19
Comparison of Two Techniques Attaining Root Coverage A
James B.
Laney, *
Victor G.
for
Saunders,f and Jerry J. Garnick*
study compared the relative success of soft tissue coverage of denuded roots by two surgical procedures: Autogenous free gingival graft (FGG) and a 2-stage coronallypositioned flap (CPF). Eight patients who had bilateral areas of gingival recession were selected. The areas of recession treated were Class I or II according to Miller's classification and caused either an esthetic problem or root sensitivity. The defects were randomly assigned to surgical procedures in each subject. In the FGG, the root surfaces were root planed, conditioned with a saturated citric acid solution, and an adjacent recipient site was prepared surgically. A thick palatal graft was then sutured to the recipient site. In the CPF, an initial autogenous free gingival graft was surgically placed in a recipient site just apical to the root recession. After 1 month of healing, the gingiva was coronally positioned to the level of the CEJ. Standardized photographs were obtained presurgically, at 2 weeks, and at 1 and 3 months. Reduction of areas of exposed root surface and distances from CEJ to gingival margin were computed. Data analysis did not demonstrate a significant difference in success between FGG and CPF at 3 months. Maximum decrease of exposed root surfaces occurred at 2 weeks postsurgically with both procedures and then some recession of each type of graft occurred. The mean distance of the exposed root surfaces decreased from 2.136 mm to 1.301 mm and from 2.187 mm to 1.400 from baseline to 3 months for the FGG and CPF respectively. The This
of root exposure was reduced from 6.692 mm2 to 3.705 mm2 and from 6.949 mm2 3.841 mm2 for the FFG and CPF respectively. Thus, the null hypothesis was accepted in that there were no differences in root surface coverage by CPF and FGG procedures. J Periodontol 1992; 63:19-23. area
to
Key
Words:
Gingival recession/surgery; grafts/surgery; surgical flaps;
tooth root/sur-
gery.
Many patients with gingival
recession are concerned with the appearance of the dentition and root sensitivity. Both of these dental problems can be resolved by surgically increasing gingival root coverage. Reports of surgical root coverage procedures have shown conflicting rates of success and have led to development of a number of innovative surgical procedures in an attempt to achieve consistently better and more predictable results. Grupe and Warren1 described the laterally positioned pedicle flap to cover exposed root surface. In this procedure the adjacent gingiva was raised, moved laterally, and placed on the root surface and adjacent periosteal bed. Guinard and Caffesse2 described certain limitations of the procedure: An insufficient amount of adjacent donor tissue may be present and undesirable gingival recession at the donor site may occur during the healing phase. Modifications of 'Private
practice, Harrisonburg,
VA.
'Private practice, Columbia, SC. *MedicaI College of Georgia, School of Dentistry, dontics, Augusta, GA.
Department of Perio-
the original laterally positioned flap, such as the "edentulous pedicle graft,"3 oblique positioned pedicle graft4 and double papilla graft5 have also been described. Unfortunately, the limitations of the initial design were not improved by these modifications. In 1926 Norberg6 introduced the coronally repositioned flap in an attempt to correct esthetic problems created by recession. Later, Bernimoulin et al.7 described a 2-stage procedure consisting of placement of a free gingival graft at the margin and then coronally positioning the flap incorporating the graft to cover denuded root surfaces. In theory the free graft component would provide an adequate width of keratinized donor tissue and the pedicle flap would reduce recession because of its patent blood supply. Several authors3,8"11 have reported that 57% to 75% of the denuded root surface can be covered utilizing this procedure. Miller12 reported improved results in obtaining root coverage even in areas of deep-wide gingival recession13 using free gingival grafts obtained from the palate. Miller reported 100% root coverage in 88 of 100 treated sites. He
20
J Periodontol 1992
January
TECHNIQUES FOR OBTAINING ROOT COVERAGE
defined 100% root coverage when the marginal gingiva was at the CEJ, probing depths less than 2 mm, and no bleeding on probing was observed at the completion of surgical
healing.
This current study was designed to compare the effectiveness of two surgical procedures: the autogenous free gingival graft12 and the coronally positioned flap14 to achieve increased root surface coverage with gingiva. The length of the study was limited to 3 months to avoid the effect of "creeping attachment" to compound the results. Our null hypothesis was that there was no difference in coverage of exposed root surface between the two surgical methods. MATERIALS AND METHODS Ten subjects were selected from a patient population attending the clinics of the Medical College of Georgia School of Dentistry. The subjects had at least two areas of recession where poor esthetics or root sensitivity were sufficient to indicate the need for surgical root coverage. Patients who smoke more than 10 cigarettes a day were not accepted into the study. The subjects consisted of five males and five females. The subjects agreed to participate in the study and signed an appropriate consent form established by the Human Assurance Committee of the Medical College of Georgia. All patients received instrumentation on all tooth surfaces and plaque control instruction. Areas of recession selected for treatment were classified as Class I or Class II.15 According to Miller,15 100% root coverage should be obtainable in these areas. In Class I, gingival recession did not extend to the mucogingival junction (MGJ) and there was no periodontal attachment loss in the interdental area. In Class II, gingival recession extended to or beyond the MGJ and periodontal loss was not present in the interdental area. In Classes III and IV, gingival recession extended to or beyond the MGJ, and loss of periodontium was present in the interdental area. The latter types of recession were considered by Miller to be less predictable candidates for root coverage. In each patient, one of two teeth with areas of gingival
was assigned randomly to one of the test surgical techniques. The alternate surgical procedure was performed in the other recession area. Standardized photographs were taken pre-surgically, at 2 weeks, and 1 month and 3 months postoperatively using the technique of Pennel et al.4 Briefly,
recession
this method consisted of a 35 mm camera with a flat rod attached to a metal ring placed around the lens. The rod extended to an occlusal stent which was made of denture compound5 and placed on the maxillary or mandibular dentition. A metal reference pin extended from the rod adjacent to the dentition and was used to measure distances from the oral structures to this fixed point. This distance was used to determine if the stent was seated completely into the teeth. The focal length, magnification, and camera position were all preset and duplicated at the specified time inter§Kerr
Impression Compound, Sybron/Kerr, Romulus,
MI.
Figure 1. A photograph of the free gingival graft placed at the facial surface of a maxillary cuspid of subject 8 and obtained at the end of the surgical session. It demonstrates the result of the surgical procedure. vals. The error of this system was computed by Bell, et al.16 to be 0.0489 mm2 for area and 0.0437 mm for distance. The standard errors for distance and area calculated in this study were 0.1637 mm and 0.1025 mm2 respectively. In addition, the probing depth was measured at the mid-facial line of the tooth. The diameter of the periodontal probe was 0.7 mm and applied with a force of approximately 20 grams.
Surgical
Procedures
surgical procedures were performed by one investigator (JG). In the autogenous free gingival graft (FGG) procedure12
All
the root surface was flattened to the CEJ in order to reduce convexity and minimize the mesio-distal dimension of the root. There was no attempt, however, to plane the root within the "bony housing" as described by Holbrook and Ochsenbein.17 The roots were conditioned with saturated citric acid solution (pH 1.7) for 5 minutes by burnishing with a cotton pledgett18 which was changed if contaminated by blood or saliva. The recipient bed was prepared with horizonal incisions at right angles to the interdental papilla at the level of the CEJ creating a butt joint and was extended apically to 3 mm beyond the exposed root. This recipient bed was extended laterally to the line angles of the adjacent teeth and included the interdental papilla. Prior to taking the donor tissue from the palate, a template of the recipient site was made with adhesive tin foil to ensure adequate graft size. After placement of the approximal 2 mm thick free graft, sutures11 were placed in each corner of the graft. Also, sutures external to the graft were placed from the adjacent papilla to the periosteum at the apical extent of the recipient site (Fig. 1). The graft was covered with periodontal dressing* for 7 to 10 days. 'Ethicon, Inc., Somerville, NJ. #Coe Pak, Coe Laboratories, Chicago, IL.
Volume 63 Number 1
LANEY, SAUNDERS, GARNICK
21
Table 1. Exposed Root Surface at Baseline and at 2, 4, and 12 Weeks After 2-Stage Coronally Repositioned Flap and Free Gingival Graft. The Midfacial Distance and Facial Area Were Computed Parameter
Baseline
2 Weeks
4 Weeks
12 Weeks
2.187 0.946 2.136 0.844
0.558 0.196 0.930 1.423
1.136 0.523 1.167 1.07
1.400 0.513 1.301 0.925
6.949 3.134 6.692 3.465
2.900 2.967 2.993 3.508
3.296 3.296 3.730 3.273
3.841 3.841 3.705 3.134
Distance CPF (mm) S.D. FGG (mm2) S.D. Area CPF (mm) S.D. FGG (mm2) S.D.
Figure 2. A photograph of the coronal position graft of the alternate site for patient 8. The flap was moved coronally and sutured at the CEJ. The gingival graft is located at 1. The coronally positioned flap (CPF) procedure consisted of two steps as described by Caffesse and Guinard.14 In the initial procedure, a free palatal mucosal graft was placed on the periosteum of a recipient site prepared just apical to the gingiva at the test site. Four weeks later, the gingiva incorporating the free graft was repositioned coronally. Two vertical incisions bordering the papillae adjacent to the recession were made and connected by an incision along the gingival margin. A full-thickness flap was reflected beyond the mucogingival junction and the periosteum incised at the base of the flap. A recipient bed on each side of the root exposure was prepared and roots were planed. The flap was raised to the CEJ and secured with sutures (Fig. 2). The parameters were measured from the standardized photographs by an examiner who was blind to the surgical technique performed at the site. The photographs were projected and magnified and areas of exposed roots were outlined on tracing paper using the CEJ and gingival margin to designate exposed root borders. Using the traced root outline and correcting for magnification, the distances were measured from the CEJ to the gingival margin at the midfacial of the root and the areas of the exposed root surfaces were obtained. The distance and areas were determined
using a computer-assisted digitizing system.1
The data derived from measurements of the two surgical techniques were compared at baseline, 2 weeks, 1 month, and 3 months postoperatively using descriptive statistics. The data were analyzed using an analysis of variance with repeated measures. Comparisons were made using orthogonal contrasts and F tests.
RESULTS The initial number of subjects for this study was 10; however, due to loss of subjects during the length of the study, the number was reduced to eight, five males and three fe-
'MicroComp M2 Analysis Program, Southern Microinstruments, Inc. Atlanta, GA and Hipad Digitizing Tablet, Bausch & Lomb, Houston, TX.
males. The average age was 37 years with a range of 25 to 56 years. In the FGG the procedure was performed on the right side of the mouth in five subjects and in three subjects on the left side. Of the eight bilateral pairs of sites, the procedures were performed on facial surfaces of eight mandibular cuspids, six mandibular incisors and two maxillary incisors. Table 1 demonstrates the mean amount of exposed root surface at baseline, 2 weeks, 1 month, and 3 months. With the FGG procedures reduction of recession at the end of 3 months was present in seven of eight subjects, compared to six of eight subjects in the CPF group. Patient 3 demonstrated complete loss of the graft in the FGG procedure by the first postoperative visit, which accounted for large differences in the data between the two methods for that subject. The resulting analysis which included these data showed greater variation and less statistical difference. Since this was the only incident of graft loss, the analysis of data was performed both with and without this subject. The data analysis did not demonstrate a significant difference between the FGG and CPF methods for distance or measurements (distance: F 0.027; 0.88; area: F for surface root 0.0005, 0.98) exposure. Because all sites probed 1 mm or less throughout the study, probing depth was not considered in the analysis. The mean distance of the exposed root surface decreased from 2.136 mm to 1.301 mm and from 2.187 mm to 1.400 mm from baseline to 3 months for the FGG and CPF metharea
=
=
=
=
respectively. The reduction from baseline was statistically significant (F 43.50, 0.0001). The reduction was greatest at the 2-week postoperative visit, with some recession occurring from the 2-week to the 3-month visits (F 9.14, 0.007). ods
=
=
=
=
The area of root exposure was reduced from 6.692 mm2 and 6.949 mm2 to 3.705 mm2 and 3.841 mm2 for FGG and CPF techniques respectively from baseline to 3 months postoperatively (F 44.28, 0.0001). The root exsmallest the 2-week area was at visit, with a nonsigposed nificant (F trend toward recession at 1.73, 0.20) the 1- and 3-month visits. One patient showed complete loss of the graft in the FGG method by the first return visit, resulting in unusually large =
=
=
=
22
differences between measurements for the two methods on that subject. The analysis was repeated, excluding the data for this patient. Only one of the statistical conclusions in the study would be changed due to this exclusion: recession in the area measurement occurring from the 2-week to the 3-month visits became significant (F 5.81, 0.027). =
=
DISCUSSION Current reports of success in root coverage vary with different authors. In 1975, Bernimoulin7 reported an average of approximately 75% soft tissue coverage for gingival recessions 1-year postoperatively. In 1978, Caffesse and Guinard14 reported 64% coverage (2.73 mm) at 6 months. Miller15 found that his technique resulted in 100% root coverage in 90% of his patients. The average gain of root coverage per site was 3.79 mm compared to approximately 1 mm in this study. Borghetti and Gordella19 used many of Miller's methods to cover root surface in a study lasting 1 year. They found 85.2% coverage or increase of coverage by 2.59 mm at the end of 1 year. However, at 1 month they found 57.2% or 1.74 mm coverage. After 60 days, creeping attachment; i.e., coronal movement of the gingival margin maintaining attachment to the tooth, increased the coverage by 28% or 0.85 mm. This amount of creeping attachment is similar to the amount found by Bell et al. (0.89 mm).16 In the present study, both therapies achieved approximately 50% soft tissue coverage at 3 months. The discrepancy between earlier investigations of root coverage and the present study can be attributed to several factors. A standardized method of obtaining data was used in the present study compared to non-standardized methods with high clinical error used with other studies. Our study had 8 subjects (16 sites) compared to 14 sites used by Caffesse and Guinard3'20 and 58 patients in Miller's study.15 Furthermore, the present study was 3 months long and, therefore, does not include coverage that may occur eventually by creeping attachment. Since the purpose of this research was to compare the effectiveness of two surgical procedures, the length of the study was purposely set at 3 months to reduce the influence of creeping attachment on the results. However, if creeping attachment of 0.89 mm (28%)16·19 was included in our data, the results are comparable to other reports. In addition, operator experience may also have had an effect in that the procedures were performed by a graduate dental student (JL). However, the student performed multiple procedures before the study was initiated to increase surgical experience. In order to standardize the surgical procedures, the graduate student studied a videotape of Miller performing his method (FGG) on a
J Periodontol 1992
TECHNIQUES FOR OBTAINING ROOT COVERAGE
patient. The techniques
used in the present study differed from Miller12-20-21 in several ways. Miller treated two or more
teeth; in this study, single sites
were treated in order to control variables which may have had an effect on blood supply to the flaps. In addition, different type of suture
January material
was
used in
technique.
our
study compared
to
Miller's
Within the limits of this study it can be concluded that there were no differences in the amount of root coverage obtained by FGG and CPF techniques. In both methods, maximum coverage of the root surfaces by the surgical techniques occurred at 2 weeks followed by gingival recession of the grafts which reached a plateau at 1-month
postoperatively.
Acknowledgments
The authors express their appreciation to Mark S. Litaker, Office of Research Computing and Statistics, who performed the statistical analysis of the data and to Dr. Jefferson F. Hardin, who reviewed the manuscript.
REFERENCES 1. Grupe H, Warren
R. Repair of gingival operation. J Periodontol 1956; 27:92-95.
defects
by
a
sliding flap
2. Guinard EA, Caffesse RG. Treatment of localized gingival recessions. I. Lateral sliding flaps. J Periodontol 1978; 49:351-356. 3. Corn H. Edentulous area pedicle grafts in mucogingival surgery. Periodontics 1964; 2:229-242. 4. Pennel BM, Higgason JD, Towner ED, King KO, Fritz BD, Sadler JF. Oblique rotated îiip. J Periodontol 1965 ; 36:305-309. 5. Cohen DW, Ross SE. The double papilla positioned flap in periodontal therapy. J Periodontol 1968; 39:65-70. 6. Norberg O. Ar en utlakning utan vovnadsfortust otankbar vid kirurgisk behandling av.s.k. alveolar-pyorrhoe. Sven Tandlak, Tidskr 1926; 19:171. 7. Bernimoulin JP, Luscher B, Muhlemann HR. Coronally repositioned periodontal flap. / Clin Periodontol 1975; 2:1-13. 8. Maynard JG. Coronal positioning of a previously placed autogenous gingival graft. J Periodontol 1977; 48:151-155. 9. Matter J. Free gingival graft and coronally repositioned flap. A twoyear follow-up report. / Clin Periodontol 1979; 6:437-442. 10. Tenebaum J, Klewansky P, Roth JJ. Clinical evaluation of gingival recession treated by coronally repositioned flap technique. J Periodontol 1980; 51:686-690. 11. Liu WJL, Solt CW. A surgical procedure for the treatment of localized gingival recession in conjunction with root surface citric acid conditioning. J Periodontol 1980; 51:505-509. 12. Miller PD. Root coverage using the free soft tissue autograft following citric acid application. III. A successful and predictable procedure in areas of deep-wide recession. Int J Periodontics Restorative Dent
1985; 5(2):15-37.
13. Sullivan H, Adkins J. Free autogenous gingival grafts I. Principles of successful grafting. Periodontics 1968; 6:121-129. 14. Caffesse RG, Guinard EA. Treatment of localized gingival recessions. II. Coronally repositioned flap with a free gingival graft. / Periodon-
tol 1978; 49:357-361. 15. Miller PD. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985 ; 5 (2): 9-14. 16. Bell LA, Valluzzo TA, Garnick JJ, Pennel BM. The presence of "creeping attachment" in human gingiva. / Periodontol 1978; 49:513517. 17. Holbrook , Ochsenbein C. Complete coverage of denuded root surface with a one stage gingival graft. Int J Periodontics Restorative Dent 1983; 3(3):8-27. 18. Corley JM, Killoy WJ. Stability of citric acid solutions during a five month period. J Periodontol 1982; 53:390-392. 19. Borghetti A, Gordella JP. Thick gingival autograft for the coverage
Volume 63 Number 1 of gingival recession: A clinical evaluation. Int J Periodontics Restorative Dent 1990; 10:216-229. 20. Miller PD. Root coverage using a free soft tissue autogenous graft following citric acid application. I. Technique. Int J Periodontics Restorative Dent 1982; 2:65-70. 21. Miller PD. Root coverage using a free soft tissue autograft following
LANEY, SAUNDERS, GARNICK
23
citric acid application. II. Treatment of the carious root, lnt J Periodontics Restorative Dent 1983; 3:(5):38-51.
Send reprint requests to: Dr. Jerry J. Garnick, Medical College of Georgia, School of Dentistry, Department of Periodontics, Augusta, GA 30912. Accepted for publication August 12, 1991.
Comparison of Two Techniques Attaining Root Coverage A
James B.
Laney, *
Victor G.
for
Saunders,f and Jerry J. Garnick*
study compared the relative success of soft tissue coverage of denuded roots by two surgical procedures: Autogenous free gingival graft (FGG) and a 2-stage coronallypositioned flap (CPF). Eight patients who had bilateral areas of gingival recession were selected. The areas of recession treated were Class I or II according to Miller's classification and caused either an esthetic problem or root sensitivity. The defects were randomly assigned to surgical procedures in each subject. In the FGG, the root surfaces were root planed, conditioned with a saturated citric acid solution, and an adjacent recipient site was prepared surgically. A thick palatal graft was then sutured to the recipient site. In the CPF, an initial autogenous free gingival graft was surgically placed in a recipient site just apical to the root recession. After 1 month of healing, the gingiva was coronally positioned to the level of the CEJ. Standardized photographs were obtained presurgically, at 2 weeks, and at 1 and 3 months. Reduction of areas of exposed root surface and distances from CEJ to gingival margin were computed. Data analysis did not demonstrate a significant difference in success between FGG and CPF at 3 months. Maximum decrease of exposed root surfaces occurred at 2 weeks postsurgically with both procedures and then some recession of each type of graft occurred. The mean distance of the exposed root surfaces decreased from 2.136 mm to 1.301 mm and from 2.187 mm to 1.400 from baseline to 3 months for the FGG and CPF respectively. The This
of root exposure was reduced from 6.692 mm2 to 3.705 mm2 and from 6.949 mm2 3.841 mm2 for the FFG and CPF respectively. Thus, the null hypothesis was accepted in that there were no differences in root surface coverage by CPF and FGG procedures. J Periodontol 1992; 63:19-23. area
to
Key
Words:
Gingival recession/surgery; grafts/surgery; surgical flaps;
tooth root/sur-
gery.
Many patients with gingival
recession are concerned with the appearance of the dentition and root sensitivity. Both of these dental problems can be resolved by surgically increasing gingival root coverage. Reports of surgical root coverage procedures have shown conflicting rates of success and have led to development of a number of innovative surgical procedures in an attempt to achieve consistently better and more predictable results. Grupe and Warren1 described the laterally positioned pedicle flap to cover exposed root surface. In this procedure the adjacent gingiva was raised, moved laterally, and placed on the root surface and adjacent periosteal bed. Guinard and Caffesse2 described certain limitations of the procedure: An insufficient amount of adjacent donor tissue may be present and undesirable gingival recession at the donor site may occur during the healing phase. Modifications of 'Private
practice, Harrisonburg,
VA.
'Private practice, Columbia, SC. *MedicaI College of Georgia, School of Dentistry, dontics, Augusta, GA.
Department of Perio-
the original laterally positioned flap, such as the "edentulous pedicle graft,"3 oblique positioned pedicle graft4 and double papilla graft5 have also been described. Unfortunately, the limitations of the initial design were not improved by these modifications. In 1926 Norberg6 introduced the coronally repositioned flap in an attempt to correct esthetic problems created by recession. Later, Bernimoulin et al.7 described a 2-stage procedure consisting of placement of a free gingival graft at the margin and then coronally positioning the flap incorporating the graft to cover denuded root surfaces. In theory the free graft component would provide an adequate width of keratinized donor tissue and the pedicle flap would reduce recession because of its patent blood supply. Several authors3,8"11 have reported that 57% to 75% of the denuded root surface can be covered utilizing this procedure. Miller12 reported improved results in obtaining root coverage even in areas of deep-wide gingival recession13 using free gingival grafts obtained from the palate. Miller reported 100% root coverage in 88 of 100 treated sites. He
20
J Periodontol 1992
January
TECHNIQUES FOR OBTAINING ROOT COVERAGE
defined 100% root coverage when the marginal gingiva was at the CEJ, probing depths less than 2 mm, and no bleeding on probing was observed at the completion of surgical
healing.
This current study was designed to compare the effectiveness of two surgical procedures: the autogenous free gingival graft12 and the coronally positioned flap14 to achieve increased root surface coverage with gingiva. The length of the study was limited to 3 months to avoid the effect of "creeping attachment" to compound the results. Our null hypothesis was that there was no difference in coverage of exposed root surface between the two surgical methods. MATERIALS AND METHODS Ten subjects were selected from a patient population attending the clinics of the Medical College of Georgia School of Dentistry. The subjects had at least two areas of recession where poor esthetics or root sensitivity were sufficient to indicate the need for surgical root coverage. Patients who smoke more than 10 cigarettes a day were not accepted into the study. The subjects consisted of five males and five females. The subjects agreed to participate in the study and signed an appropriate consent form established by the Human Assurance Committee of the Medical College of Georgia. All patients received instrumentation on all tooth surfaces and plaque control instruction. Areas of recession selected for treatment were classified as Class I or Class II.15 According to Miller,15 100% root coverage should be obtainable in these areas. In Class I, gingival recession did not extend to the mucogingival junction (MGJ) and there was no periodontal attachment loss in the interdental area. In Class II, gingival recession extended to or beyond the MGJ and periodontal loss was not present in the interdental area. In Classes III and IV, gingival recession extended to or beyond the MGJ, and loss of periodontium was present in the interdental area. The latter types of recession were considered by Miller to be less predictable candidates for root coverage. In each patient, one of two teeth with areas of gingival
was assigned randomly to one of the test surgical techniques. The alternate surgical procedure was performed in the other recession area. Standardized photographs were taken pre-surgically, at 2 weeks, and 1 month and 3 months postoperatively using the technique of Pennel et al.4 Briefly,
recession
this method consisted of a 35 mm camera with a flat rod attached to a metal ring placed around the lens. The rod extended to an occlusal stent which was made of denture compound5 and placed on the maxillary or mandibular dentition. A metal reference pin extended from the rod adjacent to the dentition and was used to measure distances from the oral structures to this fixed point. This distance was used to determine if the stent was seated completely into the teeth. The focal length, magnification, and camera position were all preset and duplicated at the specified time inter§Kerr
Impression Compound, Sybron/Kerr, Romulus,
MI.
Figure 1. A photograph of the free gingival graft placed at the facial surface of a maxillary cuspid of subject 8 and obtained at the end of the surgical session. It demonstrates the result of the surgical procedure. vals. The error of this system was computed by Bell, et al.16 to be 0.0489 mm2 for area and 0.0437 mm for distance. The standard errors for distance and area calculated in this study were 0.1637 mm and 0.1025 mm2 respectively. In addition, the probing depth was measured at the mid-facial line of the tooth. The diameter of the periodontal probe was 0.7 mm and applied with a force of approximately 20 grams.
Surgical
Procedures
surgical procedures were performed by one investigator (JG). In the autogenous free gingival graft (FGG) procedure12
All
the root surface was flattened to the CEJ in order to reduce convexity and minimize the mesio-distal dimension of the root. There was no attempt, however, to plane the root within the "bony housing" as described by Holbrook and Ochsenbein.17 The roots were conditioned with saturated citric acid solution (pH 1.7) for 5 minutes by burnishing with a cotton pledgett18 which was changed if contaminated by blood or saliva. The recipient bed was prepared with horizonal incisions at right angles to the interdental papilla at the level of the CEJ creating a butt joint and was extended apically to 3 mm beyond the exposed root. This recipient bed was extended laterally to the line angles of the adjacent teeth and included the interdental papilla. Prior to taking the donor tissue from the palate, a template of the recipient site was made with adhesive tin foil to ensure adequate graft size. After placement of the approximal 2 mm thick free graft, sutures11 were placed in each corner of the graft. Also, sutures external to the graft were placed from the adjacent papilla to the periosteum at the apical extent of the recipient site (Fig. 1). The graft was covered with periodontal dressing* for 7 to 10 days. 'Ethicon, Inc., Somerville, NJ. #Coe Pak, Coe Laboratories, Chicago, IL.
Volume 63 Number 1
LANEY, SAUNDERS, GARNICK
21
Table 1. Exposed Root Surface at Baseline and at 2, 4, and 12 Weeks After 2-Stage Coronally Repositioned Flap and Free Gingival Graft. The Midfacial Distance and Facial Area Were Computed Parameter
Baseline
2 Weeks
4 Weeks
12 Weeks
2.187 0.946 2.136 0.844
0.558 0.196 0.930 1.423
1.136 0.523 1.167 1.07
1.400 0.513 1.301 0.925
6.949 3.134 6.692 3.465
2.900 2.967 2.993 3.508
3.296 3.296 3.730 3.273
3.841 3.841 3.705 3.134
Distance CPF (mm) S.D. FGG (mm2) S.D. Area CPF (mm) S.D. FGG (mm2) S.D.
Figure 2. A photograph of the coronal position graft of the alternate site for patient 8. The flap was moved coronally and sutured at the CEJ. The gingival graft is located at 1. The coronally positioned flap (CPF) procedure consisted of two steps as described by Caffesse and Guinard.14 In the initial procedure, a free palatal mucosal graft was placed on the periosteum of a recipient site prepared just apical to the gingiva at the test site. Four weeks later, the gingiva incorporating the free graft was repositioned coronally. Two vertical incisions bordering the papillae adjacent to the recession were made and connected by an incision along the gingival margin. A full-thickness flap was reflected beyond the mucogingival junction and the periosteum incised at the base of the flap. A recipient bed on each side of the root exposure was prepared and roots were planed. The flap was raised to the CEJ and secured with sutures (Fig. 2). The parameters were measured from the standardized photographs by an examiner who was blind to the surgical technique performed at the site. The photographs were projected and magnified and areas of exposed roots were outlined on tracing paper using the CEJ and gingival margin to designate exposed root borders. Using the traced root outline and correcting for magnification, the distances were measured from the CEJ to the gingival margin at the midfacial of the root and the areas of the exposed root surfaces were obtained. The distance and areas were determined
using a computer-assisted digitizing system.1
The data derived from measurements of the two surgical techniques were compared at baseline, 2 weeks, 1 month, and 3 months postoperatively using descriptive statistics. The data were analyzed using an analysis of variance with repeated measures. Comparisons were made using orthogonal contrasts and F tests.
RESULTS The initial number of subjects for this study was 10; however, due to loss of subjects during the length of the study, the number was reduced to eight, five males and three fe-
'MicroComp M2 Analysis Program, Southern Microinstruments, Inc. Atlanta, GA and Hipad Digitizing Tablet, Bausch & Lomb, Houston, TX.
males. The average age was 37 years with a range of 25 to 56 years. In the FGG the procedure was performed on the right side of the mouth in five subjects and in three subjects on the left side. Of the eight bilateral pairs of sites, the procedures were performed on facial surfaces of eight mandibular cuspids, six mandibular incisors and two maxillary incisors. Table 1 demonstrates the mean amount of exposed root surface at baseline, 2 weeks, 1 month, and 3 months. With the FGG procedures reduction of recession at the end of 3 months was present in seven of eight subjects, compared to six of eight subjects in the CPF group. Patient 3 demonstrated complete loss of the graft in the FGG procedure by the first postoperative visit, which accounted for large differences in the data between the two methods for that subject. The resulting analysis which included these data showed greater variation and less statistical difference. Since this was the only incident of graft loss, the analysis of data was performed both with and without this subject. The data analysis did not demonstrate a significant difference between the FGG and CPF methods for distance or measurements (distance: F 0.027; 0.88; area: F for surface root 0.0005, 0.98) exposure. Because all sites probed 1 mm or less throughout the study, probing depth was not considered in the analysis. The mean distance of the exposed root surface decreased from 2.136 mm to 1.301 mm and from 2.187 mm to 1.400 mm from baseline to 3 months for the FGG and CPF metharea
=
=
=
=
respectively. The reduction from baseline was statistically significant (F 43.50, 0.0001). The reduction was greatest at the 2-week postoperative visit, with some recession occurring from the 2-week to the 3-month visits (F 9.14, 0.007). ods
=
=
=
=
The area of root exposure was reduced from 6.692 mm2 and 6.949 mm2 to 3.705 mm2 and 3.841 mm2 for FGG and CPF techniques respectively from baseline to 3 months postoperatively (F 44.28, 0.0001). The root exsmallest the 2-week area was at visit, with a nonsigposed nificant (F trend toward recession at 1.73, 0.20) the 1- and 3-month visits. One patient showed complete loss of the graft in the FGG method by the first return visit, resulting in unusually large =
=
=
=
22
differences between measurements for the two methods on that subject. The analysis was repeated, excluding the data for this patient. Only one of the statistical conclusions in the study would be changed due to this exclusion: recession in the area measurement occurring from the 2-week to the 3-month visits became significant (F 5.81, 0.027). =
=
DISCUSSION Current reports of success in root coverage vary with different authors. In 1975, Bernimoulin7 reported an average of approximately 75% soft tissue coverage for gingival recessions 1-year postoperatively. In 1978, Caffesse and Guinard14 reported 64% coverage (2.73 mm) at 6 months. Miller15 found that his technique resulted in 100% root coverage in 90% of his patients. The average gain of root coverage per site was 3.79 mm compared to approximately 1 mm in this study. Borghetti and Gordella19 used many of Miller's methods to cover root surface in a study lasting 1 year. They found 85.2% coverage or increase of coverage by 2.59 mm at the end of 1 year. However, at 1 month they found 57.2% or 1.74 mm coverage. After 60 days, creeping attachment; i.e., coronal movement of the gingival margin maintaining attachment to the tooth, increased the coverage by 28% or 0.85 mm. This amount of creeping attachment is similar to the amount found by Bell et al. (0.89 mm).16 In the present study, both therapies achieved approximately 50% soft tissue coverage at 3 months. The discrepancy between earlier investigations of root coverage and the present study can be attributed to several factors. A standardized method of obtaining data was used in the present study compared to non-standardized methods with high clinical error used with other studies. Our study had 8 subjects (16 sites) compared to 14 sites used by Caffesse and Guinard3'20 and 58 patients in Miller's study.15 Furthermore, the present study was 3 months long and, therefore, does not include coverage that may occur eventually by creeping attachment. Since the purpose of this research was to compare the effectiveness of two surgical procedures, the length of the study was purposely set at 3 months to reduce the influence of creeping attachment on the results. However, if creeping attachment of 0.89 mm (28%)16·19 was included in our data, the results are comparable to other reports. In addition, operator experience may also have had an effect in that the procedures were performed by a graduate dental student (JL). However, the student performed multiple procedures before the study was initiated to increase surgical experience. In order to standardize the surgical procedures, the graduate student studied a videotape of Miller performing his method (FGG) on a
J Periodontol 1992
TECHNIQUES FOR OBTAINING ROOT COVERAGE
patient. The techniques
used in the present study differed from Miller12-20-21 in several ways. Miller treated two or more
teeth; in this study, single sites
were treated in order to control variables which may have had an effect on blood supply to the flaps. In addition, different type of suture
January material
was
used in
technique.
our
study compared
to
Miller's
Within the limits of this study it can be concluded that there were no differences in the amount of root coverage obtained by FGG and CPF techniques. In both methods, maximum coverage of the root surfaces by the surgical techniques occurred at 2 weeks followed by gingival recession of the grafts which reached a plateau at 1-month
postoperatively.
Acknowledgments
The authors express their appreciation to Mark S. Litaker, Office of Research Computing and Statistics, who performed the statistical analysis of the data and to Dr. Jefferson F. Hardin, who reviewed the manuscript.
REFERENCES 1. Grupe H, Warren
R. Repair of gingival operation. J Periodontol 1956; 27:92-95.
defects
by
a
sliding flap
2. Guinard EA, Caffesse RG. Treatment of localized gingival recessions. I. Lateral sliding flaps. J Periodontol 1978; 49:351-356. 3. Corn H. Edentulous area pedicle grafts in mucogingival surgery. Periodontics 1964; 2:229-242. 4. Pennel BM, Higgason JD, Towner ED, King KO, Fritz BD, Sadler JF. Oblique rotated îiip. J Periodontol 1965 ; 36:305-309. 5. Cohen DW, Ross SE. The double papilla positioned flap in periodontal therapy. J Periodontol 1968; 39:65-70. 6. Norberg O. Ar en utlakning utan vovnadsfortust otankbar vid kirurgisk behandling av.s.k. alveolar-pyorrhoe. Sven Tandlak, Tidskr 1926; 19:171. 7. Bernimoulin JP, Luscher B, Muhlemann HR. Coronally repositioned periodontal flap. / Clin Periodontol 1975; 2:1-13. 8. Maynard JG. Coronal positioning of a previously placed autogenous gingival graft. J Periodontol 1977; 48:151-155. 9. Matter J. Free gingival graft and coronally repositioned flap. A twoyear follow-up report. / Clin Periodontol 1979; 6:437-442. 10. Tenebaum J, Klewansky P, Roth JJ. Clinical evaluation of gingival recession treated by coronally repositioned flap technique. J Periodontol 1980; 51:686-690. 11. Liu WJL, Solt CW. A surgical procedure for the treatment of localized gingival recession in conjunction with root surface citric acid conditioning. J Periodontol 1980; 51:505-509. 12. Miller PD. Root coverage using the free soft tissue autograft following citric acid application. III. A successful and predictable procedure in areas of deep-wide recession. Int J Periodontics Restorative Dent
1985; 5(2):15-37.
13. Sullivan H, Adkins J. Free autogenous gingival grafts I. Principles of successful grafting. Periodontics 1968; 6:121-129. 14. Caffesse RG, Guinard EA. Treatment of localized gingival recessions. II. Coronally repositioned flap with a free gingival graft. / Periodon-
tol 1978; 49:357-361. 15. Miller PD. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985 ; 5 (2): 9-14. 16. Bell LA, Valluzzo TA, Garnick JJ, Pennel BM. The presence of "creeping attachment" in human gingiva. / Periodontol 1978; 49:513517. 17. Holbrook , Ochsenbein C. Complete coverage of denuded root surface with a one stage gingival graft. Int J Periodontics Restorative Dent 1983; 3(3):8-27. 18. Corley JM, Killoy WJ. Stability of citric acid solutions during a five month period. J Periodontol 1982; 53:390-392. 19. Borghetti A, Gordella JP. Thick gingival autograft for the coverage
Volume 63 Number 1 of gingival recession: A clinical evaluation. Int J Periodontics Restorative Dent 1990; 10:216-229. 20. Miller PD. Root coverage using a free soft tissue autogenous graft following citric acid application. I. Technique. Int J Periodontics Restorative Dent 1982; 2:65-70. 21. Miller PD. Root coverage using a free soft tissue autograft following
LANEY, SAUNDERS, GARNICK
23
citric acid application. II. Treatment of the carious root, lnt J Periodontics Restorative Dent 1983; 3:(5):38-51.
Send reprint requests to: Dr. Jerry J. Garnick, Medical College of Georgia, School of Dentistry, Department of Periodontics, Augusta, GA 30912. Accepted for publication August 12, 1991.
