Aesthetic Periodontal Therapy – Root Coverage
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interproximal periodontal attachment and bone and complete root coverage can be achieved;
in Class III, the loss of interdental periodontal support is mild to moderate, and partial root
coverage can be accomplished; in Class IV, the loss of interproximal periodontal attachment
is so severe that no root coverage is feasible. More recently, other factors than the level of
interproximal attachment and bone have been shown to limit the amount of root coverage: the
reduction of papilla height, tooth rotation and tooth extrusion with or without occlusal
abrasion. In all these clinical situation, only partial root coverage can be achieved (Zucchelli
et al., 2010).
The smile line also needs to be considered. Normally, the cosmetic zone is limited to the
maxilla. Patients presenting a ‗‗gummy smile‘‘ should be carefully evaluated before root
coverage procedures. The surgical challenge is great, because the smile will expose the entire
operated zone. These patients may require orthodontics and orthognatic surgery to improve
the lip line (Bouchard et al., 2001).
5.3. Technique Characteristics
Periodontal plastic surgery is an art as much as an science and a skilled practitioner can
obtain more satisfactory results than those with less skills and experience (Grey, 2000). In
periodontal plastic surgery, the choice of procedure is based on the four cardinal principles of
any surgery: success, reproducibility, lack of morbidity and economy. Basically, the easier the
technique the more reproducible it is, since the need for technical skill of the surgeon is
reduced. The surgeon‘s choice will be based on the confidence he has of his own ability to
match the outcomes of the clinical trials (Bouchard et al., 2001).
Criteria for selection of techniques are (Takei et al. 2006):
1.
Surgical site free of plaque,
calculus, and inflammation
2.
Adequate blood supply to the donor site
3.
Anatomy of the recipient and donor site (vestibulat depth,
width of keratinized
gingival, palatal tissue thickness)
4.
Stability of the grafted tissue to the
recipient site
5.
Minimal trauma to the recipient site
Several technique-related factors may influence the treatment outcomes:
The flap thickness. Thick gingival tissue eases manipulation,
maintains vascularity,
and promotes wound healing during and after surgery. Significant moderate
correlation occurred between weighted flap thickness
andweightedmean root
coverage and weighted complete root coverage (r = 0.646 and 0.454, respectively). A
critical threshold thickness >1.1 mm existed for complete root coverage (P <0.02)
(Hwang and Wang 2006)
Elimination of flap tension is considered an important factor for the outcome of the
coronally advanced flap procedure (Wennström et al., 2008; Greenstein et al., 2009).
A. L. Dumitrescu, Liviu Zetu and Silvia Teslaru
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The position of the gingival margin relative to the cemento-enamel junction after
suturing affects the probability of complete root coveragefollowing healing
(Wennström et al., 2008).
Brouchard et al. (2001) revealed several outdated procedures: Nonsubmerged grafts are
no longer justified in the coverage of recession defects for aesthetic purposes. The procedure
is uncomfortable for the patient because of the denuded palatal donor site, and the match with
the surrounding tissues is unpredictable. The double papilla flap also seems to be a dated
technique. Use of elaborate sutures is time-consuming. The procedure requires surgeon‘s
dexterity. Sutures placed over the avascular root surface may lead to postoperative cleft
complications that may impair esthetic results. Similarly, there seems to be little clinical
advantage in using double pedicle flap to cover connective tissue grafts (Brouchard et al.,
2001).
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