QUINTESSENCE INTERNATIONAL PERIODONTOLOGY Angeliki Alexiou Comparison of enamel matrix derivative (Emdogain) and subepithelial connective tissue graft for root coverage in patients with multiple gingival recession defects: A randomized controlled clinical study Angeliki Alexiou, DDS, MSc1/Ioannis Vouros, Dr med dent2/Georgios Menexes, BMath, MA, PhD3/Antonis Konstantinidis, Prof DMD, MSc, PhD4 Objective: The purpose of the present study was to compare list. Data were analyzed within the frame of Mixed Linear the clinical efficiency of enamel matrix derivative (EMD) placed Models with the ANOVA method. Results: There were no sta- under a coronally advanced flap (CAF; test group), to a connec- tistically significantly differences observed between test and tive tissue graft (CTG) placed under a CAF (control group), in control groups in regards with the depth of buccal recession patients with multiple recession defects. Method and with a mean REC of 1.82 mm (CTG) and 1.72 mm (EMD) re- Materials: Twelve patients with multiple Miller’s Class I or II spectively. Similarly the mean PPD value was 1.3 mm for both gingival recessions in contralateral quadrants of the maxilla groups at T6, while the respective value for CAL was 1.7 mm were selected. The primary outcome variable was the change (EMD) and 1.8 mm (CTG). Statistically significant differences in depth of the buccal recession (REC), at 6 months (T6) after were observed only for the WKT, which were 3.0 mm and surgery. The secondary outcome parameters included the clin- 3.6 mm for the test and control groups respectively (P < .001) ical attachment level (CAL), the probing pocket depth (PPD), at T6. Conclusion: The use of EMD in conjunction with a CAF and the width of keratinized gingiva (WKT) apical to the reces- resulted in similar results as compared to the CTG plus CAF. sion. Recession defects were randomly divided to the test or (Quintessence Int 2017;48: 381–389; doi: 10.3290/j.qi.a38058) control group by using a computer-generated randomization Key words: enamel matrix derivative (Emdogain), gingival recessions, root coverage 1 Post-Graduate Student of Periodontology, Dental School, Aristotle University of Mucogingival surgery includes several procedures Thessaloniki, Thessaloniki, Greece; and Private Dental Practice, Thessaloniki, Greece. aimed at correcting defects in morphology, position, 2 Associate Professor, Department of Preventive Dentistry, Periodontology and 1 Implant Biology, Dental School, Aristotle University of Thessaloniki, Thessaloniki, and dimensions of the gingiva. The ultimate goal of Greece. periodontal plastic surgery is the coverage of the 3 Assistant Professor of Biometry, School of Agriculture, Laboratory of Agronomy, Aristotle University of Thessaloniki, Thessaloniki, Greece. exposed root surface when this condition is related to 4 Professor and Chairman, Department of Preventive Dentistry, Periodontology and esthetic problems, dentinal hypersensitivity, root car- Implant Biology, Dental School, Aristotle University of Thessaloniki, Thessaloniki, ies, or whenever it hinders proper plaque removal.2 Greece. Several procedures have been proven successful Correspondence: Dr Angeliki Alexiou, Gr.Palama 7, 54622 Thessaloniki, Greece. Email: [email protected] and predictable for root coverage, such as coronally VOLUME 48 • NUMBER 5 • MAY 2017 381 QUINTESSENCE INTERNATIONAL Alexiou et al positioned flaps, laterally sliding flaps, double papilla CAF (control group), in patients with multiple Miller’s flaps, free gingival grafts, subepithelial connective tis- Class I or II18 buccal gingival recessions in contralateral sue grafts (CTG), guided tissue regeneration, and quadrants of the maxilla. allografts.3-6 Among these procedures, the CTG is con- sidered the “gold standard,” as it has a high predict- METHOD AND MATERIALS ability for root coverage.7 Recent studies8,9 have shown that using a CTG is beneficial when compared to a Twelve patients with at least two Miller’s Class I or II18 coronally advanced flap (CAF) alone, while statistically buccal gingival recessions of ≥ 2 mm depth at teeth in greater recession reduction and probability of com- contralateral quadrants of the maxilla who met the plete root coverage, as well as a greater increase in inclusion/exclusion criteria were recruited among buccal keratinized tissue and better contour evalu- patients seeking treatment in the postgraduate Clinic ation were observed in the CAF when combined with of Periodontology at the Dental School of the Aristotle a CTG. University of Thessaloniki. The participants, ranging in In a randomized controlled clinical trial, Cairo et al10 age from 23 to 60 (mean age 40.1 years), included six demonstrated that even in Miller class III gingival reces- women and six men (Table 1). The study was approved sions with baseline CAL ≤ 3 mm (mesial or distal), there by the Research Ethics Committee of School of Den- is a 57% complete root coverage when CAF with CTG is tistry, Aristotle University of Thessaloniki, Greece (pro- used, against 29% when CAF was used alone. However, tocol number: 21/07-07-2015). this procedure requires a second surgical site that may Heavy smokers (≥ 10 cigarettes per day), patients cause a certain degree of discomfort, increase the risk who were pregnant or lactating, and patients who of postoperative complications, and limit the number presented with systematic disorders and/or under of teeth that can be treated in a single surgery. antibiotic or anti-inflammatory therapy were excluded. Different materials that can be used as a substitute Only defects with identifiable cementoenamel junc- for connective donor tissue are increasingly popular, tion (CEJ) were included in the study. Cases with pros- since they eliminate the disadvantages of the autoge- thetic crowns or restorations and/or the presence of nous donor graft. The enamel matrix derivative (EMD) deep abrasion defects that made the CEJ not identifi- has been evaluated for its potential both in regenera- able were excluded. Situations where no keratinized tion of intrabony defects and in gingival recessions.11-13 tissue apical to the recession defect was detected were A randomized controlled clinical trial14,15 compared the also excluded from the study, taking into account that clinical and histologic efficacy of EMD to subepithelial the use of EMD is not expected to show advantages in connective tissue placed under a CAF in patients with such cases. recession-type defects and there was no significant Before enrolment in the study, all patients com- difference in the percentage of root coverage between pleted a plaque control program.19 Four weeks after the the two groups. The use of EMD is not related with the initial treatment, patients were subjected to a full- disadvantages associated with the CTG, regarding the mouth periodontal examination. The following mea- need of a second surgical approach and the respective surements were performed in the whole dentition: discomfort.14 Also, histologic findings of root coverage • probing pocket depth (PPD) with EMD revealed that EMD enhances periodontal • clinical attachment level (CAL) regeneration.15-17 • tooth mobility The purpose of the present randomized controlled • bleeding scores clinical trial was to compare the clinical efficiency of • plaque scores. EMD placed under a CAF (test group), to the standard The primary outcome variable was the change in technique utilizing a subepithelial CTG placed under a depth of the buccal recession, measured from the CEJ 382 VOLUME 48 • NUMBER 5 • MAY 2017 QUINTESSENCE INTERNATIONAL Alexiou et al periosteal elevator. Any muscular tension was relieved. Table 1 Number of treated recessions and mean Exposed root surfaces were carefully treated with root coverage results gentle root planing. The anatomical interdental N recessions Mean rec papillae were then carefully de-epithelialized. Patient Sex Age (y) CTG EMD CTG EMD In the CAF+CTG-treated site, after measurements 1 Male 43 2 2 2 2.5 were taken from the entire recipient site in order to 2 Female 45 3 3 2.7 1.7 define the palatal donor site incisions, a CTG was har- 3 Female 38 2222vested from the palate as follows: a horizontal incision 4 Male 23 2 2 2.5 3 was placed in the palate 2 to 3 mm from the free gingi- 5 Male 43 2 2 2 2.5 val margin in the premolar to first molar area, and two 6 Male 42 2222 parallel vertical incisions, one superficial and one deep, 7 Female 29 3 3 2.7 2.3 were made and connected mesially and distally. The 8 Male 60 2 2 2 2.5 CTG of thickness 0.5 to 1.0 mm was released at its base 9 Female 45 2 2 2 2 10 Female 34 3 3 2 2 and removed. The graft was designed to provide suffi- 11 Female 36 2 2 2.5 3.5 cient dimensions for covering the exposed root about 12 Male 43 2 2 2.5 2 1 mm beyond the CEJ. Following that, it was stabilized 15 CTG, connective tissue graft; EMD, Emdogain; N recessions, number of recession with resorbable sling suturing 5-0 to the papilla on defects; mean rec, mean recession depth in mm at baseline. either side of the graft and also sutured to the adjacent attached gingiva coronal to the MGJ on either side of the exposed root. Pressure was applied for 2 minutes to the graft after suturing.15 to the most apical extension of the gingival margin, at 6 In the test group, ethylenediaminetetraacetic acid months (T6) after surgery. The secondary outcome par- (EDTA; PrefGel, Straumann) was applied on the root ameters included the PPD, measured from the gingival surface for 2 minutes before rinsing thoroughly with margin to the bottom of the gingival sulcus, the CAL, sterile saline solution.21 EMD (Emdogain, Straumann) defined as the distance from the CEJ to the bottom of was applied immediately on the exposed and condi- the gingival sulcus, and the width of keratinized gingiva tioned root surface after it had been dried.21 The flap (WKT), measured from the most apical extension of the was then coronally sutured using resorbable sling gingival margin to the mucogingival line.