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INTRODUCTION
Gingival recession effectively treats a
marginal tissue recession (MTR), since gingiva (protection periodontium) and
periodontal insertion tissues are compromised apically to the cementoenamel
junction [2,3]. According to the classification of current periodontal clinical
diagnosis, cases of loss of clinical insertion and MTR related to bone
dehiscence not caused by periodontitis should be diagnosed as “Congenital or Acquired Conditions and
Deformities” [4].
The biological distances between the gingival
sulcus epithelium, the junctional epithelium and the conjunctival insertion in
the gingival sulcus are related to the apical migration of the gingival margin
in cases of local bone dehiscence, since they are considered a biological
constant [5-7], especially those that make up the biological space (junctional
epithelium and conjunctive insertion). The mean distance between the gingival
margin and the bone crest is approximately 2.04 mm to 3.0 mm [8]. Marginal
tissue recession has a multifactorial etiology induced by bacterial plaques as
in cases of periodontal or non-plaque-induced disease, such as traumatic
brushing, dental malposition, traction of the gingival margin by braces and
bridles, limitation of the amount of keratinized gingiva, iatrogenic factors,
occlusal trauma, parafunctional habits, orthodontic movement and morphological
characteristics (bone dehiscence) [9].
Aging results in an increase in the number of
periodontal sites with RTM by the accumulation of causal factors throughout
life and, therefore, an increased risk of its occurrence [10]. The cases of RTM
in children should be proserved because of the growth of the alveolar process
and the changes in the dental positions expected during growth [11-14].
The gingival biotype is directly related to the risk for RTM, as well
as to the predictability of mucogingival surgeries of root coverage. Most cases
(60% of the teeth) of insufficiently inserted gingival area present areas of
RTM, which suggests the importance of keratinized tissue for maintaining health
and periodontal stability [15]. Thin vestibular bone walls, characterized by
being predominantly cortical, also presents a high risk of RTM [16]. The
association of thin, low keratinized tissue with a narrow vestibular bone sheet
may result in increased susceptibility to local tissue inflammation and
consequent RTM [17,18].
Periodontal tissues can be described clinically according to the
classification proposed by [19] in: periodontium type I, periodontium type II,
periodontium type III and periodontium type IV. In periodontium type I the
keratinized tissue range is ideal (3 to 5 mm) and the buccal-lingual thickness
of the alveolar process is also normal, observed in approximately 40% of the
patients. The reduction of only
In a thin-thickness gingival tissue, the
inflammatory process resulting from the accumulation of plaque on the dental
crown may infiltrate the connective tissue 1 to 2 mm in the apical direction
and cause alveolar bone resorption [20]. Some authors such as Sullivan and Atkins [21], Benqué [22] and Miller
[23] proposed different descriptive classifications of MTR, used by clinical
professionals and researchers, orient the classification of MTR in relation to
their width and depth, such as: shallow and narrow, shallow and broad, deep and
narrow and deep and shallow. This methodology is important because the
periodontal ligament nourishes up to 1.5 mm from each side of the root and,
therefore, large defects may present less predictability due to the limitation of
nutrition and viability of indicated grafts for root coverage. Benqué [22]
describe the MTRs as "U", "V" or "I". In general,
V-shaped MTRs are related to cases of occlusal trauma, whereas I-shaped defects
are more present in buccal teeth in the dental arch.
Miller's [23] classification is the most used
not only for describing the cases of MTR, but mainly for attributing to the MTR
type a greater or less predictability of success in root coverage surgeries. In
classes I and II of Miller the gingival margin is below or at the mucogingival
line, respectively. In both cases the interproximal bone crest and the
interdental papillae are preserved and the expectation of 100% root coverage
occurs. In Miller's III and IV classes, a maximum coverage of 70% and 50% of
MTR, respectively, is expected, taking as reference the height of the remaining
interproximal tissue (bone crest and papilla). In the first, what
differentiates it from Miller class I is the existence of interproximal tissue
loss and/or rotational tooth. In class IV the interproximal tissue loss is
severe and the gingival margin is located beyond the mucogingival line.
The MTR occurs mainly on the buccal surfaces of
the teeth, due to constant trauma during toothbrushing and, in the
interproximal areas due to inadequate oral hygiene [24].
The mucogingival
surgeries are indicated in cases of progressive MTR, cases of indication of
intrasulcular restorations in a thin periodontium, shallow vestibule associated
with the use of removable dental prostheses, presence of frenum with high
insertion near the gingival margin, planning of orthodontic movements of risk
for MTR and limited oral hygiene associated with local pain. The mucogingival
surgeries should precede orthodontic treatment by promoting greater
stability of the gingival contour during tooth movement [25,26].
The main damages to the patient with MTR are loss of
periodontal support, root exposure accompanied by esthetic compromise and
presence of dentin hypersensitivity, increased risk of cervical and radicular
caries, and possibility of root wear by dental brushing, difficulty in hygiene
and discomfort. The treatment of MTR may be conservative by means of
desensitizers and laser-therapy in cases of dentin hypersensitivity not
accompanied by other indications or, surgically [27,28].
Marginal tissue recession cases accompanied by loss of
dental substance (trauma, caries or abfraction) can be restored prior to root
coverage procedures. Among the restorative materials of choice for this purpose
are the composite resin and resin-modified glass ionomer [29]. These
restorations optimize the final aesthetic and morphophysiological results of
root coverage and contribute to the reduction of dentin hypersensitivity.
Among the main techniques of mucogingival surgery for
root coverage is: free gingival graft [30], rotational flaps [31] laterally
positioned flap [32], a "tunnel" technique [33], a double pedicle
flap [34,35] a semilunar flap [36-38], technique of Raetzke [9], among others;
the different flaps may or may not be associated with the subepithelial graft
with connective tissue [39]. The gold standard for root coverage surgeries is
to associate with the planned flap the accomplishment of an autogenous
connective tissue graft, in the receptor area [40]. The literature also
suggests partial-thickness flaps, called split flaps, as the most suitable
technique for this purpose [41,42].
Exposed root surfaces
affected by periodontitis have reabsorption gaps and presence of bacterial
microorganisms and endotoxins that compromise cell adhesion and fibroblasts
functions [48-50]. The indulgence layer formed during mechanical
instrumentation of the root surface acts as a physical barrier to reinsertion
and conjunctive neo insertion [51-53]. The scaling and root planing can be
performed manually (curettes and limes), by ultrasound or multilayer burs
[54-58].
Different bio modifying
solutions of the root surface have been used, especially EDTA at 24% (Prefgel®,
Straumann®, Headquarter - Basel, Switzerland) citric acid pH 1.0 and
tetracycline HCL 50 mg/mL. These products allow the removal of smear layer,
decontamination, demineralization with exposure of collagen fibers, fibroblast
adhesion, conjunctive reinsertion and cementogenesis [59]. Emdogain®
(Straumann®, Headquarter - Basel, Switzerland), a product composed
of enamel matrix proteins acquired from animal models (pig), induces the formation
of tissues that make up the periodontium of support and has been widely studied
and used for regeneration of these tissues [60,61].
The connective tissue is
used in dentistry in different indications associated with teeth or implants
such as gingival pigmentation treatment [62], root coverage [27], alveolar
ridge volume increase (LANGER & CALAGNA, A substitution alternative for the
connective tissue graft is the Mucograft® (GeistlichPharma Brazil,
São Paulo, Brazil) membrane, a fully decellularized, biocompatible, and fully
decellularized porcine connective tissue scaffold, an efficient conduction of
angiogenic and regenerative cells such as fibroblasts [63]. This ready-to-use
soft tissue graft eliminates the need to remove autogenous tissue at a second
surgical approach (donor area), reduces surgical time and patient morbidity
[64], as well as risk of accidents and complications [65]. The Mucograft® (GeistlichPharma
Brazil, São Paulo, Brazil) membrane adheres naturally and harmoniously to the
patient's own tissue, allowing optimal coverage of gingival recession [63] or
regeneration of keratinized tissue [64].
Mucograft® (GeistlichPharma
Brazil, São Paulo, Brazil) membrane is indicated to replace connective tissue
grafts, soft tissue augmentation around teeth and implants, guided bone
regeneration, alveolar ridge reconstruction, alveolar closure, to cover exposed
bone tissue and for root coverage. The membrane does not cause any damage to
the gingival tissues [66].
In root coverage surgeries,
the final result achieved is only established after the first month of tissue
repair, due to a biological event called creepingattachment. This late coronary
gingival tissue migration occurs during maturation of the post-repair/healing
tissue and may result in root recoil gains of 0.5 mm to 9 mm [67].
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