A Bioresorbable Barrier in the Treatment of Gingival Recession: Description of a New Resorbable Dome Device
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1 A Bioresorbable Barrier in the Treatment of Gingival Recession: Description of a New Resorbable Dome Device Carlo Tinti, MD, DDS* The biologic principle of guided tis- Francesca Manfrini, MD, DDS sue regeneration (GTR), initially Stefano Parma-Benfenati, MD, DDS, MScD** developed to obtain new attach- ment in various osseous lesions,1–5 The biologic principle of guided tissue regeneration has been expanded to was later expanded to mucogingival mucogingival surgery, using resorbable barrier membranes for the treatment of surgery. Such a clinical application gingival recessions. Space provision is one of the main problems in non–space associated with histologic evidence, making defects, considering the softness of resorbable membranes. In this study, as reported by several authors either we tested the possibility to create and maintain a secluded space using a slow, in animals or in human histologies, long-lasting resorbable suture so that a resorbable dome device could support suggested that GTR procedures may the barrier and immediately become a space-making device. Ten purely provide satisfactory root coverage mucogingival recessions in ten patients were treated. At 12 months, the results along with new connective tissue were evaluated. In five subjects the gingival margin was within 1 mm of the attachment, an increased band of cementoenamel junction, in four patients it was within 2 mm, and in one case a keratinized tissue, and crestal bone residual gingival recession was present (where the membrane became exposed). The mean root coverage obtained was 70.4%, while the mean gain of clinical regeneration in the treatment of 6–17 attachment was 3.3 mm. (Int J Periodontics Restorative Dent 2001;21:31–39.) human facial recession. Recently, several studies have reported the use of resorbable bar- rier membranes for the treatment of gingival recessions.18–23 The clinical outcomes were similar to previous results obtained with a nonre- sorbable membrane.24 A recent case report in humans histologically demonstrated the ability of a resorbable membrane to allow com- plete regeneration of the periodon- **Private Practice, Flero (Brescia), Italy. tal ligament in the coverage of **Department of Periodontology, University of Ferrara Dental School, human gingival recession.25 A variety Italy. of resorbable materials have been **Reprint requests: Dr Carlo Tinti, Via Cavour, 3 Flero (Bs), Italy. introduced into the market and have COPYRIGHT © 2000 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING Volume 21, Number 1, 2001 OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NOPARTOF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH- OUT WRITTEN PERMISSION FROM THE PUBLISHER. 2 recently been reviewed by Green- suture through the membrane kept consisted of three mandibular stein and Caton26 and Gottlow.27 the barrier curvature above the root canines, six maxillary canines, and The critical importance of space surface. In an effort to obtain a more one mandibular left central incisor. provision is one of the main prob- rigid structure, a gold bar (99.9% Following informed consent, each lems in GTR procedures; the goal is pure gold) has been sutured to the patient was given careful instruction to create and maintain a sufficient membrane, especially when a in proper oral hygiene techniques. space where an adequate blood clot mucogingival recession is associated All teeth were vital, and none may be established without any with a bony defect. Recently, a tita- had been subjected to previous sur- interference with blood clot stabi- nium-reinforced e-PTFE membrane gical therapy. The gingival recession lization. This defines the maximum was designed and produced by defect sites were selected based on volume that can be regenerated. It 3i/WL Gore to improve the space the following criteria: (1) a 4-mm or has been clinically proven that the provision and its maintenance, being deeper buccal gingival recession; (2) fewer the residual bony walls, the at the same time easy to handle.12 no occlusal interferences at the more difficult it is to avoid membrane All of the abovementioned clinical treated teeth; (3) an absence of gin- collapse. This is expecially true in the variations, from the e-PTFE suture givitis; and (4) good plaque control. presence of gingival recession, through the membrane to the tita- dehiscences, or fenestration-type nium-reinforced barrier, are not suit- bony defects, where there is no sup- able for the clinical application of a Clinical characterization of port to the barrier. Therefore, in the resorbable membrane because they selected sites case of non–space making defects, all require a surgical reentry; the it is extremely important to create a great advantage of using a re- Supragingival scaling and additional secluded space where the blood clot sorbable device would be com- instruction and reinforcement of is protected from mechanical injuries pletely nullified. proper oral hygiene practices were and from the colonization of cells The purpose of this study was to provided according to individual stemming from the gingival tissues. test the possibility of creating and needs. After at least 1 month of ini- If this space is maintained, only cells maintaining a secluded space using tial preparation and supervised oral deriving from the periodontal liga- a slow, long-lasting, resorbable hygiene, the same clinical protocol ment can repopulate the protected suture so that a resorbable dome was applied to every patient. Each blood clot. device could support the nonrigid patient was scored for gingival index Because of the peculiar bony resorbable barrier and immediately and bleeding index. morphology of the gingival reces- become a space-making device. At baseline prior to surgery, the sion, in the past it was difficult to cre- following measurements were ate and mantain that secluded space recorded at each recession site necessary for a regenerative proce- Method and materials using a PCP UNC 15 periodontal dure. To overcome this clinical prob- probe (Hu-Friedy): (1) gingival reces- lem, some clinical variations have Study population sion, the distance between the been introduced (for review, see Tinti cementoenamel junction (CEJ) and et al10). Root surfaces have been Ten patients (five men and five the gingival margin; and (2) attach- ground using rotary instruments in an women), aged from 27 to 55 years, ment loss, the distance between the effort to obtain a concave shape that with Class I and II gingival recession CEJ and the bottom of the sulcus. allows sufficient space for regenera- according to Miller’s classification28 During the surgical procedure, tive tissue under the membrane. In were selected; they complained dehiscence, the distance between a lateral study, a single expanded about problems of esthetics and/or the CEJ and the bony crest, was polytetrafluoroethylene (e-PTFE) root sensitivity. The tooth population measured. At the 1-year follow-up The International Journal of Periodontics & Restorative Dentistry COPYRIGHT © 2000 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NOPARTOF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH- OUT WRITTEN PERMISSION FROM THE PUBLISHER. 3 Table 1a Preoperative and intraoperative data Plaque Bleeding Gingival Attachment Initial probing Dehiscence Patient Sex Age (y) Index index recession (mm) loss (mm) pocket depth (mm) (mm) 1M270 0 5 6 1 7 2F240 0 4 6 2 7 3M350 0 5 6 1 7 4M280 0 4 5 1 6 5M250 0 4 5 1 6 6M550 0 5 6 1 7 7F280 0 4 5 1 6 8F320 0 4 5 1 7 9F270 0 7 9 2 10 10 F 30 0 0 5 7 2 7 Mean — 31 0 0 4.7 6.2 1.4 7 visit, the following clinical measure- ments were recorded: (1) residual Table 1b Postoperative data gingival recession; and (2) new clin- Residual Gain of Residual ical attachment level, the distance gingival attachment probing pocket Membrane from the CEJ to the bottom of the Patient recession (mm) (mm) depth (mm) exposure sulcus. The measurements were 11 4 1 No rounded to the nearest 1 mm (Table 21 4 1 No 1). All measurements were recorded 32 3 1 No 41 3 1 No at the midfacial buccal level. 51 2 2 No 62 3 1 No 73 1 1 Yes Selected materials 81 3 1 No 92 5 2 No 10 2 3 2 No In all of these clinical cases, Resolut Mean 1.6 3.1 1.3 10% regenerative material (Gore-Tex Periodontal Material, 3i/WL Gore), a bioresorbable matrix barrier, was used in conjuction with a PDS II suture (polidioxanone, Ethicon/ Johnson & Johnson) to create with the latter resorbable material a tem- porary dome device (Figs 1 to 3). hydrolyzed and absorbed in body regenerative material remains essen- The Resolut regenerative material tissue. The polymer components tially unchanged for 4 to 6 weeks is composed of a porous structure of have a history of use as biore- and gradually bioresorbs thereafter.29 synthetic bioresorbable glycolide sorbable sutures, surgical meshes, Its oval shape can be trimmed and polymer fiber and an occlusive mem- and implantable devices, and they shaped to cover in an ideal manner brane of synthetic bioresorbable have been found to be inert, the mucogingival defect (Fig 3). glycolide and lactide copolymer. The nonantigenic, and nonpyrogenic. In The resorbable PDS II suture is Resolut regenerative material is vivo study indicates that Resolut a monofilament prepared with the COPYRIGHT © 2000 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING Volume 21, Number 1, 2001 OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NOPARTOF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITH- OUT WRITTEN PERMISSION FROM THE PUBLISHER. 4 Fig 1 PDS II suture material is positioned Fig 2 Bioresorbable barrier membrane is Fig 3 Mirror image apical to gingival to create a dome effect.