CDEN0110

16 I I special _ root recession genousgraftcanbemadeupofeitherepithelialised gingiva or connective tissue. Initially, the therapeu- tic goal was to increase the zone of KG. The clinical objective has now evolved to covering the recessed rootwithazoneofattachedKG.Thiscanbeachieved inoneortwostages.Initially,SullivanandAtkinsde- scribed a one-stage procedure in 1968. Its purpose was to increase the zone of KG without concen- tratingoncoverageofarecessedroot.Inthe1980s, a two-stage modification was suggested for an increase in root coverage, which proved to be more successful with increased predictability. This in- volves first placing the free gingival graft or the free connective tissue graft apical to the area of recession, and using the coronally repositioned technique after healing. Free autogenous grafts are predominantly har- vested from the palate. Recently, materials other than gingival grafts have been explored. Using a guided tissue regeneration (GTR) technique, an acellular dermal matrix has been reported to yield favourable outcomes in root coverage.31,32 This materialmayprovidethepatientwithalessinvasive alternative than a palatal donor site, in order to achieve root coverage. Procedures combining both free grafts and pe- dicle techniques have also been detailed. For in- stance, when a connective tissue graft is employed, the graft is placed sub-epithelially with a coronal advancement of the overlying keratinised tissue. GTR techniques have also been developed more recently. In 1992, Pino Prato et al. described a com- bination technique of sub-epithelial placement of a membrane with coronal advancement of the flap, suchase-PTFE.33 Thefunctionofthemembraneisto maintain space during the healing period for tissue regeneration to occur. From a patient’s perspective, biodegradable membranes with GTR might be pre- ferable in order to avoid a second-stage surgery for membrane removal. The goal is to restore gingival health, colour and aesthetics by covering the exposed root predict- ably with healthy gingival tissue and in doing so decrease sensitivity. Using GTR and coronal reposi- tioning techniques, we achieve predictably covered roots. Variations in muco-gingival procedures have been developed to include root surface bio-modi- ficationsbytreatingtherootsurfaceswithavariety of materials. These measures enhance the regen- eration process of a new connective tissue attach- ment. In order to increase root coverage, a new clinical attachment is necessary. Root surface bio- modification involves treating the root surfaces with citric acid, tetracycline or EDTA in order to removethesmearlayerandexposedentinaltubules and thus facilitate a new fibrous attachment. An enamel matrix derivative claimed to support the action of enamel matrix proteins by inducing acel- lular cemetum, periodontal ligament and alveolar bone formation is also available in the range of root surface bio-modification materials. The following case report considers predictable aesthetic root coverage by comparing a GTR tech- nique to a non-GTR technique in a split-mouth procedure involving the same patient. _Case report A young, adult male patient presented with recession bilaterally in his maxilla. The upper right maxilla had extensive recession on teeth #6 and 7 (Fig. 1). The upper left maxilla had similar recession on teeth #11 and 12. Additionally, tooth #11 had a cervical groove, which was stained and hard but not decalcified. After local anaesthesia using lidocaine, the desired flap design was completed. There was an adequate zone of KG present before treatment, which was preserved and repositioned coronally. Upon reflection of the tissue, the full extent of the underlying recession was evident (Fig. 2). The area and recession were uncovered following removal of debridement and granulomatous tissue. The resorbable membrane material was shaped and placed on the exposed roots. The membrane was firstplacedontooth#6andthusthetoothappeared darker as it absorbed blood. The membrane was placed on tooth #5 second and thus the tooth had not absorbed the blood at the time of the photo- graph, which accounts for the colour difference at this time. The coronally repositioned flap was sutured in place with the flap covering the now submerged membranes and previous recession (Figs. 3 & 4). Periodontal dressing (Coe-Pak, GC) was utilised as a bandage and placed over the surgical area. It was removed a week later at the same time as the su- tures. The patient then lavaged and returned to the usual oral hygiene routine, initially lightly and gradually more vigorously. Once healed and oral health was maintained, the recession was covered and health regenerated. Upon periodontal probing, nopocketswerepresent(Fig.5).Thefinalviewpres- ents a visual symmetry of health and colour that is maintainable. Recession was also present at the maxillary left side (teeth #11 and 12; Fig. 6). After local anaes- cosmeticdentistry 1_2010