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3/31/2013
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- Gingival Recession -An Overview of Etiology and Treatment
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Trung Tran DDS, MS
What are we
Treatment Plan Development
• Recognition/Diagnosis of Gingival Recession• Determine Etiology• Counsel Patient on Plaque Control and any Modifiable Factors• Determine Need for Treatment• Determine Type of Treatment Indicated
Gingival Recession: Location of the gingival marginapical to the CEJ
AAP
How much recession is out there?
Estimated that over 23 million people in the U.S. have at least one tooth with 3mm of
recession
Over 50% of Americans older than
30 have gingival recession of 1mm
Albander and Kingman 1999
Primary Etiology
InflammationTrauma
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Secondary FactorsAberrant Frenum
Thin Tissue Biotype Lack of Facial Alveolar Bone
Labially Positioned Teeth Orthodontic Tooth Movement
Violation of Biologic Width by Subgingival Restoration
Inflammation
Toothbrush Trauma Aberrant Frenum
Lack of Facial Boneor
Thin tissue
Labially Positioned Teeth
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Facial OrthodonticMovement Does an exposed root have to be treated?
Research has proven that minimal amounts of attached gingiva can resist additional recession,
as long as plaque control is ideal and hygiene is atraumatic.
Dorfman, Kennedy, Bird 1982
Indications for Treatment
Esthetic ConcernThermal Sensitivity
Cervical DecayProgressive Loss of Attachment
Orthodontic ConsiderationsPlanned Subgingival Restorations
Lack of Attached Gingiva - Mucogingival Defect
Treatment Options and Goals
No TreatmentClass V Restoration
Tissue Graft for Root CoverageTissue Graft to Augment Existing Marginal Tissue
Classification of Recession DefectsP. D. Miller 1985
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Miller Class I Miller Class II
Miller Class III Miller Class IV
The only types of recession defects that can be grafted predictably for complete root
coverage are Miller Class I and IIMiller 1985
The Tissue is the Issue
But
The Bone Sets the Tone
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Periodontal Techniques for Treating Gingival Recession
Free Gingival GraftCoronally Positioned FlapConnective Tissue Graft
Tissue Allograft – Alloderm
Harvesting Free Gingival Graft
Free Gingival Graft and Coronally Positioned Flap
Miller Class II defect with associated thin tissue and frenum
Complete Root Coverage is not possible due to
proximal bone loss
Free Gingival Graft
Miller Class III defects
Tissue Attachment is beyond Mucogingival Junction
Graft to Aid in tissue health by:- Deepening vestibule- Increasing width of
keratinized attached tissue
Coronally Positioned Semilunar Flap
Miller Class I Defect #8
Connective Tissue Harvest
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Connective Tissue Graft
Miller Class II Defect
Alternative Tissue Source
-Epidermis removed with buffered salt solution-Dermal cells removed with patented non-denaturing detergents
-Cryogenesis / Freeze Dried
Alloderm after hydration in saline and patient’s blood
Miller Class I and II defects
Large span not ideal for autogenous tissue harvest
Alloderm Tissue Graft Symbios™ PerioDerm® Acellular Dermis
Features Benefits
No cross-linking (no gamma irradiation used in processing)
• Faster incorporation Predictable outcomes
• Less risk of surgery site inflammation and rejection
Over 90% thickness consistency Uniform revascularization and esthetic results
Excellent handling • Rehydrates quickly (3-5 minutes)
• No refrigeration required
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Perioderm
Soft Tissue Grafting versus Cervical Composites
True Biologic RestorationLong Term StabilityEsthetic Potential
Perioderm Guidelines for Selecting Cases with Cervical Decay for Tissue Grafting
• Miller Class I and II defects only
• Depth of decay must be less than 2mm
• Decay should not extend coronally into enamel
• High esthetic demand
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Consider Class V Restoration
Connective Tissue Graft with Cervical Decay
Miller Class II Defects
Connective Tissue Graft with Cervical Decay
Miller Class II Defect
Conclusions
• Treatment of gingival recession is not mandatory
• Not all recession defects can be covered by tissue grafts, although grafting may still be needed to augment existing marginal tissue
• If possible, patients should be given the option of tissue grafting
• In select cases, alternatives to harvesting autogenous tissue exist
• In select cases, tissue grafting should be considered as a treatment choice for cervical decay
Bibliography
• Sato N. Periodontal Surgery. Quintessence Publishing. 2000.• Nevins M, Mellonig J. Periodontal Therapy – Clinical Approaches and Evidence of
Success. Vol I. Quintessence Publishing. 1998.• Henderson R. Root Coverage Using Alloderm Acellular Dermal Graft Material –
Masters Thesis. University of Louisville. 2000.• Albander J, Kingman A. Gingival recession , gingival bleeding, and dental calculus
in adults 30 years of age and older in the united States, 1988-1994. J. Periodontol 70(1):30-43, 1999.
• Miller PD. A classification of marginal tissue recession. Int Journ Perio Rest Dent. 5:9:, 1985.
• Dorfman H, Kennedy J, Bird W. Longitudinal Evaluation of Free Autogenous Gingival Grafts – A Four Year Report. J Periodont 53:349-352, 1982.
Questions