Section 8

Mucogingival TherapyJan L. Wennström*

"Department ofPeriodontology, School of Dentistry, University of Göteborg, Göteborg, Sweden

Question Set1. What are the therapeutic endpoints of

success?2. What are the indications/contraindi-

cations for mucogingival therapy?3. Which procedures are justified in mu-

cogingival therapy?a. for augmenting the dimensions ofgin-

gival tissueb. for root coveragec. for augmenting the edentulous ridge

4. Is root coverage a predictable outcome ofmucogingival surgery?

5. What is the role of root surface modifi-cation in mucogingival procedures aimed atroot coverage?

6. What dento-gingival anatomy will be-come establishedfollowing root coverage pro-cedures?

7. What is the long-term stability of thehealing result following mucogingival proce-dures?

INTRODUCTIONThe goal of this review on mucogingival

therapy was primarily to cover the literaturepublished after 1988. However, in order toachieve a more complete overview of thetopic, articles providing significant informa-tion published prior to 1989 have been in-cluded. For further details on the literaturepublished before 1989 the reader is referredto the section on mucogingival surgery in theProceedings of the 1989 World Workshop inClinical Periodontics.1 A total of 590 articleswere reviewed. The papers reviewed wereranked according to the instructions givenby the Organizing Committee for the 1996World Workshop.

The final bibliography includes 216 arti-cles. Single case reports were not consid-ered to qualify for inclusion in the bibliog-raphy unless the paper provided some

important information in relation to a spe-cific question. Evidence tables include onlystudies from which clearly defined descrip-tive variables for the treatment outcomewere retrievable.

The review follows the outline below:

Definitions of Terms

Ann Periodontol 1996;1:671-701.

What Are the Therapeutic Endpoints of Suc-cess?

Increased Gingival DimensionsRoot CoverageImproved Esthetics

What are the Indications/Contraindicationsfor Mucogingival Therapy?

Vol. 1, No. 1, November 1996

672 Wennström

Augmentation of the Dimensions of Gin-gival Tissue

Root CoverageAugmentation of the Endentulous RidgeFrenectomyGeneral Considerations

Which Procedures Are Justified in Mucogin-gival Therapy?

Augmentation of the Dimensions of Gin-gival Tissue

Root Coverage ProceduresAugmentation of the Edentulous Ridge

Is Root Coverage a Predictable Outcome ofMucogingival Surgery?

Rotational FlapsCoronally Advanced FlapsGuided Tissue RegenerationFull Thickness Free Soft Tissue GraftFree Connective Tissue Graft

What is the Role of Root Surface Modifica-tion in Mucogingival Procedures Aimed atRoot Coverage?

Root PlaningRoot Surface Conditioning

What Dento-Gingival Anatomy Will BecomeEstablished Following Root Coverage Proce-dures?

What Is the Long-Term Stability of the Heal-ing Result Following Mucogingival Proce-dures?

Augmentation of the Dimensions of Gin-gival Tissue

Root Coverage ProceduresAugmentation of the Edentulous Ridge

Definition of TermsThe term "mucogingival surgery" was in-

troduced in the periodontal literature in the1950s and was at that time defined as "sur-gical procedures designed to preserve gin-giva, remove aberrant frenulum or muscleattachments, and increase the depth of thevestibule."2 Since then the definition hasbeen changed and according to the Glos-sary of Periodontal Terms,3 mucogingivalsurgery refers to "periodontal surgical pro-cedures designed to correct defects in themorphology, position and/or amount ofgingiva" surrounding the teeth. It has been

suggested45 that the term "periodontalplastic surgery" may be more appropriate,since mucogingival surgery has moved be-yond the traditional treatment of problemsassociated with the amount of gingiva andrecession type defects to also include cor-rection of ridge form and soft tissue esthet-ics. Periodontal plastic surgery would bedefined as "surgical procedures performedto correct or eliminate anatomic, develop-mental, or traumatic deformities of the gin-giva or alveolar mucosa."4

The gingiva (keratinized tissue), which iscomposed of a dense, collagen rich connec-tive tissue and covered by a keratinizing ep-ithelium, extends from the soft tissue mar-

gin (gingival margin) to the mucogingivalline. Traditionally, the gingiva has been di-vided into 1) a free portion; i.e., that part ofthe gingiva which corresponds to the prob-ing depth and 2) an attached portion, deter-mined clinically by subtracting the probingdepth from the measure describing the en-tire width (height) of the gingiva.

The supracrestal soft tissue adjacent toimplants is usually referred to as "peri-im-plant mucosa," which may consist of eithermasticatory or lining mucosa.

Recession (gingival recession) is definedas "location of the marginal tissue apical tothe cemento-enamel junction."3 Since thesoft tissue margin may not always be com-

posed of gingiva, the terms "soft tissue re-cession" and "marginal tissue recession" arealso commonly used.

WHAT ARE THE THERAPEUTICENDPOINTS OF SUCCESS?

The variables to be used as descriptors ofthe therapeutic endpoint of success mayvary depending on the specific goal of themucogingival therapy.Increased Gingival Dimensions

The gingival dimension commonly as-sessed is the width (height); i.e., the distancebetween the soft tissue margin and the mu-

cogingival line measured in mm. An in-creased width of gingiva, independent of thenumber of mm, is considered as a successfuloutcome of augmentation procedures. Also

Annals of Periodontology

Review: Mucogingivai Therapy 673

an increased thickness of the marginal tis-sue may in certain situations be consideredas an endpoint of success.

Root CoverageTo obtain root coverage in areas with lo-

calized or generalized soft tissue recessionsassociated with esthetic problems, root sen-

sitivity, and /or shallow root carries lesionsis one of the major therapeutic goals in mu-

cogingivai surgery. The amount of recessionis clinically assessed through measuring thedistance in mm between the cemento-en-amel junction (CEJ) and the soft tissue mar-

gin. This assessment is the primary outcomevariable for the therapeutic endpoint of suc-

cess. An additional variable is reduction inroot sensitivity.

Probing depth (PD) and clinical attach-ment level (CAL) assessments may also beused as descriptors of the success of rootcoverage procedures. A shallow probingdepth and gain of clinical attachment wouldbe considered as successful treatment out-come. Although gain of clinical attachmentis a positive therapeutic outcome, it doesnot disclose the quality of attachment es-tablished.6

Histologie evaluation is the only reliablemethod by which the nature of attachmentof the tissue to the root can be determined.However, only limited histological data fromhumans on the healing following mucogin-givai surgery are available. A critical pointin the histologic evaluation of the quality ofhealing against the previously detachedroot surface is that proper markings havebeen made of the extension of the defect.

Improved Esthetics

Improved esthetics is one of the major in-dications for mucogingivai surgery. This isa subjective parameter which only can bedetermined by the patient. Variables deter-mining improvements in esthetics followingmucogingivai surgery have so far rarelybeen included in studies reported in the lit-erature.

WHAT ARE THEINDICATIONS/CONTRAINDICATIONS

FOR MUCOGINGIVAL THERAPY?

Augmentation of the Dimensions ofGingival Tissue

The position in which a tooth eruptsthrough the alveolar process and its eventualposition in relation to the bucco-lingual di-mension of the alveolar process have pro-found influence on the amount of gingiva thatwill be established around the tooth.7 In chil-dren, the gingival dimensions will increasedue to growth in the alveolar process, as wellas changed position of the teeth.8-10 Longi-tudinal monitoring of the gingival dimen-sions at the facial aspect of anterior teeth inthe developing dentition has shown that a

significant increase of the gingival height willtake place.811 Also, the spontaneous changeof the tooth position in bucco-lingual direc-tion that often takes place during develop-ment will affect the gingival height.12 A more

lingual positioning of the tooth results in anincrease of the gingival height on the facialaspect with a coronal migration of the softtissue margin. The opposite will occur whenchanging to a more facial position in the al-veolar process. Furthermore, in the growingchild mucogingivai defects may be elimi-nated spontaneously, provided an adequateplaque control is established and main-tained. 13~15 In one 3-year prospective study15it was suggested that, based on the obser-vation that 25 out of 35 (71%) recession de-fects with an initial depth of 0.5 mm to 3.0mm were spontaneously eliminated follow-ing improved oral hygiene standards, repar-ative surgical treatment of soft tissuerecessions in the developing dentition maynot be necessary and should preferably bepostponed until the growth is completed.

Data on gingival dimensions in adults in-dicate that there is a tendency of increasedapico-coronal width with age.16

Gingival dimensions and periodontalhealth. The early development of mucogin-givai surgery was based on the clinical im-pression that a certain apico-coronal widthof gingiva was required for maintenance of

Vol. 1, No. 1, November 1996

674 Wennström

periodontal health and prevention of soft tis-sue recession.17-27 Based on observationsmade in young individuals it was suggestedthat 2 mm of gingiva, corresponding to 1 mmof attached portion of gingiva, is adequate tomaintain gingival health.28 Subsequent clin-ical29-39 and experimental studies40-41 allfailed, however, to generate support for theconcept of a minimal width of gingiva formaintenance of periodontal health. Further-more, longitudinal, prospective studies showedthat the incidence of soft tissue recessionwas not greater at buccal tooth surfaces witha minimal band of gingiva, or lack of at-tached portion of gingiva, than at tooth siteswith a broad zone of properly attached gin-giva.35-3942'43 Other studies32-33 show thatminimal bands of gingiva and even mucosalmargins can be maintained in periodontalhealth without progressive recession pro-vided that traumatic toothbrushing and in-flammation are controlled.

It has been proposed that the movabilityof the soft tissue margin at sites with a min-imal attached portion of gingiva (< 1 mm)may favor the establishment of subgingivalplaque and, hence, make the periodontal tis-sues more vulnerable to destruction.28 How-ever, an experimental gingivitis study29 re-

vealed no differences in the development ofclinical signs of inflammation between areaswith minimal (< 1 mm) and appreciable (> 2mm) width of gingiva. A controlled clinicaltrial on the effect of gingival augmentation inpatients who were not recalled for supportivetreatment during 5 years did not show anydifferences in loss of clinical attachment orrecession during the follow-up period afteractive treatment between control sites with< 1 mm or complete lack of attached gingivaand grafted sites.42 Also, experimental stud-ies44-46 including histological examinationsfailed to lend support to the view that a mo-bile marginal tissue offers an inferior protec-tion of the periodontium.

Gingival dimensions and orthodontic toothmovement. Recession of the marginal tissuemay occur during orthodontic therapy. 7,26,47-49

Clinical studies have shown that a narrowband of gingiva is capable of withstandingthe stress caused by orthodontic forces.5051Additionally, alterations occurring in gingi-

val dimensions are related to the direction oftooth movement; facial movement results inreduced facial gingival dimensions, while anincrease is observed following lingual move-ment.12-50'51 Results from experimental stud-ies indicate that as long as the tooth ismoved within the envelope of the alveolarprocess, the risk of harmful side-effects onthe marginal soft tissue is minimal, irre-spective of its dimensions and quality.52 If la-bial tooth movement results in the establish-ment of an alveolar bone dehiscence, therisk for development of a recession defect isevident,50 53 34 particularly if the marginal tis-sue is composed of lining mucosa.50 Clinicaland experimental studies32 54-55 have indi-cated that the volume (thickness) of the softtissue may be a factor in predicting if gingi-val recessions will occur during and/or afterthe phase of active orthodontic therapy. Athin gingiva may serve as a locus minorus re-sistentia to developing recession defects inthe presence of plaque-induced inflamma-tion or toothbrushing trauma.52

Gingival dimensions and restorative den-tistry. It has been proposed that in segmentsof the dentition involved in restorative ther-apy there is a particular demand for gin-giva.5657 The placement of restoration mar-

gins subgingivally not only creates a directoperative trauma to the tissues58 but mayalso facilitate plaque accumulation, with re-sultant inflammatory alterations in the ad-jacent gingiva.59 Subgingival restorationswill create more pronounced inflammationin areas with a narrow (< 2 mm) band of gin-giva than in areas with a wide gingiva, butnot necessarily loss of attachment.60 An ex-

perimental study in the beagle dog, in whichmetallic strips were inserted subgingivally inareas with varying dimensions of gingiva,showed that in sites with a thin gingivalmargin, recession was a more likely conse-

quence of the combined tissue traumacaused by the insertion of the strip and sub-sequent plaque accumulation than in siteswith a broad gingival zone.61 It has been sug-gested that in a thin free gingiva the inflam-matory lesion will occupy and degrade theentire connective tissue portion, resulting ina collapse of the free gingiva.62 However,whether an increase in thickness of the mar-

Annals ofPeriodontology

Review: Mucogingival Tnerapy 675

ginal tissue will reduce the risk for soft tis-sue recession as a consequence of inflam-matory reactions related to the subgingivalplacement of restoration margins has notbeen evaluated.

Soft tissue quality and implant ther-apy. There is a fundamental difference be-tween the periodontal and the peri-implanttissues with regard to the anchorage of thebordering soft tissue, which might have in-fluence on the stability of the soft tissuemargin. While the periodontal mucosa is at-tached to the tooth with collagen fibers in-serting into the supracrestal portion of theroot, the peri-implant mucosa lacks such an

attachment,63 resulting in the possibilitythat a marginal tissue composed of movablelining mucosa easily can be detached fromthe implant surface. However, the high long-term success rate of implant therapy,64-67 de-spite high prevalence of implant sites lack-ing firmly attached masticatory mucosa as

marginal border tissue (46% to 74%),68-72 in-dicates that the lining mucosa may not beinferior to the keratinized and collagen-richmasticatory mucosa as a protective tissue.Recent clinical studies addressing the ques-tion of the significance of the quality of themucosa in implant therapy have also failedto generate support for the concept that thelack of masticatory mucosa may jeopardizethe maintenance of healthy implant sup-porting tissues.71-73 Furthermore, an experi-mental study in dogs showed that an in-crease of the width of masticatory mucosa

around dental implants had no effect on theconditions of the peri-implant soft tissue.74

Alterations in the position of the soft tis-sue margin at implants, a factor that may beof concern from an esthetic point of view,have been focused on to some extent in thepast.6871 76 It was reported that apical dis-placement of the tissue margin will occurover time, but if differences depend on qual-ity or mobility of the peri-implant mucosa,have not been addressed. However, resultsfrom a recent experimental study indicatethat, in presence of plaque-induced inflam-mation, a border tissue composed of liningmucosa may be more prone to the develop-ment of recession than one composed ofmasticatory mucosa.76

SummaryA minimal amount or absence of gingiva

alone is not justification for gingival augmen-tation.1 Evidence suggests that the gingivalheight is not a critical factor for the preven-tion of marginal tissue recession.32 39 42 Thereis also evidence that in the growing child anincrease in gingival height will occur,8-12 andthat gingival defects may be eliminatedspontaneously provided an adequate plaquecontrol program is established and main-tained.15 However, gingival augmentationmay be considered in situations where a

change in the morphology of the mucogin-gival complex may facilitate proper plaquecontrol. This may be the case in the presenceof a high frenulum attachment, a deep andnarrow recession defect, and where a reces-sion extends to the level of the vestibulär for-nix. Additionally, in conjunction with facialtooth movement resulting in the establish-ment of alveolar bone dehiscences, there isevidence that gingival dimensions can influ-ence the development of marginal tissue re-cession.49525455 The presence of masticatorymucosa around implants is not a decisivefactor for the prognosis of implant ther-apy.68-73

Root CoverageSoft tissue recession; i.e., displacement of

the gingival margin apical to the cemento-enamel junction with oral exposure of theroot surface, is a common feature in popu-lations with high standards of oral hy-giene,77-80 as well as in populations with poororal hygiene.79-81-82 While loss of attachmentand gingival recession are predominantlyfound at the buccal surface of the teeth inpopulations maintaining high standards oforal hygiene,79-80-83 all tooth surfaces are usu-

ally affected in periodontally untreated pop-ulations.7981 It has therefore been suggestedthat at least two different types of gingival re-cessions may exist: one related to mechanicalfactors (toothbrushing) and one associatedwith destructive periodontal disease.79 80

Besides toothbrushing trauma and Per-iodontitis,7779-83-87 factors such as 1) tooth

Vol. 1, No. 1, November 1996

676 Wennström

malposition;85-89-91 2) alveolar bone de-hiscences;92-93 3) high muscle attachmentand frenal pull;94 and 4) iatrogenic factorsrelated to restorative and periodontal treat-ment procedures85-95 have been associatedwith the development of gingival recessions.

The main indications for root coverageprocedures are esthetic demands, root sen-

sitivity, and shallow root caries lesions.1Recession defects can be classified into 4

groups taking into consideration the antici-pated root coverage that can be obtained:96

Class I: Marginal tissue recession not ex-

tending to the mucogingival junction. Noloss of interdental bone or soft tissue.

Class II: Marginal tissue recession ex-tends to or beyond the mucogingival junc-tion. No loss of interdental bone or softtissue.

Class III: Marginal tissue recession ex-

tends to or beyond the mucogingival junc-tion. Loss of interdental bone or soft tissueis apical to the cemento-enamel junction,but coronal to the apical extent of the mar-

ginal tissue recession.Class IV: Marginal tissue recession ex-

tends beyond the mucogingival junction.Loss of interdental bone extends to a levelapical to the extent of the marginal tissuerecession.

While complete root coverage can beachieved in Class I and II defects, only par-tial coverage may be expected in Class III.Class IV recession defects are not amenableto root coverage. Thus, the critical clinicalvariable to assess to determine the possibleoutcome of a root coverage procedure is thelevel of periodontal tissue support at theproximal surfaces of the tooth.

Augmentation of the EdentulousRidge

The major indication for soft tissue aug-mentation of the edentulous ridge is esthet-ics. Phonetic considerations may also be an

indication. Lack of appropriate donor tissuewith respect to amount and/or quality is acontraindication for soft tissue augmenta-tion. Various procedures for hard tissueaugmentation may offer alternatives to softtissue augmentation in such situations.

Ridge deformities can be classified into 3groups:97 1) Class I, bucco-lingual loss of tis-sue with normal apico-coronal ridge height;2) Class II, apico-coronal loss of tissue withnormal bucco-lingual ridge width; and 3)Class III, combination type with loss of bothwidth and height of the ridge. Several factorsshould be considered regarding indicationsfor ridge augmentation:97 1) the lip line; 2)type and extent of deformity; 3} general archform, tooth form, and position of teeth; and4) the proposed relationship of the ponticsto the abutment teeth and gingiva.

FrenectomyIn the Consensus Report on mucogingival

surgery from the 1989 World Workshop,1 thefollowing situations were identified as pos-sible indications for frenectomy as a singlemode of therapy: 1) restrictive problems as-sociated with lip or tongue movement; 2) clo-sure of a midline diastema via orthodontictreatment; and 3) location of attachment inedentulous ridge compromising prostheses.Frenum attachment positioned close to thesoft tissue margin, particularly if obstruct-ing mechanical tooth cleaning, may also beconsidered as an indication. Gingival aug-mentation may be considered when a fre-nectomy is accomplished.3

In relation to diastema closure it is usu-

ally advocated to delay the surgical treat-ment until the orthodontic tooth movementis completed.4-98 The removal of an abnormalfrenulum has been shown to markedly re-duce the incidence of relapse.98

General ConsiderationsPlaque control measures/compliance. Two

of the major causative factors in the devel-opment of soft tissue recessions are traumacaused by toothbrushing and plaque-in-duced periodontal inflammation.79-80-88 Thecontrol of these factors, therefore, is of greatimportance both in preventing the develop-ment of soft tissue recessions and in suc-cessful long-term outcome of root coverageprocedures. Poor plaque control has been re-

ported to result in less favorable treatmentoutcome of root coverage procedures.99

Annals of Periodontology

Review: Mucogingival Therapy 677

Smoking. The evidence that smoking mayhave a detrimental effect on periodontalwound healing is accumulating in the liter-ature.100 Few studies on mucogingival sur-

gery have analyzed the effect of smoking on

the treatment outcome. In one study exces-sive smoking was indicated to be stronglycorrelated to the failure in obtaining rootcoverage using free soft tissue grafts, while"light" or "occasional" smokers (< 5 ciga-rettes/day) showed similar healing responseas nonsmokers.101 Other clinical studieshave reported no significant effect of smok-ing on the healing result following the use offree soft tissue graft procedures.102 103 Fur-ther studies are needed to determine the po-tential negative effect of smoking on thehealing following various procedures used inmucogingival therapy.

Age. There is no evidence in the literaturethat patient age has an influence on the suc-

cess of mucogingival therapy.

WHICH PROCEDURES AREJUSTIFIED IN MUCOGINGIVAL

THERAPY?

Augmentation of the Dimensions ofGingival Tissue

The earliest techniques proposed for in-creasing the apico-coronal dimension of thegingiva are the gingival extension procedu-res, which were designed mainly with theobjective of extending the depth of the ves-

tibulär sulcus.104-106 With the "denudationtechnique" all soft tissue was removed with-inan area extending from the alveolar bonecrest to a level apical to the mucogingivaljunction, leaving the alveolar bone completelyexposed.104 Healing following this type of treat-ment resulted often in an increased width ofthe gingival zone, although in some cases onlya very limited effect was observed. The expo-sure of alveolar bone, however, produced se-

vere bone resorption with permanent loss ofbone height.107-109 In addition, the recession ofmarginal tissue in the surgical area often ex-

ceeded the gain of gingiva obtained in the ap-ical portion of the wound.110-111 Moreover, therelapse of the vestibulär depth gained as a

consequence of the displacement of the softtissue at surgery were reported to be as muchas 50% within 6 months.112-113

With the "periosteal retention procedure" or

"split flap procedure" only the superficial por-tion of the oral mucosa within the wound areawas removed leaving the bone covered by per-iosteum.114-117 Although the preservation ofthe periosteum resulted in less severe bone re-

sorption than following the "denudation tech-nique," loss of crestal bone height was alsoobserved following this type of operation un-less a relatively thick layer of connective tissuewas retained on the bone surface.109

The apically repositioned flap procedure,22which involved the elevation of full thicknesssoft tissue flaps and their displacement dur-ing suturing in an apical position, often leav-ing 3 to 5 mm of alveolar bone denuded inthe coronal part of the surgical area, may infact be considered as a modification of the"denudation" technique. Although it wasstated that a predictable postsurgical resultwith respect to increase of the width of thegingiva was obtained following the "apicallyrepositioned flap,"22 other studies showedmostly only retained presurgical width or a

slight increase.24118 Furthermore, a long-term follow-up study of the location of themucogingival junction following the apicallypositioned flap procedure revealed that theprocedure fails to create a permanent apicalshift of the mucogingival junction.118

The procedures discussed above can

hardly be justified today as a means for wid-ening the gingival zone. The use of trans-plants offers a better potential to predict thepostsurgical result, since gingival and pala-tal soft tissues will maintain their originaltissue characteristics after transplantationto areas of alveolar mucosa.119 A number ofpedicle and free graft techniques as treat-ment modalities for gingival extension havebeen described in the literature.27 120-127 Lon-gitudinal studies revealed that these proce-dures are effective means for augmentationof the gingival dimensions.30-33 128 129 Also,with free graft procedures a more predictableincrease of the vestibulär depth can beachieved as compared to the previously dis-cussed techniques, although some relapse ofthe surgically gained depth may be expected

Vol. 1, No. 1, November 1996

678 Wennström

due to shrinkage of the tissue graft duringhealing.113 If a periosteal retention or a de-nudation procedure was used to prepare therecipient bed for a free tissue graft, or if bonefenestrations or dehiscences were present atthe recipient site, no significant influencewas observed on the healing result.130-131

SummaryThere is evidence that the most predicta-

ble procedures for gingival augmentation are

those utilizing pedicle or free autogenousgrafts of gingiva or masticatory mucosa fromthe palate. It is a consensus that under or-

dinary circumstances "denudation" proce-dures are not justified as a means forwidening the gingival zone]

Root Coverage Procedures

Mucogingival procedures used for rootcoverage may be classified as 1) pedicle softtissue grafts; 2} free soft tissue grafts; or 3)combinations of the two.

Pedicle soft tissue grafts. Depending on

the direction of transfer pedicle soft tissuegrafts can be divided into 1) rotational flaps(e.g., laterally sliding flap, papilla flap, dou-ble papilla flap) and 2) advanced flaps with-out rotation or lateral movement (e.g.,coronally positioned flap).132

One of the first surgical procedures for cov-

ering a localized recession defect, the laterallysliding flap procedure, was described in theliterature in 1950s.133 A full-thickness flapwas mobilized on the adjacent tooth and theflap was then positioned laterally and su-tured to cover the exposed root surface. Thetechnique was later modified not to includethe marginal soft tissue on the donor tooth inorder to reduce the risk for recession.134 Toreduce the potential risk for dehiscence at thedonor tooth due to denudation of the boneplate, the use of a split thickness flap was

proposed.135-136 Other modifications of theprocedure are the double papilla flap,137 theoblique rotational flap,138 the rotation flap,126and the transpositioned flap.139

As an alternative to lateral transposition ofsoft tissue pedicle grafts, a coronally posi-tioned flap to cover exposed root surfaces may

be used.140-144 In situations with only shallowrecession defects the semilunar coronally re-

positioned flap offers an alternative approach.It was originally presented in 1907145 andreappeared in the literature in the 1980s.146

The pedicle soft tissue graft procedurecombined with the use of a membrane bar-rier according to the principles of guided tis-sue regeneration (GTR) has recently beenintroduced as a treatment procedure for rootcoverage.147-148 In most studies a nonab-sorbable expanded polytetrafluorethylene(ePTFE) membrane has been used in com-bination with a coronally advanced flap pro-cedure. One critical factor in the use of GTRbarriers in mucogingival surgery is themaintenance of a space for tissue regenera-tion between the membrane and the facialroot surface. With the use of titanium rein-forced ePTFE membranes, an adequatespace can be maintained during the healingperiod.149-150 Also specially designed bioab-sorbable polylactic acid and citric acid ester-based membranes have been used in thetreatment of recession type defects.151-152From a patient comfort point of view, bio-degradable membranes should be prefera-ble, since only one surgical session is re-

quired. General considerations on the use ofGTR membranes to restore defects in theperiodontium are reviewed in Section 8 Re-generation-Natural Teeth.

Free soft tissue grafts. The free soft tissuegraft procedure can be performed as 1) an

epithelialized soft tissue graft or 2) a subep-ithelial connective tissue graft, both usuallytaken from the palate. Because the differ-entiation of the covering epithelium is con-trolled by morphogenetic stimuli from theunderlying connective tissue,119153 it is notnecessary to include the epithelial lining inthe free graft. However, there is evidencethat the deep connective tissue of the palatemay not possess the full potential to inducekeratinization of an overlaying epithelium.154

Case reports on the use of free soft tissuegrafts can be found in the dental literatureas early as in the beginning of this century.155However, it was first in the 1960s that theprocedure became commonly used in mu-

cogingival surgery.120'123 156 Initially the pri-mary goal of the free soft tissue graft pro-

AnnaLs ofPeriodontology

Review: Mucogingival Therapy 679

cedure was not root coverage but rather toprevent progression of the recession by in-creasing the width of gingiva.129 To achieveroot coverage a 2-stage procedure was ad-vocated by which the graft was initiallyplaced apical to the recession and allowed toheal before a second surgical procedure tocoronally position the grafted tissue over theexposed root surface.157 158 In the 1980smodifications of the 1-stage grafting tech-nique were presented, which from a root cov-

erage point of view was more successful andpredictable than the previous grafting pro-cedure.159160 Acid conditioning of the ex-

posed root surface before the placement ofthe graft was advocated as a critical treat-ment component for the successful outcomeof the 1-stage procedure.101

The subepithelial connective graft125161 isusually harvested from the palate by the useof a "trap door" approach. The graft can beplaced directly on the exposed root and cov-

ered with a coronally or laterally moved mu-

cosal flap,161-165 or placed within an "enve-lope" prepared by an undermining partialthickness incision from the soft tissue mar-

gin.166 This grafting technique generally re-

sults in improved esthetics as compared tothe use of an epithelialized soft tissue. Com-pared to the epithelialized graft the subepi-thelial connective tissue graft may be pref-erable from the patient's point of view due toa less invasive palatal wound and improvedesthetic result.

SummaryPedicle grafts as well as free soft tissue

grafts, as single or combined procedures,can be considered justified in the treatmentof recession type defects. Several factorsmay influence the selection of a specifictreatment procedure for the individual case;e.g., the depth and width of the recession de-fect, the availability of donor tissue, muscleattachment, and esthetics.

Augmentation of the EdentulousRidge

Reconstruction of a localized defect in an

edentulous ridge can be achieved by soft tis-

sue as well as hard tissue augmentation.While minor deformities in the ridge may besuccessfully restored by the use of pedicle167or free soft tissue grafts,97 168 larger defectsmay today preferably be treated with boneaugmentation procedures such as guidedbone regeneration, with or without the com-bination with allogenic bone grafts or hy-droxyapatite.169 The literature on these pro-cedures is reviewed in Section 11 ImplantTherapy.

IS ROOT COVERAGE APREDICTABLE OUTCOME OFMUCOGINGIVAL SURGERY?

As discussed above, complete root cover-

age may be achievable in Class I and II typerecession defects, while only partial coveragemay be expected in Class III.96 In the major-ity of studies evaluating the therapeutic ef-fect of root coverage procedures only Class Iand II defects have been included.

Rotational FlapsTable 1 presents an overview of clinical

studies on the use of rotational flaps (later-ally positioned flap and double papilla flap)for the treatment of exposed root sur-faces.99128170"177 The follow-up period in themajority of the studies is 3 to 6 months, al-though one study reports 36 months of fol-low-up.171 At teeth with a mean recessiondepth of 3 to 5 mm the average percent rootcoverage achieved with rotational flaps inthese studies varied between 34% and 74%.With consideration given to the number ofteeth treated in each study, the calculatedaverage percentage of root coverage for allthe listed studies is 64%. A closer analysisof the data indicates that the differences inamount of root coverage reported in thestudies may to a certain extent be due to dif-ferences in the width of the recession: lessfavorable treatment outcome at sites withwide recessions (> 3 mm).

To determine the predictability of the pro-cedure, the percent of treated teeth at whichcomplete root coverage is achieved is an im-portant variable. However, only one studyprovides such information.176 This study,

Vol. 1, No. 1, November 1996

680 Wennström

DC

EEoü

.E_

Ecd § Eco

.—

'-

Cfl Dl *-

cd c -c

-

co)'cd

—

Xo O

CD _Jcd <

ü

CO cd 13 c Es s ~rco o ££££

CD CD <—.

g- CD go o >s

„ yc o £co o cd| * gS ü

CDECD SP,

er S

cd ä ££ c tc CD CDE » CD3 co h-z q_

to c w 3 o§ co E

CD o

51t< o ü

coa

üai()

o -stCO

I I

1- coocö cö

<f> £

|0 oö00

'Ii coLU ^ =D

r- CMC\j C\i

C00 COT-1 C\i

CO ooö ö

T- coo<* CD

in ocö cö

u- y-

öScd lo coto 00 =co coo Kn T-

—

cm cocö cö

l l s

(00 cocö

<o

co) co6 cd

= ncd 2

$, cd&8CD c COE o o% JO o300 ä"Sr o coh- CO. c

I I

I I

I I

I I

cm

^ cm

<ü CD+00g I!2 £cd o)cd S

CO_c-3cdoäCDCOCO£ o <"cö go COO 5= =>

T- olco cö

o co

I I

co

So So

ll llo- St

CD CO00 ^coo £

I I

CDc'co

11coü

toO LO oCM CM «

cö

I I

CO h~cö cö

CO CO

öS co

ürr<ü

Li. IL c?ü_ 0_ CD

CO~ COCD to

S co I5 01 *ü

ct

oeptco cm .

ooDlcb

co co Icö cö tocoo

toco io ü^ ^ CO

cocd

3= scd 3~ coc poco

I I §!'cö §>, «

coo co

iS o

cm o

ü<r coc5 ii+ £c+ =q_ 0

CSCDCDCOCO£ te < s § sÜ r D

I I I

o co T-

cö cö cö

CO CM COCM CM Cvi

o o olo

T-; CO COcö cö cö

o o o

5 S 3

CD

IL LL IL E

CO« COCD to

§ 00 1ö?<3

ocö

cdc\i

cocö

o E coZ U} r- D

E3>coCD TO

CO CO.

O CD

ll £z

W LLCL cd

«SP§ 2 LU

Annals of Periodontology

Review: Mucogingival Therapy 681

which used the laterally positioned flap incombination with various forms of root sur-

face treatment, reported 40% to 50% oftreated teeth with complete root coverage.

In terms of probing assessments, all stud-ies report shallow post-treatment probingdepth, with a mean gain in clinical attach-ment level varying from 1.7 to 5.1 mm. In thestudies which reported data describing thegingival dimensions,99 170 172 174 an increase ingingival height of 2.2 to 4.0 mm was evidentat the follow-up examination. One studycompared the use of full and split thicknesslaterally positioned flaps and reported no dif-ferences between the procedures.172

Coronally Advanced FlapIn Table 2 pertinent data from clinical stud-

ies on the effect of coronally advanced flap forroot coverage are summarized.140178"181 The fol-low-up period in the listed studies variedfrom 5 to 77 months. The mean depth of therecession defects treated was 2.2 to 4.1 mm.

On average 70% to 99% coverage of the ex-

posed root surface was achieved. Consider-ing the number of teeth treated in eachstudy, the calculated average percentage ofroot coverage for all the listed studies is83%. The percent of teeth with complete rootcoverage in these studies varied between24% and 95%. The amount of root coveragewas not found to correlate to the preopera-tive gingival height.179

Similar to observations reported followingthe use of rotational flaps, all studies evalu-ating the effect of coronally advanced flap forroot coverage revealed shallow residual prob-ing depth and gain of clinical attachment (Ta-ble 2). The average gain of clinical attachmentreported amounted to 2.5 to 3.7 mm. A slightincrease in gingival height may also be ex-

pected.

Guided Tissue RegenerationClinical data reported in studies on the

use of GTR-barriers in root coverage proce-dures are presented in Table 3.147-152,182,183 jnmost of the studies an expanded polytetra-fluorethylene (ePTFE) membrane was usedin combination with a coronally advanced

flap procedure.147150 182 183 Two studies useda biodegradable membrane.151152 The mean

depth of the recession defects treated variedfrom 4.6 to 6.3 mm, and the time of follow-up from 6 to 18 months. The mean percentroot coverage achieved in the studies was54% to 83%. Considering the number ofteeth treated in each study, the calculatedaverage percentage of root coverage for allthe listed studies is nearly 74%. The per-cent of treated sites showing complete rootcoverage is only reported in 4 of the stud-ies,148151152182 and ranged from 0 to 42%.The initial recession depth was not reportedto negatively influence the amount of rootcoverage.147 183 However, initial recessionwidth and membrane exposure had a sig-nificant negative effect on the treatmentoutcome.183 Shallow post-treatment prob-ing depth was reported in all studies, andthe mean gain in clinical attachment levelvaried between 2.8 and 5.5 mm.

One controlled study on the treatmentoutcome following coronally advanced flapwith and without the inclusion of a GTRbarrier has been reported.147 The mean per-cent root coverage at the 18 month follow-up examination revealed similar degree ofroot coverage, but the clinical attachmentgain was significantly greater with the useof the GTR barrier. In addition, the datashowed a more favorable result with re-

spect to root coverage with the GTR pro-cedure in sites with deep (> 5 mm)recession defects as compared to the co-

ronally advanced flap.

Epithelialized Free Soft Tissue Graft-the 2-Stage Procedure

Table 4 presents an overview of clinicalstudies on the use of the 2-stage procedurefor the treatment of exposed root sur-faces.128147158171184-187 The follow-up periodvaried from 2 to 36 months. Mean percentroot coverage established ranged from 36%to 74%. When considering the number ofteeth treated in each study, the calculated av-

erage percentage of root coverage for thestudies is nearly 63%. Minimal residual prob-ing depth as well as improved clinical attach-ment level were observed in all studies.

Vol. 1, No. 1, November 1996

682 Wennström

u,<oii,

S3•atuocro> uCO

0 5 ECO .5CO co*-0 c

c u 0

'co _iCD <

O

CO cd §3 c b72 2 "Tco o ££ n" aDC C- 0

Q

0 0

S c?o oo o

0

<= 2CO o0 CC

CO <p

0 g E

0 0-0 0

E0 0_, £ 0= co H2 Q.

SS g;P E?30 o

co

sz 3 c

< o ü0coQ

Q.0

cd cd

0

o coco co

0SZt ^«5So| A0 co

!pc Oco ll£ +

CO ü

O) oo ^

_co §o c

i- o"fr *

LO oo

Si üoco co

CCCO

o

ILL™< < 0O O _J

CA<U £1 §10 N0 öS I ECO :0

>>co

S.S 1g isi

0 )co0>o

oo

BLO Sc\i °

"OcCO

co'cüsz

cn g<m '5)

0o0

c0020

COcd

CO

CO

ll p

5gZCZrü

sz

cö §5 COI T-- D

ü

"Iü Jj

08c O)0 oo55

ig*co .2 cm$ <ß II+ 0 £ll 'S gl0 £ü

C0LOcö ro™ CD 0

üLTh-

0>Is-

CO

CMCO

CNC«3CN

U0c:coo

CO

o

ll

Ölcdc'c

Q..2

I n o0 8| 8

^ coco oo .-feo °Ö II" O

iL er< <o o

Annals of Periodontology

Review: Mucogingival Therapy 683

(0 d)scd c .c

|B|-Ii'co _iCD <

ü

to co §3 c bs s *r42 £ »oc °- oo

3 Ä-c

E S "

esse

°

ffl ocd OC

I g E

co co

II«OL O

cdxiE3z öl

TO C p 3 °§ co Eg o .S8 e §

CD O

elf.c 3 c

< o OcdtoD

cd coo lo

coo-Eoü

T- CDlo co

cood

CDCOOCOCD>OCO

KEEcoAI

co T-

>_ cdo c•c o&«3 ILCO <cc oo 3

colo lo

lo lo

lo locm cm

Q- C

I— CDCD iL+ +

fl) ™> 'S<o oiö 2|-O .Eü 0_

c00 ^c00 co

CMo d

co

cm cm

cd

to

Ccoco

cco)

'co

co co

cm cm

cm cm

cd mDC cm

CD JLIL P< 5O _J

coo >-c30 co

d

cö

cmcm

co

3)

m

fi cdCD "+ f< sü -J

CD

qfo£ loc oo£2

elB,

fcDCD JL

co'S= Q!~

coo co

00 £ 3

cd 's C cd

co to h= cocd cd i cd

5 ö= 2c ff o EO rrt CD Oü 2 c o

-co

cooCOO CO

Olo>

CC <M

CD JL+ 3ul S>< 5ü J

COO—

COO CO

LOLU T-

I- JZ0- «,

= 3p O) 2>

.—

coo co

coLfi

LOCD

FE nr cd

äst0

cocd

' 53

ist >y COO CO^ ±5 <

Vol. 1, JVo. 1, November 1996

684 Wennström

B _ E0 SS E

o CD

c E

CO _lCS <

ü

CO O) |3 C fc72 2 ~rco o £

LT °- 0

0 0•i> CO

H-o o ü ü !

<= sCO o0 cc

0 g E

CO co

Q0D,

c «E0 05 0= CO h2 Q.

0 co

co

.c 3 c:

< -s3o

o ü0COQ

CD

CO CO üLO O

öCOCOQ.

co - Ecd co 9

0)CDCO

05ö

I I

EE

COaicO

'coCO0o0

0 <CLÜ

LT cC

CD co

colo lo

UJLLr—

LL °-< 3.ö CC co

i CDco°>i COT LL >r

CD < 0IL ü J

a

» 2.2 0ra ocö 2a.O .EO CL

CT) >•CT) CO

co cmcd cd

CM -r-

cd cd

T— T— CO CJlgCO g<"ü t3C C0 CO0 5et o

i i w

fcfc. CO1 1 c cCO _

£ 01 lOl £» 2^0CO oo cz

1*3 0CT) .CO J-CO 0 t; SCO etCO T3O O

co 05cd

<CJ

CO SZ

7*LL fCD 0. 0

o°8 acöc:3 S co

CD ™ 3

I I

I I

I I

I I

CM

CM

CD

COc'3CD080coCO0

,<0 CT)s coct) co

I I

V V

cd ct)co co

I I S

CM T-;CM CM

co co00 CO

oLL CC< <o o

tz CC 11

CÖ CO szCO CO CO660

0 CMc= coco Oy

o

CS)Cci

coco

<ü „t

, cm

2 £O) O)

2 CD U

c „o 1

o «fe

LL<O c\J

2 £O) O)

6 0LI_I

czCO3

oE 0r lo n

0 o) sCO T- CO

LL<ü CM

2 £0 0

3CO

g <»0 o £c co cö0 ct) 2

o10

CMCO

CT)O

COcd

<Ü

7> CCCD <LL O

oCO

CO

CO

COe

14.<O

ö>|

CO0)

3

Annais of Periodontology

Review: Mucogingival Therapy 685

.£_ ECD § ECO > ^

CO O) —

P c -5,1o ö -'

ÜCO _icd <

Ü

to coo I3 c b

dc 0Q

0 0 -~-

cScSS

5s-Ic o 2CO O 0

s Ü

cd S E

co m<d cd £cd: cc ä

5 i2 ^c 0 0E <u5 to Hz Q.

CO>.£to c

? 3 °cd CO EI o.E

co o

oO£coQ

I I

V V

cCDCDit

llCOCO

OO CO COcoco'sco

i-_ CMCM CM

CO 00cb co

Üdc LL< <o o+ + "

co co x:co) coo co

66 a

ina>TJ

V)0 £> 1;

a >,C CD CM <-Ii«?

11

CD CDCM CM

CM CM CD5

lo cxj COco co =

CO

o oco co

odc<

+ °

t« llCO CO .cCO) CO) CD6 6 CD

CO

CD CO„

tj

n CO £S 01 ^ u

CO CMCO CO

V V

too o

ccoco

in cooco cri

odc<o

*=r IIco co jzco co o)6 a §LL LI_I

CO-JOc3Qc>8tocCOtg<CD OO COCD ^- 3

o i-

cö in

co oö t-1

1 co.

i- CO 3- h-

I I

IS.^lTO lo-

CO COro TOcoo S

I I

o

in cm

CM

"5 r3o£C0|J_ O)cd o 0

CDCDco

-CO CO) COCO i-

~

o oCO CO

CO CMr CM

CDQ.

co)

co oT CO

COO COC\i CM

2? 2!coo Si

8s5 <

c co5>5cj)|J_" a>|

cd o 0LL LL _l

CDCD

C COO ;iCO coo co

—> t- Zj

t- COco in

a

I I

i- cooiri uo

<o+ m

ctlo II2 o>cSC0|J_ ö)|cd o 0

|oS oo<o ooQ T- S

cm

2 £oiö)Scd §|lL_.3

cocd8coüTJ0> o

3 1;c COcoü *

c 2oz

CD

|ü CO "CD.E co

"

2 £COOO)6 §

coCOCOE

CJ08— CD£ CD £j111

CO

cdCOcco

r*. co<° 'SCO

oz

2 £COO)CD 0

tocco

I- OOSono^ co '^

toCM

cc 112 £co d)6 §

.« c°« CDo cO CD

o o go CO

COCOsÜeöc

COCD>o

Üdc<o CM

2 £co O)6 Ii

is?"

Üdc<ÜCM

etc 11

2 £co co6 g

CD CD

og 2CQ T- LL

CO

odc<ÜCM

CO i

6 !

o>cno) CO

coco

r 112 £O) D)6 §

0

c S <

Voi. J, No. J, November 1996

686 Wennström

Epithelialized Free Soft Tissue GraftAn overview ofstudies on the effect of the free

soft tissue graft as a means for root coverage ispresented in Table 5.102,159,160,177,187-197^ meaninitial depth of the recessions included was

2.1 mm to 5.1 mm. The mean percent rootcoverage obtained with the free soft tissuegraft procedure varied between 11% and87%, with the greatest success in narrowand shallow recession defects. Consideringthe number of teeth treated in each study,the calculated average percentage of rootcoverage studies is 72%. The predictabilityof complete root coverage ranged from 0% to90%, with an average of 57%. In one study159a predictability of 100% was reported forClass I recession. The procedure consis-tently resulted in minimal probing depth.The mean gain in clinical attachment levelranged from 1.6 to 5.3 mm.

Free Connective Tissue GraftTable 6 describes studies on the effect of

free connective tissue grafts in the treatmentof recession defects.103'162'164'166'181'194-196'198-201The mean initial depth of the treated reces-sions ranged from 3.3 mm to 5.9 mm. Theoutcome of this mode of surgical treatmentin terms of mean percent root coverage was52% to 98%. When considering the numberof teeth treated in each study, the calculatedaverage percentage of root coverage for allthe listed studies is 91%. In 9 of the 12 stud-ies, the predictability of complete root cov-

erage was reported, showing a range of 27%to 89%, with an average of 66%.

Short-term clinical studies comparing thetreatment effect of the connective tissuegraft and epithelialized soft tissue graft (Ta-ble 6) demonstrate significant difference interms of root coverage between the two pro-cedures.194"196 In all three studies the con-nective tissue graft was found to be superiorto the epithelialized soft tissue graft.

SummaryEvidence suggest that root coverage is a

predictable outcome of mucogingival surgeryin Class I and II recession defects. Shallow

probing depth will be the result following allprocedures. No single treatment procedureis superior to all the others. Results pre-sented from comparative studies on the useof free grafts for root coverage favor the con-nective tissue grafts over epithelialized softtissue grafts.194"196 Further studies areneeded to define factors that may be criticalfor the predictability of the treatment out-come for the various procedures. Also, thedevelopment of treatment procedures for im-proved possibilities for root coverage inClass III recession defects are highly desir-able.

WHAT IS THE ROLE OF ROOTSURFACE MODIFICATION IN

MUCOGINGIVAL PROCEDURESAIMED AT ROOT COVERAGE?

Root PlaningBefore root coverage is attempted, the de-

tached portion of the root should be ren-dered free from bacterial plaque. Whetherextensive root planing has to be performedis more doubtful, particularly on root sur-faces that have been exposed due to tooth-brushing trauma. Controlled experimental202and clinical studies203 have demonstrated nodifferences in the healing result followingperiodontal surgery with or without rootplaning. In a controlled clinical trial on thetreatment of recession type defects, no sta-tistical differences were found in terms ofroot coverage or residual probing depth be-tween teeth which had been instrumented(root planing) and controls.176 Hence, evi-dence suggests that intentional removal ofroot structures through root planing is not acritical factor for the outcome of mucogin-gival surgery. However, root planing is indi-cated for removal of surface irregularitiesand grooves as well as shallow root carieslesions.

Extensive root planing or grinding, in or-der to reduce the convexity of the root andto minimize the mesiodistal avascular recip-ient bed in free graft procedures has beensuggested.159 160 In GTR, grinding has beenperformed to produce a flattened or concave

Annals of Periodontology

Review: Mucogingival Therapy 687

.£ _ Ecd 2 Eco .2 ~~-

co o)*-

co _1CD <

O

' CO CO §i

3 c .&ssrco o £^ n" 'S-EC 0)D

t iiöle

cdO)

I c o 2co o cdI 2* g

o

c cd cdS cd

4W =j o0 55 E

P c?Scd o

&2f< o O

0raQ

co t- cdC\i T- Q

co co ,.-

~° Aco o 4-<co co c C

co 2I CÖc h-g>oco LL

flIfCO COco

o t-

co coen 3lo cmco co

<

o < iLL O _I

t3 o3 2

CO n

= E §co :0 ^8.1 IIII]

c\i d

r--1-c\i d

cd

I I*o

n oco co

co lo

S? lS

oLL J=L-l o+ -o !

CO .is :H cO o

°>3 c:n S CO

I I

I I

ceen co 2t— t— ct)

6

so

CM i- 8

cm lo

CM CMC\l CM

cm

C IICO « 11

CT 2 £.J. CT CD

2 co—

-Q CD COCO t- 2^

u; t cdo cm coco

cd

CO „ B *

o lo to -S5cd cd

co r» 10o >Z CT

lo cm

lo lo

lo lo

O OLL LL

cdP

Is iog 2CQ ?! LL

o oco co

CM CDCM

co co g1^ CD

C5

cd y- „co »- co

oLL

cdd)2

o co SP00 g

ü

oo

DC

00 COCM CM

3> CO

o>2£|_|_ CT CTO CD mLL U_I

0cd^cc co <x c mco cn

I I

VCLcC

co t— 2d o)

CD

I ICDPO

CO t-

lo lo

o o

d 3

1o CC™ CO

O CD cd

CJ68"03i843*1

coco

2CD

COCD

J=o) "cöd .2

COco)0 0!P CO2 00 >CL Oo ü

CD *oco q. o

c *-

0 c0 ois0 0-a itC CD.2 o

»5 =

O) 0 C)

Ö 12o oo EZ CO

COCO

Q_a

H O g>-

O DC 0«LLH-I

o sO To= C m <O co S COZ X i-- Z>

co a.CM I

"a

cd £0CD20

_ t3vj- 000 co

o0a

<O co

O 53

»Ol»= o> c/J

LLQ.

a cd

o ©

S co <0 co CO

l,f£

0 C

Ö lo Eill

H o CTo cc 0

E cm <CO §) COX S D

<o+ o>^ IICO 11

P 0LL

.

I 3oja>co

o ro

VoL j, JVo. j, November 1996

688 Wennström

profile of the root surface to create space fortissue regeneration.148 With the use of tita-nium-reinforced membranes grinding maynot be necessary for establishing the re-

quired space for tissue regeneration.150Whether or not reduction of root convexitymay influence the long-term stability of sur-

gically-achieved root coverage has not beenevaluated.

Root Surface ConditioningThe use of root surface demineralization

agents has been advocated as an importanttreatment component in root coverage pro-cedures, particularly in conjunction withfree soft tissue grafts.159204 Citric acid hasbeen the most commonly used agent, buttetracycline HCl has been used in some

studies.103 164 In addition to the removal ofthe smear layer, the use of acid deminerali-zation of the root surface is intended to fa-cilitate the formation of a new fibrousattachment through exposure of collagen fi-brils of the dentin matrix and allow subse-quent interdigitation of these fibrils withthose in the covering connective tissue.205'206

Articles on the use of root conditioning inconjunction with root coverage procedures aresummarized in Table 7.99.102-103,140,159464,175,180,182,185,187,188,193,196,197,201 Controlled clinical trialscomparing the effect of free gingival graft pro-cedures with and without root condition-ingis7,193,197,201 <jid not demonstrate anybeneficial clinical effect from the use of cit-ric acid. Also controlled studies comparingthe211 effect of laterally positioned flap withand without root conditioning showed no

statistically significant positive effect withthe use of citric acid.99 175 No controlledstudies on the effect of tetracycline HCl areavailable.

The healing following treatment of local-ized gingival recessions with coronally posi-tioned flaps and citric acid was evaluated ina controlled study in dogs.207 Histologicalanalysis after 3 months of healing disclosedno differences in the amount of root coverageor new connective tissue attachment be-tween citric acid treated sites and salinetreated control sites, but root resorption was

a common finding among the citric acidtreated teeth. From a study with similar de-sign performed in monkeys, it was con-cluded that citric acid application did notresult in enhanced clinical root coverage, al-though significantly greater amount of newconnective tissue attachment was noted.208

There is no report showing that root re-

sorption is a common finding in humans fol-lowing the use of citric acid root biomodifi-cation.

SummaryThe evidence suggests that there is no

beneficial clinical effect of the use of rootconditioning with citric acid in conjunctionwith root coverage procedures.

WHAT DENTO-GINGIVAL ANATOMYWILL BECOME ESTABLISHED

FOLLOWING ROOT COVERAGEPROCEDURES?

For obvious reasons evaluation of the typeof healing against previously detached rootsurfaces following root coverage procedurescannot be studied in humans except in iso-lated case reports. Animal studies providinginformation on the healing following root cov-

erage procedures are listed in Table 8.207-212Healing where a pedicle graft was placed

in contact with the denuded root surface hasbeen studied in dogs211 and in monkeys.212After 2 to 3 months of healing, bundles ofcollagen fibers were found inserting into acementum layer on the curetted root surfacein the apical portion of the recession indogs.211 Retraction of the gingival marginamounted to 50% of the initially covered por-tion of the defect, while a new connective tis-sue attachment of about 2 mm (50%), andan epithelial attachment of the same heighthad formed in the portion of the defect suc-

cessfully covered by soft tissue.211 The monkeystudy212 reported that 44% of the successfullycovered recession in monkeys demonstratednew connective tissue attachment after 35days of healing. These observations are in ac-cordance with results from a study in dogs us-

ing a coronally advanced flap for coverage ofexperimentally-produced recession type de-

Annals of Periodontology

Review: Mucogingival Therapy 689

.£_

Eco 5 Eco >co es «0 c .c

c £co _i

CD <ü

CÖ cd Pr> c fc3 S "Tco O £

CC °- cdD

cd cd -p-

Ii«<S 6 ^

C Oco ocd CC

S £ EE § £co S3I if0 # &

^ c tp 0 0t = ca5 co l-2 OL

cd co

c 50 _2ö

I I

I Ic0Ecocd

o o cT-" T~ 0)v v s

cdcd

I I l

i- CMCM CM

CO COcb öS

üCC ll< <ü o+ + «

aj cö jeo) cn a6 6 5

a£oo

CD CMc a>co coo_i i- 3

CD CDC\i evi

- 9 cdcd c\i tu

cdcd*:

I Iico

CM LOLO LO

o oCO CO

LO LO

CO 5)

cd OO O)6 CD cd

cd

Is 1

CM COco cö

"3 "? §•i- -i- cdV V J

cd

co0

CD|-~ CO

CD LOco cö

o o

öS cB

CO COcd cd cd

6 6 §

CLCO

COt SS <0 § com £ z>

co oCM CO

CO LOcö cö

CC §< 0

2 SO XI„ COs §c co

T- CD .CO °i~CD CO - S

ü °o oZ 0-

o cmLO

5 5

ll. ll ga. CL cd

CO CO

CT) T-

ci cm

h- CT)CM CM

Q.0co

0

o co TJCM CO -g

COo

'ccdCO

CO CM

LO LO

LO LO

ü üll ll

5t c§ 2

I I

LO oCci CM

LO Is-.

N COcö cö

co co\ —.CO CO

CL 0

coco

0 T3

0 CO P

—

CT) COO ™ ü

o ocö cö

CM CDCM

CD6

0CLZ>COt;

CO

ü

o coCO -sf

CO CT)Cci CM

CT) CT)CT) CT)

ü

* '

nCO etO) 2 £|j_ cd ct)

il ll0

i- 3

coLO

U)o0

ü

oO

coin

OCC<O CM

2 £cd ct)CD 0

CO ao 5g £ Szs?

°> COCT) CO

0co

.

X)

II0

I +

1 I

5 S cS ** c

Ii 11~IL LL 1IL. O

CB et0 2

C <D „c c 0O 3O ü CO

= TTn 0*~ ~Q

II '5co

H PCCÜÖt;ll ll CD

0

CO) 0.e o

5= TO CO-r, CTT o 00 COü „

>•£ o o

_

TTTT 0CO TT

.9 Q.

$ 11 OS ll OCcl < <P- o o

Vol. 1, No. 1, November 1996

690 Wennström

£_

Ecd § Etö öl +-0) c £

|S|c E

co _JCS <

O

co ct |3 c ePS"co o £^ n" S.DZ °- ©

Q

CD CDtS co £JS co 'Sg- 33 a>

° o äSüü-

0

c Qco o cd

S O

S § ECO co

I rr §"Dl D

»Sc

coLL

0 XI

1 Q-

cd"coq

cdcdco

co'cd

CD cCD O& oCD CDXI 3=c <».2 oI c

CO CD CTO) k c

o ^O oo Ez co

CT

ü LT

3

co § co

üer<O oj+ *"

€ "2 £CT CT

CD §

cd gfflO°a

0)

co 2^ co5 cdCO T-

ü

ü Ii

LL Ol

S5

öSc CDCD CO

< T-

ü

co § COX T- D

LT

LL 9

co co COX " => O) co

I I

I I

r-. cm Iod cdr- o>

in T-

i- cd

o or-~ CM8 cCO CMco cnCM

C3

£ ü

5 g£

cocd

' o3

OCO°a o <= S« =_l T- 3 <

Annais of Periodontology

Review: Mucogingival Therapy 691

0EEoO

I °Z SS

5 ,-0 o

0X O g>ra o «ID Lt I)

0 O

§ g E

co coI ifCL C"D

0 3 ~

C X) LZ h-"-I- QJt p « o ci e

S 5 « x .E g* Z E B -

CO COC 00 X

outX =f c

12:°0"5Q

£> cox o0 0.1 JB

x oLU cö

I I

<o

o

XJ cm

3 "co

3 P

o

co

0^ S> CO£ 2

cm g §h= oc °

.2>oco o_>> a o.205 'S

gl51

OCC<o

<o

Iii

S3 coc o0 0.i 'S)

s-§LU cö

COoQ

< 0

ü

0) 0)•St- <=

siDC -a

.

0

ü

<o ° aO CO

O)LO

üCC<ü

<O

CM

II

CO

IS

i co "gn c° >

0O0

"o0"50CJ ra. o>» 0

0.2 "oE> 0

co 2?<O

"S CC.2 I—3 CD'•Jo £CO «s

co

-

aLULL

u- irO &

Sico

x

CD t- CO

« coc o0 0E 'Sg "°

LU 'cö

I Io

0c

l l

o)coj>*"5 DC.2 r-| O' co ÜCO 5

I I

COCOa>c

lt* +a c Lu«.•X + LLU- L§ U. £ 2,i +-1 ""CO

II

oQ

o a> co

0

W COX Ü0 0E ~0

g"§LU cö

COCl

ü o

E Dco 2CO0 o

CC z

COoQ

3to g= 5O 08

co <rcd ma> CO

0 0

8- §LU LÖ

CO'S ECL <3

10 X

0 "E §" 1g äco 0

i ^0 o

DC Z

co

00COCO2 a <1 § wO t- 3

Vol. J, Wo. J, November 1996

692 Wennström

fects.207 The authors found after 3 months ofhealing that, on average, 20% of the apico-co-ronal length of the original defect had been ex-

posed due to recession (i.e., about 80% rootcoverage was achieved), 40% was covered byepithelium, and 40% demonstrated new con-nective tissue attachment. The newly formedcementum was consistently in continuity withthe original cementum in the apical, non-in-strumented portion of the roots, indicatingthat the newly formed attachment was pro-duced by cells originating from the periodontalligament. In a study performed in monkeys,20938% of the successfully covered recession de-fects using a coronally advanced flap demon-strated formation of new connective tissueattachment. The use of a GTR membrane be-tween the root surface and the coronally ad-vanced flap was found to generate significantlymore new connective tissue attachment (79%of the covered recession defect).209

A few case reports with human block sec-tions following treatment of recession de-fects with pedicle or free graft procedures are

available in the literature (Table 9),213-216 pro-viding evidence that new connective tissueattachment may be formed following rootcoverage procedures. Histological evaluationof two teeth treated with a laterally posi-tioned flap213 showed that about 26% of thecovered root surface showed connective tis-sue attachment, but partly without evidenceof cementum formation. In surgically cre-ated recession defects new cementum for-mation with parallel oriented connectivetissue fibers was observed after citric acidroot demineralization but not on controlroots.214 Histological evaluation of a toothtreated with GTR procedure demonstratedconnective tissue attachment formationamounting to 74% of the length of the suc-

cessfully covered root portion.215 New ce-mentum with inserting collagen fibers; i.e.,new connective tissue attachment, covered48% of the distance between the apical bor-der of the root instrumentation and the softtissue margin.

Although new connective tissue attach-ment may only be formed in a limited part ofthe recession defect, pedicle graft proce-dures evidently rarely result in the formationof a deep periodontal pocket. Furthermore,

evidence suggests that GTR results ingreater amounts of new attachment forma-tion, but the outcome in terms of root cov-

erage and pocket closure does not appearsuperior to that achieved by traditional ped-icle graft procedures (Tables 2 and 3). How-ever, whether a connective tissue attach-ment is more favorable than an epitheliumattachment for the long-term stability of theposition of the soft tissue margin, andwhether GTR procedures can improve theclinical result in Class III recessions need tobe evaluated.

The nature of the attachment followingthe use of free grafts also remains a ques-tion. It is likely, however, that a healing pat-tern similar to the one discussed abovefollowing pedicle graft procedures will result,namely that new connective tissue attach-ment will be established in the apical andlateral parts of the recession defect, while an

epithelial attachment is formed in the coro-nal and mid-buccal portion of the root. His-tological evaluation 42 weeks after treatmentof a narrow recession defect with root bio-modification (tetracycline HCl) and an epithe-lialized free soft tissue graft was recentlyreported (Table 9).216 The root coverageamounted to 5 mm or 83% of the original re-cession. The epithelial lining was found toterminate 2.6 mm below the gingival margin,and the most coronally positioned new ce-mentum with inserting connective tissue fi-bers was seen 3.4 mm apical to the gingivalmargin. No histological reference for the ap-ical extension of the original defect was

available, but based on extrapolations frompretreatment probing assessments, the au-thor216 estimated that 3.6 mm of new attach-ment had formed, corresponding to 51% ofthe apico-coronal length of the covered, pre-viously detached root portion.

SummaryThere is histological evidence that healing

following both pedicle and free graft root cov-

erage procedures results in the formation ofsome new connective tissue attachment. Theclinical significance of a possible enhancedhealing through the formation of new con-nective tissue attachment with the use of

Annals of Periodontology

Review: Mucogingival Therapy 693

tooS

CO

Ü

^ sz

CO

Ä c <-°? 03 rnI 3 Q UJ

iS CO._

3 "o

Q §CL CO

a c=

3 0) J

o CO

O 0-

LL ü c

o $ co

o ECO CO

Z T3

DCI-CD+

_LL 1— CO< <h

LU

Ü

CD

£ « ^L O) >o co ffl

•s * « S

-So

^ CL 9p CO o

_

CD 4-1

cCDE

CO _ .ECO oo

55o

£ & -ax ffi R £CD "D O E

o

T3 J5CD D.

CD

CCD

co ECO CD

O

5CDZ

OCLCD

"O

CD E° BCD S

Ü

S 01 c nco oo co

CDd £s §CD JO ^

CD 1 2I g CD

s-8 I 1'5JDiO) fj S>I.

CC LL Üh; cl ccCD _i I—

CDoO "cöM CDCO CD4= CD£ *

COO COCL CD

~oCD Oc5 £CO

_

CL "5XCD „

LU COCL CD

LL CDCD LL

CO cC CD

O ^0)8 ö

CO S CD

Ü

II Q IILL CC << < r-O O O

Vol. 1, No. 1, November 1996

694 Wennström

root biomodifications and GTR barriers re-mains to be evaluated.

WHAT IS THE LONG-TERMSTABILITY OF THE HEALING

RESULT FOLLOWINGMUCOGINGIVAL PROCEDURES?

Augmentation of the Dimensions ofGingival Tissue

Studies with follow-up periods of up 4 to5 years3342 129 191 have reported long-termstability of surgically increased apico-coro-nal width of gingiva. Whether also an in-creased gingival thickness will demonstrateclinical stability over time has not been eval-uated.

Root Coverage ProceduresThe majority of the reports on the effect of

various root coverage procedures have a fol-low-up of less than 1 year (Tables 1 to 6).One study on the treatment with laterallypositioned flap (Table 1) reports 3 years offollow-up.171 The mean root coverage was re-

ported to be more or less unchanged whencompared to the 6 months post-treatmentevaluation. With regard to the coronally ad-vanced flap procedure (Table 2), one studywith a 3-year171 and one study with a 5- to8-year179 maintenance interval are available.These studies report 70% to 74% root cov-

erage, a figure which is comparable to datafrom studies of shorter duration. GTR pro-cedures in the treatment of recession typedefects have only been used since the early1990s, and so far no study with follow-up ofmore than 18 months is available. Data fromlong-term studies on the use of free graftsindicate maintained root coverage over per-iods of 4 to 5 years with epithelialized191192as well as with connective tissue grafts.162199

The results from the long-term studiesdiscussed suggest stability over time irre-spective of the surgical procedure used toachieve root coverage. Of importance for thelong-term outcome of root coverage proce-dures is that the major etiologic factors forthe development of recessions; i.e., tooth-

brushing trauma and plaque-induced in-flammation, are kept under control.

Augmentation of the EdentulousRidge

There are no data available in the litera-ture regarding the long-term stability of lo-calized ridge augmentation with soft tissuegrafts.

REFERENCESIntroduction

1. The American Academy of Periodontology. Proceed-ings of the World Workshop in Clinical Periodontics.Chicago: The American Academy ofPeriodontology;1989: Section VII.

2. Friedman N. Mucogingival surgery. Texas Dent J1957;75:358-362.

3. The American Academy of Periodontology. Glos-sary of Periodontal Terms, 3rd ed. Chicago: TheAmerican Academy of Periodontology; 1992.

4. Miller PD. Regenerative and reconstructive perio-dontal plastic surgery. Mucogingival surgery. DentClin North Am 1988;32:287-306.

5. Miller PD. Root coverage grafting for regenerationand aesthetics. Periodontol 2000 1993;1:118-127.

6. Fowler C, Garrett S, digger M, Egelberg J. Histo-logie probe position in treated and untreated hu-man periodontal tissues. J Clin Periodontol 1982;9:373-385.

What Are the Indications/Contraindicationsfor Mucogingival Therapy?Augmentation of the Dimensions of GingivalTissue

7. Maynard JG, Ochsenbein C. Mucogingival prob-lems, prevalence and therapy in children. J Perio-dontol 1975;46:543-552.

8. Andlin-Sobockl A. Changes of facial gingival di-mensions in children. A 2-year longitudinal study.J Clin Periodontol 1993;20:212-218.

9. Saario M, Ainamo A, Mattila K, Ainamo J. Thewidth of radiologically-defined attached gingivaover permanent teeth in children. J Clin Periodontol1994;21:666-669.

10. Saario M, Ainamo A, Mattila K, Suomalainen K,Ainamo J. The width of radiologically-defined at-tached gingiva over deciduous teeth. J Clin Perio-dontol 1995;22:895-898.

11. Bimstein E, Eidelman E. Morphological changes inthe attached and keratinized gingiva and gingivalsulcus in the mixed dentition period. A 5-year lon-gitudinal study. J Clin Periodontol 1988; 15:175-179.

12. Andlin-Sobocki A, Bodin L. Dimensional altera-tions of the gingiva related to changes of fa-cial/lingual tooth position in permanent anterior

Annals of Periodontology

Review: Mucogingival Therapy 695

teeth of children. A 2-year longitudinal study. JClin Periodontol 1993;20:219-224.

13. Powell RN, McEnlery TM. A longitudinal study ofisolated gingival recession in the mandibular cen-tral incisor region of children aged 6-8 years. JClin Periodontol 1982;9:357-364.

14. Persson M, Lennartsson B. Improvement potentialof isolated gingival recession in children. SwedDentJ 1986;10:45-51.

15. Andlin-Sobocki A, Marcusson A, Persson M. 3-yearobservation on gingival recession in mandibularincisors in children. J Clin Periodontol 1991;18:155-159.

16. Ainamo J, Talari A. The increase with age of thewidth of attached gingiva. J Periodont Res 1976;11:182-188.

17. Nabers CL. Repositioning the attached gingiva. JPeriodontol 1954;25:38-39.

18. Gottsegen R. Frenulum position and vestibulärdepth in relation to gingival health. Oral Med OralSurg OralPathol 1954;7:1069-1078.

19. Ochsenbein C. Newer concept of mucogingival sur-

gery. J Periodontol 1960;31:175-185.20. Rosenberg MM. Vestibulär alterations in periodon-

tics. J Periodontol 1960;31:231-237.21. Corn H. Periosteal separation—Its clinical signifi-

cance. J Periodontol 1962;33:140-152.22. Friedman N. Mucogingival surgery: The apically

repositioned flap. J Periodontol 1962;33:328-340.23. Friedman N, Levine HL. Mucogingival surgery:

Current status. J Periodontol 1964;35:5-21.24. Carranza FA, Carraro JJ. Mucogingival techniques

in periodontal surgery. J Periodontol 1970:41:294-299.

25. Ruben MP. A biological rationale for gingival re-construction by grafting procedures. QuintessenceInt 1979;10:47-55.

26. Hall WB. The current status of mucogingival prob-lems and their therapy. J Periodontol 1981; 52:569-575.

27. Matter J. Free gingival grafts for the treatment ofgingival recession. A review of some techniques. JClin Periodontol 1982;9:103-114.

28. Lang NP, Löe H. The relationship between thewidth of keratinized gingiva and gingival health. JPeriodontol 1972;43:623-627.

29. Miyasato M, Crigger M, Egelberg J. Gingival con-dition in areas of minimal and appreciable widthof keratinized gingiva. J Clin Periodontol 1977;4:200-209.

30. De Trey E, Bernimoulin J. Influence of free gingivalgrafts on the health of the marginal gingiva. J ClinPeriodontol 1980;7:381-393.

31. Hangorsky U, Bissada NB. Clinical assessment offree gingival graft effectiveness on maintenance ofperiodontal health. J Periodontol 1980:51:274-278.

32. Dorfman HS, Kennedy JE, Bird WC. Longitudinalevaluation of free autogenous gingival grafts. J ClinPeriodontol 1980;7:316-324.

33. Dorfman HS, Kennedy JE, Bird WC. Longitudinalevaluation of free gingival grafts. A four-year re-

port. J Periodontol 1982;53:349-352.34. Lindhe J, Nyman S. Alterations of the position of

the marginal soft tissue following periodontal sur-

gery. J Clin Periodontol 1980;7:525-530.35. Schoo WH, van der Velden U. Marginal soft tissue

recessions with and without attached gingiva. JPeriodont Res 1985;20:209-211.

36. Kisch J, Badersten A, Egelberg J. Longitudinal ob-servation of "unattached," mobile gingival areas. JClin Periodontol 1986;13:131-134.

37. Salkin LM, Freedman AL, Stein MD, BassiounyMA. A longitudinal study of untreated mucogingi-val defects. J Periodontol 1987;58:164-166.

38. Wennström JL. Lack of association between widthof attached gingiva and development of gingival re-

cessions. A 5-year longitudinal study. J Clin Per-iodontol 1987;14:181-184.

39. Freedman AL, Salkin LM, Stein MD, Green K. A10-year longitudinal study of untreated mucogin-gival defects. J Periodontol 1992;63:71-72.

40. Wennström JL, Lindhe J, Nyman S. The role ofkeratinized gingiva for gingival health. Clinical andhistologic study of normal and regenerated gingi-val tissue in dogs. J Clin Periodontol 1981;8:311-328.

41. Wennström JL, Lindhe J. The role of attached gin-giva for maintenance of periodontal health. Heal-ing following excisional and grafting procedures indogs. J Clin Periodontol 1983;10:206-221.

42. Kennedy JE, Bird WC, Palcanis KG, Dorfman HS.A longitudinal evaluation of varying widths of at-tached gingiva. J Clin Periodontol 1985; 12:667-675.

43. Eaton KA, Kieser JB. A conservative approach tothe management of gingival recession and othergingival "inadequacy." Restorative Dent 1986;2{Mar):29-35.

44. Wennström JL, Lindhe J, Nyman S. The role ofkeratinized gingiva in plaque-associated gingivitisin dogs. J Clin Periodontol 1982;9:75-85.

45. Wennström JL, Lindhe J. Plaque-induced gingivalinflammation in the absence of attached gingiva indogs. J Clin Periodontol 1983;10:266-276.

46. Kalkwarf KL, Krejci RF, Berry WC. Chronic mu-

cogingival defects in miniature swine. JPeriodontol1983;54:81-85.

47. Boyd RL. Mucogingival considerations and theirrelationship to orthodontics. J Periodontol 1978;49:67-76.

48. Maynard JG, Wilson RD. Diagnosis and manage-ment of mucogingival problems in children. DentClin North Am 1980;24:683-703.

49. Maynard JG. The rationale for mucogingival ther-apy in the child and adolescent. Int J PeriodonticsRestorative Dent 1987;7(1):37-51.

50. Coatoam GW, Behrents RG, Bissada NF. Thewidth of keratinized gingiva during orthodontictreatment: its significance and impact on perio-dontal status. J Periodontol 1981;52:307-313.

Vol. 1, No. 1, November 1996

696 Wennström

51. Dorfman HS. Mucoglngival changes resulting frommandibular incisor tooth movement. Am J Orthod1978;74:286-297.

52. Wennström JL, Lindhe J, Sinclair F, Thilander B.Some periodontal tissue reactions to orthodontictooth movement in monkeys. J Clin Periodontol1987;14:121-129.

53. Batenhorst KF, Bowers GM, Williams JE. Tissuechanges resulting from facial tipping and extru-sion of incisors in monkeys. J Periodontol 1974;45:660-668.

54. Steiner GG, Pearson JK, Ainamo J. Changes of themarginal periodontium as a result of labial toothmovement in monkeys. J Periodontol 1981;52:314-320.

55. Foushee DG, Moriarty JD, Simpson DM. Effects ofmandibular orthognatic treatment on mucogingi-val tissue. J Periodontol 1985;56:727-733.

56. Maynard JG, Wilson RD. Physiologic dimensionsof the periodontium significant to the restorativedentist. J Periodontol 1979;50:170-174.

57. Nevlns M. Attached gingiva—mucogingival therapyand restorative dentistry. Int J Periodontics Restor-ative Dent 1986;6(4):9-27.

58. Donaldson D. The etiology of gingival recession as-

sociated with temporary crowns. J Periodontol1974;45:468-471.

59. Parma-Benfenati S, Fugazzato PA, Ruben MP. Theeffect of restorative margins on the postsurgicaldevelopment and nature of the periodontium. IntJPeriodontics Restorative Dent 1985;5(6):31-51.

60. Stetler KJ, Bissada NB. Significance of the widthof keratinized gingiva on the periodontal status ofteeth with submarginal restorations. J Periodontol1987;58:696-700.

61. Ericsson I, Lindhe J. Recession in sites with in-adequate width of the keratinized gingiva. An ex-

perimental study in the dog. J Clin Periodontol1984;11:95-103.

62. Baker D, Seymour G. The possible pathogenesis ofgingival recession. A histological study of inducedrecession in the rat. J Clin Periodontol 1976;3:208-219.

63. Berglundh T, Lindhe J, Ericsson I, Marinello CP,Liljenberg B, Thomsen P. The soft tissue barrier atimplants and teeth. Clin Oral Implants Res 1991;2:81-90.

64. Adell R, Eriksson B, Lekholm U, Bränemark P-I,Jemt T. A long-term follow-up study of osseointe-grated implants in the treatment of totally eden-tulous jaws. IntJ Oral Maxillofac Implants 1990;5:347-359.

65. Chaytor DV, Zarb GA, Schmitt A, Lewis DW. Thelongitudinal effectiveness of osseointegrated den-tal implants. The Toronto study: Bone levelchanges. Int J Periodontics Restorative Dent 1991;11:113-125.

66. Lekholm U, van Steenberghe D, Herrmann I, et al.Osseointegrated implants in the treatment of par-tially edentulous jaws. A prospective 5-year mul-tlcenter study. IntJ Oral Maxillofac Implants 1994;9:627-635.

67. Jemt T, Lekholm U. Implant treatment in edentu-lous maxillae. A 5-year follow-up report on pa-tients with different degrees of jaw resorption. IntJ Oral Maxillofac Implants 1995; 10:303-311.

68. Adell R, Lekholm U, Rockler B, et al. Marginal tis-sue reactions at osseointegrated implants. A 3-year longitudinal prospective study. Int J OralMaxillofac Surg 1986; 15:39-52.

69. Lekholm U, Adell R, Lindhe J, et al. Marginal tis-sue reactions at osseointegrated titanium fixtures.A cross-sectional retrospective study. Int J OralMaxillofac Surg 1986;15:53-61.

70. Bower RC, Radney NR, Wall CD, Henry PJ. Clinicaland microscopic findings in edentulous patients 3years after incorporation of osseointegrated im-plant-supported bridgework. J Clin Periodontol1989;16:580-587.

71. Apse P, Zarb GA, Schmitt A, Lewis DW. The lon-gitudinal effectiveness of osseointegrated dentalimplants. The Toronto study: Peri-implant muco-sal response. Int J Periodontics Restorative Dent1991;11:95-111.

72. Mericske-Stern R, Steinlin Schaffner T, Marti P,Geering AH. Peri-implant mucosal aspects of ITIimplants supporting overdentures. A five-year lon-gitudinal study. Clin Oral Implants Res 1994;5:9-18.

73. Wennström JL, Bengazi F, Lekholm U. The influ-ence of the masticatory mucosa on the peri-im-plant soft tissue condition. Clin Oral Implants Res1994;5:1-8.

74. Strub JP, Garberthuel TW, Scharer P. The role ofattached gingiva in the health ofperiimplant tissuein dogs. Part I. Clinical findings. IntJ PeriodonticsRestorative Dent 1991; 11:317-333.

75. Jemt T, Book K, Lie A, Börjesson T. Mucosal to-pography around implants in edentulous upperjaws. Photogrammetric three-dimensional meas-urements of the effect of replacement of a remov-

able prosthesis with a fixed prosthesis. Clin OralImplants Res 1994;5:220-228.

76. Warrer K, Buser D, Lang NP, Karring T. Plaque-induced peri-implantitis in the presence or ab-sence of keratinized mucosa. Clin Oral ImplantsRes 1995;6:131-138.

Root Coverage77. Sagnes G, Gjermo P. Prevalence of oral soft and

hard tissue lesions related to mechanical toothcleaning procedures. Community Dent Oral Epide-miol 1976;4:77-83.

78. Wilson RD. Marginal tissue recession in generaldental practice: A preliminary study. Int J Perio-dontics Restorative Dent 1983;3(l):248-257.

79. Löe H, Änerud Ä, Boysen H. The natural history ofperiodontal disease in man: Prevalence, severity,extent of gingival recession. J Periodontol 1992;63:489-495.

80. Serino G, Wennström JL, Lindhe J, Eneroth L. Theprevalence and distribution of gingival recession insubjects with high standard of oral hygiene. J ClinPeriodontol 1994;21:57-63.

Annals of Periodontology

Review: Mucogingival Therapy 697

81. Baelum V, Fejerskov O, Karring T. Oral hygiene,gingivitis and periodontal breakdown in adult Tan-zanians. J Periodont Res 1986;21:221-232.

82. Yoneyama T, Okamoto H, Lindhe J, Socransky SS,Haffajee AD. Probing depth, attachment loss andgingival recession. Findings from a clinical exam-

ination in Ushiko, Japan. J Clin Periodontol 1988;15:581-591.

83. Källestäl C, Matsson L, Holm A-K. Periodontal con-

ditions in a group of Swedish adolescents. I. A de-scriptive epidemiologic study. J Clin Periodontol1990;17:601-608.

84. O'Leary TJ, Drake RB, Jividen GF, Allen MF. Theincidence of recession in young males: Relation-ship to gingival and plaque scores. Periodontics1968;6:109-111.

85. Gorman WJ. Prevalence and etiology of gingival re-

cessions. J Periodontol 1967;38:316-322.86. Sagnes G. Traumatization of teeth and gingiva re-

lated to habitual tooth cleaning procedures. J ClinPeriodontol 1976;3:94-103.

87. Vekalahti M. Occurrence of gingival recession inadults. J Periodontol 1989;60:599-603.

88. Khocht A, Simon G, Person P, Denepitiya JL. Gin-gival recession in relation to history of hard tooth-brush use. J Periodontol 1993;64:900-905.

89. Parfitt GJ, Mjör IA. A clinical evaluation of localgingival recession in children. J Dent Children1964;31:257-262.

90. Modeer T, Odenrick L. Post-treatment periodontalstatus of labially erupted maxillary canines. ActaOdontolScand 1980;38:253-256.

91. Källestäl C, Uhlin S. Buccal attachment loss inSwedish adolescents. J Clin Periodontol 1992; 19:485-491.

92. Bernimoulin JP, Curilivic Z. Gingival recessionand tooth mobility. J Clin Periodontol 1977;4:208-219.

93. Löst C. Depth of alveolar bone dehiscences in re-lation to gingival recessions. J Clin Periodontol1984;11:583-589.

94. Trott JR, Love B. An analysis of localized recessionin 766 Winnipeg high school students. Dent Prac-tice 1966;16:209-213.

95. Lindhe J, Socransky SS, Nyman S, Westfeit E. Di-mensional alteration of the periodontal tissues fol-lowing therapy. Int J Periodontics Restorative Dent1987;7(2):9-22.

96. Miller PD. A classification of marginal tissue re-

cession. Int J Periodontics Restorative Dent 1985;5(2):9-13.

Augmentation of the Edentulous Ridge97. Seibert JS. Reconstruction of the partially eden-

tulous ridge: Gateway to improved prosthetics andsuperior aesthetics. Pract Periodontics AesthetDent 1993;5:47-55.

Frenectomy98. Edwards JG. The diastema, the frenum, the fre-

nectomy: A clinical study. Am J Orthod 1977;71:489-508.

General Considerations99. Caffesse RG, Alspach SR, Morrison EC, Burgett

FG. Lateral sliding flaps with and without citricacid. Int J Periodontics Restorative Dent 1987;7(6):43-57.

100. Thomson MR, Garito ML, Brown FH. The role ofsmoking in periodontal disease: A literature re-view. Periodont Abstr J West Soc Periodontol 1993;41:5-10.

101. Miller PD. Root coverage with the free gingivalgraft. Factors associated with incomplete cover-

age. J Periodontol 1987;58:674-681.102. Tolmie PN, Rubins RP, Buck GS, Vagianos V, Lanz

JC. The predictability of root coverage by way offree gingival autografts and citric acid application:An evaluation by multiple clinicians. Int J Perio-dontics Restorative Dent 1991; 11:261-271.

103. Harris RJ. The connective tissue with partialthickness double pedicle graft: The results of 100consecutively-treated defects. J Periodontol 1994;65:448-461.

Which Procedures Are Justified inMucogingival Therapy?Augmentation of the Dimensions of GingivalTissue104. Bohannan HM. Studies in the alteration of vestib-

ulär depth. I. Complete denudation. J Periodontol1962;33:120-128.

105. Bohannan HM. Studies in the alteration of vestib-ulär depth. II. Periosteum retention. J Periodontol1962;33:354-359.

106. Corn H. Periosteal separation; its clinical signifi-cance. J Periodontol 1962;33:140-153.

107. Wilderman MN. Exposure of bone in periodontal sur-

gery. Dent Clin North America 1964;8:March:23-26.108. Wilderman MN, Wentz FM, Orban BJ. Histogene-

sis of repair after mucogingival surgery. J Perio-dontol 1960;31:283-299.

109. Costich ER, Ramfjord SF. Healing after partial de-nudation of the alveolar process. J Periodontol1968;39:5-12.

110. Carranza FA, Carraro JJ. Effect of removal of per-iosteum on post-operative results of mucogingivalsurgery. J Periodontol 1963;34:223-226.

111. Carraro JJ, Carranza FA, Albano EA, Joly GG. Ef-fect of bone denudation in mucogingival surgeryin humans. J Periodontol 1964;35:463-466.

112. Schmid MO. The subperiosteal vestibule extensionliterature review, rationale and technique. J WestSoc Periodontol 1976;24:89-99.

113. Jenkins WMM, Stephen KW. A clinical comparisonof two gingival extension procedures. J Dent 1979;7:91-97.

114. Stafflleno H, Levy S, Gargiulo A. Histologie study ofcellular mobilization and repair following a perios-teal retention operation via split thickness mucogin-gival surgery. J Periodontol 1966;37:117-131.

115. Stafflleno H, Wentz F, Orban B. Histologie studyof healing of split thickness flap surgery in dogs.J Periodontol 1962;33:56-69.

Vol. 1, No. 1, November 1996

698 Wennström

116. Wilderman MN. Repair after a periosteal retentionprocedure. J Periodontol 1963;34:484-503.

117. Donnenfeld OW, Marks RM, Glickman I. The api-cally repositioned flap—a clinical study. J Perio-dontol 1964;35:381-387.

118. Ainamo A, Bergenholtz A, Hugoson A, Ainamo J.Location of the mucogingival junction 18 years af-ter apically repositioned flap surgery. J Clin Per-iodontol 1992;19:49-52.

119. Karring T, Ostergaard E, Löe H. Conservation oftissue specificity after heterotopic transplantationof gingiva and alveolar mucosa. J Periodont Res1971;6:282-293.

120. Björn H. Free transplantation of gingiva propria.Swed DentJ 1963;22:684-689.

121. Haggerty PC. The use of a free gingival graft to cre-ate a healthy environment for full crown prepara-tion. Periodontics 1966;4:329-331.

122. Nabers CL. Free gingival grafts. Periodontics 1966;4:243-245.

123. Sullivan HC, Atkins JH. Free autogenous gingivalgrafts. I. Principles of successful grafting. Perio-dontics 1968;6:121-129.

124. Hawley CE, Staffileno H. Clinical evaluation of freegingival grafts in periodontal surgery. JPeriodontol1970;41:105-112.

125. Edel A. Clinical evaluation of free connective tis-sue grafts used to increase the width ofkeratinizedgingiva. J Clin Periodontol 1974;1:185-196.

126. Patur B. The rotation flap for covering denudedroot surfaces. A closed wound technique. J Perio-dontol 1977;48:41-44.

127. Espinal MC, Caffesse RG. Lateral positioned ped-icle sliding flap—revised technique in the treat-ment of localized gingival recession. Int JPeriodontics Restorative Dent 1981; 1(5): 43-51.

128. Guinard EA, Caffesse RG. Treatment of localizedgingival recessions. III. Comparison on results ob-tained with lateral sliding and coronally reposi-tioned flaps. J Periodontol 1978;49:457-461.

129. Rateitschak KH, Egli U, Fringeli G. Recession: A4-year longitudinal study after free gingival grafts.J Clin Periodontol 1979;6:158-164.

130. Dordick B, Coslet JG, Seibert JS. Clinical evalu-ation of free autogenous gingival grafts placed onalveolar bone. Part I. Clinical predictability. J Per-iodontol 1976;47:559-567.

131. Dordick B, Coslet JG, Seibert JS. Clinical evalu-ation of free autogenous gingival grafts placed onalveolar bone. Part II. Coverage of nonpathologicdehiscences and fenestrations. J Periodontol 1976;47:568-573.

Root Coverage Procedures132. Bahat O, Handelsman M. Periodontal reconstruc-

tive flaps—classification and surgical considera-tions. Int J Periodontics Restorative Dent 1991; 11:481-487.

133. Grupe J, Warren R. Repair of gingival defects by a

sliding flap operation. J Periodontol 1956;27:290-295.

Annals of Periodontology

134. Grupe J. Modified technique for the sliding flapoperation. J Periodontol 1966;37:491-495.

135. Staffileno H. Management of gingival recessionand root exposure problems associated with peri-odontal disease. Dent Clin North Am 1964;8:March: 111-120.

136. Pfeifer J, Heller R. Histologie evaluation of full andpartial thickness lateral repositioned flaps. A pilotstudy. J Periodontol 1971;42:331-333.

137. Cohen D, Ross S. The double papillae flap in per-iodontal therapy. J Periodontol 1968;39:65-70.

138. Pennel BM, Higgison JD, Towner TD, King KO,Fritz BD, Salder JF. Oblique rotated flap. J Perio-dontol 1965;36:305-309.

139. Bahat O, Handelsman M, Gordon J. The trans-positional flap in mucogingival surgery. Int J Per-iodontics Restorative Dent 1990;10:473-482.

140. Allen EP, Miller PD. Coronal positioning of existinggingiva. Short-term results in the treatment ofshallow marginal tissue recession. J Periodontol1989;60:316-319.

141. Sumner CF. Surgical repair of recession on themaxillary cuspid. Incisally repositioning the gin-gival tissues. J Periodontol 1969;40:119-121.

142. Harvey P. Management of advanced Periodontitis.Part I. Preliminary report of a method of surgicalreconstruction. New Zealand Dent J 1965;61:180-187.

143. Brustein D. Cosmetic periodontics: coronally re-

positioned pedicle graft. Dent Survey 1979;46:22-25.

144. Restrepo OJ. Coronally repositioned flap. Reportof four cases. J Periodontol 1973;44:564-567.

145. Harlan AW. Discussion of paper: Restoration ofgum tissue. Dental Cosmos 1907;49:591-598.

146. Tarnow DP. Similunar coronally repositioned flap.J Clin Periodontol 1986; 13:182-185.

147. Pini Prato G, Tinti C, Vincenzi G, Magnani C, Cor-tellini P, Clauser C. Guided tissue regenerationversus mucogingival surgery in the treatment ofhuman buccal gingival recession. J Periodontol1992;63:919-928.

148. Tinti C, Vincenzi GP, Cortellini P, Pini Prato G,Clauser C. Guided tissue regeneration in the treat-ment of human facial recession. A 12-case report.J Periodontol 1992;63:554-560.

149. Tinti C, Vincenzi GP, Cocchetto R. Guided tissueregeneration in mucogingival surgery. J Periodon-tol 1993;64:1184-1191.

150. Tinti C, Vincenzi GP. Expanded polytetrafluoro-ethylene titanium-reinforced membranes for re-

generation of mucogingival recession defects. A12-case report. J Periodontol 1994;65:1088-1094.

151. Pini Prato G, Clauser C, Magnani C, Cortellini P.Resorbable membranes in the treatment of humanbuccal recession: A nine-case report. Int J Perio-dontics Restorative Dent 1995;15:258-267.

152. Roccuzzo M, Lungo M, Corrente G, et al. Compar-ative study of a bioresorbable and a non-resorba-ble membrane in the treatment of human buccalgingival recessions. J Periodontol 1996;67:7-14.

Review: Mucogingival Therapy 699

153. Karring T, Lang NP, Löe H. Role of connective tis-sue in determining epithelial specificity. J DentRes 1972;51:1303-1304.

154. Ouhayoun JP, Sawaf MH, Goffaux JC, Etienne D,Forest N. Re-epithelialization of a palatal connec-

tive tissue graft transplanted in a non-keratinizedalveolar mucosa: A histological and biochemicalstudy in humans. J Periodont Res 1988;23:127-133.

155. Baer PN, Benjamin SD. Gingival grafts: a histori-cal note. JPeriodontol 1981;52:206-207.

156. Sullivan HC, Atkins JH. Free autogenous gingivalgrafts. III. Utilization of grafts in the treatment ofgingival recession. Periodontics 1968;6:152-160.

157. Maynard JG. Coronally positioning of a previouslyplaced autogenous gingival graft. J Periodontol1977;48:151-155.

158. Bernimoulin JP, Lüscher B, Mühlemann HR. Co-ronally repositioned periodontal flap. Clinical eval-uation after one year. J Clin Periodontol 1975;2:1-13.

159. Miller PD. Root coverage using a free soft tissueautograft following citric acid application. III. Asuccessful and predictable procedure in areas ofdeep-wide recession. Int J Periodontics RestorativeDent 1985;5(2): 15-37.

160. Holbrook T, Ochsenbein C. Complete coverage ofthe denuded root surface with a one-stage gingivalgraft. Int J Periodontics Restorative Dent 1983;3(3):9-27.

161. Langer B, Langer L. Subepithelial connective tis-sue graft technique for root coverage. J Periodontol1985;56:715-720.

162. Nelson SW. The subpedicle connective tissue graft.A bilaminar reconstructive procedure for the cov-

erage of denuded root surfaces. J Periodontol1987;58:95-102.

163. Oliver MJ. Multiple denuded root surfaces. Com-plete coverage with a one-stage, subepithelial con-nective tissue graft. Oral Health 1987;77:51-58.

164. Harris RJ. The connective tissue and partial thick-ness double pedicle graft: A predictable method ofobtaining root coverage. J Periodontol 1992;63:477-486.

165. Bruno JF. Connective tissue graft technique as-

suring wide root coverage. Int J Periodontics Re-storative Dent 1994;14:127-137.

166. Raetzke PB. Covering localized areas of root ex-

posure employing the "envelope" technique. J Per-iodontol 1985;56:397-402.

Augmentation of the Edentulous Ridge167. Scharf DR, Tarnow DP. Modified roll technique for

localized alveolar ridge augmentation. Int J Perio-dontics Restorative Dent 1992;12:415-425.

168. Langer B, Calagna LJ. The subepithelial connec-tive tissue graft. A new approach to the enhance-ment of anterior cosmetics. Int J PeriodonticsRestorative Dent 1982;2(2):23-33.

169. Seibert JS, Nyman S. Localized ridge augmenta-tion in dogs: A pilot study using membranes andhydroxyapatite. JPeriodontol 1990;61:157-165.

Is Root Coverage a Predictable Outcome ofMucogingival Surgery?Rotational Flaps170. Smuckler H. Laterally positioned mucoperiosteal

pedicle grafts in the treatment of denuded roots. Aclinical and statistical study. J Periodontol 1976;47:590-595.

171. Caffesse RG, Guinard, EA. Treatment of localizedgingival recessions. Part IV. Results after threeyears. JPeriodontol 1980;51:167-170.

172. Espinel MC, Caffesse RG. Comparison of the re-

sults obtained with the lateral positioned pediclesliding flap-revised technique and the lateral slid-ing flap with a free gingival graft technique in thetreatment of localized gingival recession. Int J Per-iodontics Restorative Dent 1981; l(6):30-37.

173. Waite IM. An assessment of the postsurgical re-sults following the combined laterally positionedflap and gingival graft procedure. Quintessence Int1984;15:441-50.

174. Zade RM, Hirani SH. A clinical study of localizedgingival recession treated by lateral sliding flap. JIndian Dent Assoc 1985;57:19-26.

175. Oles RD, Ibbott CG, Laverty WH. Effects of citricacid treatment on pedicle flap coverage of localizedrecession. JPeriodontol 1985;56:259-261.

176. Oles RD, Ibbott CG, Laverty WH. Effects of rootcurettage and sodium hypochlorite treatment on

pedicle flap coverage of localized recession. J CanDent Assoc 1988;54:515-517.

177. Kunjamma S, Varma BRR, Nandakumar K. Acomparative evaluation of coverage of denudedroot surface by gingival autograft and lateral slid-ing flap operation. J Indian Dent Assoc 1986;58:527-534.

Coronally Advanced Flap178. Marggraf E. A direct technique with a double lat-

eral bridging flap for coverage of denuded root sur-face and gingiva extension. Clinical evaluationafter 2 years. J Clin Periodontol 1985;12:69-76.

179. Romanos GE, Bernimoulin JP, Marggraf E. Thedouble lateral bridging flap for coverage of de-nuded root surface: Longitudinal study and clini-cal evaluation after 5 to 8 years. J Periodontol1993;64:683-688.

180. Harris RJ, Harris AW. The coronally positionedpedicle graft with inlaid margins: A predictablemethod of obtaining root coverage of shallow de-fects. IntJ Periodontics Restorative Dent 1994; 14:229-241.

181. Wennström JL, Zucchelli G. Increased gingival di-mensions—a significant factor for successful out-come of root coverage procedures? A 2-yearprospective clinical study. J Clin Periodontol 1996;23: in press.

Guided Tissue Regeneration182. Trombelli L, Schincaglia G, Checchi L, Calura G.

Combined guided tissue regeneration, root condi-tioning, and fibrin-fibronectin system application

Vol. 1, No. 1, November 1996

700 Wennström

in the treatment of gingival recession. A 15-casereport. J Periodontol 1994;65:796-803.

183. Trombelli L, Schincaglia G, Scapoli C, Calura G.Healing response of human buccal gingival reces-

sions treated with expanded polytetrafluoroethyl-ene membranes. A retrospective report. J Perio-dontol 1995;66:14-22.

Epithelialized Free Soft Tissue Graft184. Matter J. Free gingival graft and coronally reposi-

tioned flap. A 2-year follow-up report. J Clin Per-iodontol 1979;6:437-442.

185. Liu WJL, Solt CW. A surgical procedure for thetreatment of localized gingival recession in con-

junction with root surface citric acid conditioning.J Periodontol 1980;51:505-509.

186. Tenenbaum H, Klewansky P, Roth JJ. Clinicalevaluation of gingival recession treated by coron-

ally repositioned flap technique. J Periodontol1980;51:686-690.

187. Laney JB, Saunders VG, Garnick JJ. A compari-son of two techniques for attaining root coverage.J Periodontol 1992;63:19-23.

188. Borghetti A, Gardella J-P. Thick gingival autograftfor the coverage of gingival recession: A clinicalevaluation. Int J Periodontics Restorative Dent1990;10:217-229.

189. Matter J, Cimasoni G. Creeping attachment afterfree gingival grafts. J Periodontol 1976;47:574-579.

190. Mltnek A, Smuclder H, Büchner A. The use of freegingival grafts for the coverage of denuded roots.J Periodontol 1973;44:248-254.

191. Matter J. Creeping attachment of free gingivalgrafts. A five-year follow-up study. J Periodontol1980;51:681-685.

192. Michaelides PL, Wilson SG. An autogenous gingi-val graft technique. Int J Periodontics RestorativeDent 1994;14:113-125.

193. Bertrand PM, Dunlap RM. Coverage of deep, widegingival clefts with free gingival autografts: Rootplaning with and without citric acid deminerali-zation. Int J Periodontics Restorative Dent 1988;8(l):65-77.

194. Sbordone L, Ramaglia L, Spagnuolo G, De Luca M.A comparative study of free gingival and subepi-thelial connective tissue grafts. Periodontal case

reports. Periodont Case Reports 1988;10:8-12.195. Daniel A, Cheru R. Treatment of localised gingival

recession with subpedicle connective tissue graftand free gingival auto graft—a comparative clinicalevaluation. J Indian DentAssoc 1990;61:294-297.

196. Jahnke PV, Sandifer JB, Gher ME, Gray JL, Rich-ardson AC. Thick free gingival and connective tis-sue autografts for root coverage. J Periodontol1993;64:315-322.

197. Ibbott CG, Oles RD, Laverty WH. Effects of citricacid treatment on autogenous free graft coverageof localized recession. J Periodontol 1985;56:662-665.

Free Connective Tissue Graft198. Levine RA. Covering denuded maxillary root sur-

faces with the subepithelial connective tissuegraft. Compendium Continuing Educ Dent 1991; 12:568-577.

199. Allen AL. Use of the supraperiosteal envelope insoft tissue grafting for root coverage. II. Clinicalresults. Int J Periodontics Restorative Dent 1994;14:303-315.

200. Borghetti A, Louise F. Controlled clinical evalua-tion of the subpedicle connective tissue graft forthe coverage of gingival recession. J Periodontol1994;65:1107-1112.

201. Bouchard P, Etienne D, Ouhayoun J-P, Nilveus R.Subepithelial connective tissue grafts in the treat-ment of gingival recessions. A comparative studyof 2 procedures. J Periodontol 1994;65:929-936.

What Is the Role of Root SurfaceModification in Mucogingival ProceduresAimed at Root Coverage?202. Nyman S, Sarhed G, Ericsson I, Gottlow J, Karring

T. Role of "diseased" root cementum in healing fol-lowing treatment of periodontal disease. An exper-imental study in the dog. J Periodont Res 1986;21:496-503.

203. Nyman S, Westfeit E, Sarhed G, Karring T. Role of"diseased" root cementum in healing followingtreatment of periodontal disease. A clinical study.J Clin Periodontol 1988;15:464-468.

204. Corn H, Marks, MH. Gingival grafting for deep-wide recession—A status report. Part I. Rationale,case selection, and root preparation. CompendiumContinuing Educ Dent 1983;4:53-64.

205. SeMg KA, Ririe CM, Nilveus R, Egelberg J. Finestructure of new connective tissue attachment fol-lowing acid treatment of experimental furcationpockets in dogs. J Periodont Res 1981; 16:123-129.

206. Poison AM, Proye MP. Effect of root surface alter-ations on periodontal healing. II. Citric acid treat-ment of the denuded root. J Clin Periodontol 1982;9:441-454.

207. Gottlow J, Nyman S, Karring T, Lindhe J. Treat-ment of localized gingival recessions with coron-

ally displaced flaps and citric acid. An experimen-tal study in the dog. J Clin Periodontol 1986; 13:57-63.

208. Woodyard SG, Snyder AJ, Henley G, O'Neal RB. Ahistometric evaluation of the effect of citric acidpreparation upon healing of coronally positionedflaps in nonhuman primates. J Periodontol 1984;55:203-212.

What Dento-Gingival Anatomy Will BecomeEstablished Following Root CoverageProcedures?209. Gottlow J, KarringT, Nyman S. Guided tissue regen-

eration following treatment of recession-type defectsin the monkey. J Periodontol 1990;61:680-685.

210. Cortellini P, DeSanctis M, Pini Prato G, Baldi C,Clauser C. Guided tissue regeneration procedure

Annals ofPeriodontology

Review: Mucogingival Therapy 701

using a flbrin-flbronectin system in surgically in-duced recession in dogs. IntJ Periodontics Restor-ative Dent 1991;11:151-163.

211. Wilderman MN, Wentz FM. Repair of a dentogin-gival defect with a pedicle flap. J Periodontol 1965;36:218-231.

212. Caffesse RG, Kon S, Castelli WA, Nasjleti CE. Re-vascularization following the lateral sliding flapprocedure. J Periodontol 1984;55:352-359.

213. Sugarman EF. A clinical and histological study ofthe attachment of grafted tissue to bone and teeth.J Periodontol 1969;40:381-387.

214. Common J, McFall WT. The effect of citric acid on

attachment of laterally positioned flaps. J Perio-dontol 1983;54:9-18.

215. Cortellini P, Clauser C, Pini Prato GP. Histologieassessment of new attachment following the treat-ment of a human buccal recession by means of a

guided tissue regeneration procedure. J Periodon-tol 1993;64:387-391.

216. Pasquinelli KL. The histology of new attachmentutilizing a thick autogenous soft tissue graft in an

area of deep recession: A case report. Int J Perio-dontics Restorative Dent 1995;15:248-257.

Vol. 1, No. 1, November 1996