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June 28-July 4, 201020 perio Tribune United Kingdom Edition of the soft tissue position was reported. 20, 21 Thus, these tech- niques did not adequately ad- dress recession. In order to improve esthetics and increase KG for root coverage procedures, current periodontal surgerylargelyinvolvestheuseof gingival grafts. There are a mul- titude of surgical techniques, which can be distinguished ba- sed on the relationship between the donor and recipient sites. Gingival graft procedures involve either (a) pedicle soft- tissue grafts, which maintain the pedicle blood supply or (b) free autogenous soft tissue grafts. Techniques involving the lat- ter type require the clinician to prepare two surgical sites: one to harvest the tissue and another one to prepare the recipient site. In this case, the autogenous soft tissue graft has a separate blood supply to the recipient site. Combinations of (a) and (b) have also been reported.22–24 Soft-tissue grafts The pedicle soft-tissue graft was first described by Grupe and Warren in 1956.25 This involved raising a full thickness flap and laterally positioning and then suturing donor tissue into place from an adjacent area while maintaining a pedicle blood sup- ply. This technique and others that followed were designed to increase the zone of AG. Later modifications of the technique included the double papilla flap26 – introduced by Cohen and Ross in 1968 – the oblique rotational flap27 and the rotational flap.28 Another type of gingival movement flap was de- scribed later as the coronally re- positioned flap.29 This technique involves mobilising a full thick- ness flap and repositioning the tissue to the CEJ, thereby cover- ing the exposed recession. The use of free gingival grafts was described in the 1960s by Sullivan and Atkins.30 The free autogenous graft can be made up of either epithelialised gingiva or connective tissue. Initially, the therapeutic goal was to increase the zone of KG. The clinical ob- jective has now evolved to cover- ing the recessed root with a zone of attached KG. This can be achieved in one or two stages. Initially, Sullivan and Atkins described a one-stage pro- cedure in 1968. Its purpose was to increase the zone of KG without concentrating on coverage of a recessed root. In the 1980s, a two- stage modification was suggested for an increase in root coverage, which proved to be more success- ful with increased predictability. This involves first placing the free gingival graft or the free connec- tive tissue graft apical to the area of recession and using the coro- nally repositioned technique after healing. Autogenous grafts Free autogenous grafts are pre- dominantly harvested from the palate. Recently, materials other than gingival grafts have been ex- plored. Using a guided tissue re- generation (GTR) technique, an acellular dermal matrix has been reported to yield favorable out- comes in root coverage.31,32 This material may provide the patient with a less invasive alternative than a palatal donor site in order to achieve root coverage. Procedures combining both free grafts and pedicle tech- niques have also been detailed. For instance, 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 devel- oped more recently. In 1992, Pino Prato et al. described a combina- tion technique of sub-epithelial placement of a membrane with coronal advancement of the flap, such as e-PTFE.33 The function of the mem- brane is to maintain space dur- ing the healing period for tissue regeneration to occur. From a patient’s perspective, biode- gradable membranes with GTR might be preferable in order to avoid a second-stage surgery for membrane removal. The goal is to restore ging- ival health, colour and esthet- ics by covering the exposed root predictably with healthy gingival tissue and, in doing so, decrease sensitivity. Using GTR and coronal repositioning tech- niques, we achieve predictably covered roots. Other procedures Variations in muco-gingival procedures have been devel- oped to include root surface bio-modifications by treating the root surfaces with a variety of materials. These measures enhance the regeneration proc- ess of a new connective tissue attachment. In order to increase root coverage, a new clinical at- tachment is necessary. Root surface bio-modifica- tion involves treating the root surfaces with citric acid, tet- racycline or EDTA in order to remove the smear layer and ex- pose dentinal tubules and thus facilitate a new fibrous attach- ment. An enamel matrix deriva- tive claimed to support the ac- tion of enamel matrix proteins by inducing acellular cemetum, periodontal ligament and alveo- lar bone formation is also avail- able in the range of root surface bio-modification materials. The following case report considers predictable esthetic root coverage by comparing a GTR technique to a non- GTR technique in a split- mouth procedure involving the same patient. Case report A young, adult male patient presented with recession bilat- erally in his maxilla. The up- per right maxilla had extensive recession on teeth #6 and #7 (Fig1).Theupperleftmaxillahad similar recession on teeth #11 and #12. Additionally, tooth #11 had a cervical groove, which was stained and hard but not decalcified. After local anesthesia us- ing 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 un- derlying recession was evident (Fig 2). The area and recession were uncovered following re- moval of debridement and gran- ulomatous tissue. The resorbable membrane material was shaped and placed on the exposed roots. The mem- brane was first placed on tooth #6 and thus the tooth appeared 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 photograph, which accounts for the colour difference at this time. The coronally repositioned flap was sutured in place with the flap covering the now sub- merged membranes and previ- ous recession (Figs 3,4). Peri- odontal 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 sutures. The patient then lavaged and re- turned 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 regen- erated. Upon periodontal prob- ing, no pockets were present (Fig 5). The final view presents 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 anesthesia of the areas involved, a full thickness muco-periosteal flap was completed. This exposed the extent of the recession defects (Fig 7). Tooth #11 was treated, as was the other side of the mouth, by utilising the GTR technique using an acellular connective tis- sue membrane to preserve the space for regeneration. Tooth #12 was treated the same way, except that no mem- brane barrier, resorbable or non- resorbable, was used (Figs 8,9). Thus, there was no use of a GTR technique on tooth #12. Both teeth had the flap manipulated with the coronally repositioned graft, cov- ering the recessed root and sutur- ing to the CEJ level. Both sides were covered with periodontal dressing. Antibiot- ics (tetracycline) and an analge- sic (Tylenol-Codeine) were pre- scribed for the first week after the operation. One week after the surgical phase, the dressing and sutures were removed and the mouth lav- aged. Oral Hygiene was restored to good, maintainable habits follow- ing the healing phase of over two months. Upon observation, tooth #11, for which the GTR mem- brane had been employed, had re- attached healthy gingiva that was not probable. The recessed root and the stained cervical groove were cov- ered. In contrast, tooth #12, for which no GTR membrane had been utilised, displayed recession as prior to the surgery (Fig 10). In summary, this split-mouth technique demonstrated that us- ing an acellular resorbable barrier membrane is more predictable for achieving root recession coverage than coverage of a recessed root without such a membrane. DT About the author Dr David L Hoexter, 654 Madison Avenue, New York, NY. To get in touch, you can call him on +1 212 355 0004 or email drdavidlh@aol.com. page 19DTß Fig. 7: Cervical groove on tooth #11is solid, hard and non-carious. Fig. 8: GTR membrane placed over the root surface of tooth #11 only; no membrane was placed on the surface of the reces- sion of tooth #12. Fig. 9: Gingival tissue coronally repositioned to cover the GTR membrane on tooth #11 and tooth #12. Fig. 10: Post-op view. ‘The goal is to restore gingival health, col- our and esthetics by covering the exposed root predictably with healthy gingival tis- sue and, in doing so, decrease sensitivity’ A complete list of references is available from Dr Hoexter.