October 2018 Gingival Autogenous Soft Tissue Grafting JournaCALIFORNIA DENTAL ASSOCIATION

TO GRAFT OR NOT TO GRAFT? AN UPDATE ON DIAGNOSIS AND TREATMENT MODALITIES Richard J. Nagy, DDS Ready to save 20%? Let’s go! Discover The Supply Company’s online shopping experience that delivers CDA members the supplies they need at discounts that make a difference.

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DEPARTMENTS

605 The Editor/Nothing but the

607 Letter to the Editor

609 Impressions

663 RM Matters/Are Your Patients Who They Say They Are? Preventing Medical Identity Theft

667 Regulatory Compliance/OSHA Regulations: Fire Extinguishers, Eyewash, Exit Signs 609 674 Tech Trends

FEATURES

615 To Graft or Not To Graft? An Update on Gingival Grafting Diagnosis and Treatment Modalities An introduction to the issue. Richard J. Nagy, DDS

617 : What Is It All About? This article reviews factors that enhance the for gingival recession, describes at what stage interceptive treatment should be recommended and expected outcomes. Debra S. Finney, DDS, MS, and Richard T. Kao, DDS, PhD

625 Autogenous Soft Tissue Grafting for the Treatment of Gingival Recession This article reviews the use of autogenous soft tissue grafting for root coverage. Advantages and disadvantages of techniques are discussed. Case types provide indications for selection and treatment. Elissa Green, DMD; Soma Esmailian Lari, DMD; and Perry R. Klokkevold, DDS, MS

639 Acellular Dermal Matrix Allografts in Periodontal Therapy This article reviews the material, techniques and rationale for ACD when there is inadequate autogenous donor tissue for the treatment site or the patient prefers a single surgical site. Joan Otomo-Corgel, DDS, MPH; Chanook David Ahn, DMD; and Allen Gunn, DDS

647 The Pinhole Surgical Technique: A Clinical Perspective and Treatment Considerations From a Periodontist This commentary is intended to help guide clinicians in the decision-making process when considering root-coverage strategies. Tina M. Beck, DDS, MS

653 Tissue Engineering for Improving Periodontal Phenotype This article provides clinicians with an understanding of how certain biotechnologies associated with tissue engineering may be incorporated into mucogingival surgery. Cherissa Chong, DMD, MS; Yung-Ting Hsu, DDS, MDSc; Paul Y. Lee, DDS; and Richard T. Kao, DDS, PhD

OCTOBER 2018 603 CDA JOURNAL, VOL 46, Nº10

Volume 46, Number 10 JournaCALIFORNIA DENTAL ASSOCIATION October 2018 CDA Classifieds.

Free postings. published by the Editorial Production Manuscript Kerry K. Carney, DDS, CDE Val B. Mina Submissions EDITOR-IN-CHIEF SENIOR GRAPHIC DESIGNER Priceless results. Dental Association www.editorialmanager. 1201 K St., 14th Floor [email protected] com/jcaldentassoc Sacramento, CA 95814 Randi Taylor SENIOR GRAPHIC DESIGNER 800.232.7645 Ruchi K. Sahota, DDS, CDE ASSOCIATE EDITOR cda.org Letters to the Editor Upcoming Topics www.editorialmanager. Brian K. Shue, DDS, CDE November/General Topics com/jcaldentassoc CDA Offi cers ASSOCIATE EDITOR December/ Natasha A. Lee, DDS January/CAMBRA/PBRN PRESIDENT Gayle Mathe, RDH Subscriptions SENIOR EDITOR [email protected] Subscriptions are available Advertising only to active members of R. Del Brunner, DDS Richard J. Nagy, DDS Sue Gardner the Association. The PRESIDENT-ELECT GUEST EDITOR ADVERTISING SALES subscription rate is $18 and [email protected] [email protected] is included in membership Andrea LaMattina, CDE 916.554.4952 dues. Nonmembers can PUBLICATIONS MANAGER Richard J. Nagy, DDS view the publication online VICE PRESIDENT at cda.org/journal. Permission and [email protected] Kristi Parker Johnson EDITORIAL SPECIALIST Reprints Manage your subscription Judee Tippett-Whyte, DDS Andrea LaMattina, CDE online: go to cda.org, log in SECRETARY Blake Ellington PUBLICATIONS MANAGER and update any changes to TECH TRENDS EDITOR [email protected] [email protected] your mailing information. 916.554.5950 Email questions or other Steven J. Kend, DDS Jack F. Conley, DDS changes to membership@ TREASURER EDITOR EMERITUS cda.org. [email protected] CDA classifiedsclassifieds wworkork harder to Robert E. Horseman, DDS HUMORIST EMERITUS bbringring you resuresults.lts. SeSellinglling a practice Craig S. Yarborough, DDS, MBA or a piece ooff equipment? Now you SPEAKER OF THE HOUSE [email protected] Stay Connected cda.org/journal can include photos to help buyers Clelan G. Ehrler, DDS see the potential. IMMEDIATE PAST PRESIDENT [email protected]

And if you’re hiring, candidates Journal of the California Dental Association (ISSN 1043–2256) is published monthly by the Management California Dental Association, 1201 K St., 14th Floor, Sacramento, CA 95814, 916.554.5950. anywhere can apply right from Periodicals postage paid at Sacramento, Calif. Postmaster: Send address changes to Journal Peter A. DuBois of the California Dental Association, P.O. Box 13749, Sacramento, CA 95853. the site. Looking for a job? You can EXECUTIVE DIRECTOR post that, too. And the best part— The California Dental Association holds the copyright for all articles and artwork published Carrie E. Gordon herein. The Journal of the California Dental Association is published under the supervision of it’s free to all CDA members. CHIEF STRATEGY OFFICER CDA’s editorial staff . Neither the editorial staff , the editor, nor the association are responsible for any expression of opinion or statement of fact, all of which are published solely on the authority Kristine Allington of the author whose name is indicated. The association reserves the right to illustrate, reduce, All of these features are designed to VICE PRESIDENT, MARKETING revise or reject any manuscript submitted. Articles are considered for publication on condition AND MEMBERSHIP help you get the results you need, that they are contributed solely to the Journal. faster than ever. Check it out for Alicia Malaby Copyright 2018 by the California Dental Association. All rights reserved. COMMUNICATIONS yourself at cda.org/classifieds. DIRECTOR

604 OCTOBER 2018 Editor CDA JOURNAL, VOL 46, Nº10

Nothing but the Tooth Kerry K. Carney, DDS, CDE

“ picture is worth a thousand words.” Some might say that is an understatement. There What if we zoom in on that tooth and consider was a graduate student in nothing but the tooth. What is it about that small anthropology who wrote organ, the tooth, that makes it so special? Aher entire master’s thesis based on one photograph. Her advisor had given her an old photo of the studio of a well-known artist from a northwest coast Native American culture. She meticulously The tooth endures. It can last samples divulge that cataloged every identifi able item in the millions of years. The enamel of more than 3 million years ago our photo of the cluttered studio. She devised teeth in fossilized remains is the ancestors had diversifi ed their diet a relative ruler and gave the dimensions original enamel that was laid down beyond that of chimpanzees. of the visible artworks. She researched during the developmental period The tooth is a tool. It is a tool for the motifs used in the sculptures and of the individual’s lifetime. Enamel mastication as well as a cultural tool. It their cultural relevance. She was able demarcation lines can be delineated can tell us what kind of food it can best to track down some of the pieces and and counted. The enamel lines are process: meat, grains, grasses. It can tell us place them in the three-dimensional somewhat similar to tree rings. They how it was used and abused. We can tell world of today. That picture was worth seem to demarcate a short daily if it was worn down by the incorporation much more than a thousand words. pattern and a longer eight-day period. of abrasives like sand into the daily diet. In the same way that a tattered If the individual died before the This can tell us something about how and photograph was a repository of volumes of tooth was completely developed, it is where food was gathered and processed. data, which needed only to be recognized possible to count the lines from the We can tell from the wear marks on and interpreted, so too can a single tooth birth demarcation line and estimate a tooth if it was used in the preparation be worth more than a thousand words. the individual’s age at death and of materials for clothing or in the The tooth is the basic unit of our compare rates of maturation with adapting of materials for building or science. In the profession of we modern Homo sapiens. That rate food gathering or cultivating. Wear are usually interested in a more “macro” can be contrasted with nonhuman patterns may indicate if sinew or view. Our attention is focused not so much primate maturation. The tooth plant fi bers were chewed or scraped on the single tooth but on how each tooth supplies evidence that our prehistoric to prepare them for use in the making functions together with the other teeth, the ancestors manifested a change in the of clothing, baskets or weapons. supporting periodontal structures and how rate of maturation. The prolongation The tooth is a thing of beauty. We they fulfi ll the functional requirements of of childhood that we observe today can tell if it was adapted or adorned oral health. In an expanded view, all the can be seen in the fossil record and for cultural reasons. Was it fi led into teeth perform their part in the psychosocial documented through enamel lines. a point to refl ect a cultural preference health of the individual through a healthy The tooth is a biochemical archive. for or admiration of a dagger smile? smile. In an even more universal view, The proportions of carbon isotopes Was there an inlay of stone or jade? teeth serve as bits of evidential data we rely C-13 and C-12 are different in tropical Was it abraded by contact with a on in formulating policy decisions aimed grasses and sedges compared to fruits ornament like a labret? Was it otherwise at promoting oral health on a global scale. and nuts. During maturation, a record modifi ed for aesthetic reasons? Why is the tooth such a treasure trove of the categories of plants that were Morphological characteristics like the of information? What if we zoom in on being ingested is incorporated into the shovel shape of an incisor or an extra talon that tooth and consider nothing but the enamel. There are also biochemical or can indicate the probability of a tooth. What is it about that small organ, markers that help estimate the genetic commonality with a population the tooth, that makes it so special? proportion of meat-to-plant intake. from a specifi c geographic area.

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The presence of naturally occurring radiographic matches of hard tooth salute at interment might hold only a fl uorosis in the tooth can help narrow the structure morphology or restorations to single tooth. It may be the information probable locations where the individual confi rm an individual’s identity. Now from a single tooth that helps provide grew up. Certain genetic disorders are pulpal tissue may supply the DNA sample closure for a family in mourning. expressed in the development of the tooth necessary to aid in identifi cation. The single tooth is not the only and can tell us about the distribution Sometimes in catastrophic plane thing that concerns us in the practice of that trait within a population. crashes or battlefi eld disasters, the of dentistry. But it is an amazing, long- In the fossil record, the enamel only surviving body part is a tooth. It lasting, informative little organ. The is a treasure trove of information. In may be a single tooth that establishes tooth can be worth more than a thousand the living tooth, there are soft tissue identity. The identifi cation provided words. That is the tooth, the whole resources to investigate. Research has by a single tooth may allow a military tooth and nothing but the tooth. ■ shown that stem cells can be harvested honor guard to demonstrate respect from primary teeth and banked for later for those who have made the ultimate use. Postmortem identifi cation need sacrifi ce for our constitution. A military not rely solely on forensic analysis of told me that the coffi n they

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606 OCTOBER 2018 Letter CDA JOURNAL, VOL 46, Nº10

August 2018 Tooth Eruption Pathophysiology of Et tu, CDA? Oral Cancer Sleep Physiology JournaCALIFORNIA DENTAL ASSOCIATION

I have been a member of CDA since Activists merely want tax money for joining as a University of California, their pet projects. Otherwise they San Francisco, student in the 1960s. would call for a ban on sugary drinks CDA has done a lot for organized completely. A 1-cent tax on an ounce dentistry and in protecting dentists from amounts to 12 cents per can or 72 cents OSHA witch hunts, fi ghting penalties per six-pack. This tax is falling mostly assessed for noncompliance of ill-defi ned on the poor laborer who can ill afford CRANIOFACIAL PHYSIOLOGY:Y WHAT MAKES nonestablished rules. But now with it and just wants some sugar to replace US TICK? DanielDanieele N. N Jenkins, Jenkins DDSDDS, CDE C CDA’s support of a tax on sweetened the energy he expended working each drinks, CDA and I part company. day. These greedy activists today attack Ever notice when an activist dislikes soft drinks. Will your croissant or something it gets the label “Big?” Big bagel be next? The CDA-CMA ballot Tobacco. Big Oil. Big Government. Now initiative will amount to $1.7 BILLION it’s Big Soda. There is a tremendous a year! That is billion with a “B!” difference between the harmful ingredients Our personal freedoms have decreased industry’s recent strong-arming of the from smoking cigarettes to drinking soft in the name of helping us. Those useful legislature to ban local soda taxes for 12 drinks. Smoking cigarettes exposes one plastic bags that grocery stores once used years to protect profi ts prompted CDA to acetone, lead, benzene, formaldehyde, are gone. Plastic straws are next. Taxes and the California Medical Association nicotine, tar, carbon dioxide and a host of may shift consumer choices, but why to fi ght back with a 2020 ballot measure other toxic substances. Coca-Cola exposes should government taxation restrict our that taxes sugar-sweetened beverages. us to carbonated water, sugar, caffeine and freedom of choice. Don’t let the CDA An average bottle of soda is 20 some fl avoring. None of these are toxic! take away or tax our choice of drinks. ounces, which contains more than 15 The CDC’s report shows only 49 teaspoons of sugar,1 far more than the REFERENCES percent of adults and 63 percent of youths 1. Centers for Disease Control and Prevention. Get the Facts: added sugar per day recommended by drank sugar drinks per day.1 This amounts Sugar-Sweetened Beverages and Consumption. cdc.gov/ the American Heart Association.2 These to only 145 and 143 calories respectively nutrition/data-statistics/sugar-sweetened-beverages-intake.html. liquid calories do not suppress “the hunger 2. Starbucks. Explore Our Menu. starbucks.com/menu/ per day! Visit Starbucks and eat a butter catalog/nutrition?food=all#view_control=nutrition. hormone” in the same way that sugar croissant (260 calories), a chocolate 3. Coca-Cola Company. Nutritional facts from a can of does in complex solid foods, leading to chip cookie (570), coffee cake (390) or a sugared Coke. an increase in total caloric intake.3 plain bagel (280)2 and you far exceed the MURRAY S . LEVINE, DDS As dentists, we see fi rsthand the average calories from a sugar-sweetened Encino, Calif. damage caused from soda drinking, soda plus any sugar you may need to but the ill health effects go far beyond sweeten your coffee. Eating these foods The Editor-in-Chief Responds tooth enamel. People who consume exposes you to 29 grams of fat that you With $195 billion in U.S. sales, one or more sugary drinks per day have won’t fi nd in soft drinks. You also get up dubious political tactics and proven a 26 percent higher risk of diabetes.4 to 320 mg sodium versus 45 mg in a can adverse health effects, the soda Among adults, even after adjusting for of Coke.3 Sodium causes water retention industry has earned the moniker “Big race and household income, people that strains the kidneys, heart, arteries Soda.” Overwhelming evidence links who drink one or more sodas each and brain, leading to arterial damage, consumption of sugar-sweetened day are 27 percent more likely to heart damage, heart attacks and strokes. beverages to obesity, diabetes, be overweight or obese than adults If these activists leading the attack on and heart disease. who do not drink soda.5 California sugary drinks were serious, they would be CDA adopted policy in 2008 that adolescents drink 1.2 sodas per day on banning Starbucks from selling anything directs the organization to pursue the average, which equates, conservatively, except coffee and tea. Or is Big Activism’s enactment of a manufacturer’s fee on the to 39 pounds of sugar each year.5 next goal banning your morning croissant syrup used to produce soda, sport and The economic burden of diseases and your child’s chocolate chip cookie? energy drinks to fund disease prevention related to sugar-sweetened beverages It is time we look at this rationally. and treatment programs. The soda is staggering. More than 2.5 million

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adult Californians have diabetes with health care costs of $12.98 billion.6 The estimated $2 billion to $3 billion raised from a statewide soda tax would reduce consumption by 15 to 35 percent.7 Consumers will still have a wide choice of beverages, including sweetened ones with nutritional value that would not include a public health tax. Additionally, voters will have the choice to approve or defeat the House 1/2 island statewide soda tax at the 2020 ballot box — a right that Big Soda circumvented.

REFERENCES 1. Coca-Cola Co. Product Facts. coca-colaproductfacts.com/ en/products/coca-cola/original/20-oz. 2. American Heart Association. Added Sugars. heart.org/en/ healthy-living/healthy-eating/eat-smart/sugar/added-sugars. 3. Mourao DM, et al. Eff ects of food form on appetite and energy intake in lean and obese young adults. Int J Obes (Lond) 2007 Nov;31(11):1688–1695. Epub 2007 Jun 19. 4. Soft Drinks and Disease. Harvard School of Public Health. TOGETHER 5. Bubbling Over: Soda Consumption and Its Link to Obesity in California. UCLA Health Policy Research Brief, 2009. 6. Economic Burden of Chronic Disease in California, 2015. WE ARE California Department of Public Health LIMITLESS 7. lao.ca.gov/ballot/2018/180384.pdf.

The Journal welcomes letters We reserve the right to edit all ® communications. Letters should discuss an item published in the Journal within the last two months or matters of general interest to our readership. Letters must be no more than 500 words and cite no more than fi ve references. No illustrations will be accepted. Letters should be submitted at editorialmanager.com/jcaldentassoc. By sending the letter, the author certifi es that neither the letter nor one with substantially similar content under the writer’s authorship has been published or is being considered for publication elsewhere, and the author cda.org acknowledges and agrees that the letter and all rights with regard to the letter become the property of CDA.

608 OCTOBER 2018 Impressions CDA JOURNAL, VOL 46, Nº10

Disclosing Ethical Secrets David W. Chambers, EdM, MBA, PhD

The marketing folks tell us that “leaked secrets” is an inviting phrase and much more likely to prompt interest than the word “ethics.” My point will be that there is even greater power in being able to suppress ethical secrets. It is one of the new ethical norms: “I know something that could help others, but I can’t tell because I am so ethical.” A colleague sent me a CV to review as he was considering nominating this individual for fellowship in the American College of Dentists. On paper, this was a clear shot. But I happened to know a little background about the case because of a “need to know” relationship with the university. The possible candidate was under administrative sanction for violation of ethical standards. The university had screened my colleague and others from getting this information. What should I say? The rationale for the secrecy was to protect the faculty member’s reputation. Quite possibly the university was protecting itself as well from bad publicity and possible legal action. But a penalty that no one knows about has to be considered a strange one. Ethicists debate these things: If you have been damaged The nub: (say, by praising someone who should not be praised) but are not aware that you have misled others, is it wrong? Yes, 1. The reputation of the profession and the fault lies with the third party that has unnecessarily matters just as the reputation of its covered an ethical secret for its own advantage. Disciplined licenses for dentists are public records and a quick members does. check will show that the proportion of disciplinary actions in 2. It is a double ethical challenge some states, such as California, is two or three times the rate in other states. It is not because California dentists are unethical. to act based on what we know Phone conversations with responsible agents indicate that unless we have permission to know many states simply lack suffi cient enforcement resources and that sort of thing. others try to suppress information about inconvenient facts. Several billboards appeared in 2016 in another state asking 3. Ethical principles are sometimes motorists to consider whether their dentist was honest. The phone number of the state association was displayed at the used as an excuse to cover bottom of the message inviting drivers to phone and fi nd systemic ethical weakness. out. This is a frightening use of innuendo. I know exactly what happened, but no one I talked with in the state or nationally seems to have any knowledge of this ethical secret. David W. Chambers, EdM, MBA, PhD, is a professor There are two levels of ethical knowledge: What one knows of dental education at the University of the Pacifi c, Arthur and what one is allowed to know. A. Dugoni School of Dentistry, San Francisco, and the editor These are tough cases, but generally it works well to keep the of the American College of Dentists. secret when there is a potential for harm to others. If there is potential harm in keeping the secret, think about speaking up. If it is really a tight situation, confront the person or organization that is responsible for the gag order and challenge them to be ethical. ■

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Dental Care Could Benefi t Patients Scheduled for Cancer Surgery Scanning electron microscope image of silver Preoperative oral care by a dentist may help reduce postoperative nanoparticles. (Credit: Dr. T. Theivasanth/ complications, such as pneumonia that may be caused by aspiration of oral and Wikimedia Commons) pharyngeal secretions, in patients who undergo cancer surgery, according to a new British Journal of Surgery study conducted by Miho Ishimaru, PhD, of the department of clinical epidemiology and health economics, School of Public Health at the University of in Japan. Catalytic Nanoparticles The retrospective cohort study was undertaken to assess the association Prevent Tooth Decay between preoperative oral care and postoperative complications among patients who underwent major surgery for head and neck, oesophageal, gastric, In a study published in Nature colorectal, lung or liver cancer between May 2012 and December 2015. The Communications, researchers led by Hyun nationwide administrative claims database in Japan was analyzed. (Michel) Koo, DDS, MS, PhD, of the Of 509,179 patients studied, 16 percent received preoperative oral care University of Pennsylvania School of from a dentist. When a surgeon requested that a dentist provide preoperative oral Dental Medicine, used FDA-approved care to a patient with cancer, the dentist checked the patient’s oral condition, nanoparticles to effectively disrupt provided professional tooth cleaning, taught the patient self-cleaning methods for biofi lms and prevent tooth decay in the teeth and provided any treatment needed, according to the study. both an experimental human plaque- The researchers found that 15,724 patients (3.09 percent) developed like biofi lm and in an animal model postoperative pneumonia and 1,734 (0.34 percent) died within 30 days of that mimicked early childhood caries. surgery. After adjustments, preoperative oral care by a dentist was linked with a The nanoparticles break apart dental decrease in postoperative pneumonia (3.28 percent versus 3.76 percent) and plaque through a unique pH-activated death within 30 days (0.30 percent versus 0.42 percent). antibiofi lm mechanism. Because caries- “The findings could help improve strategies causing plaque is highly acidic, the new for the prevention of postoperative complications,” therapy is able to precisely target areas of Dr. Ishimaru said. the teeth harboring pathogenic biofi lms, Read more of this study in the without harming the surrounding oral British Journal of Surgery (2018); tissues or microbiota, according to the study. doi.org/10.1002/bjs.10915. The iron-containing nanoparticle used in the experiments, ferumoxytol, is already FDA-approved to treat iron defi ciency, which indicates that a topical application of the same nanoparticle would also be tooth-enamel-like material, the team Further studies in a rodent model safe for human use, according to the study. moved on to an experimental set- that closely mirrored the stages of caries Though some scientists have questioned up that more closely replicated the development in humans showed that whether coatings used on ferumoxytol conditions of the . twice-a-day rinses of ferumoxytol and and other nanoparticles used for medical “We used plaque samples from caries- greatly reduced the applications would render them catalytically active subjects to reconstruct these highly severity of caries on all of the surfaces of inert, the researchers demonstrated pathogenic biofi lms on real the teeth and completely blocked the that they maintained peroxidase-like enamel,” Dr. Koo said. “This simulation formation of cavities in the enamel. activity, activating hydrogen peroxide. showed that our treatment not only disrupts Learn more about this study at After testing the ferumoxytol- the biofi lm but also prevents mineral Nature Communications (2018); doi. hydrogen peroxide combination on a destruction of the tooth’s surface.” org/10.1038/s41467-018-05342-x.

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Physicians Don’t Educate Older Patients About Opioids Nearly a third of older adults have 50–80, conducted by the University received a prescription for an opioid of Michigan Institute for Healthcare pain medicine in the past two years, Policy and Innovation and sponsored but the associated dangers often go by AARP and Michigan Medicine, option or what to do with leftover pills. unaddressed, according to fi ndings from U-M’s academic medical center, found Additionally, nearly three-quarters the National Poll on Healthy Aging that many patients didn’t get enough of surveyed older adults would support published in an article on the University counseling about the that come with limits on how many opioid pills a of Michigan Health Lab website. the potent painkillers, how to reduce doctor could prescribe at once. And The poll of 2,013 adults aged their use, when to switch to a non-opioid even more supported other efforts to limit exposure to these medications and potentially combat the national epidemic of opioid misuse due to medication diversion, according to the poll. Researchers Sequence Rare That Causes The poll results suggest that health Tooth Decay care providers who prescribe or dispense A team of bioengineering researchers led by Paul Jensen, PhD, assistant opioids should do more to help patients professor at the University of Virginia, has successfully sequenced the complete understand how to safely use and dispose of them, in language that patients genomes of three strains of S. sobrinus, a harmful bacteria that accelerates tooth understand, the article states. This decay. While scientists know much about the bacteria Streptococcus mutans, which should include a disposal plan that helps also causes cavities, little has been known about S. sobrinus until now. The research patients understand why and how they was published in the journal Microbiology Resource Announcements in June 2018. should dispose of extra medications. According to Dr. Jensen, S. sobrinus is difficult to work with in the lab and is Jennifer Waljee, MD, MPH, MS, not present in all people, so researchers have instead focused their efforts over the the co-director of the Michigan Opioid years on understanding the more stable and prevalent S. mutans, which was Prescribing Engagement Network sequenced in 2002. (Michigan OPEN) and an associate “Although it is rare, S. sobrinus produces acid more quickly and is associated professor of surgery at Michigan Medicine, with the poorest clinical outcomes, especially among children,” Jensen said. “If S. said when patients are prescribed an sobrinus is present along with S. mutans, you’re at risk for rampant tooth decay, opioid, many other aspects of care are which means there’s some level of communication or synergy between the two that often at the forefront of their minds, such we don’t understand yet.” as their diagnosis, social stressors, work- Now that the S. sobrinus sequencing is complete, Dr. Jensen and his students related concerns and caring for loved ones, are building computational models to better understand how the two bacteria which can result in education fatigue. interact and why S. sobrinus can cause such potent tooth decay when combined “But we spend a lot of time educating with S. mutans. our patients on when they can drive, Already they have confirmed, for example, that S. sobrinus lacks complete return to work and take care of their pathways for quorum sensing, which is the painful condition or surgical incision ability bacteria have to sense and react to sites. Similarly, we need to educate our nearby bacteria and ultimately proliferate. patients on what to expect following Read more of this study in Microbiology pain, the role and risks of opioids and Resource Announcements (2018); important alternatives such as over- doi:10.1128/MRA.00804-18. the-counter analgesics, breathing, exercise and sleep,” Dr. Waljee said. Learn more about the poll Viridans streptococci. (Credit: Wikimedia Commons) at labblog.uofmhealth.org.

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Opioids Unwise for Teens Who Have Wisdom Teeth Removed Young people aged 13 to 30 who filled an opioid prescription immediately (Credit: Wikimedia Commons) before or after they had their wisdom teeth out were nearly 2.7 times as likely as their peers to still be filling opioid prescriptions weeks or months later, according to new research from a University of Michigan team. E-cigarettes, Tobacco-Product Those in their late teens and 20s had the highest odds of persistent opioid Use Linked to Increased Oral use, compared with those of middle-school and high-school age, the researchers report in a research letter published in the August 2018 issue of the Journal of Cancer Risk the American Medical Association. A vast majority of noncigarette Led by Calista Harbaugh, MD, a U-M research fellow and surgical resident, tobacco users are exposed to carcinogen the researchers used insurance data to focus on young people who were “opioid levels comparable to or exceeding naïve” — who hadn’t had an opioid prescription in the six months before their exposure among exclusive cigarette wisdom teeth came out and who didn’t have any other procedures requiring smokers — levels that are likely to place anesthesia in the following year. users at substantial risk, according to a “Wisdom tooth extraction is performed 3.5 million times a year in the United poster entitled “Nicotine and Carcinogen States, and many dentists routinely prescribe opioids in case patients need it for Exposure by Tobacco Product Type postprocedure pain,” said Dr. Harbaugh. “Until now, we haven’t had data on and Dual-Use” presented at the 96th the long-term risks of opioid use after wisdom tooth extraction. We now see that General Session of the International a sizable number go on to fill opioid prescriptions long after we would expect Association for Dental Research they would need for recovery, and the main predictor of persistent use is (IADR) held in conjunction with the whether or not they fill that initial prescription.” IADR Pan European Regional (PER) Learn more about this study in the Journal of Congress in England in July 2018. the American Medical Association (2018); Tobacco use remains a leading cause doi:10.1001/jama.2018.9023. of oral cancer but the tobacco landscape is evolving with increasing use of noncigarette tobacco products and dual- By Steven Fruitsmaak (Credit: Wikimedia Commons) use of multiple product types. Co-authors Benjamin Chaffee, DDS, MPH, PhD, and Neal Benowitz, MD, of the University of California, San Francisco, evaluated metabolite of lung carcinogen (NNK) demonstrated elevated nicotine and exposure to known carcinogens according and total nicotine equivalents. TSNA concentrations relative to non- to recent use of different tobacco product Participants were categorized users. TSNA exposures were highest types, alone or in combination. according to use of combustible, which among smokeless tobacco users, whether Data was analyzed from the Population includes cigarettes, cigars, water pipes, used alone or together with other Assessment of Tobacco and Health, pipes, blunts (marijuana-containing product types. Exclusive e-cigarette which included a sample of U.S. adults cigars), smokeless, which includes users were exposed to lower NNN who provided urine specimens for moist snuff, chewing tobacco and snus, and NNAL levels than other product analysis of tobacco-specifi c nitrosamines e-cigarettes and nicotine replacement users, despite comparable nicotine (TSNAs) N’-nitrosonornicotine products. For each product, recent use was exposure. However, most e-cigarette (NNN), a known oral and esophageal defi ned as within the prior three days and users concurrently used combustible carcinogen, 4-(methylnitrosamino)- non-use defi ned as none within 30 days. tobacco resulting in TSNA exposure 1-(3)-pyridyle-1-butanol (NNAL), a All tobacco use categories similar to exclusive cigarette smokers.

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Avoid Processed Starch for Better Oral Health An examination of research on oral Although researchers found no health commissioned by the World Health association between the total amount of Organization (WHO) has indicated that starch eaten and tooth decay, they did sticking to whole grain carbohydrates fi nd that more processed forms of starch and avoiding processed ones, especially if increased the risk of cavities. This is sweet, is best for oral health. The fi ndings, because they can be broken down into very few available studies and weaker published in August 2018 in the Journal of sugars in the mouth by amylase found data, suggested a lower risk of oral Dental Research, came from a review of 33 in saliva, according to the research. cancer from consuming whole grain academic papers on starch and oral health. Further fi ndings, although based on starches and that whole grains may also offer protection against gum disease. Paula Moynihan, PhD, professor of nutrition and oral health at Newcastle Doctors Prescribed Fewer Opioids After Learning of University, U.K., who led the research, said the evidence suggests that a diet Patient Overdose rich in whole grain carbohydrates is less A study published in the journal Science in August 2018 found that when a likely to damage your oral health than clinician learned one of their patients had suffered a fatal overdose, they reduced one containing processed starches. the amount of opioids prescribed by almost 10 percent in the following three In the review, 33 papers were included months. The study leveraged behavioral insights and psychology to give prescribers of studies on foods containing what were personal experience with the risk associated with opioids. characterized as rapidly digestible starches “Clinicians may never know a patient they prescribed opioids to suffered a fatal (e.g., white bread, crackers, biscuits, overdose,” said lead author Jason Doctor, PhD, the director of health informatics at cakes, pretzels) and slowly digestible the USC Schaeffer Center for Health Policy and Economics and associate professor starches (e.g., whole grains, legumes) at the Price School of Public Policy. “What we wanted to evaluate is whether closing and their relationships with dental that information gap will make them more judicious prescribers.” caries, oral cancer and gum disease. Dr. Doctor and his colleagues conducted a randomized trial between July 2015 The WHO, which is currently updating its guidance on carbohydrate and June 2016 of 861 clinicians who had prescribed to 170 patients who intake, recommends reducing free-sugar subsequently suffered a fatal overdose involving prescription opioids. Half the intake to less than 10 percent of total clinicians were randomly selected to receive a letter from the San Diego County energy (calorie) intake and suggests medical examiner notifying them that a patient they had prescribed opioids to in the further reduction to less than 5 percent past 12 months had a fatal overdose. The letter, which was supportive in tone, also for additional health benefi ts, according provided information on safe prescribing guidelines from the Centers for Disease to the published study. Free sugars are Control and Prevention, nudging clinicians toward better prescribing habits. sugars that are added to foods by the In the three months after receiving the letter, prescribing decreased by 9.7 manufacturer, cook or consumer, plus percent compared to the control group that didn’t receive a letter. Furthermore, those naturally present in honey, syrups, clinicians who received the letter were 7 percent less likely to start a new patient on fruit juices and fruit juice concentrates. opioids and less likely to prescribe higher doses. Additional research commissioned by “Interventions that use behavioral insights to the WHO into the effects of carbohydrate nudge clinicians to correct course are powerful, quality on other health outcomes, low-cost tools because they maintain the autonomy including cardiovascular diseases, cancer of the physician to ultimately decide the best and Type 2 diabetes, will be used to course of care for their patient,” Dr. Doctor said. inform the forthcoming guideline. Read more of this study in Science (2018); Read more of this study in the doi:10.1126/science.aat4595. Journal of Dental Research (2018); doi. org/10.1177/0022034518788283.

OCTOBER 2018 613 introduction

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To Graft or Not To Graft? An Update on Gingival Grafting Diagnosis and Treatment Modalities

Richard J. Nagy, DDS

GUEST EDITOR

Richard J. Nagy, DDS, atients present to our practices guide which patients may or may not be is a board-certifi ed with either localized or generalized acceptable candidates as well as defects for periodontist and has gingival that they may or grafting. Perry Klokkevold, DDS, MS, Elissa actively integrated may not be aware of. Some patients Green, DMD, and Soma Esmailian Lari, academic pursuits with a private practice limited to may ask about the recessions and DMD, discuss autogenous gingival grafting, periodontics, sedation and Pwhat may need to be done. These patients looking at the connective tissue graft as implant therapy in Santa usually are most concerned about the the current standard of care, and the free Barbara, Calif. Dr. Nagy effect the recessions have on aesthetics gingival graft and other autogenous grafting is the former director of and/or they are dealing with sensitivity techniques in their manuscript “Autogenous postgraduate periodontics and department chairman issues on these teeth. Then there is you, Soft Tissue Grafting for the Treatment of at the Greater the dental practitioner, who feels teeth Gingival Recession.” Joan Otomo-Corgel, VA Healthcare System and with recessions as well as teeth with thin DDS, MPH, Chanook David Ahn, DMD, has published numerous unattached tissues regardless of recession and Allen Gunn, DDS, discuss the use of scientifi c papers and need to be addressed due to concerns for acellular dermal matrix allografting as an abstracts in peer-reviewed journals and textbook either tooth loss or restorative issues. These alternative to autogenous grafting. Tina M. chapters. He is the former patients are typically not aware of their Beck, DDS, MS, explains her experience editor of Periodontal recessions or mucogingival problem. As with the Pinhole Surgical Technique, Abstracts and past a periodontist, I often get questions from which has received much press these days. president of the California general dentists and dental hygienists on These treatment modality papers attempt to Society of Periodontists and the Western Society of when to perform gingival grafting: Who discuss surgical technique and posttreatment . Dr. Nagy, a are the acceptable candidates, what are the outcomes. Cases are used to emphasize diplomate of the American treatable defects and what are the available the appropriate use of surgical approaches Board of Periodontology, is and most predictable techniques? It is and to provide readers with examples of currently the vice president important that not just the periodontist the aesthetic improvements. These papers of the California Dental Association. but all members of the dental team also discuss the literature and the authors’ Confl ict of Interest understand the thought process of how to personal experiences of the advantages, Disclosure: None reported. address recessions and other mucogingival disadvantages and case selection specifi cs defects so that all dental practitioners can for that procedure. Finally, Cherissa Chong, help explain to patients the diagnosis and DMD, MS, Yung-Ting Hsu, DDS, MDSc, treatment options for the best and most Paul Y. Lee, DDS, and Richard T. Kao, DDS, predictable outcomes, whether the clinician PhD, discuss the future of grafting with the will be doing the corrective procedure current and future use of biologics on teeth or referring the case to a specialist. with recessions and mucogingival defects This issue of the Journal was designed as well as in conjunction with surgically to help the reader answer these questions. facilitated orthodontic treatment. It is hoped In their manuscript “Gingival Recession: this issue will provide readers with a greater What Is It All About?” Debra S. Finney, understanding of the diagnosis, treatment DDS, MS, and Richard T. Kao, DDS, PhD, planning and treatment modalities associated discuss diagnosis, terminology, classifi cation with recessions, mucogingival defects systems and case selection that will without recession and gingival grafting. ■

OCTOBER 2018 615 “We treat our patients with respect and great service. Th at’s exactly how First Republic treats us.”

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CDAJour Oct_18 LeeYoung ND2017.indd 1 8/21/18 12:09 PM gingival recession

CDA JOURNAL, VOL 46, Nº10

Gingival Recession: What Is It All About?

Debra S. Finney, DDS, MS, and Richard T. Kao, DDS, PhD

ABSTRACT Gingival recession is a common dental problem that escalates with increasing age. From the patient’s perspective, this may be associated with intensifi ed symptoms of dentinal hypersensitivity, impaired aesthetics, plaque retention with increased localized infl ammation and greater susceptibility to root caries. This article reviews factors that enhance the risk for gingival recession, describes at what stage interceptive treatment should be recommended and expected outcomes.

AUTHORS

Debra S. Finney, DDS, ingival recession is one of Mucogingival Assessment MS, a board-certifi ed the most common forms of and Phenotype periodontist, practices in mucogingival deformities. Gingival recession results when the Folsom, Calif. She was It is a prevalent but often marginal tissue migrates apical to the president of the California Dental Association in 2004 overlooked problem. The cementoenamel junction (CEJ), exposing and has held numerous G2012 National Health and Nutrition the root surface. Recession is measured positions with the CDA and Examination Survey study reported a from the CEJ to the coronal tissue margin. the ADA. prevalence of gingival recession in 50 In addition, it is important to measure and Confl ict of Interest percent of those aged 18 to 64 and that 88 monitor the width of attached gingiva, Disclosure: None reported. percent of those 65 and older have at least which can be determined by measuring Richard T. Kao, DDS, one site. It increases with age and males the distance from the coronal margin of PhD, is a clinical professor have more recession defects than females.1 the gingiva to the at the University of Once recession is present, a 3-mm recession (MGJ) and subtracting the sulcular California, San Francisco, will worsen 67 percent of the time and a probing depth. At times, especially if School of Dentistry and is in private practice in 4-mm recession will worsen 98 percent the gingiva is thin, it can be challenging Cupertino, Calif. of the time.2 In the clinical evaluation to identify the MGJ. Gently rolling the Confl ict of Interest and monitoring process, determining the mucosa with an instrument such as a Disclosure: None reported. causes of gingival recession is important in (FIGURE 1) can be defi ning if the mucogingival defects need to helpful in locating the apical extent of the be addressed. Etiologic causes for gingival attached gingiva. The position of frenum recession include traumatic attachments should also be noted as part habits, chronic periodontal infl ammation, of the mucogingival evaluation. A frenum malposition of the tooth, orthodontic attachment at or near the movement, regional frenum pull, may contribute to recession (FIGURE 2). biological width invasion and underlying Another signifi cant parameter in bony dehiscence. Experience, careful assessing mucogingival health and observation of the dental environment treatment planning for restorative and good history intake will help the procedures is the tissue type. Ochsenbein clinician discern the true etiology. and Ross fi rst described the concept

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of thick and thin gingival biotypes.3 More recently, the 2017 American Academy of Periodontology World Workshop on Disease Classifi cation has described this not as biotypes but FIGURE 1. Gently rolling the mucosa can FIGURE 2. A frenum attachment close to the as gingival phenotypes.4 Appreciating help to demarcate the mucogingival junction gingival margin may contribute to gingival recession if the gingival phenotype will help the when assessing the width of attached gingiva. lip movement pulls on the marginal gingiva. clinician predict how fast recession or attachment loss may occur. Employing gingival phenotype as a prognostic indicator for further gingival recession/ attachment loss is a skill that clinicians learn over time with clinical experience. In defi ning and identifying the gingival a a phenotype, the components of the b b b mucogingival complex that should be considered include the gingival thickness FIGURE 3A. Thin scalloped tissue may appear (GT), keratinized tissue width (KTW), translucent; notice the roots are apparent under the gingival morphotype (GM), bone thin tissue. morphotype (BM) and tooth dimension. FIGURE 3B. When the gingiva is thin, the underlying Utilizing these parameters, one recent alveolar bone often has dehiscences (a) and fenestrations (b). classifi cation system categorized gingival 5 phenotypes into three categories: KT ■ Thin scalloped phenotype — Teeth that are associated with a gingival phenotype with a narrow zone of KT, clear thin delicate gingiva and a relatively thin alveolar bony housing. This is usually associated with narrow triangular crowns with a FIGURE 4A. A thick fl at phenotype has a broad buccal profi le that is more subtly zone of keratinized gingiva (KT) and teeth that tend to convex and with interproximal be more square. FIGURE 4B. The alveolar housing is contacts that are proximal to thicker with a thick fl at phenotype and contacts are located more apically. the incisive edge (FIGURES 3). ■ Thick fl at phenotype — Teeth that a narrow coronal band of Though there are average parameters are associated with a broad zone thick fi brotic gingiva and a for each of the mucogingival components of KT, thick fi brotic gingiva and pronounced gingival scallop. in each of these phenotypes, it is a comparatively thick alveolar This phenotype is a hybrid of more important to appreciate how the bony housing. The coronal the two phenotypes described phenotypes behave in the presence tooth morphology tends to be above with the coronal aspect of infl ammation, trauma, restorative squarer in design with increased having characteristics consistent treatment, exodontia and orthodontic cervical convexity and a with a thick phenotype and movement. Each of the phenotypes proximal contact that is located the apical aspect having will respond to these conditions in more apically (FIGURES 4). mucogingival characteristics a different fashion as fi rst described ■ Thick scalloped phenotype — that are more similar to a by Kao and Pasquinelli.6 In general, Teeth that are associated with thin phenotype (FIGURE 5). the biological responses are:

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FIGURE 6. A thin phenotype and chronic FIGURE 5. A thick scalloped phenotype has a infl ammation often result in gingival recession. FIGURE 7. A history of vigorous brushing with a narrow coronal band of thick gingiva with thin tissue fi rm brush resulted in recession defects. more apically.

not be readily apparent, it can occur years after the treatment. • Surgical consideration: With extraction, the loss of results in extensive alveolar remodeling. The resulting thin alveolar ridge is often a challenge for the restorative dentist. It may be diffi cult to achieve an optimum aesthetic FIGURE 8A. Pulling dental fl oss into the tissue FIGURE 8B. Flossing clefts on the lingual. result and a ridge lap pontic instead of wrapping it around the tooth can create design may be necessary. For clefts that lead to recession. the implant surgeon, these are challenging cases in that ridge preservation and/or ridge augmentation is often needed for implant site development. ■ Thick fl at phenotype condition: • Infl ammation: Chronic gingival infl ammation tends to be a hallmark for this phenotype. As infl ammation persists, pocket formation with intrabony and FIGURE 9A. The lateral incisor is tipped to the distal FIGURE 9B. The same patient demonstrating furcation defects forms. and is positioned more labially in the alveolus resulting the malposition on the lingual and resulting • Restorative treatment: This in thin overlying bone and gingiva that contributed to mucogingival defects. tissue phenotype is the ideal tissue gingival recession. to work with for the restorative dentist. It tends to rebound well ■ Thin scalloped phenotype condition: • Exodontia: Due to the thin bony from reasonable restorative trauma. • Infl ammation: Marginal infl am- housing, the surrounding bundle • Exodontia: There is less mation with the hallmark being bone would be lost with removal post-extraction remodeling gingival recession with no/minimal of the periodontal ligament and but the extent is dependent periodontal pocketing. There will extensive ridge resorption is likely. on the thickness/volume of be increasing clinical attachment • Orthodontic treatment: The pre-existing buccal bone. loss (CAL) as recession progresses. bony housing is thin and often • Orthodontic treatment: • Restorative treatment: Delicate associated with dehiscence and/ Generally, no recession with tissue management is essential as or fenestration. Orthodontic conventional orthodontic trauma due to tooth preparation movement is often associated movement unless excessive and/or tissue retraction may with further bone remodeling. force moves the tooth out of the result in gingival recession. Though gingival recession may thicker coronal bony housing.

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FIGURE 10. The fi rst premolar is displaced toward FIGURE 11A. Premolar and fi rst molar roots are FIGURE 11B. Canines commonly have prominent the buccal making it more prominent and more likely to prominent and have more recession defect. roots that exhibit recession. incur trauma resulting in gingival recession.

• Surgical consideration: Though These mucogingival parameters are an they are positioned more buccal or lingual this is the ideal gingival phenotype important component of a comprehensive in the alveolar bone (FIGURES 9). Such to work with both from a restorative periodontal evaluation and should be teeth may incur greater forces during oral and surgical perspective, ridge obtained as a baseline on adult patients and hygiene because they are more prominent preservation strategy should be anyone who presents with a mucogingival (FIGURE 10). Canines and the mesial buccal taken when there is concern for defect.8 Mucogingival abnormalities root of fi rst molars are often prominent extensive ridge remodeling post- should be evaluated at each exam to in the arch and may be subject to heavier extraction. This is so the ideal ridge determine if there has been progression. brushing forces contributing to recession for an ovate pontic or implant defects (FIGURES 11). Patients should placement can be developed. Etiology and Contributing Factors be made aware of these conditions and ■ Thick scalloped phenotype condition: Etiologic factors must also be identifi ed educated in proper oral hygiene to reduce The behavior of this phenotype is to allow them to be addressed as part of the possibility of gingival recession. dependent on whether the problem the corrective treatment if indicated. The Mechanical trauma leading to gingival area is limited to the thicker coronal most common causes of gingival recession recession may also be the result of oral band. If this is the case, the tissue are plaque-induced infl ammation and piercings. A piercing can rub on behaves similar to the thick fl at mechanical trauma.2,9 Chronic periodontal the lingual aspect of the lower incisors phenotype. If recession is present infl ammation can result in gingival (FIGURE 12) and lip piercings may affect or the trauma spreads to the more recession and attachment loss, especially the buccal aspect. Other contributing apical thinner phenotype, recession with thin anatomy (FIGURE 6). Mechanical factors include chemical erosion from and mucogingival remodeling trauma may occur as a result of brushing acid refl ux or bulimia (FIGURE 13) or may occur at a much more rapid with a hard toothbrush10 especially with the combined chemical and mechanical rate. With implant placement, the a vigorous brushing technique and/or action of smokeless tobacco (FIGURE 14). surgeon must take caution in that using an abrasive dentifrice (FIGURE 7). Gingival recession is typically the apical portion is quite thin Buccal gingival recession is noted more the result of several factors but not and care must be taken to avoid frequently on the left side of the jaw, necessarily simultaneously or equally. buccal plate perforation. This is most likely related to the fact that most easy to do because the coronal people are right-handed and brush more Disease Progression and aspect gives the false image that thoroughly on the left sides of their mouths. Modifying Factors there is a thick bony housing. In patients with hypersensitivity, Once the putative etiologic contributing While it is not the purview of more gingival recession and sensitivity are factor(s) and the gingival phenotype have this paper, it should be mentioned found on the left side of the mouth and the been identifi ed, the greatest challenge to that these characteristics also lowest amount of plaque is seen on teeth the clinician is to defi ne the rate of disease apply to the mucogingival complex with recession and sensitivity.11 Improper progression. To defi ne how fast the disease is around implants. The conclusion of fl ossing technique can lead to fl ossing clefts progressing, clinical records must provide a a systematic review indicated that in the gingiva (FIGURES 8), which may history of the progress of gingival recession. based on current evidence, a lack of contribute to gingival recession. Improper This may at times prove challenging in adequate keratinized gingiva around and aggressive use of other interproximal that it would require diligent monitoring of implants is associated with more plaque aids may also lead to mucogingival defects. attachment loss (AL), pocket depth (PD) accumulation, tissue infl ammation, Anatomical abnormalities often result and gingival recession (GR). This challenge gingival recession and attachment loss.7 in teeth with a thin phenotype because has been previously described.12 Each of

620 OCTOBER 2018 CDA JOURNAL, VOL 46, Nº10

a

FIGURE 14. A smokeless tobacco habit contributed FIGURE 12. Lingual recession on lower FIGURE 13. in a bulimic patient with a to recession and leukoplakia (a). incisors as a result of a tongue piercing rubbing thin phenotype contributed to generalized recession. against the gingival margin. the aforementioned gingival conditions and the number of affected areas. As recession occurs, there is a decrease in the will have different parameters changing Consideration of these decision- width of the attached gingiva. If a restoration depending on the gingival phenotype. For making factors is further elaborated is to be placed onto the root surface, it is the thin scalloped phenotype, one would on in two recent articles.15,16 important to fi rst re-establish the normal notice an increase in AL and GR but the gingival contour by correction of the recession PD will generally remain 2–3 mm deep. Indications for Increasing Keratinized with a gingival graft procedure to reduce the With a thick fl at gingival phenotype, one Tissue Around Natural Dentition need for apical extension of the restorative would note an increase in AL and PD but Indications for gingival margin as seen in FIGURE 15. When a GR will not increase until periodontitis augmentation procedures include: restoration is placed onto the root surface, has reached the moderate-advanced ■ The presence of gingival it compromises the ability to achieve tissue stage associated with tissue recession. recession extending to/beyond attachment to the root and to increase the In a thick scalloped phenotype, the the mucogingival junction. keratinized and attached gingiva. Extension AL and PD will progress at a moderate ■ Minimal/lack of attached gingiva. of a restorative margin onto the root also rate; once it is past the mucogingival ■ Persistence of gingival makes it more diffi cult to achieve good junction, the rate of progression will infl ammation. marginal fi t and aesthetics. A subgingival increase quite rapidly for both of these ■ The need for subgingival placement margin placed on a tooth surface with a parameters. In this latter condition, GR of a restorative margin. lack of keratinized gingiva will most likely is generally a late disease phenomenon. ■ High frenum attachment associated result in a biologic width violation such as Systemic modifying factors that will with gingival recession. that seen in FIGURE 15, which will result affect treatment outcomes include smoking ■ History of progressive in further infl ammation and recession. and uncontrolled diabetes mellitus, gingival recession. The amount of attached gingiva both of which are consistent with poor ■ Prerestorative/pre-orthodontic necessary for periodontal health has been wound healing. An important reason procedure to increase keratinized debated but it appears to be a function for a less than ideal outcome is smoking. tissue around the treatment area. of the patient’s oral hygiene.18 Therefore, Miller reported that heavy smoking (≥ It is important for the clinician the presence of a wide band of keratinized 10 cigarettes) is highly correlated with to appreciate how the mucogingival and attached gingiva is advantageous. gingival root-coverage failures.13 Poor characteristics can infl uence the rate of disease wound healing due to uncontrolled diabetes progression. The classic study by Lang and Classifi cation of Recession Defects or immunosuppression can negatively Loe suggested that a minimum of 2 mm of and Outcome Prediction affect gingival augmentation procedures.14 keratinized gingiva is needed to maintain Several classifi cations of tissue Systemic and parafunctional habits such gingival health.17 However, in the presence of recession have been described in the as smoking and health issues that would good to excellent oral hygiene, it is possible literature to assist in diagnosis and compromise wound healing should be to maintain periodontal health with minimal prediction of treatment outcomes. considered in the patient selection process. or lack of keratinized gingiva. If there is a lack One of the most widely accepted Local modifying factors include of good hygiene, infl ammation may occur classifi cations was introduced by Miller patient compliance with treatment and result in progression of the recession. in 1985.19 The level of the interproximal recommendations, poor plaque control This study further noted that if restorative bone and soft tissue are evaluated fi rst (high localized plaque scores), the treatment is involved, 5 mm of attached followed by the extent of the recession. periodontal phenotype for the affected gingiva composed of 2 mm of free gingiva The defect can be classifi ed as a Miller area, defi ning if aesthetics is an issue and 3 mm of attached gingiva would be ideal. Class I if there is no loss of interproximal

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FIGURE 16B. MGJ No loss of interproximal bone.

FIGURE 16A. Miller Class I recession has no loss of interproximal tissue and recession does not extend beyond the mucogingival junction (MGJ). FIGURE 15. A biologic width violation most likely occurred when the was placed on tooth No. 5 due to close proximity of the crown margin to the gingival margin and inadequate attached gingiva, both of which may result in increased infl ammation FIGURE and further recession. 17B. No underlying bone or tissue and the recession does bone loss. not extend to the MGJ (FIGURES 16). If there is no loss of interproximal bone or tissue and the recession extends beyond the MGJ, it would be considered MGJ a Miller Class II defect (FIGURES 17). Complete root coverage is often possible with gingival augmentation performed FIGURE 17A. Miller Class II recession extends on Miller Class I and II defects. Once beyond the MGJ. interproximal bone and tissue loss have occurred in conjunction with recession to or beyond the MGJ, the FIGURE 18B. predictability of complete root coverage Underlying diminishes. A Miller Class III defect has bone loss. minor interproximal attachment loss (FIGURES 18) and may have minor tooth malpositioning. Partial root coverage (50–70 percent) can be anticipated with corrective procedures. If the bone loss or tooth malpositioning is severe (FIGURES 19), the defect would fall into a Miller Class IV and less than 10 percent FIGURE 18A. Miller Class III recession; note loss of root coverage would be predicted. interproximal tissue height.

Mucogingival Corrective Treatment during the corrective procedure and term study demonstrated that 83 percent In treatment planning, the clinician the anticipated clinical outcome. of sites receiving gingival augmentation must initially defi ne factors infl uencing Once the etiologic factors have been maintained a reduction in recession for patient selection for treatment. This identifi ed, it is important to educate up to 35 years and 48 percent of untreated is essential whether the clinician will the patient and provide instruction in sites had an increase in recession.20 This be doing the corrective procedure or any corrective behavior indicated. In study showed that thin biotypes remain referring the case to a specialist. This addition to informing patients of their more stable over time if grafting procedures initial assessment and conversation responsibility, they should be given the are performed to thicken the tissue as with the patient is essential so that treatment options and alternatives with compared to thin biotypes; however, the patient’s expectation can be set expected outcomes. The consequences highly motivated patients can prevent at a reasonable level in regard to of no treatment should be explained so the development/progression of gingival the complexity of the problem, the that patients can make informed decisions recession and infl ammation for more than diffi culties that may be encountered about their treatment. A recent long- 20 years. FIGURE 20A depicts a young

622 OCTOBER 2018 CDA JOURNAL, VOL 46, Nº10

FIGURE 19B. Underlying

advanced REFERENCES bone loss. 1. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Genco RJ. Prevalence of periodontitis in adults in the United States: 2009 and 2010. J Dent Res 2012;91:914–920. 2. Serino G, Wennstrom JL, Lindhe J, Eneroth L. The prevalence and distribution of gingival recession in subjects with a high standard of oral hygiene. J Clin Periodontol 1994;21:57–63. 3. Ochsenbein C, Ross A. A re-evaluation of osseous surgery. Dent Clin North Am 1969;13:87–103. 4. Cortellini P, Bissada NF. Mucogingival conditions in the FIGURE 19A. Miller Class IV recession with loss of normal dentition: Narrative review, case defi nitions and interproximal tissue. diagnostic considerations. J Periodontol 2018 Jun;89 Suppl 1:S204–S213. doi:10.1002/JPER.16-0671. 5. Zweers J, Thomas RZ, Slot DE, Weisgold AS, Van der Weijden GA. Characteristics of periodontal biotype, its dimensions, associations and prevalence: A systematic review. J Clin Periodontol 2014;41:958–971. 6. Kao RT, Pasquinelli K. Thick versus thin gingival tissue: A key determinant in tissue response to disease and restorative treatment. J Calif Dent Assoc 2002;30:521–526. 7. Lin G, Chan H, Wang H-L. The Signifi cance of Keratinized Mucosa on Implant Health: A Systematic Review. J Periodontol 2013:84:1755–1767. 8. American Academy of Periodontology. Parameter on mucogingival conditions. J Periodontol 2000;71:861–862. 9. Sarfati A, Bourgeois D, Katsahian S, Mora F, Bouchard P. FIGURE 20A. Connective tissue grafting was FIGURE 20B. No treatment was performed and one Risk assessment for buccal gingival recession defects in an adult recommended for this young patient with a thin year later there is gingival recession. population. J Periodontol 2010;81:1419–1425. phenotype and lack of keratinized gingiva. 10. Khocht A, Simon G, Person P, Denepitiya J. Gingival recession in relation to history of hard toothbrush use. J Periodontol 1993; 64:900–905. patient with a thin phenotype and a lack Interdisciplinary communication 11. Kassab MM, Cohen RE. The etiology and prevalence of gingival recession. J Am Dent Assoc 2003;134:220–225. of keratinized gingival. Connective tissue and collaboration are important to 12. Kao RT, Lee S, Harpenau L. Clinical challenge in grafting was recommended but the patient optimize outcomes for patients. diagnosing and monitoring periodontal infl ammation. J Calif Dent Assoc 2010;38:263–270. did not return for one year (FIGURE 20B), 13. Miller PD Jr. Root coverage using the free soft tissue at which time recession had occurred. Conclusion autograft following citric acid application. Part III. A successful Several treatment modalities exist to Gingival recession is a common and predictable procedure in areas of deep-wide recession. Int treat gingival recession. These include periodontal defect. In this review, we J Periodontics Restorative Dent 1985;5:14–37. 14. Iacopino AM. Diabetic periodontitis: Possible lipid-induced gingival grafting techniques utilizing described how to identify gingival defect in tissue repair through alteration of macrophage autogenous tissue, allograft or xenograft recession that is at risk for further phenotype and function. Oral Dis 1995;1:214–229. materials. Autogenous grafting may deterioration, the possible etiologies 15. Vanchit J, Langer L, Rasperini R, et al. Periodontal soft tissue non-root-coverage procedures: Practical applications involve lateral sliding fl aps, coronally involved, the various strategies for the from the AAP Regeneration Workshop. Clin Adv Periodontics positioned fl aps or autogenous donor surgical management and the potential 2015;5:11–20. tissue. In more severe defects, guided treatment outcome that may result. Like 16. Richardson CR, Allen EP, Chambrone L, et al. Periodontal soft tissue root-coverage procedures: Practical applications tissue regeneration may be desired. many dental and periodontal problems, from the AAP Regeneration Workshop. Clin Adv Periodontics Orthodontic movement may be early identifi cation will generally result 2015;5:2–10. recommended to move malpositioned in a simple correction with a predictable 17. Lang NP, Loe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol teeth into a more desirable location. In outcome. Clinicians are encouraged 1972;43:623–627. cases with a thin phenotype or existing to train their dental team members, 18. Maynard JG Jr, Wilson RD. Physiologic dimensions of the mucogingival defect, it is preferable especially dental hygienists, to identify signifi cant to the restorative dentist. J Periodontol 1979;50:170–174. in most cases to perform gingival recession problems, to be familiar 19. Miller PD Jr. A classifi cation of marginal tissue recession. Int augmentation prior to tooth movement with the symptomatic complaints that J Periodontics Restorative Dent 1985:5(2):8–13. to prevent initiation or progression of patients may report and both surgical 20. Agudio G, Cortellini P, Buti J, Prato G. Periodontal conditions of sites treated with gingival augmentation surgery gingival recession. It is also preferable and nonsurgical solutions for correcting compared with untreated contralateral homologous sites: An to perform corrective treatment prior these problems. To do so will result in 18- to 35-year long-term study. J Periodontol 2016;87:1371– to restorative procedures on exposed a more effective periodontal screening 1378. root surfaces to allow for new gingival and maintenance program that will THE CORRESPONDING AUTHOR, Debra S. Finney, DDS, MS, can attachment as coronal as possible. result in better patient care. ■ be reached at dfi [email protected].

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Autogenous Soft Tissue Grafting for the Treatment of Gingival Recession

Elissa Green, DMD; Soma Esmailian Lari, DMD; and Perry R. Klokkevold, DDS, MS

ABSTRACT Gingival recession is prevalent. It can adversely affect the health, stability and appearance of the involved teeth. Exposed root surfaces may be susceptible to caries, root sensitivity or result in aesthetic concerns. A variety of procedures are described in the literature for the treatment of gingival recession. This article reviews the use of autogenous soft tissue grafting for root coverage. Advantages and disadvantages of techniques are discussed. Case types provide indications for selection and treatment.

AUTHORS

Elissa Green, DMD, Perry R. Klokkevold, ingival recession is a Introduction earned a bachelor’s degree DDS, MS, earned a prevalent condition that can Gingival recession is a prevalent in molecular cell biology at doctor of dental science the University of California, degree at the University of adversely affect the health, condition, reported to affect about 50 Berkeley in 2009. She California, San Francisco, stability and appearance of percent of the adult population aged earned her doctor of dental in 1986. His postdoctoral the involved teeth. Exposed 18–64 and 88 percent of those over 65 medicine degree at Tufts training at UCLA includes Groot surfaces may increase susceptibility to years old.1 It is described as the apical University in 2015 and the hospital-based general caries and root sensitivity and/or result in displacement of the gingival margin recently completed the practice residency, the periodontics residency periodontics residency aesthetic concerns for the patient. There away from the cementoenamel junction and a master’s degree and the surgical implant are a variety of periodontal plastic surgery (CEJ) resulting in exposed root structure. in periodontics and oral fellowship at UCLA. He procedures that have been developed and Depending on the extent of periodontal biology at the University of earned a master’s degree described in the literature for the treatment attachment and bone loss, gingival California, Los Angeles. in oral biology concurrently of gingival recession. This article reviews recession can adversely affect the health, Confl ict of Interest with his specialty training. Disclosure: None reported. He is a diplomate of the use of autogenous soft tissue grafting as stability and appearance of involved teeth. the American Board of a predictable and effective treatment when It may increase susceptibility to caries, Soma Esmailian Lari, Periodontology and a indicated for gingival recession, focusing root sensitivity and, based on the location, DMD, earned a bachelor’s fellow of the American on the goal of root coverage. Various gingival recession may cause signifi cant degree in biomedical College of Dentists. He is procedures are presented in a historical aesthetic concerns for the patient. engineering at the University professor of clinical dentistry of California, Los Angeles, and currently serves as context. Advantages and disadvantages Topical agents are available to reduce in 2011 and her doctor of the periodontics residency of each technique are discussed and root sensitivity and aid in the prevention dental medicine degree at program director at UCLA. gingival recession case types are defi ned to of caries. However, these medicaments the Western University of Confl ict of Interest provide indications and guidelines for case tend to be palliative and do not correct Health Sciences, School Disclosure: None reported. selection. A completed case with long- the anatomical defects. Class V composite of Dentistry in 2015. She recently completed the term follow-up is presented to demonstrate restorations have also been advocated periodontics residency at the use of the subepithelial connective as a treatment to mask root sensitivity, UCLA. tissue graft with a tunnel approach and correct cervical , cover dark, Confl ict of Interest coronally advanced fl ap as a predicable unsightly roots and repair tooth structure Disclosure: None reported. technique for aesthetic root coverage. lost to caries or abrasion/.

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FIGURE 1B.

However, this treatment fails to correct the periodontal anatomical defect. The authors contend that, when possible, class V composite restorations should be avoided as a treatment for root coverage FIGURE 1A. because cervical restorations place margins in close proximity to or slightly below the gingival margin and contribute to FIGURE 1D. increased biofi lm accumulation and an altered subgingival microbiota, which can perpetuate the infl ammatory response.2–4 Diligent biofi lm removal and control of infl ammation can prevent further gingival recession. Surgical correction of gingival recession with autogenous soft tissue grafting is indicated for sites that are diffi cult to clean, chronically infl amed, FIGURE 1C. progressively receding, highly sensitive and/ or aesthetically unacceptable to the patient. There are a variety of periodontal FIGURE 1F. plastic surgery procedures that have been developed and used to treat gingival recession as well as other mucogingival problems such as a lack of keratinized attached gingiva, a shallow vestibule or an aberrant frenum attachment.5 Identifying and selecting appropriate cases for root coverage and determining the predictability FIGURE 1E. of success for a given case depends on a number of factors including the etiology of recession, severity of tissue destruction and FIGURE 1H. control of contributing factors. Selecting the best procedure to treat gingival recession will depend on presenting factors. This article describes the etiology of gingival recession, reviews the variety of root-coverage procedures and provides guidelines for case selection and treatment of gingival recession. FIGURE 1G.

Etiology of Gingival Recession The etiology of gingival recession is primarily attributed to biofi lm and/or FIGURES 1. Clinical view of Miller Class I recession with radiograph demonstrating good interdental soft tissue and trauma-induced infl ammation superimposed bone height (1A, 1B). Clinical view of Miller Class II recession with radiograph demonstrating good interdental soft tissue and bone height (1C, 1D). Clinical view of multiple Miller Class III gingival recessions demonstrating some on a susceptible anatomy. Namely, teeth loss of interdental soft tissue and bone height (1E, 1F). Notice class V composite restorations with leaking, rough that are prominent in the arch with thin margins near the gingiva (courtesy of Travis Steinberg, DDS). Clinical view of Miller Class IV recession defect with labial bone and/or soft tissue (i.e., thin radiograph demonstrating severe loss of interdental soft tissue and bone height (1G, 1H).

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periodontal biotype) are more susceptible Root-Coverage Procedures inserting connective tissue fi bers and new to gingival recession than teeth in a normal The methods used to treat gingival bone; this can only be determined with or lingual/palatal position with a thick recession have progressively advanced histology. Although true periodontal biotype. Factors that increase the risk over time from early basic attempts to regeneration seems to be an elusive of gingival recession include aggressive transplant gingival soft tissue from one goal, there is limited human histologic toothbrushing, tooth malposition, alveolar site to another to more sophisticated evidence that it has been achieved bone dehiscence, high muscle/frenum techniques of creating recipient sites with autogenous soft tissue grafting attachment, plaque-induced infl ammatory with an envelope, pouch or tunnel over exposed root surfaces.9–12 The lesions, iatrogenic habits and factors related approach and the use of subepithelial periodontal regeneration achieved in to restorative and periodontal treatments.5,6 connective tissue grafts with or without these cases always formed at the apical biologic mediators and biomaterials. extent of the grafted site from the existing Classifi cation of Gingival Recession Regardless of surgical techniques or periodontium with the more coronal In 1985, P.D. Miller published a materials used for root coverage, all aspect consisting of closely adapted classifi cation scheme for gingival recession procedures share the common endpoint connective tissue fi bers running parallel and associated the prognosis for root to the root surface (i.e., not inserting coverage with each type.7 He correlated perpendicular) and a long junctional the predictability of therapeutic success epithelial attachment above it. The (i.e., root coverage) with the extent of the While all soft tissue most likely and predominant form recession defect and the height of adjacent of attachment following autogenous interdental soft and hard tissues. Miller grafting techniques provide soft tissue grafting for root coverage Class I defects are defi ned as gingival margin reduction in gingival will be an apical zone of connective recession that does not extend beyond recession, some are more tissue adherence with fi bers running the mucogingival junction with no loss of parallel to the root surface, little or no interdental tissues. Miller Class II defects eff ective than others. new or bone and a coronal are defi ned as gingival margin recession zone of long junctional epithelial that extends to or beyond the mucogingival attachment.13 This attachment will be junction with no loss of interdental tissues. predictable and stable long term.14,15 Miller Class III defects are defi ned as objective to cover exposed roots Autogenous soft tissue grafting gingival margin recession that extends to with tissues that are stable, healthy techniques are reviewed here in the or beyond the mucogingival junction with and aesthetic. In a patient with high order that they were fi rst described in some loss of interdental bone or soft tissues aesthetic demands, obtaining complete the literature. Procedures include the and/or malpositioning of teeth. Miller Class root coverage is the primary objective.8 laterally positioned fl ap16 (Grupe and IV defects are defi ned as gingival margin Secondary objectives, depending on Warren, 1956), free gingival grafts17 recession that extends to or beyond the specifi c case fi ndings, may be to increase (Sullivan and Atkins, 1968), free mucogingival junction with severe loss the amount of keratinized tissue and/ connective tissue grafts18 (Edel, 1974), of interdental bone or soft tissues and/ or to decrease . coronally advanced fl aps19 (Bernimoulin or malpositioning of teeth (FIGURES 1). Root-coverage procedures must also et al., 1975), subepithelial connective According to Miller, complete root result in tissue coverage that is well tissue grafts in combination with coverage can be anticipated in Miller Class adapted and adherent to the previously coronally advanced fl aps20 (Langer and I and Miller Class II recession defects where exposed root surface. It would be Langer, 1985) and variations of these there is no interproximal attachment loss, problematic, and considered a failure, techniques. While all soft tissue grafting partial root coverage can be expected in if the soft tissue grafting resulted in techniques provide reduction in gingival Miller Class III defects where there is some periodontal pocket formation. The ideal recession, some are more effective loss of interproximal bone and soft tissue outcome of soft tissue grafting for root than others. See other articles in this height and no root coverage is expected coverage would be a true regeneration issue regarding the use of biomaterials, in Miller Class IV defects where there is of the periodontal attachment with allografts and biologic mediators as severe interproximal attachment loss. new cementum, periodontal ligament, adjuncts to root-coverage procedures.

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FIGURE 2A. FIGURE 2B. FIGURE 2C. FIGURES 2. Miller Class III recession of mandibular central incisor (2A). There is slight loss of height. Notice the lack of keratinized tissue and high frenum attachment at the gingival margin. There is also evidence of on the root surface. Recipient site was prepared by de-epithelializing the adjacent tissues and resecting the mucosa/frenum (2B). Healed site more than fi ve years later (2C). Notice the incomplete root coverage with increased zone of keratinized, attached tissue. There is also a clear color demarcation outlining the .

Laterally Positioned Pedicle Graft The laterally positioned pedicle graft technique was introduced by Grupe and Warren in 1956.6 It utilizes a split-thickness fl ap design with vertical incisions directed apically toward the recipient site thereby allowing keratinized tissue from an adjacent location to be repositioned over an exposed root surface FIGURE 3A. FIGURE 3B. while remaining attached at the base. Tissues adjacent to the area of recession are de-epithelialized with a split-thickness fl ap to expose a connective tissue bed for attachment and nutrients (blood supply) of the laterally positioned fl ap. Tissue survival and root coverage depends on a fl ap design with a wide base that allows good blood supply, adequate fl ap (periosteum) release, connective FIGURE 3C. FIGURE 3D. tissue exposure for blood supply at the FIGURES 3. Miller Class I recession aff ecting several maxillary incisors (3A). Split-thickness fl ap preparation of recipient site, intimate adaptation and fl ap recipient site with vertical releasing incisions on the distal aspect of the papilla adjacent to recession defects (3B). stabilization with sutures. Advantages of Periosteum is released at the base of the fl ap. Coronally advanced fl ap to cover recession defects (3C). Flap is the laterally positioned pedicle graft are secured coronally with interrupted and mattress sutures. Healed site about six months after surgery. Root coverage of the treated sites is nearly complete (3D). relative ease of procedure, time effi ciency, excellent aesthetic results and avoidance of a second surgical site. Disadvantages predictability of this technique has Free Gingival Graft are the limited applicability to isolated not been evaluated in a systematic The free gingival graft (FGG) recession defects and the possible risk of review or meta-analysis. technique was introduced by Sullivan creating gingival recession, dehiscence or Variations of the laterally and Atkins in 1968.17 The FGG fenestration at the adjacent donor site. positioned fl ap procedure include is harvested from the surface of a There is also a requirement for adequate the double papilla graft (Cohen keratinized area on the and placed keratinized tissue at a neighboring and Ross, 1968)23 and the obliquely on a de-epithelialized recipient bed donor site along with a deep vestibule. rotated graft (Pennel et al., 1965).24 at the defect site (FIGURES 2). Survival The success rate of the laterally It is important to recognize that all of of the graft depends on the intimate positioned pedicle graft for root these rotational pedicle grafts work contact of the graft with an adequate coverage is limited, ranging from best when the adjacent donor papilla area of exposed connective tissue/ 61 percent to 77 percent.21,22 The and zone of keratinized tissue is wide. vascular bed and stabilization of the

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FIGURE 4A. FIGURE 4B. FIGURE 4C.

FIGURES 4. Miller Class I recession aff ecting the maxillary premolars, cuspid and lateral incisor (4A). The maxillary lateral incisor is treated with a semilunar coronally advanced fl ap (4B). Notice the semilunar incision and coronal advancement of the existing tissue to cover the recession defect at the lateral incisor. The other recession defects are treated with SCTG and pouch technique. Healed sites about four months after surgery (4C). Root coverage of all sites, including the lateral incisor, is nearly complete. graft by sutures. The free gingival graft, Free Connective Tissue Graft as with FGGs, the free connective tissue which is separated from its original The free connective tissue graft graft for root coverage probably has limited blood supply, survives initially via technique was introduced by Edel in success due to the lack of blood supply plasmatic circulation and over time by 1974.18 Similar to the free gingival graft, over the root surface and limited blood neovascularization. Hence, the critical the free connective tissue graft was utilized supply from only one side (recipient bed) importance of graft stabilization during to increase the width of keratinized of the graft. For this reason, various fl ap the initial healing phase. Advantages of tissue with less donor site morbidity and techniques have been developed and this technique are that it is a relatively improved aesthetics. The procedure is described to cover free connective tissue less sensitive technique, it can be performed identically to the traditional grafts for better circulation and graft applied to both single and multiple free gingival graft at the recipient site but survival. See the section on subepithelial recession defects and it has the potential varies at the donor site where subepithelial connective tissue grafts on page 630. to increase the width of keratinized connective tissue is harvested from below tissue, deepen the vestibular depth the surface rather than harvesting the graft Coronally Advanced Flap and modify the periodontal biotype. with the surface . The primary The coronally advanced fl ap Disadvantages are palatal donor sites advantage of this technique is the ability (CAF) is a form of pedicle graft that that heal by secondary intention with to obtain wound closure at the donor site was introduced by Bernimoulin et al. increased susceptibility to bleeding resulting in less postoperative discomfort in 1975.19 This procedure does not and pain and the unfavorable color to the patient. This technique also require a palatal donor site. It can be match of an FGG at the recipient provides enhanced aesthetics compared to used to treat shallow recession defects site. Thin free gingival grafts are the FGG due to improved color matching (≤ 4 mm) when the existing tissue susceptible to necrosis and sloughing with the adjacent tissues because the biotype is thick (≥ 1 mm) and a broad while thick free gingival grafts have epithelium grows over the graft from zone of keratinized tissue (≥ 3 mm) higher survival rates but result in deeper, the recipient site. This technique can exists apical to the recession defect. The slow-healing donor sites. Thicker be used for the same applications as the fl ap design is created with two vertical grafts also tend to be more noticeable FGG because the genetic specifi city for incisions on the papillae adjacent to the at the recipient site after healing. keratinization comes from the dense recession area and reverse-bevel sulcular The success rate of this root-coverage connective tissue close to the epithelial incisions along the gingival margin. procedure is limited, ranging from layer.32 The connective tissue must be These incisions are connected with two 12 percent to 66 percent, with mean harvested from beneath a keratinized horizontal, reverse-bevel incisions made root coverage of 41 percent for thin zone of epithelium. Disadvantages of the in the papillae adjacent to the recession grafts.25–27 The success rate is higher free connective tissue graft may include defect. The coronal surface of the for thicker grafts (≥ 2mm) ranging more shrinkage at the recipient site and adjacent papillae are de-epithelialized from 39 percent to 100 percent with a more susceptibility to surface necrosis over a length that is equivalent to mean root coverage of 69 percent.28–31 due to a lack of epithelial covering. the depth of the gingival recession. Predictability data indicates that 90 The success rate and predictability A full-thickness fl ap is elevated. The percent or greater root coverage was of free connective tissue grafts for root periosteum of the fl ap is released at achieved only 16 percent of the time.25,27 coverage has not been reported. However, the base with a horizontal incision

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FIGURE 5A. FIGURE 5B. FIGURE 5C.

FIGURES 5. Free gingival graft donor site (5A). Free gingival graft harvested (5B). Donor site healing at one week (5C). and the fl ap is coronally positioned to Semilunar Coronally Advanced Flap order to preserve the maximum soft tissue cover the recession. Alternatively, a Several variations of the coronally thickness above the root exposure. This partial-thickness fl ap can be used. Tissue advanced flap have been proposed. incision should be extended laterally adjacent to the area of recession is de- Tarnow described the semilunar to include at least one adjacent tooth epithelialized with a split-thickness fl ap coronally repositioned flap in 1986.36 on each side of the gingival recession. to expose connective tissue and provide This technique uses a semilunar a blood supply for the advanced fl ap. incision that is parallel to the gingival Subepithelial Connective Tissue Graft The coronally advanced fl ap is sutured margin above the recession defect. With Flap Coverage at a level to cover exposed root surfaces A split-thickness incision is made The use of a “submerged” subepithelial (FIGURES 3). This procedure can be through the sulcus to elevate and connective tissue graft (SCTG) for root applied at single or multiple recession coronally advance the tissue over the coverage was originally introduced by sites with adequate keratinized tissue denuded root (FIGURES 4). Advantages Langer and Langer in 1985.20 The technique apical to the root exposure. With this include no tension, no shortening of utilized an SCTG and split-thickness CAF approach, the soft tissue used to cover the vestibule and no manipulation of with releasing vertical incisions that is the root exposure is similar in color, interdental papilla. Disadvantages are repositioned over the connective tissue texture and thickness to that originally similar to the CAF procedure. Namely, graft to partially cover it. Advantages of present at the labial aspect of the tooth it does not increase the zone of this technique are the dual blood supply with the recession defect, providing a keratinized tissue, may be susceptible contributing to the high predictability satisfactory aesthetic result. Advantages to retraction and cannot be used in and improved aesthetics compared to the of the coronally advanced fl ap procedure cases with a gingival cleft, high frenum free gingival graft or the free connective include relative ease, good aesthetics attachment or shallow vestibule. tissue graft. The SCTG with CAF provides and no secondary donor site required. more tissue thickness than the CAF alone. Disadvantages are that this procedure Modifi ed Coronally Advanced Flap Furthermore, harvesting SCTG from does not increase the zone of keratinized De Sanctis and Zucchelli (2007) the donor site involves less postoperative tissue and may be susceptible to fl ap proposed a modifi ed surgical approach of morbidity as compared to the donor site for retraction and relapse of the recession if split-full-split-thickness fl ap compared free gingival grafts. In situations where the the fl ap is not adequately released and to the conventional CAF procedure overlying fl ap does not completely cover sutured. The CAF procedure cannot with vertical releasing incisions for the connective tissue, the exposed tissue be used if there is a lack of keratinized the treatment of localized gingival becomes keratinized thereby potentially tissue, a cleft through the gingival recessions.37 For multiple recession types, increasing the zone of keratinized tissue. margin, a high frenum attachment at the Zucchelli and de Sanctis (2000, 2007) The disadvantage of this technique is the gingival margin or a shallow vestibule. presented further changes to the CAF use of vertical releasing incisions, which The coronally advanced fl ap procedure to improve the predictability may compromise vascularization in wound procedure for root coverage was shown of multiple recession-type defects.38,39 healing and result in fi brotic scars. to be successful with mean root coverage The authors proposed the use of a Following the introduction of the of 79 percent.33 Predictability data horizontal incision and a split-full-split original Langer and Langer technique, showed that complete root coverage was approach to create an “envelope fl ap” several modifi cations of the recipient achieved 40 percent of the time.34,35 with no vertical releasing incisions in site preparation have been proposed.

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FIGURE 6A.

FIGURE 6B. FIGURE 6C.

FIGURES 6. Strip gingival autograft donor site (6A). Strip gingival grafts (6B). Donor site healing at one week (6C). Notice the shallow depth and rapid re-epithelialization as compared to the typical FGG donor site.

Envelope fl aps were introduced to avoid reported to be a highly successful method the graft either completely or partially. In the use of vertical incisions with the SCTG with mean root-coverage outcomes of the case of a tunnel or pouch technique, either completely covered or left partially 91.1 percent and 95.8 percent for molar incisions are made through the sulcus and exposed.40 Further modifi cations include and non-molar sites, respectively.45,46 horizontal incisions across interdental combining the free connective tissue graft Predictability data indicates that complete papilla are avoided; the fl ap is extended with partial- or full-thickness fl aps, single- root coverage and long-term success of beyond the mucogingival junction and tooth tunnel or pouch technique, subpedicle the SCTG with fl ap coverage for Miller I under each papilla to allow passive, tension- fl aps and double papilla pedicle fl aps.41 and II recession defects is 98.4 percent.47 free coronal mobilization of the overlying All of these techniques offer a bilaminar This is the gold standard for root coverage fl ap. The tissues are less likely to retract blood supply increasing the chance for in terms of predictability, percentage when using this fl ap design because the revascularization of the graft and complete of coverage and long-term stability. interdental tissues are not severed. Incisions root coverage. In 2005, Harris compared See the following case presentation. and fl ap refl ection are accomplished various recipient site fl ap designs used to entirely through the . cover SCTG and found them all to be Recipient Site Considerations The etiology of the lesion must be equally effective in obtaining root coverage identifi ed and addressed prior to surgical and improving clinical parameters.42 Recipient Site Preparation therapy. This may include the removal Another bilaminar technique using a Recipient site preparation includes and control of biofi lm, modifi cation of dual blood supply was introduced by Zadeh soft tissue fl ap design and root surface oral hygiene techniques, orthodontic in 2011.43 He proposed a variation of the treatment. The primary purpose of the tooth movement, surgical reduction of SCTG that used a midline vestibular recipient site soft tissue fl ap preparation prominent root surfaces and complete incision and subperiosteal tunnel approach is to expose stable connective tissue that removal of class V restorations. (VISTA) to prepare the recipient site. serves to provide nutrients (blood supply) Root surfaces must be thoroughly The VISTA technique utilizes a vertical and an area for attachment (suturing and cleaned prior to surgical preparation of incision in the vestibule, away from the healing) of the graft. In the case of free the recipient site. Typically, roots are recession area, to provide access for full- gingival grafts or free connective tissue scaled and root planed. Root surface thickness, tension-free soft tissue elevation grafts, the recipient site is prepared by biomodifi cation may be performed, and insertion of graft materials (i.e., dissecting the epithelium, connective tissue although the clinical benefi t is unclear.48 subepithelial connective tissue or acellular and muscle fi bers, leaving the periosteum The purpose, in conjunction with dermal matrix). The outer “fl ap” tissue is as the base. The recipient bed should be , is to remove coronally advanced along with the graft nonmobile. It should be even and the the smear layer, expose fi bers and stabilized with suspensory sutures that donor tissue should be well adapted to within the dentin and eliminate any toxic are tacked to the crowns with composite. prevent blood pooling, which can lead to substances on the root surface. Citric acid, Subepithelial connective tissue grafts a hematoma and subsequent necrosis.17 In , sodium hypochlorite and with fl ap coverage have clearly been the case of subepithelial connective tissue ethylenediaminetetraacetic acid (EDTA) established as a highly effective means of graft with fl ap coverage, the recipient site are chemical agents commonly used to covering recession defects providing the is prepared by elevating a full- or partial- remove the smear layer and prepare the most signifi cant gains in root coverage thickness fl ap with or without vertical root surface. The use of lasers to clean and the greatest long-term stability.44 It is incisions and repositioning the fl ap over and prepare root surfaces has also been

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reported but without advantages.49,50 In fact, root surface biomodifi cation with the Nd:YAG laser was found to be detrimental to the success of root- coverage procedures.49 No particular root surface biomodifi cation technique has FIGURE 7A. FIGURE 7B. been shown to produce any advantage over another, including no treatment.51

Donor Site Considerations

Donor Site: Harvesting Free Gingival Graft The free gingival graft must be harvested from an area of keratinized epithelium with a dense lamina propria. This can include edentulous ridge tissue, FIGURE 7C. FIGURE 7D. attached gingiva and palatal mucosa.17 FIGURES 7. Trap door technique donor site with vertical incisions at both ends (7A). Harvesting SCTG from trap A minimum palatal thickness of 3 mm door (7B). SCTG harvested from trap door (7C). Trap door donor site sutured with mattress and interrupted sutures (7D). is recommended for this technique. Graft thickness relates to graft survival, shrinkage and appearance. Thinner grafts blend better than thicker grafts but may Donor Site: Harvesting Subepithelial of the greater palatine artery in 198 not survive as well over root surfaces. Connective Tissue Graft periodontally healthy individuals, it was An FGG for root coverage requires a There are important anatomical determined that it is possible to harvest a thicker graft than for gaining attached structures that must be considered when connective tissue graft measuring 5 mm gingiva.52 Overall, a graft thickness electing to harvest SCTGs from the in height for all cases and approximately of 1–1.5 mm has been reported to be palate. The depth of the palatal vault 8 mm in height for 93 percent of cases in functionally optimal5 (FIGURES 5). must be evaluated prior to surgery. The the premolar region.56 Direct evaluation The strip gingival autograft technique primary concern is violation of the of the greater palatine artery in 41 human has been described as a technique to neurovascular bundle that extends from cadavers confi rmed that it is possible to address the disadvantage of large, slow the greater palatine foramen anteriorly harvest a connective tissue graft measuring healing palatal donor sites with the in the palatal vault. It has been reported at least 5 mm in height.57 Palatal tissue traditional FGG.53,54 Donor tissue is that the greater palatine vascular bundle thickness is thinner in younger individuals harvested in thin and narrow (2 mm is located 7 mm apical to the free gingival and females as compared to older wide) strips from multiple separate margin in shallow , 12 mm apical to individuals and males, respectively. The sites to create small, shallow donor site the free gingival margin in average palates amount of tissue that can be harvested wounds with more wound edges and and 17 mm apical to the free gingival varies depending on the height of the less exposed connective tissue area for margin in steep palates.55 In shallow palatal vault and thickness of tissue.56,58 rapid epithelialization and decreased palates, the harvest site must be restricted There are multiple methods for the discomfort for the patient (FIGURES 6). to a position closer to the teeth and harvesting of subepithelial connective tissue This technique cannot be used for root limited in depth. The optimal location grafts. The overall goals are to achieve a coverage because the donor tissue is for harvesting SCTGs is palatal to the graft of desired dimensions while respecting too thin to survive over root surfaces; maxillary premolars and fi rst molar sites. anatomical landmarks and minimizing tissue it may be used in combination with Harvesting of SCTGs must be limited to sloughing during healing. The overlying a subsequent coronally advanced fl ap the depth that avoids injury to the major fl ap tissue must remain thick enough to procedure to cover exposed roots. vessels. Based on the estimated position survive and to be sutured adequately for

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FIGURE 8A. FIGURE 8B. FIGURE 8C. FIGURES 8. Parallel incision technique donor site (8A). SCTG harvested from parallel incisions (8B). Parallel incision donor site sutured with mattress sutures (8C). (Photos courtesy of Charlene Pham, DDS, UCLA periodontics resident.)

thickness dissection is made within this incision, leaving adequate fl ap thickness to minimize sloughing. The incisions are extended as long and apically as needed for the desired graft size while respecting anatomical limitations. The connective tissue is then elevated from the bone with a blunt instrument for a graft of maximum thickness with periosteum or with a second incision closer to the bone FIGURE 9A. FIGURE 9B. for a graft of desired thickness without FIGURES 9. Single-incision technique donor site. SCTG harvested from single incision (9A). Single-incision donor periosteum. Internal vertical incisions are site sutured with mattress sutures (9B). Notice primary closure achieved with this technique. required at the mesial and distal ends to join the incisions. A horizontal incision is then made at the base to release the graft stabilization. Flap designs for harvesting incisions that converged at each end to apically. The advantage of this technique SCTGs include trap door, parallel harvest a CTG wedge with an epithelial compared to the parallel incision incisions and single-incision approaches. collar.40 Alternatively, Harris developed technique is primary closure of the palatal The trap door technique, advocated a double-blade knife to create parallel wound, which allows for accelerated by Edel,18 uses a horizontal incision incisions between the palatal surface healing and decreased patient discomfort. parallel to the gingival margin and vertical and the bone with a single stroke, which Once a graft is harvested, it must be releasing incisions at one or both ends. A helps to harvest a graft of uniform 1.5 mm kept in a sterile, moist environment and partial thickness fl ap is raised (FIGURES 7). thickness.59 Internal vertical incisions are should be sutured to the recipient bed as This technique is easier to use because it required at the mesial and distal ends to soon as possible with resorbable sutures. creates increased access to the underlying join the incisions. A horizontal incision connective tissue. However, the vertical is then made at the base to release the Case Presentation incision interrupts the vascular supply, graft apically. The graft is removed with A 42-year-old healthy female which predisposes the tissue to sloughing, a narrow collar of epithelium, which can presented with the complaint of especially if the fl ap is too thin. be excised after harvesting if desired. Due moderate to severe gingival recession The parallel incision technique, to the removal of epithelium with the affecting most of her maxillary teeth. introduced by Langer and Langer,20 uses a graft, complete primary closure of the She wanted to improve her smile as she horizontal incision made 2–3 mm apical palatal wound is not predictably obtained did not like the uneven tooth length to the gingival margin of the maxillary (i.e., there is usually a 1–2 mm gap of and gingival asymmetry (FIGURES teeth perpendicular to the palatal surface. exposed connective tissue after closure). 10). She also complained about root A second parallel incision is made 1–2 mm The single-incision technique, sensitivity. The most likely etiology of apically but directed parallel to the long introduced by Hurzeler and Weng,60 the gingival recession was trauma from axis of the teeth to create a split thickness uses a single horizontal incision made aggressive toothbrushing habits with fl ap to harvest a connective tissue graft with perpendicular to the palatal tissue surface a medium- or stiff-bristled brush on a an epithelial collar (FIGURES 8). Raetzke 2–3 mm apical to the gingival margin of susceptible, thin periodontal biotype introduced a similar procedure with two the maxillary teeth (FIGURES 9). A partial with labially prominent teeth. Biofi lm

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FIGURE 10C.

FIGURE 10A. FIGURE 10B.

FIGURE 10F. FIGURE 10D. FIGURE 10E.

FIGURE 10D. FIGURE 10E.

FIGURE 10G. FIGURE 10I.

FIGURE 10H.

FIGURE 10J. FIGURE 10K. FIGURE 10L.

FIGURE 10N. FIGURE 10M. FIGURE 10O.

FIGURES 10. Patient presents with several Miller Class II recession defects aff ecting most maxillary teeth (10A). Gingival margins are uneven and asymmetrical. Preoperative clinical view of many recession defects (10B–10D). Recession defects treated with SCTGs using a pouch technique to mobilize and advanced tissues through the sulcular incisions (10E–10G). Palatal stent fabricated for patient comfort to cover donor site wounds during initial healing phase (10H). Healed sites about four months after surgery prior to restorations. (10I–10K). Smile view about six years after surgery and restorations (10L). Healed sites about six years after surgery (10M–10O). The combined treatment of SCTGs and restorative treatment provided an excellent aesthetic result that is stable.

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TABLE Factors That Can Adversely Influence the Expected Outcomes of Root-Coverage Procedures Patient-related factors ■ Smoking levels with autogenous soft tissue grafts to dentistry. Examination about six years after ■ Systemic conditions that adversely aff ect healing provide root coverage for teeth Nos. 5, 6, the surgical procedure reveals good healing, ■ Inadequate biofi lm control 7, 10, 11 and 12 and to crown lengthen nearly complete root coverage and good

■ Poor compliance or inability to follow instructions tooth No. 8. The crown No. 9 would be gingival contours. The patient reports no replaced and veneers were planned for root sensitivity. The combined treatment of ■ Psychological impairment adjacent teeth to level incisal edges and SCTGs and restorative dentistry provided ■ Unrealistic expectations balance tooth dimensions and contours. an excellent aesthetic result that is stable. Defect-related factors The procedure was performed under ■ Recession type local anesthesia with 2% lidocaine with Postoperative Complications ■ Single or multiple recession defects 1:100,000 epinephrine. All exposed root Complications following autogenous surfaces were scaled and root planed. soft tissue grafts can include pain, ■ Mucogingival defects The recipient sites were prepared with a bleeding, infection and necrosis. These ■ Amount of keratinized tissue pouch technique. Sulcular incisions were can be minimized through patient ■ Periodontal biotype made with a microblade. A split-thickness selection, careful surgical technique and ■ Vestibule depth pouch was prepared with sharp dissection adherence to postoperative instructions. ■ Subgingival restorations beyond the mucogingival junction

■ Caries or noncarious cervical lesions until the entire area was separated and Postoperative Instructions mobilized. Continuity of the pouch space Treatment of gingival recession Technique-related factors from end to end was confi rmed by passing with autogenous soft tissue grafting ■ Stability of graft and fl ap an instrument through the tunnel. Two typically involves two surgical sites ■ Position of the gingival margin SCTGs were harvested from the right that need to be carefully managed after ■ Adequate vascular supply and left palate using the parallel incision surgery. Prior to patient discharge, both ■ Adequate release of fl ap tension technique. Donor sites were well adapted donor and recipient sites should be and closed with mattress sutures (5-0 carefully inspected to assess hemostasis ■ Appropriate technique chromic gut). The connective tissue grafts and wound stability. Postoperative were inserted through the sulcus at one end, instructions should advise patient to control was fair and there was slight pulled through the tunnel with a suture avoid manipulation of the surgical sites. marginal gingival infl ammation. The passed in from the other end, positioned Specifi c instructions may include: maxillary central incisor No. 9 had and secured in place over exposed root ■ Avoid manipulation of a PFM crown with a gingival margin surfaces with sutures (5-0 chromic gut). the surgical area. that was 2–3 mm more apical than the The fl ap was secured with mattress sutures ■ Avoid attempting to look at contralateral unrestored central incisor (5-0 chromic and 6-0 prolene). Stability or inspect the surgical sites. No. 8. Exposed root surfaces were clean of grafts and fl aps was verifi ed with careful ■ Brush all teeth normally except and smooth with a glassy, polished examination. Tooth No. 8 was crown those in surgical sites. appearance. Slight surface wear was noted lengthened with a gingival excision of ■ Biofi lm should be gently removed on roots, especially the patient’s left approximately 2–3 mm. The labial bone from treated teeth with an extra side, which also presented with greater level was assessed and reduced through the soft brush and/or a cotton swab. recession depth. Although there was sulcular incision using hand instruments. ■ Gently rinse two to four times a some incipient loss of interdental papilla, A palatal stent was provided to protect day with salt water (or prescribed the interproximal spaces were nearly the donor site wounds — mostly as an aid for antimicrobial ) full with peaked papillary tissues and patient comfort during the initial healing. during the fi rst two weeks. interproximal bone levels were normal. Postoperative instructions were provided ■ Use ice pack and cold water The patient was advised to use a soft- and the patient was scheduled to return for to keep surgical sites cool bristled toothbrush and her brushing habits postoperative care and suture removal. during fi rst two days. were modifi ed. The treatment, which was The patient healed uneventfully. ■ Limit diet to mild, soft foods. planned in coordination with her restorative Tissues were allowed to heal and mature ■ Avoid hot, spicy, hard dentist, was to improve gingival margin four months prior to initiating restorative or crunchy foods.

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■ Take anti-infl ammatory/ Defect-Related Factors using tension-free fl aps and suturing analgesic medications as The severity of the recession defect techniques are essential to minimize directed or needed for pain. (Miller’s classifi cation) and surrounding retraction during healing because increased ■ Use palatal stent to protect tissues can adversely affect the outcome fl ap tension causes tissues to retract. The donor site wound as needed for of root-coverage procedures. Teeth utilization of pouch, envelope and tunnel fi rst two weeks (optional). that are labially prominent in the arch, procedures, which avoid making incisions malaligned or crowded with a thin biotype across or through interdental papilla, also Therapeutic Endpoint of Success pose a greater challenge for root-coverage helps to reduce the likelihood of fl ap The therapeutic endpoints of success procedures. Likewise, recession defects retraction. for the treatment of gingival recession are associated with little or no keratinized to achieve complete root coverage and tissue, a lack of vestibular depth, subgingival Conclusion improve aesthetics. Secondary benefi ts may restorations, caries or noncarious cervical Gingival recession is a common include reducing sensitivity and increasing lesions pose a greater challenge for root condition. Consequences of gingival gingival width and thickness. As with coverage. Covering multiple recession recession include loss of clinical attachment, most surgical procedures, there are risk defects can be less predictable than single root sensitivity, susceptibility to root caries factors that may diminish the success of recession defects. Initial tissue thickness and abrasion, challenges to effective biofi lm root coverage. There are patient-related, directly correlates with the predictability control and poor aesthetics. The ultimate site-related and technique-related factors of complete root coverage. Increasing goal of treatment for gingival recession is that can adversely infl uence the expected tissue thickness results in complete root achieving complete root coverage with a outcomes of root-coverage procedures coverage irrespective of width of keratinized healthy, thick and suffi ciently broad zone (TABLE). Hence, it is important to select tissue or recession depth. Complete of keratinized gingiva. It is also important the most predictable and easy-to-perform coverage with a coronally positioned for the newly formed tissue to blend in surgical technique with careful evaluation fl ap requires soft tissue thickness ≥ 1 mm with the surrounding tissues in terms of and consideration of these risk factors. (less results in incomplete coverage). color, surface texture and harmony.64 The coronally advanced fl ap with subepithelial Patient-Related Factors Technique-Related Factors connective tissue graft has been consistently Some of the patient-related factors Precise, careful surgical management of reported as the most effective and that may adversely affect the outcome soft tissues at the recipient and donor sites is predictable procedure for root coverage, of root-coverage procedures include essential to the success of root-coverage often referred to as the gold standard. This smoking, systemic conditions, biofi lm procedures. Blood supply, blood supply, article reviews the etiology and classifi cation and poor patient compliance. Smokers blood supply. Adequate vascular supply of gingival recession, the evolution of had 17.5 percent less root coverage obtained from the bone, periosteum, PDL or autogenous soft tissue grafting and describes and about 36 percent fewer sites with overlying fl ap at the recipient site is techniques used for root coverage. ■ complete root coverage when treated with essential for complete root coverage 61 REFERENCES SCTG. Systemic conditions such as regardless of procedure or technique used. 1. Kassab MM, Cohen RE. The etiology and prevalence of gingival poorly controlled diabetes and immune- Recipient sites must be designed and recession. J Am Dent Assoc 2003;134:220–225. compromised conditions can adversely managed to optimize the blood supply to 2. Broadbent JM, Williams KB, Thomson WM, Williams SM. Dental restorations: A risk factor for periodontal attachment loss? J Clin affect healing and may impair the results the graft. Bilaminar vascular supply with an Periodontol 2006;33(11):803–10. of root-coverage procedures. Inadequate or overlying fl ap is preferred as it contributes to 3. Kois JC. The restorative-periodontal interface: Biological poor biofi lm control following surgery may increased predictability of root coverage by parameters. Periodontol 2000 1996;11:29–38. 4. Paolantonio M, D’ercole S, Perinetti G, Tripodi D, Catamo adversely affect the results of root-coverage subepithelial connective tissue grafts as G, Serra E, Bruè C, Piccolomini R. Clinical and microbiological procedures. Poor compliance with or an compared to free gingival and free eff ects of diff erent restorative materials on the periodontal tissues inability to follow instructions may adversely connective tissue grafts. Surgical positioning adjacent to subgingival class V restorations. J Clin Periodontol 2004;31(3):200–7. affect healing and results. Psychological of the tissue margin coronal to the 5. Takei HH, Scheyer ET, Azzi RR, et al. Periodontal Plastic and impairment as well as unrealistic cementoenamel junction is an important Esthetic Surgery. In: Newman MG, Takei HH, Klokkevold PR, expectations can have an adverse effect on factor that improves root coverage Carranza FA eds. Carranza’s Clinical Periodontology, 12th ed. St. 62 63 Louis: Elsevier; 2015. the result of root-coverage procedures. outcomes. Releasing the periosteum and 6. Checchi L, Daprile G, Gatto MR, et al. Gingival recession and

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toothbrushing in an Italian school of dentistry: A pilot study. J Clin 28. Miller PD Jr. Root coverage using the free soft tissue autograft 47. Harris RJ. Root coverage with connective tissue grafts: Periodontol 1999;26:276–280. following citric acid application. III. A successful and predictable An evaluation of short- and long-term results. J Periodontol 7. Miller PD Jr. A classifi cation of marginal tissue recession. Int J procedure in areas of deep-wide recession. Int J Periodontics 2002;73:1054–1059. Periodontics Restorative Dent 1985;5:8–13. Restorative Dent 1985;5:14–37. 48. Oliveira GH, Muncinelli EA. Effi cacy of root surface 8. Stefanini M, Marzadori M, Aroca S, et al. Decision making in 29. Borghetti A, Gardella JP. Thick gingival autograft for the biomodifi cation in root coverage: A systematic review. J Can Dent root-coverage procedures for the esthetic outcome. Periodontol coverage of gingival recession: A clinical evaluation. Int J Assoc 2012;78:c122. 2000 2018;77:54–64. Periodontics Restorative Dent 1990;10:216–229. 49. Dilsiz A, Aydin T, Canakci V, et al. Root surface biomodifi cation 9. Goldstein M, Boyan BD, Cochran DL, Schwartz Z. Human 30. Jahnke PV, Sandifer JB, Gher ME, et al. Thick free gingival with Nd:YAG laser for the treatment of gingival recession with histology of new attachment after root coverage using subepithelial and connective tissue autografts for root coverage. J Periodontol subepithelial connective tissue grafts. Photomed Laser Surg connective tissue graft. J Clin Periodontol 2001 Jul;28(7):657–62. 1993;64:315–322. 2010;28:337–343.PMC2966850. 10. E. Rasperini G, Silvestri M, Schenk RK, Nevins ML. Clinical and 31. Paolantonio M, di Murro C, Cattabriga A, et al. Subpedicle 50. Dilsiz A, Aydin T, Yavuz MS. 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J Periodontal Res Oct;19(5):439–47. 33. Wennstrom JL, Zucchelli G. Increased gingival dimensions. 2016;51:175–185. 12. Pasquinelli KL. The histology of new attachment utilizing a thick A signifi cant factor for successful outcome of root coverage 52. Miller PD Jr. Root coverage with the free gingival graft. Factors autogenous soft tissue graft in an area of deep recession: A case procedures? A two-year prospective clinical study. J Clin Periodontol associated with incomplete coverage. J Periodontol 1987;58:674– report. Int J Periodontics Restorative Dent 1995 Jun;15(3):248–57. 1996;23:770–777. 681. 13. Majzoub Z, Landi L, Grusovin MG, Cordioli G. Histology 34. Pini-Prato G, Baldi C, Pagliaro U, et al. Coronally advanced fl ap 53. Han TJ, Takei HH, Carranza FA. The strip gingival autograft of connective tissue graft. A case report. J Periodontol 2001 procedure for root coverage. Treatment of root surface: Root planing technique. Int J Periodontics Restorative Dent 1993;13:180–187. Nov;72(11):1607–15. versus polishing. J Periodontol 1999;70:1064–1076. 54. Han TJ, Klokkevold PR, Takei HH. Strip gingival autograft used 14. Harris RJ. The connective tissue with partial thickness double 35. Saletta D, Pini Prato G, Pagliaro U, et al. Coronally advanced to correct mucogingival problems around implants. Int J Periodontics pedicle graft: The results of 100 consecutively treated defects. J fl ap procedure: Is the interdental papilla a prognostic factor for root Restorative Dent 1995;15:404–411. Periodontol 1994 May;65(5):448–61. coverage? J Periodontol 2001;72:760–766. 55. Ricci G, Aimetti M. Gingival surgery, mucogingival therapy and 15. Pini Prato GP, Franceschi D, Cortellini P, Chambrone L. Long-term 36. Tarnow DP. Semilunar coronally repositioned fl ap. J Clin periodontal plastic surgery. In: Ricci G ed. Periodontal Diagnosis evaluation (20 years) of the outcomes of subepithelial connective Periodontol 1986;13:182–185. and Therapy. Milan: Quintessenza Edizioni; 2014. tissue graft plus coronally advanced fl ap in the treatment of maxillary 37. de Sanctis M, Zucchelli G. Coronally advanced fl ap: A modifi ed 56. Monnet-Corti V, Santini A, Glise JM, et al. Connective tissue single recession-type defects. J Periodontol 2018 Jun 6. doi: surgical approach for isolated recession-type defects: three-year graft for gingival recession treatment: Assessment of the maximum 10.1002/JPER.17-0619. [Epub ahead of print] PubMed PMID: results. J Clin Periodontol. 2007;34:262–268. graft dimensions at the palatal vault as a donor site. J Periodontol 29873085. 38. Zucchelli G, De Sanctis M. The coronally advanced fl ap for 2006;77:899–902. 16. Grupe H, Warren R. Repair of gingival defects by a sliding fl ap the treatment of multiple recession defects: A modifi ed surgical 57. Klosek SK, Rungruang T. Anatomical study of the greater operation. J Periodontol 1956;27:92–95. approach for the upper anterior teeth. J Int Acad Periodontol palatine artery and related structures of the palatal vault: 17. Sullivan HC, Atkins JH. Free autogenous gingival grafts. 2007;9:96–103. Considerations for palate as the subepithelial connective tissue graft 3. Utilization of grafts in the treatment of gingival recession. 39. Zucchelli G, De Sanctis M. Treatment of multiple recession- donor site. Surg Radiol Anat 2009;31:245–250. Periodontics 1968;6:152–160. type defects in patients with esthetic demands. J Periodontol 58. Ksv R, P S, V K, et al. Assessment of thickness of palatal 18. Edel A. Clinical evaluation of free connective tissue grafts used 2000;71:1506–1514. masticatory mucosa and maximum graft dimensions at palatal vault to increase the width of keratinised gingiva. J Clin Periodontol 40. Raetzke PB. Covering localized areas of root exposure associated with age and gender — a clinical study. J Clin Diagn Res 1974;1:185–196. employing the “envelope” technique. J Periodontol 1985;56:397– 2014;8:ZC09–13.PMC4080056. 19. Bernimoulin JP, Luscher B, Muhlemann HR. Coronally 402. 59. Harris RJ. The connective tissue with partial thickness double repositioned periodontal fl ap. Clinical evaluation after one year. J 41. Nelson SW. The subpedicle connective tissue graft. A bilaminar pedicle graft: The results of 100 consecutively treated defects. J Clin Periodontol 1975;2:1–13. reconstructive procedure for the coverage of denuded root surfaces. Periodontol 1994;65:448–461. 20. Langer B, Langer L. Subepithelial connective tissue graft J Periodontol 1987;58:95–102. 60. Hurzeler MB, Weng D. A single-incision technique to harvest technique for root coverage. J Periodontol 1985;56:715–720. 42. Harris RJ, Miller LH, Harris CR, et al. A comparison of three subepithelial connective tissue grafts from the palate. Int J 21. Smukler H. Laterally positioned mucoperiosteal pedicle grafts techniques to obtain root coverage on mandibular incisors. J Periodontics Restorative Dent. 1999;19:279–287. in the treatment of denuded roots. A clinical and statistical study. J Periodontol 2005;76:1758–1767. 61. Chambrone L, Tatakis DN. Periodontal soft tissue root-coverage Periodontol 1976;47:590–595. 43. Zadeh HH. Minimally invasive treatment of maxillary anterior procedures: A systematic review from the AAP Regeneration 22. Caff esse RG, Espinel MC. Lateral sliding fl ap with a free gingival gingival recession defects by vestibular incision subperiosteal tunnel Workshop. J Periodontol 2015;86:S8–51. graft technique in the treatment of localized gingival recessions. Int J access and platelet-derived growth factor BB. Int J Periodontics 62. Bouchard P, Malet J, Borghetti A. Decision-making in aesthetics: Periodontics Restorative Dent 1981;1:22–29. Restorative Dent 2011;31:653–660. Root coverage revisited. Periodontol 2000 2001;27:97–120. 23. Cohen DW, Ross SE. The double papillae repositioned fl ap in 44. Chambrone L, Pannuti CM, Tu YK, et al. Evidence-based 63. Pini Prato GP, Baldi C, Nieri M, et al. Coronally advanced fl ap: periodontal therapy. J Periodontol 1968;39:65–70. periodontal plastic surgery. II. An individual data meta-analysis The post-surgical position of the gingival margin is an important 14. Pennel BM, Higgason JD, Towner JD, et al. Oblique Rotated for evaluating factors in achieving complete root coverage. J factor for achieving complete root coverage. J Periodontol Flap. J Periodontol 1965;36:305–309. Periodontol 2012;83:477–490. 2005;76:713–722. 25. Mlinek A, Smukler H, Buchner A. The use of free gingival grafts for 45. Harris RJ. A comparative study of root coverage obtained with 64. Cortellini P, Pini Prato G. Coronally advanced fl ap and the coverage of denuded roots. J Periodontol 1973;44:248–254. an acellular dermal matrix versus a connective tissue graft: Results combination therapy for root coverage. Clinical strategies based 26. Livingston HL. Total coverage of multiple and adjacent denuded of 107 recession defects in 50 consecutively treated patients. Int J on scientifi c evidence and clinical experience. Periodontol 2000 root surfaces with a free gingival autograft. A case report. J Periodontics Restorative Dent 2000;20:51–59. 2012;59:158–184. Periodontol 1975;46:209–216. 46. Harris RJ. Root coverage in molar recession: Report of 50 27. Matter J. Creeping attachment of free gingival grafts. A fi ve-year consecutive cases treated with subepithelial connective tissue grafts. J THE CORRESPONDING AUTHOR, Perry R. Klokkevold, DDS, MS, follow-up study. J Periodontol 1980;51:681–685. Periodontol 2003;74:703–708. can be reached at [email protected].

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CDA JOURNAL, VOL 46, Nº10

Acellular Dermal Matrix Allografts in Periodontal Therapy

Joan Otomo-Corgel, DDS, MPH; Chanook David Ahn, DMD; and Allen Gunn, DDS

ABSTACT Adequate keratinized tissue thickness and height enhance periodontal and implant stability. In order to correct gingival recession or augment keratinized gingival tissue, acellular dermal matrix (ACD) grafts from human donors provide an option for the clinician. This article reviews the material, techniques and rationale for ACD when there is inadequate autogenous donor tissue for the treatment site or the patient prefers a single surgical site.

AUTHORS

Joan Otomo-Corgel Chanook David Ahn, ingival augmentation is root coverage, acellular dermal matrix DDS, MPH, is a clinical DMD, is a periodontist a periodontal procedure (ADM) from human donor tissue. Note associate professor at the who completed his performed to enhance that ADM is also available from bovine, University of California, periodontics residency at Los Angeles, School of the VA Greater Los Angeles keratinized tissues around equine, porcine and plant sources. Dentistry, department of Healthcare System. Dr. Ahn teeth and dental implants. Acellular dermal matrices were periodontics and faculty graduated from Tufts School GPatients today are interested in the initially used for the resurfacing at the Greater Los Angeles of Dental Medicine and long-term health, aesthetics and function of burn injuries,1–3 replacement of VA Healthcare Center then completed a general of their periodontium. Periodontics tympanic membranes,4–8 dural repairs,9 Dental Service. She is practice residency at Yale 10–12 the past president of the New Haven Hospital. involves advanced training to evaluate the abdominal wall repairs, tendon/joint 13–16 17,18 American Academy of Confl ict of Interest individual patient and site for indications, repairs that are “hard to heal” and Periodontology, California Disclosure: None reported. as well as contraindications, for the reconstructive breast surgery.19–22 Studies Society of Periodontists myriad options for gingival augmentation. for use in urethral reconstruction23 are and Western Society of Allen Gunn, DDS, is a These procedures have been extensively also under review. ADM are created Periodontology. She has a 2018 graduate of the private practice limited to VA Greater Los Angeles studied for long-term stability, histology, by a process that decellularizes human periodontics, oral medicine Healthcare System comparability and outcomes based on donor soft tissue leaving the extracellular and implantology in Los residency in periodontics. the severity of the gingival recession matrix intact. This matrix provides Angeles. Dr. Gunn graduated from (Miller’s Classifi cation) or tissue thickness. repopulation by the patient’s own cells as Confl ict of Interest the Columbia University It is known that thicker biotypes with well as revascularization of the implanted Disclosure: None reported. College of Dental Medicine and fi nished a one-year adequate zones of keratinized tissue ADM tissue. The donor tissue epidermal AEGD with the U.S. Air around teeth and implants have improved layer is removed with all the dermal Force, followed by four long-term gingival stability. The cellular structures, thus removing the years of active duty service. purpose of this section is to provide the factors responsible for graft rejection Confl ict of Interest current status of one option to achieve and infection.24 It is a freeze-dried, cell- Disclosure: None reported. enhanced gingival tissue thickness and free dermal matrix with a structurally

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TABLE 1 Acellular Dermal Matrix Graft Products

Tissue Distribution agent Processor AlloDerm BioHorizons IPH Inc. LifeCell Puros Dermis Zimmer Biomet Tutogen via RTI Biologics integrated basement membrane and PerioDerm Dentsply Implants Musculoskeletal Transplant Foundation (MTF) in which collagen Oracell Puragraft/LifeNet Health Oracell bundles and elastic fi bers are the main components. This bioactive scaffold SureDerm Hiossen Hans Biomed provides for fi broblast, epithelial cell and endothelial cell migration, providing integration into host tissues.25,26 There are currently various acellular dermal graft products applicable to the tissue without damage from ice crystal PerioDerm (Dentsply periodontics according to Silc and formation. Histologic testing is then done Sirona, York, Pa.) undergoes a three-phase Petrunagro.27 Their article provided on each fi nal lot to verify cell removal. process that gently cleans, decellularizes information comparing the available Puros Dermis Allograft Tissue Matrix and disinfects without crosslinking or materials. They reviewed the differences (Zimmer Biomet Dental, Palm Beach compromising the integrity of the dermal among fi ve main products (TABLE 1). Gardens, Fla.) is recovered following the matrix. Each piece is quality controlled for Acellular dermal matrix has two sizes: rigorous standards of both the Food and 90%+ uniformity in thickness. Biologic the 0.25 mm to 1.25 mm thin-size grafts Drug Administration and the AATB with integrity is maximized via a proprietary are recommended for root coverage either a scalpel or dermatome from the process that avoids high-dose gamma and soft-tissue ridge augmentation. back of the thighs of the cadaver donor. irradiation. PerioDerm is aseptically Thicker sized grafts (0.8 mm to 1.8 The tissue is recovered by a recovery team processed by the Musculoskeletal mm) are recommended for guided bone within 24 hours of death using an aseptic Transplant Foundation and is rendered regeneration and process that meets the standards set by the sterile per United States Pharmacopeia function. The thickness of the ADM AATB. The tissue enters the Tutoplast Standard 71 (USP 71). PerioDerm used is predicated, however, on the needs tissue sterilization process (Tutogen has a shorter hydration period, no of the individual site to be treated. Medical/RTI Biologics Inc., Alachua, Fla.) need for refrigeration, no added The following is a review of only after it passes serological tests, such as antibiotics and a three-year shelf life. the preparation and differentiation those for human immunodefi ciency virus, Oracell (LifeNet Health, Virginia of allograft ADM materials from hepatitis, human T-lymphotropic virus and Beach, Va.) is decellularized with Silc and Petrugaro’s article:26 syphilis. The multistep Tutoplast process LifeNet Health’s patented technology AlloDerm Regenerative Tissue Matrix removes all antigenicity, inactivates all called Matracell, which renders the (BioHorizons IPH Inc., Birmingham, kinds of pathogens, preserves tissue structure product acellular without compromising Ala.) is an acellular dermal matrix derived and collagen, preserves biomechanics, biomechanical or biologic properties. More from donated human skin. It has an guarantees sterility and results in graft than 97 percent of the DNA is removed excellent safety history, having been used healing comparable to autografts. The from the dermis, so immunogenic potential in more than 1 million procedures ranging process itself consists of donor selection, is low. Oracell is infused with glycerin-based from general/urogenital, orthopedic and osmotic treatment, oxidative treatment, solution to replace rehydration at chairside. dental. In the procurement and safety alkaline treatment (different from bone) SureDerm (Hans Biomed, Daejeon, process of AlloDerm, tissue is accepted and solvent dehydration. Tutoplast Korea) is transported in ambient from tissue banks in compliance with the processing of Puros Dermis involves a temperature but requires refrigeration to American Association of Tissue Banks limited-dose gamma irradiation, which preserve better shelf life. It is packaged (AATB) guidelines. AlloDerm processing provides a sterility level that preserves graft in antibiotics and requires a separate from donor tissue involves a multistep integrity. The Puros Dermis tissue allograft rehydration rinse similar to AlloDerm. proprietary process that removes the has a strength-to-failure measurement of Although the “gold standard” is the epidermis and cells in the dermis that 5 pounds ± 0.8 pounds, can be stored at autograft, acellular dermal matrix provides can lead to graft rejection and/or failure room temperature, has a fi ve-year shelf the potential to enhance soft-tissue root of recipient responses. The extracellular life and, because of the Tutoplast process, coverage and increase the gingival width/ matrix that remains is then put through a has no residual chemicals when it is thickness without the morbidity of a donor proprietary freeze-drying step that preserves packed and delivered to the clinician. site. Often, there is an inadequate amount

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FIGURE 1A. FIGURE 1B. FIGURE 1C. FIGURES 1. This case shows an example of the material used with a traditional surgical approach to enhance the band of keratinized tissue around implants. (Case images courtesy of Biohorizons and performed by Carl E. Misch, DDS, MDS, Beverly Hills, Mich.) of available autogenous tissue available marginal tissue health. This stability was orienting the ADM with the connective for the designated procedure. This may confi rmed in a recent article by Agudio,30 tissue side facing the native periosteal be due to myriad reasons: anatomical, which showed excellent stability and bed.32–34 An example of the material used access, aesthetics or the requirements of indeed progressive creeping attachment with a traditional surgical approach to the surgical site. Patients may also prefer of sites augmented by free gingival enhance the band of keratinized tissue to opt out of a second surgical site, thus graft. This long-term study also showed around implants is shown in FIGURE 1. providing less postoperative discomfort a tendency for apical displacement Note that this technique relies on and complications. However, many of the gingival margin of untreated a signifi cant amount of secondary- patients are averse to allograft materials contralateral sites over 35 years despite intention healing, which may be for religious reasons or personal bias. excellent oral hygiene. The debate uncomfortable for the patient. A review of the use of acellular dermal continues regarding the importance of Techniques that cover ADM with the matrix for enhancing the thickness and/ tissue quality around implants as well. native soft tissue fl ap, similar to those or keratinized band of gingival tissue and While not all researchers agree, current employed for root coverage, can lead root-coverage procedures follows. The evidence suggests that a thick36,37 and to a more comfortable postoperative rationale (pros and cons), techniques and broadly keratinized38 band of tissue course for the patient. A discussion results will be reviewed for both uses. leads to better peri-implant health. A of root-coverage techniques using 2015 systematic review from the AAP ADM follows in the next section. Enhancing the Thickness and Band of Regeneration Workshop concluded While these procedures may increase Gingival Tissue that “the rationale for gingival the thickness of marginal tissue, the augmentation has to be dependent on practitioner should not expect the Rationale the particular clinical situation and the same gain of keratinization achieved The need for gingival augmentation patient’s oral hygiene competence.”31 by secondary-intention healing. to increase the band of keratinized tissue around teeth has been a matter of some Techniques Results (Clinical) debate for decades. The oft-quoted 1972 Most studies of ADM with the All of the included studies reported a paper by Lang and Loe demonstrated exclusive goal of gingival augmentation reasonably uneventful healing period for a relationship between the width of employ a variation of the traditional ADM. Wei33 reported that the healing keratinized tissue and the marginal surgical preparation used for a free gingival stages of ADM are, in general, two weeks health of teeth.28 However, a 1985 graft. This involves a horizontal marginal slower than that of a free gingival graft. study by Kennedy29 compared marginal or submarginal incision and a refl ection of He noted clinical epithelialization of the recession between sites with no attached a partial-thickness fl ap to expose a thin, graft at four weeks (along with striking gingiva and contralateral sites treated even periosteal bed. Harris32 modifi ed the shrinkage) and keratinization six to eight by free gingival graft for augmentation. classic surgical bed preparation by scoring weeks postoperatively. When evaluating Over six years, the researchers found the periosteum when placing ADM. the increase in keratinized tissue obtained no additional recession at sites without He also made an attempt to partially by grafting with ADM, Harris found no attached gingiva, provided that they were cover the material with the apically signifi cant difference from a free gingival kept free from infl ammation. Of note, positioned fl ap. Other studies made no graft (4.1 mm increase).32 However, the sites augmented by free gingival graft special modifi cations to the traditional Wei found a signifi cant difference seemed resistant to recession regardless of bed preparation, but all paid attention to between ADM and the free gingival

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FIGURE 2A. FIGURE 2B. FIGURE 2C.

FIGURES 2. Examples of soft tissue grafting using ADM. Preoperative (2A); immediate postoperative (2B) and one-year postoperative (2C). One year post-op. (Images courtesy of Chanook David Ahn, DMD, Los Angeles) graft, favoring autogenous tissue.33 In keeping with the histologic fi ndings below, he also noted that the new band of tissue created by ADM showed “alveolar mucosa characteristics, which included thin, non- or parakeratinized epithelium and visible capillaries.” FIGURE 3A. FIGURE 3B. While it appears that the tissue produced by augmentation with ADM is substantially different from a free gingival graft, all authors reported satisfactory gains in keratinized tissue and often superior aesthetics.32–34 It seems that the diffuse nature of the keratinization leaves less of the FIGURE 3C. FIGURE 3D. “patchwork” appearance that is so FIGURES 3. This case provides an example of Miller I and II recession defects. Greater predictability with root typical of an autogenous free gingival coverage can be achieved with the height when an adequate height of interproximal alveolar bone is available. graft. When balancing the merits of Preoperative (3A) — note the cervical lesions and restorations. Cervical restorations are removed, roots planed, the material, it would be important to AlloDerm graft placed in a coronally positioned tunnel and sutured with a single continuous sling suture (3B); know the stability of the marginal tissue two months post-op (3C); 18 months post-op (restorations by Tom Dawson, DDS, Mansfi eld, Texas) (3D). augmented by ADM. Unfortunately, (Clinical case courtesy of Edward Pat Allen, DDS, PhD, Dallas) there are no long-term studies of this material such as we have for the free gingival graft. As usual, it falls to the of the original ADM collagenous the overlying epithelium. The gingival practitioner to weigh each situation structure by 10 weeks.34 Wei obtained attachment to the root surface was carefully and judge the clinical histologic samples of the healed sites comparable for the connective tissue benefi ts of the possible approaches. augmented with ADM after six months. and ADM grafts (a combination of long He discovered that the sites showed and connective Results (Histologic) an inconsistent superfi cial layer of tissue) and the underlying alveolar Histologic analysis of the ADM in situ keratinization and a diffuse nature of the bone was essentially unaffected. over the fi rst few weeks shows a gradual mucogingival junction. In general, the increase in the number of resident grafted material appeared more similar Root Coverage fi broblasts and blood vessels, along with to scar tissue.35 Cummings performed a decrease in the infl ammatory infi ltrate. a histologic evaluation of ADM six Rationale At four weeks, the graft material months following coverage with a native Perio plastic surgery has been a shows drastic changes consistent with soft tissue fl ap, of the type employed major component of periodontics since degradation of the collagen matrix. Six for root coverage.39 He found that the the beginning of the specialty. Among weeks of healing shows a re-epithelialized buccolingual dimension of the tissue was the different mucogingival problems, gingiva and intact basement membrane. indeed thickened, however there was gingival recession (GR) is a frequent There are few histologic traces remaining no infl uence on the keratinization of fi nding among patients who are over age

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TABLE 2 Mean Percentage Range of Root Coverage for Miller Class I and II Defects Reference Number of sites Mean percentage Range of coverage Mean increase of Type of Root coverage of root coverage (percent) keratinized tissue (mm) recession (percent) Dodge et al. 6 patients/18 sites 96.12 ± 12.43 50 to 100 NR Class I and II 88.88 Harris 25 patients/65 sites 95.8 75 to 100 1.2 (0 to 2.8) Class I and II 87.72 Santos 12 patients/26 sites 74 0 to 100 1.19 (0 to 3) Class I and II 50 Aichelmann-Reidy 22 patients/22 sites 65.9 ± 46.7 0 to 100 1.2 ± 1.3 Class I and II NR et al. Henderson et al. 10 patients/20 sites 95 67 to 100 0.8 ± 1.14 Class I and II 75 Novaes et al. 9 patients/15 sites 66.5 60 to 98.9 0.63 ± 0.85 Class I and II 33.3 Paolantonio et al. 15 patients/15 sites 83.3 ± 11.4 NR 0.53 ± 0.51 Class I and II 26.6 Tal et al. 7 patients/7 sites 89.1 70 to 100 86 (0 to 2) Class I and II 42.8

NR = not reported. Adapted from Santos A, Goumenos G, Pascual A. Management of gingival recession by the use of an acellular dermal graft material: A 12-case series. J Periodontol 2005 Nov;76(11)1982–1990.

30.40 GR is a concern for patients due conjunction with ADM in a very Results to unaesthetic appearance, discomfort predictable way. Another surgical Clinical studies have reported the (primarily cold and tactile), root surface technique option is to utilize varying successful use of ADM since the 1990s. caries, diffi cult plaque control and tunneling techniques to prepare the The mean percentage of root coverage infl ammation. Many patients focus on recipient site and coronally advance ranged from 65.9 percent to 96.12 percent these problems because they are visible the fl ap with ADM. The tunnel can for Miller Class I and II defects according and symptomatic. The gold standard be either made through the sulcus to different studies (TABLE 2). The mean of gingival root coverage has been a (Pat Allen’s technique) or a portal increase of keratinized tissue was noted subepithelial connective tissue graft can be made in the vestibular area from 0.53 mm to 1.2 mm in increase (SCTG) with a coronally advanced fl ap. and tunneled coronally (VISTA after ADM was used for root coverage in However, due to myriad confounding with ADM). ADM can also be used addition to reducing GR. ADM has been issues with an alternative graft donor in conjunction with the classic a reliable substitute SG when necessary.44 site, perio plastic surgery with SCTG Langer and Langer fl ap design. Multiple studies have compared may be deemed unfavorable. One of Examples of soft tissue grafting using results to the subepithelial connective the alternatives that has been widely ADM are shown in FIGURES 2A–C. This tissue graft when ADM is used for root used is the ADM graft in place of the case shows that tunneling was completed coverage. Hirsch et al. concluded that the subepithelial graft. The convenience of through a vestibular incision allowing root coverage by ADM and SCTG had avoiding a donor site has been a huge the ADM to be placed underneath comparable predictability and was stable enticement for the use of the allograft. the periosteum. The gingival fl ap was for two years postoperatively. However, coronally advanced with the ADM subepithelial grafts showed a signifi cant Technique secured by sling sutures. After healing, increase in defect coverage, keratinized Perio plastic surgery for gingival all Miller Class I defects were restored gingival gain, attachment gain and recession is very predictable, for and the tissue was thickened. However, residual probing depth. In 2004, Harris both SCTG and ADM, in repairing Miller Class III defects were not fully also compared ADM to SCTG and found the recession of Miller Class I and II resolved, leaving about 1 mm gingival that short-term results showed comparable defects. When informing the patient recession. This case is a good example of results, but SCTG showed better long- of what results should be expected, what can and what cannot be achieved term mean root coverage. The SCTG is the clinician should point out that with soft tissue treatment using ADM. still the gold standard when it comes to Miller Class III and IV defects cannot The case shown in FIGURE 3 provides root-coverage graft choice. In addition, be predictably covered. When the an example of Miller I and II recession Chambrone et al. performed a systematic clinician has chosen the cases correctly, defects. Greater predictability with review of various root-coverage techniques there are multiple ways to approach root coverage can be achieved when and materials. Free gingival grafts, coronally the problem. Zuchelli’s split-thickness an adequate height of interproximal advanced fl aps alone or in combination fl ap advancement can be used in alveolar bone is available. with guided tissue regeneration, ADM,

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34. Scarano A, Barros RM, Lezzi G, et al. Acellular dermal matrix graft for gingival augmentation: A preliminary clinical, histologic and ultrastructural evaluation. J Periodontol 2009;80:253–259. 35. Wei PC, Laurell L, Lingen MW, Geivelis M. Acellular dermal matrix allografts to achieve increased attached gingiva. Part 2. A histological comparative study. J Periodontol 2002 Mar;73(3):257–265. 36. Linkevicius T, Puisys A, Steigmann M, Vindasiute E, Linkeviciene L. Influence of vertical soft tissue thickness on crestal bone changes around implants with platform switching: A comparative clinical study. Clin Implant Dent Relat Res 2015 Dec;17(6):1228–1236. doi:10.1111/ cid.12222. Epub 2014 Mar 28. 37. Suarez-Lopez del Amo F, Lin G, Monje A, Galindo- Moreno P, Wang HL. Influence of soft tissue thickness on peri-implant marginal bone loss: a systematic review and meta-analysis. J Periodontol 2016; 87 (6)690–699. 38. Lin G, Chang HL, Wang HL. The significance of keratinized mucosa on implant health: A systematic review. J Periodontol 2013 Dec;84(12):1755–1767. doi:10.1902/jop.2013.120688. Epub 2013 Mar 1. 39. Cummings LC, Kaldahl, WB, Allen EP. Histologic evaluation of autogenous connective tissue and acellular dermal matrix grafts in humans. J Periodontol 2005 Feb;76(2):178–186. 40. Barker TS, Cueva MA, Rivera-Hidalgo F, et al. A comparative study of root coverage using two different cellular dermal matrix products. J Periodontol 2010 Nov;81(11):1596–1603. doi:10.1902/ jop.2010.090291. Epub 2010 Jul 14. 41. Richardson CR, Allen EP, Chambrone L, et al. Periodontal soft tissue root-coverage procedures: Practical applications from the AAP regeneration workshop. Clin Adv Periodontics 2015;5:2–10. Give health, hope 42. Harris RJ. A short-term and long-term comparison of root coverage with an acellular dermal matrix and a subepithelial graft. J Periodontol 2004 May;75(5):734–743. 43. Hirsch A, Goldstein M, Goultschin J, et al. A two-year and happiness. follow-up of root coverage using subpedicle acellular dermal matrix allografts and subepithelial connective tissue By contributing your time and talent, you relieve pain, autografts. J Periodontol 2005 Aug;76(8):1323–1328. 44. Santos A, Goumenos G, Pascual A. Management restore dignity and create smiles for thousands of people of gingival recession by the use of an acellular dermal graft material: A 12-case series. J Periodontol 2005 who face barriers to care. Volunteer at CDA Cares Modesto Nov;76(11)1982–1990. to help provide essential dental care to those in need. 45. Chambrone L, Tatakis DN. Periodontal soft tissue root- coverage procedures: A systematic review from the AAP regeneration workshop. J Periodontol 2015 Feb;86,(2 Suppl):S8–51. doi:10.1902/jop.2015.130674. CDA Cares Modesto THE CORRESPONDING AUTHOR, Joan Otomo-Corgel, DDS, MPH, can be reached at [email protected]. October 26–27, 2018 Modesto Centre Plaza

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CDA JOURNAL, VOL 46, Nº10

The Pinhole Surgical Technique: A Clinical Perspective and Treatment Considerations From a Periodontist

Tina M. Beck, DDS, MS

ABSTRACT Multiple treatment options exist when considering therapeutic approaches for the management of gingival recession. The patented Pinhole Surgical Technique is one of the most recent of such procedures and one of the most poorly understood. The following commentary is intended to help guide clinicians in the decision-making process when considering root-coverage strategies.

AUTHOR

Tina M. Beck, DDS, MS, is umerous therapeutic change the gingival phenotype and a diplomat of the American solutions have been increase the band of attached keratinized Board of Periodontology proposed for the treatment gingiva.2–5 I was initially hesitant to and a solo practitioner in of gingival recession.1 offer PST as a viable treatment option San Diego. Her professional career has been dedicated One of the most recent because of the lack of long-term studies, to leadership in organized Nroot-coverage techniques, the Pinhole specifi cally on its effi cacy and stability. dentistry and patient Surgical Technique (PST), has rapidly However, through trial and error and care. She is published gained popularity over the last few more than 100 cases completed with in the Journal of the years but is poorly understood by a minimum of one-year follow-up, I American Academy of Periodontology. many clinicians. Even more confusing have established some guidelines that Confl ict of Interest is the fact that there are numerous I use in my decision-making process Disclosure: None reported. options available for gingival recession when considering treatment options treatment, each with its own benefi ts for recession defects. The purpose of and limitations. As a periodontist well this discussion is to elucidate how trained in a vast array of techniques, PST is performed, review its benefi ts incorporating PST into my practice and limitations and share my personal four years ago was a bit of a treatment- decision-making process in order to planning challenge. Like many assist other clinicians in determining periodontists, my preferred technique when this procedure would be a viable had been subepithelial connective treatment option as well as answer some tissue grafting because of its ability to of the most commonly asked questions predictably cover exposed root surfaces, regarding this novel technique.

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The most alluring aspect of this FIGURE 1B. procedure for the general public, and FIGURE 1A. FIGURES 1. Maxillary central incisors with Class I Miller recession (1A). One year after PST (1B). some clinicians, is that PST does not require the use of autogenous or allogenic graft material (tissue harvested from a different site from the same patient or from a cadaver, respectively). Instead, the patient’s existing gingiva is simply moved coronally to cover the exposed root surface. This is achieved using a 16-gauge FIGURE 2A. sterile hypodermic needle to penetrate the alveolar mucosa and pierce the periosteum FIGURE 2B. apical to the recessed area creating a “pinhole” through which instruments can be inserted. In cases with multiple adjacent sites, multiple pinholes may be required. Specifi cally designed instruments are inserted through the pinhole to elevate a full-thickness fl ap without severing FIGURE 2C. the interproximal papillae to move the FIGURE 2D. tissue to the desired coronal position. In FIGURES 2. 2A and 2B show pretreatment of Class II Miller recession defects with thin biotype and no attached my mind, I thought of the PST elevation gingiva on teeth Nos. 21, 23, 28. 2C and 2D are one year after PST and demonstrate complete root coverage. technique to be an alternative method for achieving a full-thickness fl ap while keeping the papillae intact, similar to tissue support to secure the marginal more lateral extension and fl ap release will popular tunneling and modifi ed tunneling gingiva in the new position. The use be required to allow tension-free coronal procedures6,7 or the vestibular incision of such a membrane is not new in the advancement of the gingival margin subperiosteal tunnel access (VISTA) periodontal literature and has a long at the site of recession. For this reason, technique,8 which many surgeons utilize history of being safe and effective both many of my patients prefer a technique to prepare a site for graft placement. in the treatment of gingival recession10 that allows for a smaller surgical area, like A critical factor for the success of as well as periodontal regeneration.11 a subepithelial connective tissue graft most root-coverage procedures is the The elimination of the need for sutures with a double papilla fl ap technique.12 elimination of tension on the gingival is another unique aspect of this procedure. Postsurgically, the pinhole is left margin of the newly positioned tissue.9 In order to allow tension-free coronal to heal by primary intention without With PST, wound stabilization is repositioning of the gingival margin suturing and is often healed within 48 achieved with the use of a malleable, without using sutures, it is necessary to hours. Patients are instructed to bathe the noncross-linked bioresorbable porcine also elevate and coronally advance the surgical area with 0.12% collagen membrane (Bio-Gide, Geistlich, gingival tissues of several adjacent teeth, gluconate oral rinse and avoid brushing Princeton, N.J.) that is carefully inserted both mesially and distally to the treatment or fl ossing the area for six to 12 weeks. through the pinhole and tucked under area. This requirement is of clinical Although patients experience very little the gingival tissues, over the root signifi cance for some patients who want to pain following the procedure, there can surfaces, supporting the fl ap in the minimize the area of treatment for faster be a considerable amount of swelling desired coronal position, without the recovery. For example, it would not be that subsides after about seven days. The need for suturing, dressings or tissue uncommon to require release from fi rst collagen membrane is slowly resorbed adhesive. Wound stabilization is thus molar to fi rst molar to treat a single, deep over the next three to four months, as achieved by distending the fl ap with the recession defect of a mandibular incisor. the newly coronally advanced gingiva collagen membrane, resulting in adequate The more severe the recession defect, the settles and re-establishes periodontal

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attachment to the previously exposed treatments. Miller explained that class I support these claims. When discussing root surface. Histological studies are and II recession defects can expect 100 treatment options with my patients, currently lacking to determine the exact percent root coverage, class III defects they are fully informed of this fact biology of the healing process, either can expect only partial root coverage and and it is left to them to make an connective tissue attachment, long class IV defects are highly unpredictable educated decision. They usually choose junctional epithelium or perhaps even and little to no root coverage can be subepithelial grafting in cases where some bone regeneration. Clinically, expected due to the presence of horizontal there is only a single tooth with little probing depths usually range from 1–3 mm bone loss and loss of interdental papillae. to no attached keratinized gingiva. when measured six months after surgery. These same guidelines should apply Initially, I only offered PST to patients Like all surgical techniques, there are to PST as well. Additional limitations who have ample attached gingiva and limitations to the success of PST that include the inability to treat recession thick phenotypes (FIGURE 1). However, must be considered when determining defects located on palatal surfaces, after my experience with the procedure treatment options. Most important, the diffi culty in physically accessing and witnessing fi rst-hand some of the patient must be healthy enough to be mandibular lingual areas using the PST dramatic results it can produce, I began considered a surgical candidate, similar to offer it for more complex cases (FIGURE to all the other treatment modalities. 2). In cases where there are several Heavy smoking, uncontrolled or teeth in a single arch with recession poorly controlled diabetes and certain Patients should be free and minimal attached gingiva, patients medications are just some of the factors often want to try PST over the multiple that can compromise the healing process of active periodontal rounds of surgery required for connective and increase the risk of complications,1 disease or severe gingival tissue grafting of an entire arch. FIGURE 2 which may outweigh the benefi t of infl ammation prior to demonstrates that good root coverage and treating the condition at all. As with some gain in attached gingiva is possible other root-coverage therapies, patients performing PST. with PST and I consider it an acceptable should be free of active periodontal treatment option despite the lack of disease or severe gingival infl ammation documented stability, as long as patients prior to performing PST and should are made aware of this fact. Additionally, demonstrate compliance with periodontal protocol and instruments and anatomical I evaluate the gingival phenotype of recall appointments and home care considerations involving the sublingual the recession site and explain that PST instructions. Also similar to other surgical spaces and related structures that may might not alter it signifi cantly, increasing therapies, occlusal discrepancies and present signifi cant risk in an apical-style the risk of recurrence. Due to the lack nocturnal bruxism or clenching should be approach for mandibular lingual surfaces. of evidence regarding the long-term appropriately identifi ed and managed. When considering soft tissue stability of PST in cases with very thin There are many anatomical factors biotype and attached keratinized biotypes and minimal or no attached to account for when considering gingiva, autogenous grafting is the most gingiva, I ensure that these patients treatment options, including but not documented procedure demonstrating understand that additional procedures limited to location of defect, severity of predictable and stable increases in may be required if the desired results defect, presence or absence of bone loss, tissue volume, i.e., altering the soft are not achieved, although I have yet number of teeth involved, amount of tissue biotype and amount of attached to see such recurrence. This word of attached keratinized gingiva and gingival keratinized gingiva.2–5 However, caution is based on existing studies phenotype. Miller’s classifi cation of analogous to alternative treatment involving coronally positioned fl aps gingival recession13 is the most widely modalities including allogenic soft tissue that suggest a minimum tissue thickness used method for categorization of the grafting and guided tissue regeneration, of 0.8–1mm for predictable and stable different types and severities of recession anecdotal evidence suggests that PST root coverage.15–17 Notwithstanding defects and is useful to establish general is capable of increasing tissue volume these limitations, there are some unique guidelines for clinicians when predicting and attached keratinized gingiva,14 but and signifi cant advantages to PST the success of various gingival recession currently there is limited evidence to for both the patient and clinician.

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Compared to conventional FIGURE 3B. autogenous soft tissue grafting, patients anecdotally report reduced postoperative FIGURE 3A. pain with the elimination of a secondary FIGURES 3. Grade IV Miller recession due to horizontal bone loss (3A). One year after PST and showing 100 harvest site.1 This fact may also improve percent coverage on two of six sites and 50–70 percent coverage on four of six sites (3B). Note the black triangle between the central incisors remains after treatment. case acceptance for PST due to the perceived pain associated with autogenous grafting and other alternative techniques. the gingival margin and connective together with a shift to patient-centered Patient-centered investigations are tissue attachment beyond the outcomes, has driven the development needed to substantiate these notions. cementoenamel junction onto enamel or of alternative therapies with improved An additional advantage of PST over over restorative surfaces. This limitation patient acceptance and less overall autogenous grafting procedures is the applies to PST as well. However, PST patient morbidity (pain, swelling and ability to treat an unlimited number of can be used to cover noncarious cervical bleeding) compared to autogenous sites at one time because the clinician is lesions as well as previously restored or grafting. Additionally, the inherent not limited by the ability to harvest an decayed root surfaces, similar to other limitation in the availability of donor adequate amount of tissue to cover the methods for treating gingival recession. tissue when performing autogenous desired area. In contrast to most other Although common in practice, the grafting has compelled clinicians to procedures commonly performed for the removal of a restoration to eliminate explore other methods. As a result, reversal of gingival recession, PST also recurrent decay or improve gingival clinicians are now faced with a plethora does not require sutures, reducing the aesthetics, in combination with a of treatment modalities for achieving time required to perform the procedure root-coverage procedure, is a relatively root coverage. Systematic reviews and and eliminating the overhead cost of recent concept in the literature.24–28 consensus statements produced as a result suture and related surgical instruments. Another misconception regarding of the recent American Academy of Moreover, the usage of a noncross-linked root-coverage procedures in general Periodontology regeneration workshop bioresorbable collagen membrane with is related to the ability to predictably concluded that viable alternative PST may encourage bone regeneration attain signifi cant root coverage in treatment modalities are currently similar to that noted in the literature the presence of horizontal bone loss. available that are capable of achieving regarding guided tissue regeneration for This type of recession often results in root coverage and providing keratinized the treatment of gingival recession,18–21 cosmetic compromise due to the lack tissue augmentation without the need however, histological evidence is of interproximal papillae, commonly for palatal donor tissue.29 To date, the needed to support this theory. referred to as “black triangles.” only peer-reviewed published clinical PST is not taught in universities Analogous to other procedures,13 PST research to date that is specifi c to PST and clinicians must attend a specifi c does not predictably fi ll these spaces is a retrospective study of 100 sites privately taught course to learn how to (FIGURE 3). A fi nal question many treated with PST that found an average perform the procedure, causing many unfamiliar with the technique have is of 86.9 percent defect coverage and an untrained clinicians to be unclear about in relation to the mental nerve. Due average residual recession of only 0.4 its limitations. Some of the limitations to the apicocoronal approach required mm.8 Average follow-up period was 18 of PST are not exclusive to this one with PST, special consideration must months, comparable to other long-term particular procedure because it is due to be taken to avoid damage to the mental studies evaluating the stability of root- the biologic nature of the periodontal nerve, a concern that is addressed coverage procedures.1,4,6 Research is attachment apparatus itself. It is well with a simple modifi cation to the currently in progress to further examine accepted in the periodontal community technique taught during the training. the effi cacy, predictability, limitations that connective tissue attachment An increased understanding of the and long-term stability of PST. In will only form on cementum and not importance of treating gingival recession conclusion, many treatment modalities are restorative surfaces or enamel.22,23 and the establishment of an adequate available for the purpose of root coverage, Therefore, there is currently no procedure zone of attached keratinized gingiva in and PST is yet another treatment that will predictably coronally advance preventing , option for clinicians to consider. ■

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DISCLOSURE Thickness a Relevant Predictor to Achieve Root coverage? A John Chao, DDS, holds patents for PST instruments and 19-Case Series. J Periodontol 1999;70:1077–1084. trademarks for the Pinhole Surgical Technique. 16. Berlucchi I, Francetti L, Del Fabbro M, Basso M, Weinstein RL. The Influence of Anatomical Features on the ACKNOWLEDGMENT Outcome of Gingival Recessions Treated With Coronally The author thanks Richard Nagy, DDS, for inviting her to write Advanced Flap and Enamel Matrix Derivative: A One-Year an article for this issue of the Journal. Prospective Study. J Periodontol 2005;76:899–907. 17. Huang LH, Neiva RE, Wang HL. Factors Affecting the REFERENCES Outcomes of Coronally Advanced Flap Root-coverage 1. Chambrone L, Tatakis D. Long Term Outcomes of Procedure. J Periodontol 2005;76:1729–1734. Untreated Buccal Gingival Recessions: A Systematic Review 18. Vincenzi G, De Chiesa A, Trisi P. Guided Tissue and Meta-Analysis. J Periodontol 2016;87:796–808. Regeneration Using a Resorbable Membrane in Gingival 2. Oates T, Robinson M, Gunsolley J. Surgical Therapies for Recession-Type Defects: A Histological CAs Report in the Treatment of Gingival Recession: A Systematic Review. Humans. Int J Periodontics Restorative Dent 1998;18:24– Ann Periodontol 2003;8:303–320. 33. 3. Roccuzzo M, Bunino M, Needleman I, Sanz M. 19. Cortellini P, Clauser C, Prato GP. Histological Periodontal Plastic Surgery for the Treatment of Localized Assessment of New Attachment Following the Treatment Gingival Recessions: A Systematic Review. J Clin of Human Buccal Recession By Means of a Guided Tissue Periodontol 2003;29:178–194. Regeneration Procedure. J Periodontol 1993;64:387–391. 4. Cairo F, Pagliaro U, Nieri M. Treatment of Gingival 20. Parma-Benefanti S, Tinti C. Histologic Evaluation of Recession with Coronally Advanced Flap Procedures: A New Attachment Utilizing a Titanium-Reinforced Barrier Systematic Review. J Clin Periodontol 2008;35:136–162. Membrane in a Mucogingival Recession Defect. A Case 5. Chambrone L, Sukekava F, Arujo M, Pustiglioni F, Report. J Periodontol 1998;69:834–839. Chambhone L, Lima L. Root-Coverage Procedures for the 21. McGuire MK, Cochran DL. Evaluation of Human Treatment of Localized Recession-Type Defects: A Cochrane Recession Defects Treated with Coronally Advanced Flap Systematic Review. J Periodontol 2010;81:452–478. and Either Enamel Matrix Derivative or Connective Tissue. J 6. Allen AL. Use of the Supraperiosteal Envelope in Periodontol 2003;74:1126–1135. Soft Tissue Grafting for Root coverage I. Rationale 22. Martins T, Bosco A, Nobrega F, Nagata M, Garcia and Technique. Int J Periodontics Restorative Dent V, Fucini S. Periodontal Tissue Response to Coverage 1994;14:216–27. of Root Cavities Restored With Resin Materials: A 7. Tözüm TF, Dini FM. Treatment of Adjacent Gingival Histomorphometric Study in Dogs. J Periodontol Recessions with Subepithelial Connective Tissue Grafts 2007;78:1075–1082. and the Modified Tunnel Technique. Quintessence Int 23. McGuire MK. Soft Tissue Augmentation on Previously 2003;34:7–13. Restored Root Surfaces. Int J Periodontics Restorative Dent 8. Zadeh H. Minimally Invasive Treatment of Maxillary 1996;16(6):570–581. Anterior Gingival Recession Defects by Vestibular 24. Golstein M, Nasatzky E, Goultschin J, Boyan B, Incision Subperiosteal Tunnel Access and Platelet-Derived Schwartz Z. Coverage of Previously Carious Roots Is Growth Factor BB. Int J Periodontics Restorative Dent Predictable a Procedure as Coverage as Intact Roots. J 2011;31(6):653–660. Periodontol 2002;73:1419–1426. 9. Pini Prato G, Pagliaro U, Baldi C, et al. Coronally 25. Anson D. Periodontal Esthetics and Soft-Tissue Root Advanced Flap Procedure For Root coverage. Flap Tension coverage for the Treatment of Cervical Root Caries. versus Flap Without Tension: A Randomized Controlled Compend Contin Educ Dent 1999;20(11):1043–1046. Clinical Study. J Periodontol 2000; 71:188–201. 26. Corsair A. Root coverage of a Previously Restored 10. Al-Hamdan K, Eber R, Sarment D, Kowalski C, Wang Tooth. A Case Report With a Seven-Year Follow-up. Clin HL. Guided Tissue Regeneration-Based Root coverage: Cosmet Investig Dent 2009;1:35–38. Meta-Analysis. J Periodontol 2003;74:1520–1533. 27. Fourel J. Gingival Reattachment on Carious Tooth 11. Murphy K, Gunsolley J. Guided Tissue Regeneration Surfaces. A Four-Year Follow-Up. J Clin Periodontol for the Treatment of Periodontal Intraboney and 1982;9:285-289. Furcation Defects. A Systematic Review. Ann Periodontol 28. Prato GP, Tinti C, Tortellini P, Magnani C, Clauser 2003;8:266–302. C. Periodontal Regenerative Therapy with the Coverage 12. Cohen W, Ross S. The Double Papillae Repositioned of Previously Restored Root Surfaces: Case Reports. Int J Flap in Periodontal Therapy. J Periodontol 1968;39:65– Periodontics Restorative Dent 1992;12:450–461. 70. 29. Richardson C, Allen E, Chambrone L, Langer B, 13. Miller PD Jr. A Classification of Marginal Tissue McGuire M, Zabalegui I, Zadeh H, Tatakis D. Periodtonal Recession. Int J Periodontics Restorative Dent Soft Tissue Root-Coverage Procedures: Practical 1985;5(2):8–13. Applications From the AAP Regeneration Workshop. Clin 14. Chao J. A Novel Approach to Root coverage: The Adv Periodontics 2015;5:2–10. Pinhole Surgical Technique. Int J Periodontics Restorative Dent 2012;32:521–531. THE AUTHOR, Tina M. Beck, DDS, MS, can be reached at 15. Baldi C, Pini-Prato G, Pagliaro U, et al. Coronally [email protected]. Advanced Flap Procedure for Root coverage: Is Flap

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CDA JOURNAL, VOL 46, Nº10

Tissue Engineering for Improving Periodontal Phenotype

Cherissa Chong, DMD, MS; Yung-Ting Hsu, DDS, MDSc; Paul Y. Lee, DDS; and Richard T. Kao, DDS, PhD

ABSTRACT Tissue engineering is a new fi eld whereby healing and regeneration is manipulated for an improved result. There are two main approaches. The fi rst is to use tissue engineering as an approach to repair the recession defect. The second is to augment the soft and hard tissue in preparation of teeth for orthodontic movements. From this review, clinicians will be able to appreciate some new strategies for the correction of recession defects.

AUTHORS

Cherissa Chong, DMD, Paul Y. Lee, DDS, is n this issue, the importance of clinicians with an understanding of how MS, is a diplomate of in private practice in correcting gingival recession and certain biotechnologies associated with the American Board Cupertino, Calif. mucogingival defects for periodontal tissue engineering may be incorporated of Orthodontics and Confl ict of Interest the American Board of Disclosure: None reported. health has been advocated. Though this into mucogingival surgery. It focuses Periodontology. She is is an ideal goal, our patients often have on clinically available biotechnologies, in private practice in Richard T. Kao, DDS, Ihesitation due to surgical concerns. These their scientifi c merit or potential Saratoga, Calif. PhD, is a clinical professor concerns center on the lack of adequate to improve clinical outcomes and Confl ict of Interest at the University of autogenous donor tissue, multiple considerations for incorporation into Disclosure: None reported. California, San Francisco, School of Dentistry and surgeries to gain adequate bone/soft tissue clinical practice. More important, it Yung-Ting Hsu, DDS, is in private practice in volume, pain associated with donor site, addresses some of our patients’ concerns MDSc, MS, is a diplomate Cupertino, Calif. increased risk for bleeding, necrosis of the regarding mucogingival augmentation. of the American Board of Confl ict of Interest donor site and delayed healing. Tissue There are two basic strategies for Periodontology and is a Disclosure: None reported. engineering is a highly promising fi eld applying a tissue engineering approach clinical assistant professor, department of graduate whereby biotechnologies are used to for correcting recession defects. The periodontology at the facilitate regeneration of a particular tissue fi rst is to repair and change a thin University of Detroit Mercy (FIGURE 1). A tissue engineering approach phenotype into a thick phenotype. School of Dentistry, and consists of applying biologic signaling This is applicable in gingival recession an adjunct clinical assistant molecules (e.g., growth/differentiation cases where there is a need to repair professor, department of periodontics and oral factors and plasma preparations), cells the recession and obtain root coverage medicine at the University of (stem cells) and/or scaffolding matrices with a secondary goal of thickening the Michigan. to promote regeneration whereby the mucogingival tissue to prevent future Confl ict of Interest new tissue is characteristically and recession. It should be appreciated that, Disclosure: None reported. functionally indistinguishable from the in these situations, the repair process is original tissue.1 This article provides the “masking” of the loss of bony plate

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Signaling molecules e.g., PDGF, BMP

Time and the replacement of soft tissue is Regeneration of tissue/organs bound to the tooth with connective Appropriate tissue attachment. The second approach environment is to change the mucogingival-alveolar complex whereby not only is there soft tissue augmentation, but also alveolar Cells Scaff olds augmentation. This latter approach not Lynch, 2000 e.g., osteoblasts, fi broblasts e.g., CaPO4 CaSO4, FDBA, collagen only increases the bone volume of the , but may also increase the thickness of the mucogingival tissue. FIGURE 1. Tissue engineering approach suggests that regeneration/healing can be enhanced by the A summary of the research in this fi eld manipulation of one or more of the modulators. This can be resultant of manipulating the signaling molecule(s) (i.e., and two clinical cases are presented rhPDGF, Emdogain, PRP, etc.), cells (i.e., stem cells) and scaff old (i.e., bone grafts and barrier membranes). below to support this clinical approach. improve root coverage in the recession and coworkers compared mucogingival Tissue Engineering Approach for area. This approach is effective and wound healing between a commercially Enhancing Soft Tissue Components has been considered the gold standard available living cellular sheet and a free of Gingival Phenotype due to its high level of success.6 The gingival graft (FGG) procedure. After six Enhancing soft tissue components clinical challenges, however, are the months of healing, the tissue engineered and gingival augmentation procedures limited availability of donor sites and allograft cellular sheets were superior performed around natural dentition aim tissue volume, the need for a secondary in both patient preference and tissue to improve plaque control, reduce patient surgical wound, increased pain and match over the FGG sites. However, the discomfort, promote interdisciplinary patient morbidity. To overcome these FGG group had a signifi cantly greater treatment outcomes and prevent disadvantages, clinicians introduce soft amount of KT gain after six months, further periodontal attachment loss.2 tissue substitutes, such as allogeneic soft 4.46 mm versus 2.40 mm, although both Improvement of tissue thickness could tissue grafts or a xenogenic collagen groups demonstrated normal epithelial produce better treatment outcomes matrix. Without the limitation of graft , i.e., uneventful wound measured by higher chances of complete tissue amount, these materials allow healing under histological assessment.7 root coverage3 and reduced risk of for correction of mucogingival defects Although the mechanism remains wound exposure.4 Over the past decades, in multiple teeth with higher patient unclear, the literature has shown that attempts have been made to increase satisfaction in postoperative care. Even cell-sheet therapy may have better both the width of keratinized tissue though the short-term results showed healing potential because of its inherent (KT) and gingival thickness through that these alternatives may be effective antimicrobial effects and putative local soft tissue grafting procedures and in KT augmentation, further studies with production of angiogenic factors.9,10 While emerging regenerative approaches. a longer experimental period and larger these proof-of-principle applications are In the 1950s, gingival grafting sample size are needed.2 Nevertheless, attractive, the cost-effectiveness for the procedures were applied to repair augmentation with allografts and patient is unreasonable. Additionally, mucogingival defects and to increase xenografts refl ects an early tissue the safety and effi cacy of its long-term the zone of KT. For sites with thin tissue engineering approach that improves effects need further evaluation. biotype (< 0.8 mm), the combination of soft tissue augmentation by providing Improving clinical results with the use a coronally advanced fl ap (CAF) with a a more readily available cell matrix. of local delivery of porcine enamel matrix connective tissue graft has been shown In recent years, researchers have made derivative (EMD) or recombinant human to not only increase tissue thickness, efforts on promoting wound healing platelet-derived growth factors (rhPDGF) but also to gain greater KT.5 In this and periodontal regeneration via tissue has been applied for mucogingival approach, a sheet of connective tissue is engineering approaches. Various biologic augmentation. These growth factor/ harvested from the patient’s palate and agents and cell-based therapies are biological modulators improve regenerative placed at the donor site. The overlying currently available or under investigation.7 outcomes by improving various steps of soft tissue is advanced coronally to In a proof-of-principle study, McGuire wound healing, including DNA synthesis,

654 OCTOBER 2018 CDA JOURNAL, VOL 46, Nº10

FIGURE 2A. FIGURE 2B. FIGURE 2C.

FIGURES 2. This elderly female patient presented with a chief complaint of wanting to improve her appearance (2A). Tooth No. 7 was aesthetically crown lengthened. Gingival recession was present on teeth Nos. 5–6 and 11–12 that were treated with CTG with coronal advancement of the buccal fl ap. Tooth No. 10 had a composite in the Cl V area that was removed and the graft bed had odontoplasty and was treated with EMD to enhance healing and root coverage (2B). Clinical presentation immediately after the delivery of restorations (2C). Note that gingival infl ammation was still present from the mandibular veneers. chemotaxis, cell differentiation and matrix postoperative coronal migration of revealing a large class V composite on synthesis.11 Clinically, EMD application gingival margin.22,23 Though epithelial the area to be grafted (FIGURE 2B). The in conjunction with CAF graft procedures and connective tissue attachment composite was removed and the area was have been advantageous for correction of can be stable, a histologically more root planed. The area remained stained Miller Class I or II defects.12 Despite this, appealing type of graft attachment to and there were concerns whether root increase in KT gain with EMD is not as teeth has been demonstrated when coverage was possible. To enhance root effective as using either a subepithelial EMD or PDGF has been used. In a coverage for this area, EMD was used in connective tissue graft or xenogenous case report, the EMD-treated site conjunction with the placement of the collagen matrix.13,14 In precursor studies to exhibited signs of new cementum, connective tissue graft. The buccal fl ap the use of rhPDGF, platelet concentrate periodontal ligament fi ber and islands was advanced coronally to ensure blood was shown to improve root-coverage of bone after six months of healing.21 supply for the area. Though it may be procedures but failed to show superiority on Similar fi ndings of periodontal debatable whether EMD was necessary, it KT gain.15,16 When rhPDGF concentrate regeneration have also been reported with provided regional enrichment of growth was used, a similar trend was noted in the the use of PDGF.24 In KT augmentation, factors that may have enhanced the success treatment of gingival defects.17,18 A recent tissue-engineered cell therapy was capable of the graft. Soon after the fi nal delivery study utilizing the combination therapy of gaining KT that was integrated within of the veneers and crowns, one can see of rhPDGF and acellular dermal matrix the host connective tissue.8 It can be a more balanced smile where aesthetic showed improved healing (35 percent) argued that these histological tooth forms root coverage was achieved for teeth Nos. compared to the sites with acellular of regeneration and healing may be more 5-6, 10 and 11-12 (FIGURE 2C). Due to dermal matrix (15 percent) only one week stable than epithelial and connective the increased cost for the use of biologics, postoperatively.19 These studies suggest that tissue attachment, but further evidence the clinician must be prudent and have EMD, rhPDGF and platelet concentrate and longitudinal studies are needed.25 justifi cation for its use only in situations may aid and enhance healing, but if the Case 1: The use of a tissue engineering whereby conventional approach will not or outcome criteria are to gain an increased approach for altering gingival phenotype cannot reliably achieve satisfactory results. band of attached tissue, an autologous may be benefi cial in complex cases where grafting approach may be superior. one is concerned whether the conventional Tissue Engineering Approach for From a histological perspective of approach may not provide adequate Altering Gingival Phenotype for healing, tissue engineering approaches correction of the recession defect. In the Orthodontic Treatment not only accelerate wound healing but clinical case shown in FIGURE 2A, the Poor dental alignment and also improve the healing outcomes patient presented with multiple recession malocclusion are the most common from new attachment to regeneration. issues particularly in the area of teeth Nos. reasons people seek orthodontic Conventionally, soft tissue grafts or their 5-6 and 11-12. Additionally, aesthetic treatment. As teeth are repositioned for substitutes adhere to the root surface concerns included the need to increase more ideal occlusal scheme, one needs to primarily by epithelial and connective clinical length for tooth No. 7 and decrease consider if there is an adequate volume of tissue attachment.20,21 Additional the crown length on tooth No. 10. It was bone and soft tissue that will heal with no improvement in root coverage and decided to accept the clinical crown length long-term negative results such as gingival increased KT can potentially be gained of Nos. 8-9. In attempting to resolve these recession. These deleterious consequences over time by creeping attachment, a issues, the restorations were removed may be immediately evident, but at times

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it may take several years or more before Decortication of the alveolar housing PAOO has been shown to be they appear. Therefore, as the orthodontist creates transient demineralization effi cacious in the treatment of is planning for orthodontic tooth and the resulting soft tissue matrix malocclusions, as well as presurgical movement, the gingival biotype needs to of the bone can be carried out with decompensation for orthognathic be considered. Orthodontic movement in the root during orthodontic tooth surgeries.26 The benefi ts of PAOO include a thick phenotype environment is both movement. Remineralization of accelerated treatment time,32 greater predictable and without any deleterious the bone occurs after orthodontic stability of clinical outcomes and less results. This is because there is adequate treatment is completed. During this relapse,29 enhanced scope of the treatment volume of bone and soft tissue that will time, there is an accelerated rate of of malocclusion and increased alveolar permit remodeling and healing. However, tooth movement due to the altered volume and enhanced periodontium.26 moving teeth in a thin phenotype physiologic response known as the Clinical studies have shown the environment can be challenging. This is regional acceleratory phenomenon application of PAOO to resolve crowding because teeth that are moved in a thin (RAP) effect. The regional acceleratory of the dentition,33 accelerate canine bony plate often are compromised with phenomenon was fi rst described by retraction in closing extraction spaces,33 increased incidence of fenestrations and facilitate the eruption of impacted teeth34 dehiscence. As these thin bony plates and facilitate orthodontic expansion in remodel, there may be compromised borderline orthognathic cases,35 dental 26,36 healing or bone deposition that may result PAOO is a relatively new intrusion and open bite correction. in gingival recession during treatment PAOO has been proposed as an many years afterward. Additionally, the surgical technique that, when alternative treatment plan for borderline overlying gingiva is often so thin that performed in conjunction with orthognathic/orthodontic surgical orthodontic movement may result in traditional orthodontics, can cases. Combining proper diagnosis and gingival recession. Recently, utilizing a patient desires, PAOO may be a feasible combination of gingival augmentation, accelerate tooth movement. treatment for tooth movement necessary alveolar and periodontally beyond orthodontic “camoufl age” but not accelerated osteogenic orthodontics severe enough to warrant orthognathic (PAOO — also called Wilckodontics or surgery.37 Wilcko et al. demonstrated surgically facilitated orthodontic therapy, Frost,29–31 where injury to bone results that orthodontic therapy combined SFOT), it is now possible to create an in acceleration of all processes involved with alveolar decortication results in a environment whereby teeth can be moved in healing, including remodeling, cell signifi cant increase in keratinized tissue to an ideal position, reinforced with turnover, metabolism and repair. The height. The authors found that 1½ years increased osseous volume and augmented biologic limits of tooth movement are after completion of active orthodontic with soft tissue such that there is an determined by the alveolar bone and treatment, keratinized gingival tissue adequate zone of attached gingiva. surrounding soft tissues. Movement of height increased signifi cantly, by 0.78 While there are several reviews teeth outside the alveolar housing can mm (P < 0.001) in the corticotomy on gingival augmentation and bone result in fenestrations and dehiscence group, and decreased by 0.38 mm (P grafting, PAOO is a relatively new in the alveolar bone. In individuals = 0.002) in the conventional group surgical technique that, when performed with thin gingival biotype, movement treated without corticotomy.38 Stability in conjunction with traditional of the teeth outside of the thin bony post-orthodontic treatment is also a key orthodontics, can accelerate tooth housing may present clinically as root benefi t of PAOO. It is believed that movement and expand the scope of recession. This may present itself PAOO patients have fewer tendencies conventional orthodontic treatment immediately after orthodontic treatment for relapse post-orthodontic treatment by two- to threefold in most spatial or in years following treatment. By because scarring of the alveolar cortex dimensions26 and accelerate tooth combining soft tissue augmentation initiates an infl ammatory healing, i.e., movement 1 ½ times to four times26–28 and bone grafting techniques, it is now RAP, which increases tissue turnover.39 the normal rate of traditional possible to convert the thin phenotype This tissue turnover may be partly orthodontic tooth movement. environment into a thick phenotype. responsible for the loss in tissue memory,

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which allows for bone augmentation that increases cortical thickness of the alveolar FIGURE 3A. FIGURE 3B. bone surrounding the dentition. The increased thickness of the alveolar bone is believed to enhance post-orthodontic stability of the dentition.40 In a 2016 systematic review,32 corticotomy did not appear to have any important sequelae on periodontal health, including periodontal probing depths, plaque indices, gingival recession, clinical attachment levels and alveolar crestal bone heights. FIGURE 3C. FIGURE 3D. While many studies have shown that PAOO is safe for the oral tissues and accompanied by a phase of accelerated tooth movement, further well-designed prospective studies are needed to draw valid conclusions on this technique.41,42 Case 2: To demonstrate the principle of utilizing tissue engineering with orthodontic mechanical strategy, this 42-year-old Asian FIGURE 3E. FIGURE 3F. female presented with a chief complaint of crowding but refused further extractions FIGURES 3. Conventional PAOO treatment. 3A is the clinical presentation at pretreatment; 3B–D is the (FIGURE 3A). Patient presented with thin gingival biotype with areas of existing surgical view and with corticotomy; 3E is the surgical area bone grafted; 3F is the clinical presentation after gingival recession and generalized dental treatment; and 3G are the representative pre- and wear on her teeth. A cone beam computed post-op CBCT. tomography (CBCT) was taken prior to PAOO, which showed the prevalence of a thin cortical plate, if any, in several areas from canine to canine. A sample pre-op FIGURE 3G. CBCT is presented in FIGURE 3G. The goal of tooth movement was to enhance the thickness of the alveolus to allow for of accelerated tooth movement.43 A gingival recession. Decortication was protraction of the upper and lower anterior full-thickness mucoperiosteal fl ap was performed at each inter-radicular area, teeth and alleviate crowding. To achieve raised in the coronal portion and a split- as well as apical to each root apex. this, a PAOO-RAP approach was utilized thickness dissection was made in the apical Vertical grooves were made extending with the addition of a tissue engineering portion. The purpose of the split-thickness just below the interproximal alveolar modifi cation (i.e., bone grafting). dissection is to provide mobility of the bone margin to beyond the apex of each Bracket placement was performed one fl ap and reduce tension in the fl ap. Upon tooth. Horizontal grooves were made to week before surgery, however it has been fl ap refl ection, it is evident that prior to join the apical extensions of the vertical suggested that bracketing can occur up any orthodontic treatment, this patient grooves39 (FIGURES 3B–D). The purpose to one week after surgery.43 Initiation of already had several existing dehiscence of decortication is to initiate the RAP orthodontic force should not be delayed and fenestrations. If orthodontic treatment phenomenon and bone turnover. It is more than two weeks after surgery in order was performed under such conditions and recommended that the corticotomy cut to take full advantage of the four- to six- teeth were moved further buccally, this minimally breaks through the cortical month RAP phenomenon or “window” patient would be predisposed to developing plate into the medullary bone on the

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buccal and lingual aspect in order to in increased mobility as well as extensive the second phase focused on PAOO enhance suffi cient vascularization of the gingival recession. In this particular with a commercially available stem cell overlying graft to occur. A combination case, slight recession did occur at the preparation. The fi rst surgery was performed of demineralized freeze-dried bone completion of treatment. The corrective as an autogenous connective tissue graft allograft-mineralized freeze-dried allograft procedure would have been a root-coverage from teeth Nos. 20–29. In order to assure (DFDBA-FDBA) mixture was used to procedure. Because there was adequate zone the survival of the graft and the overlying augment the bone (FIGURE 3E). Gingival of attached gingiva and lack of dentinal gingiva, rhPDGF was used with the fl aps were repositioned and sutured in hypersensitivity, the patient elected not objective of improving healing. After the place. Healing was uneventful. Ten days to have further surgical treatment and the fi rst phase, the area was allowed to heal. It following the periodontal bone grafting additional expense. She was happy with the should be noted that during this healing procedure, traditional nitinol wires were aesthetic results and the improved stability phase, there were small areas of epithelial placed to begin leveling and aligning. of her dentition. This case demonstrates sloughing. This suggests that in extremely The patient was seen every two weeks to that PAOO can provide increased thin cases, the simple act of lifting the assess alignment and maintain effi cient opportunities for achieving better occlusion mucoperiosteal fl ap may compromise the tooth movement during the “window” of blood supply such that some superfi cial accelerated tooth movement. Finishing tissue necrosis may occur. It is these authors’ and detailing was completed in a contention that the rhPDGF improved comparable time frame as a traditional Many cases are now wound healing, but this is an observation orthodontic case. The overall goal of being treated with a that requires further confi rmation. alleviating crowding and enhancing combination of soft tissue Furthermore, this preliminary CTG grafting alveolar housing had been achieved. A provided a thicker gingiva and increased follow-up CBCT scan taken six months grafting or with the addition the zone of attached gingiva. On re-entry, postsurgery showed the presence of of stem cells in order to one can see numerous areas of fenestrations a robust thickness of alveolar bone. enhance the soft tissue quality. and dehiscence that were previously present Simultaneous coronal repositioning for the but may have been accentuated due to fl ap mucoperiosteal fl ap in conjunction with refl ection for the previous connective tissue bone grafting corrected recession defects grafting procedure (FIGURE 4D). The area shown on several teeth in the initial and improving oral hygiene access. One was decorticated on both the buccal as well scan (FIGURE 3F). Pre- and postoperative possible negative consequence, however, as the lingual aspect as previously described CBCT scans demonstrated radiographic is this may result in minor gingival in Case 1 and augmented with stem cell suggestion of thickened labial plate recession that may require an additional allograft preparation that consisted of stem (FIGURE 3G). Many cases are now being gingival root-coverage procedure. cells seeded onto DFDBA (Osteocel). treated with a combination of soft tissue Case 3: In this case, a 30-year-old female In order to prevent dispersal of the graft grafting or with the addition of stem cells with a severe Class III malocclusion and material, a resorbable collagen membrane in order to enhance the soft tissue quality. extremely thin phenotype was presented was used to contain the graft in the area of This case demonstrates the for treatment (FIGURES 4A–C). The basic interest. The collagen membrane helped potential benefi ts as well as some of strategy was to convert the thin biotype by keeping the graft materials in the proper the complications that may result from characteristics in the mandibular anterior place; without the use of membrane, there the PAOO procedure. Without doing segment into thick phenotype. This is a tendency for the graft material to pool the PAOO procedure, the preoperative would be done prior to initial orthodontic apically. The area was sutured and allowed CBCT and surgical observations suggest and subsequent orthognathic treatment. to heal (FIGURE 4E). Note that three that it would not have been possible to Given the thin gingival tissue, there were months after healing, the tissue on the have treated this case orthodontically. surgical concerns that simply refl ecting buccal of tooth No. 22 was still remodeling. The negative consequences of pursuing the mucogingival fl ap would result in When very thin soft tissue is grafted with treatment without PAOO would be to tissue necrosis. Therefore, the case was connective tissue, remodeling may occur up orthodontically move teeth out of the planned in two phases. The fi rst phase to six months after the grafting procedure. bony housing. This would have resulted centered on thickening the gingiva and Additionally, it should be noted that the

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papillae was lost between teeth Nos. 23–26. One should note that during the surgical entry (FIGURE 4D), the interproximal bone was low and the orthodontic uncrowding of

FIGURE 4A. FIGURE 4B. the lower anteriors during this early healing stage resulted in the appearance of papillae loss. In comparing the panoramic images after six months of healing, the increase in bone corticated pattern over the central body of the mandible is notable (FIGURE 4E). Additionally, a sample of the CBCT scan demonstrates that there is an increase in thickness of the buccal and lingual bone (FIGURE 4F). Interestingly, the buccal bone is in close proximity of the ideal bone level,

FIGURE 4C. FIGURE 4D. refl ective of the desired biological width. In a CBCT taken 18 months after this treatment (FIGURE 4G), the radioopacity appeared to have condensed and the orthodontic tipping action did not result in negative consequences in the apical area. In these last two cases, the reader should appreciate that changing gingival phenotype is no longer associated with just gingival grafting or root-coverage procedure. Rather, it is about changing the phenotypic characteristics of the periodontium. This includes thickening of the alveolar process so orthodontic movements can be achieved, which provides a foundation whereby long-term stability of the periodontium may be possible. Besides the aesthetic improvement, FIGURE 4E. FIGURE 4F. dental crowding can be eliminated to allow for improved oral hygiene access. Whereas Case 2 demonstrated that this FIGURE 4G. may result in compromises such as slight increases in gingival recession, the last case demonstrated how recession can be minimized/prevented with gingival FIGURES 4. PAOO with tissue engineering approach. 4A and 4B are the clinical presentation at pre- grafting. This is a new area of collaboration treatment; 4C is the surgical view and with corticotomy; 4D is the clinical presentation after treatment; 4E–G between the periodontal and orthodontic are the pre- and postoperative panoramic fi lms of surgical area at pre-surgical, six months and 18 months specialties. It offers new options for patients post-PAOO procedure. Note the increase in radioopacity in the body of the mandible apical of the mandibular where no treatment was possible. These anterior teeth. (A new CBCT system was used for the 1 1/2-years imaging.) Also presented are representative pre- and post-op CBCT showing increased appearance of radioopacity suggesting bone deposition on the types of interceptive treatments were made buccal and lingual aspect of the PAOO-treated site at six months and 18 months. Note that the bone has possible only through the use of a tissue remodeled and is more radioopaque in appearance. engineering approach.

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Conclusion 11. Anusaksathien O, Giannobile WV. Growth factor delivery therapy. Sem Orthod 2015;21:176–186. Tissue engineering has the potential to to re-engineer periodontal tissues. Curr Pharm Biotechnol 27. Bockow R. Treatment Planning with Corticotomy Facilitated 2002;3(2):129–39. Orthodontics. Sem Orthod 2014;20:228–238. alter gingival phenotype. This approach 12. Alkan EA, Parlar A. EMD or subepithelial connective tissue 28. Wilcko MT, Ferguson DJ, Makki L, Wilcko W. Keratinized can thicken gingival thickness and graft for the treatment of single gingival recessions: A pilot study. J gingiva height increases after alveolar corticotomy provide root coverage in situations where Periodontal Res 2011;46(6):637–42. and augmentation bone grafting. J Periodontol 2015 13. Alexiou A, Vouros I, Menexes G, Konstantinidis A. Oct;86(10):1107–1115. doi: 10.1902/jop.2015.150074. there is recession or increase the gingival Comparison of enamel matrix derivative (Emdogain) and Epub 2015 Jul 3. resistance to infl ammatory or restorative subepithelial connective tissue graft for root coverage in patients 29. Makki L, Ferguson DJ. Stability of Mandibular Irregularity trauma. Additionally, when used in with multiple gingival recession defects: A randomized controlled Index With and Without PAOO: A Review. Adv Dent & Oral clinical study. Quintessence Int 2017;48(5):381–89. Health 2017;4:1–3. conjunction with a PAOO approach, 14. Sangiorgio JPM, Neves F, Rocha Dos Santos M, et al. 30. Ferguson DJ, Machado I, Wilcko MT, Wilcko W. Root augmentation with both soft tissue and Xenogenous Collagen Matrix and/or Enamel Matrix Derivative resorption following periodontally accelerated osteogenic stem cells can increase the bone volume for Treatment of Localized Gingival Recessions: A Randomized orthodontics. APOS Trends in Orthodontics 2016;6:78–84. Clinical Trial. Part I: Clinical Outcomes. J Periodontol 31. Murphy KG, Wilcko MT, Wilcko WM, Ferguson DJ. and permit nontraditional orthodontic 2017;88(12):1309–18. Periodontal Accelerated Osteogenic Orthodontics: A Description movement. These new exciting clinical 15. Oncu E. The Use of Platelet-Rich Fibrin Versus Subepithelial of the Surgical Technique. J Oral Maxillofac Surg 2009 translational applications may be applied Connective Tissue Graft in Treatment of Multiple Gingival Oct;67(10):2160–2166. doi: 10.1016/j.joms.2009.04.124. Recessions: A Randomized Clinical Trial. Int J Periodontics 32. Wilcko MT, Wilcko WM, Bissada NF. An evidence-based in areas with compromised periodontal Restorative Dent 2017;37(2):265–71. analysis of periodontally accelerated orthodontic and osteogenic phenotypes where no treatment would 16. Lafzi A, Faramarzi M, Shirmohammadi A, et al. Subepithelial techniques: A synthesis of scientifi c perspectives. Sem Orthod have been considered in the recent past. ■ connective tissue graft with and without the use of plasma rich in 2008;14:305–16. growth factors for treating root exposure. J Periodontal Implant 33. Aboul-Ela SM, El-Beialy AR, El-Sayed KM, Selim EM, El Sci 2012;42(6):196–203. Mangoury NH, Mostafa YA. Miniscrew implant-supported REFERENCES 17. McGuire MK, Scheyer ET, Snyder MB. Evaluation of recession maxillary canine retraction with and without corticotomy- 1. Lynch SE (1999) Introduction to tissue engineering. In: Lynch defects treated with coronally advanced fl aps and either facilitated orthodontics. Am J Orthod Dentofacial Orthop SE, Genco RJ, Marx RE eds. Tissue Engineering: Applications recombinant human platelet-derived growth factor-BB plus - 2011;139:252–9. in Maxillofacial and Periodontics. Chicago: Quintessence; tricalcium phosphate or connective tissue: Comparison of clinical 34. Fischer TJ. Orthodontic treatment acceleration with 1999:xi–xviii. parameters at fi ve years. J Periodontol 2014;85(10):1361–70. corticotomy-assisted exposure of palatally impacted canines. 2. Kim DM, Neiva R. Periodontal soft tissue non-root-coverage 18. Rubins RP, Tolmie PN, Corsig KT, Kerr EN, Kim DM. Angle Orthod 2007; 77:417–20. procedures: A systematic review from the AAP Regeneration Subepithelial connective tissue graft with growth factor for the 35. Vercellotti T, Podesta A. Orthodontic microsurgery: A Workshop. J Periodontol 2015;86(2 Suppl):S56–72. treatment of maxillary gingival recession defects. Int J Periodontics new surgically guided technique for dental movement. Int J 3. Richardson CR, Allen EP, Chambrone L, et al. Periodontal Restorative Dent 2013;33(1):43–50. Periodontics Restorative Dent 2007;27:325–31. soft tissue root-coverage procedures: Practical applications from 19. Carney CM, Rossmann JA, Kerns DG, et al. A comparative 36. Akay MC, Aras A, Gunbay T, Akyalcin S, Koyuncue BO. the AAP Regeneration Workshop. Clinical Adv Periodontics study of root defect coverage using an acellular dermal matrix Enhanced eff ect of combined treatment with corticotomy and 2015;5(1):2–10. with and without a recombinant human platelet-derived growth skeletal anchorage in open bite correction. J Oral Maxillofac 4. Chao YC, Chang P, Fu J, Wang H, Chan H. Surgical factor. J Periodontol 2012;83(7):893–901. Surg 2009; 67:563–9. site assessment for soft tissue management in ridge 20. Goldstein M, Boyan BD, Cochran DL, Schwartz Z. 37. Gantes B, Rathbun E, Anholm M. Eff ects on the Periodontium augmentation procedures. Int J Periodontics Restorative Dent Human histology of new attachment after root coverage Following Corticotomy-Facilitated Orthodontics. Case Reports. J 2015;35(5):e75–83. using subepithelial connective tissue graft. J Clin Periodontol Periodontol 1990; 61:234–238. 5. Cairo F, Cortellini P, Pilloni A, et al. Clinical effi cacy of coronally 2001;28(7):657–62. 38. Frost HM. The regional acceleratory phenomenon: A review. advanced fl ap with or without connective tissue graft for the 21. McGuire MK, Cochran DL. Evaluation of human recession Henry Ford Hosp Med J 1983;31(1):3–9. treatment of multiple adjacent gingival recessions in the aesthetic defects treated with coronally advanced fl aps and either enamel 39. Frost HM. The biology of fracture healing. An overview area: A randomized controlled clinical trial. J Clin Periodontol matrix derivative or connective tissue. Part 2: Histological for clinicians Part II. Clin Orthop Relat Res 1989 Nov (248): 2016;43(10):849–56. evaluation. J Periodontol 2003;74(8):1126–35. 294–309. 6. Scheyer ET, Sanz M, Dibart S, et al. Periodontal soft tissue 22. Harris RJ. A short-term and long-term comparison of root 40. Frost HM. The biology of fracture healing. An overview for non-root-coverage procedures: A consensus report from the coverage with an acellular dermal matrix and a subepithelial clinicians. Part I. Clin Orthop Relat Res 1989;248:283–293. AAP Regeneration Workshop. J Periodontol 2015;86(2 graft. J Periodontol 2004;75(5):734–43. 41. Patterson BM, Dalci O, Darendeliler MA, Papadopoulou AK. Suppl):S73–6. 23. Zucchelli G, Mounssif I, Mazzotti C, et al. Coronally Corticotomies and Orthodontic Tooth Movement: A Systematic 7. Ishikawa I, Iwata T, Washio K, et al. Cell sheet engineering and advanced fl ap with and without connective tissue graft for the Review. J Oral Maxillofac Surg 2016 Mar;74(3):453–473. doi: other novel cell-based approaches to periodontal regeneration. treatment of multiple gingival recessions: A comparative short- and 10.1016/j.joms.2015.10.011. Epub 2015 Oct 24. Periodontol 2000 2009;51:220–38. long-term controlled randomized clinical trial. J Clin Periodontol 42. Hoogeveen EJ, Jansma J, Ren, Y. Surgically facilitated 8. McGuire MK, Scheyer ET, Nunn ME, Lavin PT. A pilot 2014;41(4):396–403. orthodontic treatment: A Systematic Review. Am J Orthod study to evaluate a tissue-engineered bilayered cell therapy 24. Kaigler D, Avila G, Wisner-Lynch L, et al. Platelet-derived Dentofacial Orthop 2014; 145: S51–64. as an alternative to tissue from the palate. J Periodontol growth factor applications in periodontal and peri-implant bone 43. Al-Naoum F, Hajeer MY, Al-Jundi A. Does alveolar 2008;79(10):1847–56. regeneration. Expert Opin Biol Ther 2011;11(3):375–85. corticotomy accelerate orthodontic tooth movement when 9. Falanga V, Isaacs C, Paquette D, et al. Wounding of 25. Vignoletti F, Nunez J, Sanz M. Soft tissue wound healing at retracting upper canines? A split-mouth design randomized bioengineered skin: Cellular and molecular aspects after injury. J teeth, dental implants and the edentulous ridge when using barrier controlled trial. J Oral Maxillofac Surg 2014;72:1880. Invest Dermatol 2002;119(3):653–60. membranes, growth and diff erentiation factors and soft tissue 10. Villar CC, Zhao XR, Livi CB, Cochran DL. Eff ect of living substitutes. J Clin Periodontol 2014;41 Suppl 15:S23–35. THE CORRESPONDING AUTHOR, Richard T. Kao, DDS, PhD, can be cellular sheets on the angiogenic potential of human microvascular 26. Ferguson DJ, Wilcko MT, Wilcko WM, Makki L. Scope of reached at [email protected]. endothelial cells. J Periodontol 2015;86(5):703–12. treatment with periodontally accelerated osteogenic orthodontic

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LOS ANGELES COUNTY ORANGE COUNTY RIVERSIDE & SAN BERNARDINO COUNTIES CARSON— Price Reduced!! Long established GP in a GARDEN GROVE - LH & Equip Only! Has 3 eq ops, CHINO HILLS— GP in busy shopping center. Grossed small shopping center. Grossed $277K in 2017. Net 1 plmbd not equip in a 2 story professional bldg. $352K . NET $141K. PPO & Cash Only! Has 3 eq ops $132K. Has 3 eq ops & 2 plmbd not eq. Rering Great for a Perio or GP. Property ID #5239. and 1 plmbed op. EstablishedSOLD in 1992. Property ID seller work 3 days/wk. Great street visibility. Prop- #5219. erty ID #5181. IRVINE - Well established Cash Only GP w/ 5 eq ops in a1,915 sq office . Grossed approx. $482K ENCINO - GP w/ 4 eq ops in a prof. bldg. w/ widow in 2017. Property ID #5193. CORONA— Beauful GP w/ 6 eq ops / 4 plmbd not views to the mountain. Fee for service. Net $144K. eq for expansion in a 3,700 sq office. Located on a Gross. $488K in 2017.SOLD Property ID #5210.0 LA PALMA— With 60 years of goodwill this GP one story free standing building next to a busy shop- pracce is located in 2 story dental bldg w/ 4 eq ping center. Grossed $346K in 2017. Great potenal GLENDALE—Beauful office w/ 3 eq ops in a 850 sq ops. Grossed $443K in 2017. Property ID # 5234. . LH & Equip Only! Great starter office. Near resi- for a full me denst. Property ID #5224. denal & commercialSOLD area. Property ID #5208. ORANGE— Est. in 1978 GP in one story free stand- ing duplex w/ 3 eq SOLDops. Grossed approx. $386K in DESERT HOT SPRINGS— GP + Real Estate! Two GLENDALE - GP located in a med bldg w/3 eq ops in 2017. Property ID #5213. partners one office. Consists of 4 eq ops / 1 plmbd a 1,123 sq ste. Ins & Cash Only! Est. in 1994. not eq. Est. in 1986. Proj.SOLD approx. $802K for 2017. ORANGE— LH & Equip Only! Beauful office w/ 4 Grossed $473K in 2017. Prop. #5216. Property ID #5198. eq ops in a 1,300 sq office in single free standing LANCASTER (GP + Bldg) Long established pracce bldg. Property ID #5229. FONTANA— GP + Real Estate!! Premier office with w / 4 eq ops in a 1,600 sq office. Grossed $693K in SANTA ANA— Well established pracce. PPO & 50 years of goodwill. In a 3,000 sq bldg with 8 eq 2017. NET $220K. Property ID #5222. Cash only. Gross. approx. $500K. Prop. ID #5113. ops. Has the latest technology.SOLD Grossed approx. $2.3M in 2016. Net of $968K. Property ID #5140. MOTEBELLO—Grossed approx. $1M in 2017, locat- TUSTIN—Well established GP in a 2 story busy ed in a free standing bldg w/ 5 eq ops. Established in shopping center. Projecng $1.8M in 2018. Has 3 PALM DESERT— Beauful GP located in a single 2002. Property ID #5168SOLD eq ops in 1,222 sq suite. Property # 5236. story corner building. Heavy traffic flow. Consists of SANTA CLARITA—GP w/ 36 yrs of goodwill in prof. TUSTIN— LH & EQUIP ONLY! Beauful remodeled 4 eq ops in a 1,800 sq office. Reasonable rent. bldg. w/ 5 eq ops. Grossed $449K in 2017. Property office with 3 eq op and 1 plmbd not eq. Located in Monthly revenues of $132K. Grossed $1.4M in 2017. ID #5207. a single story professional building. Has two price NET $383K. Property ID #5217. points. Property ID #5244. TARZANA - Established in 1929 w/ 5 eq ops in a PALM SPRINGS – General pracce with 3 equipped 1,552 sq suite. Delta Premier and Cash Only! ops located in a free standing bldg. Established in Grossed $681K in 2017. Buyer’s Net $225K. Proper- 2005. Suite is approx. 1,200. Seller work 5 days/wk. ty #5226. BUYER’S NET OF $311K. Property ID #4487. WOODLAND HILLS - Well established GP in a 5 story RANCHO CUCAMONGA— GP established in 2004 in med/dent bldg with 4 eq ops and 1 plmbd not eq. SAN DIEGO COUNTY ProjecƟng $1M for 2018. Property ID #5246. busy shopping center. Consists of 3 eq ops in a 1,200 sq suite. Grossed $422K in 2017. Net $149K. Prop- LA JOLLA— 4 eq ops in 2 story med building. PPO SOLD & Cash Only! Grossed approx. $1.1M in 2017. erty ID #5169. KERN, VENTURA, & SAN LUIS OBISPO COUNTIES Property ID #5220. UPLAND—Pediatric dental pracce located in a FRESNO— GP 4 eq ops in a retail shopping center. LA MESA— Beauful GP office in shopping center medical bldg with 40 years of goodwill. Consists of 4 w/ 5 eq ops & 1 plumbd not eq. Sees 80-100 new Grossed $448K in 2017. NET $202K. Prop. #5214. chairs in open with Alpha-Dent so ware. Grossed paents/mo. Grossed $1.5M in 2017. Net $368K. SOLD $271K in 2016. Property ID #5188. GOLETA—GP w/ 27 yrs of gdwll in a 2 story mix Prop.#5228. bldg. 4 eq ops. Grossed $572K. Prop. #5205. OCEANSIDE— Orthodonc pracce w/4 chairs in open bay in a 1,550 sq office. Grossed $263K in OXNARD—Est, in 1973 w/ 4 eq ops in a 1,100 sq 2017. Property ID #5225. COMING SOON IN LEMOORE, RANCHO suite. Grossed $585K Net $186K. Prop. #5206. SAN DIEGO— Price Reduced!! GP in med/dent BERNARDO, SAN DIEGO AND TEMECULA SIMI VALLEY— GP + Real Estate. Pracce has 4 eq bldg. w/ 3 eq ops. Fee for service. Estab. circa ops & 2 plmbd not eq ops. Net of $92K. ID #5185. 1950. Grossed $301K in 2017. Net $117K. Prop- erty ID # 5212.

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Are Your Patients Who They Say They Are?

Preventing Medical Identity Theft TDIC Staff

dental professional can treat According to the Ponemon According to the Federal Trade dozens of patients each day. Institute, a private cybersecurity Commission, medical identity theft Patients present, provide their research fi rm, more than 2.3 million stems from several scenarios. The most information, get checked in people became victims of medical common are data breaches within and proceed with treatment. identity theft between 2014 and 2015, medical care providers, where thieves ADo you ever stop to wonder whether representing uninsured individuals gain access to medical data systems, your patients are who they say they are? seeking care under a stolen identity and “friendly fraud,” where someone In a case reported to The Dentist or, more commonly, obtaining known to the victim assumes his or her Insurance Company’s Risk Management prescription medications fraudulently. identity. Another type of scenario is Advice Line, a patient presented for a root On average, patients spent $13,500 one wherein thieves target unsuspecting canal treatment. The patient provided to resolve a case of stolen medical individuals by posing as an employee a name, date of birth, phone number, identity. But the nonmonetary costs of an insurance company, pharmacy or insurance information and Social Security are even greater. Patients report a lack medical or dental offi ce and asking for number. The dentist completed the of trust in their medical providers for personal information, including plan treatment without incident and the offi ce failing to protect their private data. numbers or Social Security numbers. submitted a claim to the insurance company to receive payment for services rendered. The offi ce staff realized they had been given false information when they received a call from the individual whose Social Security number and insurance information were used to obtain treatment. The caller questioned why his insurance You are not was billed when he was not even a a sales goal. patient at that practice. The offi ce tried calling the individual who was treated, but the woman who answered stated that there was no one there by that name. Once the offi ce realized that they did not know the true identity of the individual they treated, they contacted the Advice Line for guidance. The Risk Management analyst advised the dentist not to release any information about the mystery patient You are a dentist deserving of an insurance company relentless to the individual whose identity was stolen. in its pursuit to keep you protected. At least that’s how we see The analyst also recommended that the it at The Dentists Insurance Company, TDIC. Take our Risk dentist fi le a police report and report the Management program. Be it seminars, online resources or our incident to the dental benefi ts plan provider. Advice Line, we’re in your corner every day. With TDIC, This case illustrates the unfortunate reality that medical identity theft has you are not a sales goal or a statistic. You are a dentist. made its way into the dental offi ce. And just as dental offi ces have an ® obligation to prevent fi nancial identity Protecting dentists. It’s all we do. theft by protecting patients’ personal 800.733.0633 | tdicinsurance.com | CA Insurance Lic. #0652783 data, so too do they have an obligation to prevent medical identity theft.

OCTOBER 2018 663 OCT. 2018 RM MATTERS

CDA JOURNAL, VOL 46, Nº10

Commonly, these thieves will make to capture photos. If patients are hesitant further and then make other arrangements false offers of free or discounted care. to have their pictures taken, reassure them for payment until the issue is resolved. Another common source of medical that it is only for internal use and will In addition, ensure that your staff identity theft is a dishonest employee who not be posted on social media or used for is trained to educate patients on best either steals patients’ private data to sell any marketing purposes. Let them know practices for keeping their private data on the black market or allows uninsured of your commitment to protect their private. For example, patients should be friends or family members to use stolen personal information and prevent fraud. informed that your staff will never ask for identity to obtain free dental care. When training your staff on spotting Social Security numbers or dental benefi t It’s crucial that dentists know and possible fraudulent patient activities, plan numbers over the phone, so if they trust their staff, says Taiba Solaiman, some red fl ags to look for are: receive unsolicited calls from people senior risk management analyst at The ■ Questionable or altered requesting this information, they should Dentists Insurance Company. Conducting documents or signatures. hang up immediately. Remind patients comprehensive background screenings and ■ Information not matching with to carefully review statements from random audits of charts and billing activity information previously collected. insurance companies to look for suspicious for any friends or family members who have ■ Suspicious behavior, such or unauthorized treatments or payments. been seen in the offi ce can go a long way as an inability to quickly Medical identity theft is a in catching and thwarting illegal activity. answer basic questions. multifaceted, complex crime and it takes Preventing fraud begins at the ■ Refusing to present identifi cation the diligence of all players — medical and front desk. Therefore, it is imperative or provide identifying dental professionals, patients, insurance to instruct employees to ask for photo information when requested. providers and law enforcement — to halt identifi cation as patients present. ■ Forms of identifi cation that its progress. And while dentists certainly It is not a violation of HIPAA and, don’t match the description of aren’t expected to take on the role of while it is not required, it is highly the patient producing them. crime fi ghter, there are simple steps they recommended. Most dental patients are ■ An accompanying individual can take to ensure their patients and already familiar and comfortable with addressing the presenting their practice remain free from fraud. ■ providing photo identifi cation when individual with a different name. visiting their medical care providers. Should your practice team spot a red To schedule a confi dential consultation Some offi ces take photos of their fl ag, it’s advisable to alert the authorities. with an experienced risk management analyst, patients, making it easier to identify It is not advisable to refuse treatment; visit tdicinsurance.com/RM consult or call patients when they arrive. Many dental instead, inform the patient that there are 800.733.0633. TDIC’s Risk Management software programs have built-in features discrepancies that need to be looked into Advice Line is a benefi t of CDA membership.

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664 OCTOBER 2018 CARROLL “Matching the Right Dentist to the Right Practice” V &COMPANY

4248 MENLO PARK FACILITY Remodeled, 930 sq. ft. dental facility with 4321 SAN JOSE GP Incredible location on the corner of two major ING 2 fully equipped ops. and plumbed forN 2D additional ops, reception area, thoroughfares. Seller retiring after 20+ years. Solid, loyal staff and patient doctor's office, sterilization, lab, storagePE and restroom. Medical/Dental base. 1,200 active patients (Seller is contracted with Delta PPO & Premier) 4 building in highly desirable location. Asking $135K. ops in 1,400 sq. ft. Seller works 4 days/wk with 4+ hygiene days. Average GR $739K with average adj net of $282K. Asking price $561K. 4246 SUNNYVALE GP Retiring sellerL offeringD a well est. general practice with loyal staff in organized office withSO 3 fully-euipped ops. Located in highly 4216 SIERRA FOOTHILLS 23 year practice located in the heart desirable neighborhood. 2017 Gross Receipts $540K+. Asking $390K. of the Sierra Nevada foothills in modern building close to downtown area. 1,024 square foot office with 4 fully- equipped ops., upgraded major 4269 SAN JOSE GP Well established practice offering 46 yrs of goodwill. equipment and digital radiography. Average Gross Receipts $890K+ with Excellent West San Jose location. 7ops, 5I fullyNG equipped in 2,000 sq. ft 56% average overhead. Asking price for practice $604K. Seller is offering ND facility. Approx 3,000 active patients,PE all fee-for-service. 9 days of hygiene/ real estate for sale to the buyer of his practice. week. Outstanding staff. Average annual GR $1.3M with an adjusted net of $473K. Asking price $1,015,000. Potential to purchase bldg interest, price 4172 NAPA GP Amazing opportunity to own the practice of your dreams in to be determined. Owner willing to help in the transition. one of the world’s premier wine destinations! Situated in a prime neighborhood close to many amenities. 1,200 square foot office with 4 fully- 4261 CAPITOLA GP Retiring doctor offering an established practice in equipped and updated operatories. Over 1,000 active patients. Average professional office complex built around a garden setting. Beautiful and annual gross receipts over $700K. Asking price for practice $484K. Building modern 1,465 square foot facility with 4 fully-equipped operatories. Average available for purchase. gross $743K+ with 3 doctor days and 6 hygiene days per week. Approximately 1,800 active patients. Asking $562K. 4322 MENLO PARK GP Practice in seller owned facility in desireable corner location in the heart of Menlo Park, 1 block fron Santa Cruz Ave. 60% 4267 SAN JOSE GP 36-year established 4 op practice near Willow Glen of patients are private pay. Great upside potential from retiring seller. Asking D area grossing $650K average. 950+O activeL patients. Beautifully maintained $25K. and updated 1,450 sq. ft. facility. 3-dayS doctor week, 3 hygiene days. Asking $450K. 4326 SANTA CLARA GP Practice with an emphasis on Restorative dentistry with over 1,000 active patients located in sought-after 4233 SF GP Seller offering 26+ year general practice in SF Financial district. neighborhood close to major routes, shopping centers and hospitals. Ground floor office with high volume foot traffic. Approx. 1,200 sq. ft. facility Approximately 850 sq. ft. facility with 3 fully-equipped ops. pljus a seasoned with 4 fully-equipped ops. $930K+ avg. annual GR. Seller willing to help for a and loyal staff. Avg. Gross Receipts $617K. smooth transition. Asking $640K. 4324 SF GP Seller offering 33 years of goodwill in busy financial district 4271 SOUTH SF DENTAL FACILITY Turnkey facility in well known bldg. Gorgeous 890 sq. ft. office with 3 fully equipped ops (plumbed for 4). beautiful, professional building with dedicated parking lot. Incredible location Incredible panoramic views with amazing natural light pouring into each with EZ freeway access to Hwys 280, 380 and 101. Asking only $30K. window. 500+ active patients. 2 days of hygiene/wk. Current average GR approx. $410K with adj net of $115K. Asking $282K. 4198 PETALUMA DENTAL BUILDING Condominiumized dental office conveniently located close to Petaluma Valley Hospital and nearby shops, 4210 UNION CITY GP Retiring GP offering 40+ years of goodwill. 5 ops in with easy access to Highway 101 and with ample, dedicated parking. 1,100 sq. ft. 350 active patients, all fee-for-service. 2 yr average GR Approximately 1,600+ square feet with five (5) fully-equipped operatories set $177K. Asking $85K. up for right hand delivery. There is a reception area, business office, consult room, staff lounge, lab, sterilization area, private office and separate storage 4262 MOUNTAIN VIEW GP Desirable 1,700 square foot Mountain View area. Asking $495K. location. 5 fully equipped operatories. Average Gross Receipts $886K+ with 4 doctor days and 6 hygiene days. Practice with an emphasis on Restorative 4178 SONOMA COUNTY PERIO Seller retiring from 21 year practice with and Preventative care. Seller retiring. Great opportunity for a skilled dentist to trained, seasoned staff and great location. Exceptional 2,100 sq. ft. ample take over a 35 year practice with seasoned staff and loyal patient base. office with 6 fully equipped ops. Majority of equipment purchased in 2002. 4 Asking $619K. doctor-days & 3 hygiene days per week. Average gross receipts $1M+. Asking $677K.

4225 EUREKA GP & BUILDING Established since 1981 in charming Carroll & Company Northern California port city. Retiring doctor is offering practice and building. 2055 Woodside Road, Suite 160 Practice has approximately 1,200 active patients with new patients accepted Redwood City, CA 94061 on a selective basis. Average Gross Receipts of $765K+ with 61% average BRE #00777682 overhead. Beautiful 1,400 square foot office with four (4) fully-equipped operatories. Asking price for practice $468K. Mike Carroll Pamela Carroll-Gardiner Mary McEvoy Carroll

carroll.company [email protected] (650) 362-7004 (650) 362-7007 Making your transition a reality.

Dr. Lee Dr. Thomas Dr. Russell Jim Kerri Gina Jaci Steve -D\ Thinh Maddox Wagner Okihara Engel McCullough Miller Hardison Caudill +DUWHU Tran LIC #01801165 /,& /,& /,& /,& /,& /,& /,& /,& /,& (949) 675-5578                   

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ќџѡѕђџћȱюљіѓќџћіюȱѓѓіѐђ ќѢѡѕђџћȱюљіѓќџћіюȱѓѓіѐђ 1.800.519.3458 www.henryscheinppt.com 1.888.685.8100 Ž—›¢ȱŒ‘Ž’—ȱ˜›™˜›ŠŽȱ›˜”Ž›ȱǛŖŗŘřŖŚŜŜ Regulatory Compliance CDA JOURNAL, VOL 46, Nº10

Other Cal/OSHA Regulations: Fire Extinguishers, Eyewash, Exit Signs CDA Practice Support

ental professionals hear much ■ Alternate protection must about Cal/OSHA’s blood- be provided when portable borne pathogens, Employers should be extinguisher is removed from communication and injury and service for maintenance illness prevention regulations aware of other occupational and recharging. Dbecause they require employers to safety regulations applicable ■ Empty and recharge every six years develop written plans and train to dental facilities. These a stored pressure dry chemical employees on specifi c elements. These are found in the California extinguisher that requires a 12-year are not the only Cal/OSHA regulations, hydrostatic test except if it has a however. Employers should be aware of Code of Regulations nonrefi llable disposable container. other occupational safety regulations Title 8 Chapter 4. ■ Hydrostatic testing performed by applicable to dental facilities. These a trained individual with suitable are found in the California Code of testing equipment and facilities. Regulations Title 8 Chapter 4 Subchapter 1 Unfi red Pressure Vessel Safety Orders, Subchapter 3 Compressed Air Safety Orders, Subchapter 5 Electrical Safety Orders and Subchapter 7 General Industry Safety Orders and can be viewed on the Department of Industrial Relations website, dir.ca.gov. This article reviews Cal/OSHA regulations on: ■ Portable fi re extinguishers. ■ Eyewash stations. ■ Exit signs. ■ Maintenance and access to exits.

§6151 Portable Fire Extinguishers The regulation applies to the placement, use, maintenance and testing of portable fi re extinguishers provided for the use of employees. In offi ces where extinguishers are provided but are not intended for employee use and the employer has an emergency action plan and a fi re prevention plan that meet Cal/ OSHA requirements, then the employer need only meet the following inspection, maintenance and testing requirements: ■ Monthly visual inspection. ■ Annual maintenance check. Record date of maintenance check and retain record for one year after last entry.

OCTOBER 2018 667 OCT. 2018 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 46, Nº10

If it is intended for employees to Fire Classifi cation Extinguisher Type use the fi re extinguishers, an employer ■ Class A fires include wood, ■ Water and foam – for must provide training to employees paper and textiles — place Class A fi res only. to familiarize them with the general extinguisher every 75 feet ■ Carbon dioxide – for Class principles of fi re extinguisher use and or less. B and C fi res; ineffective of their use. Training must be done ■ Class B fires include flammable on Class A fi res. upon employment and at least annually liquids — place extinguisher ■ Dry chemical, multipurpose thereafter. Mount extinguishers on the every 50 feet or less. – for Class A, B and C fi res. wall and identify and maintain them in ■ Class C fires include electrical ■ Dry chemical, ordinary – a fully charged and operable condition. equipment — extinguisher for Class B and C fi res. They should be kept in their designated placement dependent on ■ Wet chemical – for kitchen locations at all times except during use. placement of other extinguishers. fi res (deep-fat fryers). Selection and distribution of ■ Class D fires include metal ■ Clean agent – Class fi re extinguishers within the dental powders and shavings — A, B and C fi res. facility must be based on type of fi res place extinguisher every ■ Dry powder – Class D fi res only; anticipated in the work place. 75 feet or less. ineffective on all other fi res. ■ Water mist – Class A and C fi res. ■ Cartridge-operated dry chemical.1

§5162 Emergency Eyewash and Shower Equipment A dental facility must have a plumbed or self-contained eyewash or eye/facewash equipment that meets at a minimum the standards set in section 5, 7 or 9 of ANSI Z358.1–1981, “Emergency Eyewash and Equipment.” Personal eyewash units or drench hoses may be used in support of the required equipment but not in lieu of them. The equipment must be in an accessible location that requires no more than 10 seconds for an injured person to reach. Keep the area around the equipment free of obstructions. The required equipment must be able to supply potable water at 1.5 liters per minute for 15 minutes, which is the fl ow rate and time duration specifi ed in the ANZI standard. The control valve must allow the water fl ow to remain on without requiring the use of an operator’s hands, and the valve must remain activated until intentionally shut off. CONTINUES ON 670

668 OCTOBER 2018 QUESTIONS MOST OFTEN ASKED BY SELLERS:

1. Can I get all cash for the sale of my practice?

2. If I decide to assist the Buyer with financing, how can I be guaranteed payment of the balance of the sales price?

3. Can I sell my practice and continue to work on a part time basis?

4. How can I most successfully transfer my patients to the new dentist?

5. What if I have some reservation about a prospective Buyer of my practice?

6. How can I be certain my Broker will demonstrate absolute discretion in handling the transaction in all aspects, including dealing with personnel and patients?

7. What are the tax and legal ramifications when a dental practice is sold? QUESTIONS MOST OFTEN ASKED BY BUYERS:

1. Can I afford to buy a dental practice?

Can I afford not to buy a dental practice? LEE SKARIN 2. INC. & ASSOCIATES

3. What are ALL of the benefits of owning a practice?

4. What kinds of assets will help me qualify for financing the purchase of a practice?

5. Is it possible to purchase a practice without a personal cash ?

6. What kinds of things should a Buyer consider when evaluating a practice?

7. What are the tax consequences for the Buyer when purchasing a practice? 2IÀFHV Lee Skarin & Associates have been successfully assisting Sellers and Buyers of Dental Practices for nearly 30 years in providing the answers to these and other 805.777.7707 questions that have been of concern to Dentists. 818.991.6552 Call at anytime for a no obligation response to any or all of your questions Visit our website for current listings: www.LeeSkarinandAssociates.com 800.752.7461 CA DRE #00863149 OCT. 2018 REGULATORY COMPLIANCE

CDA JOURNAL, VOL 46, Nº10

CONTINUED FROM 668 Activate plumbed eyewash equipment face of the sign may not be less than 50 adjacent to an exit door. The path to an monthly to fl ush the line and verify lux. An exit sign must be at every exit exit should be kept clear and should not proper operation. Logging this activity door, at the intersection of corridors, at exit require an individual to pass through a is highly recommended. Maintain a stairways or ramps and at other locations restroom, closet or high-hazard area. ■ self-contained unit in accordance with and intervals deemed necessary to inform REFERENCES manufacturer’s instructions. Improperly individuals. Exit signs that are required 1. Fire Equipment Manufacturers Association. www. maintained eyewash stations may to be electrically illuminated should be femalifesafety.org/types-of-extinguishers.html. Accessed July cause damage to employees’ eyes.2 lighted with two bulbs, either one of which 27, 2018. 2. OSHA InfoSheet. Health Eff ects from Contaminated Water shall be suffi cient to provide the required in Eyewash Stations, undated. www.osha.gov/Publications/ §3216 Exit Signs luminance on the face of the sign. OSHA3818.pdf. Accessed Aug. 7, 2018. Exit signs are required for any room or building that has an occupant load of §3225 Maintenance and Access Regulatory Compliance appears more than 50. The words on the exit sign to Exits monthly and features resources about laws must be in block letters at least 6 inches Every required exit must be kept free of that impact dental practices. Visit cda.org/ in height with a stroke of not less than obstructions or impediments at all times. practicesupport for more than 600 practice 3/4 of an inch. The color or design of the Do not hang draperies, mirrors or other support resources, including practice letters must be in strong contrast to the hangings that can conceal or obscure management, employment practices, dental sign background. The luminance on the an exit door. No mirror may be placed benefi ts plans and regulatory compliance.

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670 OCTOBER 2018 Specialists in the Sale and Appraisal of Dental Practices Practices Serving California Dentists since 1966 How much is your practice worth?? Wanted Selling or Buying, Call PPS today!

NORTHERNNORT CALIFORNIA SOUTHERN CALIFORNIA (415) 899-8580 – (800) 422-2818 (714) 832-0230 – (800) 695-2732 Raymond and Edna Irving Thomas Fitterer and Dean George [email protected] [email protected] www.PPSsellsDDS.com www.PPSDental.com California DRE License 1422122 California DRE License 324962 6150 HAYWARDYWARD Strong Dental DNA. DNA Well-designed 5-op office. off ALTA LOMA HiJKLdentityORFDWLRQGrossing $700. 5ops Digital radiography DQGcomputers. 2018 trending $850,000+. 5-days of ZLWK3-equipped. hygiene. Full Price $200,000. BAKERSFIELD Will do $1 Million. $650 includes RE. 6149 NOVATO Stand-alone building at busy stop light intersection off BAKERSFIELD $5($ Grossing $1. OwneU works 16- Highway 101. All new 2-years ago. 4-ops, digital, paperless, Pano with Ceph at cost of $280,000. At doorway into Hamilton neighborhood with KRXUSHUZHHNNets $300. hundreds of homes. No competition. Perfect for nearby DDS to UHORFDWH BAKERSFIELD AREA Grossing $40K/mth on 2-days. 5-ops. WKHLUSUDFWLFHor Growing GroupVHHNing WKDWQH[Wperfect location. BELLFLOWER Part-time doing $100. FP $65 Building DQGturn-key office available for purchase. &2/721Latino. Absentee. Grosses $350. 5-ops. 6148 SAN LEANDRO Great location on Hesperian Boulevard. CORONA Near Capistrano Beach exit. Part-time grossing Absentee owned. Shall collect $400,000 in 2018. Has done $670,000 in $200 )XOO3ULFH recent past with owner here. Associate relocating. Seller’s daughter shall  DEL MAR -- ENCINITAS +02 grossing near $400K. 4-ops. provide transition assistance. DIAMOND BAR Million Dollar location-to-be. 4-ops 6147 SAN FRANCISCO BAY AREA – “OUT-OF-NETWORK” DQG 2017 collected $2 Million. 2018 tracking $2.15 Million. Hygiene digital pan.5HVWDXUDQWVEULQJLQVRIFRQVXPHUVHDFKGD\ produces $1+ Million. Seller available for long transition. 9HU\UDUH DIAMOND BAR HiJKLdentity Asian VWULScenter. %HDXWLIXO5- 6146 LOWER SACRAMENTO FOOTHILLS Highly regarded ops. 6XFFHVVRUZill do $1 Million. family community. 6-days of hygiene evidences strong foundation. 2017 GARDENA Did $2 Million when Owner here. Doing $1.5QRZ collected $880,000. 2018 projecting $950,000. GLENDALE / BURBANK Grosses $840. Includes apt. 6145 MARIN COUNTY - NOVATO Excellent foundation. Best INLAND EMPIRE Adec, cone beam. Gross $1.3. InclXGHV RE. location, beautiful office, Adec equipped with everything new since 2014. INLAND EMPIRE DentiCal gross near $300K. FP $150. 500-active files. 2018 tracking $250,000. Full Price $125,000. INLAND EMPIRE Union Practice can do $1+ Million. RSV 6144 SACRAMENTO AREA 14-days of Hygiene. 2017 collected $1.85 Million. Strong staff. 7-ops. Great location. Condo optional INLAND EMPIRE 2 practices grossing $1.80LOOLRQ Right purchase. %X\HUdoes $30LOOLRQGorgeousZLWKFRQHEHDPV 6143 BERKELEY’S ALTA BATES VILLAGE Perfect for nearby IRVINE )HPDOH*rossing $1.2 Million. 5-ops. Premier Dentist to relocate their practice into stand-alone building on LA MIRADA Like new 5-ops, 3-equipped. Grossing $450. Webster Street. 3-day week collected $550,000 in 2017. 4-days of LANCASTER Successor will do $120LOOLRQ Area booming. Hygiene. NORTH LONG BEACH Hi Identity. 50% Latino. Only $75K. 6142 OAKLAND’S PIEDMONT - “OUT-OF-NETWORK” 3-ops, 1257+3$6$'(1$Million 'ROODUpractice. 5-opEXLOGLQJ paperless and Planmeca ProMax. 2017 collected $667,000. Profits across from Starbucks. $300,000+. Successor should be proficient in Ortho or willing to learn. GLUHFWO\ Seller available for transition. OC BEACH 6-ops, Dentrix, digital, computerized. FP $150 6141 NAPA VALLEY’S ST. HELENA 3-day per week PPO practice. OC BEACH Absentee owned, grossing $550. 4-ops. 3-days Hygiene. 2017 Collected $359,000. Attractive 3-op office. OC BEACH Grossed $100K last month. FXOO3ULFH $900,000. 15-QHZSDWLHQWVSHUmRQth. Full Price $100,000. OC BEACH Grossing $1 Million. 4-opsZLWKcone beam. 6140 SAN RAFAEL 2OGHU'entist VD\VLWLVQRZWLPHWRretirH. Delta OC’S FASHION ISLAND Grossing $650K. Rare opportunity. PPO provider. Has averaged $390,000 in collections on 26.5-hour week. 3$/0635,1*6/$48,17$Doing $1.5 0LOOLRQbut can do $223,000+ in Profits in 2017. Full Price $125,000. $2 Million. RSV 6139 S$1)5$1&,6&2BAY AREA PROSPRACTICE - “OUT-OF- PEDO Chinese & Latino. Grosses $450. FXOO3ULFH$285,000. NETWORK”2017 billed $1.2 Million, collected $1.19 Million. 4-days of Hygiene.Owner available for transition. REDLANDS Once did $1 Million. Grossing over $400. 6138 SILICON VALLEY Best technology and well-designed suite. 5,$/72Empty VTIW9-op office in 10,000 sq.ft. building 2017 collected $900,000+ with Profits of $420,000. Perfect for Dentist near 210. Did $1+ Million.%XLOGLQJ)RU6DOH wishing to create high-end brand.&RQGRRSWLRQDOSXUFKDVH RIVERSIDE Grossing $250. 30-new pts/mth. FP $165. 6129 FOSTER CITY – “OUT-OF-NETWORK” Wish to infuse your SANTA CLARITA 70,000 cars pass daily. 8-ops. FP $250K. nearby practice with quality patients? WUHQGLQJ$50,000 in THOUSAND OAKS / AGOURA HILLS 5-ops, part-time part-time schedule. Seller and Hygienist shall relocate into FROOHFWLRQVRQ *rossing DOPRVW$500 JHQHUDWLRQVRIOR\DOSDWLHQWV Buyer’s practice to transition patients. Full Price $100,000. TORRANCE Entrance to P Verdes. Grossing $300 6122 SANTA CLARA Best exposure in beautiful strip center on El  DORV  WR Camino Real. 5-Ops. Delta PPO practice currently trending $1 Million . FXOO3ULFH$290. in Collections on 4-days. Perfect platform to operate 6-days a week. 83/$1'Grossing $135 part-time. 3-ops. Wants to do $1.5+ Million. WEST COVINA Grossing $650. 2 days hygiene.

Largest BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA NORTHERN CALIFORNIA CONTINUED

AC-782 SAN FRANCISCO: Well maintained, mul- CC-846 SAN RAFAEL: Prof/Retail Building Complex. 3 EC-729 GREATER SACRAMENTO AREA: HN-618 SIERRA FOOTHILLS: Broker in level Professional Medical Complex. 1450 sf w/ 5 ops 640 sf Collections $433k in 2017 $295k Call for details! $65k ops $195k CG-616 NAPA: State-of-the-Art practice and on EN-664 SACRAMENTO Facility: HN-740 SHASTA CO: AC-886 SAN FRANCISCO (Facility): Unsurpassed track to do $100k more in 2018. Seller is ready for Now Only: $30k $475k/ Northern visibility & locaon! Potenal here is limitless! 850 sf retirement! $425k EN-755 FOLSOM: Real Estate $350k w/ 3 ops $85k CG-859 SONOMA: On track to collect over $700k in Now Only: $100k HN-773 SUTTER CREEK: Seller Movated! AC-893 SAN FRANCISCO (Facility): Amazing Move In 2018! 2000sf w/ 4 ops highly esteemed FFS Prac- EN-791 SO. SACRAMENTO CO: ! $175k California Ready Facility in Union Square. 1000 sf w/ 3 ops tice $395k $495k HN-816 CHESTER/ALMANOR AREA:

$75k CN-878 VALLEJO: Highly desirable thriving communi- EG-788 ROSEVILLE: AG-852 SAN FRANCISCO: PRIME LOCATION! 600 sf ty! 2 story prof bldg. 2000 sf w/4 ops $315k . Reduce Price $275k/ Real Estate Available Pracce $140k/ Real Estate TBD w/ 2 fully equipped, computerized ops. Reduced DC-812 REDWOOD CITY Facility: Reasonable rent EG-849 AUBURN: HN-879 SONORA: Over $34.5M Price: $365k and great landlord! 740 sf w/ 3 fully equipped ops $275k AG-871 SAN FRANCISCO: The LOCATION of this $65k $350k office is the envy of all! 600 sf w/ 2 ops $88k DG-844 SAN JOSE: Beloved pracce delivers quality EG-887 FOLSOM Facility: CENTRAL VALLEY & SOUTHERN CALIFORNIA in 2017 sales AG-880 SAN FRANCISCO: Seller rering aer 39 care and warm relaonships which paents have Priced for quick Sale! $50k years! Remodeled in 2010. ~ 700 sf w/ 2 ops $350k come to expect. 1500sf 3 ops + 1 add’l. $195k/ EN-797 WOODLAND: IG-832 OAKHURST: $235k/ Real Estate 375k

AG-895 SAN FRANCISCO: This pracce has a stellar Real Estate Available! Pracce $575k/ Real Estate TBD IG-881 TURLOCK: reputaon and delivers the highest quality of dens- DG-854 SUNNYVALE: Do your best denstry here to EN-831 SACRAMENTO $360K Extensive Buyer try! 1500 sf w/ 4 ops $675k an educated, diverse, family-oriented, business- “a cut above” Now Only: $650k IN-764 STOCKTON: AG-896 SAN FRANCISCO: Don’t less this opportunity friendly populaon! 782sf w/ 3 ops $875k EN-836 CITRUS HEIGHTS: $267.5k Database & pass you by! ~ 1300 sf w/ 2 ops $600k DG-862 MID-PENINSULA: Pracce is a rare gem with $188k JC-811 FRESNO COUNTY: AG-900 SAN FRANCISCO: State-of-the-art equip- up to 7 operatories in the Bay Area!! 1800sf w/ EN-858 ORANGEVALE: $350k Unsurpassed ment in this pracce, already primed for proven 6ops + 1 add’l. $475k Priced to Sell Only $70k! JC-823 LOS BANOS: success at this locaon. 2000sf w/ 5 ops $695k DG-865 SANTA MARIA: Live and pracce in this de- EN-885 ROSEVILLE Facility: $80k Exposure allows BC-710 WALNUT CREEK: Desirable location. Stand- sirable collegiate coastal community! 930sf w/ 3 $95k JG-778 FRESNO: alone, single-story bldg. 1313sf w/ 3 ops $150k ops $395k EN-899 DIXON: $275k us to offer you BC-741 DANVILLE (FACILITY): Move in Ready facility DG-868 SUNNYVALE: Hesitate and you might lose $195k JG-807 FRESNO: to build the practice of your dreams! ~ 1600sf w/ out on the pracce of your dreams! 1350sf w/ 5 Seller Movated $99k FC-650 FORT BRAGG:

3 fully equipped ops $150k ops. $725k KG-779 SAN CLEMENTE Ortho: $350k for the Pracce & $400k for the Real Estate BC-789 OAKLAND (Facility): Perfect layout for Pedo DN-771 SOQUEL Facility: The perfect place to FG-841 ARCATA: $325k/ Real Estate Available! or Ortho. 2800 sf w/ 6 fully equipped ops. Plumb- sink down roots, raise a family & build an empire! $275k/Real Estate TBD er for 2 add’l $135k 1100sf w/2 ops + 1 add’l. $38,500 FN-754 SO. HUMBOLDT: SPECIALTY PRACTICES Better BC-894 BRENTWOOD: Perfect locaon – Will be DG-785 SANTA CRUZ: Great price and cash flow for your best purchase ever! 1230 sf w/ 2 ops. only 3 days a week!! 1000sf w/ 4 ops. Seller Mo- Now $150k! AC-748 SAN FRANCISCO Perio: Plumbed for 2 add’l $225k vated: $165k FN-855 NO. HUMBOLDT: $750k Candidate B G- 73 4 A N TI OCH: The perfect place to work, live DG-842 FREMONT: Imagine being able to live, $275k BC-784 CENTRAL CONTRA COSTA CO Perio: and play! Located in desirable professional neigh- pracce and play here! 3200 sf w/ 10 ops $395k GG-769 REDDING AREA: $395k borhood. 1,323 sf w/ 4 ops. $315k DG-857 SAN JOSE: Do the math - this associate- Pracce $390k/ Real Estate $540k BG-843 WALNUT CREEK Perio BG-839 PINOLE: Sink your roots into this community driven pracce with profitability consistently! GN-799 PARADISE: Reduced Price: $595k which retains many “turn-of-the-century” buildings! 1709 sf w/5 ops $595k Pracce $375k, Real Estate $325k EG-903 CARMICHAEL Oral Surgery: Better 1212sf w/ 3 ops + 1 add’l. $350k DG-892 SAN JOSE: Excellent locaon and stellar GN-853 REDDING: BN-891 PINOLE: This one won’t last! Build your reputaon in a one-of-a-kind seng! 1500 sf w/ $595k Amazingly Priced: $450k dental empire in this bedroom community! 3 ops + 2 add’l. $295k GN-884 YUBA CITY Real Estate w/ Equip: EN-821 DAVIS Perio: Fit 1300sf w/3 ops. $425k DN-806 WATSONVILLE: This quality, family-oriented $400k $385k CC-798 PETALUMA: Partially equipped dental office pracce thrives $ focuses on delivering quality care. HG-815 SIERRA CO: EN-822 SACRAMENTO Perio: for lease. Only $2500/mo for 1400 sf! Call for De- 1,182 SF W/ 4 OPS. $495K/ Real Estate TBD Reduced Price: $165k/ Real Estate $437k $790k tails! DN-845 FREMONT Facility: Build your dream HG-827 SO. LAKE TAHOE: JG-757 VISALIA Perio: CC-802 SANTA ROSA: Retail shopping center w/ 1200 Pracce! Primed for success in this proven loca- $310k Better sf and 4 fully equipped ops $220k or $260k w/CT on! 1800sf w/3 ops + 2 add’l. $90k HG-851 SO LAKE TAHOE: Reduced Price: $350k Scanner $425k

Price 800.641.4179 [email protected] “ASK THE BROKER” WWW.WESTERNPRACTICESALES.COM

Timothy Giroux, DDS Jon B. Noble, MBA Mona Chang, DDS John M. Cahill, MBA Edmond P. Cahill, JD Largest BAY AREA BAY AREA CONTINUED NORTHERN CALIFORNIA NORTHERN CALIFORNIA CONTINUED

AC-782 SAN FRANCISCO: CC-846 SAN RAFAEL: EC-729 GREATER SACRAMENTO AREA: Seller rering! FFS Pracce and Real HN-618 SIERRA FOOTHILLS: Seller Retiring! Huge opportunity for growth by Broker in $295k Estate Available! Call for details! increasing office hours! 750sf w/ 2 ops $65k $195k CG-616 NAPA: EN-664 SACRAMENTO Facility: Great corner locaon, excellent visibility & HN-740 SHASTA CO: Beauful mountain community, well-established AC-886 SAN FRANCISCO (Facility): Seller is ready for easy access! 2300sf w/ 4 ops. Now Only: $30k pracce, exceponal long-term staff. 2400+sf w/5 ops + 1 add’l. $475k/ Northern retirement! $425k EN-755 FOLSOM: A perfect locaon, envied by all! Enjoy an amazing qual- Real Estate $350k $85k CG-859 SONOMA: ity lifestyle in this thriving city. 1200sf w/ 4 ops. Now Only: $100k HN-773 SUTTER CREEK: Seller Movated! Locaon known for beauful scen- AC-893 SAN FRANCISCO (Facility): EN-791 SO. SACRAMENTO CO: Highly esteemed pracce to an adoring & ery, excellent wine & rich history! 1536sf w/4 ops + 1 add’l!! $175k California $395k appreciave paent base! 1950sfw/ 5 ops. $495k HN-816 CHESTER/ALMANOR AREA: The perfect place to work, live and

$75k CN-878 VALLEJO: EG-788 ROSEVILLE: Do not pass up on this remarkable opportunity! play! Do not hesitate, or this pracce will be gone! 1250 sf w/ 4ops. AG-852 SAN FRANCISCO: $315k 2700sf w/ 6 ops.. Reduce Price $275k/ Real Estate Available Pracce $140k/ Real Estate TBD Reduced DC-812 REDWOOD CITY Facility: EG-849 AUBURN: Imagine living in a peaceful, rural town that has an HN-879 SONORA: Live and pracce in the capvang beauty of this family- Over $34.5M Price: $365k ideal climate and “big city” amenies less than an hour away. 1400 sf w/ oriented, scenic town in Tuolumne County! 2950 sf w/ 3 ops $275k AG-871 SAN FRANCISCO: $65k 4 ops $350k $88k DG-844 SAN JOSE: EG-887 FOLSOM Facility: Build the pracce of your dreams here! 1200 sf CENTRAL VALLEY & SOUTHERN CALIFORNIA in 2017 sales AG-880 SAN FRANCISCO: w/ 2 ops Priced for quick Sale! $50k $350k $195k/ EN-797 WOODLAND: Do not hesitate or this enviable opportunity will fulfill IG-832 OAKHURST: 2048sf w/3 ops + 1 add’l. $235k/ Real Estate 375k

AG-895 SAN FRANCISCO: Real Estate Available! someone else’s dream! 2316sf w/ 6 ops. Pracce $575k/ Real Estate TBD IG-881 TURLOCK: Offering a philosophy to provide “Nothing but the Very DG-854 SUNNYVALE EN-831 SACRAMENTO: Locaon & pracce philosophy make this opportunity Best” in dental care! 10 ops $360K Extensive Buyer $675k “a cut above” others! ~1600sf w/4 ops. Now Only: $650k IN-764 STOCKTON: Well-established, fully computerized, paperless, digital- AG-896 SAN FRANCISCO: $875k EN-836 CITRUS HEIGHTS: well-established, quality pracce comes loaded ized pracce just waing for your talent & skill! 5,000sf w/10 ops $267.5k Database & $600k DG-862 MID-PENINSULA: W/ 30+ years of goodwill. 1300sf w/3 ops + 2 add’l. $188k JC-811 FRESNO COUNTY: Amazing Opportunity! Considerable Goodwill in AG-900 SAN FRANCISCO: EN-858 ORANGEVALE: Perfect for a second locaon or satellite situaon! Community! 3,000 sf w/ 6 ops $350k Unsurpassed $475k 850 sf w/ 3 ops. Priced to Sell Only $70k! JC-823 LOS BANOS: Unique opportunity. Heavy emphasis on hygiene. Growth $695k DG-865 SANTA MARIA: EN-885 ROSEVILLE Facility: Looking for the ideal locaon, great visibility, potenal by increasing DDS days. 1000 sf w/ 3 ops $80k Exposure allows BC-710 WALNUT CREEK: and close to just about anything? Here it is! 1000sf w/3 ops. $95k JG-778 FRESNO: What a steal. Consistent collecons over $600k with cash $150k $395k EN-899 DIXON: State-of–the-art office, with all the “bells and whis- flow over $300k!! 1452 sf w/ 4 ops $275k us to offer you BC-741 DANVILLE (FACILITY): DG-868 SUNNYVALE: tles”! This fantasc pracce has 3 ops. $195k JG-807 FRESNO: Reasonable Overhead, Stellar Reputaon, Excellent Loca- on! 1000 sf w/3 ops Seller Movated $99k FC-650 FORT BRAGG: Family-oriented pracce. 5 ops in 2000sf, 6 npts/

$150k $725k KG-779 SAN CLEMENTE Ortho: Huge growth potential by expanding mo $350k for the Pracce & $400k for the Real Estate BC-789 OAKLAND (Facility): DN-771 SOQUEL Facility: FG-841 ARCATA: Live and own a little slice of heaven, when you practice work week! 2896 sf w/ 6 open bay chairs $325k/ Real Estate Available! here! 1114sf w/3 ops $275k/Real Estate TBD Better $135k $38,500 FN-754 SO. HUMBOLDT: If you love the lure of sea air, a relaxed lifestyle SPECIALTY PRACTICES BC-894 BRENTWOOD: DG-785 SANTA CRUZ: & charm of coastal living, then look no further! 1500sf w/ 3 ops + 1 add’l. Seller Mo- Now $150k! AC-748 SAN FRANCISCO Perio: Reputable PERIO practice with million dollar $225k vated: $165k FN-855 NO. HUMBOLDT: Seller relocang! Long-established, quality 100% Bay views! 980 sf w/ 3 ops $750k Candidate BG-734 ANTIOCH: DG-842 FREMONT: fee-for-service pracce could be yours! 1600sf w/ 3ops + 1 add’l. $275k BC-784 CENTRAL CONTRA COSTA CO Perio: Seasoned Staff. Office runs like $395k GG-769 REDDING AREA: Offering a full spectrum of general denstry and well-oiled machine! 3 ops $395k $315k DG-857 SAN JOSE: total care! 2700sf w/ 6ops. Pracce $390k/ Real Estate $540k BG-843 WALNUT CREEK Perio: Collecons over $1M! Great gross and profit BG-839 PINOLE: GN-799 PARADISE: This remarkable opportunity is undeniably too good to for only 2 ½ days per week! 1085sf w/ 4 ops Reduced Price: $595k $595k be true! 1800sf w/ 4 ops. Pracce $375k, Real Estate $325k EG-903 CARMICHAEL Oral Surgery: Gross receipts were over $1.1 million in Better $350k DG-892 SAN JOSE: GN-853 REDDING: A great place to visit…and an even beer place to 2017! Stable paent base won’t be affected by transion! 2282sf w/ 5 ops BN-891 PINOLE: This one won’t last! live, work and play! 1450sf w/ 5 ops $595k Amazingly Priced: $450k $295k GN-884 YUBA CITY Real Estate w/ Equip: Designed specifically w/ paent EN-821 DAVIS Perio: Live, pracce & play here! It’ll be the BEST decision Fit $425k DN-806 WATSONVILLE: flow &efficiency in mind. 1750sf w/ 5 ops. $400k you’ll ever make! 1700sf w/4 ops + 1 add’l. $385k CC-798 PETALUMA: HG-815 SIERRA CO: Perfect location for outdoor enthusiast! 1000 sf w/ 3 ops EN-822 SACRAMENTO Perio: This pracce is known throughout Sacramento $495K/ Real Estate TBD Reduced Price: $165k/ Real Estate $437k for its stellar reputaon! 2200sf w/ 5 ops + 1add’l. $790k DN-845 FREMONT Facility: HG-827 SO. LAKE TAHOE: Ski, live, play and pracce here where your JG-757 VISALIA Perio: Keep implants in house and imagine the growth CC-802 SANTA ROSA: lifestyle can’t be beat! 1200sf w/4 ops. $310k possibilities! 9 hygiene days per week! Rare Gem! 2,000 sf w/ 5 ops Better $220k or $260k w/CT $90k HG-851 SO LAKE TAHOE: Don’t wait another day to start living your dream of Reduced Price: $350k Scanner a serene lifestyle! 2100 sf w/ 5 ops $425k

Price 800.641.4179 [email protected] “ASK THE BROKER” can now be found at WWW.WESTERNPRACTICESALES.COM Tech Trends CDA JOURNAL, VOL 46, Nº10

A look into the latest dental and general technology on the market

Dental Patient Education ($49.99, 3D4Medical) CephNinja (Free to $49 per year) The ability to take three-dimensional, layered models of the human Reliable handheld devices with responsive touch interfaces, minimal anatomy to demonstrate dental conditions and procedures for maintenance costs and information synchronization can streamline patients has long been a goal of every provider looking to educate many practice workfl ows, from patient chart management to laboratory their patients using technology. Physical models and expensive case tracking. However, the reality of mobile clinical technology professional videos have tried to meet this goal with limited success. contrasts with this envisioned ideal, replete with pitfalls like HIPAA 3D4Medical, an award-winning creator of medical and fi tness security concerns, information barriers between diff erent applications software, developed the Dental Patient Education app, available on and general user-unfriendliness. CephNinja, a subscription-based macOS and iPad, to integrate valuable patient education content Android and iOS cephalometric analysis application, highlights both with the latest in 3D technology. the great potential and frustrating obstacles of mobile technology for clinical dentistry. This review utilized an iPhone X and focuses on the The Dental Patient Education app (iPad version) centers on a free version of the application, which has limited access to the gamut of beautifully detailed 3D model of the human head. Users can swipe orthodontic analyses and contains commercial ads. to rotate and use single- and multiple-fi nger double-tap gestures to zoom in and out of the model. Layers of anatomy can be explored Described by the CephNinja creators as a “powerful cephalometric by adding and removing them at a tap of a button. Certain analysis and patient management tool,” it presents itself as a anatomical objects in specifi c layers, such as teeth, can be further comprehensive solution for those interested in performing orthodontic isolated by a double tap on superimposed blue zoom icons located treatment. Its main screen is dedicated to information entry as it has throughout various layers in the 3D model. Users can subsequently options to upload radiographs, add photographs, input progress notes take these isolated objects and apply drag gestures to cut and and even manage 3D models. Patient information can be transferred view them cross-sectionally. Every part of the anatomy is labeled into CephNinja via email, the mobile device’s camera roll or Microsoft’s in a searchable index that points users to a specifi c layer and area OneDrive. Once a ceph has been uploaded, the analysis workfl ow on the 3D model. No matter which layer is being viewed on the is identical to other cephalometric analysis software: crop the image, 3D model, users can easily navigate back to the top layer through calibrate the ruler, pick the analysis, then plot the points. According to a home icon on the upper left. Custom pins and annotations can Cyncronus, there have been two studies that compared CephNinja’s be placed anywhere for quick reference. In addition to anatomy, results favorably versus hand tracing. The basic Wit’s analysis, which was the app contains a searchable index of more than 200 animation available in the free version, appeared to be accurate and repeatable videos with audio narration categorized by conditions, treatment, across multiple uses. The resulting analysis can be saved then shared as prevention and diagnostics to off er patients a unique chairside a PDF through email, text message or any cloud storage system. educational experience. Providers can take any image of the 3D Despite the promising ease of use and seeming accuracy in its analyses, model viewed and send it to patients through text messaging or CephNinja has no discernible security measures — anyone with email attachment using the share button. access to the phone will have access to CephNinja’s patient records. The user interface is rich with features, but discovering them is not Transferring patients both to and from CephNinja relies on potentially intuitive. Navigation tips are prominently displayed throughout the HIPAA noncompliant methods like email and cloud storage. Finally, app to help users learn the interface. CephNinja does not appear to have any integrations with any other EHRs, making the information diffi cult to use as it has no other patient — Hubert Chan, DDS management functionality (patient billing comes to mind as a potential hurdle if CephNinja is used). CephNinja is undoubtedly promising and, for instruction in an educational setting, imminently useful as only de-identifi ed patient information is being used. For an active clinical practice, CephNinja does not address the security concerns. — Alexander Lee, DMD 674 OCTOBER 2018 FIND YOUR WONDER at CDA Presents

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