Novaes 2019

DOI: 10.1111/prd.
12247
REVIEW ARTICLE
Experimental and clinical studies on plastic periodontal

procedures
Arthur Belém Novaes Jr | Daniela Bazan Palioto

Department of Periodontology, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
Correspondence
Arthur Belém Novaes Jr, Department of Periodontology, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil.
Email: [email protected]
1 | INTRODUCTION tissue is attached or inserted, and if a biomaterial is properly

resorbed or incorporated into the host tissues, were all answered by
Plastic periodontal procedures encompass a series of surgical tech- animal studies. Concomitantly, the clinical evidence brought by well‐
niques that aim to achieve improvements in what is now called “the conducted trials and, more recently, by the compilation of all this
pink esthetic”. In addition to attaining good results, these procedures data in systematic reviews, has extensively addressed the feature of
seek to obtain a degree of balance between function and esthetics. plastic periodontal procedures.
Furthermore, as implant rehabilitations became part of the periodon- Knowing how to apply the scientific evidence in favor of a given
tal armamentarium, the need to accomplish esthetics became case will ultimately dictate the results. More than a shift from one
increasingly more important. The purpose of plastic periodontal pro- trend to another, the choice of an appropriate surgical design resides
cedures is to prevent and correct anatomic, developmental, trau- in the ability to predict the final results and their long‐term stability.
matic, or plaque‐induced defects of the gingiva, alveolar mucosa, or Moreover, understanding the systemic situation of patients may lead
1
bone. Among these procedures are bone and soft tissue augmenta- to different decisions in terms of how to perform a procedure and
tion, interdental papilla reconstruction, gummy smile correction and also what to expect from it.
crown lengthening for esthetic purposes, and root coverage proce- All Latin American literature analyzed concerning experimental
dures. Understanding the principles of each procedure might lead to and clinical studies on periodontal plastic procedures led to a discus-
a better way of achieving good esthetic results. The plastic surgery sion, in this review, of the features and treatment outcomes of root‐
arsenal is vast and able to provide an appropriate solution for each coverage procedures. Over time, knowledge on this subject has
indication. However, the body of knowledge, namely the scientific become less empirical and rather supportive of the clinical manage-
evidence that drives the decisions and surgical choices, is not equally ment of recession‐type defects.
supportive of all the different situations.
Several points must be considered, and answers obtained to rele-
vant questions, in order to achieve a good degree of success in an 2 | GINGIVAL RECESSION ETIOLOGY
esthetically compromised case. As a first step, namely to decide on
an appropriate surgical approach and determine how a case will be Displacement of the gingival margin apical to the cementoenamel
conducted, the etiological factor leading to that condition must be junction, with oral exposure of the root surface, is a common feature
assessed and addressed. Determining which predisposing factors are in populations with high standards of oral hygiene, as well as in pop-
present in that specific situation is mandatory to prevent and to ulations with poor oral hygiene.2
treat the condition, and to maintain the esthetic results. One of the Tissue dehiscence, either associated with gingivitis or with mar-
most important of these factors is the periodontal biotype, and when ginal periodontitis, has been historically attributed to trauma from
selecting the appropriate technique, it is vital to take the biotype occlusion and proliferation of the pocket epithelium into the gingival
into consideration. corium and its subsequent anastomosis with the outer epithelium as
The evidence brought by experimental studies in animals repre- an extension of periodontal inflammation, tissue trauma, laceration
sents a fundamental pillar of our current knowledge on conducting induced by toothbrushing, and iatrogenic procedures. Also important
plastic periodontal procedures. Questions such as the type of struc- are the interrelationships that may exist between the primary patho-
ture developed in contact with the roots after a coverage procedure, genic factors (ie, periodontal inflammation) and the local anatomic
how the connective tissues underneath behave, if the connective factors, which are environmentally conductive, not only to the
56 | © 2019 John Wiley & Sons A/S. wileyonlinelibrary.com/journal/prd Periodontology 2000. 2019;79:56–80.
Published by John Wiley & Sons Ltd
NOVAES AND PALIOTO | 57
formation but also to the quality and morphology of gingival lesions. that, under circumstances in which the traumatic lesion precedes the
In 1975, Novaes et al3 described the process of how gingival reces- development and spread of the inflammatory process on the gingiva,
sion, which they called “the periodontal cleft”, took place. The devel- trauma from occlusion may first of all induce bone resorption with
opment of a gingival recession may be related to a number of concomitant development of a replacement periosteal‐cemental
etiologic and environmental factors, and, in a general context, inflam- attachment. It should be emphasized, however, that root resorption
mation is constant. In a series of photomicrographs, Novaes et al3 is solely related to an inflammatory process elicited by the biofilm
illustrate the merge of the pocket with the outer gingival‐mucosal and/or by chronic traumatic toothbrushing.
epithelium and subsequent soft tissue fenestration (Figure 1). Noncarious cervical lesions4 may be a consequence of a multifac-
Analysis of the lesions indicates not only apically directed spread torial process including tooth structure loss caused by nonbacterial
of the inflammatory process through the connective tissues, with acids (erosion), traumatic toothbrushing (abrasion), and occlusal load-
concurrent epithelial resorptive and proliferative reactions, but also ing (abfraction). It can frequently extend apically underneath the free
lateral progression of the inflammatory process toward the outer gingival margin. Based on its etiology and severity, the most com-
aspect of the gingiva and alveolar mucosa. As the inflammatory pro- mon therapies for a noncarious cervical lesion are occlusal adjust-
cess caused by the biofilm in the sulcus destroys the connective tis- ment, toothbrushing instructions, and/or restorative procedures.
sues, these tissues become partly covered by proliferating and Conventional restorative procedures result in protection against fur-
migratory pocket epithelium. Eventually, anastomosis occurs ther loss of tooth structure and sensitivity; however, they may not
between the pocket and the gingiva‐mucosa epithelium as the inter- meet the esthetic demands of the patients (relative to the length of
vening connective tissue is progressively lost. This process seems to the tooth or teeth involved).5,6 In such cases, periodontal plastic sur-
be slowly progressive and rarely associated with acute destructive gery in association with restorative procedures may result in an opti-
gingival changes. mal solution.
Some factors, anatomical in nature, favor the formation of root
recessions: buccal‐lingual dimensions of the soft and hard tissues—in
other words, a thin periodontal profile, would predispose to the 3 | ROOT‐COVERAGE PROCEDURES
occurrence of such lesions. Among these factors are a narrow zone
of attached gingiva—the thinner the tissues, the greater the poten- Root‐coverage procedures aim to restore both gingival esthetics and
tial for recession; a wide zone of alveolar mucosa (which is often function in recession defects.
very thin) covering a prominent root may manifest not only quantita-
tively inferior amounts of collagen but also differently located and
arranged fiber orientation which favors the spread of the inflamma- 4 | ANIMAL STUDIES: DEHISCENCE‐TYPE
tory process. Furthermore, tooth alignment on the arch is related, in DEFECTS
most cases, to the subjacent presence of a thin, and largely cortical,
buccal bone. This bone is strikingly vulnerable to the effects of the The quantity and quality of soft tissue are important in determining
inflammatory process. the success of reconstructive and plastic surgery procedures. Several
Although information on the relationship between the inflamma- studies in the literature have aimed to verify how tissues were
tory process and traumatic lesions is meager, it may be hypothesized attached to the root surfaces following coverage procedures
A B C
F I G U R E 1 A, Biopsy. Histological cut

on the periphery of the perforation
showing intense inflammatory infiltrate
with marked epithelial projections. At the
top (gingival sulcus), a thin marginal oral
and sulcular epithelia are in close proximity
to each other. B, Appearance of the cut
right at the limit of perforation, stressing
the point of union between the epithelia.
C, When the histological section is cut
Split in the center of the perforation, the
part of the sulcus was separated from the
apical (inflamed). It is simple to understand
that any action would cause necrosis or
traumatic loss of a bridge, starting a
gingival recession [Colour figure can be
viewed at wileyonlinelibrary.com]
58 | NOVAES AND PALIOTO
performed to treat dehiscence‐type defects. As the feasibility of Biomodification of roots has been adopted using approaches
periodontal regeneration became a fact, efforts were made to opti- such as application of platelet‐rich plasma10 or the use of enamel
mize the root‐coverage procedure and obtain, instead of an attached matrix derivative11 to obtain periodontal regeneration in dehiscence‐
long junctional epithelium, a regenerated and attached new connec- type defects. The combined therapy—guided tissue regenera-
tive tissue. tion + enamel matrix derivative—was also evaluated in dogs.12 The
7
da Silva Pereira et al compared, histologically and histometri- results demonstrated a superior length of new cementum in sites
cally, the healing process of dehiscence‐type defects treated by treated with enamel matrix derivative (3.7 mm) and with enamel
guided tissue regeneration with bioabsorbable polylactic acid mem- matrix derivative + guided tissue regeneration (3.8 mm) in compar-
branes and nonresorbable expanded polytetrafluoroethylene mem- ison with open flap debridement (2.4 mm; P < 0.05). The authors
branes. These procedures were also compared with open flap concluded that enamel matrix derivative alone, or in combination
debridement and no‐treatment controls. The authors demonstrated a with guided tissue regeneration barriers, may effectively promote
superior length of new cementum in sites treated with guided tissue new cementum formation, but that the combination of both thera-
regeneration, regardless of the type of barrier used, in comparison pies may not yield additional benefits. Another histometric study
with open flap debridement. No statistically significant differences compared the healing process of dehiscence‐type defects treated
were found between bioabsorbable polylactic acid and expanded with enamel matrix derivative or guided tissue regeneration under
polytetrafluoroethylene membranes in any of the parameters with the effect of nicotine in the dog model.13 A superior length of new
the exception of bone area, which was larger in the bioabsorbable cementum was observed in the sites treated with enamel matrix
polylactic acid group. derivative in comparison with open flap debridement (P ≤ 0.05);
Casati et al8 evaluated the healing response of gingival reces- however, no statistically significant differences were observed
sions treated by guided tissue regeneration with a bioabsorbable between the guided tissue regeneration group and the other groups.
membrane and with a coronally positioned flap. The amount of new It was concluded that in the presence of nicotine, enamel matrix
cementum was not statistically different between the guided tissue derivative may promote more new cementum formation than open
regeneration group and the coronally positioned flap group. How- flap debridement, while guided tissue regeneration failed to show a
ever, new cementum was observed on 61% of the defect extension significant difference.
in the guided tissue regeneration group and on 36.8% of that in the The quantity and quality of soft tissue are important in determin-
coronally positioned flap group. The connective tissue attachment ing the success of reconstructive and plastic surgery procedures.
without cementum formation was greater in the coronally positioned Accordingly, searches are ongoing for biocompatible materials that
flap group. The coronal displacement of the flap, and the extension could be integrated with and replaced by host tissues, with the
of the distance which epithelial cells have to cover, may have intent to repair soft tissue defects. The periodontal tissues covering
enhanced the chance of new attachment but also the risk of root Class V resin restorations were evaluated in dogs.14 Histomorpho-
resorption. The observed osseous response was similar for the two metric analysis revealed apical migration of epithelial tissue onto the
techniques and this may be related to the type of defect treated— restorative materials, while the control group presented significantly
the buccal alveolar plate was generally thin and the space between longer connective tissue attachment (P < 0.05) than the resin‐modi-
the barrier and the root surface was almost nonexistent. Both proce- fied glass ionomer cement or the composite resin groups and a sig-
dures, however, provided acceptable defect coverage (90.5% for the nificantly higher level of bone regeneration (P < 0.05) compared
guided tissue regeneration group and 91.9% for the coronally posi- with the resin‐modified glass ionomer cement group. Histologically,
tioned flap group). the cervical third of all groups had the most marked chronic inflam-
The healing response of gingival recessions treated with collagen matory infiltrate. It was concluded that the restorative materials used
membrane + demineralized freeze‐dried bone allograft was histomet- exhibited biocompatibility; however, both materials interfered with
rically compared with coronally positioned flap in dogs.9 A statisti- the development of new bone and the connective tissue attachment
cally significant difference was found between groups with a larger process.
extension of neoformed cementum (guided tissue regenera- Acellular dermal matrix grafts are collagen materials with the
tion = 32.72%; coronally positioned flap = 18.82%; P = 0.0004), new potential of working as a scaffold that can be replaced with native
bone (guided tissue regeneration = 23.20%; coronally positioned collagen. Acellular dermal matrix grafts have been used extensively
flap = 9.90%; P = 0.0401), and with a smaller area of residual gingi- in plastic and reconstructive surgeries, and because of the reliable
val recession in the test group (guided tissue regeneration = 50.69%; results obtained, their application in periodontics has been estab-
coronally positioned flap = 59.73%; P = 0.0055) compared with the lished as a safe and viable alternative to native collagen, especially in
control group. The authors concluded that the treatment of gingival periodontal plastic surgeries carried out to achieve root coverage.
recession defects with guided tissue regeneration, associating colla- Luczysyn et al15 reported a histological study (Figure 2)15 in dogs
gen membrane with demineralized freeze‐dried bone allograft, that was performed with the objective to describe the incorporation
showed better outcomes in terms of a larger extension of neo- process resulting after the use of acellular dermal matrix grafts. The
formed cementum and bone, as well as in terms of a smaller propor- analysis demonstrated, at 4 weeks after placement of acellular der-
tion of residual recessions. mal matrix graft, initial vessel infiltration from the connective tissue
A B
C D
E F
F I G U R E 2 A, Sample at 4 wk—the area between the connective tissue from the flap (CT) and the acellular dermal matrix graft is delineated
by arrows. The borders between the acellular dermal matrix graft and the gingival connective tissue adjacent to both the flap and the
periosteal surface are very distinct (Mallory trichrome; original magnification ×25).15 B, Higher magnification of box in (A). The area between
the connective tissue from the flap (CT) and the acellular dermal matrix graft is delineated by arrows. The surface in contact with the flap (FS)
showed parallel thick collagen fibers arranged in a well‐defined pattern of distinct bundles. The surface facing the periosteum (PS) presented
less‐organized thick and dispersed fibers. (Mallory trichrome; original magnification ×50).15 C, Sample at 8 wk. A hazy border between the
acellular dermal matrix graft fibers (arrows) and the gingival connective tissue (CT) can be seen (Mallory trichrome; original magnification
×50).15 D, Higher magnification of box in (C). Fiber bundles of the acellular dermal matrix graft (arrows) are more dispersed and surrounded by
connective tissue (CT; Mallory trichrome; original magnification ×100).15 E, Sample at 12 wk. The connective tissue presented a normal, well‐
vascularized aspect, with few collagen fibers remaining from the acellular dermal matrix graft (arrows; Mallory trichrome; original magnification
×50).15 F, Higher magnification of box in (E). The acellular dermal matrix graft material and the connective tissue seemed to be integrated into
a single, highly vascularized structure. Note the vessels (arrows) and the remaining fibers of the acellular dermal matrix graft (F) (Mallory
trichrome; original magnification ×100)15 [Colour figure can be viewed at wileyonlinelibrary.com]
to the acellular dermal matrix graft. The penetration of blood vessels the connective tissues into the material, the acellular dermal matrix
was similar in areas in contact with the flap and in areas facing the grafts were not completely incorporated into the host tissues—thick,
root surface and periosteum. These observations demonstrate that brownish‐colored bundles of fibers were consistently identified.
this initial phase of integration of the graft material into the host tis- After 8 weeks, the continuous blood vessel penetration throughout
sues is marked by intense vascular proliferation. During this 4‐week the acellular dermal matrix grafts attested to greater integration
period, despite infiltration of blood vessels and collagen fibers from between the acellular dermal matrix graft and the connective tissue.
In this phase, the fibers of the acellular dermal matrix graft were difference (P > 0.05) in the number of cell layers, epithelial area, or
more organized, probably because of more intense cell penetration, inflammatory infiltrate between the two groups at any stage of heal-
especially of fibroblasts from the flap and/or from the periosteum, ing. The authors proposed that enhanced vascularization in vivo in
which are responsible for collagen fiber extrusion, and consequently the early stages of healing may support the important role of fibrob-
by its deposition throughout the acellular dermal matrix graft struc- lasts in improving graft performance and wound healing of cultured
ture. At 12 weeks, it was not possible to see a clear distinction graft substitutes.
between the acellular dermal matrix graft and the connective tissue. The periodontal literature has already reported the use of tissue
Only a few remaining collagen fibers from the graft could be seen, engineering techniques involving the seeding of autogenous cells in
indicating that incorporation of the acellular dermal matrix graft was different scaffolds as an intelligent way of delivering growth factors
almost complete. The incorporation process of the acellular dermal to a healing site. The same aforementioned group20 evaluated if
matrix graft seemed to follow a relatively similar healing pattern, acellular dermal matrix is suitable as a 3‐dimensional scaffold by
beginning with initial blood vessel and collagen fiber infiltration into seeding acellular dermal matrix with human gingival fibroblasts and
the graft material, and continuing with gradual intensification that canine gingival fibroblasts. The B16F10 murine melanoma cell line,
culminated in total incorporation of the acellular dermal matrix graft because of its highly proliferative and metastatic features, was used
into the adjacent tissues. The results showed that acellular dermal to evaluate the possibility of ingrowth of cells in the matrix. For up
matrix grafts are capable of consistently integrating into host con- to 14 days, culture canine gingival fibroblasts were adherent but of
nective tissue. low density and unevenly distributed on the acellular dermal matrix
Acellular dermal matrix was subcutaneously implanted into the surface, whereas human gingival fibroblasts and B16F10 formed a
calvarian skin of Wistar rats16 and a low‐level laser was locally continuous cell layer lining the acellular dermal matrix surface. The
applied in the experimental group above the skin flap. Grafts were presence of cells inside the acellular dermal matrix was only occa-
harvested at 1, 3, 7, and 14 days after surgery. The results showed sionally observed. In the previous methodology it was found that
that, in low‐level laser‐treated animals, the extent of edema and the addition of gingival fibroblasts to the matrix enhanced vasculariza-
number of inflammatory cells were reduced (P < 0.05) and that the tion in vivo during the early stages of healing. In that experiment,
amount of collagen in the graft was significantly higher than in con- however, the acellular dermal matrix was placed in contact with cells
trols (P < 0.05). The mean count of fibroblasts was significantly near the explant in the early stages of function, which may explain
higher in the low‐laser therapy group by the third day, showing a the entrance of the cells and subsequently the good results in vivo.
marked influx of fibroblasts into the area. It was concluded that Nevertheless, no in vitro analysis to confirm the effectiveness of cell
wound healing of the acellular dermal matrix appears to be positively seeding was performed. In the second study, many cells were neces-
affected by laser therapy. sary in each repetition, so the cells were used in subsequent pas-
With the objective of evaluating the healing of gingival recession sages. Although cells adhered to and spread on the surface of the
treated by coronally positioned flaps, with or without acellular der- acellular dermal matrix, the low number of cells inside the matrix,
mal matrix as a subepithelial graft, a histometric study was con- especially at the central slice, suggests that acellular dermal matrix
17
ducted. The authors reported no statistically significant difference collagen bundles are arranged too densely to allow a homogeneous
for any parameters except for increased gingival thickness after the cell distribution and the establishment of a tissue‐like network. The
use of acellular dermal matrix grafts. de Oliveira et al18 failed to low porosity and pore interconnectivity in acellular dermal matrix
demonstrate the ability of enamel matrix derivatives to provide addi- may interfere with the diffusion of nutrients, which prevents the
tional benefits to those found with acellular dermal matrix grafts growth of cells in vitro, both in the surface and inside the matrix.
alone. Possibly, for tissue engineering, selection of tissues with less dense
Because acellular dermal matrix grafts have no blood vessels or collagen matrices could allow homogeneous migration of cells
cells, slower healing and incorporation are observed compared with throughout the matrix, providing a more favorable scaffold for the
a subepithelial connective tissue graft. Fibroblasts may accelerate transport of cells. The authors concluded that acellular dermal matrix
the healing process by regulating matrix deposition and synthesis of is not suitable as a 3‐dimensional matrix for gingival fibroblast
a variety of growth factors. With the intention to evaluate if gingival ingrowth.
fibroblasts affect healing and incorporation of acellular dermal matrix
grafts when used as a subepithelial allograft, a histological study in
dogs was conducted.19 Gingival fibroblasts were established from 5 | FREE GINGIVAL GRAFTS
explant cultures of connective tissue obtained from the keratinized
gingiva collected from the maxilla of seven mongrel dogs. Acellular Free gingival grafts are still commonly used to increase the kera-
dermal matrix graft was seeded with autogenous gingival fibroblasts tinized tissue dimensions around teeth21,22 and implants.23 The
and transferred to the dogs. Biopsies were performed after 2, 4, and absence of keratinized tissue is among the mucogingival conditions
8 weeks of healing. The quantity of blood vessels was significantly recognized as a distinct clinical entity. Although no absolute mini-
higher in acellular dermal matrix graft seeded with fibroblasts at mum amount of attached gingiva is required for gingival health to be
2 weeks of healing (P < 0.05); however, there was no statistical maintained, there are several clinical situations in which intervention
might be indicated, for a number of reasons. For example, when gin- development of buccal bony exostosis in areas in which free gingival
giva is thin or absent, it may be difficult to perform adequate oral grafts were placed.
hygiene, resulting in accumulation of plaque and inflammation and
subsequently in loss of attachment and possibly development of gin-
gival recession. One disadvantage of a free gingival graft is the dif- 6 | PEDICLE FLAPS
ferent shade of the graft obtained from the donor palatal mucosa.
The donor tissue may be more opaque, and thicker, which may lead Pedicle flaps are considered to be an adequate choice because vas-
to esthetic problems of varying severity, depending on the shade of cular connections with the adjacent soft tissues can be maintained
the palate and gingiva, and may become worse by the formation of using this procedure, which increases the chance of survival of the
keloids. flap on the avascular root surface. Among pedicle flaps, semilunar,
Shrinkage of free gingival graft is a well‐known clinical phe- laterally positioned, and coronally positioned flaps present the possi-
nomenon that occurs during the healing process. The results of some bility to cover the recession, using a single surgical procedure, with
studies in the literature indicate that when using free gingival graft gingival tissues that are more harmonic with the adjacent teeth. Lat-
placed on a periosteal bed, considerable shrinkage is observed post- erally positioned flap and coronally positioned flap can also be per-
operatively, even if the graft is sutured in a manner that minimizes formed as a two‐stage procedure following the placement and
21,24
any suture‐induced trauma to the graft tissue. The results of the healing of a free gingival graft or by the insertion of a subepithelial
two studies that evaluated both width and length changes consis- connective tissue graft. Among the disadvantages of the two‐stage
tently showed that width shrinkage is much greater (typically double procedures are the increased morbidity caused by multiple surgical
in magnitude) than length shrinkage. The influence of the recipient sites and procedures, longer healing times, and eventual poor color
bed is a possible explanation for this observation, although other, match of the free gingival graft with the recipient site. Thus, single‐
yet unidentified, factors might account for the preferential reduction stage procedures are preferred. However, the laterally positioned
in width compared with length. When a free gingival graft is placed flap and coronally positioned flap procedures require, respectively,
on a periosteal bed, graft shrinkage is mostly attributable to the loss donor sites of adequate thickness, and at least 3 mm‐wide kera-
of vestibular depth caused by cicatricial contraction. tinized tissue laterally or apically to the recession defect. An impor-
The use of a low‐intensity laser in conjunction with a free gingi- tant factor for case selection for either procedure is the location of
val graft was evaluated in a split‐mouth, double‐blind design.25 As available tissue as a requirement for the donor site.
concluded by the authors, low‐intensity laser did not provide visible
clinical improvement in the healing of gingival grafts or appear to
influence the analgesia. 7 | SEMILUNAR FLAPS
Curiously, some soft and bony lesions have been described in
the literature after the use of a free gingival graft. There have been Semilunar flaps are described as coronally advanced, tensionless, and
a few case reports of cystic lesions occurring after gingival grafting. sutureless flaps that do not involve the adjacent papillae.28 The fact
de Castro et al26 described a case of a cyst‐like lesion developing that a semilunar flap does not shorten the vestibule, and that it
secondarily to a free gingival graft. A cystic cavity lined with an could result in a perfect color blend with adjacent tissues, with a
orthokeratinized, hyperplastic, stratified squamous epithelium cov- simple, predictable and fast procedure, is seen as an advantage com-
ered with fibrous connective tissue was found after histological anal- pared with other procedures. Some case reports, available in the lit-
ysis of the surgerized bulky tissue that had developed under the erature, show a highly successful rate for this procedure. In 2006,
grafted area. Bittencourt et al29 conducted a long‐term controlled randomized
Bony exostosis is described as a benign localized overgrowth of clinical trial in which data were assessed regarding predictability and
bone of unknown etiology. Development of buccal bony exostosis percentage of recession resolution using semilunar flaps. They com-
secondary to soft tissue graft procedures has been reported in a pared the subepithelial connective tissue graft with the semilunar
small number of cases. The dental literature also describes buccal coronally positioned flap in a split‐mouth design for the treatment of
bony exostosis development at sites in which free gingival grafts Miller Class I gingival recession defects. In spite of the high resolu-
have been used to increase the amount of gingiva. Chambrone and tion obtained with both proceduress—90.95% in the semilunar coro-
Chambrone27 have published a case series describing development nally positioned flap group and 96.10% in the subepithelial
of buccal bony exostosis at nine sites (five cases) in which free gingi- connective tissue graft group—a statistically increase in the thick-
val grafts were performed to increase the width of the attached gin- ness of keratinized tissue was observed in the subepithelial connec-
giva. The presence of exostosis has been recognized during tive tissue graft group compared with the semilunar coronally
postoperative visits, and the histological examination revealed oss- positioned flap group. At the 6‐month analysis, the increase in thick-
eous enlargements compatible with the diagnosis of exostosis at two ness of keratinized tissue did not lead to additional root‐coverage
re‐entry procedures. The reason given by the authors, based on pre- outcomes. However, only the results of long‐term follow‐up studies
vious reports, was that periosteal trauma, such as fenestration, could determine if the increase in the thickness of keratinized tissue
seemed to be the main etiologic agent associated with the makes the treated sites less susceptible to future recession or if
toothbrushing habits may be of greater importance than increased observed after 6 months of healing, with the gingival color, texture,
gingival thickness for the long‐term maintenance of the surgically and contour being identical to those of the adjacent soft tissues, and
established position of the soft tissue margin. Semilunar coronally minimal scarring noticeable in the alveolar mucosa. Areas treated
positioned flaps and subepithelial connective tissue grafts showed an using the semilunar coronally positioned flap procedure exhibited a
esthetic improvement after 6 months, and patients were generally significantly different clinical healing pattern, in which a transient,
satisfied with both procedures (94.1% and 100%, respectively). long‐term (3 months), reddish phase, and altered color and texture
One of the major challenges in periodontal plastic surgery is the were observed for the duration of the study. One important clinical
long‐term stability of the soft tissue reattachment over the previ- finding was the presence of significant white scars in all the sites
ously exposed root surface. In a continuation of their first study, Bit- treated using the semilunar coronally positioned flap 6 months after
tencourt et al30 observed the long‐term stability of root coverage the procedure. These unique aspects of the healing phenomena
obtained with subepithelial connective tissue grafts and semilunar associated with the semilunar coronally positioned flap procedure, as
coronally positioned flaps. No major difference was observed mentioned by the authors, need further consideration with regard to
between the groups with regard to the position of the gingival mar- case selection, especially considering that the procedure is mostly
gin at 30 months. With both procedures, the high percentage of root indicated for cosmetic reasons. A significantly delayed reddish heal-
coverage observed at 6 months (90.95% in the semilunar coronally ing phase followed by a noticeable semilunar white scar located just
positioned flap group and 96.30% in the subepithelial connective tis- a few millimeters apical to the cementoenamel junction is a potential
sue graft group) was preserved at 30 months (89.25% and 96.83%, drawback, especially in patients with a high smile‐line. In summary,
respectively). Nevertheless, complete root coverage must be consid- both flap designs were effective in obtaining and maintaining coronal
ered the true goal of treatment because it assures recovery from the displacement of the gingival margin; however, the clinical improve-
hypersensitivity and esthetic defects associated with recessions. ments (percentage of root coverage, frequency of complete root
Thus, root coverage that does not reach the cementoenamel junc- coverage, and gain in clinical attachment level) observed from use of
tion may not be satisfactory for the patient because the coronal part the coronally positioned flap design were significantly superior to
of the still‐uncovered root surface may show while smiling. In addi- those observed using the semilunar coronally positioned flap. It is
tion, the root area near the cementoenamel junction is the most sus- concluded that root coverage is significantly better with the coro-
ceptible to hypersensitivity. This could explain the observations of nally positioned flap than with the original semilunar coronally posi-
their study, in which the resolution of root hypersensitivity at tioned flap in the treatment of small maxillary Miller Class I gingival
30 months favored the graft procedure that had a higher frequency recession defects when this is performed under standard clinical sit-
of complete root coverage (58.82% in the semilunar coronally posi- uations without surgical magnification.
tioned flap group and 88.23% in the subepithelial connective tissue
graft group). With regard to esthetic improvement, after 30 months,
patients in the semilunar coronally positioned flap and subepithelial 8 | LATERALLY POSITIONED FLAP
connective tissue graft groups were generally satisfied with both
procedures (82.3% and 100%, respectively). Although they presented Important factors in case selection for a laterally positioned flap pro-
similarly good results, more patients preferred, based on the esthet- cedure re the location of available tissue in the donor site and the
ics achieved, treatment with subepithelial connective tissue graft. proximity of contiguous roots. The laterally positioned flap proce-
This can be explained by the higher percentage of complete root dure has been evaluated in case reports, clinical experiments, and
coverage and the absence of hypertrophic scars or fibrosis in this controlled clinical trials. Deliberador et al32 treated a series of chal-
group, whereas in the semilunar coronally positioned flap group, lenging Class III recession type defects with simultaneous application
seven patients complained about the presence of hypertrophic scars, of a combination of three procedures: the tunnel preparation, con-
although they were not visible while smiling. The increase in thick- nective tissue graft, and laterally positioned flap. The laterally posi-
ness of gingival tissue may be a desired effect in decreasing the pos- tioned flap plus subepithelial connective tissue graft was selected to
sibility of recurrence of gingival recession because chronic trauma increase the gingival thickness of some elements. The authors
sustained from injuries during inadequate toothbrushing or inflamma- revealed partial root coverage, as expected, in Class III recession
tory reactions in thin marginal tissue may result in gingival recession. defects, and some creeping attachment after 1 year of follow‐up.
A recent study31 compared the clinical outcomes of the semilu- Clinical long‐term assessment of a laterally positioned flap was
nar coronally positioned flap and coronally positioned flap procedure performed in 32 systemically healthy, nonsmoking patients, with one
in the treatment of maxillary Miller Class I recession defects. The Miller Class I or II buccal gingival recessions of ≥3 mm.33 At
results demonstrated that both flap designs were effective in obtain- 24 months following surgery, root coverage obtained with the later-
ing a coronal displacement of the gingival margin; however, the ally positioned flap was 93.8%, complete root coverage was obtained
coronally positioned flap design resulted in clinical improvements sig- in 62.5%, and both measurements were statistically significant com-
nificantly superior to those obtained by the semilunar coronally posi- pared with baseline. Interestingly, patients with maxillary recessions
tioned flap. Following placement of the coronally positioned flap, a recorded statistically superior gains in the width of keratinized tissue
normal healing process (relative to periodontal flap procedures) was than patients with mandibular recessions. The results of this study
demonstrate that the laterally positioned flap is an effective proce- speculated that the clinical and microbiological findings could be a
dure for covering localized gingival recession. result of improvement of hygiene in the treated areas. Some
Santana et al34 compared the efficacy of single‐stage laterally hypotheses can be made in an attempt to explain the improvements
positioned flap and coronally positioned flap procedures in the treat- of biofilm control observed after treatment with a coronally posi-
ment of localized maxillary Class I gingival recession defects. The tioned flap, such as reduction of dentin hypersensitivity, a shift in
results demonstrated that both flap designs were effective in treat- the gingival margin from an apical position to a coronal position that
ing maxillary single gingival recession defects—visually, soft tissue could aid in brushing of the dento‐gingival interface, increased moti-
healing was not significantly different between the two procedures: vation for hygiene because the volunteers were enrolled in a clinical
the areas treated showed normal healing relative to that of peri- study, and/or the fact that the subjects had undergone a surgical
odontal flap procedures; gingival color, texture, and contour were procedure.
identical to the adjacent soft tissues; and minimal scarring was Nazareth and Cury38 have recently published a pilot study clini-
observed in the alveolar mucosa. The results obtained using the cally evaluating the treatment outcome of coronally positioned flap
coronally positioned flap procedure were clinically similar to those associated with Anorganic Bovine Mineral/P‐15 in terms of root cov-
obtained using the laterally positioned flap procedure, albeit with erage and clinical attachment gain and in relationship to the bone
more limited gains in keratinized tissue—the laterally positioned flap level in isolated Class I gingival recession defects. They showed that
design resulted in a significantly higher gain of keratinized tissue coronally positioned flap associated with Anorganic Bovine Mineral/
compared with the coronally positioned flap. No significant differ- P‐15 provides no significant difference in root coverage and clinical
ences between the groups were observed for percentage of root attachment gain compared with coronally positioned flap alone.
coverage, complete root coverage, changes in probing depth, and Although not clinically significant, a statistically significant increase in
gain in clinical attachment level. Both groups exhibited similarly gingival thickness was observed in the Anorganic Bovine Mineral/P‐
reduced bleeding on probing and visual plaque scores, indicating a 15 group. At the 6‐month follow‐up, mean coverage of roots was
good standard of supragingival plaque control during the study per- 85.56% and 90% in the test and control groups, respectively. Com-
iod. plete coverage was obtained in 66.67% and 73.33% of cases in the
test and control groups, respectively. Interestingly, a greater reduc-
tion in gingival recession, associated with a higher bone level at
9 | CORONALLY POSITIONED FLAP baseline, was observed.
The high efficacy and predictability of the coronally positioned
The coronally positioned flap and the subepithelial connective tissue flap procedure were demonstrated in the treatment of intact
graft (with several variants) are among the procedures most com- exposed roots that were suitable for planing to achieve flattened
monly employed for obtaining root coverage. The coronally posi- surfaces. When root exposure is associated with a noncarious cervi-
tioned flap is a very versatile flap design that can be executed using cal lesion, the cosmetic component of the surgical or restorative pro-
a variety of incisions and sutures. It is indicated when a minimum of cedure may not be successful, especially in apically extensive lesions.
3 mm of keratinized gingiva is present apically to the recession. Therefore, to solve problems of sensitivity and esthetics simultane-
However, coronally positioned flap procedures often result in healing ously, a combined restorative‐surgical therapy was proposed to treat
with a long junctional epithelium and limited connective tissue gingival recession associated with noncarious cervical lesions.5 From
attachment. Coronally positioned flap procedures have been exten- the prospective, parallel, and randomized clinical design it was
35 33
sively reported in case series and in clinical trials. observed that effectiveness of the coronally positioned flap for cov-
The composition of the subgingival biofilm was evaluated erage of previously restored root surfaces was similar to that of an
6 months after treatment with a coronally positioned flap.36 A peri- intact root. The same group also analyzed the impact of covering the
odontal plastic procedure is considered as successful when the gingi- roots’ surfaces and the restorations on the microbiological features.
val margin is at the cementoenamel junction and with the presence In a 6‐month evaluation, they observed that well‐finished resin‐modi-
37
of clinically attached gingiva. The results showed that exposed root fied glass‐ionomer cement or microfilled composite subgingival
surfaces demonstrated improvements in clinical outcomes in terms restorations did not negatively affect periodontal health. Further-
of recession height reduction, clinical attachment gain, shallower more, glass‐ionomer cement seems to exert more positive effects on
probing depth (1.2 ± 0.5 mm), reduced frequency of bleeding on the subgingival biofilm composition than microfilled composite.39
probing, and unchanged keratinized tissue 6 months after surgery. The long‐term success of the coronally positioned flap procedure
The mean percentage of root coverage was 81.64%. In addition to in treating gingival recessions associated with a noncarious cervical
reduction in bleeding on probing and clinical attachment gain, their lesion, combined with a cervical restoration or not, was addressed in
analyses demonstrated a decrease in the proportion of some patho- a split‐mouth, randomized‐controlled clinical trial—a 2‐year follow‐up
gens and a trend for an increase in the proportions of health‐asso- of gingival recessions associated with a noncarious cervical lesion
ciated microorganisms after treatment with a coronally positioned that were treated with a coronally positioned flap, either alone or in
flap. Although a statistically significant reduction of visible plaque conjunction with a glass ionomer restoration.40 It was assumed that
accumulation was not observed 6 months after surgery, it was the presence of the restoration on the cervical area may not prevent
soft tissue coverage by the coronally positioned flap. It is important attempted in natural teeth,42 in teeth with noncarious cervical
to note that the amount of noncarious cervical lesion covered in that lesions,43 as well as in implants.44 Its use was also successful in cor-
study (51.57% in the coronally positioned flap + restoration group recting dental gingival recessions caused by lip‐piercing.45 Others
and 53.87% in the coronally positioned flap group) should not be have described a 5‐year follow‐up of a case involving the treatment
directly compared with other studies that included gingival reces- of gingival recession with a subepithelial connective tissue graft
sions on intact roots. This comparison is not possible because the before orthodontic tooth movement.46
noncarious cervical lesion simultaneously affects parts of the root da Silva et al47 presented the first controlled split‐month clinical
and the crown of the tooth and, with its progression, the cementoe- trial comparing coronally positioned flap with or without subepithe-
namel junction generally disappears. Thus, estimation of the position lial connective tissue graft. The results showed no significant differ-
of the cementoenamel junction was performed. Based on these val- ences between the two modalities concerning the amount of root
ues, mean root coverage was calculated as 80.37% for the coronally coverage. However, an increase in the width of both keratinized gin-
positioned flap + restoration group and 83.46% for the coronally giva and alveolar mucosa could be noted. To what extent the
positioned flap only group. The authors, however, regarded these increased gingival width has any clinical significance is dependent on
results with caution because of the subjective component of the the clinical question asked. If the question is whether it leads to bet-
method used to estimate the cementoenamel junction. This method ter root‐coverage outcomes, the answer, given by the authors of the
does not allow precise determination of complete root coverage study, has to be no. Nevertheless, the increased width in keratinized
achieved by each procedure. The findings of the present 2‐year fol- gingiva could have reduced susceptibility to future recession. This
low‐up study corroborate previous findings41 suggesting that gingival possibility must be considered and should be evaluated during long‐
margin stability may be obtained after the coronally positioned flap term follow‐up studies. In a longitudinal study48 it was observed that
procedure is performed on cervical lesions restored with glass‐iono- the root coverage displayed by the coronally positioned flap alone
mer cement. As the amount of soft tissue coverage achieved in the changed from 71.2% in 6 months to 55.98% in 24 months. There-
coronally positioned flap + restoration group was 51.57%, the fore, in the longer term it could be assumed that some recurrence of
restorations present in this group remained approximately 50% cov- recession is expected with both procedures, but the final recession
ered by the soft tissue and, as a consequence, the apical margin of height would be smaller with the inclusion of a graft.
the restoration was located subgingivally. However, no bleeding on In an attempt to assess the possible influence of local anatomic
probing or signs of gingival inflammation were observed during the characteristics on the amount of root coverage achieved, several
study period. The biocompatibility of the material, combined with studies were conducted. At 6 months after surgery, root coverage
the fact that the patients were followed up every 4 months for pro- obtained with subepithelial connective tissue grafts was not influ-
phylaxis, plaque control, and reinforcement of oral hygiene instruc- enced by the shape of crowns.49 Santamaria et al50 conducted a
tions, may help to explain the gingival health observed during the regression analysis correlating two different surgical approaches
study. In addition, flap elevation allowed proper isolation of the (coronally positioned flap and subepithelial connective tissue graft)
operative field, and a well‐finished filling could be achieved that to treat gingival recessions associated with noncarious cervical
might have facilitated plaque control. Despite the fact that this is a lesions. One interesting observation found in this study was a sta-
2‐year follow‐up study, longer periods of observation are recom- tistically significant association between the characteristics of the
mended to assess the rate of success and the possible complications cervical lesion and reduction in the recession. A significant associa-
of this combined approach. It should be recognized that the peri- tion between cervical lesion height and root coverage was
odontal surgery associated with the restorative procedure required a observed after use of either the coronally positioned flap or the
longer clinical time compared with the isolated surgical procedure. subepithelial connective tissue graft procedure. It was speculated
Although the coronally positioned flap can obtain good root cov- that for larger defects, greater absolute root coverage may be
erage, it has limited indications, it has better results for upper teeth achieved, although complete coverage of the defect may not nec-
than for lower teeth, can be used only when associated with natural essarily be accomplished. This observation may also be valid when
teeth and, more importantly, does not increase tissue thickness along gingival recession is associated with noncarious cervical lesions.
with root coverage (an important factor to reduce recurrence). To When these two defects are concurrent, part of the tooth crown,
solve this, techniques that associate the coronally positioned flap just above the cementoenamel junction, is destroyed by noncarious
with auto or allografts were developed. cervical lesions and may represent the most coronal zone of the
combined defect. This condition makes complete root coverage of
the combined lesion unpredictable. Another interesting observation
10 | SUBEPITHELIAL CONNECTIVE TISSUE is the statistically significant association (P = 0.0045; R2 = 0.51)
GRAFT seen between cervical lesion depth and root coverage when the
coronally positioned flap is applied alone (ie, without the restora-
Subepithelial connective tissue grafting has been proposed as a way tion). Data show that the deeper the cervical lesion, the greater
to improve the amount of root coverage obtained with a coronally the coverage in the coronally positioned flap group. The explana-
positioned flap. Case reports have been published in which this was tion for this finding may lie in the absence of root convexity when
noncarious cervical lesions are present concurrently with the reces- 11 | ACELLULAR DERMAL MATRIX
sion. Thus, the presence of a cervical lesion may eliminate the
excessive convexity of the root, and the flap could be well The subepithelial connective tissue graft procedure has achieved
adapted and sutured without tension. However, the same associa- high success and predictability through combining the advantages of
tion could not be observed when the subepithelial connective tis- both a free gingival graft and a pedicle graft. However, this proce-
sue graft was applied. The distance between the bone crest and dure requires a second surgical site that may cause a certain degree
the incisal border of noncarious cervical lesions was significantly of discomfort, increase the risk of postoperative complications, and
associated with root coverage when overall data and data from limit the number of teeth that can be treated in a single surgery. As
the subepithelial connective tissue graft group were analyzed an alternative to autogenous graft procedures, an acellular dermal
(P = 0.0006 and R2 = 0.53 for overall data; P = 0.02 and R2 = 0.63 matrix graft has been proposed in an attempt to minimize the disad-
for the subepithelial connective tissue graft group). This finding vantages described above for the autogenous donor graft.54 This
may confirm a positive association between the height of lesions allograft is obtained from a human donor, and the skin tissue is trea-
and the amount of recession reduction because larger recessions ted through a process that removes all cell components while pre-
are associated with a greater distance between the bone crest and serving the remaining bioactive extracellular matrix, which is
the incisal border of the cervical lesion. This observation could subsequently frozen and dried. Acellular dermal matrix graft contains
indicate that bone dehiscence does not negatively interfere with undamaged collagen and elastin matrices that function as a scaffold
root coverage. to allow ingrowth of host tissues. Acellular dermal matrix grafts may
Although the majority of studies have shown excellent outcomes be an alternative to subepithelial connective tissue grafts in cases in
after treatment with a subepithelial connective tissue graft, Carnio et which a secondary surgical site and its associated morbidity are of
al51 reported a case of root resorption following a clinically success- significance for the patient.
ful root‐coverage procedure on a maxillary lateral incisor. Two years Novaes et al have extensively evaluated acellular dermal matrix
after the graft procedure was performed, the tooth was extracted in grafts in a variety of experimental and clinical situations, which
conjunction with the buccal attachment apparatus. Histologic exami- include use of the material to eliminate gingival melanin pigmenta-
nation of the specimen revealed signs of active resorption of the tion,55 and for guided tissue regeneration,56 guided bone regenera-
dentinal surface and bone formation in the deepest portion of the tion,57,58 and root‐coverage59 procedures.
resorption cavity. The group58 began to compare the effectiveness of acellular der-
52
Caffesse et al conducted a study to evaluate the effectiveness mal matrix grafts with subepithelial connective tissue grafts for root
of subepithelial connective tissue graft in covering localized gingival coverage. They showed that the amount of recession reduction
recessions after the roots had been modified by citric acid. The obtained with the acellular dermal matrix graft procedure was similar
authors demonstrated no benefits from the addition of citric acid— to the amount of recession reduction obtained using a connective
the surgical technique gave similar results regardless of whether or tissue graft procedure combined with a coronally positioned flap.
not citric acid was applied. Moreover, citric acid had no detrimental Others have clinically evaluated the treatment of Miller Class I
effects. Whether there is any histological difference after demineral- gingival recessions using coronally positioned flap, with or without
ization of the root could not be assessed using this experimental acellular dermal matrix graft as a subepithelial connective tissue
model. However, because a minimal change was detected in probing graft.60 The mean root coverage achieved in the acellular dermal
depths, the coverage achieved was the result of gain in clinical matrix graft group was 76.2% compared with 71.2% in the coronally
attachment levels and could be a result of insertion of fibers into the positioned flap group, with no significant difference between the
surfaces of the roots. groups. As previously observed, a significant increase in the thick-
In 2008, a systematic review53 was conducted to answer the fol- ness of keratinized tissue, favoring the acellular dermal matrix graft
lowing question: Can subepithelial connective tissue grafts be con- group, was shown. In a long‐term observation of the above study48
sidered the gold standard procedure in the treatment of recession‐ it was noted that acellular dermal matrix graft may further reduce
type defects? From a total of 568 references, 23 studies were con- the residual gingival recession observed after 24 months in defects
sidered relevant. The results indicated a statistically significantly treated with a coronally positioned flap.
greater reduction in gingival recession for subepithelial connective Coronally positioned flap + connective tissue graft was com-
tissue grafts than for acellular dermal matrix grafts and for guided pared with coronally positioned flap + acellular dermal matrix
tissue regeneration with resorbable membranes. No significant differ- grafts61 to treat Miller Class I and II recessions in a pilot study. Cor-
ences were observed between groups for clinical attachment level onally positioned flap associated with either a subepithelial connec-
changes. Regarding changes in keratinized tissue, the results showed tive tissue graft or an acellular dermal matrix graft was effective in
a statistically significant gain in the width of keratinized tissue for root coverage. However, coronally positioned flap + connective tis-
subepithelial connective tissue grafts when compared with guided sue graft provided a more favorable clinical outcome regarding root
tissue regeneration. The overall comparisons allow the authors to coverage.
consider subepithelial connective tissue graft as the gold standard Acellular dermal matrix graft has become widely used in peri-
procedure in the treatment of recession‐type defects. odontal surgery as a substitute for subepithelial connective tissue
graft. However, these grafts exhibit different healing processes than flap also allowed for better tissue manipulation, especially in obtain-
usual because of their distinct nonvital structure. As a consequence, ing a tensionless coronally positioned flap to cover the allograft com-
cells and blood vessels from the recipient site are necessary to pletely. This is particularly important because the acellular dermal
achieve reorganization. Healing and revascularization of an autograft matrix graft has the ability to revascularize only when in direct con-
are based on the anastomoses between blood vessels of the gingival tact with vital tissues. In addition, displacement of the releasing inci-
corium and those pre‐existing in the graft. When acellular dermal sions also reduces the possibility of exposure compared with the
matrix graft is associated with a coronally positioned flap, the overly- other procedure, which is important because exposure of the allo-
ing flap, which represents an extra source of blood , favors healing graft may compromise root coverage. These results led to the con-
and also incorporation of the allograft. As the allograft is an avascu- clusion that the extended flap procedure in the treatment of
lar and acellular material, the subepithelial connective tissue graft localized gingival recessions with acellular dermal matrix graft is bet-
technique, in which the releasing incisions are placed on the proxi- ter, exhibiting a superior clinical performance compared with the
mal surfaces of the tooth, may not be adequate. The close proximity procedure routinely used. Successful and predictable long‐term
of the incisions to the allograft limits the blood supply and source of results in surgical gingival recession treatment require not only strict
cells, and could also allow epithelial invagination, predispose expo- selection of patients and sites, but also the appropriate surgical pro-
sure of the graft and, as a result, compromise the amount of root cedure for each case. Long‐term results were demonstrated at 1264
coverage. As the main blood supply of the gingiva is directed cau- and 36 months63 (Figure 7). Therefore, the surgical procedure pri-
docranially from the vestibule to the gingival margin, displacement of marily developed for the autograft may not be adequate for the allo-
the releasing incisions to the adjacent teeth could provide better graft. When it is the preferred treatment option, a broader recipient
conditions for the allograft healing process. Based on all these asser- site should be provided.
tions, Barros et al62 compared the clinical results of two surgical pro- In a randomized, controlled clinical trial, Felipe et al56 compared
cedures—the conventional coronally positioned flap (Figure 3) and a two surgical procedures for root coverage with the acellular dermal
modified procedure (Figure 4)—for the treatment of localized gingi- matrix to evaluate which procedure provided better root coverage, a
val recessions with the acellular dermal matrix as the graft itself. The better esthetic result, and less postoperative discomfort. The control
modified procedure proposed an extended flap to facilitate incorpo- group was treated with a broader flap and vertical releasing inci-
ration of acellular dermal matrix graft because this process is depen- sions62 (Figure 8A)56; and the test group was treated with the pro-
dent on host cell infiltration and blood vessel invasion. Instead of posed surgical procedure, without vertical releasing incisions
the two releasing incisions being placed mesial and distal to the root (Figure 8B).56 In this procedure,65 access to the root surface is
to be covered, they were placed in the mesial and distal aspects of achieved through an initial horizontal incision made in the interproxi-
the adjacent teeth. Comparisons between groups showed no statisti- mal tissue at the base of the papilla, at the level of the cementoe-
cally significant differences in probing depth, clinical attachment namel junction or slightly coronal (Figures 9 and 10).66 Analyses
level, and keratinized tissue after 6 months; however, there was a between the two groups after 6 months showed statistically signifi-
statistically significant difference in the amount of root coverage cant differences in the keratinized tissue and the percentage of root
63
obtained which favored the test procedure (Figures 5 and 6). The coverage favoring the control group. In this group, root coverage of
root coverage obtained using the conventional procedure was 64% 84.81% was achieved compared with 68.99% in the test group. For
—equivalent to the percentage obtained in another study using the the control group, root coverage of 100% was achieved in nine of
acellular dermal matrix graft (66%).58 The modified procedure 15 cases, whereas for the test group it was achieved in five of 15
showed a better result (root coverage = 79%). The modified surgical cases. No statistically significant differences were observed in the
procedure presented a significant improvement in terms of mean remaining parameters, the esthetic results, or the pain evaluation.
root coverage compared with the conventional procedure. A broader After 12 months66 there was a statistically significant reduction in
F I G U R E 3 Schematic drawing of
conventional technique [Colour figure can
be viewed at wileyonlinelibrary.com]
F I G U R E 4 Schematic drawing of
modified technique [Colour figure can be
recession height in both groups, and there was no statistically signifi- 12 | MULTIPLE GINGIVAL RECESSIONS
cant difference between the procedures regarding root coverage.
The authors commented that both procedures may have impaired Universally, literature reporting on multiple recession‐type defects is
the blood supply to some extent—through the releasing incisions in scarce, especially for cases in which subepithelial connective tissue
the control group and via the horizontal incisions through the papil- grafts are associated with a coronally positioned flap. Following anal-
lae in the test group. ysis of the four studies amenable for systematic reviews69 it was
In some cases of root coverage, primary shrinkage of soft tissue concluded that mean root coverage ranged from 94% to 98%, and
can lead to exposure of the grafts. This may be very harmful when complete root coverage was achieved for 68%‐90% of the cases. It
acellular dermal matrix graft is used because the exposed part, with- seems that the clinical practice for treating multiple recession‐type
out nutrition, usually disintegrates, resulting in a less than optimal defects is supported by the same principles used in root‐coverage
desired result.67 Thus, the graft and flap positioning at the level of procedures performed at individual sites. However, the treatment of
the cementoenamel junction might favor exposure of the acellular multiple recession‐type defects (ie, involving three or more teeth)
dermal matrix graft, making it impossible to achieve complete root with one surgical procedure is directly linked to the amount of
coverage. Based on this statement, to prevent exposure of acellular subepithelial connective tissue graft available. In cases in which the
dermal matrix graft and to compensate for the shrinkage of primary subepithelial connective tissue graft harvested from the palate is not
68
soft tissue, Ayub et al compared the clinical results of two surgical sufficient to cover all adjacent recessions, more than one surgical
techniques: the extended flap proposed by Barros et al62 and a mod- procedure will be required. A case report70 showed, in 3‐year follow‐
ified procedure for the treatment of localized gingival recessions up, that subepithelial connective tissue graft used with the tunnel
with the acellular dermal matrix as the graft itself. The modified pro- technique to treat multiple gingival recessions resulted in satisfactory
cedure proposed positioning the graft 1 mm apical to the cementoe- coverage. As a result of anatomic limitations in the donor area, one
namel junction, and the flap 1 mm coronal to the cementoenamel of the difficulties in obtaining coverage of multiple recessions with
junction (Figure 11). The comparisons between groups showed sta- subepithelial connective tissue graft is acquiring a graft of adequate
tistically significant differences favoring the proposed technique for size; therefore, a technique used to extend the graft was also
all parameters analyzed after 12 months (Figures 12 and 13).68 A described. The graft is usually removed from the palate in the region
statistically significant difference in the amount of root coverage of the premolars and first molar. If this length is respected, three
obtained favored the test procedure with the extended flap proce- teeth is the maximum area of coverage. If the coverage area involves
dure exhibiting 65.85% and 78.81% root coverage, while the modi- a larger number of teeth or a curved area of the dental arch, a graft
fied procedure exhibited 88.37% and 92.23% root coverage, at 6 with a larger area is necessary. If a subepithelial connective tissue
and 12 months, respectively. Thus, the proposed technique proved graft, a surgical approach is necessary to enlarge it. In this case, per-
to be more suitable for root‐coverage procedures with acellular der- forming a cross‐sectional split of the graft resulted in a graft of
mal matrix grafts. At 12 months, however, the amount of keratinized almost twice the initial length, enabling it to encompass the curved
gingival was similar for both procedures. area of the dental arch involving five adjacent teeth with a thickness
A B C
D E F
F I G U R E 5 Conventional technique group: A, preoperative Miller Class I; B, the releasing incisions at the proximal line angles of the
involved tooth; C, the partial‐thickness flap reflected; D, acellular dermal matrix graft trimmed to the shape and size of the surgical bed and
sutured in place; E, flap coronally sutured to completely cover the graft; F, the treated area 36 mo after surgery63 [Colour figure can be
of 1.5 mm. Overall, the result obtained with the subepithelial con- The superficial layer (epithelium and a thin zone of connective tis-
nective tissue graft and the tunnel technique was rather favorable. sue) was then dissected from the graft and replaced at the donor
There was considerable reduction in the multiple gingival recessions, site to facilitate faster healing. The subjacent layer of connective tis-
together with an increase in the volume of soft tissue and gain of sue was placed as needed to obtain root coverage. The clinical appli-
gingiva. Furthermore, after a 3‐year follow‐up, these results were cation of this technique was successfully applied for multiple gingival
maintained. Others reported an alternative surgical approach to the recessions.
harvesting of subepithelial connective tissue graft from thin Chambrone and Chambrone72 evaluated the clinical results
71
palates. A partial thickness flap was raised, and a graft composed obtained with a subepithelial connective tissue graft placed under a
of epithelium and connective tissue was removed from the palate. coronally positioned flap for the treatment of multiple recession‐type
A B C
D E F
F I G U R E 6 Modified technique group: A, preoperative Miller Class I recession on a maxillary right canine; B, a partial‐thickness flap
reflected and delimited by the releasing incisions displaced to the proximal line angles of the adjacent teeth; C, acellular dermal matrix graft
trimmed to the shape and size of the surgical bed and sutured over the defect of the tooth in question only; D, flap coronally sutured to cover
the graft; E and F, the treated area 36 mo after surgery63 [Colour figure can be viewed at wileyonlinelibrary.com]
F I G U R E 7 Root coverage (%) after 6, 12, and 36 mo63 [Colour

figure can be viewed at wileyonlinelibrary.com]
defects. As a second objective, differences between patients with B

maxillary or mandibular multiple recession‐type defects were
assessed. These authors observed that the combination of coronally
positioned flap surgery with a subepithelial connective tissue graft
was effective for covering multiple recession‐type defects. When the
6‐month measurements were compared with baseline values, signifi-
cant improvement was observed in all clinical parameters. The mean
increase of root coverage between baseline and the final 6‐month
postoperative time point was 96%, and complete root coverage was
achieved in 71% of the sites with multiple recession‐type defects.
No differences relative to defects that involved two consecutive
teeth vs three or four consecutive teeth were observed during the
surgical procedures.
Multiple recessions were treated at the same time with a modifi- F I G U R E 8 Schematic drawing: A, control group and B, test
group56 [Colour figure can be viewed at wileyonlinelibrary.com]
cation of the coronally positioned flap procedure22 primarily
described by Zucchelli and De Sanctis.73 Briefly, the flap was created recession defect. The oblique incisions started at the cementoenamel
by making oblique submarginal incisions in interdental areas and junction of the central tooth at the site of multiple teeth containing
then by making intrasulcular incisions at the adjacent teeth with the recession‐type defects and were continued toward the most apical
A B
F I G U R E 9 Clinical sequence of the

control group. A, Preoperative gingival
C D recession on a maxillary right canine. The
restorations on the root surfaces were
removed before the surgery. B, Flap
elevated with a partial‐thickness dissection
and the acellular dermal matrix graft
sutured in place. C, Flap coronally sutured
covering the entire graft. D, Postoperative
image of the treated area after 12 mo66
[Colour figure can be viewed at wile
yonlinelibrary.com]
A B
F I G U R E 1 0 Clinical sequence of the

test group. A, Preoperative gingival
C D recession on a maxillary left canine. The
restorations on the root surfaces were
removed before the surgery. B, Flap
sutured in place. C, Flap coronally sutured
covering the entire graft. D, Postoperative
image of the treated area after 12 mo66
[Colour figure can be viewed at wile
yonlinelibrary.com]
point of the gingival margin at adjacent teeth. The flap was raised bed, and held in place using sling sutures. The flaps were positioned
using a split‐full‐split approach in the coronal‐apical direction: from at the level of, or slightly coronal to, the cementoenamel junction, in
the oblique interdental incisions, a split‐thickness flap was raised to such a way that the surgical papillae created were moved coronally
create surgical papillae, the gingival tissue apical to the root reces- and laterally over the anatomical papilla (ie, mesial papillae were
sions was raised in a full‐thickness manner to expose about 3.0 mm rotated in a mesial‐coronal direction, and distal papillae were rotated
of bone, and a split‐thickness flap was elevated at the most apical in a distal‐coronal direction). The study showed that modified coro-
portion of the flap to allow flap coronal movement without tension. nally advanced flap associated with a subepithelial connective tissue
The remaining tissue of the anatomic interdental papilla was then graft was an effective and predictable approach in cases of multiple
deepithelialized, creating a connective bed for flap coronal advance- adjacent gingival recessions, resulting in average root coverage of
ment. Connective tissue graft of appropriate dimensions to cover 96.7% and complete root coverage in 93.1% of recessions. Residual
the root surfaces and surrounding bone was harvested from the recessions were observed in two of the 29 treated defects, both in
palate in the premolar area and trimmed to remove visible epithe- the same patient, at posterior teeth, and were probably related to
lium. The graft was placed at the level of the cementoenamel junc- short papillae. Nevertheless, in 90% (nine of 10) of the patients,
tion, covering the entire defect and interdental connective tissue complete root coverage was obtained. The authors argue that the
report43 discussed the treatment of multiple gingival recessions asso-

ciated with cervical abrasions using subepithelial connective tissue
graft combined with coronally positioned flap onto a previously resin
composite‐restored root surface. The success of the restorative/sur-
gical approach was confirmed by the absence of bleeding on probing
and periodontal pockets, as well as by the presence of gingival tissue
with normal color, texture, and contouring. After 18 months of fol-
low‐up, the clinical conditions were stable with satisfactory root cov-
erage and periodontal health. The authors reported that an excellent
esthetic outcome was achieved and the patient was satisfied with
the case resolution.
F I G U R E 1 1 Representative image of the modified technique

13 | GUIDED TISSUE REGENERATION
[Colour figure can be viewed at wileyonlinelibrary.com]
As the concept of guided tissue regeneration became widely used
etiology of recession defects is related to the thickness of the gingi- for intrabony and furcation defects, attempts were made also to
val margin (ie, thinner gingival tissues are more prone to develop apply these principles to treat gingival root recession defects. Qui-
recessions). The use of connective grafts associated with root‐cover- ñones74 describes the surgical technique for clinical application of
age procedures increases the thickness of soft tissue. Moreover, these principles.
connective tissue grafts create the possibility to cover recessions Subepithelial connective tissue graft and guided tissue regenera-
associated with carious and noncarious cervical lesions. By contrast, tion with a bioabsorbable collagen membrane and bone graft (dem-
root‐coverage procedures based on soft tissue manipulation alone ineralized freeze‐dried bone allograft) demonstrated significant
seem to lack efficacy for such defects. The presence of a dead space clinical and esthetic improvements for gingival root coverage.75 The
between the inner face of the flap and the root surface might nega- results obtained with subepithelial connective tissue grafts, however,
tively interfere with adaptation and stability of soft tissues. were significantly better than those of guided tissue regeneration
Extensive gingival recessions associated with deep caries or cer- procedures regarding keratinized thickness, height of gingival reces-
vical abrasions caused by incorrect toothbrushing are commonly sion, and root coverage. On the other hand, guided tissue regenera-
observed in dental practice. In these cases, complete coverage using tion was statistically superior to subepithelial connective tissue graft
traditional mucogingival surgical procedures might be contraindicated when probing depth was evaluated 18 months after surgery. The
because of the need for extensive root planing, which could compro- authors concluded that subepithelial connective tissue grafting may
mise the tooth. The combination of an adhesive restorative material be a more suitable procedure for creating an increased amount of
and surgical coverage may be an ideal solution. Another case keratinized gingiva.
A B

control group. A, Preoperative gingival C D
recession on a maxillary left canine. B, Flap
sutured at the level of the cementoenamel
junction. C, Flap sutured at the level of
cementoenamel junction covering the
entire graft. D, Postoperative image of the
treated area after 6 mo68 [Colour figure
can be viewed at wileyonlinelibrary.com]
A B

C D test group. A, Preoperative gingival
recession on the maxillary right canine. B,
Flap elevated with partial‐thickness
dissection and the acellular dermal matrix
graft sutured 1 mm apical to the
cementoenamel junction. C, Flap sutured
1 mm coronal to the cementoenamel
junction. D, Postoperative image of the
treated area after 6 mo68 [Colour figure
can be viewed at wileyonlinelibrary.com]
The use of guided tissue regeneration compared with coronally regeneration when used in combination with a subepithelial connec-
positioned flap in root‐coverage procedures was evaluated in a split tive tissue graft was observed in human histology of 4 teeth in 2
mouth design.76 After 6 months of analysis, the results indicated that cases.78 It was observed that in those four specimens, enamel matrix
when paired gingival recession defects are treated by coronally posi- derivative promoted limited periodontal regeneration in the apical
tioned flap or guided tissue regeneration (in the latter using coro- region of one tooth, despite the fact that clinical signs of root cover-
nally positioned flap with titanium‐reinforced expanded age were achieved with the combined therapy. Predominantly, the
polytetrafluoroethylene membranes) there may be discrepancies modality of attachment observed between the graft and the root
between the responses of soft and hard tissue. Root coverage was surface consisted of dense collagen fibers running parallel to the
greater for coronally positioned flaps, while bone gain was greater root surface, without new cementum or the presence of Sharpey's
for guided tissue regeneration. The average root coverage was 45% fibers. The results suggest that although feasible in apical areas, the
for guided tissue regeneration and 60% for coronally positioned potential of enamel matrix derivative to promote regeneration is not
flaps. The less favorable results obtained with guided tissue regener- predictable. Interestingly, no signs of pathologic root resorption were
ation may be caused by postoperative membrane exposure, a com- observed in any of the specimens, which has been reported to occur
mon occurrence in the early healing phase of guided tissue when gingival connective tissue is in direct contact with the root
regeneration procedures. Furthermore, the authors suggested that surface in root coverage procedures.51 The authors then speculate
barrier contamination might also interfere with the expected clinical whether the enamel matrix derivative might influence wound heal-
outcomes. ing, possibly by inhibiting the differentiation and proliferation of
The results of a meta‐analysis showed that the use of subepithe- cementoclasts and dentinoclasts. The development of a long junc-
lial connective tissue grafts led to a statistically significant reduction tional epithelium was not observed in any of the four specimens
in gingival recession and gain in keratinized thickness, especially examined. This is of interest because the formation of a long junc-
when compared with guided tissue regeneration procedures.77 Con- tional epithelium has been observed following successful root cover-
sidering that subepithelial connective tissue grafts were statistically age using subepithelial connective tissue grafts. In turn, the authors
superior to guided tissue regeneration (with or without bone substi- speculate whether enamel matrix derivative may act on epithelial
tutes) and because of the technical difficulty of the latter, guided tis- cells in a manner that inhibits their proliferation.
sue regeneration procedures have lost popularity as root coverage A 12‐month, prospective, parallel clinical trial79 was designed to
procedures, especially in highly demanding esthetic cases. evaluate the use of coronally positioned flap with the addition of
enamel matrix derivative. The objective was to observe if the results
of using coronally positioned flap could be improved by the addition
14 | ENAMEL MATRIX DERIVATIVE of enamel matrix derivative, so that the coronally positioned flap
could become the technique of choice for certain types of recession.
The rationale for the use of enamel matrix derivative in plastic peri- The authors also analyzed a block biopsy of one of the cases stud-
odontal surgery was derived from the reported ability of enamel ied. Interestingly, there was a significant increase in the mean width
matrix derivative to promote periodontal regeneration in osseous of keratinized tissue following treatment with coronally positioned
defects. The ability of enamel matrix derivative to promote true flap + enamel matrix derivative. The authors speculate that enamel
matrix derivative also acts as a barrier, thus allowing granulation tis- The fact that enamel matrix derivative + coronally positioned
sue growing from the periodontal ligament surrounding the recession flap seems to be superior to coronally positioned flap alone in root‐
to repopulate the exposed root surface under the protection of coverage procedures, especially regarding the amount of keratinized
coronally positioned flap. A certain apical‐coronal width of gingiva is tissue gain,77,81 may be more a function of connective tissue healing
required for the maintenance of periodontal health and to prevent conditioning blocking junctional epithelium and/or improving gingival
soft tissue recessions. Therefore, the favorable outcome of the coro- contours, rather than truly regenerating the periodontium.
nally positioned flap + enamel matrix derivative treatment may pro-
mote use of this procedure for recession coverage because an
increased gingival dimension is one of the main goals of periodontal 15 | SMOKING
plastic surgery. From a histologic point of view, however, there was
limited evidence indicating that new cementum formation, insertion There is rather a large body of evidence attesting that smoking nega-
of periodontal ligament fibers, and new bone formation could be tively influences periodontal tissues, increasing the risk for periodon-
achieved after use of coronally positioned flap + enamel matrix tal disease.82,83 Smoking is capable of changing the tissue response
derivative. to bacterial aggression, decreasing the number of lymphocytes and
Recently, Alves et al,80 in a randomized controlled clinical immunoglobulins in crevicular fluid, modifying neutrophil chemotaxis
study, compared the use of acellular dermal matrix grafts, with or and phagocytosis, and misregulating the production of inflammatory
without the enamel matrix derivate, in smokers to evaluate which mediators. As a consequence, smokers have increased probing
procedure would provide better root coverage (Figures 14 and depths, greater attachment loss, and a greater prevalence, extent,
15).80 The mean recession height change of the test group (acellu- and severity of recession compared with age‐matched nonsmokers.
lar dermal matrix graft + enamel matrix derivative) was superior to In addition to clinical outcomes, another aspect to be considered is
that obtained in the control group (acellular dermal matrix grafts the possible changes in soft tissues caused by smoking. Nicotine has
only; P = 0.042); and the percentage of root coverage in the test a vasoconstrictor effect on the blood vessels of the gingival tissues,
group (55.4%) was higher than that in the control group (44.0%). decreasing some clinical signs of inflammation, such as bleeding of
Although improvements in the test group were greater, no signifi- the marginal gingiva. Mucogingival problems are more prevalent in
cant differences between the groups were found in the other smokers, with smoking exhibiting a dose‐response effect. Moreover,
parameters (gingival recession height (GRH), gingival recession smokers present poorer short‐ and long‐term periodontal plastic sur-
width (GRW), keratinized tissue width (KTW), probing depth, gery outcomes. In addition, smokers may be at greater risk for cer-
relative clinical attachment level (RCAL). The test group showed tain postoperative complications following such procedures. Smokers
complete root coverage in three gingival recessions, whereas the have the same esthetic needs as nonsmokers. In fact, there is a
control group showed complete root coverage in only one gingival strong association between smoking and gingival recession that is
recession. Thus, the authors concluded that the association of independent of the severity of the interproximal attachment loss.84
acellular dermal matrix graft and enamel matrix derivative is bene- A prospective clinical study demonstrated that connective tissue
ficial in promoting root coverage of gingival recessions in smokers, grafts might provide benefits for smokers and nonsmokers through
6 months after surgery. improving gingival recession, keratinized tissue width, gingival
A B
F I G U R E 1 4 Representative images of
surgical procedures. A, Flap elevated with
partial‐thickness dissection and acellular
dermal matrix graft sutured in place C D
(control group). B, Enamel matrix derivative
application at the acellular dermal matrix
graft/soft tissue interface (test group). C,
Enamel matrix derivative application at the
acellular dermal matrix graft/root surface
interface (test group). D, Flap coronally
sutured covering the entire graft (control
and test groups)80 [Colour figure can be
A C
B D F I G U R E 1 5 Pre‐ and postoperative

images: A, Preoperative gingival recession
on a mandibular left first premolar (control
group). B, Postoperative image of the
treated area after 6 mo (control group). C,
Preoperative gingival recession on a
mandibular right second (test group). D,
Postoperative image of the treated area
after 6 mo (test group)80 [Colour figure can
be viewed at wileyonlinelibrary.com]
thickness, and clinical attachment level.85 Smokers, however, exhibit subjects (15 smokers and 15 nonsmokers). Any brown‐staining
less favorable results than nonsmokers—cigarette consumption sig- endothelial cell was considered as a countable vessel, and a vessel
nificantly affects therapy outcomes. The mean root coverage lumen was not necessary for the structure to be counted as a blood
obtained was 58.84% and 74.73% for smokers and nonsmokers, vessel. The results showed that blood vessel density was 30% lower
respectively. Interestingly, in this study it was found that heavy in subepithelial connective tissue grafts of smokers than in such
smokers had greater keratinized tissue than nonsmokers, 4 months grafts in nonsmokers. The reduced availability of blood vessels may
postoperatively. It could be speculated that this increase in kera- retard the revascularization of the subepithelial connective tissue
tinized tissue is part of the reaction of the oral mucosa to the toxins graft. Adequate blood supply is critical for healing of the graft, and
present in tobacco smoke. Over time, smokers tend to lose some of reduction in blood supply could have contributed to the clinical dif-
the root coverage originally gained. The longitudinal observation of ferences in root coverage between smokers and nonsmokers.
those patients86 revealed that, at 24 months postoperatively, smok- A prospective study clinically evaluated and compared, in smok-
ers presented statistically poorer outcomes with regard to probing ers and nonsmokers, the dimensional changes of free gingival graft
depth, gingival recession, and clinical attachment level; in addition, a used to increase the amount of keratinized tissue and the healing
more satisfactory stabilization of the gingival tissue was found in the aspects of the free gingival graft donor site.24 The authors discussed
nonsmoker group. The authors concluded that smoking may repre- the differences in probing depth, gingival margin position, clinical
sent a challenge to root‐coverage outcomes because smoking signifi- attachment level, keratinized tissue width, and gingival thickness
cantly affects the stability of gingival tissue over time. Silva et al87,88 between smokers and nonsmokers. Free gingival graft dimensions
also found poorer outcomes after coronally positioned flap, as a (width, length, and area) were assessed and recorded before surgery,
root‐coverage procedure for smokers, at both 6 and 12 months and 7, 15, 30, 60, and 90 days postoperatively. Free gingival graft
postoperatively. dimensions changed significantly postoperatively. At 90 days postop-
Souza et al89 evaluated the outcomes of a coronally positioned eratively, free gingival graft width, length, and area were reduced by
flap associated with a subepithelial connective tissue graft for root 31%, 22%, and 44%, respectively, in nonsmokers, and by 44%, 25%,
coverage of Miller Class I and II recession defects in smokers and and 58%, respectively, in smokers. There were no statistically signifi-
nonsmokers, analyzing clinical parameters and graft vascularization cant differences between smokers and nonsmokers, despite the con-
patterns between groups. The clinical results of this study indicated sistent trend for greater shrinkage, in smokers, for all free gingival
that smoking could reduce the root coverage obtained with a subep- graft dimensions and overall at all postoperative time points. Signifi-
ithelial connective tissue graft associated with a coronally positioned cant increases of keratinized tissue were observed in both nonsmok-
flap. As observed in other studies, the percentages of root coverage ers and smokers. The palatal donor area was evaluated for
in smokers 3 months (62.10%) and 6 months (58.02%) after treat- immediate bleeding and complete wound epithelialization. A signifi-
ment with coronally positioned flap were substantially lower than cantly lower proportion of smokers exhibited immediate bleeding
those of nonsmokers (82.17% and 83.35%, respectively). Smoking after graft harvesting compared with nonsmokers. Hence, the collec-
also limits the number of cases with complete root coverage: 6.7% tive results suggest that following palatal graft harvesting, hemosta-
in smokers compared with 53.3% in nonsmokers. In this study, a sis can be more readily obtained in smokers. This could be attributed
blood vessel density count was performed in 30 biopsies from 30 to the chronic long‐term effect of smoking on gingival blood vessels,
an effect that can be clinically observed as less gingival redness, less be covered. Based on these assertions, Reino et al90 suggested the
prevalent bleeding on probing, and fewer visible vessels. In terms of use of the extended flap technique proposed by Barros et al62 in
donor‐site wound healing, 2 weeks after surgery, 92% of nonsmok- smokers, as this new technique may increase root coverage in smok-
ers and only 20% of smokers presented complete epithelialization, ers, improving graft vascularity. Twenty heavy smokers with two
whereas 1 month after surgery all sites were epithelialized. To con- bilateral Miller Class I gingival recessions received corronally
clude, the results indicate that smoking alters free gingival graft advanced flap on one side (control group) (Figure 16)90 and an
donor‐site wound healing by reducing the immediate postoperative extended flap on the other side (test group) (Figure 17).90 Clinical
bleeding incidence and by delaying epithelialization; however, smok- measurements (probing pocket depth, clinical attachment level,
ing did not significantly affect graft shrinkage. bleeding on probing, GRH, GRW, keratinized tissue, and the width
In order to achieve higher vascularization levels in periodontal and height of the papillae adjacent to the recession) were deter-
plastic surgery procedures with acellular dermal matrix, Barros et al62 mined at baseline, and 3 and 6 months postoperatively, and salivary
described a new technique, which consisted of extending the flap cotinine samples were taken as an indicator of the nicotine exposure
with vertical incisions to the adjacent teeth to the recession area to level. No statistically significant differences (P > 0.05) were detected
A B C
D E
F I G U R E 1 6 Conventional technique: A, preoperative view, B, the releasing incisions at the proximal line angles of the involved tooth, C,
graft sutured to the receptor site, D, flap coronally sutured to completely cover the graft was sutured in position, E, treated area 6 mo after
surgery90 [Colour figure can be viewed at wileyonlinelibrary.com]
A B C
D E
F I G U R E 1 7 Extended technique: A, preoperative view, B, the releasing incisions displaced to the proximal line angles of the adjacent teeth,
C, graft sutured to the receptor site, D, flap coronally sutured to completely cover the graft was sutured in position, E, treated area 6 mo after
surgery90 [Colour figure can be viewed at wileyonlinelibrary.com]
for the clinical measurements or smoke exposure. Both techniques benefits in the treatment of teeth with gingival recessions.29 The
promoted low root coverage (43.18% in the control group and authors suggest that the good esthetic results for root coverage,
44.52% in the test group). In conclusion, no difference was found in obtained using the semilunar technique, could be a consequence of
root coverage between the techniques. Limited root coverage is pos- use of the operative microscope, which offers advantages, such as:
sible and uneventful, even in heavy smoker patients with low plaque enhanced visual acuity through magnification; improved illumination
and bleeding indices. of the field; and more accurate and atraumatic manipulation of the
A meta‐analysis91 was conducted to assess the results obtained soft tissue.
in the literature for root‐coverage procedures in smokers and non- The hypothesis that the improved visual acuity and better soft
smokers. Concerning subepithelial connective tissue grafts, it was tissue handling that result from the application of a microsurgical
demonstrated that significantly more root coverage and clinical approach would improve the predictability of the coronally posi-
attachment gain was obtained for nonsmokers than for smokers. tioned flap + enamel matrix derivative procedure for root coverage
However, coronally positioned flaps produced similar outcomes for and provide less postoperative discomfort was tested in a random-
smokers and nonsmokers in terms of changes in gingival recession, ized, controlled, clinical trial.92 The only variables in the study were
clinical attachment level, and width of keratinized tissues. Noticeable the use of an operating microscope, microsurgical instruments, and a
variation was found in the percentages of mean root coverage and microsurgical suture material in the test group. Thus, two clinical
complete root coverage between studies and procedures. Smokers approaches that applied the same surgical procedure (coronally posi-
who received subepithelial connective tissue grafts for treatment of tioned flap + enamel matrix derivative) to similar types of recession
gingival recession had fewer sites exhibiting complete root coverage defects were compared. There was a notable difference between the
than did nonsmokers. Overall, nonsmokers had the best outcomes. groups in the healing patterns of the releasing incisions and papillae
areas, which were faster with the use of the microsurgical approach.
At 6 months, there was a statistically significant difference between
16 | MINIMALLY INVASIVE PROCEDURES the control group and test group only in the keratinized tissue,
which favored the test group. The additional keratinized tissue gain
Minimally invasive techniques have broadened the horizons of peri- observed in the test group may be ascribed to some advantages of
odontal plastic surgery to improve treatment outcomes. The adjunct the microsurgical approach, such as a more accurate and atraumatic
use of a surgical microscope is associated with additional clinical manipulation of the soft tissues that may have improved the initial
healing in these sites. Also, the coronal displacement of the flaps possible explanation for the higher mean root‐coverage value and
over the defects, which was easier and had less tension with the frequency of complete root coverage in the test group is the
microsurgical technique, may facilitate, during the healing period, advantage of using the surgical microscope in periodontal surgery.
the return of the mucogingival line to its original position. Curi- These advantages are associated with the use of specially designed
ously, complete root coverage was achieved in 11 sites of the test microsurgical instruments that allow a more accurate, atraumatic
group and in seven sites of the control group; however, in both manipulation of the soft tissue, which may result in rapid healing.
groups, complete root coverage was observed in both maxillary In addition, the root area near the cementoenamel junction is the
and mandibular arches. In the test group, there was complete root area most susceptible to hypersensitivity. Thus, the difference
coverage in five canines (four maxillary and one mandibular), five between groups regarding the frequency of complete root cover-
premolars (two maxillary and three mandibular), and one maxillary age could explain why no patient in the test group reported resid-
central incisor, whereas in the control group there was complete ual hypersensitivity, whereas 27.3% in the control group still had
root coverage in five canines (two maxillary and three mandibular) this complaint 12 months after treatment. In conclusion, both
and two premolars (two maxillary). The potential of enamel matrix approaches are capable of producing root coverage; however, the
derivative to increase keratinized tissue may be related to the use of the surgical microscope is associated with additional clinical
ability of enamel matrix derivative to alter the expression of ker- benefits in the treatment of teeth with gingival recessions.
atinocytes and the effect of enamel matrix derivative on gingival It is important to understand that the microsurgical approach is
fibroblasts. Thus, it is reasonable to assume that enamel matrix not easy to perform—intense clinical and laboratory training are
derivative could exert better biological activity in microsurgically required to use a surgical microscope. The use of minimally invasive
treated sites (because of reduced tissue trauma and vessel injury) procedures, however, does not necessarily mean the use of a surgi-
to improve vascularization and achieve primary wound closure, cal microscope. Rather, it is a matter of how the tissues are treated
which allows optimal retention of enamel matrix derivative. during the incisions, how defects are treated, and what surgical
Furthermore, in the maxillary arch, a more coronal displacement of instruments and sutures are used.
the flap over the defects is possible because of better flap mobil-
ity; hence, this may have contributed to the additional keratinized
tissue gain observed in the test group. The study also evaluates 17 | CONCLUSION
the increase in thickness of keratinized tissue that was only statis-
tically significant in the test group. Although other studies have Some factors, anatomical in nature, favor the formation of root
not evaluated this clinical measurement, it may be speculated that recessions; however, it is the inflammatory process (caused by the
the increased biologic activity of enamel matrix derivative on gingi- presence of biofilm and/or by traumatic toothbrushing) that is
val fibroblasts in microsurgically treated sites may explain this responsible for the development of root recessions.
result. This is particularly important because the marginal tissue The pedicle flaps, especially the coronally positioned flap, are
thickness is a critical determinant of future recession. extremely versatile and are the most predictable techniques for root‐
Another randomized controlled clinical trial93 was conducted to coverage procedures, especially when combined with subepithelial
evaluate the benefits of using a surgical microscope in the treat- connective tissue graft and/or allogeneic grafts. Subepithelial connec-
ment of Miller Class I and II gingival recessions with a subepithelial tive tissue graft is considered the first option to augment gingival
connective tissue graft procedure. The results demonstrated that width and thickness and may provide better long‐term results in root
both treatments produced satisfactory percentages of root cover- coverage procedures. The same principles of root coverage proce-
age. However, better results were observed in the microsurgery dures in individual sites seem to orient the clinical practice for multi-
group for this parameter. Twelve months after surgery, the per- ple recession‐type defects.
centage of root coverage was 98.0% and 88.3% for microsurgery Allograft is an efficient alternative to subepithelial connective tis-
and control groups, respectively (P < 0.05). After 12 months, com- sue graft and, when it is the chosen treatment option, the use of
plete root coverage was attained in 87.5% (21 of 24) of the trea- wide, extended flaps should be considered.
ted cases in the test group, and in 58.3% (14 of 21) in the control As a result of the superiority of plastic periodontal procedures
group. No patient in the test group showed less than 77% root over guided tissue regeneration and the technical difficulty of the
coverage, and in the control group, no patient showed less than latter, guided tissue regeneration has become obsolete for root cov-
50% root coverage. The patients’ evaluation of esthetics demon- erage procedures, especially in highly demanding esthetic cases.
strated that at the end of the experimental period, 100% were sat- There is rather a large body of evidence attesting that smoking
isfied with the results of the surgery performed using the negatively influences root coverage procedures, especially subepithe-
microscope and 79.1% were satisfied with the results of surgery lial connective tissue grafts.
without use of the microscope. The results of that study after Minimally invasive techniques may be of great value to improve
12 months demonstrated that subepithelial connective tissue graft results obtained with plastic periodontal procedures; however, they
performed using a surgical microscope was more predictable than need to be better addressed in clinical trials, in terms of both the
the same procedure performed without using this microscope. A quality and quantity of new tissues generated.
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DOI: 10.1111/prd.

Experimental and clinical studies on plastic periodontal

Arthur Belém Novaes Jr | Daniela Bazan Palioto

1 | INTRODUCTION tissue is attached or inserted, and if a biomaterial is properly

F I G U R E 1 A, Biopsy. Histological cut

F I G U R E 7 Root coverage (%) after 6, 12, and 36 mo63 [Colour

defects. As a second objective, differences between patients with B

F I G U R E 9 Clinical sequence of the

F I G U R E 1 0 Clinical sequence of the

report43 discussed the treatment of multiple gingival recessions asso-

F I G U R E 1 1 Representative image of the modified technique

F I G U R E 1 2 Clinical sequence of the

F I G U R E 1 3 Clinical sequence of the

B D F I G U R E 1 5 Pre‐ and postoperative

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