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doi: 10.1902/jop.2010.090701
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Volume 81 Number 7
up to the nearest 0.5 mm (Fig. 1). These measurements were performed by a single masked examiner
(MM) 7 days before the surgeries. She did not perform
the surgeries and did not make the clinical measurements after surgery. Before the study the examiner
was calibrated to reduce intraexaminer error (k >0.75)
to establish reliability and consistency.
Clinical Measurements
Clinical measurements were carried out by a single
masked examiner (CM). He did not perform the surgeries and was unaware of the predetermined level of root
coverage. Before the study, the examiner was calibrated to reduce intraexaminer error (k >0.75) to establish reliability and consistency.
Full-mouth and local plaque scores were recorded
1 week before the surgery (baseline) and 3 months
after the surgery as the percentage of total surfaces
(four aspects per tooth) that revealed the presence
of plaque.9 Bleeding on probing was assessed dichotomously at a force of 0.3 N with the manual pressuresensitive probe. Full-mouth and local bleeding scores
were recorded as the percentage of total surfaces
(four aspects per tooth) that bled on probing. The distance from the StRP and the most apical extension of
the GM was measured at baseline, 15, 30, and 90 days
after the surgery at the mid-buccal aspect of the study
teeth (Fig. 1). Probing depth, the distance from the
GM to the bottom of gingival sulcus, was measured
at baseline and 3 months after surgery. All measurements were rounded up to the nearest 0.5 mm.
Surgical Techniques
The surgeries were performed by an experienced
periodontist (GZ). He was unaware of the predetermined level of root coverage and did not make the
clinical measurements.
Based on his own experience the periodontist (GZ)
decided to perform a CAF with (SCTG) or without connective tissue graft. Main factors influencing the decision to add a connective tissue graft were the lack of
keratinized tissue apical to the root exposure, the need
to increase the soft tissue thickness,10 and the presence of a deep abrasion defect (Fig. 2). In the case
of single-type recession defects, the modified CAF
approach described by De Sanctis and Zucchelli11
was used, whereas the envelope-type of CAF described by Zucchelli and De Sanctis12 was performed
in the case of multiple gingival recessions affecting
adjacent teeth in the same quadrant of the jaw.
Post-surgical Infection Control
Patients were instructed not to brush teeth in the
treated area, but rinse for 1 minute with a 0.12%
Pattern Resin, GC Italy, San Giuliano Milanese, Italy.
PCP-UNC 15 probe tip, Hu-Friedy, Chicago, IL.
i Brodontic spring device, Dentramar, Waalwijk, Holland.
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Figure 1.
A) Distance between StRP and GM measured at baseline at the mid-buccal aspect of a study tooth.
B) Distance between StRP and MRC at the mid-buccal aspect of a study tooth. C) Distance between
StRP and GM measured 15 days after surgery, at time of suture removal, at the mid-buccal aspect
of a study tooth. D) Distance between SRP and GM measured 90 days after the surgery at the midbuccal aspect of a study tooth. This distance coincides with the distance SRP-MRC measured before
surgery.
surgery were within the range expected for data from a normal distribution (i.e., within the range of
-2 and +2).
Thus, a general linear model
was fitted and multiple-regression
analysis of variance for repeated
measures with teeth nested in
patients was used to evaluate the
existence of any significant timerelated difference (15, 30, and
90 days after surgery) regarding
the StRP-GM distance. In case of
significance, the Bonferroni t test
was applied as a multiple comparison test.
A general model, considering
teeth nested in patients, was also
fitted to relate the agreement
(presence or absence of any significant difference in the coincidence between the StRP-MRC
distance measured before the surgery and the StRP-GM distance
measured 90 days after the surgery) with the two techniques
(CAF versus SCTG) and the jaw
(gingival recessions belonging to
the mandible or maxilla) and to relate the number of cases with overestimation and underestimation of
the level of root coverage between
the two techniques (CAF versus
SCTG).
RESULTS
Following the initial oral hygiene phase and at the
post-treatment examinations, all subjects showed
low frequencies of plaque-harboring tooth surfaces
(full-mouth plaque score <20%) and bleeding gingival
units (full-mouth bleeding score <15%), indicating
good standard of supragingival plaque control during
the study period.
A total of 135 (90 in the maxilla and 45 in the mandible) gingival recessions were treated. Ten recessions were treated with the single-flap approach:
four (three upper canines and one upper premolar)
with CAF and six (three lower canines, one upper canine, one upper premolar, and one lower incisor) with
SCTG. A total of 125 recession defects (in 40 patients,
mean number of treated teeth per patients was 3.12
0.9 with a range 2 to 5) were treated with the envelope-type surgical approach. Sixty-six defects (58
in the maxilla and eight in the mandible) were treated
SAS, Version 6.09, SAS Institute, Cary, NC.
Figure 3.
Mean and 95% Bonferroni intervals of the distance SRP-GM at 15, 30,
and 90 days after surgery.
Figure 4.
Number of cases with underestimation and overestimation of the
actual level of root coverage in the group of recessions treated with SCTG
or CAF techniques.
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The reduction of the papilla height decreased the potential advancement of the coronally displaced flap
and reduced the vascular exchanges between the soft
tissues covering the root and the interdental connective tissue beds.
The method adopted in the present study was effective in predetermining the position of the soft tissue
margin 90 days after the healing of root coverage surgical procedures: in 97 (71.8%) of the 135 treated gingival recessions, the StRP-MRC distance measured by
an expert periodontist before the surgery exactly coincided with the StRP-GM distance measured 90 days
after surgery by an independent periodontist. No statistically significant difference was demonstrated in
the number of cases with exact predetermination between gingival recessions belonging to the mandible
or maxilla and between gingival defects treated with
CAF or SCTG. Thus, the method was equally reliable
to predetermine the level of root coverage in the gingival defects of the mandible and maxilla, treated by
means of CAF with and without connective tissue graft.
In 24 of the treated gingival recessions (17.7%) the
mean StRP-MRC distance was greater than the StRPGM distance measured 90 days after surgery. Therefore, in these defects, the actual root coverage was
underestimated. Better root coverage results were
achieved with respect to those predetermined before
surgery. Present data do not allow one to discriminate
if the present method resulted in an incorrect predetermination or if better than expected root coverage
results were achieved with surgery. Most of these gingival defects were treated with the SCTG (18 [75%] of
24) and only a few (six [25%]) with CAF alone. This is
in accordance with the data reported in the other studies,8,15 which indicated better results in terms of complete root coverage achieved with SCTG compared to
CAF alone. The presence of a graft under the flap
might give stability to the coronally advanced soft tissue margin and reduce soft tissue contraction.8,13
Thus, one could speculate that at least in some of
the clinical cases of the present study, the adjunctive
use of a graft permitted achievement of better root
coverage outcome than those correctly predetermined. Furthermore, if one considers that the predetermination of root coverage is clinically used to shift
CEJ apically by means of cervical restorations and
that the difference between StRP-MRC and StRP-GM
(range, 0.5 to 1 mm) was equal or lower than the buccal PD in every single treated case, all cases with better actual than expected root coverage outcomes
should be considered clinically and esthetically successful. In fact, in these situations the patients would
not see any exposed dentin in the cervical area and the
finishing line of the restorative material would be confined within the depth of the buccal probing area and
thus easy to clean by the patient and to check by the
clinician or dental hygienist. From a clinical standpoint the data suggest adding a connective tissue graft
below CAF when even more than complete root coverage is the desired outcome.
In 14 (10.3%) of the treated defects the mean StRPMRC distance measured before surgery was lower
than the StRP-GM distance measured at 90 days.
Therefore, in these gingival recessions, the soft tissue
margin did not reach the predetermined level, remaining <1 mm. These should be considered failing outcomes, especially in patients with an esthetic
request, because an exposed dentin area would appear even in the case of elongation of the clinical
crown with a restorative material. Almost all (12 of
14) of these gingival recessions were treated with
CAF alone. It is not in the scope of the present study
to distinguish if the adopted method resulted in an incorrect predetermination or if lower than expected
root coverage results were achieved with CAF procedure. However, it is interesting to note that recent
studies, by the same research group, on the use of
CAF techniques for the treatment of single11 and multiple12 Miller Class I and II gingival recessions reported
percentages of complete root coverage of 88% and
89.3%, respectively. In other words, 10% to 12% of
the gingival recessions treated in these clinical trials
were not covered with soft tissues up to CEJ. This is
very similar to the 10.3% of gingival defects of the
present study, most of them treated with CAF alone,
in which the soft tissue margin did not reach MRC.
From a clinical standpoint, present data suggest increasing the length of the clinical crown (of 1 mm)
by means of the composite restoration when CAF is
used to optimize the esthetic outcome.
CONCLUSIONS
Within the limits of the present study the following
conclusions can be drawn: 1) The adopted method
was able to predict the exact position of the soft tissue
margin 90 days after root coverage surgery in about
72% of the treated gingival defects; 2) The method
was equally reliable to predetermine the level of root
coverage in the gingival defects of the mandible and
maxilla treated by means of CAF or SCTG; 3) The
maximum level of root coverage achieved with surgery was underestimated in 17.7% and overestimated
in 10.3% of the treated defects, however, no data are
available to distinguish if these are incorrect predeterminations or variable outcomes of the surgical procedures; and 4) The cases with better actual than
expected root coverage outcomes should be considered clinically and esthetically successful.
Further multicenter studies with longer-term evaluations are needed to confirm the efficacy of the present method to predetermine the maximum level of
root coverage achievable with surgery.
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ACKNOWLEDGMENTS
This study has been self-supported by the authors.
The authors report no conflicts of interest related to
this study.
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m JL. Mucogingival surgery. In: Lang NP,
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anatomical factors limiting treatment outcomes of
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