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Periodontology 2000, Vol. 75, 2017, 296–316 Printed in Singapore. All rights reserved © 2017 John Wiley
Periodontology 2000, Vol. 75, 2017, 296–316 Printed in Singapore. All rights reserved © 2017 John Wiley

Periodontology 2000, Vol. 75, 2017, 296–316 Printed in Singapore. All rights reserved

© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

PERIODONTOLOGY 2000

Periodontal plastic surgery of gingival recessions at single and multiple teeth

F RANCESCO C AIRO

In the past two decades, clinicians and researchers have demonstrated an increasing interest in mucogingival surgery to reconstruct soft tissue around teeth and implants. Surgical procedures of the mucogingival complex (38) aim at correcting de- fects in the morphology, position, or enhance the dental gingival junction, since defects in the morphol- ogy of the gingival and alveolar mucosa can acceler- ate the course of periodontal disease, or interfere with the successful outcome of periodontal treat- ment(39). The term Periodontal Plastic Surgery, ini- tially suggested by Miller in 1993 (62), became accepted in modern periodontology to denote surgi- cal procedures performed to prevent or correct ana- tomic, developmental, traumatic or disease-induced defects of the gingiva, alveolar mucosa or bone(109). This denition includes different techniques for gingi- val augmentation, root coverage, soft-tissue augmen- tation at dental implants, crown-lengthening procedure, gingival preservation at teeth with ectopic eruption, removal of aberrant frena, prevention of ridge collapse and expansion of the edentulous ridge (109). The purpose of this manuscript is to evaluate the procedures used in periodontal plastic surgery for root coverage at single and multiple recession defects and to assess the clinical and esthetic outcomes of various types of plastic surgery.

Gingival recession: prevalence, etiology, classication and prognosis

Gingival recession, dened as displacement of the soft-tissue margin apical to the cementoenamel junction (7), is a frequent clinical feature in the

general population (11, 98, 99). Loe et al. (55) assessed the prevalence of gingival recession in two cohorts of individuals, 1550 years of age, in a parallel longitudinal study in Norway and Sri Lanka, and showed that the prevalence of recession in Norwe- gians was 60% at 20 years of age, with recession mostly located at buccal surfaces, and that it exceeded 90% at 50 years of age. In the Sri Lankan cohort, gingival recession occurred in more than 30% of individuals before the age of 20 years, in 90% of individuals at 30 years of age (with recession mostly located at interproximal surfaces) and in 100% of individuals at 40 years of age (55). The authors hypothesized that one type of recession was associ- ated with traumatic toothbrushing, involved predom- inantly buccal surfaces and was very frequent in the Norwegian population, and another type of recession was mostly related to periodontal disease, involved predominantly interproximal surfaces and was a common nding in Sri Lanka (55). A recent system- atic review (93) pointed to an association between toothbrushing frequency and recession, although denitive evidence is lacking. Among the possible predictors of gingival recession were duration of toothbrushing, brushing force, frequency of changing the toothbrush, bristle hardness and toothbrushing technique (93). Despite a large amount of data showing that inammation is the key factor in developing peri- odontal osseous defects (81), the etiology of gingival recession remains more obscure. Goldman & Cohen (40), in the 1970s, emphasized the role of inamma- tion in gingival recession and proposed that the inammatory process leads to growth and anastomo- sis of rete pegs of the oral epithelium, favoring the creation of oral clefts. In a rat model, Baker &

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Seymour (12) found that localized gingival inamma- tion led to proliferation of epithelial cells into the connective tissue, which may induce a collapse of the epithelial surface and subsequently gingival reces- sion. Inammation can also lead to connective tissue destruction and marked bone resorption, especially in the presence of a thin buccal cortical plate (105). The accumulation of plaque, possibly irrespective of the overall status of periodontal disease, may cause gingival recession, especially at sites with a thin peri- odontal biotype and difculty in tooth cleaning. Addi- tional predisposing factors for gingival recession include areas with thin, minimal or no keratinized tis- sue (108), orthodontic movement leading to buccal tooth displacement (107), direct trauma associated with class II malocclusion (48) and acute infection with herpes simplex virus (87). Various attempts to classify gingival recession have been published. Miller (64) proposed four classes of gingival recession based on the level of the gingival margin with respect to the mucogingival junction and the underlying alveolar bone level. In Miller class I defects, the recession does not extend to the mucogingival junction; in class II defects, the gingival margin reaches the mucogingival junction but with no loss of interproximal bone; in class III defects, the gingival margin is located at or beyond the mucogin- gival junction with interproximal bone loss and/or tooth malpositioning; and class IV defects show seri- ous interproximal bone loss and/or severe tooth mal- positioning. Miller (64) suggested, based on his clinical experience, that complete coverage of reces- sion defects was feasible only for classes I and II, par- tial coverage was achievable for class III and no root coverage was possible for class IV (64). More recently, Cairo et al. (21) proposed a classica- tion system that identied three types of gingival reces- sion. In this system, recession type 1 includes gingival recession with no loss of interproximal attachment (Fig. 1), recession type 2 is associated with interproxi- mal attachment loss less than or equal to the buccal

site (Fig. 2) and recession type 3 shows more interprox- imal attachment loss than the buccal site (Fig. 3). The reproducibility/reliability of the classication system was found to show an almost perfect intraclass correla- tion coefcient of 0.86. Furthermore, the classication system was able to predict the nal recession reduction with a high level of condence (P < 0.0001), thus sup- porting the importance of analyzing baseline interden- tal clinical attachment loss to assess the prognosis of gingival recession treatment (21). Complementary to the soft-tissue assessment, Pini- Prato et al. (85) have outlined a classication system of dental surface defects in areas of gingival recession, based on the visual presence (A) or absence (B) of the cementoenamel junction, and the presence (+) or absence ( ) of dental surface discrepancy caused by abrasion. Four possible classes (A+, A , B+ and B ) were then identied, and, using this system, 14% of dental surface defects were found to be class A+, 46% class A , 24% class B+ and 15% class B (85). The kappa statistics for intra-observer agreement ranged from 0.74 to 0.95 (almost perfect agreement) and those for interobserver agreement ranged from 0.26 to 0.59 (moderate agreement), suggesting that the classication system constitutes a useful method for identication of root-enamel defects in areas of gingi- val recession (85). An elevated risk of progression of gingival recession may exist in individuals with a high level of plaque control. Matas et al. (58) identied gingival recession in 85% of dental students; re-examination of the same group of individuals, 10 years later, found a signi- cant increase in the mean number of sites with gingi- val recession per individual and in mean recession height, despite excellent plaque control. Furthermore, a recent systematic review assessed the prognosis of untreated gingival recession and found that 78.1% of sites with gingival recession at baseline experienced an increase in recession severity during a 2-year fol- low-up period, and 79.3% of patients showed an increase in the number of recession defects (29). The

A BC
A
BC

Fig. 1. Miller type 1 recession. (A) Buccal recession at the maxillary cuspid. (B) Clinical buccal loss of attachment is 5 mm. (C) The interproximal cementoenamel junction is not detectable at mesial or distal sites.

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AB C Fig. 2. Miller type 2 recession. (A) Buccal recession at the first premolar. (B)
AB
C
Fig. 2.
Miller type 2 recession. (A) Buccal recession at the first premolar. (B) Clinical buccal loss of attachment is 4 mm. (C)

Interdental loss of clinical attachment is 3 mm at the mesial site.

AB C
AB
C

Fig. 3. Miller type 3 recession. (A) Buccal recession at the left central incisor. (B) Clinical buccal loss of attachment is 6 mm. (C) Interdental loss of clinical attachment is 9 mm at the distal site.

data available suggest that untreated gingival reces- sion has a high probability of undergoing further progression, even in the presence of good oral hygiene.

Indications and principles of periodontal plastic surgery for root coverage

The major indications for root-coverage procedures are esthetic requests, treatment of dental sensitivity and increase of keratinized tissue to reduce the risk of defect progression. The clinical goal of the root- coverage procedure is complete root coverage, meaning a location of the gingival margin slightly coronal to the cementoenamel junction with no residual probing depth and with no detectable inammation (18). However, the gingival margin position by itself may not ensure a successful esthetic outcome, as poor esthetics can occur in the presence of an irregular prole of the gingival margin, poor color matching or scar tissue. Impor- tantly, treatment of gingival recession should focus on the total esthetic outcome, not just on complete root coverage (18).

Surgical measures to obtain root coverage involve placement of surgical aps onto exposed roots, often in conjunction with grafts, followed by a series of complex healing events. The surgical ap must have sufcient thickness to accommodate nutritional requirements in order to stabilize over the avascular root. In a pioneering study in a dog model, Wildeman & Wentz (112) divided the healing process after pedi- cle graft surgery into four stages:

Adaptation stage (04 days). The surgical ap is separated from the root by a thin brin layer, and proliferating epithelial cells start to make contact with the root surface. Proliferation stage (421 days). Connective tissue invades the brin layer from the basal level of the ap, and broblasts are detectable near the root surface and differentiate into cementoblasts. Epithelium is detected over the root at the coronal level of the wound, while a thin connective tissue is detectable more apically, even if bers are not inserted into the root at this stage. Attachment stage (2128 days). Fibers are inserted into a layer of new cementum in the apical part of the recession defect. Maturation stage (16 months). An increase in for- mation of collagen bers occurs in this period, leading to a variable amount of connective tissue

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repair coronal to the bone crest and apical to the junctional epithelium. A similar arrangement of broblasts and collagen bers is evident at the level of the crestal alveolar bone. A later study by Kon et al. (52) showed that the highest degree of cellular activity occurred 6 days fol- lowing surgery and was associated with the formation of new connective tissue within the blood clot. Mormann & Ciancio (67), who used uorescein angiography to study gingival vessel formation during healing and variations in gingival blood supply at var- ious ap designs, concluded that the ap base should be wide to incorporate as many supraperiosteal ves- sels as possible, that a certain positive relationship was mandatory between the ap length and the ap base, and that ap tension should be avoided to pre- vent vessel constriction at the time of suturing (67). A subsequent study by Mormann et al. (66) studied experimental wound healing of buccal gingiva; they found ischemia 6 h after the wound injury and that most ischemia occurred for wounds located in the long axis of mandibular incisors. Mid-axial attached gingiva seemed to develop more ischemia than did mid-papillary gingiva, probably because of a more efcient collateral blood supply of the latter (66). The study also suggested that collateral circulation from lateral and marginal vasculature partly prevented the development of ischemia (66). Nobuto et al. (74) examined the effect of blood sup- ply on the healing process following ap surgery and showed that the periosteal vascular plexus communi- cates with the periodontal ligament through Volk- manns canals. A surgical incision interrupts this communication and is followed by an inammatory response (74). The authors also assessed, in dogs, the blood supply after mucoperiosteal ap surgery and showed that, a few days after the mucoperiosteal sur- gery, the periodontal ligament vascular plexus formed new blood vessels toward the bony and root sides, whereas alveolar bone resorption was observed around the openings of Volkmanns canals (71). Osteogenesis surrounding the newly formed blood vessels was detectable 3 weeks later (71). Nobuto et al. (7173) also studied the interface between the perios- teal surface/cortical bone and the inner surface of the ap and showed angiogenesis in the periosteal vascu- lature. At day 3 after surgery, endothelial cells and new blood vessels appeared on the bony side. After 1 week, the new blood plexus interconnected with supraperiosteal blood vessels within the surgical ap, in support of the healing process of the ap (7173). Soft-tissue grafting beneath a surgical ap may complicate healing as the survival of the graft

depends on an adequate blood supply from the recip- ient bed and the overlying ap. Early studies on free gingival grafts in animals showed that, for the survival of the graft, establishment of plasmatic circulation between the recipient bed and the connective tissue side of the graft was crucial before graft revasculariza- tion and surgical wound stabilization (74,78). Nobuto et al. (75) found that the plasmatic circulation during healing originated from supraperiosteal vessels of the recipient bed until day 3, followed by interloop anas- tomoses at day 5. Graft revascularization leads to intersection of the supraperiosteal blood vessels with the pre-existing vascular network of the graft. The graft epithelium simultaneously exfoliates, which is followed by epithelial proliferation from the adjacent tissues to establish new epithelium on the graft. Mature interloop anastomoses and new epithelium become detectable at day 14 and a capillary network is detectable at day 28 (75). A reduction of broblasts and an augmentation in collagen bers with an increase in the thickness of the transplanted graft is evident at day 60 (75). Proper healing of connective tissue grafts may depend predominantly on the vascular ingrowth from the recipient bed. In Beagle dogs, Caffesse and coworkers (41) created gingival recessions surgically and then performed root coverage by placing a con- nective tissue graft beneath a coronally advanced ap. At day 7, a blood clot was formed in the space between the graft and the ap, and ap revasculariza- tion was almost complete from ingrowth of periodon- tal and supraperiosteal blood vessels. The graft was completely vascularized at day 14, and junctional epithelium, with no separation between graft and ap, was formed along the root at day 28. These nd- ings support the hypothesis that a connective tissue graft leads to a rapid and effective revascularization of a periodontal ap and can enable root coverage

(41).

Single gingival recession treatment

Several surgical techniques have been proposed to treat single gingival recessions, mostly based on repo- sitioning keratinized tissue adjacent to the recession site onto the exposed root. In fact, the laterally slid- ing ap, introduced by Grupe & Warren in 1956 (43), was, for decades, considered as the gold standard in the treatment of gingival recession. In the 1960s, the use of soft-tissue allografts became popular to increase apical keratinized tissue and the depth of the vestibule (69). In the modern era, coronally advanced

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ap, or its possible combinations with soft-tissue grafts or biomaterials, has become a common proce- dure to obtain root coverage at single recession sites.

Coronally advanced ap and its combinations for single recession

The coronally advanced ap procedure involves a coronal shift of the soft tissue located apically to the recession to cover the exposed root. In 1926, Norberg (76) outlined aspects of the procedure, but Berni- moulin et al. (13), in 1975, were the rst to describe the coronally advanced ap technique at both single and multiple recessions, which was performed subse- quently to free gingival graft augmentation. In 1989, Allen & Miller (5) proposed a coronally advanced ap technique for single recession that needed no previ- ous gingival augmentation if at least 3 mm of residual keratinized tissue was present. The technique included a split-thickness ap with two vertical- release incisions that was raised beyond the mucogin- gival junction to detach the alveolar mucosa to allow for a coronal shift of the residual keratinized tissue (5). Pini Prato et al. (82), in 1992, combined the coro- nally advanced ap procedure with nonresorbable barrier membranes, and employed a trapeziodal ap with two vertical and divergent incisions into alveolar mucosa to obtain a large base of the ap. The two vertical incisions were connected by a horizontal intrasulcular incision, and the resulting ap was a combined full-thickness (until the mucogingival junc- tion) and split-thickness (beyond the mucogingival junction) ap. Recently, De Sanctis & Zucchelli (37) proposed a modied coronally advanced ap procedure for sin- gle recession sites, performed as follows:

two horizontally bevelled incisions, mesial and distal to the recession defect, located at the papilla bases, with a distance from the tip of the anatomi- cal papillae equal to the depth of the recession plus 1 mm, allowed suturing of the gingival mar- gin coronally to the cementoenamel junction. two bevelled oblique, slightly divergent, incisions starting at the end of the two horizontal incisions and extending to the alveolar mucosa for 34 mm were then made. The resulting ap was a com- bined split-thickness (surgical papilla), full-thick- ness (from the gingival margin until 34 mm of bony exposure) and split-thickness (beyond the mucogingival junction) thickness ap. Muscle insertions in the ap were eliminated apically to the bony exposure to move the ap passively in a coronal direction.

the root surface was mechanically treated with the use of curettes, but only in the area corresponding to the loss of clinical attachment, in order to avoid possible damage to residual connective tissue bers still inserted into the root cementum. The facial soft tissue of the anatomic papillae coronally to the horizontal incisions was de-epithelized. the ap was sutured using a combination of sling (at the level of interdental papillae) and single (at the level of vertical incisions) sutures. Care was taken to position the soft tissue coronally to the cementoenamel junction in order to counteract physiological shrinkage during healing (88) (Fig. 4). De Sanctis & Zucchelli (37) tested this modied coronally advanced ap in a case-series study of sin- gle gingival recessions and found a degree of root cov- erage in 97% of the study sites and complete root coverage in 85%. In recent decades, the addition of a connective tis- sue graft under the pedicle ap has been suggested as a highly predictable approach to obtain root cover- age. Different ap/graft size modications have been described, including an envelopeapproach to posi- tion the graft over the exposed root (3, 92), a reposi- tioned ap with an epithelial-connective and partially exposed graft (53), and coronally advanced aps with (70, 108) or without (14) vertical release incisions, or double papilla aps (46) for covering the connective tissue graft. The use of a connective tissue graft in conjunction with a coronally advanced ap proce- dure was accepted as a reliable method to obtain root coverage and improve esthetics (17, 115). After ap elevation and the elimination of all muscle insertions, a connective tissue graft was harvested from the palate. The dimension of the graft should be approxi- mately 3 mm larger than the dehiscence area and have a thickness of approximately 1 mm. The con- nective tissue graft should be stabilized slightly apical to the cementoenamel junction by single and/or crossed resorbable sutures engaging the lateral/apical periosteum. The ap is then coronally advanced to cover the graft completely and is sutured by a combi- nation of sling and single sutures (Fig. 5). Zucchelli et al. (115) compared this procedure with a similar technique in which a thick graft exceeding the dimen- sion of the dehiscence was placed under the ap. The two bilaminar procedures resulted in similar root coverage, but the modied coronally advanced ap technique yielded better esthetic and postoperative outcomes (115). Harvesting the connective tissue graft for root cov- erage requires operator skill to minimize patient

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A B C D
A
B
C
D
Fig. 4. Coronally advanced flap procedure for single reces- sion. a) buccal recession at maxillary cuspid.
Fig. 4.
Coronally advanced flap procedure for single reces-
sion. a) buccal recession at maxillary cuspid. b) flap raised
and dissected beyond the muco-gingival junction. c) flap is
coronally sutured. d) complete root coverage at 1-year
post-surgery.
A
B
C
D

Fig. 5. Coronally advanced ap procedure with connective tissue graft. (A) Buccal recession at the maxillary cuspid. (B) Flap raised and dissected beyond the mucogingival junction and connective tissue graft is secured at the

morbidity. In the early technique (53), a split-thick- ness ap was raised with two vertical-release inci- sions to access the subepithelial connective tissue graft. Modications of this technique included a sin- gle mesial vertical incision and a single or a double horizontal incision (14, 46, 56). These procedures were associated with primary closure of the palatal site but required adequate soft-tissue thickness. A free gingival graft procedure was later used to obtain the connective tissue graft (120), which included removal of the overlaying epithelium by a surgical blade (de-epithelialized free gingival graft) after har- vesting the graft. Data are inconclusive on the pre- ferred technique for harvesting a connective tissue graft. Initial studies suggest that the completely cov- ered palatal site is associated with a faster healing time than the donor site of the free gingival graft (36, 110), but Zucchelli et al. (120) found no major differ- ence in painkiller consumption, postoperative dis- comfort or bleeding. The connective tissue graft

dehiscence area using periosteal sutures. (C) Flap is coro- nally advanced to cover the graft completely. (D) Complete root coverage 1 year after surgery.

group revealed lower stress and better ability to chew, but analgesic consumption increased with increasing height of the graft and with dehiscence/necrosis of the primary ap (120). Pain was also negatively corre- lated with the residual thickness of the soft tissue cov- ering the palatal bone (120). These data suggest that selection of the grafting procedure depends on the amount of soft tissue required, the tissue availability at the palatal site and the operator experience. A con- nective tissue and a free gingival grafting approach may also lead to different types of tissue graft, as the closed connective tissue graft produces deep connec- tive tissue, while the de-epithelialized free gingival graft technique harvests supercial connective tissue/ lamina propria and has the risk of leaving epithelial islands within the graft. Long-term studies are needed to determine possibly important differences in clini- cal and esthetic performance between the connective tissue graft technique and the free gingival graft tech- nique.

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The need for a second surgical site and high opera- tor skills are constraining factors for tissue grafting with the coronally advanced ap technique and thus various biomaterials/membranes have been pro- posed in lieu of genuine tissue grafts. Barrier membranes (guided tissue regeneration) have been used extensively in past decades to regen- erate connective tissue attachment with gingival recessions (82). A mean root coverage of 4887% was reported for both resorbable and nonresorbable membranes (23). However, membrane exposure and infection were frequent complications that reduced the clinical benet and applicability in modern peri- odontal plastic surgery. Enamel matrix derivative plus coronally advanced ap was applied for root coverage to improve the level of the gingival margin and obtain periodontal regeneration along the root (94). Histologic analysis has described the re-formation of new cementum in the apical part of the dehiscence with inserted collagen bers (94). Clinical outcomes from ran- domized controlled trials showed a mean root coverage ranging from 84% to 94% (23). Clinical trials showed that coronally advanced ap + enamel matrix derivative (Fig. 6) resulted in more root coverage than did coronally advanced ap alone, and also produced a signicant increase in keratinized tissue (23). Collagen matrix placed under a coronally advanced ap was recently used for root coverage (23). Histo- logic analysis revealed that the porcine collagen matrix was able to promote soft-tissue regeneration and periodontal new attachment in experimental recessions in a dog model (104). One randomized controlled trial (50) found that collagen matrix

produced more recession reduction than did coro- nally advanced ap alone, but another randomized controlled trial (60) showed less reduction of reces- sion and similar keratinized tissue gain as coronally advanced ap + connective tissue graft. Further stud- ies are necessary to determine the potential benet of combining collagen matrix with a coronally advanced ap. Root coverage with the addition of acellular dermal matrix (an allograft of cadaveric origin applied under a coronally advanced ap) was tested in different clinical trials. The results showed mean nal root coverage ranging from 50% to 97% and a great variability of the clinical benets (17). The critical review of available evidence suggests caution in employing acellular dermal matrix to treat single gingival recessions (23). The free gingival graft is the most effective proce- dure to obtain gingival augmentation at sites with a minimal amount of keratinized tissue (102). Great variability in outcome is reported when using free gingival graft for root coverage, probably because of inadequate blood supply when the free gingival ap is placed over an exposed root. The reported amount of root coverage ranges between 11% and 87% (mean 63%) (109). An improvement in clinical outcome may be expected if applying a very thick and large graft, which is able to capture a large blood supply from the periosteum adjacent to the dehiscence area (63). The gingival margin position over the root surface may gradually improve over time through creeping attachment, which connotes the process of coronal migration of the long-junctional epithelium over the root (1, 59). Free gingival graft may also be applied using the two-stage technique, which includes initial

A B C D
A
B
C
D

Fig. 6. Coronally advanced ap pro- cedure in combination with enamel matrix derivative. (A) Buccal reces- sion at the maxillary premolar. (B) Application of enamel matrix deriva- tive over the root after ap elevation. (C) The ap is coronally advanced and sutured. (D) Complete root cov- erage 1 year after surgery.

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Plastic surgery for gingival recession

augmentation of gingiva apically to the recession area and coronally advanced ap surgery 3 months later (13). This technique allows for a reduction of the orig- inal graft size. However, scar tissue formation at the donor site and lack of color matching at the recipient site can limit the use of free gingival graft for root cov- erage. A preferred area of indication for the free gingi- val graft is still root coverage at mandibular incisors with a minimal amount of baseline keratinized tissue (Fig. 7). The laterally sliding ap or laterally positioned ap was long considered the gold-standard tech- nique for treatment of a single gingival recession when an adequate amount of keratinized tissue was available lateral to the recession site (43). Dif- ferent modications of the original technique were proposed, including the use of a partial thickness ap (100), a submarginal incision at the donor site to preserve marginal tissue at adjacent teeth (44), a mixed-thickness ap for moving the full-thickness part of the ap over the root (95) and lateralcoro- nal advancement of the ap (116). A further modi- cation of the original laterally positioned ap was the double papilla ap (32), connecting two pedicle papilla aps over a single gingival recession. Early review of the clinical outcomes in case-series stud- ies found the root coverage to be between 41% and 74% (mean 68%) (109) but the treatment outcome with deep single recession may be improved by adding a connective tissue graft under the laterally positioned ap (46, 70). Although poorly supported by randomized controlled trials, the main indica- tion for the laterally positioned ap technique seems to be treatment of deep single recessions associated with little or no keratinized tissue.

Root coverage at gingival recession with abrasion around the cementoenamel junction

The successful outcome of a root-coverage procedure is a stable gingival margin positioned coronally to the

cementoenamel junction. Thus, the cementoenamel junction is an important reference point in the diagnosis and treatment of a gingival recession. However, gingival recessions are often associated with tooth abrasion in the cervical area, leading to total or partial disappearance of the cementoenamel junction and sometimes to a deep enamel/root dis- crepancy (98). Missing the cementoenamel junction may lead to difculty in suturing the graft/ap at the proper location and to residual dental hypersensitiv- ity in the event of incomplete gingival coverage of dental defects (19). Studies have attempted to compensate for a miss- ing cementoenamel junction by applying composite resin material no more than 1 mm apical to the planned cementoenamel junction, using the cementoenamel junction of a contralateral homolo- gous tooth or adjacent teeth as a reference point (19, 117). Treatment of a deep recession or a residual root defect can then be performed by using a coronally advanced ap, with or without a connective tissue graft (Fig. 8). This technique yielded complete root coverage in 80% of treated sites or signicantly reduced recessions at the 2-year follow-up time point

(19).

More recently (118), a combined restorative and mucogingival procedure was tested in patients with noncarious cervical lesions, who were treated with one of ve treatments: (i) coronally advanced ap, (ii) a bilaminar procedure, (iii) coronal odon- toplasty + restoration + root odontoplasty + coro- nally advanced ap, (iv) restoration + coronally advanced ap, and (v) restorative therapy. The treatments were selected according to the type of recession and the associated tooth defect. After 1 year, all ve procedures resulted in high patient satisfaction and optimal esthetic outcomes as rated by an expert periodontist. The combined restora- tive and mucogingival approach to recession defects in sites with an abraded cementoenamel junction seems promising and warrants further investigation (118).

A BC
A
BC

Fig. 7. Free gingival graft for root coverage. (A) Buccal recession at a central mandibular incisor. (B) The graft is

sutured and anchored to the periosteum. (C) Healing 1 year after surgery.

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AB CD E
AB
CD
E

Fig. 8. Coronally advanced ap procedure with a connec- tive tissue graft at the gingival recession with root-enamel abrasion (lateral view). (A) Buccal recession at the maxil- lary cuspid with a severe dental abrasion. (B) Flap raised and dissected beyond the mucogingival junction; the restored cementoenamel junction level was performed

Clinical efcacy of techniques for single recession treatment and long-term outcomes

The European Federation of Periodontology (23) per- formed a comprehensive systematic review to assess the clinical efcacy of periodontal plastic surgery in the treatment of localized gingival recessions, with or without interdental clinical attachment loss. The pri- mary outcome variable was complete root coverage and the secondary outcome variables were recession reduction and keratinized tissue gain. The main con- clusions were:

coronally advanced ap is the root-coverage method most commonly studied in randomized controlled trials. coronally advanced ap + connective tissue graft and coronally advanced ap + enamel matrix derivative produced more complete root coverage and more reduction of gingival recession than did coronally advanced ap alone. coronally advanced ap + connective tissue graft produced more root coverage at recessions with interdental clinical attachment loss than did coro- nally advanced ap alone. initial data suggest that coronally advanced ap + collagen matrix achieved higher recession reduction than did coronally advanced ap alone. coronally advanced ap + connective tissue graft was associated with a higher probability of com- plete root coverage compared with coronally advanced ap + enamel matrix derivative,

before surgery. (C) The graft is sutured with periosteal sutures. (D) The ap is coronally advanced to cover the graft completely. (E) Complete root coverage 1 year after surgery with soft-tissue integration at the area of the restored cementoenamel junction.

coronally positioned semilunar ap, free gingival graft and laterally positioned ap. coronally advanced ap + connective tissue graft was associated with higher recession reduction compared with coronally advanced ap + barrier membrane-associated guided tissue regeneration, coronally advanced ap + enamel matrix deriva- tive and coronally advanced ap + collagen matrix. guided tissue regeneration treatment did not improve the clinical efcacy of coronally advanced ap and was associated with a higher incidence of complications. acellular dermal matrix applied beneath a coro- nally advanced ap caused great variability in out- come and no signicant benet compared with the use of coronally advanced ap alone. multiple combinations rather than a single graft/ biomaterial beneath a ap usually yielded similar or less root coverage than more simple proce- dures. Table 1 depicts the mean root coverage following common treatments of single gingival recessions. Evaluation of both short-term and long-term stability of root-coverage outcomes is critical in clinical prac- tice, but a recent systematic review (23) revealed that only 8% of randomized controlled trials reported 5 years or more of follow up (54, 61, 68, 80). Trau- matic toothbrushing is strongly associated with recur- rence of recession after 5 years at sites treated with coronally advanced ap + acellular dermal matrix or with coronally advanced ap + connective tissue graft (68) or after 6 years at sites treated with

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Table 1. Outcomes of root-coverage procedures for single recession treatment in randomized clinical trials

Surgical procedure

Number of randomized

Mean root

Sites with complete

controlled trials

coverage (%)

root coverage (%)

Coronally advanced ap

+ connective tissue graft

28

  • 84.7 51.8

 

Coronally advanced ap

19

  • 71.2 38.6

 

Coronally advanced ap

+ enamel matrix derivative

9

  • 86.9 58.6

 

Coronally advanced ap

+ guided tissue regeneration

16

  • 64.7 24.2

 

Coronally advanced ap

+ acellular dermal matrix

10

  • 75.4 37.1

 

Data were obtained from Cairo et al. (23).

coronally advanced ap + guided tissue regeneration or with coronally advanced ap (54). A randomized controlled trial, which evaluated treatment with coro- nally advanced ap with a 14-year follow-up period, found recurrence of gingival recession of 39% (91). On the other hand, a private periodontal ofce study reported a stable gingival margin for 10 years after treatment with coronally advanced ap + enamel matrix derivative or with coronally advanced ap + connective tissue graft (61). In sum, treatment of single recession defects with coronally advanced ap + connective tissue graft provides more gingival stability long term than does treatment with coronally advanced ap alone, probably because of the increased gingival thickness or larger amount of kera- tinized tissue, but control of traumatic toothbrushing may be the most important factor in preventing recurrence of gingival recession (23).

Prognosticative factors for root coverage

Patient-related factors

Smoking is associated with impaired periodontal heal- ing as a result of vasoconstriction, microvascular occlu- sion, tissue ischemia and higher risk of postsurgical infection, and is a potential negative predictor of root coverage outcome (16). A systematic review by Cham- brone et al. (31), on connective tissue grafting, showed less improvement in gingival recession, less gain in clin- ical attachment and more incomplete root coverage in smokers than in nonsmokers. However, the negative effect of smoking may be of less importance when employing coronally advanced ap alone (31).

Tooth-related factors

Loss of interdental bone has traditionally been consid- ered as a great limitation in the treatment of gingival recession. Based mainly on free gingival graft proce- dures, root coverage was thought to be fully achievable for Miller class I and II defects, only partially

achievable for Miller class III defects and not possible for Miller class IV defects (64). However, using modern surgical procedures, a retrospective study of single recessions with a 6-month follow-up found complete root coverage in 25% of recessions in sites with inter- dental bone loss equal to or less than the buccal loss (21). Similarly, a randomized controlled trial of single maxillary recessions achieved complete root coverage in 28% of sites treated with coronally advanced ap alone and in 52% of sites treated with coronally advanced ap + connective tissue graft (22). More than 80% of gingival recessions with 3 mm of inter- dental bone loss, which were treated with coronally advanced ap + connective tissue graft, showed com- plete root coverage, which remained stable for at least 3 years, underscoring the benet of adding a connec- tive tissue graft in the treatment of interdental bone loss (24) (Fig. 9). Complete root coverage was also accomplished in 38% of multiple Miller class III reces- sions treated with a modied tunnel/connective tissue graft technique, with or without addition of enamel matrix derivative (8). The amount/thickness of residual keratinized tis- sue can be a critical factor in treatment with a coro- nally advanced ap, but few studies exist on the inuence of baseline keratinized tissue on the clinical outcome (35). A case-series study found a signicant association between ap thickness and root coverage outcome, and demonstrated a ap thickness of > 0.8 mm to be a strong predictor of complete root coverage (10). A systematic review on root coverage found a positive relationship between gingival thick- ness and clinical outcome (49). The predictive value of the apicocoronal dimension of baseline keratinized tissue is still undetermined. An 8-year case-series study of patients with single recessions found that the deeper the baseline recession and the smaller the amount of apicocoronal keratinized tissue, the lower the probability for complete root coverage and long- term stability of the gingival margin (90). These

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A BC
A
BC

Fig. 9. (A) Miller type 2 gingival recession (interdental clin- ical loss of attachment is higher than that detectable at the buccal site). (B) X-ray examination demonstrating loss of bone. (C) Complete root coverage 1 year after surgery; the

ndings may further support the notion of adding connective tissue graft to treatment of deep, single recessions with a thin periodontal biotype (23). The dimension of the interdental papilla may also inuence root coverage after coronally advanced ap treatment of single recessions. Saletta et al. (96) found that complete root coverage correlated inver- sely with papilla height, suggesting a greater probabil- ity of complete root coverage for thick periodontal biotypes with short interdental papillae (79). Con- versely, a randomized controlled trial comparing con- nective tissue graft and acellular dermal matrix under a coronally advanced ap found that papilla height and papilla width were signicant, positive predictors of root coverage, and that papilla height of 5 mm was associated with complete root coverage (45).

Treatment-related factors

Pini-Prato et al. (83) studied the effect of root sur- face treatment on single recessions treated by coro- nally advanced ap, and found at 3 months post- treatment no signicant difference between heavy root planing and gentle treatment with a rubber cup and prophylaxis paste. A 14-year study of simi- lar root treatments reported recurrence of recession in 39% of sites, irrespective of the type of original root instrumentations (83). A randomized controlled trial comparing hand and ultrasonic root instru- mentation in combination with coronally advanced ap therapy in patients with single recessions also

recession was treated with coronally advanced ap + con- nective tissue graft. There was minimal probing depth at buccal and interproximal sites.

found no difference in long-term outcome (119). Saletta et al. (97) detected no alteration in root cur- vature following vigorous root planing. Also, various studies have shown no signicant benets in add- ing chemical agents, such as citric acid or tetracy- clineHCl, to exposed root surfaces during treatment of gingival recessions (77). The body of evidence suggests that heavy mechanical treatment of exposed roots and intentional removal of cemen- tum/root dentin are not warranted as a pretreat- ment for root coverage. Flap tension may be a critical factor during heal- ing, as excessive tension may interfere with the blood supply from supraperiosteal vessels, causing constriction and hindering proper blood support of the gingival graft over the exposed root surface (67). Pini Prato et al. (84) investigated the role of residual ap tension, monitored using a dynamometer, with coronally advanced ap treatment of single reces- sions. A residual ap tension of 04 g was obtained in the control group using additional periosteal inci- sions, while the residual ap tension was 47 g in the test group receiving no further releasing incisions. This proof-of-principle study showed less root coverage in the test group than in the control group at 3 months post-treatment (84). Burkhardt & Lang (15), in a study on primary wound closure of mucoperiosteal aps for implant placement, found that residual ap tensions of 0.010.4 N were associ- ated with a higher incidence of ap dehiscence.

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The position of the gingival margin in relation to the cementoenamel junction is an important prog- nosticative factor for root coverage. Pini Prato et al. (88) treated maxillary buccal Miller class I recessions with coronally advanced ap, and found that 2 mm of coronal placement of the ap was associ- ated with complete root coverage in all cases. The study also showed that an apical shift of the gingival margin occurred from the time of suturing to the nal follow up, leading to recurrence of recession between 3 and 6 months in some patients (88). Ran- domized controlled trials of Miller type 1 (34) and Miller type 2 (22) recession defects have also identi- ed the risk of recession recurrence at several months post-treatment. However, a connective tis- sue graft added to the coronally advanced ap may act as a biological ller and provides early stability of the gingival margin with no signicant apical shift of the gingival margin at 3- and 6-month follow-up time points (22). This notion may explain, at least in part, the superior root coverage obtained by the coronally advanced ap + connective tissue graft compared with other types of coronally advanced aps (22, 34).

Multiple gingival recession treatment

Multiple gingival recessions are usually more chal- lenging defects than single recession defects because the surgical eld is larger with higher anatomical vari- ability that may include prominent roots, shallow ves- tibules, enamelroot abrasions and unevenness in residual keratinized tissue. Also, treatment of multiple recessions must consider the total number of surgical procedures, the amount of donor tissue that can be obtained from the palate and patientsesthetic requests.

Coronally advanced ap for multiple gingival recessions

Bernimoulin et al. (13) described, in the mid- 1970s, a technique to treat multiple gingival reces- sions, which included a free gingival graft for gin- gival augmentation that was followed, 3 months later, by a coronal positioning of the gingival mar- gin. The authors performed a surgical papilla inci- sion based on the depth of the gingival recessions, elevated a combined split (at the surgical papil- lae)full (from the gingival margin to the mucogin- gival junction)split (beyond the mucogingival

junction) thickness ap and included two vertical- release incisions to mobilize the ap that was sutured coronally (13). Complete root coverage was obtained in 43% of the treated sites at 1 year of follow up (13). Zucchelli et al. (114) made a signicant modica- tion of the original coronally advanced ap designed by Bernimoulin et al. by introducing the envelope coronally advanced ap, which eliminated the verti- cal-release incisions and included the following steps:

intrasulcular incisions involving at least one tooth mesial and at least one tooth distal to the teeth showing gingival recessions. oblique incisions using a split-thickness approach at the level of the interdental soft tissue in order to elevate each surgical papilla, followed by a full-thickness ap raised until the mucogingival junction using a periosteal elevator. mobilization of soft tissue with a horizontal supraperiosteal incision beyond the mucogingi- val junction in order to relieve muscular tension and allow a coronal advancement of the gingi- val mucosa without causing tension of any tooth. gentle instrumentation of exposed root sur- faces and de-epithelization of the interdental papillae. passively positioning the splitfullsplit thickness ap coronally to the cementoenamel junction of all involved teeth and stabilizing the ap by means of sling sutures around anatomic papillae (clinical case in Fig. 10). The same group tested, in a randomized controlled trial, the clinical and esthetic outcomes of the multi- ple coronally advanced ap, with or without vertical- releasing incisions, and found no statistically signi- cant difference between the two study groups in terms of recession reduction and clinical attachment gain (122). Conversely, the envelope coronally advanced ap showed more sites with complete root coverage, a greater increase in buccal keratinized tis- sue, fewer postoperative complications and superior esthetic outcome than the coronally advanced ap with vertical incisions (122).

Coronally advanced ap and connective tissue graft for multiple gingival recessions

The introduction of a connective tissue graft under the coronally advanced ap constituted a signicant improvement in the treatment of multiple gingival

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A B C D
A
B
C
D

Fig. 10. Coronally advanced ap for multiple recessions. (A) Baseline recessions at cuspid, and lateral and central incisors. (B) The lateral inci- sor is at the center of the ap; the surgical papillae were oriented toward the center. (C) The ap is coronally advanced and sutured at the anatomic papillae. (D) Complete root coverage of all treated reces- sions at 1 year postsurgery.

recessions (53). In a classical clinical article, Langer & Langer (53) proposed a split-thickness ap that was coronally advanced over the graft, although some area of the graft was left exposed to allow nal gingi- val augmentation from a second-intention healing process. Subsequently, a connective tissue graft was used in conjunction with a coronally advanced ap (28, 30, 86, 121). Cairo et al. (25) performed a ran- domized controlled trial to assess the clinical efcacy of the envelope coronally advanced ap, with or with- out a connective tissue graft, in the treatment of mul- tiple gingival recessions (Fig. 11). At 12 months post- treatment, 69% of patients treated with coronally advanced ap + connective tissue graft, but only 25% of patients treated with coronally advanced ap alone, showed full coverage of all treated recessions (P = 0.0016) (25). Patients treated with only coronally advanced ap revealed a tendency to an apical shift

of the gingival margin, as complete root coverage was observed at 89% of the sites 3 months after surgery, but only at 47% of the sites 6 months after surgery. In contrast, the sites treated with coronally advanced ap + connective tissue graft exhibited a similar level of complete root coverage at 3- and 6-month follow- up time points (25). These data further show that the placement of a connective tissue graft under a coro- nally advanced ap minimizes the postoperative shrinkage of the gingival margin in the apical direc- tion.

Allograft and replacement biomaterials

Various allografts or replacement biomaterials have been used under a coronally advanced ap instead of a connective tissue graft in order to reduce patient morbidity. Enamel matrix derivative was tested for

A B C D
A
B
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Fig. 11. Multiple coronally advanced ap and connective tissue graft. (A) Baseline recessions from the rst molar to the cuspid. (B) The ap is raised up and a connective tissue graft is secured at the premolars/ molar area. (C) The ap is coronally advanced and sutured at the ana- tomic papillae. (D) Complete root coverage of all treated recessions at 1 year postsurgery.

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possible benets in the treatment of multiple gingival recessions using the coronally advanced ap tech- nique (33). The study found a mean root coverage of 83% in the test group and 80% in the control group at 6 months and similar outcomes were also demonstrated at 2 years of follow up (33). Apparently, the addition of enamel matrix derivative to a coro- nally advanced ap does not improve outcome in the treatment of multiple recessions. Collagen matrix under a coronally advanced ap was compared with coronally advanced ap alone in a ran- domized controlled trial on multiple gingival recessions (27). Complete root coverage was obtained in 72% of sites treated with coronally advanced ap + collagen matrix compared with 58% of sites treated with coro- nally advanced ap alone (27). However, a large multi- center randomized controlled trial (103), which compared coronally advanced ap + collagen matrix with coronally advanced ap + connective tissue graft, found complete root coverage in 79% of sites treated with coronally advanced ap + connective tissue graft and only in 48% of sites treated with coronally advanced ap + collagen matrix (Fig. 12). A randomized controlled trial of multiple gingival recessions found that the addition of acelluar dermal matrix under a coronally advanced ap yielded signif- icantly more root coverage than a coronally advanced ap used alone (101). Another randomized controlled trial of multiple recessions associated with a thin peri- odontal biotype reported a complete root coverage of 83% for treatment with acellular dermal matrix + coronally advanced ap and a complete root coverage of 50% for treatment with coronally advanced ap alone (2).

Tunnel techniques for multiple gingival recessions

The tunnel procedure for root coverage includes intrasulcular incisions and a split-thickness ap design beyond the mucogingival junction, leaving the interdental papillae intact, followed by graft insertion (3, 4). Zabalegui et al. (113) presented details of the surgical procedure:

the tunnel is prepared with a split-thickness inci- sion at each area of recession involved in the pro- cedure. Care is taken to undermine the tissue beyond the mucogingival junction in order to obtain a tension-free tunnel, allowing the inser- tion of the graft. a delicate incision is performed at the level of interdental papillae, which are gently raised with- out detaching the tip of the papillae. a graft is harvested from the palate, extending from the canine area to the tuberosity, to obtain a graft long enough to achieve root coverage of all involved teeth. the graft is then inserted into the tunnel by apply- ing a specic suture technique. The rst suture is inserted throughout the most distal recession part and the needle exits in the most medial part of the recession. The second suture is placed at the opposite side and the needle exits at the same medial recession. the graft detained by both sutures (mesial and dis- tal) is gently moved into the tunnel, sliding under the interdental papillae. Specic instruments may help in adapting the graft into the tunnel. when the graft achieves the desired position, both sutures are closed with knots to stabilize the

A B C D
A
B
C
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Fig. 12. Coronally advanced ap and collagen matrix for multiple gingival recessions. (A) Baseline recessions at cuspid and rst premolar. (B) After ap elevation, the collagen matrix is stabilized. (C) The ap is coronally advanced and sutured. (D) Complete root coverage of both recessions at 1 year postsurgery.

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inserted graft. The graft is exposed in the area of recession. Figure 13 shows a complex clinical case of multiple gingival recessions treated using the connective tissue graft + tunnel technique. A modication of the original tunnel technique covers the graft by a coronal position of the gingival margin, using double-crossed sutures to move the gingival margin coronally and stabilize the graft at the crowns by temporary resin stops (123). Aroca et al. (8) tested, in a randomized controlled trial, the efcacy of the modied tunnel technique plus connective tis- sue graft for treatment of multiple class III gingival recessions, with or without the addition of enamel matrix derivative. The 1-year data showed complete root coverage at several sites, but the addition of enamel matrix derivative provided no signicant ben- ets (8). Other studies, which applied the tunnel pro- cedure in conjunction with acellular dermal matrix (57) or collagen matrix (9), reported promising initial outcomes in terms of root coverage in the absence of connective tissue graft.

Clinical outcomes at multiple gingival recessions and long-term stability

Two reviews (32, 47) on the treatment of multiple gin- gival recessions showed complete root coverage after surgery to vary greatly between 24% and 89%. Sub- group analysis and a Bayesian network meta-analysis

found that modied coronally advanced ap and tun- nel approaches produced the highest percentages of complete root coverage, and coronally advanced ap + connective tissue graft appeared to achieve the best outcome (42). Pini-Prato et al. (85) compared coronally advanced ap + connective tissue graft with coronally advanced ap alone and detected no difference in complete root coverage at the 6-month follow-up time point, but sites treated with coronally advanced ap + connective tissue graft showed a higher percentage of sites with complete root cover- age (52%) compared with sites treated with coronally advanced ap alone (35%) at the 5-year follow-up point. These data and those of Zucchelli et al. (116) point to a stable gingival margin for at least 5 years in sites treated with coronally advanced ap + connec- tive tissue graft, but an apical relapse of the gingival margin in several sites treated with a coronally advanced ap only.

Esthetic outcomes of periodontal plastic surgery

Classical mucogingival surgery aims to improve the amount of attached gingiva in order to prevent fur- ther progression of the gingival recession (38), which was considered previously to be related to frictional forces during mastication. Early techniques used bone denudation or periosteal retention to improve

ABC DEF
ABC
DEF

Fig. 13. The tunnel procedure and connective tissue graft for multiple gingival recessions. (A) Baseline recessions at maxillary and mandibular teeth. (B) Connective tissue graft is harvested. (C) Connective tissue graft is inserted into the tunnel at the maxillary incisor. (D) Connective

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tissue graft is prepared for the tunnel at mandibular teeth. (E) Connective tissue graft is sutured into the tunnel at mandibular incisors. (F) Final healing at 1 year after sur- gery (clinical case courtesy of Dr Ion Zabalegui, Bilbao, Spain).

Plastic surgery for gingival recession

the mucogingival anatomy (111), but these treat- ments were gradually abandoned after the introduc- tion of the free gingival graft treatment (1). In the 1970s and the 1980s, as more attention was given to treatment of gingival recession, free gingival grafts (alone or in combination with coronally advanced ap) and laterally positioned ap became the pre- ferred treatments. However, these grafting techniques were frequently associated with a low amount of root coverage and poor esthetic outcomes. The introduc- tion of modern surgical procedures in the late 1980s, along with the increased attention to esthetic peri- odontics, opened a new era in periodontal treatment, which focused not only on the reconstruction of an adequateamount of attached gingiva, but also on obtaining root coverage to enhance soft-tissue esthet- ics. The concept of periodontal plastic surgery was then introduced (7, 62), which has remained an important part of contemporary periodontal treat- ment. Even though complete root coverage remains the main goal of periodontal plastic surgery (65), a mere assessment of the level of the gingival margin post- surgery may not be adequate to evaluate the overall esthetic outcome. In fact, esthetic failure of plastic surgery may occur in cases of partial root coverage, as well as with poor gingival color match, misalignment of the mucogingival junction and keloid-like tissue texture. Early attempts to rate esthetic outcomes included double evaluation performed by a periodon- tist, blinded to the treatment, and by the patients (106). In this study (106), the periodontist rated 15 out of 16 barrier membrane sites and 11 connective tissue graft sites, at 6 months post-treatment, as having an excellent color match, and patients had the same high esthetic rating for color match, overall satisfac- tion and amount of root coverage, and greater overall satisfaction was expressed for barrier membrane- treated sites (106). Similar high esthetic scores by double evaluation were obtained for coronally advanced ap + acellular dermal matrix and for coro- nally advanced ap + connective tissue graft (6). Patient satisfaction can also be measured by a visual analogue scale, in which the patient assigns a value position along a continuous line between two end points (102). An attempt to standardize the evaluation of esthetic periodontal outcomes uses a ve-point ordi- nal scale (poor, fair, good, very good, excellent), which has shown satisfactory reproducibility among periodontists (51). The root coverage esthetic score at the professional level has also been introduced (18). The root coverage ve-point esthetic scoring system

assesses the amount of root coverage (primary vari- able), marginal tissue contour, soft-tissue texture, mucogingival junction alignment and gingival color, as follows:

gingival margin position: zero points = failure to obtain root coverage (gingival margin apical or equal to the baseline recession); 3 points = partial root coverage; 6 points = complete root coverage. marginal tissue contour: zero points = irregular gingival margin (does not follow the cementoenamel junction); 1 point = proper marginal con- tour/scalloped gingival margin (follows the cementoenamel junction). soft-tissue texture: zero points = scar formation and/or keloid-like appearance; 1 point = absence of scar or keloid formation. mucogingival junction alignment: zero points = mucogingival junction not aligned with the mucogingival junction of adjacent teeth; 1 point = mucogingival junction aligned with the mucogingival junction of adjacent teeth. gingival color: zero points = color of tissue varies from the gingival color at adjacent teeth; 1 point = normal color and integration with the adjacent soft tissues. Ten points is the ideal esthetic score. Zero points is assigned if the nal position of the gingival margin is equal or apical to the previous recession depth (fail- ure to achieve root coverage), irrespective of color, the presence of scar tissue or other secondary out- comes. Zero points is also assigned if a partial or total loss of interdental papilla (black triangle) occurs fol- lowing treatment (18). The root coverage esthetic score revealed an almost perfect inter-rater agree- ment of 0.92 among periodontists, conrming its effectiveness for evaluating esthetic outcome at the professional level (20). The root coverage esthetic score system has also been used to evaluate different treatment approaches to gingival recession; only 1% of treated recessions obtained the maximum root coverage esthetic score of 10, treatment of single and multiple recessions by coronally advanced ap, with or without connective tissue grafting, yielded similar esthetic scores and free gingival grafts had the lowest score (89). A systematic review of randomized controlled trials of periodontal plastic surgery for treatment of single and multiple gingival recessions found coronally advanced ap + connective tissue graft and coronally advanced ap + acellular dermal matrix graft to yield the highest root-coverage esthetic score at the profes- sional level (best probabilities 24% and 64%, respec- tively), and coronally advanced ap + connective

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A B
A
B

Fig. 14. (A) Multiple recessions at the maxillary jaw in a demanding patient. (B) Complete root coverage of all trea- ted teeth at 1 year postsurgery.

tissue graft and coronally advanced ap + connective tissue graft + enamel matrix derivative yielded the highest value on the visual analogue scale at the patient level (best probabilities 44% and 26%, respec- tively) (26). Those ndings show that periodontal plastic surgery is able to improve patient esthetics (Figs 14 and 15). Studies have also assessed factors of root-coverage procedures that may compromise the esthetic out- come. Zucchelli et al. (122) showed a higher probabil- ity of complete root coverage and better esthetics when avoiding vertical incisions with multiple coro- nally advanced aps, possibly because vertical inci- sions impair blood supply to the gingival margin and thus the stability of the primary wound. Zucchelli et al. (115) found also that coronally advanced ap + connective tissue graft, using either a graft of a similar dimension as the dehiscence area or a coro- nally advanced ap + connective tissue graft with a thick graft, which exceeded the dimensions of the dehiscence, resulted in similar root-coverage out- comes but grafts of similar dimension as the dehis- cence area yielded better esthetic outcome and postoperative course (115). Also, the study showed that a thick graft was associated with increased ap dehiscence and poorer esthetics, which suggests

limiting the dimensions of the graft to those of the dehiscence areas (115). Similar observations were reported by Cairo et al. (25), who showed that coro- nally advanced ap alone yielded better root-cover- age esthetic scores than coronally advanced ap + connective tissue graft in recession sites with a baseline gingival thickness of > 0.75 mm, suggesting that connective tissue grafts are preferable at sites with thin soft-tissue.

Conclusions

This review shows that periodontal plastic surgery procedures for root coverage are important tech- niques in contemporary periodontics. The following conclusions can be drawn:

the coronally advanced ap design for treat- ment of single recessions is supported by the highest level of evidence compared with other designs. the coronally advanced ap + connective tissue graft for root coverage of single and multiple recessions provides the most optimal clinical out- come. ap tension, ap thickness and graft dimension can inuence treatment outcome. root-coverage treatment may prevent further pro- gression of gingival recessions, but traumatic toothbrushing may still lead to recession recur- rence. the tunnel procedure is a promising treatment of multiple recessions. a highly esthetic outcome of periodontal treat- ment at both the professional and the patient level is a major goal of modern periodontics.

Acknowledgment

I thank Dr Ion Zabalegui (Bilbao, Spain) for providing a clinical case of multiple recessions treated using the tunnel technique and connective tissue grafting.

A B 312
A
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Fig. 15. (A) Baseline smile of the patient in Fig. 14. (B) Complete root coverage of all 12 treated teeth at 1 year postsurgery.

Plastic surgery for gingival recession

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