Periodontics

Simultaneous treatment of multiple, bilateral, deep buccalrecession defects with bioabsorbable barrier membranes:A case report

Filippo Cangini, DDS, MSVRoberto Cornelini, MD. DDS /̂Sebastiano Andreana, DDS. MS=

Gingival recessions are of concern both eslheticaily and lunctionaiiy for the dental patient, Bioabsorbablebarriers were used to simultaneously treat six mucogingival recessions affecting six teeth in both maxillaryquadrants ot a 34-year-old woman. Root exposures ranging trom 4 to 6 mm were successfully treated;complete root coverage was obtained at all treated sites. Follow-up visits up to 18 months revealed thestability of the clinical outcome, confirming the efficacy of the procedure. (Quintessence Int 2003:34:15-18)

Key words: bioabsorbable membrane, gingival recession, guided tissue regeneration

Localized and generalized gingiva! recession, de-fined as the displacement of gingival margin apical

to the cementoenamel junction of one or multipleteeth,' is a common finding among patients with incip-ient to advanced periodontai disease as well as in pa-fients without periodontai disease and good oral hy-giene. Several factors have been suggested tocontribute to the development of gingival recession,including mechanical trauma, mainly as a result of im-proper or aggressive toothhrushing technique; local-ized chronic inflammation arising from localizedplaque accumulation; and generalized destructive pe-riodontai disease.

Indications for the treatment of gingival recessioninclude the management of dentinal sensitivity, the pa-fient's esthetic concerns, the prevention of root caries

Clinical Instructor, Penodonlal Disease Reseafch Cenler, Départirent otOral Biology, State University of New York at Buffalo, Sctiool of DenialMedicine, Buffalo, New York,

^Pfofessore a Coniratlo, Department of Restorative Dentistry, University ofChieti, School of Dentistry, Cfiieti, Italy; Private Practice, Rimini, Italy.

K;iinical Assistant Professor, Departments of Endodontology andPeriodentology and Oral and Maxillofacral Surgery, State University otNew York at Buffalo, Sctiool of Dental Medicine, Butfalo, New York.

Reprint requests: Dr Sebastiano Andreana, Departments oíBidodontology and Periodontology. State University of New York at Bijftalo,Sctiool of Dental Medicine, 250 Squire Hall, 3435 Main Street, Buffalo,N e w Y j * 14214. E-maii: andreangacsu.buffalo.edu

and cervical abrasion, and the restorafion of a physio-logic mucogingival complex that allows easy and ef-fective plaque removal. A variety of periodontai plasticsurgery techniques have been proposed for the correc-tion of gingival recessions, and these have achievedpositive, although often variable, results.-

Among otbers, guided tissue regeneration (GTR)procedures have been proposed to promote root cov-erage and formation of new connective tissue attach-ment to denuded root surfaces. Guided tissue regener-ation bas been tested in several clinical studies ofperiodontai estbetic surgery with encotiraging results.Nonresorbable membranes as well as bioabsorbablemembranes bave been proven to acbieve similar re-sults in terms of root coverage, gain in clinical attach-ment, and increase in the width of keratinized tis-sue.̂ "̂ Bioabsorbable membranes have been reportedto be preferred by patients who received both proce-dures as part of a split-mouth study design."

The present case report describes the application ofGTR principles and bioabsorbable membranes for tbetreatment of multiple bilateral, deep recession defects.

CASE REPORT

Tbe patient was a 34-year-old woman, in good generalhealtb, who presented generalized gingival recessionson aU maxillary teeth. The recessions were the result

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Cangini étal

F¡g1 Recessions in the maxillary arch orior Fig 2 Periodontai defects in the maxillary Fig 3 Periodontai delects in the maxiliaryto surgery. right arch belore surgery. let arch belore surgery.

Fig 4 Extent cf the recessions in the maxil- Fig 5 Membranes applied to Ihe left ca- Fig 6 Flap coronally repositioned and su-iary left arch, visible after the flap was raised, nine, second premolar, and first molar. tured in piace.

of traumatic toothbrushing, characterized by incorrectbrushing technique and a bard toothbrush. The depthof tbe recessions ranged from 4 mm (molars) to 7 mm(canines). The patient's chief complaints were general-ized dentinal sensitivity and her estbetic concern thatber teeth were "getting longer and longer" (Figs 1 to3). Sbe had excellent oral hygiene and was very moti-vated to undergo GTR therapy in an attempt to covertbe exposed roots and regenerate part of tbe lostperiodontai tissues.

After informed consent was obtained, it was de-cided to simultaneously treat tbe defects on tbe rightcanine, second premolar, and first molar and on tbeleft canine, second premolar, and first molar (Patient'sleft and rigbt first premolars bad been extracted sev-eral years prior for ortbodontic reasons). Bioab-sorbable membranes (polylactic acid softened witb cit-ric acid ester [PLACA]) would be used in tbeprocedure. None of the areas baving recession bad aprobing depth deeper than 2 mm at any site. Also, awide band of keratinized attached gingiva was adja-cent to the recessions,

Tbe surgical procedure was identical at botb sides.After loca! anesthesia was administered (xylocaine 2%,1:100.000), gentle mecbanical instrumentation of tbeexposed roots was performed with Gracey curettes andpolisbing rubber cups. Because tbe cause of tbe reces-sion defects was very likely to be patient's diligent but

aggressive oral bygiene procedures, no abundant in-fected cementum and endotoxins were expected to bepresent. Tberefore, no extensive root preparation wasdeemed necessary, in accord witb Pini Prato et al.̂

Intrasulcular incisions were made on tbe buccal as-pect of tbe involved teeth, extending, on each side of thearch, from tbe mesial aspect of tbe canine to tbe distalaspect of tbe molar, wbere vertical releasing incisionswere placed. A large full-thickness flap was raised up to3 to 4 mm beyond tbe bone crest; After incision of tbeperiosteum, the flap was continued as a partial-thick-ness flap in tbe vestibule until it was possible to coro-nally advance it to cover tbe cementoenamel junctionsof tbe teeth witbout any tension (Fig 4). After tbe flapswere raised, clinical aftacbment loss ranging from 5 mm(premolars) to 7 mm (molars and canines) was evident.

Tbe Guidor PLACA barrier membranes (Guidor),one per tootb, were appropriately trimmed and placedto cover the exposed roots and tbe surrounding bonefor 3 to 4 mm. Six membranes were used (Fig 5). Tbemembranes were tightly sutured at tbe level of the ce-mentoenamel junction witb the preplaced resorbableligatures. Tbe naps were tben coronally advanced tocompletely cover tbe barrier membranes and stabi-lized, free of tension, witb interrupted sutures (Fig 6),

Tbe patient was prescribed amoxicillin, 500 mgevery 8 hours, for 5 days, starting 2 hours before tbesurgery (Amoxil, SmithKline Beecbam), ibuprofen,

16 Volume 34, Number 1, 2003

• Cangini el al

Fig 7 Healing at 24 weeks around the lefl Fig 8 Healing at 24 weeks around [he (ight Fig 9 Excellent clinical oulcome 18 momfiscanine, second premolar, and first molar. canine, second premolar and first molar. after surgery.

400 mg every 6 hours, for 3 days (Advil, WhitehaU-Robins), and 0,12''.o chiorhexidine gluconate rinse,twice daily for 2 weeks (PerioGard, Colgate), The pa-tient was instructed to completely avoid hrushing andttossing In the surgical areas for 2 weeks and to per-form a gentle roll-stroke technique afterward.

Sutures were removed after 2 weeks, and the pa-fient was reevaluated at 1. 2, 4, 6, 8, 12, 16, 24, 36,and 48 weeks. Professional toothcleaning and polish-ing of the treated teeth was performed at each visit, asneeded. Healing occurred without complicafions in alltreated sites, except for membrane exposure of 1 to 2mm, localized at the right second premolar and leftcanine without any symptom or sign of infecfion, atweek 4; the exposure was no longer present at the fol-lowing réévaluations. Intraoral photographs weretaken at the 24-week follow-up visit (Figs 7 and 8),

Figure 9 shows. 18 months after surgery, the excel-lent clinical outcome resulting from the complete cov-erage of all the exposed root surfaces, A gain in clini-cal aftachment level ranging from 4 mm (premolars)to 6 mm (molars and canines), an adequate band ofkeratirfized tissue (more than 2 mm), and a markeddecrease of dental sensitivity were also ohtained,Periodontal probing remained within 2 mm deep at alltreated sites. The parient was fully sarisfied with thefuncfional and esthefic result.

DISCUSSION

The treatment of gingival recession defects often repre-sents a therapeutic challenge. Several techniques,including various mucogingivai surgery and GTR pro-cedures, have become part of the clinicians' arma-mentarium to achieve predictable root coverage andsatisfactory estheric results. Successful results of GTRprocedures in the treatment of recession defects appearto he influenced by a variety of factors. Appropriate pa-tient selection is of paramount importance for GTR

procedures. The amount of regenerated tissue is strictlyand directly correlated to the patient's short- and long-term compliance,^ Therefore, parients who are unableto maintain proper oral hygiene and adequately followpreoperative and postoperative instructions are notgood candidates for treatment with GTR,

Similarly, accurate defect selection is a determiningfactor of the success of GTR procedures. Deep reces-sion defects (more than 5 mm) respond hetter to GTRthan do shallow defects. In the treatment of deep de-fects, GTR procedures are ahle to obtain a percentageof root coverage at least comparable to those obtainedwith mucogingival procedures,'"

In the present clinical case, the principles of GTRwere successfully applied to the treatment of multiple,deep, buccal recessions. This yoimg, very motivated,and compliant patient presented deep (4- to 7-mm)multiple gingival recessions as a result of impropertoothbrushing technique. The GTR procedure waschosen, in this case, to allow simultaneous treatmentof as many defects as possible without the need for alarge or multiple donor sites in the palate. Bio-ahsorhahle membranes (polylactic acid softened withcitric acid ester) were preferred over nonresorbablemembranes because of tbeir excellent fissue compati-bility, manageability, low exposure rate," and, mostimportantly, because they do not require a second sur-gical intervention for membrane retrieval.

CONCLUSION

This clinical report demonstrates tbat. tbrougb the ap-plicafion of GTR principles and bioabsorbable mem-branes, it was possible to treat six deep gingival reces-sion defects simultaneously in one surgical visit. Thistreatment plan reduced surgical invasiveness to a mini-mum, avoiding second surgical sites as donor areas andaddifional surgeries for membrane retrieval. The resultsatisfied the pafient's esthetic and funcfional needs.

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• Cangini et al

REFERENCES

1, American Academy of Periodontoiogy, Glossary of Perio-dontal Terms, ed 3, Chicago: American Academy of Perio-dontoiogy, 1992:41,

2, Trombelli L, Periodontal regeneration in gingival recessiondefects, Periodontol 2000 1999:19:138-150,

3, Tinti C, Vincenzi G, Cocchetto R, Guided tissue regenera-tion in mucogingival surgery, J Periodontol 1993:64:1184-1191.

4, Trombelli L. Schincaglia GP, Scapoli C, Calura G, Healingresponse of buccal gingival recessions treated with ex-panded polytetrafluurethylene membranes, A retrospectivereport J Periodontol 1995 ;66:14-22.

5, Roccuzzo M, Lungo M, Corrente G, Gandolfo S,Comparative study of a bioabsgrbable and a non-resorbabicmembrane in the treatment of human huccal gingival reces-sions, J Periodontol 1996;67:7-14,

6, Genon P, Genon-Romagna C, Gottlow J, Traitement des re-cessions gingivales par la regeneration tissulaire guidée:Barriere resorbable, J Parodontol 1994:13:289-296,

7, Lattanzi U, Andreana S, Comelini R, Pécora G, Use of a ti-tanium-reinforced ePTPE membrane for treatment üf gingi-val recession, Periodontal Insights 1996;|Apr):8-12,

8, Pini Prato GP, Tinti C, Vincenzi G, Magnani C, Corleilini P,Clauser C, Guided tissue regeneration versus mucogingivalsurgery in the treatment of human buccal recession, JPeriodontol 1992;63:919-928,

9, Fini Prato GP, Baldi C, Pagliaro U, ef al, Coronally ad-vanced flap procedure for root coverage treatment of rootsurface: Root planing versus polishing, J Periodontol1999 ;70:1064-1076,

10, Tonetti MS, Pini Prato GP, Cortellini R Periodontal regen-eration of human intrabony defects, IV, Determinants ofhealing response. J Periodontol 1993:64:934-940.

11, Laureii L, Falk H, Fornell J, Johard G, Gottlow J, Clinicaluse of a bioabsorbable matrix barrier guided tissue regenera-tion therapy. Case series. J Periodontol 1994:65:967-975,

18 Volume 34, Number t, 2003

Mastering DentalPhotographyWolfgang Bengel

Images are funda-mental in the day-to-day practice of den-tistry. They serve asdocumentation of .den-tal procedures and asforensic evidence, andthey play an essentialrole in dentist-patientcommunication, pro-viding the basis forpatients' expectationsfor treatment. How-ever, many dentists,daunted by modern

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