The Presence of "Creeping Attachment" in Human Gingiva
MATERIALS A N D M E T H O D S
The subjects were obtained from the patient popula tion attending the Periodontal Clinic of the School of Dentistry, Medical College of Georgia. The periodontal treatment of the patients contained plans for the surgical correction of localized areas of recession located in the anterior mandibular region of the dentition. A questionnaire completed by the patient did not reveal any general health problems. This sample population contained 11 females and one male with an average age of 33 years and a range of 9 to 59 years.
by
LEE A . BELL* THOMAS A . V A L L U Z Z O †
The gingival margin was followed for periods of time up to 1 year with the use of the standardized photo graphic technique of K i n g and Pennel. A compound or acrylic stent was fabricated in such a manner that a fixed reference rod was located adjacent to the area of the denuded root surface. A Nikhormat intraoral camera with a special adaptor was attached to this stent to obtain reproducible photographs at specific time intervals. The control group consisted of nondenuded root surfaces and healthy gingival tissue on nearby teeth. The photographs of the areas were projected on a view box at magnifica tion of 4.24 X and tracings of the gingiva, teeth and the fixed reference point were obtained on cellulose tracing paper. The tracings of various time points of the same area were superimposed on each other using the fixed reference point for orientation and measurements were obtained. Measurements consisted of the following: (1) the distance from one fixed point on the rod to the most apical point of the gingival defect; (2) the average area of the defect computed by a compensating polar planimeter to the nearest mm. The area was bounded on three sides by the gingival margin and by a line on the fourth side through two fixed points on the tip of the reference rod. The measurements were obtained presurgically, 2 weeks, 1 month, 3 months, 6 months, and 1 year after the surgical procedure.
JERRY J . G A R N I C K ‡
11
BILLY M . PENNEL§ "CREEPING ATTACHMENT" is a phenomena that was de
scribed by Goldman as the "post operative migration of the gingival marginal tissue in a coronal direction over portions of a previously denuded root". The recom mended operative treatment varied and included mucogingival procedures, free gingival grafts, and coronal repositioned flaps. Clinically the migration occurred slowly during a long period of time and apparently resulted in an attachment to the tooth that could not be disturbed with the use of the periodontal probe. "Creep ing attachment" must be differentiated from bridging or surgical attachment where the graft attaches directly to the exposed root surface as a direct result of the surgical procedure. 1
1
2
3
3
Bernimoulin assessed the level of the gingival margin for 1 year after the coronal repositioned periodontal flap. He found a statistical increase of 1.51 mm of the attach ment level during the first month. The level remained constant for the following 11 months. It was not known if the increase occurred as a result of surgical attachment or "creeping attachment". There are many clinical reports in the literature on the affect of free grafts on the gingival margin level. The reports varied but most showed "creeping attach ment" of 0.12 to 3.5 mm during a period of 2 years. Most reports lacked control groups and/or used initial meas urements of gingival margins prior to the surgical pro cedures. Again it was not known from most reports i f the new gingival margin was due to surgical attachment of the graft to the root formed during the treatment procedure or "creeping attachment" which occurred after surgery. The purpose of this study was to determine the extent of "creeping attachment" that can occur after surgical intervention and the rate of coronal movement.
2
The surgical procedure consisted of an autogenous free gingival graft. A partial thickness flap was employed to prepare a periosteal bed adjacent and apical to the area of recession. The masticatory tissue was obtained from the palate and placed over the exposed root surface and adjacent periosteal bed in an attempt to bridge the area of recession. The average thickness of the graft was 0.86 ± 0.34 mm. The graft was sutured in place with two coronal sutures and periodontal pack was not used. Sutures were removed 1 week later. Comparisons of gingival margin level changes were made between the control and the experimental teeth. The student t test for independent means was used at 0.05 level. The average rate of change was computed using the best fit slope (regression lines) and slope.
2, 3 - 1 0
* Resident in Periodontics, present address: 2925 Player St., Bruns wick, Ga 31520. † Resident in Periodontics, present address: 35 Tamarack Ave., Danbury, Conn 06810. ‡ Professor of Periodontics, Director of Graduate Periodontal Stud ies, Medical College of Georgia, Augusta, Ga 30901. § Professor of Periodontics, Chairman of the Department, Medical College of Georgia, Augusta, Ga 30901.
ERRORS OF STUDY
In the standardized photographic technique, a point on the reference bar was used to measure distances from the oral structures to this fixed point. The focal length, magnification and camera position were preset and du513
514
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J. Periodontol. October, 1978
F I G U R E 1. The subject was a 54-year-old female with a negative medical history. An area of recession and impinging frenulum was present at the facial aspect of the mandibular left central incisor (a). Note the presence of the reference bar. The width of root exposure was greater than 3 mm. A free gingival graft was placed over the exposed root (b). Analysis showed greater axial recession at 1 month (c) than the preoperative time point. Apparently the graft over the root surface was lost. In the sequential periods at 3 months (d), 6 months (e) and 1 year (f), "creeping attachment" occurred amounting to 1.06 mm in an axial direction. Photographs (g), (h) and (i) are examples of the control sites. The tooth was a mandibular right first bicuspid and during the period of "creeping attachment", this area showed axial recession of 0.33 mm.
plicated at various longitudinal time intervals with the use of the acrylic or compound stent. The reference rod was part of the stent and camera adaptor. In order to determine the error i n the system, measurements were repeated on the same teeth at three different occasions in three subjects. The area of exposed root surface and distances from a point on the bar to a point on the gingival margin were calculated. The average differences and standard errors were computed to be 0.0489 ± 0.0442 mm for area and 0.0437 ± 0.0483 mm for distance. 11
2
RESULTS
Standardized photographs and data were accumulated on seven subjects for a period of 3 to 6 months. The data from five subjects were incomplete due to loss o f film or teeth, or patient moved to another distant location, and were not included. A 2 week postsurgical photograph on subject one was lost and data was not included. This case was documented from a 1 month postsurgical period to 1 year (Figs. 1 and 2). The data showed a significant amount of "creeping attachment" compared to the control (t = 4.3518—sig at 0.05 level) during a period of 1 year. O n an average it amounted to 0.8900 ± 0.4632 m m compared to loss of
F I G U R E 2. The regression lines and tracings at different time intervals for gingival marginal position for the subject in Figure 1. It was apparent from the tracings that "creeping attachment" did occur in the experimental area ( E ) but not in the control ( C ) . In the graph illustrating the regression lines, the abscissa was the time of observation period in months and the ordinate was the distance from the gingival margin to the reference rod (mm). The regression lines showed high correlation coefficients and slopes of 0.18 mm per month (average rate of movement of gingival margin) for the experimental tooth ( E ) and 0.05 mm per month for the control. After the 1 month postoperative period, the direction of movement of the gingival margin was highly consist ent.
attachment (recession) present i n the control (0.1483 ± 0.3564 mm) (Table 1). When the preoperative time point
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TABLE I. The Data are Presentedfor the Differences From the 2 Week Postsurgical Time Point to the Last Time Point thefor Gingival Margin, and Area of Root Exposure Slope and regression lines and correlation coefficients are included.
Patient
Postsurgical change in
Postsurgical change in
margin of gingiva
root area
E
C
E
mm *1*2*3*4*5*6*7-
(-) 1.22 (-) 0.50 (-) 1.61 (-) 0.92 (—) 0.71 (-)0.38
Average SD
E
(-)3.06 0.00 (-) 3.72 (-)0.73 (-) 2.78 (-) 0.23
(-) 1.95 2.78 6.68 (-) 1.67 (-) 2.78 0.34
0.1483
(-) 1.7533
0.4632
0.3564
1.6169
C
E
mm per month
mm
(-) 0.8900
Student t t = 4.3518 Sig 0.05 *(-)-
C 2
0.14 (-) 0.05 0.82 (-) 0.02 (-) 0.19 0.19
Correlation coefficient
Slope Duration
1 year 1 year 6 months 1 year 3 months 6 months 3 months
(-) 0.18 (-)O.11 (-) 0.08 (-) 0.06 (-) 0.20 (-) 0.13 (-)0.14
0.05 0.013 (-) 0.02 0.07 0.008 (-)0.03 0.05
C r
(-) (-) (-) (-) (-) (-) (-)
0.924 0.987 0.944 0.380 0.996 0.998 0.945
0.853 0.929 (-) 0.420 0.675 (-) 0.176 (-) 0.584 0.759
+5.667 3.6017
1.4394 NS
-creeping attachment (coronal movement of gingival margin) after surgery; (+)--apical movement.
F I G U R E 3. This subject was a 19-year-old female. The area of root exposure and lack of attached gingiva was located at the facial surface of the mandibular right central incisor (a). A split thickness flap was raised at the recipient site with periosteal retention (c) and a free gingival graft was sutured covering the exposed root (b). In the 2 week postoperative period, the graft was lost over the exposed root surface (d). At 3 months, (f) and 1 year (g), "creeping attachment" was attained amounting to 1.49 mm. In the controls recession occurred (0.19 mm) between the preoperative time point (b) and 1 year later (i).
was included, the experimental group had a greater amount of attachment which was on an average 1.2157 ± 0.5712 m m compared to recession i n the control of 0.1243 ± 0.4375 mm. The direction of change of the
gingival margin varied, caused by recession and "creep ing attachment" alternating in successive time points. In only two experimental teeth and one control tooth did the direction of change remain consistent. The estimated
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average rate o f change per month was computed and varied from 0.06 to 0.20 m m per month of "creeping attachment" i n the experimental group and from 0.03 mm per month to 0.07 m m per month of recession i n the control group. Within the scope o f the error o f the method, changes i n control group were not significant but changes o f rate that occurred i n the experimental group were significant. High correlation coefficient were obtained for all teeth i n the experimental group except for subject four (Table I). The changes i n the exposed root area were not statis tically significant between the experimental and control groups. The experimental group showed a consistent loss
F I G U R E 4. The regression lines and tracings of the gingival margin of subject in Figure 3. The tracings showed "creeping attachment" at the experimental area. The lines of "bestfit"had a slope of 0.11 mm per month for the experimental tooth and 0.013 mm per month for the control tooth. The regression line for the experimental tooth (e) demonstrated the average loss of axial exposed root surface.
of exposed surface amounting to an average of 1.7533 ± 0.6169 m m compared to recession of 5.667 ± 3.6017 mm i n the control group. The great variations i n both groups caused the differences not to be statistically sig nificant at the 0.05 level. With this limited number of subjects, "creeping attachment" was more consistent i n the axial direction o f the exposed root compared to the overall area of the root. 2
2
DISCUSSION
In the limited scope of this study, the placement of
F I G U R E 6. The regression lines and tracings of the teeth in Figure 5. The tracings showed only time points where "creeping attachment" occurred. Even though the amount of "creeping attachment" at the end of the year was the greatest (1.61 mm) for all the patients, the slope of the regression lines was small. These differences were due to the great variations in directions that the gingival margin took at various time intervals. It is apparent from this example that the rate of movement (mm per month) shown in Table I must be interpreted with care.
F I G U R E 5. This subject was a 29-year-old female. The area of recession was at the facial of mandibular right lateral incisor (a). The control tooth was the mandibular left cuspid (h). The free gingival graft was placed over the exposed root surface (b). At 2 weeks, further recession amounting to 0.31 mm (c) and a wider zone of attachment was present. During that same time, the control showed root exposure of 0.82 mm (recession). From this latter period to 1 month (d), 2.01 mm of "creeping attachment" was evident. At 3 months (e) 0.85 mm of recession was computed. From 3 months to 6 months (f) and 1 year (g) further attachment occurred. Total amount of "creeping attachment" was 1.6 mm from the 2 week postoperative period.
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and the method of placing the free gingival graft. A l though he demonstrated increased attachment from 1 month to 2 years i n his illustrations, he measured from the presurgical time point and not from the immediate postsurgical point (Fig. 7). Therefore after 2 years the amount of attachment was caused by the surgical pro cedure itself (surgical attachment) and "creeping attach ment" that occurred after the procedure. From the results of this study, and other published reports, it is recommended that free autogenous grafts be placed over the exposed root surface and 4 to 5 mm of periosteal bed apical to the localized gingival reces sion. Apparently surgical attachment may occur, espe cially i f the width of the root defect is less than 3 mm (Fig. 7). However, i f this phenomena does not occur, "creeping attachment" may occur over a period of time to reduce or eliminate the localized area of recession. 2
2, 9
SUMMARY A N D CONCLUSIONS
Standardized photography was used to determine the presence of "creeping attachment" after free autogenous graft procedures on localized areas of root recessions. "Creeping attachment" occurred in all seven experimen tal teeth with an average of 0.89 ± 0.46 m m and a range of 0.38-1.61 mm during a period of 1 year. The results encourage the use of grafts over exposed root surface i n an attempt for gingival coverage. ACKNOWLEDGMENT
FIGURE 7. This subject was a 36-year-old female with recession on the facial surface of mandibular right central incisor (a). Two weeks postoperative surgery, 2.00 mm of coverage of root surface was achieved (b) probably as a result of the surgical procedure. From 2 weeks to 3 months 0.38 mm of more attachment occurred. In this subject, 2.00 mm of surgical attachment and 0.38 mm of "creeping attachment" resulted from the surgical procedure.
free autogenous graft on a mandibular anterior site with localized root exposure caused "creeping attachment" in an axial direction in all experimental subjects in an average amount of 0.8900 ± 0.4632 m m and at a rate which varied from 0.06 to 0.20 m m per month (Figs. 1 to 6). The range of attachment was 0.50 to 1.61 m m during 3 to 12 months after the surgical procedures. "Creeping attachment" did not seem to occur at a con stant progression. Recession may occur at one time point but was followed by "creeping attachment" at successive time points. The control site which had little root expo sure also showed this phenomena but generally tended to recede slightly i f at all. The average amount of "creeping attachment" of 0.89 mm found in this study compared to 0.43 ± 0.28 m m , 0.12 ± 0.91 m m and 0.74 m m published in the litera ture. The variation in amount was probably due to difference in method of the studies. During a period of 2 years, Matter found coverage of the exposed root surface with free autogenous graft varied from 0 to 100% and recession decreased from 0 to 3.5 mm. The amount of coverage was related to the width of the root exposure 8
1 0
2
6
T h e a u t h o r s w i s h to t h a n k D r . K e n M o r s e for h i s assistance i n the statistical a n a l y s i s . REFERENCES 1. G o l d m a n , H . M . , S c h l u g e r , S., F o x , L . , a n d C o h e n , D . W . : Periodontal Therapy, e d 3, p 560. St. L o u i s , C . V . M o s b y C o . 1964. 2. M a t t e r , J . , a n d C i m a s o n i , G . : C r e e p i n g a t t a c h m e n t after free g i n g i v a l grafts. J Periodontol 47: 574, 1976. 3. B e r m i m o u l i n , J . P . , L u s c h e r , B . , a n d M u h l e m a n n , H . R . : C o r o n a l l y r e p o s i t i o n e d p e r i o d o n t a l flap—clinical e v a l u a t i o n after one year. J Clin Periodont 2: 1, 1975. 4. L i v i n g s t o n , H . L . : T o t a l coverage o f m u l t i p l e a n d adjacent d e n u d e d root surfaces w i t h free g i n g i v a l a u t o g r a p h . C a s e re port. J Periodontol 46: 209, 1975. 5. P e n n e l , B . M . , T a b o r , J . C , K i n g , K . D . , T o w n e r , J . D . , Fritz, B . D . , and Higgason, J. D . : Free Masticatory M u c o s a G r a f t . J Periodontol 40: 162, 1969. 6. W a r d , V . J . : A c l i n i c a l assessment o f the use o f the free g i n g i v a l graft for c o r r e c t i n g l o c a l i z e d recession associated w i t h frenal p u l l . J Periodontol 45: 78, 1974. 7. E g l i , U . , V o l l m e r , W . H . , a n d R a t e i t s c h a k , K . H . : F o l l o w u p studies o f free g i n g i v a l grafts. J Clin Periodont 2: 98, 1975. 8. F a g a n , F . : C l i n i c a l c o m p a r i s o n o f the free soft tissue a u t o g r a p h a n d p a r t i a l thickness a p i c a l l y p o s i t i o n e d flap— p r e o p e r a t i v e g i n g i v a l o r m u c o s a l m a r g i n s . J Periodontol 46: 586, 1975. 9. M l i n e k , A . , S m u k l e r , H . , a n d B u c h n e r , A . : T h e use o f free g i n g i v a l grafts for the coverage o f d e n u d e d roots. J Per iodontol 44: 248, 1973. 10. Y u k n a , R . A . , T o w , H . D . , C a r r o l l , P . B . , V e r n i n o , A . R . , a n d B r i g h t , R . W . : E v a l u a t i o n o f the use o f freeze d r i e d s k i n allografts i n the treatment o f h u m a n m u c o g i n g i v a l p r o b lems. J Periodontol 48: 187, 1977. 11. K i n g , H . , a n d P e n n e l , B . : P h o t o - i n t e r p r e t a t i o n . J Perio dontol 38: 684, 1967.
MATERIALS A N D M E T H O D S
The subjects were obtained from the patient popula tion attending the Periodontal Clinic of the School of Dentistry, Medical College of Georgia. The periodontal treatment of the patients contained plans for the surgical correction of localized areas of recession located in the anterior mandibular region of the dentition. A questionnaire completed by the patient did not reveal any general health problems. This sample population contained 11 females and one male with an average age of 33 years and a range of 9 to 59 years.
by
LEE A . BELL* THOMAS A . V A L L U Z Z O †
The gingival margin was followed for periods of time up to 1 year with the use of the standardized photo graphic technique of K i n g and Pennel. A compound or acrylic stent was fabricated in such a manner that a fixed reference rod was located adjacent to the area of the denuded root surface. A Nikhormat intraoral camera with a special adaptor was attached to this stent to obtain reproducible photographs at specific time intervals. The control group consisted of nondenuded root surfaces and healthy gingival tissue on nearby teeth. The photographs of the areas were projected on a view box at magnifica tion of 4.24 X and tracings of the gingiva, teeth and the fixed reference point were obtained on cellulose tracing paper. The tracings of various time points of the same area were superimposed on each other using the fixed reference point for orientation and measurements were obtained. Measurements consisted of the following: (1) the distance from one fixed point on the rod to the most apical point of the gingival defect; (2) the average area of the defect computed by a compensating polar planimeter to the nearest mm. The area was bounded on three sides by the gingival margin and by a line on the fourth side through two fixed points on the tip of the reference rod. The measurements were obtained presurgically, 2 weeks, 1 month, 3 months, 6 months, and 1 year after the surgical procedure.
JERRY J . G A R N I C K ‡
11
BILLY M . PENNEL§ "CREEPING ATTACHMENT" is a phenomena that was de
scribed by Goldman as the "post operative migration of the gingival marginal tissue in a coronal direction over portions of a previously denuded root". The recom mended operative treatment varied and included mucogingival procedures, free gingival grafts, and coronal repositioned flaps. Clinically the migration occurred slowly during a long period of time and apparently resulted in an attachment to the tooth that could not be disturbed with the use of the periodontal probe. "Creep ing attachment" must be differentiated from bridging or surgical attachment where the graft attaches directly to the exposed root surface as a direct result of the surgical procedure. 1
1
2
3
3
Bernimoulin assessed the level of the gingival margin for 1 year after the coronal repositioned periodontal flap. He found a statistical increase of 1.51 mm of the attach ment level during the first month. The level remained constant for the following 11 months. It was not known if the increase occurred as a result of surgical attachment or "creeping attachment". There are many clinical reports in the literature on the affect of free grafts on the gingival margin level. The reports varied but most showed "creeping attach ment" of 0.12 to 3.5 mm during a period of 2 years. Most reports lacked control groups and/or used initial meas urements of gingival margins prior to the surgical pro cedures. Again it was not known from most reports i f the new gingival margin was due to surgical attachment of the graft to the root formed during the treatment procedure or "creeping attachment" which occurred after surgery. The purpose of this study was to determine the extent of "creeping attachment" that can occur after surgical intervention and the rate of coronal movement.
2
The surgical procedure consisted of an autogenous free gingival graft. A partial thickness flap was employed to prepare a periosteal bed adjacent and apical to the area of recession. The masticatory tissue was obtained from the palate and placed over the exposed root surface and adjacent periosteal bed in an attempt to bridge the area of recession. The average thickness of the graft was 0.86 ± 0.34 mm. The graft was sutured in place with two coronal sutures and periodontal pack was not used. Sutures were removed 1 week later. Comparisons of gingival margin level changes were made between the control and the experimental teeth. The student t test for independent means was used at 0.05 level. The average rate of change was computed using the best fit slope (regression lines) and slope.
2, 3 - 1 0
* Resident in Periodontics, present address: 2925 Player St., Bruns wick, Ga 31520. † Resident in Periodontics, present address: 35 Tamarack Ave., Danbury, Conn 06810. ‡ Professor of Periodontics, Director of Graduate Periodontal Stud ies, Medical College of Georgia, Augusta, Ga 30901. § Professor of Periodontics, Chairman of the Department, Medical College of Georgia, Augusta, Ga 30901.
ERRORS OF STUDY
In the standardized photographic technique, a point on the reference bar was used to measure distances from the oral structures to this fixed point. The focal length, magnification and camera position were preset and du513
514
Bell, Valluzzo, Garnick, Pennel
J. Periodontol. October, 1978
F I G U R E 1. The subject was a 54-year-old female with a negative medical history. An area of recession and impinging frenulum was present at the facial aspect of the mandibular left central incisor (a). Note the presence of the reference bar. The width of root exposure was greater than 3 mm. A free gingival graft was placed over the exposed root (b). Analysis showed greater axial recession at 1 month (c) than the preoperative time point. Apparently the graft over the root surface was lost. In the sequential periods at 3 months (d), 6 months (e) and 1 year (f), "creeping attachment" occurred amounting to 1.06 mm in an axial direction. Photographs (g), (h) and (i) are examples of the control sites. The tooth was a mandibular right first bicuspid and during the period of "creeping attachment", this area showed axial recession of 0.33 mm.
plicated at various longitudinal time intervals with the use of the acrylic or compound stent. The reference rod was part of the stent and camera adaptor. In order to determine the error i n the system, measurements were repeated on the same teeth at three different occasions in three subjects. The area of exposed root surface and distances from a point on the bar to a point on the gingival margin were calculated. The average differences and standard errors were computed to be 0.0489 ± 0.0442 mm for area and 0.0437 ± 0.0483 mm for distance. 11
2
RESULTS
Standardized photographs and data were accumulated on seven subjects for a period of 3 to 6 months. The data from five subjects were incomplete due to loss o f film or teeth, or patient moved to another distant location, and were not included. A 2 week postsurgical photograph on subject one was lost and data was not included. This case was documented from a 1 month postsurgical period to 1 year (Figs. 1 and 2). The data showed a significant amount of "creeping attachment" compared to the control (t = 4.3518—sig at 0.05 level) during a period of 1 year. O n an average it amounted to 0.8900 ± 0.4632 m m compared to loss of
F I G U R E 2. The regression lines and tracings at different time intervals for gingival marginal position for the subject in Figure 1. It was apparent from the tracings that "creeping attachment" did occur in the experimental area ( E ) but not in the control ( C ) . In the graph illustrating the regression lines, the abscissa was the time of observation period in months and the ordinate was the distance from the gingival margin to the reference rod (mm). The regression lines showed high correlation coefficients and slopes of 0.18 mm per month (average rate of movement of gingival margin) for the experimental tooth ( E ) and 0.05 mm per month for the control. After the 1 month postoperative period, the direction of movement of the gingival margin was highly consist ent.
attachment (recession) present i n the control (0.1483 ± 0.3564 mm) (Table 1). When the preoperative time point
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515
TABLE I. The Data are Presentedfor the Differences From the 2 Week Postsurgical Time Point to the Last Time Point thefor Gingival Margin, and Area of Root Exposure Slope and regression lines and correlation coefficients are included.
Patient
Postsurgical change in
Postsurgical change in
margin of gingiva
root area
E
C
E
mm *1*2*3*4*5*6*7-
(-) 1.22 (-) 0.50 (-) 1.61 (-) 0.92 (—) 0.71 (-)0.38
Average SD
E
(-)3.06 0.00 (-) 3.72 (-)0.73 (-) 2.78 (-) 0.23
(-) 1.95 2.78 6.68 (-) 1.67 (-) 2.78 0.34
0.1483
(-) 1.7533
0.4632
0.3564
1.6169
C
E
mm per month
mm
(-) 0.8900
Student t t = 4.3518 Sig 0.05 *(-)-
C 2
0.14 (-) 0.05 0.82 (-) 0.02 (-) 0.19 0.19
Correlation coefficient
Slope Duration
1 year 1 year 6 months 1 year 3 months 6 months 3 months
(-) 0.18 (-)O.11 (-) 0.08 (-) 0.06 (-) 0.20 (-) 0.13 (-)0.14
0.05 0.013 (-) 0.02 0.07 0.008 (-)0.03 0.05
C r
(-) (-) (-) (-) (-) (-) (-)
0.924 0.987 0.944 0.380 0.996 0.998 0.945
0.853 0.929 (-) 0.420 0.675 (-) 0.176 (-) 0.584 0.759
+5.667 3.6017
1.4394 NS
-creeping attachment (coronal movement of gingival margin) after surgery; (+)--apical movement.
F I G U R E 3. This subject was a 19-year-old female. The area of root exposure and lack of attached gingiva was located at the facial surface of the mandibular right central incisor (a). A split thickness flap was raised at the recipient site with periosteal retention (c) and a free gingival graft was sutured covering the exposed root (b). In the 2 week postoperative period, the graft was lost over the exposed root surface (d). At 3 months, (f) and 1 year (g), "creeping attachment" was attained amounting to 1.49 mm. In the controls recession occurred (0.19 mm) between the preoperative time point (b) and 1 year later (i).
was included, the experimental group had a greater amount of attachment which was on an average 1.2157 ± 0.5712 m m compared to recession i n the control of 0.1243 ± 0.4375 mm. The direction of change of the
gingival margin varied, caused by recession and "creep ing attachment" alternating in successive time points. In only two experimental teeth and one control tooth did the direction of change remain consistent. The estimated
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average rate o f change per month was computed and varied from 0.06 to 0.20 m m per month of "creeping attachment" i n the experimental group and from 0.03 mm per month to 0.07 m m per month of recession i n the control group. Within the scope o f the error o f the method, changes i n control group were not significant but changes o f rate that occurred i n the experimental group were significant. High correlation coefficient were obtained for all teeth i n the experimental group except for subject four (Table I). The changes i n the exposed root area were not statis tically significant between the experimental and control groups. The experimental group showed a consistent loss
F I G U R E 4. The regression lines and tracings of the gingival margin of subject in Figure 3. The tracings showed "creeping attachment" at the experimental area. The lines of "bestfit"had a slope of 0.11 mm per month for the experimental tooth and 0.013 mm per month for the control tooth. The regression line for the experimental tooth (e) demonstrated the average loss of axial exposed root surface.
of exposed surface amounting to an average of 1.7533 ± 0.6169 m m compared to recession of 5.667 ± 3.6017 mm i n the control group. The great variations i n both groups caused the differences not to be statistically sig nificant at the 0.05 level. With this limited number of subjects, "creeping attachment" was more consistent i n the axial direction o f the exposed root compared to the overall area of the root. 2
2
DISCUSSION
In the limited scope of this study, the placement of
F I G U R E 6. The regression lines and tracings of the teeth in Figure 5. The tracings showed only time points where "creeping attachment" occurred. Even though the amount of "creeping attachment" at the end of the year was the greatest (1.61 mm) for all the patients, the slope of the regression lines was small. These differences were due to the great variations in directions that the gingival margin took at various time intervals. It is apparent from this example that the rate of movement (mm per month) shown in Table I must be interpreted with care.
F I G U R E 5. This subject was a 29-year-old female. The area of recession was at the facial of mandibular right lateral incisor (a). The control tooth was the mandibular left cuspid (h). The free gingival graft was placed over the exposed root surface (b). At 2 weeks, further recession amounting to 0.31 mm (c) and a wider zone of attachment was present. During that same time, the control showed root exposure of 0.82 mm (recession). From this latter period to 1 month (d), 2.01 mm of "creeping attachment" was evident. At 3 months (e) 0.85 mm of recession was computed. From 3 months to 6 months (f) and 1 year (g) further attachment occurred. Total amount of "creeping attachment" was 1.6 mm from the 2 week postoperative period.
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and the method of placing the free gingival graft. A l though he demonstrated increased attachment from 1 month to 2 years i n his illustrations, he measured from the presurgical time point and not from the immediate postsurgical point (Fig. 7). Therefore after 2 years the amount of attachment was caused by the surgical pro cedure itself (surgical attachment) and "creeping attach ment" that occurred after the procedure. From the results of this study, and other published reports, it is recommended that free autogenous grafts be placed over the exposed root surface and 4 to 5 mm of periosteal bed apical to the localized gingival reces sion. Apparently surgical attachment may occur, espe cially i f the width of the root defect is less than 3 mm (Fig. 7). However, i f this phenomena does not occur, "creeping attachment" may occur over a period of time to reduce or eliminate the localized area of recession. 2
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SUMMARY A N D CONCLUSIONS
Standardized photography was used to determine the presence of "creeping attachment" after free autogenous graft procedures on localized areas of root recessions. "Creeping attachment" occurred in all seven experimen tal teeth with an average of 0.89 ± 0.46 m m and a range of 0.38-1.61 mm during a period of 1 year. The results encourage the use of grafts over exposed root surface i n an attempt for gingival coverage. ACKNOWLEDGMENT
FIGURE 7. This subject was a 36-year-old female with recession on the facial surface of mandibular right central incisor (a). Two weeks postoperative surgery, 2.00 mm of coverage of root surface was achieved (b) probably as a result of the surgical procedure. From 2 weeks to 3 months 0.38 mm of more attachment occurred. In this subject, 2.00 mm of surgical attachment and 0.38 mm of "creeping attachment" resulted from the surgical procedure.
free autogenous graft on a mandibular anterior site with localized root exposure caused "creeping attachment" in an axial direction in all experimental subjects in an average amount of 0.8900 ± 0.4632 m m and at a rate which varied from 0.06 to 0.20 m m per month (Figs. 1 to 6). The range of attachment was 0.50 to 1.61 m m during 3 to 12 months after the surgical procedures. "Creeping attachment" did not seem to occur at a con stant progression. Recession may occur at one time point but was followed by "creeping attachment" at successive time points. The control site which had little root expo sure also showed this phenomena but generally tended to recede slightly i f at all. The average amount of "creeping attachment" of 0.89 mm found in this study compared to 0.43 ± 0.28 m m , 0.12 ± 0.91 m m and 0.74 m m published in the litera ture. The variation in amount was probably due to difference in method of the studies. During a period of 2 years, Matter found coverage of the exposed root surface with free autogenous graft varied from 0 to 100% and recession decreased from 0 to 3.5 mm. The amount of coverage was related to the width of the root exposure 8
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T h e a u t h o r s w i s h to t h a n k D r . K e n M o r s e for h i s assistance i n the statistical a n a l y s i s . REFERENCES 1. G o l d m a n , H . M . , S c h l u g e r , S., F o x , L . , a n d C o h e n , D . W . : Periodontal Therapy, e d 3, p 560. St. L o u i s , C . V . M o s b y C o . 1964. 2. M a t t e r , J . , a n d C i m a s o n i , G . : C r e e p i n g a t t a c h m e n t after free g i n g i v a l grafts. J Periodontol 47: 574, 1976. 3. B e r m i m o u l i n , J . P . , L u s c h e r , B . , a n d M u h l e m a n n , H . R . : C o r o n a l l y r e p o s i t i o n e d p e r i o d o n t a l flap—clinical e v a l u a t i o n after one year. J Clin Periodont 2: 1, 1975. 4. L i v i n g s t o n , H . L . : T o t a l coverage o f m u l t i p l e a n d adjacent d e n u d e d root surfaces w i t h free g i n g i v a l a u t o g r a p h . C a s e re port. J Periodontol 46: 209, 1975. 5. P e n n e l , B . M . , T a b o r , J . C , K i n g , K . D . , T o w n e r , J . D . , Fritz, B . D . , and Higgason, J. D . : Free Masticatory M u c o s a G r a f t . J Periodontol 40: 162, 1969. 6. W a r d , V . J . : A c l i n i c a l assessment o f the use o f the free g i n g i v a l graft for c o r r e c t i n g l o c a l i z e d recession associated w i t h frenal p u l l . J Periodontol 45: 78, 1974. 7. E g l i , U . , V o l l m e r , W . H . , a n d R a t e i t s c h a k , K . H . : F o l l o w u p studies o f free g i n g i v a l grafts. J Clin Periodont 2: 98, 1975. 8. F a g a n , F . : C l i n i c a l c o m p a r i s o n o f the free soft tissue a u t o g r a p h a n d p a r t i a l thickness a p i c a l l y p o s i t i o n e d flap— p r e o p e r a t i v e g i n g i v a l o r m u c o s a l m a r g i n s . J Periodontol 46: 586, 1975. 9. M l i n e k , A . , S m u k l e r , H . , a n d B u c h n e r , A . : T h e use o f free g i n g i v a l grafts for the coverage o f d e n u d e d roots. J Per iodontol 44: 248, 1973. 10. Y u k n a , R . A . , T o w , H . D . , C a r r o l l , P . B . , V e r n i n o , A . R . , a n d B r i g h t , R . W . : E v a l u a t i o n o f the use o f freeze d r i e d s k i n allografts i n the treatment o f h u m a n m u c o g i n g i v a l p r o b lems. J Periodontol 48: 187, 1977. 11. K i n g , H . , a n d P e n n e l , B . : P h o t o - i n t e r p r e t a t i o n . J Perio dontol 38: 684, 1967.
