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Revista Facultad de Odontología Universidad de Antioquia

Print version ISSN 0121-246X

Rev Fac Odontol Univ Antioq vol.26 no.2 Medellín Jan./June 2015

 

ORIGINAL ARTICLES DERIVED FROM RESEARCH

 

FACTORS ASSOCIATED WITH THE CORONALLY POSITIONED FLAP OF ONE OR TWO TEETH. A LITERATURE REVIEW

 

Miguel Fernando Vargas del Campo1; Lissette Menestrey Hoyos2

 

1 DDM, Periodontist and Oral Medicine Doctor, Clinical Epidemiologist, Associate Professor, Universidad El Bosque. Member of Unidad de Investigación Epidemiológica Clínica Oral (UNIECLO). E-mail miguelvargas99@yahoo.com
2 DDM, Universidad El Bosque. This paper is part of the requirements for the degree of Periodontics and Oral Medicine at Universidad El Bosque.

 

SUBMITTED: MARCH 5/2013-ACCEPTED: APRIL 22/2014

 

Vargas MF, Menestrey L. Factors associated with the coronally positioned flap of one or two teeth. A literature review. Rev Fac Odontol Univ Antioq 2015; 26(2): 368-397.

 

 


ABSTRACT. INTRODUCTION:marginal tissue recessions produce esthetic problems, tooth sensitivity, root caries, and difficulty to perform proper oral hygiene. There are various periodontal plastic surgery techniques for root coverage. The goal of this literature review is to assess factors associated with the coronally positioned flap technique to cover gingival recessions, bearing in mind that several variables can intervene in the complete coverage of root surface.
METHODS: this was a literature review on the coronally positioned flap technique for coverage of Miller class I and class II recessions of one or two teeth. It included articles published between 2000 and 2012 by searching the PubMed, Ebsco, and Cochrane databases for studies performed in humans, including longitudinal, transverse, and cohort studies, as well as clinical trials and meta-analyses.
RESULTS AND CONCLUSIONS:interdental papilla height, keratinized gingiva width, and gingival thickness are prognostic factors for total root coverage and its long-term stability. Integrity of the cemento-enamel junction is important in diagnosis and success of the technique; moreover, modification of root surface with technical and/or chemical mechanisms is a prerequisite. The coronally advanced flap technique combined with connective tissue, enamel matrix derivative, porcine collagen, or dermal matrix is effective in the treatment of Miller class I and class II gingival recessions, but the one with the greatest predictability is the bilaminar technique with connective tissue.

Key words: gingival recession/surgery, surgical flaps, tooth root/surgery, coronally positioned flap.


 

 

INTRODUCTION

Root coverage in the treatment of marginal tissue recession is one of the most demanding clinical challenges; therefore, being familiar with surgical techniques helps make the right decision for successful treatment. Gingival recession is the result of gingival margin migration from the cemento-enamel junction towards apical, leaving the root surface exposed and leading to esthetic problems, dentin sensitivity, and areas of difficult access for oral hygiene. This makes it one of the most common reasons for periodontal consultation.

Periodontal plastic surgery aims to correct or eliminate anatomical, developmental, or traumatic alterations of the gingiva, which may produce apical displacement of gingival margin and result in root exposure.

Periodontal surgery seeking root coverage takes into account several factors that must be considered when analyzing each case: anatomy and position of teeth, bone density, amount of interproximal bone, type of marginal recession, gingival characteristics, shape of gingival margin, width and depth of recession, and width of keratinized gingiva (whether it is present of absent). Prognosis and predictability of the technique to be used depend on these factors. It is important to be aware of the goal of periodontal surgery in order to determine the procedure that will be used, having the expectations of both clinician and patient in mind.

It is necessary to differentiate between actual and apparent gingival location. Actual location corresponds to the level of epithelial adhesion to tooth, while apparent location corresponds to gingival margin height. The actual location of gingiva, not its apparent location, is the one that determines severity of the recession.1 Recessions may be found in either a single tooth or a group of teeth, or even generalized in the entire mouth.

The cemento-enamel junction serves as a point of reference for definition, diagnosis and treatment of gingival recessions.2



METHODS

Method of location, selection, and evaluation of primary studies

Relevant articles were collected by searching the PubMed, Ebsco, and Cochrane databases. The keywords and MeSH terms included in this search were "Gingival Recession/therapy" ("Surgical flaps" AND gingival recession AND root coverage AND coronally advanced flap), connective tissue graft, tooth root.

This search led to the selection of articles with the following inclusion criteria: articles dealing with root coverage using the coronally advanced flap technique alone and with different materials; clinical diagnosis of flaws in localized recessions, classified as Miller class I and class II; studies performed in humans; longitudinal, cross-sectional, and cohort studies; clinical randomized trials, and meta-analysis.

Classification of gingival recessions and predictability

The literature reports two methods to classify gingival recessions: Sullivan & Atkins',3and Miller's. In 1968, Sullivan and Atkins,3 classified gingival recession in four morphological categories: shallow narrow, shallow wide, deep narrow, and deep wide. On the other hand, Miller,4 in 1985, established the following classification of gingival recessions: Class I: recession of marginal tissue not extending to the mucogingival line, with no loss of bone or soft tissue in the interdental area. Class II: marginal tissue recession apically extending to the mucogingival line with no loss of interproximal tissue. Class III: recession of marginal gingival tissue apically extending to the mucogingival line, with loss of proximal periodontium height in teeth. Class IV: recession of marginal tissue apically extending to the mucogingival line, with loss of proximal periodontium height apically extending to the margin of the recession.

Recession type determines not only the surgical technique to be implemented but also prognosis and success. Mucogingival surgery implies various procedures that help correct defects in morphology, position, and gingiva dimensions. Since these procedures have an aesthetic approach, the term periodontal plastic surgery has been suggested as the most appropriate because root coverage is one of the esthetic procedures that raises the most interest in mucogingival surgery.5

This classification is just a guideline to determine treatment prognosis but other factors should be considered, including vestibular depth, root convexity, the presence of root abrasions, papillae dimensions, noticeable imbalance between bone and dental planes, and the avascular/vascular area proportion, to name just a few. Predictability of complete root coverage is higher in recessions with no loss of interproximal support. Other risk factors contraindicating root coverage techniques include severe bad tooth position—which requires prior orthodontic treatment—, poor oral hygiene habits —which must be corrected before intervention—, and the habit of smoking.6

According to the criteria Miller7 used in his publications, it has been accepted that root coverage is complete when, after the healing period, the gingival margin is located at the cemento-enamel junction, there is clinical insertion in the root, sulcus depth is 2 mm or smaller, and there is no bleeding on probing.

Objectives and purposes of the coronally positioned flap technique

One of the goals of periodontal therapy is to surgically correct recessions, and therefore efficiency and predictability of some techniques are important considerations for patients and clinicians. During the last three decades, clinicians have suggested different surgical techniques to treat gingival recessions. In the 70s and 80s, the goal of gingival recession treatment was to increase the amount of keratinized tissue. The surgical techniques used back then were the pediculated flaps either laterally positioned or toward coronal, and free gingival grafting in cases of inappropriate keratinized tissue. The ultimate purpose is complete root coverage by reinserting the coronal gingival margin to the cemento-enamel junction. However, this variable alone is not sufficient to evaluate the final aesthetic outcome; the ideal result is achieved when complete coverage is associated with both minimum depth at probing and a harmonious and optimal integration of soft tissue and adjacent teeth.

Description of the technique

The coronally displaced flap technique, initially described by Bernimoulin8 and later modified by Liu and Solt,9requires treating localized gingival recession when there is no edentulous donor area adjacent to the recession area. First, a free gingival graft is placed, waiting for a 6-week healing period to later lift a flap and move it towards coronal. By using this technique, Mendes et al,10 achieved a coverage area of 72.17% in cases of extensive recessions. Allen11 and Miller7 achieved 84% root coverage and Harris12proved 98% success in covering Miller class I recessions using coronally displaced flaps. The technique described by Bernimoulin8 excluding the margin of the adjacent tooth; by connecting with an internal bevel incision in the margin and creating new mesial and distal papilla, a mucoperiosteal flap is lifted up to 3 mm below the recession's bone margin, and a mucosal flap is made in order to influence the periosteum to release muscle tension and allow coronal positioning. Epithelium is removed from papillae, coronally positioning the flap. The relaxing incisions are sutured first with single stitches and then with single interpapillae sutures to stabilize the flap. Digital pressure is subsequently made.8 One of the most important variations includes partial dissection at the flap's papilla, with mucoperiosteal dissection up to the mucogingival line and mucous dissection of the mucogingival line towards apical.13

Importance of the cemento-enamel junction

In general, gingival recession is associated with tooth abrasion in the cervical area, making the cementoenamel junction totally or partially disappear, and severe discrepancy may sometimes occur in the area. Furthermore, gingival recession is associated with unpleasant appearance, non-carious cervical lesions (surface abrasion and abfraction), dentin sensitivity, and root caries.14 If the cemento-enamel junction cannot be located, it will be difficult to assess the actual depth of gingival recession and therefore diagnosis will not be accurate.

Another problem can happen during surgery, since a poorly identifiable cemento-enamel junction does not allow easily locating a flap's gingival margin at the time of suturing. The presence of non-carious cervical lesions (abrasion: associated with traumatic brushing, erosion: associated with intrinsic factors such as regurgitation or extrinsic factors such as acidic drinks, and abfraction: associated with large tensile forces) with no integrity of the cementoenamel junction, may complicate the flap's accurate adaptation, leading to collapse of soft tissue and poor stabilization of the graft on the exposed root.

Therefore, the absence of cemento-enamel junction will hinder the accurate assessment of clinical results after root coverage treatment, this is why it is impossible to know if complete root coverage has been actually achieved. In this case, even if complete root coverage has been achieved, the final aesthetic results can be poor because the gingival profile will tend to be flat and parallel to the abrasion's edge.15 Therefore, restoring cementoenamel junction before treatment to achieve root coverage is in some cases indicated.16

Coronally positioned flap and treatment of root surface

In a systematic review in 2007, Cheng et al17 evaluated different techniques for root coverage of Miller class I and class II recessions using coronally positioned flap, coronally positioned flap plus chemical conditioner in roots, and coronally positioned flap plus enamel matrix derivative. They wanted to know if there was any difference between these techniques. All the studies were selected from the Medline database of late 2005. Each study assessed clinical attachment levels, amount of keratinized gingiva, probing depths, size of gingival recession, and percentage of root coverage before and after performing the techniques of coronally positioned flap, coronally positioned flap + chemical conditioning of roots, and coronally positioned flap + enamel matrix derivative.

One of the groups included 7 studies on the coronally positioned flap technique plus enamel matrix derivative, another group had 4 studies on the technique of coronally positioned flap plus root chemical conditioning, and the other group had 7 studies on coronally positioned flap. The results in terms of clinical parameters such as clinical attachment levels, depth of recessions, depth on probing, amount of keratinized gingiva, and percentage of root coverage usingcoronally positioned flap plus enamel matrix derivative showed significant differences compared with the group using chemical conditioning and the coronally positioned flap alone (p < 0.001) in a period of 6 to 12 months. These results suggest that root coverage with coronally positioned flap, with or without chemical conditioning, is less predictable than the technique of coronally positioned flap plus enamel matrix derivative.17

A prerequisite for root coverage is the treatment or modification of exposed root surface by means of different technical and chemical methods. Root scaling is used to remove biofilm, minimizing toxicity in the cement (Bertrand and Dunlap,18, 1988) and smoothing the irregularities and sulci of the exposed root surface (Wennstrom,19 1996), and to remove carious lesions from root (Fourel,20 1982; Miller,21 1983). Intense scaling has also been suggested to reduce root convexity (Holbrook and Ochsenbein,22 1983), improving the possibility of greater reduction of recessions.

Root polishing with a rubber cup may be used in patients with Miller class I and class II gingival recessions associated with traumatic tooth brushing as well as in patients with good oral hygiene, clinically healthy gingiva, and clean root surfaces. Mechanical instrumentation of exposed root surfaces in these patients has been questioned. In a randomized clinical trial in 2009, Zucchelli23 compared root coverage effectiveness by preparing roots with curettes and ultrasonic instrumentation in addition to coronally positioned flap. His study included 11 periodontal and systemic healthy patients with bilateral Miller class I gingival recessions (> or = 3 mm) or (< or = 1 mm), without non-carious cervical lesions. In the experimental group, the exposed roots were treated with curettes, whereas the control group's roots were treated with ultrasound. All the recessions were operated using the coronally advanced flap technique and reassessed 6 months after surgery.

They scored high in terms of root coverage (95.4% in the control group and 84.2% in the experimental group) and complete coverage (82% in the control group and 55% in the experimental group).

Both groups improved clinical attachment levels (3.36 ± 0.92 mm in the control group and 2.90 ± 0.70 mm in the experimental group). In terms of keratinized gingiva improvement, the control group gained 0.55 ± 0.52 mm and the experimental group gained 0.36 ± 0.67 mm. There were no significant differences between groups in the evaluated measurements. The researchers concluded that the procedure of root surface adjustment combined with coronally advanced flap has no significant differences in root coverage. Both groups achieved the coverage goals. They recommended conducting longitudinal studies increasing sample size in order to verify if there are differences.23

In a 14-year longitudinal study in 2011, Pini-Prato2 used coronally advanced flap (CAF) in combination with two different root surface modification methods (root surface polishing versus root scaling) in order to evaluate the long-term results of the coronally advanced flap technique (CAF) in the treatment of gingival recessions. They included 10 patients with similar bilateral recessions (> 2 mm) in a randomized clinical trial design. The exposed root surfaces were subjected to root surface polishing (study group) or root planing (control group). The interaction between treatment and keratinized tissue was significant (p = 0.0035). This study proved that during a long-term follow-up, gingival recessions reappeared in 39% of sites treated with the coronally advanced flap technique (CAF). In conclusion, scaling and planing exposed root surfaces in combination with the coronally advanced flap technique (CAF) proved to have similar results in terms of recession reduction after 14 years. This randomized study, however, has methodological limitations since it included a small sample.24

In 2012, Oliveira and Muncinelli25 made a systematic review to evaluate the effectiveness of combining chemical processes prior to any root coverage technique, searching for significant differences in clinical attachment levels, sulcus depth, and percentage of postoperative root coverage. As inclusion criteria, they used citric acid EDTA, laser therapy like chemical agents, and periodontal techniques such as free gingival graft, coronally flap with sub-epithelial connective tissue and semilunar coronally positioned flap. They concluded that there is no evidence of significant clinical differences in surgical techniques using different chemical agents prior to surgery.

Coronally positioned flap and enamel matrix derivative

In 2005, Spahr et al,26 in their study in the University of ULM in Germany, evaluated the technique of coronally advanced flap combined with and without enamel matrix derivative in a 2-year follow-up. They chose two groups of 30 patients who had gingival recessions. All patients were treated with the coronally advanced flap technique. One group was treated with enamel matrix derivative and the other group with a placebo (propylene glycol alginate). They were evaluated before and after surgery for clinical attachment levels, depth and width of recessions, amount of probing depth, keratinized gingiva, and alveolar bone levels. Two years after surgery, both groups showed coverage of recessions and improvement in clinical attachment levels; recessions decreased 3.6 to 0.8 mm in the group treated with enamel matrix derivative and 3.8 to 1.4 mm in the placebo group. No significant differences were found (p = 0.122). Concerning the other clinical parameters, there were significant differences when comparing the groups, except for recession width (p = 0.027) and probing depth (p = 0.046), noting reduction of recessions in the group treated with enamel matrix derivative. Root coverage remained in 53% during the 2 years in the group with enamel matrix derivative and 23% in the control group, with 47% recession increase in the control group, compared with the group treated with enamel matrix derivative. The researchers concluded that using enamel matrix derivative yields better results in the long term.

The study by Del Pizzo27 in 2005 sought to assess the capacity of enamel matrix derivative in combination with coronally advanced flap (CAF) and its effects in root coverage during a 2-year follow-up. They chose 15 patients with bilateral Miller class I and class II recessions for a total of 30 selected recessions, sorted out in two groups. One group was treated with the technique of coronally advanced flap (CAF) and the other with coronally advanced flap + enamel matrix derivative (CAF+EMD). At baseline, they took into account parameters like depth of recession (R), width of recession (WR), probing depth (PD), clinical attachment level (CAL), and width of keratinized tissue (KT). Measurements were made at 6, 12 and 24 months.

The results showed reduction in depth of recession (R) and increase in keratinized tissue (KT) in both groups. Concerning probing depth, no variations were found. The group treated with CAF+EMD showed recession decrease ranging from 4.07 mm (SD ± 0.59) to 0.47 mm (SD ± 0.74) at 24 months, corresponding to 90.67% coverage, while in the control group recession dropped 4.13 mm (DS ± 0.74) to 0.60 mm (DS ± 0.83), with 86.67% coverage. Both groups experienced decreased recessions as well as increased keratinized gingiva with 73.33% root coverage at 24 months. The researchers concluded that the combination of coronally advanced flap + enamel matrix derivative (CAF+EMD) is an alternative for root coverage. There are no significant differences using the technique with or without enamel matrix derivative in terms of root coverage.

Coronally positioned flap and dermal matrix

In 2007, Shin et al28 conducted a comparative study to establish clinical result differences using the coronally advanced flap technique with acellular dermal matrix (ADM) and with or without enamel matrix derivative (EMD) in the treatment of root coverage. All patients had Miller class I or class II gingival recessions. The coronally advanced flap technique was used. 82 sites in 14 patients with Miller class I or class II recessions > or = 2 mm were treated. 41 sites were treated with coronally advanced flap (CAF) using acellular dermal matrix (ADM) and enamel matrix derivative (EDM). The patients were screened 3 and 6 months after surgery. T test was used for statistical analysis and this yielded the percentages of root coverage, clinical attachment levels, and amount of keratinized gingiva.

The researchers found out that only the group treated with CAF+ADM+EMD showed significant increase in keratinized gingiva, in comparison with the control group in an evaluation made 6 months after surgery (p = 0.006). They concluded that using coronally advanced flap + acellular dermal matrix + enamel matrix derivative (CAF+ADM+EMD) significantly increases keratinized gingiva but it has no significant effects in terms of root coverage and clinical attachment levels.

Coronally positioned flap and porcine collagen matrix

In 2012, Cardaropoli et al29 claimed that coronally advanced flap plus connective tissue graft is the most predictable technique for root coverage. In their prospective randomized trial, they sought to analyze this technique evaluating its behavior with porcine collagen matrix as an alternative. They assessed 18 patients who had 22 single Miller class I and class II recessions. A group chosenat random was treated with coronally advanced flap + porcine collagen matrix (CAF+PCM) and a control group was treated with coronally advanced flap plus connective tissue graft (CAF+CTG). They evaluated probing depth, clinical attachment levels and the amount of keratinized gingiva. These parameters were taken into account at baseline and 12 months later.

The researchers observed that at month 12, recessions in the experimental group averaged 0.23 mm and 0.09 mm in the control group. The percentage of root coverage was 94.32% in the experimental group and 96.97% in the control group. They also observed improved clinical attachment levels of 2.41 mm in the experimental group and 2.95 mm in the control group. Similarly, there was improved keratinized gingiva of 1.23 mm in the experimental group and 1.27 mm in the control group (p < 0.01). Gingival thickness increased from 0.82 to 1.82 mm in the experimental group and from 0.86 to 2.09 mm in the control group (p < 0.01).

They concluded that both treatments met the objective of reducing recessions during 12 months. They observed no significant differences between both procedures, coronally advanced flap + porcine collagen matrix (CAF+PCM) and coronally advanced flap plus connective tissue graft (CAF+CTG). Despite the limitations of their study, a possible alternative is using porcine collagen matrix as a replacement of connective tissue graft in cases where patients lack appropriate tissues to donate.

Coronally positioned flap and connective tissue graft

By placing connective tissue exactly below the coronally positioned flap, surgeons can achieve a more aesthetic and functional result. In the long term, the tissue can keratinize. The surgical procedure is similar to that of the subepithelial connective tissue graft presented by Langer and Langer30 in 1985, with a difference: rather than allowing the connective tissue to be positioned coronally to the flap, the surgeon situates the coronal flap in such a way that it completely covers the grafted connective tissue. Therefore, during initial healing, tissue thickness and color are in excellent conditions.

In comparing coronally positioned flap with and without sub-epithelial graft, there was a significant recession reduction 6 months after surgery (p < 0.05) in lesions 3 mm deep, increasing the width of keratinized gingiva and root coverage. The results of this study show that both techniques are effective in root coverage.31

In 2010, Zucchelli et al32, compared morbidity and root coverage using connective tissue graft and nonepithelialized gingival grafts plus the technique of coronally positioned flap in the coverage of recessions. They did not find differences in terms of postoperative pain by using the two grafting techniques, and both graft types plus coronally positioned flap were effective in the coverage of recessions. They also noticed a greater increase in vestibular soft tissue thickness when using nonepithelialized gingival grafts.

Coronally positioned flap and non-carious cervical lesions

Gingival recessions associated with non-carious cervical lesions can be successfully treated with glass ionomer restorations combined with coronally advanced flap (CAF). This can be done with or without connective tissue graft. In 2008, Santamaría et al,16 in a randomized clinical trial, evaluated the treatment of gingival recessions associated with non-carious cervical lesions using the coronally advanced flap technique (CAF) in one group, and in combination with resin modified glass ionomer (CAF+R) in another group. They randomly chose 19 patients with bilateral Miller class I recessions associated with non-carious cervical lesions. They evaluated bleeding on probing, probing depth, gingival recessions, clinical attachment levels, and dentin sensitivity. Measurements were made at baseline, 45 days, 2, 3, and 6 months after surgery.

They took into account the absence or presence of keratinized gingiva at baseline and six months afterwards, evaluating the height of non-carious cervical lesions in relation to gingival recession, in order to estimate and calculate achieved root coverage. Both groups showed significant improvement in root coverage and clinical attachment levels. The difference between both groups was not significant, taking into account the items to be evaluated 6 months afterwards. The percentage of covered noncarious cervical lesions was 56.14% ± 11.74% with coronally advanced flap plus restoration (CAF+R) and 59.78% ± 11.11% (p < 0.05) with coronally advanced flap without restoration.

The roots and crowns affected by non-carious lesions measured 1.67 ± 0.31 mm and 0.96 ± 0.28 mm, respectively. Coronally advanced flap plus restoration (CAF+R) had 1.59 ± 0.1 mm of root coverage, while coronally advanced flap had 1.01 ± 0.33 mm of coverage. The coronally advanced flap technique (CAF) produced 88.02% ± 19.45% of coverage and the coronally advanced flap technique plus restoration produced 97.48% ± 15.36% (p < 0.05).

The researchers found out that coronally advanced flap plus restoration reduces sensitivity in patients, compared to coronally advanced flap without restoration. They concluded that both groups met the root coverage objectives after 6 months but it is necessary to conduct longitudinal studies in order to evaluate differences in the long term. After a process of healing, there was a successful aesthetic result and gingival health without signs of inflammation.16, 33

The report by Lucchesi et al34 in 2007 also showed successful results when using a surgical technique for root coverage on restored root surfaces.

The 2-year prospective study by Santamaría et al35in 2009 compared two groups, one group of patients treated with the coronally advanced flap technique (CAF) alone and the other one treated with the coronally advanced flap technique (CAF) plus restoration. The results of this study suggest that combining the coronally advanced flap technique (CAF) for root coverage with a restoration using glass ionomer may provide stable results two years later. The statistical analysis between the two groups was not significant (p > 0.05); therefore, the researchers recommended studies with longer observation periods in order to evaluate the success rate and possible complications of this combined technique.

The study by Zucchelli et al36 in 2011 was intended to suggest a technique to treat non-carious cervical lesions (NCCLs) associated with gingival recessions, based on the topographic relationship between maximum root coverage level (MRC) and non-carious cervical lesions (NCCLs). Five treatments were performed in 94 patients with non-carious cervical lesions (NCCLs) and a single gingival recession. The five treatments were: 1) coronally advanced flap (CAF), 2) bilaminar procedure, 3) coronal odontoplasty + restoration + root odontoplasty + coronally advanced flap (CAF), 4) restoration + coronally advanced flap (CAF), and 5) restorative therapy.

The results of this study proved that the diverse procedures provided good aesthetic appearance and an appropriate profile for the majority of non-carious cervical lesions (NCCLs) associated with gingival recessions.

Within the limits of this pilot study, it might be suggested that predetermination of maximum root coverage (MRC) can be used select the treatment of non-carious cervical lesions (NCCLs) associated with gingival recessions. Additionally, the researchers recommended to conduct more studies to evaluate the efficacy of treatments of non-carious cervical lesions (NCCLs) associated with gingival recessions.

Modifications to the coronally positioned flap technique

In 2009, Zucchelli et al37 conducted a comparative study to verify if doing a vertical incision in the technique of coronally advanced flap (CAF) for the covering of recessions caused any significant differences in terms of postoperative esthetic results. They assessed 32 patients who had at least two Miller class I and class II gingival recessions (> or = 1 mm) in the same maxillary quadrant. 16 of these patients with 45 gingival recessions were included in the control group and treated with relaxing vertical incisions plus coronally advanced flap, while patients in the test group were not treated with relaxing incisions plus coronally advanced flap (CAF). Connective tissue graft was placed in patients from both groups.

All patients were evaluated one week after surgery and had periodontal control for a year. There were no significant differences between the two groups, and both improved clinical attachment levels and reduced recessions. The results showed statistically significant improvement in root coverage (CI 0.92-15.33) (p < 0005) and increase of keratinized gingiva. The patients were satisfied with the esthetic results. In conclusion, the technique of coronally advanced flap (CAF) reduces recession depth and does not affect patients' esthetic conditions if relaxing vertical incisions are performed.

In 2007, De Sanctis and Zucchelli13 conducted a study to assess the effectiveness of root coverage using coronally advanced flap for the treatment of Miller class I or class II gingival recessions. In 2000, Zucchelli and De Sanctis38 introduced a modification to the technique of coronally advanced flap to treat multiple recessions. The main goal was to maintain the maximum thickness of soft tissue above root exposure. They suggested that, in terms of root coverage, regardless of the technique used, it is preferable to make a change in the new papilla to obtain satisfactory clinical results. Clinical evaluation was made one and three years after surgery. After one year of surgery, root coverage averaged 3.72 + 1.0 mm (98.6%). Clinical attachment levels improved by 3.65 + 1.10 mm after one year and 3.70 + 1.09 mm after three years. Between baseline and year 3, the average increase in keratinized tissue was 1.78 + 0.90 mm. All changes in keratinized tissue (difference between baseline and year 1, and between baseline and year 3) were statistically significant. This study concluded that the coronally advanced flap technique is effective in multiple gingival recessions in the upper maxilla.39

Similar results are reported by Lafzi et al,40 who used coronally advanced flap in combination with connective tissue graft in different directions, in Miller class I and class II recessions. All of the variables evaluated in their study, such as recession depth, recession width, gingival sulcus depth, clinical attachment level, and percentage of root coverage, showed better results compared with baseline (p < 0.0001), but there were no significant differences among the different connective graft directions (p > 0.05). The researchers concluded that using connective tissue graft with coronally advanced flap is efficient in Miller class I and class II recessions, and the clinical short-term results of this surgical method is not affected by the direction of the connective tissue graft.

In 2011, De Sanctis et al41 stated that coronally advanced flap is an effective technique in the coverage of recessions after 5 years. In their study, coronally advanced flap (CAF) associated with connective tissue graft was used in 10 patients who had at least 2 gingival recessions in lower posterior teeth. A total of 26 recessions were treated. There were no complications or patients desertion. Recessions reduced in depth from 3.40 ± 0.83 mm at baseline to 0.28 ± 0.32 mm in the first year. There were no significant differences in gingival sulcus dimensions. There was increased gingival keratinized width from 0.57 ± 0.46 mm to 3.05 ± 0.71 mm. The reduction in recession depth was observed from the beginning until the end of the study, with 91.2% ± 4.1% of coverage. The researchers concluded that the technique of coronally advanced flap plus connective tissue graft achieves the objective of covering the recessions.

Another useful technique that seeks to create a space with greater vascularity for the connective tissue graft implies partially elevating the flaps to produce less trauma at the receiver site thus creating a vascular bed.42 Mazzocco et al compared the effectiveness of partial and full thick flaps in combination with subepithelial connective tissue graft. They selected 25 patients with Miller class I or class II defects (52 teeth). 25 teeth were randomly allocated in the study group and treated with coronally positioned flap plus subepithelial connective tissue graft, using a flap of full or total thickness, while the control group (27 teeth) was treated with coronally positioned flap associated with a subepithelial connective tissue graft and a flap of partial thickness. Probing depth (PD), length of gingival recession, and width of the keratinized tissue were evaluated at baseline and 6 months after surgery.

Full coverage was 97% in the study group (an average reduction of gingival recession of 2.27 + 1.15 mm) and 95% in the control group (an average reduction of gingival recession (GR) of 1.68 + 0.74 mm). The keratinized tissue gained 0.46 + 1.47 mm in the study group and 0.49 + 1.3 mm in the control group. The probe depth ranged from 1.33 to 1.55 mm in the study group and 1.31 to 1.64 mm in the control group. There were no statistically significant differences between both groups in all the evaluated parameters (p > 0.05). The researchers concluded that partial or total flap lifting did not seem to influence the amount of the keratinized tissue or the percentage of root coverage reached after surgery. They recommended conducting some more extensive studies to confirm the results.

Predictability of the coronally positioned flap technique

In another study, Zucchelli et al43 evaluated a method to determine maximum root coverage predictability by comparing the coronally advanced flap technique with and without subepithelial connective tissue graft. They assessed 50 patients with single and multiple recessions. A periodontist determined maximum root coverage (MRC) by evaluating interdental papilla height. 135 Miller class I, II and III gingival recessions were treated. No statistically significant differences were found among the cases by exact predetermination between gingival recessions belonging to the maxilla or the mandible, and between the gingival defects treated with coronally positioned flap with or without subepithelial connective tissue graft. More underestimation and less overestimation of root coverage were found in the group treated with coronally positioned flap plus subepithelial connective graft compared to the one treated with coronally positioned flap only. The difference was statistically significant (P < 0.01).

The used method was effective in determining the position of soft tissue 90 days after root coverage surgery.

In 2012, Cortellini and Pini-Prato,44 based on scientific-evidenced clinical experiences, claimed that during the last three decades there have been several periodontal techniques for root coverage of one or several teeth. The evidence shows that the coronally advanced flap with connective tissue graft offers the best clinical results in the short and long term, with improved keratinized gingiva and soft tissue stability.

In 2002, Kassab and Cohen,45 in reviewing controlled clinical trials, assessed the root coverage techniques used in gingival recession patients with esthetic problems and sensitivity, finding out optimal coverage results. Several techniques focus on root coverage for the treatment of gingival recessions, namely connective tissue graft with different flap designs, guided tissue regeneration, and the technique of coronally positioned flap, to name just a few. The studies showed that the technique of coronally positioned flap in combination with connective tissue graft has a high rate of root coverage, compared with other techniques. The technique of guided tissue regeneration with absorbable and non-absorbable membrane showed no difference when compared to connective tissue graft because the results were inconclusive. Some of the studies included in this review conclude that the results of guided tissue regeneration have no significant differences if compared with connective tissue graft, while the coronally positioned flap technique has high success rate for root coverage of gingival recessions.

In 2002, the scientific evidence on periodontal plastic surgery had not been evaluated in the treatment of gingival recessions. The objective of this systematic review was to assess the effectiveness of periodontal plastic surgery (PPS) in the treatment of gingival recessions for root coverage.

The revised procedures were: guided tissue regeneration (GTR), connective tissue graft (CTG) and coronally advanced flap (CAF). The information was collected in electronic databases and journals.

The researchers found out that reduction of gingival recessions has limitations with significant benefits in terms of coverage. There are no significant differences when comparing connective tissue graft (CTG) and guided tissue regeneration (GTR), with a weighted mean difference of 0.43 mm (95% IC 0.62-0.23). They found no significant differences between guided tissue regeneration and coronally advanced flap with or without resorbable membranes. The three techniques they compared showed improved clinical attachment levels. They conclude that periodontal plastic surgery was effective in reducing gingival recessions and increasing clinical attachment levels, although no treatment can be considered superior to others. Connective tissue graft was significantly more effective than guided tissue regeneration in the coverage of gingival recessions. They recommend conducting further research to identify factors associated with successful results.46

It is important to evaluate percentages achieved after periodontal plastic surgery, analyze all cases individually, and observe the factors that can influence the percentage of coverage. In 2005, Huang et al47 studied 23 systemically healthy patients aged 43.8 ± 11.9 years who had Miller class I gingival recessions. The studied parameters were: depth and width of recession, periodontal biotype, amount of keratinized gingiva, clinical attachment level, probing depth, bacterial plaque index, and gingival index. The technique they used for root coverage was coronally advanced flap (CAF). Patients were evaluated 2, 3, 12 and 24 months after mucogingival surgery.

The results obtained at baseline were: 2.9 ± 0.4 mm of recession depth, 3.4 ± 0.6 mm of recession width, 2.7 ± 1.3 mm of keratinized gingiva, and 4.5 ± 0.8 mm of clinical attachment level. Six months after surgery, the researchers observed a coverage of 82.3% ± 24.7%, (0.5 ± 0.7 mm), 0.4 ± 0.9 mm of recession width, 3.2 ± 0.9 mm of keratinized gingiva width, and 4.5 ± 0.8 mm of improved clinical attachment levels. They noted that six months after mucogingival surgery there were significant changes in terms of depth and width of recessions and keratinized gingiva gain, with (p < 0.05). 14 patients achieved 100% root coverage. In cases of partial coverage, the percentage of coverage was 54.8% ± 16.8%. Marginal thickness, comparing measurements from the beginning and the end of the study, was 1.2 ± 0.3 mm, and was associated with complete root coverage (p < 0.05). They concluded that coronally advanced flap is a predictable mucogingival technique in root coverage of Miller class I recessions. Marginal thickness is an important factor associated with complete root coverage.

One systematic review showed that coronally advanced flap is a safe technique as well as a predictable procedure for root coverage, and is usually associated with complete coverage of exposed root surface. On the other hand, it has also been said that the technique with connective tissue graft or proteins from enamel matrix derivative, in combination with coronally advanced flap, improves the likelihood of achieving complete root coverage and recession reduction in Miller class I and class II gingival recession.48 Treatment success greatly depends on clinical characteristics, taking into account Miller's classification of gingival recessions. Regardless of the technique to be used in class I and class II, complete root coverage can be achieved, but only a partial coverage can be expected in class III, and there is little chance of success in class IV, where it is not possible to achieve root coating. Since the coating mucosa is elastic, it can be coronally positioned in order to cover the exposed root surface. This flap can be used for root coverage of one or several teeth if there is adequate donor tissue.

In cases of small recessions (2 mm) and minimum vestibular probing depths, the semilunar coronally positioned flap may be an alternative treatment. A prerequisite for using this technique is the presence of 3 mm of keratinized gingiva to avoid fenestrations. Its stability is questionable.49 Although the coronally advanced flap technique offers substantial root coverage (83%, range 60-99%), complete root coverage is not predictable. For this reason, it has been important to identify possible factors influencing the clinical results of coronally advanced flap. Several studies have examined these factors, finding out that initial gingival thickness is one of the most critical factors associated with complete root coverage. It is more likely that a gingival thickness > 1.2 ± 0.3 mm achieves 100% root coverage than a smaller gingival thickness.

The objective of the study was to analyze the relationships between the different variables of the coronally advanced flap technique for root coverage, using Bayesian structural learning. Sixty patients with recessions > or = to 2 mm in the maxilla were analyzed. All the gingival recessions were treated with the coronally advanced flap technique, evaluating factors such as depth of recession and distance between gingival margin and cemento-enamel junction. The distance from the gingival margin in relation to the cemento-enamel junction was taken at baseline as an analytical parameter immediately after surgery and 6 months afterwards. The researchers noted that recession depth after surgery was associated with the location of the apical gingival margin to the cemento-enamel junction, in relation to the initial measurement.

They concluded that using Bayesian statistics allowed assessing the factors that affect complete root coverage. One factor is the location of the gingival margin in relation to the cemento-enamel junction immediately after surgery.50

In 2012, in an 8-year longitudinal study, Pini-Prato et al51 evaluated the results of coronally advanced flap (CAF) in 60 patients with single recessions greater than 2 mm with no loss of interproximal tissue. Their research criteria included keratinized gingiva gain, root coverage, and recession reduction. Three patients abandoned the study. During the 8 years, recession reduction was 2.3 ± 1.1 mm (p < 0.0001). Sites with gingival recessions improved by 53% from 6 months up to the 8 years included in the study (0.5 ± 0.7 mm), (p < 0.0001). The percentage of sites with complete root coverage decreased from 55% after 6 months to 35% after 8 years (p = 0.0047).

They claimed that recession reduction is associated with the amount of keratinized gingiva at the beginning of treatment. The findings by Pini- Prato et al51proved that the coronally advanced flap technique (CAF) is effective in the treatment of gingival recessions and that the amount of keratinized tissue at baseline is a factor of prognosis of recession decrease: the greater the thickness of keratinized tissue, the greater the reduction in recession. They suggested that it is important to conduct a longitudinal long-term follow-up in order to observe the clinical evolution and predict factors associated with recession reduction.

In 2012, Hofmänner et al52 conducted a systematic review and analyzed 16 publications. They found out that predictability of the coronally advanced flap technique and coronally advanced flap plus connective graft in root coverage of Miller class I and class II recessions was 74.6 and 89.3% respectively. At 6 and 12 months postoperative follow-up, they found coverage percentages of 91.5 and 97.27%, respectively. Miller class I recessions showed adequate coverage after 5 years. They concluded that coronally positioned flap with or without connective tissue graft showed long-term stability (5 years).

In 2012, Chambrone et al53 evaluated the individual situation of one patient based on meta-analysis of randomized clinical trials, taking into account data at baseline and during the procedure as well as the involvement of factors influencing the achievement of total recession coverage. Data were collected from Medline, Embase, Cochrane (Cochrane Central Analysis and Register of Controlled Trial), and Cochrane Oral Health Group's Specialized Register, until May 2011. For more than 6 months, they evaluated Miller class I and class II recessions treated for root coverage. They adjusted the different variables by means of logistic regression analysis in order to evaluate possible associations between root coverage data recorded at baseline and at the end.

From the 70 randomized clinical trials included in the meta-analysis, a total of 320 patients and 16 procedures were evaluated, and no randomized clinical trial was included as low-risk. From 602 treated recessions, 310 met the objective of root coverage, with 51.5%. The evaluated root coverage techniques were subepithelial connective tissue grafting (SCTgs), acellular dermal matrix, and enamel matrix derivative (EMD). These were compared against coronally advanced flap (CAF). They noted better results with the aforementioned techniques, in comparison with CAF. To make individual analysis of patient, they adjusted the variables in relation to data obtained at baseline. The greater the initial recession depth, the lower the possibility of achieving root coverage [OR = 0.55] with [95% IC 0.44-0.70]. Analysis of procedures yielded [OR = 0.56] with [95% IC 0.45-0.71].

These data were important to assess possible associations and make individual decisions with the patient. The researchers concluded that subepithelial connective tissue, acellular dermal matrix and enamel matrix derivative provide better results in the root coverage technique, compared with coronally advanced flap (CAF) alone. However, subepithelial connective tissue graft showed greater predictability, although it was not possible to include all the connective tissue graft procedures demonstrating proper interpretation of results.

 

CONCLUSIONS

Once surgery is completed, interdental papilla height, width of keratinized gingiva, gingival thickness, and positioning of the margin coronal to the cementoenamel junction are prognostic factors for complete root coverage and its long-term stability.

Integrity of the cemento-enamel junction is important in the diagnosis and success of the technique to be chosen; also, the modification of root surface with mechanical and chemical procedures is a prerequisite for coverage of gingival recessions.

The coronally advanced flap technique combined with connective tissue, enamel matrix derivative, porcine collagen, or dermal matrix are effective in the treatment of Miller class I and class II gingival recessions, but the one with the greatest predictability in complete root coverage is the bilaminar technique with connective tissue. The flap thickness (total or partial) does not affect the percentage of root coverage.

 

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