Actualización de las técnicas para el tratamiento de las recesiones periodontales / Update of techniques for the treatment of periodontal recessions

RESUMEN Introducción: A lo largo de los años se ha propuesto una notable variedad de protocolos quirúrgicos periodontales, cuyo enfoque pasó de la simple resolución de defectos de tejidos blandos a la realización de procedimientos predecibles y mínimamente invasivos. Inicialmente se usaba el injerto gingival libre. Posteriormente se han probado diversas técnicas, incluidas aquellas con sustitutos de tejidos blandos, como membranas tipo Alloderm. Hoy en día se considera el gold standard el injerto de tejido conectivo subepitelial asociado al colgajo de avance coronal. Por último, se ha examinado la técnica Pinhole, con mayor preservación de tejido y resultado más estético. Objetivos: El objetivo de esta revisión fue la comparación de técnicas actualizadas para el tratamiento de recesiones múltiples en maxilar superior e inferior. El resultado del procedimiento se evaluó en términos de cobertura radicular completa, reducción de la recesión, ganancia en altura y volumen, resultado estético, dolor postoperatorio y morbilidad del lecho donante y receptor del paciente. Material y métodos: Se realizaron búsquedas electrónicas y manuales para recopilar estudios de boca dividida, ensayos clínicos controlados aleatorios, series de casos, estudios piloto, libros de periodoncia, estudios de casos, revisiones sistemáticas y metanálisis, incluyendo los defectos de recesiónes gingivales múltiples, en maxilar y mandibular, de las cuatro clases de Miller, debido a su extensa evidencia. Resultados: Se incluyeron treinta y cuatro publicaciones y se extrajeron datos sobre el resultado de las técnicas quirúrgicas de dieciocho artículos. La evaluación clínica analizó la cantidad de cobertura radicular completa, la reducción de la recesión y la ganancia de altura y volumen, mientras que la perspectiva del paciente se expresó en términos de satisfacción estética y posibles complicaciones postoperatorias. Los procedimientos de los últimos diez años mostraron mejores resultados en todos los factores mencionados anteriormente. Conclusión: La predictibilidad y la estabilidad del tratamiento a largo plazo representan los factores que guían el proceso de elección de la técnica y que añaden valor a los procedimientos más actualizados. Se observaron progresos tanto a nivel estético, al reducir las discrepancias entre el área intervenida y el tejido circundante, como a nivel postoperatorio, al aminorar las molestias del paciente. Los desafíos propios de esta rama pronto podrían encontrar respuesta gracias a su rápida evolución, la cual permite concebir más avances.

ABSTRACT Background: Along the years, a remarkable variety of periodontal surgical protocols has been proposed, the focus of which has shifted from the mere resolution of a soft tissue defect to the performance of predictable and minimally invasive procedures. Initially, the free gingival graft was used. Subsequently, many different techniques were experimented, including those using soft tissue substitutes, such as the Alloderm membrane. Nowadays, the association of the connective tissue graft with the coronally advanced flap is considered the gold standard. Finally, the Pinhole technique, being a more conservative method in terms of tissue preservation and aesthetic outcome, was proposed. Objectives: The aim of this review was the comparison of the updated techniques for the treatment of multiple periodontal recessions, affecting both maxilla and mandible. The procedure outcome was assessed in terms of complete root coverage, recession reduction, gain in height and volume, aesthetic outcome, patient's post-operative pain and morbidity of donor and recipient sites. Material and methods: Electronic and hand searches were performed to collect split- mouth studies, randomized controlled clinical trials, case series, pilot studies, periodontal books, case studies, systematic reviews and meta-analysis, including maxillary and mandibular multiple gingival recession defects of all four Miller's classes, for its extensive evidence. Results: Thirty-four publications were included and data regarding the surgical techniques outcome were extracted from eighteen articles. The clinical evaluation analyzed the amount of complete root coverage, recession reduction and gain in height and volume, while the patient's perspective was expressed in terms of aesthetic satisfaction and possible postoperative complications. Procedures in the last ten years showed better results in all the above-mentioned factors. Conclusion: Procedural predictability and long-lasting treatment stability embody the factors driving the technique election process and adding value to more updated procedures. Progress was observed both at an aesthetic level, by reducing the discrepancias between the surgical region and the surrounding tissue, and at a postoperative level, by reducing patient discomfort. The challenges inherent to this branch could soon find answers thanks to its prompt evolution, which allows for further advances to be conceived.

Actualización de las técnicas para el tratamiento de las recesiones periodontales

Introducción: A lo largo de los años se ha propuesto una notable variedad de protocolos quirúrgicos periodontales, cuyo enfoque pasó de la simple resolución de defectos de tejidos blandos a la realización de procedimientos predecibles y mínimamente invasivos. Inicialmente se usaba el injerto gingival libre. Posteriormente se han probado diversas técnicas, incluidas aquellas con sustitutos de tejidos blandos, como membranas tipo Alloderm. Hoy en día se considera el gold standard el injerto de tejido conectivo subepitelial asociado al colgajo de avance coronal. Por último, se ha examinado la técnica Pinhole, con mayor preservación de tejido y resultado más estético. Objetivos: El objetivo de esta revisión fue la comparación de técnicas actualizadas para el tratamiento de recesiones múltiples en maxilar superior e inferior. El resultado del procedimiento se evaluó en términos de cobertura radicular completa, reducción de la recesión, ganancia en altura y volumen, resultado estético, dolor postoperatorio y morbilidad del lecho donante y receptor del paciente. Material y métodos: Se realizaron búsquedas electrónicas y manuales para recopilar estudios de boca dividida, ensayos clínicos controlados aleatorios, series de casos, estudios piloto, libros de periodoncia, estudios de casos, revisiones sistemáticas y metanálisis, incluyendo los defectos de recesiónes gingivales múltiples, en maxilar y mandibular, de las cuatro clases de Miller, debido a su extensa evidencia. Resultados: Se incluyeron treinta y cuatro publicaciones y se extrajeron datos sobre el resultado de las técnicas quirúrgicas de dieciocho artículos. La evaluación clínica analizó la cantidad de cobertura radicular completa, la reducción de la recesión y la ganancia de altura y volumen, mientras que la perspectiva del paciente se expresó en términos de satisfacción estética y posibles complicaciones postoperatorias. Los procedimientos de los últimos diez años mostraron mejores resultados en todos los factores mencionados anteriormente. Conclusión: La predictibilidad y la estabilidad del tratamiento a largo plazo representan los factores que guían el proceso de elección de la técnica y que añaden valor a los procedimientos más actualizados. Se observaron progresos tanto a nivel estético, al reducir las discrepancias entre el área intervenida y el tejido circundante, como a nivel postoperatorio, al aminorar las molestias del paciente. Los desafíos propios de esta rama pronto podrían encontrar respuesta gracias a su rápida evolución, la cual permite concebir más avances.

Background: Along the years, a remarkable variety of periodontal surgical protocols has been proposed, the focus of which has shifted from the mere resolution of a soft tissue defect to the performance of predictable and minimally invasive procedures. Initially, the free gingival graft was used. Subsequently, many different techniques were experimented, including those using soft tissue substitutes, such as the Alloderm membrane. Nowadays, the association of the connective tissue graft with the coronally advanced flap is considered the gold standard. Finally, the Pinhole technique, being a more conservative method in terms of tissue preservation and aesthetic outcome, was proposed. Objectives: The aim of this review was the comparison of the updated techniques for the treatment of multiple periodontal recessions, affecting both maxilla and mandible. The procedure outcome was assessed in terms of complete root coverage, recession reduction, gain in height and volume, aesthetic outcome, patient's post-operative pain and morbidity of donor and recipient sites. Material and methods: Electronic and hand searches were performed to collect split- mouth studies, randomized controlled clinical trials, case series, pilot studies, periodontal books, case studies, systematic reviews and meta-analysis, including maxillary and mandibular multiple gingival recession defects of all four Miller's classes, for its extensive evidence. Results: Thirty-four publications were included and data regarding the surgical techniques outcome were extracted from eighteen articles. The clinical evaluation analyzed the amount of complete root coverage, recession reduction and gain in height and volume, while the patient's perspective was expressed in terms of aesthetic satisfaction and possible postoperative complications. Procedures in the last ten years showed better results in all the above-mentioned factors. Conclusion: Procedural predictability and long-lasting treatment stability embody the factors driving the technique election process and adding value to more updated procedures. Progress was observed both at an aesthetic level, by reducing the discrepancias between the surgical region and the surrounding tissue, and at a postoperative level, by reducing patient discomfort. The challenges inherent to this branch could soon find answers thanks to its prompt evolution, which allows for further advances to be conceived.

A modified tunnel technique to treat multiple gingival recessions: Case Series

Abstract This case series reports a modified tunnel technique with connective tissue graft for the root coverage of multiple Miller Class I, II, and III gingival recessions. The modified approach presents an innovative suture technique to improve the stability and position of the graft. Ten patients with multiple gingival recessions (n=85 teeth) received surgical root coverage treatment. The gingival recession height and width were measured and presented as median, minimum, and maximum values. The percentage of the root coverage after at least 12 months expressed the treatment effectiveness. The Shapiro-Wilk test evaluated the normality; pared Wilcoxon test determined the exact P-value for the differences in the height of the gingival recession before and after surgical treatment (α = 0.05). An average of 97.9% (± 5.6%, p < 0.0001) root coverage after treatment occurred, and 73 out of 85 recessions presented complete root coverage after 12 months. Treatment of Miller class I and II gingival recessions resulted in root coverage higher than 99 and class III higher than 95% (p < 0.0001). The presented case series report the efficacy of a modified surgical technique promoting more than 95% of root coverage after 12 months in multiple Miller Class I, II, and III gingival recessions. Well-designed blind randomized controlled trials are needed to validate the proposed technique.

Resumo Esta série de casos relata uma técnica de túnel modificada com enxerto de tecido conjuntivo para o recobrimento radicular de múltiplas recessões gengivais Classe I, II e III de Miller. A abordagem modificada apresenta uma técnica de sutura inovadora para melhorar a estabilidade e a posição do enxerto. Dez pacientes com múltiplas recessões gengivais (n=85 dentes) receberam tratamento cirúrgico de recobrimento radicular. A altura e a largura da recessão gengival foram mensuradas e apresentadas como valores medianos, mínimos e máximos. A eficácia do tratamento foi expressa como uma porcentagem da cobertura radicular após pelo menos 12 meses. O teste de Shapiro-Wilk avaliou a normalidade; o teste de Wilcoxon pared determinou o valor P exato para as diferenças entre a altura da recessão gengival antes e após o tratamento cirúrgico (α = 0,05). Uma média de 97,9% (± 5,6%, p < 0,0001) de cobertura radicular após o tratamento ocorreu, e 73 das 85 recessões apresentaram cobertura radicular completa após 12 meses. O tratamento das recessões gengivais classe I e II de Miller resultou em recobrimento radicular superior a 99 e classe III superior a 95% (p < 0,0001). A série de casos apresentada relata a eficácia de uma técnica cirúrgica modificada promovendo mais de 95% de cobertura radicular após 12 meses em múltiplas recessões gengivais Classe I, II e III de Miller. Ensaios controlados randomizados cegos bem desenhados são necessários para validar a técnica proposta.

Application of soft tissue augmentation in labial contour aesthetics of anterior dental implants / 口腔疾病防治

@#After tooth extraction, labial contour collapses due to inevitable physiologic bone remodeling. To achieve optimal outcomes for pink esthetic treatment at anterior implant sites, bone or soft tissue augmentation has been advocated to maintain or reconstruct the labial tissue contour. When choosing soft tissue augmentation for esthetic restoration, it is necessary to strictly grasp the indications for surgery. Soft tissue augmentation to maintain or reconstruct the labial tissue contour could be considered in patients with healthy soft tissue and no bone defects or only mild horizontal bone defects. In immediate, early and late implant placement, the timing of soft tissue augmentation may vary. In immediate implantation, the labial bone plate is intact, so it is highly recommended to simultaneously manage soft tissue during implant placement. However, patients may have large bone defects with early or late implant placement. The risk of augmenting bone and soft tissue simultaneously is likely too high, and bone augmentation surgery is often performed at the first stage while soft tissue augmentation surgery is performed at the second stage. Therefore, soft tissue surgery is often carried out simultaneously with abutment connection. Currently, soft tissue augmentation is achieved mostly with adjacent autologous soft tissue grafts, such as free gingival grafts, subepithelial connective tissue grafts or pedicle palatal flaps, which are often accompanied by a second surgical area. The replacement of autogenous soft tissue grafting with new biological materials will become an inevitable trend. In this article, we analyze and summarize the indications, timing and different methods of soft tissue augmentation to maintain and reconstruct the labial contour.

Systematic review of clinical effects of enamel matrix derivative as adjunctive therapy for gingival recession / 口腔疾病防治

Objective @#To evaluate the clinical effect of enamel matrix derivative(EMD) assisted with connective tissue graft(CTG) in the treatment of gingival recession.@*Methods @#Search The Cochrane Library, PubMed, EMbase, Web of Science, Wanfang Public Database,VIP database and CNKI to search for randomized controlled trials of EMD in the treatment of gingival recession. The search period is from the establishment of the databases to October 3, 2022. The test group was treated with EMD+CTG, while the control group was treated with CTG alone. Meta-analyses were performed using Review Manager 5.4.1 and Stat12.0.@*Results@# Meta analysis results showed that only 12 months after treatment, there was a statistically significant difference in the PD and CAL outcome indicators between the EMD assisted treatment group and the control group [MDPD=-0.10, 95% CI (-0.19, -0.01), P = 0.03], [MDCAL=-0.38, 95% CI(-0.71, -0.04), P = 0.03]. There was no significant difference between the test group and the control group in other indicators.@*Conclusion @#EMD assisted CTG in the treatment of gingival recession may be beneficial to the reduction of PD and CAL.

Comparison of the efficacy and long-term stability of tunnel technique and coronally advanced flap in the treatment of gingival recession: a Meta-analysis / 华西口腔医学杂志

OBJECTIVES@#This study aimed to evaluate the efficacy and long-term stability of tunnel technique (TUN) and coronally advanced flap (CAF) combined with connective tissue graft (CTG) in treating gingival recession.@*METHODS@#Databases including PubMed, Web of Science, Embase, and CNKI were electronically searched to collect randomized controlled trial (RCT) of CAF+CTG compared to TUN+CTG in the treatment of Miller class Ⅰ or Ⅱ gingival recession on September 1, 2022.@*RESULTS@#There were 8 RCTs with 305 patients (454 recession sites) participating. The results of the Meta-analysis revealed that, in terms of mean root coverage (MRC) of main indicators, no significant difference was found between the CAF group and the TUN group in both short- and long-term results, which were [MD: 1.45%, 95%CI (-2.93%, 5.82%), P=0.52] and [MD: -0.70%, 95%CI (-6.41%, 5.00%), P=0.81]. However, the CAF group outperformed the TUN group in the long term [MD: 5.69%, 95%CI (0.87%, 10.50%), P=0.02], and the results of complete root coverage (CRC) analysis were similar to those of MRC. In the short term, the TUN group grew keratinized gingiva significantly faster than the CAF group [MD: -0.38 mm, 95%CI (-0.67 mm, -0.10 mm), P=0.008]. Long-term findings revealed no significant difference between the two groups [MD: -0.26 mm, 95%CI (-0.94 mm, 0.43 mm), P=0.46]. The TUN group's secondary index root coverage esthetic score (RES) was statistically significantly higher than the CAF group's [MD: 0.62, 95%CI (0.28, 0.96), P=0.000 3]. Given that there were few results included in the literature and the heterogeneity was too great, no significant difference was observed in the postoperative VAS pain index score [MD: 0.53, 95%CI (-1.96, 3.03), P=0.68].@*CONCLUSIONS@#This study discovered that both CAF+CTG and TUN+CTG can achieve good root coverage in treating gingival recession, with CAF outperforming TUN and both groups achie-ving good long-term stability. After the operation, the TUN group had a higher RES than the CAF group. Given the limitations of this study, more high-quality studies are needed in the future to demonstrate the efficacy of TUN in gingival retraction surgery.

Coverage Of Multiple Maxillary Gingival Recessions Using Coronally Advanced Flap With Subepithelial Connective Tissue Graft: A Case Report

Background:This case report describes treatment of multiple gingival recession with subgingival connective tissue graft and coronally advanced flap technique in treatment of maxillary teeth. Material And Methods:Connective tissue grafting wasdone in relation to upper right second premolar, first premolar, canine, right central incisor, left central incisor and left lateral incisor (#15,#14,#13,#11,#21,#22). A split thickness flap was elevated without disturbing periosteum in this region. The area between canine and second premolar was selected to harvest the graft. The graft was placed on the recipient bed and suturing was done. Result:Predictable root surface coverage could be obtained with use of coronally advanced flap and subepithelial connective tissue graft. Conclusion:Subepithelial connective tissue graft along with coronally advanced flap still stand as a gold standard treatment for gingival recession coverage.

Traditional and modified tunnel technique for the treatment of maxillary anterior teeth gingival recession / 口腔疾病防治

Objective @#To compare the clinical effect of the tunnel technique (TUN) and vestibular incision subperiosteal tunnel access (VISTA) combining connective tissue grafts (CTGs) on recovering the exposed root surface in a case of gingival recession over the upper anterior teeth and then to provide clinical evidence for gingival recession treatment. @*Methods@# A case of gingival recession (Miller I type) over teeth 13-14 and 22-23 was treated using different techniques bilaterally. 22-23 were treated by a TUN combined CTG transplantation,while teeth 13-14 were treated by a VISTA technique combined with CTG transplantation. The gingival retraction height (GRH), gingival retraction width (GRW), keratinized gingival width (KW), root coverage aesthetic score (RES) and visual analog scale (VAS) were measured after operation. @*Results @#The effect of post-operation were ideal and complete ginglval recovering were achieved, the postoperative effects of the two methods were stable, GRH and GRW decreased, and KW increased. RES was 10. The VAS score of VISTA combined with CTG transplantation was 6, which was higher than that of TUN+CTG. @*Conclusion@#Gingival recession can be treated by TUN+CTG or VISTA+CTG with ideal prognosis. VISTA with an additional incision facilitates the operative procedure but leads to less comfort.

Use of dermal matrices to change gingival phenotypes

ABSTRACT: A variety of periodontal plastic surgery techniques have been proposed to correct aesthetic and functional problems of periodontal tissues. The most common procedure uses the connective tissue graft from the palate. However, patient discomfort and the limited quantity of palatal tissue results in many cases where the surgeon uses connective tissue substitutes. In this case report, we describe the use of a human dermal matrix for gingival volume augmentation in the lower incisors with a novel modified VISTA technique stabilizing the flap with sutures and cyanoacrylates, avoiding comorbidity of a second surgical site. The follow up at 6 months showed an increase in gingival thickness and a reduction in recessions length.

Regeneración de tejido blando en una clase 3 mediante un colgajo desplazado lateral e injerto de tejido conjuntivo. Reporte de un caso clínico / Elian class 3 regeneration of soft tissue using a laterally moved flap and connective tissue graft. A clinical case report

RESUMEN: Se describe el caso clínico de una paciente de 60 años, sexo femenino, sana, la cual presentaba en el diente 1.1 una recesión de 6 mm de longitud con extensa pérdida ósea en vestibular correspondiente a una clase 3 de Elian. En el presente reporte se expone los pasos que se siguieron para llegar a una Clase 2 de Elian, mediante un colgajo desplazado lateral con injerto de tejido conjuntivo subepitelial.

ABSTRACT: We describe the clinical case of a 60-year-old female patient, healthy, who presented a 6mm-long recession on tooth 1.1 with extensive vestibular bone loss corresponding to an Elian class 3. In the present report, the steps followed to reach an Elian class 2,by means of a laterally moved flap with subepithelial connective tissue graft, are shown.

The effects of hard and soft tissue grafting and individualization of healing abutments at immediate implants: an experimental study in dogs

PURPOSE: To evaluate the effects of intra-alveolar socket grafting, subepithelial connective tissue grafts, and individualized abutments on peri-implant hard and soft tissue outcomes following immediate implant placement. METHODS: This randomized experimental study employed 5 mongrel dogs, with 4 sites per dog (total of 20 sites). The mesial roots of P3 and P4 were extracted in each hemimandible and immediate dental implants were placed. Each site was randomly assigned to 1 of 4 different treatment groups: standardized healing abutment (control group), alloplastic bone substitute material (BSS) + standardized healing abutment (SA group), BSS + individualized healing abutment (IA group), and BSS + individualized healing abutment + a subepithelial connective tissue graft (IAG group). Clinical, histological, and profilometric analyses were performed. The intergroup differences were calculated using the Bonferroni test, setting statistical significance at P<0.05. RESULTS: Clinically, the control and SA groups demonstrated a coronal shift in the buccal height of the mucosa (0.88±0.48 mm and 0.37±1.1 mm, respectively). The IA and IAG groups exhibited an apical shift of the mucosa (−0.7±1.15 mm and −1.1±0.96 mm, respectively). Histologically, the SA and control groups demonstrated marginal mucosa heights of 4.1±0.28 mm and 4.0±0.53 mm relative to the implant shoulder, respectively. The IA and IAG groups, in contrast, only showed a height of 2.6 mm. In addition, the height of the mucosa in relation to the most coronal buccal bone crest or bone substitute particles was not significantly different among the groups. Volumetrically, the IA group (−0.73±0.46 mm) lost less volume on the buccal side than the control (−0.93±0.44 mm), SA (−0.97±0.73 mm), and IAG (−0.88±0.45 mm) groups. CONCLUSIONS: The control group demonstrated the most favorable change of height of the margo mucosae and the largest dimensions of the peri-implant soft tissues. However, the addition of a bone substitute material and an individualized healing abutment resulted in slightly better preservation of the peri-implant soft tissue contour.

Long-term stability of periodontal root coverage procedures for gingival recession / 中华口腔医学杂志

Gingival recession could result in root exposure, dental hypersensitivity and poor aesthetics. It has been demonstrated that varieties of root coverage procedures can significantly improve gingival recession in short-term (≤6 months), of which coronally advanced flap combined with connective tissue graft is the gold standard technique for treatment of gingival recession. It could obtain the optimally complete root coverage and maintain long-term stability (≥2 years). However, clinical knowledge about the long-term effectiveness of the other alternative graft materials remain very limited. Based on the existing clinical evidence, this article reviews coronally advanced flap, coronally advanced flap combined with connective tissue graft or alternative graft materials, with particular attention to the long-term stability of them, in order to provide reference for the design of further clinical trials and the plan of clinical treatments.

Clinical evaluation and comparison of three surgical procedures for treatment of root surface exposure after epulis resection / 中华口腔医学杂志

Objective@#To evaluate and compare the clinical effects of three surgical procedures for the periodontal treatment of root surface exposure after resection of epulis.@*Methods@#Thirty patients with epulis were selected in this study and the exposed root surfaces of the patients′ teeth were covered with laterally transposition flap, laterally pedicled transposition flap or coronally advanced flap combined with a connective tissue graft in the treatments of epulis. At the time of follow-up during the operation, 3 months after operation and 6 months after operation, respectively, the color, shape and quality of the gum in the operation area and the coordination of the diaphragm and diaphragm were observed, and the root surface exposure (recession depth, RD) and angle were recorded. Keratinized tissue height (KTH), root coverage rate (RC) and patients′ satisfaction with the surgery were also recorded.@*Results@#The flap widths in groups of laterally pedicled transposition flap and coronally advanced flap combined with a connective tissue graft were significantly wider than that in the group of laterally transposition flap at three-month and six-month follow-ups after the surgery. The width of keratoderma [(2.70±1.16) mm] in the group of laterally transposition flap was significantly lower at 6 months postoperatively than that in the other two groups [(4.80±1.14) and (4.90±1.66) mm, respectively] (P<0.01). At the 6th month after surgery, the root flap coverage was at the lowest level [(24±43)%] in the group of laterally transposition flap, and it was significantly lower than that in the other two groups [(80±23)% and (86±24)%, respectively] (P<0.01). There was no significant difference of the root flap coverage between groups of laterally pedicled transposition flap and coronally advanced flap combined with a connective tissue graft. At the time of follow-up, patients were satisfied with the aesthetic effects of the three surgical procedures.@*Conclusions@#After the resection of the gingival tumor, the defect of the gingiva is caused. The laterally pedicled flap and pedicled flap combined with connective tissue transplantations for soft tissue repairing can achieve satisfactory aesthetic effects which are superior to the effect of simple flap technique.

Abordagem interdisciplinar no tratamento das recessões gengivais: relato de caso / Interdisciplinary approach in the treatment of gingival recessions: case report

Objetivo: o artigo faz uma revisão literária com abordagem interdisciplinar acerca do tratamento das recessões gengivais, por meio de relato de caso, exemplificando características clínicas e protocolo de resolução. Relato de caso: paciente com queixa principal de insatisfação estética na região dos dentes 11 e 21,em que se observou a presença de recessões gengivais rasas associadas à esses, sendo maior a do incisivo central superior esquerdo com a presença de coroas provisórias acrílicas com contornos fisiológicos inadequados e núcleos metálicos fundidos. O plano de tratamento indicado inicialmente foi deslize coronal do retalho com enxerto de tecido conjuntivo na região dos dentes 11 e 21, com objetivo de recobrimento radicular e confecção de novas coroas provisórias. Considerações finais: a técnica cirúrgica do envelope, associada ao enxerto de tecido conjuntivo, promoveu ganho clínico de inserção e recobrimento radicular, representando uma alternativa viável e altamente previsível para o tratamento das recessões gengivais, principalmente aquelas relacionadas aos defeitos classe I e II de Miller. O tratamento interdisciplinar associando cirurgia periodontal e tratamento protético contribuiu para o aumento de espessura da mucosa ceratinizada e a estabilidade da margem gengival respectivamente; coroas provisórias confeccionadas com contornos fisiológicos dão suporte à margem gengival e, consequentemente, favorecem a saúde periodontal.(AU)

Objective: The study presents a literature review with an interdisciplinary approach to the treatment of gingival recessions, by means of a case report, exemplifying their clinical characteristics and resolution protocol. Case report: Patient with the major complaint of aesthetic dissatisfaction in the region of teeth 11 and 21, which showed the presence of shallow gingival recession associated with said teeth. The greatest recession was in the upper left central incisor with the presence of temporary acrylic crowns, inadequate physiological contours, and molten metal nuclei. The initial treatment plan was the coronal slide of the flap with connective tissue graft in the region of teeth 11 and 21 to cover the root and the production of new temporary crowns. Final Considerations: The surgical technique of the envelope associated with the connective tissue graft promoted the clinical gain of insertion and root coverage, representing a viable and highly predictable alternative for the treatment of gingival recessions, especially those related to Miller class I and II defects. The interdisciplinary treatment associating periodontal surgery and prosthetic treatment contributed to increase the thickness of keratinized mucosa and to the stability of the gingival margin, respectively. Temporary crowns produced with physiological contours support the gingival margin and consequently favor periodontal health.(AU)

Tratamiento de recesiones gingivales múltiples clase I y III de Miller combinando injerto de tejido conectivo sub-epitelial con técnica en túnel / Treatment of multiple Miller class I and III gingival recessions by means of sub-epithelial connective tissue graft and tunnel technique

Resumen Introducción: La recesión gingival puede estar relacionada con la enfermedad periodontal o condiciones mucogingivales ocasionando hipersensibilidad, caries radicular y problemas estéticos. La combinación de la técnica en túnel y el injerto de tejido conectivo subepitelial puede considerarse una opción para el tratamiento de recesiones gingivales múltiples. Presentación del caso: Paciente de sexo femenino de 38 años de edad, al interrogatorio refiere tener hipersensibilidad dentaria en los dientes superiores (13, 14, 22, 23, 24) que presentan recesión gingival. A la valoración periodontal se observan recesiones gingivales clase I y III de Miller en cuadrante I y II, el diagnóstico periodontal es periodonto sano. Para realizar la cobertura radicular se planea combinar la colocación de injerto de tejido conectivo subepitelial con técnica en túnel, siendo un procedimiento adecuado cuando las papilas interdentales son amplias, además de ser una técnica de alta predictibilidad para lograr la cobertura radicular. En este caso, se decidió iniciar por el segundo cuadrante, ya que eran los sitios con mayor hipersensibilidad dentaria y un mes después realizar el tratamiento en el primer cuadrante. Conclusiones: La técnica que se aplicó permitió eliminar la hipersensibilidad dentaria en un 100% considerando como única desventaja el doble sitio quirúrgico del sitio donador. Es importante mencionar que además de lograr mejoría en la hipersensibilidad dentaria, se mejoraron las condiciones estéticas.

Abstract Introduction: Gingival recession can be associated to periodontal disease or muco-gingival conditions causing hypersensitivity, root caries and esthetic problems. A combination of the tunneling technique with sub-epithelial connective tissue graft can be considered an option for multiple gingival recession treatment. Case presentation: A 38 year old female patient who informed of suffering hypersensitivity in upper teeth (13, 14, 22, 23, 24), exhibiting gingival recession. Periodontal evaluation revealed Miller class I and III gingival recessions in quadrants I and II. Periodontal diagnosis was healthy periodontium. In order to achieve root coverage, placement of sub-epithelial connective tissue graft with tunneling was planned. This represents a suitable procedure in cases when interdental papillae are wide, moreover, it constitutes a high predictability technique in order to achieve root coverage. In the present case, it was decided to initiate treatment on the second quadrant since it lodged sites with greater dental hypersensitivity, to be followed a month later by treatment on the first quadrant. Conclusions: This applied technique allowed for 100% elimination of tooth hypersensitivity, only considering a disadvantage the double surgical site of the donor site. It is important to mention that, in addition to achieving improvement in tooth hypersensitivity, esthetic appearance was improved.

Construction of an experimental millerⅢ gingival retraction animal model in beagle dogs / 口腔疾病防治

Objective @#To construct a Miller class Ⅲ gingival recession animal model and to lay the foundation for exploring the treatment of Miller class Ⅲ gingival recession. @*Methods@#Two adult male beagle dogs were selected, and four teeth from each beagle dog were selected to establish an experimental Miller class Ⅲ gingival recession model. The root surface was revealed by removing the soft and hard tissues of the buccal side. The success of the model was determined by measuring the vertical gingival retraction (VGR), horizontal retraction (HGR), keratosis tissue width (KTW), gingival tissue thickness (GTT), and probing depth (PD) at 1, 2, 4, 6, and 8 weeks after modeling. @*Results@#After observing the clinical indexes, the PDs before and after the modeling were all smaller than 3 mm and no deep-period pockets were formed. The VGR before modeling was 0 mm, and the VGR range after modeling was 5-6.38 mm. A comparison of the before and after modeling results showed that this difference was statistically significant (P < 0.05). The postoperative VGR results were grouped according to timepoint. A comparison between the two groups showed that the differences at 2, 4, 6 and 8 weeks postoperatively were not statistically significant (P > 0.05). The HGR before the modeling was 0 mm, and the HGR fluctuated around 10.5 mm after the modeling, and this difference was statistically significant (P < 0.05). The HGR results were grouped by timepoint after surgery, and a one-way analysis of showed that the differences between the two groups were not statistically significant (P > 0.05). The KTW range before modeling was 6~9 mm, and it fluctuated around 2 mm after modeling, and this difference was statistically significant (P < 0.05). The KTW results were grouped by timepoint after surgery, and they indicated that significant differences did not occur between the groups postoperatively (P > 0.05). The pre-modeling GTT was 1.5 mm, and the GTT range after modeling was 1.5-2 mm. The preoperative and postoperative GTT results were grouped by timepoint, and the results showed that significant differences did not occur between 1 week and 2 weeks after surgery (P = 0.123), although a statistically significant difference was observed at 1 week postoperatively between this group and the other groups (P < 0.05).@*Conclusion@#The method used in this experiment can successfully build a Miller class III gingival recession animal model, and the model remains stable after wound healing.

Coronally advanced flap combined with connective tissue grafts for the treatment of mandibular anterior teeth gingival recession / 口腔疾病防治

Objective @#To compare the effect of the combined coronally advanced flap and connective tissue flap techniques with that of a guided tissue regeneration (GTR) technique on recovering the exposed root surface in a case of gingival retraction over the lower anterior teeth.@*Methods@#A case of gingival recession (Miller Ⅲ type) over teeth 33-43 accompanied by hypersensitivity of the right lower teeth was treated using different techniques bilaterally. Teeth 42-43 were treated by a combined coronally advanced flap and connective tissue flap technique, while teeth 33-41 were treated by a GTR technique of a coronally advanced flap combined with an absorbable collagen membrane.@*Results @#Teeth 42-43 exhibited ideal gingival recovering of the exposed root surface, with the disappearance of the hypersensitivity symptoms, during the follow-up visits at 3.5 months after surgery. However, the exposed root surface of teeth 33-41 exhibited no significant change in coverage at the same time points compared with the preoperative coverage. At 12 months after surgery, the recovered gingiva on the root surface of teeth 42-43 was stable.@*Conclusion@#The combined coronally advanced flap and connective tissue flap approach, which can achieve better coverage of the exposed root surface than the GTR technique, is a feasible and safe surgical method for treating cases with gingival recession. The GTR technique is not an effective method for treating cases with Miller Ⅲ type gingival recession over multiple teeth due to proximal attachment loss.

Tratamento das retrações gengivais unitárias classes I e II de miller com matriz de colágeno xenógena: revisão de literatura / Treatment of single Miller class I and II gingival recessions with a xenogeneic collagen matrix: literature review

Objetivo: Verificar, através de uma revisão da literatura, a eficácia de uma matriz de colágeno xenógena associada ao retalho deslocado coronalmente no tratamento das retrações gengivais unitárias classes I e II de Miller. Materiais e métodos: A estratégia de busca das pesquisas foi realizada na base de dados MEDLINE pela combinações dos termos MESH e palavras-chave. Além disso, as bibliografias de todos os artigos incluídos e de revisões relevantes ao assunto foram consideradas para possível análise. Um mesmo pesquisador realizou as três fases da pesquisa. A primeira fase, a análise dos títulos, foi realizada para eliminar os materiais claramente irrelevantes ou que não tinham relação com o assunto abordado.A segunda fase, avaliação dos resumos dos artigos, foi baseada no tipo de estudo, característica da população/problema, intervenção e resultados obtidos. Na terceira fase, os textos completos selecionados para a revisão foram analisados e interpretados de acordo com os princípios da leitura crítica de artigos científicos. Resultados: Os estudos selecionados ficaram, assim, distribuídos: 05 (cinco) revisões sistemáticas, 12 (doze) ensaios clínicos randomizados, 02 (dois) estudos com modelo animal, (01) um estudo transversal observacional, 05 (cinco) séries de casos, 02 (dois) relatos de casos clínicos e 02 (duas) revisões de literatura, totalizando 29 (vinte e nove) artigos científicos. Conclusão: Por meio de uma revisão da literatura, constatou-se que a matriz de colágeno xenógena associada ao retalho deslocado coronalmente representa uma alternativa viável para o tratamento das retrações gengivais unitárias classes I e II de Miller, bem como proporciona satisfação estética aos pacientes.(AU)

Aim: To verify, through a review of the literature, the efficacy of a xenogeneic collagen matrix plus the coronally advanced flap in the treatment of Miller's class I and II single gingival recessions. Materials and methods: The studies` search strategy was carried out in the MEDLINE database through the combinations of the MESH terms and keywords. In addition, the bibliographies of all articles included and relevant reviews to the subject were considered for possible analysis. The same researcher carried out the three steps of the study. The first step, the analysis of the titles, was carried out to eliminate materials that were clearly irrelevant or had no relation to the subject addressed. The second, evaluation of the abstracts of the articles, was based on the type of study, characteristic of the population/problem, intervention and results obtained. In the third step, the complete texts selected for these review were analyzed and interpreted according to the principles of critical reading of scientific articles. Results: The selected studies were thus distributed: 05 systematic reviews, 12 randomized clinical trials, 02 animal model studies, 01 cross-sectional study, 05 case series, 02 clinical cases and 02 reviews of the literature, totaling 29 articles. Conclusion: Through a review of the literature, it was found that the xenogeneiccollagen matrix plus the coronally advanced flap represents a viable alternative in the treatment of Miller's class I and II single gingival recessions, as well as provides patients` aesthetic satisfaction.(AU)

Enxerto de tecido conjuntivo subepitelial e retalho coronal em recessões gengivais múltiplas / Subepithelial connective tissue graft and coronal fl ap in multiple gingival recessions

Algumas das principais indicações para o recobrimento de superfícies radiculares expostas por recessão gengival compreendem a hipersensibilidade dentinária cervical e o tratamento de defeitos estéticos. Este trabalho descreveu o tratamento de recessão gengival múltipla classe III de Miller em um periodonto delgado, após 36 meses de uma intervenção cirúrgica com enxerto gengival livre. O tratamento cirúrgico periodontal proposto foi o recobrimento radicular por meio de enxerto de tecido conjuntivo subepitelial associado a retalho reposicionado coronalmente na região vestibular dos elementos 31, 41 e 42. Após 90 dias, foi possível observar o recobrimento parcial da recessão, aumento da espessura tecidual e o controle do biofi lme pelo paciente, promovendo maior proteção da região e redução do risco de recidiva das recessões. Diante da resolução do caso clínico apresentado, pôde-se concluir que a técnica do enxerto de tecido conjuntivo subepitelial associado ao retalho reposicionado coronalmente, quando bem indicada e realizada, pode ser empregada com sucesso em áreas de recessões múltiplas e periodonto com espessura reduzida.

Some of the main indications for the root coverage of gingival recessions include cervical dentin hypersensitivity and treatment of aesthetic defects. This manuscript describes the treatment of a Miller's Class III multiple gingival recession 36 months after a free gingival graft surgical procedure. The periodontal surgical treatment proposed was the subepithelial connective tissue graft associated with a coronally repositioned fl ap at vestibular region of elements 31, 41 and 42. After 90 postoperative days, it was possible to observe an increase on tissue thickness and biofi lm control by the patient, promoting a greater protection of the region and reducing the risk of recession recurrence. It can be concluded that the subepithelial connective tissue graft technique associated with the coronal repositioned fl ap, when well indicated and performed, can be successfully used in multiple recessions and periodontal regions with reduced thickness.

Cobertura radicular con el procedimiento de colgajo de avance coronal en combinación con injerto de tejido conectivo autólogo: Revisión bibliográfica y reporte de caso

l procedimiento de cobertura radicular para tratar recesiones gingivales es el tratamiento ideal según la literatura actualizada, siendo más utilizado el colgajo de avance coronal con diferentes resultados clínicos y estéticos que ponen en duda si realizar este procedimiento sumando a un injerto de tejido conectivo se van a obtener resultados más predecibles y más estéticos en cuanto a la eliminación del defecto. En este reporte un paciente de 24 años de edad, masculino, refiere hipersensibilidad y disconformidad estética en la zona de la recesión gingival. En este caso se utilizará el cubrimiento radicular con colgajo de avance coronal más injerto de tejido conectivo autólogo. A los seis meses de sanado el paciente refiere mejoras en cuanto a: sensibilidad, control de placa y estética.

he root coverage procedure to treat gingival recessions is the best line of treatment, being the most used the coronal advanced flap. There have been multiple clinical and aesthetic results that cast doubt on whether this procedure by adding a connective tissue graft will be a more predictable and more aesthetic regarding defect removal. In this case report a patient 24-year-old male refers hypersensitivity and aesthetic discomfort in the area of gingival recession. An autologous graft with a coronal flap advancement of connective tissue will be used. After six months of healing the patient reports improvements in: sensitivity, plaque control and aesthetics.