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523
Fig 1 Trans-Mucosal Papilla Elevators. Fig 2 Full-thickness flap elevation. Fig 3 Elevation of the papillae on each
side of the affected tooth.
Surgical method of the clinician, the incision posed which was then positioned coro-
no risk of injury to the mental nerve. nally to extend beyond the CEJ.
All surgeries were performed by the Specially designed instruments For stabilization of the flap, a mal-
author. Following injection of lo- (Trans-Mucosal Papillae Elevators leable bioresorbable membrane
cal anesthetic, caries, restorations, [TMPEs], H & H) were inserted (BM; Bio-Gide, Geistlich) was used
surface irregularities, and convexi- through the entry incision to elevate for 100 root defects, while acellu-
ties on the root were removed and a full-thickness flap (Figs 1 and 2). lar dermal matrix (ADM; Alloderm,
planed using rotary burs, ultrasonic Elevation of the flap was guided by BioHorizons) was used for the other
instruments, and hand curettes. Us- visualization of the shape and move- 21. Two to four 2 × 12-mm strips of
ing a no. 12 scalpel (Bard-Parker), ment of the instruments through the BM presoaked in sterile water were
a minimal horizontal incision of 2 mucosa and gingival tissue. The flap threaded one by one through the
to 3 mm was made in the alveolar was then extended coronally and entry incision using PST graft pliers
mucosa near the base of the vesti- horizontally to allow for elevation of (H & H) and tucked into the subgin-
bule, apical to the recipient site(s). the two adjacent papillae on each gival spaces under the papillae and
In cases with mandibular premolar side of the denuded root(s) (Fig 3). marginal soft tissue (Figs 4 and 5).
involvement, the incision was made The inclusion of at least four papil- The actual number of strips used
near the base of the vestibule suffi- lae is a unique feature of PST. This depended on the amount of mate-
ciently mesial to the root of the first interproximal extension of the flap rial needed to secure the flap in the
premolar such that, in the judgment resulted in a freely movable flap, desired position.
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524
Tissue tension created by dis- patient was assessed for expected 4 to 6, and severe if the score was
tention or “pouching” of the flap clinical signs of early healing the 7 to 10.13 Dentinal sensitivity was
was sufficient in all cases to hold next business day and the following rated by the patient on a scale of 0
the graft strips in place without su- week. Patients were further checked to 10 according to the effect of hot/
tures, surgical dressing, or tissue at 3 and 6 weeks. Light debride- cold food and drink, air, toothbrush-
adhesive. Gentle digital pressure ment was done at each follow-up ing, and sweet and sour food on the
was applied to the flap for ap- appointment as necessary. At the teeth.16 Each patient also was asked
proximately 5 minutes. The entry sixth week, patients were instructed to rate overall satisfaction with the
incision was left to heal by first in- on the roll brushing technique us- root coverage procedure as a per-
tention, without suturing. ing an extra-soft toothbrush. There- centage (0% [totally unsatisfied] to
ADM was used in 21 sites. The after, patients were re-assessed at 100% [complete satisfaction]).
slippery nature of ADM required a every periodontal maintenance ap-
novel sling suturing technique. A pointment, which was generally ev-
2 × 5-mm strip of ADM was tied ery 3 months. Statistical analysis
at each end with a separate 4-0,
24-mm, 3/8c bioresorbable suture Quantitative data were recorded
(Vicryl, Ethicon). Each needle was Questionnaire and information as means ± standard deviations.
threaded through the entry incision collection Data were analyzed using the Stu-
to emerge from under the facial mar- dent t test for paired observations
ginal gingiva of the recipient root. Using a questionnaire, a staff mem- to assess changes obtained within
One needle was then threaded un- ber interviewed each patient re- and between groups. Kurtosis and
der the mesial contact and the other garding the following patient-based skewness curves were used to ver-
under the distal. The ends of the outcome variables. The first variable ify the normality of the data. The
graft were allowed to slip through was esthetics, described by Zucchel- significance level for rejection of
the entry incision by tugging on one li and De Sanctis as a “completely the null hypotheses for all tests was
end and then the other from the satisfying result for the patient.”15 set at α = .05.
oral apsect. Tugging both sutures Each patient was asked to rate his or
simultaneously advanced the entire her degree of esthetic satisfaction
graft strip along with the overlying on the basis of any set of criteria Results
flap coronally enough to cover the personal to the patient, expressed
CEJ. Threading each suture under as a percentage (0% [total dissat- Predictability was measured as the
the opposite contacts allowed the isfaction] to 100% [complete sat- percentage of the time duration
sutures to be tightened and knotted isfaction]). To add a time-to-event either complete root coverage or
from the facial aspect. This manner measurement, the patient was fur- near complete (≥ 90% ) root cov-
of suturing stabilized the flap. Loose ther asked to state the time (day) erage was achieved.14 Of the 121
ends of the bioresorbable sutures the esthetic improvement (or lack sites, 85 were Miller Class I and II
were cut and removed when they of) was first noticed. Each patient and 36 were Miller Class III. When
appeared during follow-up appoint- also was asked to rate complica- Class III sites were included with
ments (Figs 6a to 6f). tions related to pain, bleeding, and data from Class I and II sites, com-
Postoperative instructions in- swelling on a scale from 0 to 10.13 plete root coverage was achieved
cluded use of a chlorhexdine gluco- A complication, whether it was pain, in 69.4% of sites and 90% defect
nate 0.12% oral rinse (Peridex, 3M bleeding, or swelling, was rated coverage was obtained in 77.7% of
ESPE) and avoidance of brushing at as none to mild if the score was sites. When only the 85 Class I and
the surgical site for 6 weeks. Each 0 to 3, moderate if the score was II sites were computed, complete
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525
Fig 6a Needle is threaded through the Fig 6b Needle is threaded under the Fig 6c A needle at the other end of the
entry incision to emerge under the facial mesial contact. graft has been passed under the flap and
marginal gingiva of the recipient root. under the distal contact to appear at the
oral aspect. Tugging on one end and then
the other from the facial aspect allowed the
ends of the graft to slip through the entry
incision.
Fig 6d The distal needle is passed under Fig 6e Tugging both sutures from the Fig 6f The suturing technique from the
the mesial contact to appear at the facial facial aspect simultaneously advances the facial perspective.
aspect. entire graft strip coronally. Sutures are tied
and the knot is tugged under the flap.
defect coverage was attained in age and mean defect reduction tion, 1.4 mm; CAL gain, 4.4 mm;
81.2% of sites and near complete were 88.4% and 3.0 ± 1.1 mm, and KT gain, 1.3 mm (Table 1).
defect coverage was observed in respectively. When only Class I The mean number of recession
90.6% of sites. and II sites were included in the sites treated per procedure was
Effectiveness was measured calculation, mean percent defect 2.8. The mean follow-up assess-
as the mean percent defect cov- coverage and mean defect reduc- ment period was 18 ± 6.7 months
erage and mean defect reduc- tion were 94% and 3.1 ± 1.1 mm, (range, 5 to 33 months) (Table 1). In
tion.14 Mean baseline recession for respectively (Table 1). The mean a subset of 10 patients with 20 root
all sites was 3.4 ± 1.0 mm. When postoperative measurements of the recession sites, the mean duration
all 121 sites were computed, other relevant parameters for all of the PST procedure per recession
the mean percent defect cover- 121 sites were positive: PD reduc- site was 22.3 ± 10.1 minutes.
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526
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527
a b
Figs 7a and 7b Single surgery on multiple sites with ADM. (a) Presurgical photograph; (b) follow-up 3 years later.
Pain
Intensity (degree ± SD) 0.8 ± 0.8
No pain (%) 6 (14.0)
Mild pain (%) 32 (74.4)
Moderate pain (%) 3 (7.0)
Severe pain (%) 2 (4.6)
Duration (day ± SD) 2.6 ± 1.5
Bleeding
Intensity (degree ± SD) 0.7 ± 0.5
No bleeding (%) 14 (32.6)
Mild bleeding (%) 29 (67.4)
Moderate bleeding (%) 0 (0.0)
Severe bleeding (%) 0 (0.0)
Duration (day ± SD) 1.2 ± 1.1
Swelling
Intensity (degree ± SD) 0.8 ± 0.5
No swelling (%) 11 (25.6)
Mild swelling (%) 30 (69.8)
Moderate swelling (%) 2 (4.6)
Severe swelling (%) 0 (0.0)
Duration (day ± SD) 2.0 ± 1.8
SD = standard deviation.
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528
Clinical notes and photographs tive tissue grafts.27 In this study, clinical parameters of FCTG pro-
showed healing to be uneventful in complete root coverage for Class I cedures were reported to be 0.20,
all cases. Complete healing for all and II sites was achieved 81.2% of 1.93, and 4.40 mm, respectively.29
cases was observed to have taken the time (see Table 1). Patient-based outcomes such
place at the 6-week follow-up vis- With respect to using near as esthetic satisfaction, intensity
it. Furthermore, clinical data and complete (≥ 90%) root coverage as and duration of postoperative pain,
follow-up photographs indicated an indicator for success, Greenwell bleeding, reduction in sensitivity,
no observable differences in color et al proposed that for a technique and overall satisfaction are impor-
and tissue match between pre- and to be deemed successful, 90% (de- tant and relevant considerations in
postoperative gingival tissue in all fect) coverage should be achieved root coverage procedures.2,3,20 As
cases at the first 3-month follow-up at least 75% of the time.12 In this has been proposed, the predomi-
visit and all other follow-up visits study, near complete coverage nant indication for root coverage
thereafter (Fig 7b). was achieved 90.6% of the time for is esthetic concerns.21,28 The results
Mean percent defect coverage Class I and II sites and in 77.7% of all of this study showed that the mean
derived from measuring initial and sites, of which 29.7% were Class III level of esthetic satisfaction was
follow-up recession on study casts (see Table 1). 95.1% through the course of the as-
(86.5%) was compared to that ob- While predictability is mea- sessment period of 18 ± 6.7 months
tained from intraoral measurements sured by frequency of defect cover- (range, 5 to 33 months). Most no-
(87.9%). Since there was no signifi- age, effectiveness is measured by tably, this result was first observed
cant difference between the two, mean percent defect coverage.14 by patients within a mean of 7.4
the clinical data with respect to re- The criterion for successful mean days. Although clinical data and
cession were further confirmed. defect coverage is 80% to 100%.12 photographic records indicated the
Using PST, mean percent defect presence of at least some mild de-
coverage for Class I and II sites was gree of inflammation at the 1-week
Discussion 94%. These results compare well follow-up appointment, it is notable
with a 6-month case series study by that most patients observed the
The most critical factor of root cov- Chambrone and Chambrone28 that degree of improvement to be suf-
erage procedures is the technique’s evaluated the results obtained with ficient to meet their esthetic expec-
predictability,17 as measured by the a connective tissue graft placed un- tations in fewer than 8 days.
frequency of complete root cover- der a coronally advanced flap for Regarding postoperative pain,
age or, alternatively, near complete the treatment of multiple gingival PST results were compared to
(≥ 90%) root coverage.14 Further- recessions involving 28 patients those of a study by Wessel and
more, complete root coverage has with Class I and II defects. The mean Tatakis,30 who reported patient
been deemed a primary outcome defect coverage for that study was outcomes for 23 patients who had
variable and is considered to be 96%, which was not significantly dif- undergone procedures with FCTGs
the best indicator of success.2,14,18–20 ferent from the results with PST. or free gingival grafts. Wessel and
Previous studies on FCTGs have re- Regarding the other clinical Tatakis used a visual analog scale
ported the frequency of complete parameters observed in this study, (VAS) that scored postoperative
root coverage to vary from 29% to overall PD reduction (1.4 mm), pain from 0 to 10, with 0 indicating
90%.20–26 More recently, Rossberg gain in KG (1.3 mm), and gain in no pain and 10 indicating severe
et al reported that complete root CAL (4.4 mm) showed relatively pain. While mean duration of pain
coverage was achieved in 82% of positive results compared to the for PST patients was 2.6 ± 1.5 days,
sites in a long-term retrospective results of a study by Paolantonio with no patient reporting any pain
study using subepithelial connec- et al in which these postoperative at the end of 1 week, 6 of 12 FCTG
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529
Baseline Follow-up
recession recession Defect coverage % defect
No. of teeth (mm ± SD) (mm ± SD) (mm ± SD) coverage
Maxilla 71 3.4 ± 1.0 0.2 ± 0.5 3.2 ± 1.1 93.6
Mandible 50 3.3 ± 1.0 0.7 ± 1.0 2.7 ± 10.9 79.4
Carious/restored 45 3.5 ± 0.9 0.6 ± 0.9 2.9 ± 1.0 83.2
Intact roots 76 3.3 ± 1.1 0.3 ± 0.7 3.0 ± 1.1 91.5
Age < 57.5 y 62 3.4 ± 1.1 0.3 ± 0.6 3.1 ± 1.2 90.1
Age > 57.5 y 59 3.3 ± 1.0 0.5 ± 0.9 2.8 ± 0.9 85.4
Early group 53 3.3 ± 1.1 0.1 ± 0.2 3.2 ± 1.1 96.0
Later group 68 3.5 ± 1.0 0.6 ± 0.9 2.9 ± 1.0 83.1
ADM 21 3.6 ± 1.1 0.3 ± 0.8 3.0 ± 1.3 91.4
BM 100 3.4 ± 1.0 0.4 ± 0.8 2.9 ± 1.0 86.9
ADM = acellular dermal matrix; BM = bioresorbable membrane.
patients in the Wessel and Tatakis 600 mg). Bleeding and swelling for Table 3 compares PST intra-
study reported pain at the end of PST patients were mild and of short group differences. A slight but signif-
the third week.30 The mean pain duration (see Table 2). The relative- icant statistical difference was noted
score for PST patients based on ly rapid diminishment of symptoms between maxillary and mandibular
the VAS scale was 0.8 ± 0.08. The in PST patients is coincidental with teeth in terms of follow-up reces-
mean VAS score for pain for FCTG the quickness of healing observed sion (0.2 ± 0.5 and 0.7± 1.0 mm,
patients in the Wessel and Tatakis clinically and in postoperative pho- respectively). Significant statistical
study was 1.6 ± 2.3. When com- tographs. differences in FCTG results between
paring PST patients with FCTG Twenty-five patients in this study mandibular and maxillary teeth
patients in the Wessel and Tatakis reported sensitivity prior to surgery. were also found by Chambrone and
study with respect to postopera- Of those, 12 (48%) reported sensi- Chambrone.28 In the latter study,
tive pain pills taken, the number tivity after surgery. In a study by Pini an FCTG procedure involving mul-
of postsurgery analgesics taken by Prato et al, 4 of 10 (40%) patients tiple sites was performed for 28 pa-
PST patients was 1.7 ± 2.6 (over- with preoperative dentinal sensitivity tients, half of whom were treated
the-counter), while that of Wessel continued to experience sensitivity for mandibular recessions while the
and Tatakis was 8.6 ± 5.5 (ibuprofen postoperatively.31 other half were treated for multiple
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530
maxillary recessions. All sites were Goldstein et al,33 which concluded Results indicate that with PST,
either Class I or II. Mean final re- that coverage of previously carious multiple sites (see Fig 7a) may be
cession depths for mandibular and or restored roots is just as predict- treated simultaneously in signifi-
maxillary groups were 0.21 and 0.07 able as coverage of intact roots. cantly less time and therefore may
mm, respectively, a threefold dif- In PST cases, no significant dif- incur lesser costs. Recession sites
ference. Interestingly, results with ferences in treatment results were treated (procedures) per appoint-
PST also showed an approximate evident between younger and older ment for this study and the study
threefold difference between the age groups. by Griffin et al13 were 2.8 and 1.45,
mandibular and maxillary proce- With regard to the surgeon’s respectively.
dures (0.7 and 0.2 mm, respec- learning curve as a possible factor According to Griffin et al,13 the
tively). The greater final RD in the for bias,18 comparing the results most significant risk indicator for
PST study as compared to that of of an earlier group with those of postoperative pain was time dura-
Chambrone and Chambrone28 may a later group categorized accord- tion of the procedure, particularly
be due to the inclusion of Class III ing to the time of surgery yielded for those who received autogenous
sites in the PST study. PST Class III percent defect coverage results grafts. The difference in mean du-
defects accounted for 16 of 50 man- of 96.0% and 83.1%, respectively. ration of surgery per recession site
dibular sites and 20 of 71 maxillary Since defect coverage for the early (procedure) between this study and
sites. Chambrone and Chambrone group was slightly higher, though the study by Griffin et al13 was sub-
cited depth of the vestibular for- not statistically significantly better stantial and significant: 22.3 ± 10.1
nix, flap tension, flap thickness, and than that of the later group, effect (range, 18 to 40) and 45.1 ± 19.1
mucogingival phenotype as pos- of the surgeon’s learning curve or minutes, respectively.
sible proximal links to explain their progressive improvement as a pos- Thus, it is reasonable to con-
findings.28 This difference between sible avenue of bias was not appar- clude that within the limits of this
mandibular and maxillary groups ent (see Table 3). In addition, with study, PST may be deemed a pre-
may also be a result of the possibil- respect to comparing results be- dictable, effective, minimally inva-
ity that functional mechanical forces tween BM and ADM, no significant sive, and time- and cost-effective
act much more heavily on wound differences emerged (see Table 3). alternative to FCTG techniques for
margins in the mandible than in the Aside from the intragroup re- obtaining optimal patient-based
maxilla, as suggested by Amarante sults reported in Table 3, this study outcomes. In light of the potential
et al.32 It should also be noted that also addressed the issue of selec- impact of PST on patient benefits,
even though Class III cases were in- tion bias18 of the treated sites. further investigation through ran-
cluded, 79.4% defect coverage for During the observation period, domized controlled trials to prove
all mandibular PST procedures still all patients needing root cover- its plausibility is warranted.
measured favorably against the cri- age surgery were offered PST
terion for successful mean defect along with FCTG procedures, but
coverage suggested by Greenwell all patients preferred the PST and Disclosure
et al, which was 80% to 100%.12 Fur- were treated as they wished. Thus,
Dr Chao has a patent (no. 8,007,278) for
ther investigations focusing on the patients being treated consecutive-
TMPE instruments and a trademark regis-
effects of PST or FCTGs in mandibu- ly with the same procedure (PST) in
tered for Pinhole and PST.
lar sites are recommended. the random order they presented
With respect to nonintact roots, themselves addressed the issue of
results with PST were concordant selection bias to the extent pos-
with those of a previous study by sible in this retrospective study.
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531
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moulis PD. Postoperative complications V, Lanz JC. The predictability of root cov-
1. Miller PD Jr. Regenerative and reconstruc- following gingival augmentation proce- erage by way of free gingival autografts
tive periodontal plastic surgery. Mucogin- dures. J Periodontol 2006;77:2070–2079. and citric acid application: An evaluation
gival surgery. Dent Clin North Am 1988; 14. Maloney WJ, Weinberg MA. Implemen- by multiple clinicians. Int J Periodontics
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Sanz M. Periodontal plastic surgery for system in periodontal practice. J Peri- tissue grafts: An evaluation of short- and
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soft tissue autograft following citric acid et al. Oral reconstructive and corrective treatment of multiple recession-type de-
application. II. Treatment of the carious considerations in periodontal therapy. fects. J Periodontol 2006;77:909–916.
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