AAP Consensus matrix graft provide long-term stable surface conditioning to detoxify and root-coverage results (>24 months). demineralize root surfaces, creating Report All root coverage procedures a more favorable environment promote concomitant significant enhancing root coverage. The Brown In 2015, the American Academy reduction in and of Regeneration clinical attachment level gain. Sub- Wound Healing Workshop issued a consensus report epithelial connective tissue grafting, on root coverage procedures. acellular dermal matrix grafting and Most gingival augmentation Predictable root coverage is possible xenogeneic collagen matrix-based procedures result in formation of a tm for single- and multiple-tooth PDL procedures increased the density of long and recession defects, with subepithelial the underlying connective tissue, but connective tissue attachment with connective tissue graft procedures may not add to the width of keratinized PerioDontaLetter fibers parallel to the root surface. I. Stephen Brown, D.D.S., Summer providing the best root coverage tissue. An additional finding was the Periodontics & Implant outcomes. subepithelial connective tissue graft For Miller Class I and II single- may be more cost effective and Conclusion tooth recession defects, subepithelial provide superior long-term stability. There are many mucogingival From Our Office Diagnosing and Treating Gingival connective tissue graft procedures to Yours.... provide the best outcomes. Results grafting techniques to correct Recession: What To Do, and What Root Preparation recession defects. These procedures may be enhanced by the use of The management of gingival are quite predictable with minimal recession defects using root and platelet Exposed roots may exhibit surface Treatments are Available postoperative trauma, and produce coverage procedures is an derived growth factor (PDGF). There changes, including necrotic satisfactory solutions to the problems important aspect of periodontal is recent evidence that platelet-derived and softened dentin, resulting in the reatment of recession defects presented by gingival recessions. regenerative therapy. The initial phase in managing growth factor and xenogeneic collagen need for mechanical or chemical root is indicated for the prevention Selection of the appropriate Although it seldom results in gingival recession should be matrix may be used as alternatives to biomodification, which can improve procedure, and precise, meticulous tooth loss, tissue recession is Tof root caries, reducing eliminating or correcting etiological autogenous donor tissue. the quality of the root surface and surgical technique, will provide associated with thermal and root hypersensitivity, enhancing enhance the results of root coverage factors. Subepithelial connective tissue successful and highly predictable tactile sensitivity, esthetic esthetics, augmenting keratinized procedures. Once the etiological factors have graft, enamel matrix derivative in results in the treatment of gingival complaints, and a tendency tissue, eliminating inconsistency been managed effectively, gingival conjunction with the coronally Such root preparation may include recessions. toward root caries. of the , and to root planning and/or chemical root advanced flap, and acellular dermal PDL tm The outcome of root coverage enhance plaque control. recession can be overcome or procedures is predictable, esthetic, and, together with the use of guided tissue regeneration, at the forefront of regenerative procedures. This current issue of The PerioDontaLetter reviews how Figures 1 and 2. to treat exposed root surfaces, A tunnel or and the current available surgical pinhole procedures for the coverage of technique can exposed root surfaces. dramatically As always, we welcome your repair severe comments and suggestions. root recession.

Figures 7 and 8. A connective tissue graft with a coronal tunnel access was utilized to cover the exposed roots.

I. Stephen Brown, D.D.S. 220 South 16th Street, Suite 300 • Philadelphia, PA 19102 • (215) 735-3660 I. Stephen Brown, D.D.S. 220 South 16th Street, Suite 300 • Philadelphia, PA 19102 • (215) 735-3660 Class I: Marginal tissue recession that does not extend to the , with no periodontal loss in the interdental area, and the tooth is well-aligned in the arch. With sophisticated and carefully performed treatment, one hundred percent root coverage can usually be anticipated. Class II: Marginal tissue recession Figure 5. A thin biotype combined with Figure 6. A free autogenous gingival graft was that extends to or beyond the inadequate attached gingiva, gingival utilized to repair the defects and create a mucogingival junction, with no inflammation and has led to strong band of keratinized gingiva. periodontal loss in the interdental severe gingival recession. area, and the tooth is well-aligned in Figure 3. Etiologic factors contributing to this gingival recession the arch. One hundred percent begin with thin buccal bone, inadequate attached gingiva, high root coverage can usually be biomaterials and surgical technique, the use of barrier membranes frenum pull on the gingival margin and orthodontic tooth anticipated. The Decision and operator experience all factor in and chemical stimulators such movement in the presence of these factors. Class III: Marginal tissue Not to Treat, to the success of root coverage as enamel matrix derivatives. recession that extends to or beyond to Treat, and procedures. In patients with high cosmetic the mucogingival junction, bone or In addition, published evidence expectations, coronally advanced eliminated with a variety of effective designed partial dentures causing soft tissue loss in the interdental How to Treat on the predictability of various flaps or laterally moved flaps, surgical modalities. Assessing gingival recession around abutment area is present, or there is techniques can guide in the selection assuming adequate keratinized periodontal support, including bone teeth. malpositioning of the teeth. Partial The decision not to treat or to treat of which approach is most likely to tissue, may be the best choice. levels and the height of soft tissue, root coverage can be expected. recession, and the prognosis for be successful. Choosing these procedures is including papilla, are essential to Class IV: Marginal tissue specific sites, depends on the Miller Classification of classification of the defect, patient- beneficial because there is no need obtaining a successful result. recession that extends to or beyond for palatal or other harvest sites. Gingival Recession the mucogingival junction. The loss specific factors, and technical Surgical Procedures considerations. Consequently, post-operative pain The Etiology of of soft tissue and bone in and attendant complications is all Dr. P.D. Miller has classified In the case of root sensitivity, if The ultimate goal of a root the interdental area and/or but eliminated. Gingival Recession gingival recessions to correlate malpositioning of the teeth is so there is no concomitant esthetic coverage procedure is complete treatment prognosis with anatomical severe that root coverage should not complaint, a less invasive treatment coverage of the recession defect, The anatomical factor most features. be attempted. is the local application of chemical with an esthetic appearance related The Tunnel Technique commonly correlated with gingival desensitizing agents, although to the adjacent soft tissues, and recession is a narrow band of long-term resolution is only minimal probing depth following The unique characteristic of keratinized gingiva. Other correlated obtained with grafting. healing. tunneling procedures for root anatomical features are a pre- If hypersensitivity persists or There are three basic surgical coverage, also known as the existing lack of alveolar buccal is associated with unfavorable procedures used in the treatment of supraperiosteal envelope technique, bone, high frenum pull, tooth esthetics, surgical and prosthetics recession defects: is that a tunnel is created keeping the malposition, and gingival can be employed effectively. 1. Free soft-tissue autografts, interdental papillae intact. dimension. Patient-Specific Factors: Choose allografts and xenografts The tunnel starts from the apical Occlusal trauma and plaque- the surgical procedure which is • The approach through a pinhole or induced gingival inflammation may most likely to be successful. • The subepithelial connective coronally through the sulcus. also contribute to gingival recession. Present options to the patient and tissue graft A connective tissue graft, acellular Iatrogenic factors include labial let them choose what seems right to 2. Pedicle soft-tissue autografts dermal matrix graft, or a collagen orthodontic movement which may them. • Coronally positioned flaps membrane is then placed in the result in the loss of the alveolar Patients should understand what • Rotational flap procedures, tunnel. buccal plate and subsequent gingival Figure 4. Multiple factors can contribute to gingival recession. caused the recession and, if clinically such as the laterally sliding The absence of vertical incisions recession; preparations Inadequate plaque control and orthodontic therapy without possible, instructed in the modification flap and others. tends to produce better esthetics and which extend too far subgingivally, adequate attached gingiva can contribute to bone loss and of those contributory factors. 3. Soft-tissue graft procedures in less discomfort. impression techniques involving gingival recession. Technical Considerations: The combination with regenerative gingival retraction, and poorly- experience of the clinician, choice of procedures, which may include

PerioDontaLetter, Summer Class I: Marginal tissue recession that does not extend to the mucogingival junction, with no periodontal loss in the interdental area, and the tooth is well-aligned in the arch. With sophisticated and carefully performed treatment, one hundred percent root coverage can usually be anticipated. Class II: Marginal tissue recession Figure 5. A thin biotype combined with Figure 6. A free autogenous gingival graft was that extends to or beyond the inadequate attached gingiva, gingival utilized to repair the defects and create a mucogingival junction, with no inflammation and occlusal trauma has led to strong band of keratinized gingiva. periodontal loss in the interdental severe gingival recession. area, and the tooth is well-aligned in Figure 3. Etiologic factors contributing to this gingival recession the arch. One hundred percent begin with thin buccal bone, inadequate attached gingiva, high root coverage can usually be biomaterials and surgical technique, the use of barrier membranes frenum pull on the gingival margin and orthodontic tooth anticipated. The Decision and operator experience all factor in and chemical stimulators such movement in the presence of these factors. Class III: Marginal tissue Not to Treat, to the success of root coverage as enamel matrix derivatives. recession that extends to or beyond to Treat, and procedures. In patients with high cosmetic the mucogingival junction, bone or In addition, published evidence expectations, coronally advanced eliminated with a variety of effective designed partial dentures causing soft tissue loss in the interdental How to Treat on the predictability of various flaps or laterally moved flaps, surgical modalities. Assessing gingival recession around abutment area is present, or there is techniques can guide in the selection assuming adequate keratinized periodontal support, including bone teeth. malpositioning of the teeth. Partial The decision not to treat or to treat of which approach is most likely to tissue, may be the best choice. levels and the height of soft tissue, root coverage can be expected. recession, and the prognosis for be successful. Choosing these procedures is including papilla, are essential to Class IV: Marginal tissue specific sites, depends on the Miller Classification of classification of the defect, patient- beneficial because there is no need obtaining a successful result. recession that extends to or beyond for palatal or other harvest sites. Gingival Recession the mucogingival junction. The loss specific factors, and technical Surgical Procedures considerations. Consequently, post-operative pain The Etiology of of soft tissue and bone in and attendant complications is all Dr. P.D. Miller has classified In the case of root sensitivity, if The ultimate goal of a root the interdental area and/or but eliminated. Gingival Recession gingival recessions to correlate malpositioning of the teeth is so there is no concomitant esthetic coverage procedure is complete treatment prognosis with anatomical severe that root coverage should not complaint, a less invasive treatment coverage of the recession defect, The anatomical factor most features. be attempted. is the local application of chemical with an esthetic appearance related The Tunnel Technique commonly correlated with gingival desensitizing agents, although to the adjacent soft tissues, and recession is a narrow band of long-term resolution is only minimal probing depth following The unique characteristic of keratinized gingiva. Other correlated obtained with grafting. healing. tunneling procedures for root anatomical features are a pre- If hypersensitivity persists or There are three basic surgical coverage, also known as the existing lack of alveolar buccal is associated with unfavorable procedures used in the treatment of supraperiosteal envelope technique, bone, high frenum pull, tooth esthetics, surgical and prosthetics recession defects: is that a tunnel is created keeping the malposition, and gingival can be employed effectively. 1. Free soft-tissue autografts, interdental papillae intact. dimension. Patient-Specific Factors: Choose allografts and xenografts The tunnel starts from the apical Occlusal trauma and plaque- the surgical procedure which is • The free gingival graft approach through a pinhole or induced gingival inflammation may most likely to be successful. • The subepithelial connective coronally through the sulcus. also contribute to gingival recession. Present options to the patient and tissue graft A connective tissue graft, acellular Iatrogenic factors include labial let them choose what seems right to 2. Pedicle soft-tissue autografts dermal matrix graft, or a collagen orthodontic movement which may them. • Coronally positioned flaps membrane is then placed in the result in the loss of the alveolar Patients should understand what • Rotational flap procedures, tunnel. buccal plate and subsequent gingival Figure 4. Multiple factors can contribute to gingival recession. caused the recession and, if clinically such as the laterally sliding The absence of vertical incisions recession; crown preparations Inadequate plaque control and orthodontic therapy without possible, instructed in the modification flap and others. tends to produce better esthetics and which extend too far subgingivally, adequate attached gingiva can contribute to bone loss and of those contributory factors. 3. Soft-tissue graft procedures in less discomfort. impression techniques involving gingival recession. Technical Considerations: The combination with regenerative gingival retraction, and poorly- experience of the clinician, choice of procedures, which may include

PerioDontaLetter, Summer AAP Consensus matrix graft provide long-term stable surface conditioning to detoxify and root-coverage results (>24 months). demineralize root surfaces, creating Report All root coverage procedures a more favorable environment promote concomitant significant enhancing root coverage. The Brown In 2015, the American Academy reduction in gingival recession and of Periodontology Regeneration clinical attachment level gain. Sub- Wound Healing Workshop issued a consensus report epithelial connective tissue grafting, on root coverage procedures. acellular dermal matrix grafting and Most gingival augmentation Predictable root coverage is possible xenogeneic collagen matrix-based procedures result in formation of a tm for single-tooth and multiple-tooth PDL procedures increased the density of long junctional epithelium and recession defects, with subepithelial the underlying connective tissue, but connective tissue attachment with connective tissue graft procedures may not add to the width of keratinized PerioDontaLetter fibers parallel to the root surface. I. Stephen Brown, D.D.S., Summer providing the best root coverage tissue. An additional finding was the Periodontics & Implant Dentistry outcomes. subepithelial connective tissue graft For Miller Class I and II single- may be more cost effective and Conclusion tooth recession defects, subepithelial provide superior long-term stability. There are many mucogingival From Our Office Diagnosing and Treating Gingival connective tissue graft procedures to Yours.... provide the best outcomes. Results grafting techniques to correct Recession: What To Do, and What Root Preparation recession defects. These procedures may be enhanced by the use of The management of gingival are quite predictable with minimal recession defects using root enamel matrix derivative and platelet Exposed roots may exhibit surface Treatments are Available postoperative trauma, and produce coverage procedures is an derived growth factor (PDGF). There changes, including necrotic cementum satisfactory solutions to the problems important aspect of periodontal is recent evidence that platelet-derived and softened dentin, resulting in the reatment of recession defects presented by gingival recessions. regenerative therapy. The initial phase in managing growth factor and xenogeneic collagen need for mechanical or chemical root is indicated for the prevention Selection of the appropriate Although it seldom results in gingival recession should be matrix may be used as alternatives to biomodification, which can improve procedure, and precise, meticulous tooth loss, tissue recession is Tof root caries, reducing eliminating or correcting etiological autogenous donor tissue. the quality of the root surface and surgical technique, will provide associated with thermal and root hypersensitivity, enhancing enhance the results of root coverage factors. Subepithelial connective tissue successful and highly predictable tactile sensitivity, esthetic esthetics, augmenting keratinized procedures. Once the etiological factors have graft, enamel matrix derivative in results in the treatment of gingival complaints, and a tendency tissue, eliminating inconsistency been managed effectively, gingival conjunction with the coronally Such root preparation may include recessions. toward root caries. of the gingival margin, and to root planning and/or chemical root advanced flap, and acellular dermal PDL tm The outcome of root coverage enhance plaque control. recession can be overcome or procedures is predictable, esthetic, and, together with the use of guided tissue regeneration, at the forefront of regenerative procedures. This current issue of The PerioDontaLetter reviews how Figures 1 and 2. to treat exposed root surfaces, A tunnel or and the current available surgical pinhole procedures for the coverage of technique can exposed root surfaces. dramatically As always, we welcome your repair severe comments and suggestions. root recession.

Figures 7 and 8. A connective tissue graft with a coronal tunnel access was utilized to cover the exposed roots.

I. Stephen Brown, D.D.S. 220 South 16th Street, Suite 300 • Philadelphia, PA 19102 • (215) 735-3660 I. Stephen Brown, D.D.S. 220 South 16th Street, Suite 300 • Philadelphia, PA 19102 • (215) 735-3660