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Treatment of Localized Gingival Recessions Using Enamel Matrix Derivative As an Adjunct to Laterally Sliding Flap: 2 Case Reports Bahar Eren Kuru, Prof Dr, Phd, DDS1

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Treatment of Localized Gingival Recessions Using Enamel Matrix Derivative As an Adjunct to Laterally Sliding Flap: 2 Case Reports Bahar Eren Kuru, Prof Dr, Phd, DDS1 QUINTESSENCE INTERNATIONAL Treatment of localized gingival recessions using enamel matrix derivative as an adjunct to laterally sliding flap: 2 case reports Bahar Eren Kuru, Prof Dr, PhD, DDS1 Predictable and optimal coverage of exposed root surfaces is an important goal in periodontal plastic surgery. In this report, recession coverage was performed as laterally sliding flap technique with the adjunctive use of enamel matrix derivative (EMD). The cases of 2 female patients with gingival recession on the maxillary canines are presented with 1-year follow-up observation. Initial vertical gingival recessions were 4.0 mm each, with a probing depth of 1.0 mm. The surgical procedure immediately produced a marked reduction in gingival recessions. In the course of healing, the soft tissue margin on the operated teeth showed some shrinkage in the first months. After 1 year, complete root coverage (100%) was observed, with a probing depth of 0.5 mm and 5.0-mm gain of clini- cal attachment in both cases, and there was 0.5-mm creeping tissue above the cemento- enamel junction. Within the limits of these cases, the results demonstrated the possibility of treating human buccal recessions with EMD plus laterally sliding flap, with predictable root coverage and clinical attachment gain. (Quintessence Int 2009;40:461–469) Key words: bioengineering, enamel matrix protein derivative, gingival recession, laterally sliding flap, mucogingival surgery, root coverage Gingival recession is the location of marginal which are involved in the formation of cemen- periodontal tissues apical to the cemento- tum during root and periodontal tissue devel- enamel junction (CEJ).1 To cover the exposed opment, have the potential to induce the root surfaces, various surgical techniques regeneration of the periodontal attachment have been proposed, including free gingi- apparatus. EMD, harvested from embryonic val/connective tissue grafting, various flap porcine teeth, has been studied extensively in designs, and guided tissue regeneration.2 animals and humans, and provided evidence Varying rates of success and predictability of tissue regeneration.10–20 Three human are obtained with these procedures.3–7 Even biopsy reports revealed that true periodontal though no single treatment can be consid- regeneration can be achieved with the topical ered superior to all others,8 regenerative application of EMD.21–23 Several clinical inves- approaches seem to be promising for obtain- tigations and case studies were undertaken ing root coverage with the formation of a to evaluate the use of EMD in the treatment of functional periodontal ligament.9 various types of periodontal defect; however, Use of enamel matrix protein derivatives the volume of published studies evaluating (EMD) is one of the tissue engineering modal- the use of EMD as an adjunct to convention- ities in regenerative periodontal treatment. It al surgical techniques in the treatment of gin- has been suggested that these proteins, gival recession is limited, and conflicting results regarding the clinical benefits have been reported.24–33 In this process, trials pre- 1Department of Periodontology, Marmara University Dental senting the efficacy of combined procedures Faculty, Istanbul,Turkey. in the treatment of gingival recessions can Correspondence: Dr Bahar Eren Kuru, Marmara University add valuable information for the clinician in Dental Faculty, Department of Periodontology, Büyükciftlik sok. No: 6 Nisantası, 80200, Istanbul, Türkiye. Email: btkuru@ considering effective and predictable treat- superonline.com ment alternatives for root-surface coverage. VOLUME 40 • NUMBER 6 • JUNE 2009 461 © 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. QUINTESSENCE INTERNATIONAL Kuru Fig 1 Initial appearance of case 1. Fig 2 Initial appearance of case 2. The aim of this report is to present the 1- incision around the denuded root was made year clinical follow-up results of soft tissue to remove the adjacent epithelium and con- root coverage using EMD with the lateral slid- nective tissue. The V-shaped incision was ing flap technique. beveled out on the opposite side from the donor area to permit overlap and increase vascularity for the donor tissue in this area (Fig 3). Intrasulcular incisions extended 2 DESCRIPTION OF CASES teeth distal to the recession. Vertical releas- ing incision down to the mucosa, in corre- Two female patients, 36 and 25 years of age, spondence to the line angle of the second were treated for gingival recessions that were premolar, was performed (Fig 4). creating sensitivity and esthetic problems on A full-thickness mucoperiosteal flap at the the buccal aspects of maxillary canines (Figs coronal portion, which was more of a split- 1 and 2). The patients were systemically thickness flap by partial mucosal dissection healthy, and there were no contraindications at its more apical end, was elevated to mobi- for periodontal surgery. They had no known lize the flap, ensuring passive lateral posi- drug allergies and denied use of alcohol. tioning. Partial dissection was extended far Neither were smokers. After a thorough clini- enough apically into the mucosal tissue to cal examination, the patients received permit adequate mobility of the flap. The flap plaque-control instructions and underwent was free enough to permit movement to the professional tooth cleaning on all tooth sur- recipient site, with no tension (Fig 5). By use faces. Recession depth, keratinized gingiva, of hand instruments, the exposed portion of probing depth, and clinical attachment level the roots was then planed gently to decrease were measured with a graded manual peri- the risk of removing intact periodontal fibers odontal probe to the nearest millimeter (CP from the root surfaces. The surgical area was 15 UNC, Hu-Friedy). rinsed with sterile saline, and the exposed root surfaces of all teeth were conditioned Treatment procedure for 2 minutes with ethylenediaminete- The unilaterally pedicled lateral sliding flap traacetic acid (EDTA) gel (pH 6.7) (PrefGel, technique was used in both cases to ensure Straumann). At this point, root surfaces were primary closure with the gingiva across the dis- again thoroughly rinsed with saline. EMD tal line angle of the lateral incisor. Prior to sur- gel, as Emdogain (Straumann), was then gery, the prominent convexity of the root was placed on the root surfaces (Fig 6). reduced by using diamond burs. A V-shaped 462 VOLUME 40 • NUMBER 6 • JUNE 2009 © 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. QUINTESSENCE INTERNATIONAL Kuru Fig 3 Beveling out of the V-shaped incision. Fig 4 Vertical releasing incision down to the mucosa. Fig 5 Passive lateral positioning. Fig 6 Application of EMD. The pedicle flap was then laterally reposi- The patients received systemic antibiotic tioned to meet and overlap with the external- therapy for 2 weeks postoperatively. The reg- ly beveled-out portion of the V-shaped imen consisted of oral administration of incision at the distal line angle of the lateral doxycycline 200 mg the first day and then incisor. The flap was secured by suturing. 100 mg daily afterward. In addition, the Single suturing to the papilla regions was patients were advised to avoid hard chewing performed to pull the papilla interproximally in the surgical area and to rinse twice daily and hold the tissue tightly against the necks with a 0.2% solution of chlorhexidine diglu- of the teeth (Fig 7). Following the lateral repo- conate for 4 weeks. After 4 weeks, gentle sitioning of the flap, the placement of a free tooth brushing was resumed in the surgical gingival graft onto the exposed bone was area. Recall appointments were scheduled performed (see Fig 7). No periodontal dress- every second week during the first 2 months ing was applied to the surgical area. After a following the surgical procedure, and the healing period of 2 weeks, the sutures were patients were recalled once a month for the removed. remaining observation period. During the 12- Postsurgical care was directed at mainte- month follow-up period, neither subgingival nance of wound stability and infection control. instrumentation nor probing of the operated VOLUME 40 • NUMBER 6 • JUNE 2009 463 © 2009 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. QUINTESSENCE INTERNATIONAL Kuru Fig 7 Suturing and placement of a free gingival graft. Fig 8 Twelve-month postoperative clinical appear- ance of case 1. Fig 9 Three-month postoperative clinical appear- Fig 10 Twelve-month postoperative clinical appear- ance of case 2. ance of case 2. areas was performed. At 12 months, the Immediately after surgery, only case 2 cases were reevaluated and all measure- showed any recession (1.0 mm); at 3 ments repeated (Fig 8). months, recession was 0.5 mm and 1.5 mm for cases 1 and 2, respectively. Treatment outcomes In the course of healing, the soft tissue Postoperative healing was uneventful, and margin on the treated teeth showed some no complications such as allergic reactions, shrinkage in the first months (Fig 9). At the abscesses, infection, or flap dehiscence 1-year follow-up, a complete root coverage were observed. At baseline, vertical reces- was observed in both cases (100% root cov- sion in the 2 cases was 4.0 mm each, with a erage) (Figs 8 and 10) with probing depths of probing depth of 1.0 mm. The clinical attach- 0.5 mm and a total of 5.0-mm gain of clinical ment level in each case was 5.0 mm. The attachment in each case, indicating a reduc- amount of keratinized gingiva in cases 1 and tion of 0.5 mm in probing depth and 0.5 mm 2 was 2.0 mm and 0.5 mm, respectively.
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