves the marginal gingiva thus avoiding the risk of recession. It is recommended in cases where an increase in attached gingiva is desired. This study reports on the results of 54 single buccal areas consecutively treated in 38 healthy patients. The increase in the amount of attached gingiva, the impact on marginal tissue recession, and the impact on probing depth were analyzed. All 54 areas were evaluated at 8 weeks; 21 areas were analyzed for 24 weeks; and 19 areas for a period of 72 weeks. The final measurements were compared to baseline values. The analysis of variance of measurement (ANOVA) shows a significant increase of keratinized and attached gingiva (P <0.001). There was no statistical change in marginal tissue recession (P = 0.370) or probing depth. The results of this study demonstrate that this modification of the apically repositioned flap is effective and efficient for increasing the height of attached gingiva. This surgical procedure produces minor surgical trauma and does not require palatal donor tissue or membrane placement. It is simpler since it is less time-consuming, requires no suturing, and results in an ideal color match of tissue.

Comparative clinical study of a bioabsorbable membrane and subepithelial connective tissue graft in the treatment of human gingival recession

BACKGROUND

Connective tissue grafts and guided tissue regeneration (GTR) are the most current procedures in the treatment of gingival recession, but very few clinical comparative studies have been conducted.

METHODS

The purpose of this study was to compare 2 types of treatment of gingival recession in the same patients. Fourteen pairs of Miller Class I defects were selected in 14 patients. In each pair, one recession was randomly assigned for treatment by GTR using a bioabsorbable membrane, and the other treated by subepithelial connective tissue graft (CTG). Height of recession (HR), clinical attachment level (CAL), probing sulcus depth (PSD), height of keratinized tissue (HKT), and distance from the cemento-enamel junction to the mucogingival junction (CEJ-MGJ) were recorded before surgery and 6 months postoperatively.

RESULTS

The initial width and height of recession were, respectively, 3.73 mm (SD 0.56) and 3.85 mm (SD 1.15) for the CTG group, and 4.04 mm (SD 0.92) and 4.28 mm (SD 1.20) for the GTR group. The differences were not significant. CAL changes were not different. Both in the CTG group and in the GTR group, mean HR reduction was 2.89 mm (SD 1.18), representing a mean root coverage of 76% and 70.2%, respectively. The difference was not significant. HKT mean gain was significantly greater (P = 0.0001) with CTG (2.03 mm, SD 0.92) than with GTR (0.42 mm, SD 0.91). The GTR technique displaced the mucogingival junction significantly (P = 0.007) more coronally (2.35 mm, SD 1.44) than the CTG technique (0.78 mm, SD 1.23).

CONCLUSIONS

Within the limits of this study, no difference could be found between subepithelial connective tissue graft and GTR with a bioabsorbable membrane with regard to root coverage, but the GTR technique did not increase the height of keratinized tissue and displaced the mucogingival junction more coronally at 6 months.

A comparison of 2 root coverage techniques: guided tissue regeneration with a bioabsorbable matrix style membrane versus a connective tissue graft combined with a coronally positioned pedicle graft without vertical incisions. results of a series of consecutive cases

Root coverage procedures have become an important part of periodontal therapy. The purpose of this study was to compare 2 techniques, 1) guided tissue regeneration (GTR) with a bioabsorbable polylactic acid softened with citric acid ester membrane and 2) the connective tissue graft combined with a coronally positioned pedicle graft without vertical incisions. The GTR procedure produced a mean root coverage of 92.3% and the connective tissue graft combined with a coronally positioned pedicle graft, 95.0%. This difference was not statistically significant. Both procedures produced similar reductions in recession depth, recession width, and probing depth. The connective tissue graft combined with a coronally positioned pedicle graft resulted in a greater increase in the amount of keratinized tissue. Based on this study, both procedures can result in statistically similar amounts of mean root coverage, but the results are not identical. In most cases, the connective tissue with coronally positioned pedicle graft produced a more bulky result than guided tissue regeneration. Therefore, the procedures are not interchangeable.

Treatment of gingival recession with titanium reinforced barrier membranes versus connective tissue grafts

It was the aim of this study to compare barrier membrane therapy with connective tissue grafts in the treatment of recession defects. Fifteen patients with 2 paired vestibular recession defects participated in the study. After thorough scaling and root surface conditioning with tetracycline-HCl, defects were randomly assigned to 1 of 2 treatment modalities. In one of the defects, a trapezoidal mucoperiosteal flap was prepared, and a titanium reinforced expanded polytetrafluoroethylene membrane was adapted to the defect and secured by a sling suture. The membrane was subsequently covered by a coronally positioned flap secured with crown attached sutures. The other defect was treated with a connective tissue graft employing the "envelope technique." Twelve months after therapy, both treatment modalities showed significant root coverage and probing attachment gain. Gingival recession decreased from 3.6+/-0.7 mm to 0.5+/-0.5 mm for membrane treated defects and from 3.6+/-1.0 mm to 0.5+/-0.5 mm following use of grafts, corresponding to mean root coverages of 87.1% and 86.9%, respectively. Mean gains of keratinized tissue of 1.5 mm (membrane) and 2.5 mm (graft) could be observed. Thus, the results of this study demonstrate that both titanium reinforced barrier membranes and connective tissue grafts can be successfully used to treat periodontal recession defects.

Mucogingival versus guided tissue regeneration procedures in the treatment of deep recession type defects

The objective of the study was to compare the clinical efficacy of 3 surgical approaches in the treatment of deep recession type defects. Fifty-four (54) gingival recessions > or = 5 mm were randomly assigned to 1 of the 3 treatment groups by blocking the prognostic variables. The first group was treated with a guided tissue regeneration (GTR) procedure using a bioabsorbable membrane, the second with non-resorbable membrane, and the third with a mucogingival surgical approach consisting of a connective tissue graft combined with a coronally advanced flap (bilaminar technique). No differences, in terms of baseline oral hygiene and defect characteristics, were observed among the 3 groups showing an effective blocking approach. The 1-year results indicated that 1) all treatment approaches resulted in clinically significant root coverage and attachment gain; 2) a statistically significant treatment effect (P = 0.012, ANOVA) was observed comparing the bioabsorbable (4.9+/-0.3 mm), the non-resorbable (4.5+/-0.8 mm), and the bilaminar (5.3+/-0.7 mm) groups, in terms of root coverage; 3) the difference in terms of root coverage between the bilaminar and the non-resorbable membrane groups was statistically significant while differences between the 2 GTR groups or between the bilaminar and the bioabsorbable membrane groups did not reach statistical value; 4) the 95% confidence intervals for the proportions of complete successes showed a similar pattern; 5) no statistical difference was demonstrated in the amount of attachment gain among the 3 groups (P=0.73, ANOVA). A regression model showed that the amount of root coverage was significantly affected by the initial recession depth, the procedure and smoking habits: a poorer root coverage result is expected in case of shallow recession type defects, when either bioabsorbable (P < 0.05) or non-resorbable (P < 0.001) membranes are used instead of a bilaminar technique and if the patient smokes (P < 0.01). It was concluded that the mucogingival bilaminar technique is at least as effective as GTR procedures in the treatment of gingival recession > or = 4 mm and thus recession depth is not the parameter which influences the selection of the surgical procedure.

Creeping attachment associated with the connective tissue with partial-thickness double pedicle graft

The occurrence of creeping attachment has been documented with epithelialized autogenous masticatory mucosa grafts (free gingival grafts) and suggested in other root coverage techniques. The purpose of this study was to examine whether or not creeping attachment occurred after a connective tissue with partial-thickness double pedicle graft had been performed. This study examined 22 defects, in 19 patients, treated where less than complete root coverage was obtained at 4 weeks postoperative. Creeping attachment occurred in 21 of the 22 defects (95.5%), in 18 of the 19 patients (94.7%). Complete root coverage occurred in 17 of the 22 defects (77.3%), in 15 of 19 patients (78.9%). The mean creeping attachment obtained was 0.8 mm. Additionally, it was the goal of this study to see if any factor could be associated with creeping attachment. This study did not find any factors that could be associated with the amount of creeping attachment seen. Creeping attachment seems to occur commonly, but complete root coverage is not predictable.

Clinical evaluation of tetracycline HCl conditioning in the treatment of gingival recessions. A comparative study

Thirty Class I and Class II recessions in 30 patients were treated with a modified subepithelial connective tissue graft procedure. Fifteen recessions in the test group received a tetracycline hydrochloride (50 mg/ml) root treatment for 5 minutes (TTC-HCl group); the remaining 15 recessions composed the control group and received a citric acid root treatment for 3 minutes (CA group). Clinical assessments were taken at baseline and at 6 months. The differences between treatments were not statistically significant. In the central area of the recession, the mean percentage of root coverage was 81.7% corresponding to a mean percentage of 79.3% and 84.0% for the TTC-HCl and the CA group, respectively. In the test group, 6 of the 15 recessions exhibited complete root coverage; the gingival augmentation was 57.8%. In the control group, 8 of the 15 recessions exhibited complete root coverage; the gingival augmentation was 43.6%. The mean surface area of root exposure was reduced from 11.53 mm2 and 13.30 mm2 to 0.34 mm2 and 0.29 mm2 for the TTC-HCl group and the CA group, respectively. This reduction corresponds to a mean percentage of 97.4% root coverage for both groups. Within the limits of this study, the results indicate that tetracycline hydrochloride and citric acid root conditioning have comparable clinical effects in root coverage surgical therapy. The data also suggest that the measurement of the surface area of the recession is a more accurate criterion in the evaluation of the mean percentage of root coverage than a single central vertical linear measurement.

Gingival hyperplasia: interaction between cyclosporin A and nifedipine? A case report

Treatment with either cyclosporin A or nifedipine may induce gingival hyperplasia. A case report is presented which describes a patient medicated simultaneously with both drugs and who subsequently developed extreme hyperplasia. Could such a severe gingival pathology have resulted from an additive interaction between the two drugs?

Fibrin glue application in conjunction with tetracycline root conditioning and coronally positioned flap procedure in the treatment of human gingival recession defects

A split-mouth clinical study was designed to determine the effect of fibrin glue (FG) in addition to tetracycline HCI (TTC) root conditioning and the coronally positioned flap (CPF) procedure in the treatment of maxillary buccal recession defects. 11 patients presenting with a pair of Class I or II recession defects were selected. After initial therapy, defect-specific and full-mouth oral hygiene standards and gingival condition, recession depth, recession width, probing depth, attachment level, and width of keratinized gingiva were recorded. The surgical procedure included elevation of a full split thickness flap, root debridement and root conditioning with a 10 mg/ml TTC solution for 4 minutes. According to a randomization list, in each patient, 1 defect was treated with topical FG application, while the paired defect did not receive FG. The flap was adapted and sutured coronally to the cemento-enamel junction without tension. Healing was evaluated 6 months postsurgery. Significant recession depth reduction and attachment gain were observed for both treatments. Average root coverage amounted to 65% in FG treated defects and 55% in defects treated with TTC conditioning only. There were no clinical and statistical significant differences between the treatments for any parameter considered. This study suggests that FG may not meaningfully enhance the outcome of the CPF procedure with TTC root conditioning.

Subepithelial connective tissue grafts in the treatment of gingival recessions. A comparative study of 2 procedures

Thirty (30) class I and class II recessions in 30 subjects were treated with a subepithelial connective tissue graft procedure. In one group (15 sites), the surgery was carried out in a traditional fashion: the epithelial collar of the graft was preserved and left exposed (CTG group). In the second group (15 sites), the epithelial collar of the graft was removed and the recession areas were conditioned with citric acid. The graft was then sutured and completely immersed under the facial flap which was coronally repositioned (CR group). Clinical assessments included probing depth, probing attachment level, surface area of the recession, and gingival width. These measurements were taken at baseline and at 6 months. In addition, an esthetic evaluation was done. The differences between treatments were not statistically significant except for the augmentation of gingiva (P < or = 0.05). Based on the midfacial measurements taken in the central area of the recession, the mean percentage of root coverage was 69.2%. In the CR group, 3 of the 15 recessions exhibited complete root coverage; the gingival augmentation was 65.5%. In the CTG group, 5 of the 15 recessions exhibited complete root coverage; the gingival augmentation was 94.4%. The mean surface area of root exposure was reduced from 13.82 mm2 and 13.67 mm2 to 2.15 mm2 and 2.34 mm2 for the CR group and the CTG group, respectively. One-hundred percent (100%) of good-to-moderate esthetic results were found by a panel of independent examiners; there was tendency toward better results in the CR group.(ABSTRACT TRUNCATED AT 250 WORDS)

Histologic assessment of new attachment following the treatment of a human buccal recession by means of a guided tissue regeneration procedure

A deep, long-standing recession on a mandibular incisor was treated in a 56-year-old female patient. The tooth was tilted buccally and was scheduled for extraction. The recession was 8 mm deep, with a pocket depth of 1 mm and no keratinized tissue. The recession was treated by guided tissue regeneration; the membrane was left in place for 4 weeks. The tooth was extracted along with marginal tissues 5 months after the removal of the membrane. At the time of extraction, 4 mm of root coverage had been achieved and 3 mm of keratinized tissue were measured buccally. Histologic measurements showed that 3.66 mm of new connective tissue attachment had been obtained associated with newly formed cementum (2.48 mm) and bone growth (1.84 mm). The crestal bone level after treatment was located coronal to the preoperative location of the gingival margin.

Guided tissue regeneration versus mucogingival surgery in the treatment of human buccal gingival recession

A surgical technique involving membranes was used to treat localized human buccal recessions 3 mm to 8 mm. The results on 25 patients (test group) were evaluated 18 months postoperatively and compared with the results obtained in 25 other patients (control group) having undergone mucogingival surgery. In the test group, a trapezoidal flap with a large base was raised beyond the mucogingival junction. The exposed root surface was scaled thoroughly to a concave shape. A membrane was bent and adapted onto the concave root surface. The flap was sutured far coronally and the membrane removed one month later. The control patients underwent a 2-step procedure, consisting of a free gingival graft and a coronally positioned flap. The amount of root coverage obtained was similar in the 2 groups (test = 72.73%; control = 70.87%), although the clinical attachment gain (test = 5.12 mm; control = 3.56 mm) and pocket variation (test = 1 mm reduction; control = 0.06 mm increase) differed significantly (P < 0.001). The keratinized tissue width was greater in the control group. The regression analysis showed that the amount of covered root surface after treatment was in strict correlation with the depth of the original recession in the test group, while no correlation was found in the control group. The expected root coverage was greater in the test group when the recession was greater than 4.98 mm, while it was greater in the control group when the recession was less than 4.98 mm. These results indicate that a guided tissue regeneration procedure can be used to successfully treat recession. The membrane procedure compared favorably with the mucogingival surgery in the treatment of deep recession.

Effect of free gingival grafts on naturally-occurring recession in miniature swine

Miniature swine exhibit naturally-occurring, progressive recession on facial surfaces of the permanent mandibular incisors. The purpose of this study was to determine whether placing a free gingival graft to augment the width of keratinized gingiva of mandibular incisors in miniature swine would prevent or retard recession at the grafted site compared to an untreated contralateral control site. In 8 litter-mate miniature swine, free gingival grafts were placed on the facial surface of the permanent central and lateral incisors on one side of the mandible. The contralateral mandibular incisors did not receive any treatment and served as controls. Clinical measurements, including eruption, recession, pocket depth, attachment level, and keratinized gingival width were obtained preoperatively, 2 to 3 weeks after surgery to assess the success of gingival augmentation, and 3, 6, and 9 months postoperatively. Eight grafted sites were successful and showed significant augmentation of the keratinized gingival width, with a mean increase of 5.8 +/- 0.7 mm, while 6 grafts failed and showed a slight decrease in the mean width of -0.4 +/- 0.5 from the preoperative to postoperative examination. All sites showed significant recession during the experimental period. Successful sites showed no statistically significant or clinically major difference in the rate or amount of recession than contralateral control sites. By 9 months, the average increase in recession from the baseline examination was 2.8 +/- 1.5 mm for successfully grafted sites and 2.6 +/- 1.3 mm for contralateral controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Guided tissue regeneration in the treatment of human facial recession. A 12-case report

A guided tissue regeneration procedure was used to treat human buccal recessions, 3 to 7 mm deep, in 12 patients. No procedure for increasing the width of keratinized tissue was performed prior to treatment. A thick bipedicled flap was raised with a semilunar incision in the alveolar mucosa and a marginal incision was extended to the adjacent papilla. The root surface was made concave by curets and burs to create space for regeneration. The membrane was fixed to the cemento-enamel junction and covered by the flap which consisted of the residual gingiva and of alveolar mucosa. The membranes were removed 4 weeks after placement. The patients were recalled 6 months after the reentry procedure. The average reduction in recession was 2.50 mm (P less than 0.01) and the average attachment gain was 2.84 (P less than 0.01). Pocket depth was slightly reduced (0.33 mm), although the degree of reduction was not of statistical significance. The width of keratinized tissue increased slightly (0.83 mm). These results demonstrate the possibility of treating human buccal recessions by means of a guided tissue regeneration procedure, with predictable recession reduction and attachment gain. A minimal amount of keratinized tissue was needed.

Significance of probing force for evaluation of healing following periodontal therapy

The present report compares pre- and postoperative probing pocket depths and probing attachment levels in deep pockets treated non-surgically as well as surgically using probing forces at 0.25 N, 0.50 N and 0.75 N. The results demonstrated that the recorded mean pre- and postoperative probing depths were deeper with increasing probing force. In deep preoperative pockets, the difference amounted to as much as 2.0 mm comparing measurements at 0.25 N and 0.75 N. The use of 0.25 N for evaluation of therapy showed less mean pocket reduction and probing attachment gain than the use of 0.50 N or 0.75 N. Selection of a higher probing force before therapy (i.e. 0.75 N) and a lower force after therapy (i.e. 0.25 N) resulted in increased values for pocket reduction and probing attachment gain compared to use of the same probing force for both pre- and postoperative recordings. The findings emphasize the significance of using a known and standardized probing force for evaluation of results following periodontal therapy.

A direct technique with a double lateral bridging flap for coverage of denuded root surface and gingiva extension. Clinical evaluation after 2 years

We are introducing a new surgical technique which enables us to cover gingival recessions and extend the gingiva with a one-step procedure. This method can be described generally as a combination of a coronally repositioned flap and a modified vestibulum plastic. So far this method has been applied to 55 teeth of 19 different patients. The results have been observed for 2 years. After this time, 54.4% (30 teeth) still had complete coverage of the previously denuded root surfaces. The results show that it is possible to cover gingival recessions without increasing the zone of keratinized gingiva.

Pocket epithelium removal via crestal and subcrestal scalloped internal bevel incisions

This study assessed the extent of pocket epithelium removal by crestal and subcrestal scalloped inverse bevel incisions during mucoperiosteal flap surgery. Fifty-six gingival biopsies were obtained from 52 participants, who had extractions of periodontally involved teeth. Sulcular incisions which severed the epithelial attachment served as controls. Experimental scalloped internal bevel incisions were made: (1) at the gingival crest extending apical to the osseous crest (crestal incision) and (2) 1 to 2 mm apical to the gingival margin extending apical to the osseous crest (subcrestal incision). In the two procedures the initial incisions were followed by sulcular incisions to sever the epithelial attachment. After both crestal and subcrestal incisions full thickness flaps were reflected, pocket contents were removed, and flaps were replaced against the teeth. Gingival biopsies were then obtained from control and experimental sites followed by extraction of teeth. All specimens were processed, embedded in paraffin, sectioned, stained with hematoxylin and eosin and examined for residual pocket epithelium. Control incisions eliminated pocket epithelium in two of 20 specimens. Crestal incisions eliminated pocket epithelium in 11 of 25 areas, while subcrestal incisions eliminated pocket epithelium in 13 of 25 areas. All 10 papillary areas treated by crestal incisions and 8 of the 10 papillary areas treated by subcrestal incisions displayed residual pocket epithelium. Neither crestal nor subcrestal scalloped internal bevel incisions consistently eliminated all pocket epithelium.

[Krioélektronika-1 cryogenic dental unit]

The cryogenic dental unit "Cryoelectronica-1" is recommended for therapy of parodontosis and oral mucosa diseases. It is built on the closed-loop throttle cooling system. The unit is easy and safe in use and provides continuous operation during years non-requiring the refill with coolants. Supplied with handpieces of various configurations the unit may be used in dermatology, urology, otorhinolaryngology.

The free autogenous gingival graft

The free autogenous gingival graft is an excellent surgical procedure for treating gingival extension. It is a procedure that can be performed rapidly with little postoperative trauma to the patient. Its greatest feature is the high degree of predictability of success in producing a specific dimension of masticatory mucosa. However, we have a moral and ethical obligation to our patients to be more selective in its use in treating gingival recession. Too many patients have been subjected to unnecessary surgery, especially in cases in which the recession has been of long duration and is stable. In the maintenance of such cases, surgical intervention should be elective to solve problems of maintenance of the dentoginginval junction as they arise. As a result of the innovations from the 1970s, the gingival graft procedure appears to be extremely versatile. It will probably undergo further innovative developments in the future as a procedure to be extremely helpful to the restorative dentist. We have already seen its use in new attachment procedures, for improving the edentulous ridge for denture prosthesis, and in other restorative procedures.

[The corrective phase of periodontal therapy]

After pointing to the hygienizing phase which must in any case precede, the author deals with the medicinal local and general treatment, the occlusal function diagnosis, the function analysis, and the fundamentals of the grinding therapy. Furthermore, the temporary splinting, the treatment of secondary malpositions and problems as well as methods of periodontal surgery are mentioned.

[Uses of collagen in the treatment of periodontal bony pockets]

The use of collagen to fill periodontal bony pockets was tested in a clinical study. The material appears to be well suited for the reconstruction of two- to three-wall defects and for filling furcations.

Recession: a 4-year longitudinal study after free gingival grafts

Free gingival grafts were performed on recession areas around 42 teeth in 12 patients, with postoperative evaluation of recurrent recession after 1, 6, 12, 24 and 48 months. No changes in degree of recession were observed during the 4-year period. The vestibuloplasties, which were always wider than the transplants, exhibited recurrence up to the transplant margin 6 months after surgery, while the transplants themselves exhibited an average shrinkage of 25%. In addition, 25% of the increase in vestibular depth achieved by the surgery was lost 1 month postoperatively, but there was a tendency toward increasing vestibulum depth during the ensuing 47 months. Gingival sulcus depth was not affected by the surgery.