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| 4.1.4. Pedicle Soft Tissue Graft Procedures Combined with Enamel Matrix
Proteins Enamel matrix derivative (EMD; Emdogain; Biora AB, Malmö, Sweden), harvested from embryonic porcine teeth, has been extensively studied in animals and humans and has been also proposed to be used in the treatment of root coverage ((Berlucchi et al., 2002, 2005; Aesthetic Periodontal Therapy – Root Coverage 15 Abbas et al., 2003 ; Hägewald S, et al., 2002; McGuire and Nunn, 2003; Nemcovsky et al., 2004;Cueva et al., 2004; Modica et al., 2000). The technique as described by Berlucchi et al. (2005) is as follows: An intrasulcular incision is made, under local anesthesia, on the buccal aspect of the gingiva. The incision is extended horizontally up to one or two teeth mesially and distally to the tooth involved in order to mobilize the flap, avoiding vertical releasing incisions to preserve as much blood supply as possible. A full thickness flap was then elevated beyond the mucogingival junction; next, a partial thickness flap is elevated in order to mobilize the flap, ensuring a passive coronal adaptation 1 to 2 mm above the cemento-enamel junction. Afterwards, the papillae adjacent to the involved tooth were de-epithelialized and a sling suture is placed, but left untied, mesially and distally to the recession. Then, the root surface is conditioned with an ethylenediamine-tetraacetic acid (EDTA) gel 24% for 2 minutes, in accordance with the manufacturer‘s indication, and rinsed with saline solution. EMD is applied on the conditioned root surface and the suture is tied, positioning the flap 1 to 2 mm above the cemento-enamel junction. Single or sling sutures are used to secure the other papillae (Berlucchi et al., 2005). Cheng et al. (2007) reviewed coronally positioned flap, coronally positioned flap + chemical root surface conditioning, or coronally positioned flap + enamel matrix derivative (EMD) for the treatment of Miller class I and II gingival recession. Clinically, the present analysis demonstrated that all three groups are useful in treating Miller‘s class I and II recession defects. All three groups achieved considerable root coverage and gains in clinical attachment, and maintained the amount of keratinized tissue and shallow probing pocket depths. The application of EMD to denuded root surfaces treated with the coronally positioned flap procedure significantly increased the percentage of root coverage and the attachment level compared with coronally positioned flap alone and the coronallypositioned flap + chemical root surface conditioning procedure. In thepresent review, the coronally positioned flap and coronally positioned flap + chemical root surface conditioning groups resulted in root coverage percentage values ranging from 55 to 75%. The mean root coverage percentage of coronally positioned flap + EMD-treated sites ranged from 71.7 to 95.1%. The average root coverage of coronally positioned flap plus EMD amounted to 84.33 ± 7.72% after 6 mo and 84.42 ± 8.75% at 12 mo. The outcome of coronally positioned flap + EMD was better than coronally positioned flap alone after 6 months (74.12 ± 15.80%) and 12 months (79.00 ± 0.00%). The amount of root coverage obtained was quite stable between 6 and 12 mo in the coronally positioned flap + EMD group for root coverage. This suggests that root coverage procedures in the coronally positioned flap alone and coronally positioned flap + chemical root surface conditioning procedures were unpredictable. They became more predictable when the coronally positioned flap procedure was improved by the modification of adding EMD (Cheng et al., 2007). 4.2. Free Soft Tissue Grafts The autogenous free soft tissue graft procedures may be performed as (1) an epithelized graft or (2) a subepithelial connective tissue graft (non-epithelized graft), both usually taken from the area of the masticatory mucosa in the palate. |