Region

Bony situation

Soft-tissue situation

n aesthetic region nnon-aesthetic regionn single tooth gap nmultiple tooth gapn single tooth

n bone defect present nno bone defect present

n recession nno recession

n inflamed ninfected

n thick biotype nthin biotype

n primary wound closure possible nprimary wound closure not possible

n intact papillae nimpaired, missing papillae

n adequate keratinised mucosa n inadequate keratinised mucosa n uneventful

1 Wennström J, Pini Prato G. Mucogingival therapy-periodontal plastic surgery. In: Lindhe J, Karring T, Lang N (eds). Clinical Periodontology and Implant Dentistry. Copen-hagen: Munksgaard, 2003:576–649.

2 Wennström J. Mucogingival therapy. Ann Periodontol 1996;1:671–706.3 Cortellini P, Clauser C, Prato GP. Histologic assessment of new attachment following the treatment of a human buccal recession by means of a guided tissue regeneration

procedure. J Periodontol 1993;64:387–391. 4 Wang HL, Bunyaratavej P, Labadie M, Shyr Y, MacNeil RL. Comparison of 2 clinical techniques for treatment of gingival recession. J Periodontol 2001;72:1301–1311.5 Miller PD. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8–13.6 Pini Prato G, Clauser C, Cortellini P, Tinti C, Vincenzi G, Pagliaro U. Guided tissue regeneration versus mucogingival surgery in the treatment of human buccal recessions.

A 4-year follow-up study. J Periodontol 1996;67:1216–1223.7 Tatakis DN, Trombelli L. Gingival recession treatment: Guided tissue regeneration with bioabsorbable membrane versus connective tissue graft. J Periodontol

2000;71: 299–307.8 Ainamo A, Bergenholtz A, Hugoson A, Ainamo J. Location of the mucogingival junction 18 years after apically repositioned flap surgery. J Clin Periodontol 1992;19:49–52.9 Matarasso S, Cafiero C, Coraggio F, Vaia E, de Paoli S. Guided tissue regeneration versus coronally repositioned flap in the treatment of recession with double papillae.

Int J Periodontics Restorative Dent 1998;18:444–453.10 Amarante ES, Leknes KN, Skavland J, LieT. Coronally positioned flap procedures with or without a bioabsorbable membrane in the treatment of human gingival recession.

J Periodontol 2000;71:989–998. 11 Cardaropoli D, Cardaropoli G. Healing of Gingival Recessions Using a Collagen Membrane with a Demineralized Xenograft: A Randomized Controlled Clinical Trial. Int J

Periodontics Restorative Dent. 2009 Feb;29(1):59-67.

4

© Geistlich Pharma AG Business Unit Biomaterials CH-6110 Wolhusen phone +41 41 492 56 30 fax +41 41 492 56 39 www.geistlich-pharma.com

1

3141

3.1/

1012

/e

Literature references

Suppliers > Sutures: Resopren 5/0 (Resorba, Germany) and Glycolon 5/0 (Resorba, Germany)

Contact > Dr. Daniele Cardaropoli, Corso Galileo Ferraris 148, 10129 Turin, Italy telephone: +39.011.323683, fax: +39.011.323683, e-mail: dacardar@tin.it, website: www.cardaropoli.it

Further Indication Sheets> For free delivery please contact: www.geistlich.com/indicationsheets> If you no longer wish to collect Indication Sheets, please unsubscribe with your local distribution partner

Treatment concept by Dr. Daniele Cardaropoli, Private Practice, Turin, Italy

> Gingival recession coverage > Gingival biotype modification> Coronally advanced flap

Soft-Tissue RegenerationIndication Sheet STR-1

1. Indication profile

2

Dr. Daniele Cardaropoli:Gingival recession is defined as the displacement of the marginal tissue apical to the cemento- e namel junction with exposure of the root surface1,2. Problems commonly associated with the presence of gingival recessions are compromised aesthetics, root hypersensitivity, higher inci-dence of root caries, and compromised plaque control.

Treatment of gingival recession is performed via mucogingival therapy, which includes surgical and nonsurgical procedures (periodontal plastic surgery, oral hygiene, orthodontic therapy) for correction of soft-tissue defects3-5. The treatment of buccal soft-tissue defects is mainly concerned with reshaping of the gingival architecture, and in some cases concomitant efforts to increase the amount of keratinised tissue is indicated6-11. Thus, the rationale for treating gingival recessions is related to aesthetics and root hypersensitivity. Patient: Male, 59 years old, referred to the practice for gingival and orthodontic therapy.

Chief complaints: Root sensitivity on tooth 13. The patient was concerned with function and aesthetics.

Anamnesis: Good general health, no family history of periodontitis, never smoker.

Intraoral examination: Slight generalised gingival inflammation associated with the presence of deposits of plaque and calculus.

Initial treatment plan: Cause-related therapy, motivation and oral hygiene instructions.

Treatment objectives: Root coverage and gain in gingival thickness on tooth 13, in order to resolve root sensitivity and improve both function and aesthetics.

Surgical treatment plan: Coronally advanced flap in Class I Miller‘s type defect5, associated with the use of a resorbable collagen matrix (Geistlich Mucograft®).

Background information

2. Aims of the therapy > Aim of the therapy is to resolve root hypersensitivity and, at the same time, improve the aesthetic appearance. Periodontal plastic surgery will be performed.> A 3 mm Class I Miller‘s type defect present on tooth 13 will be treated via a coronally advanced flap. Using the principles of Guided Tissue Regeneration, a collagen matrix (Geistlich Mucograft®) will be inserted under the flap in order to obtain a gain in gingival thickness.

3

Fig. 1 Photograph at baseline: clinical evidence of gingival recession affecting upper right canine.

Fig. 2 Measurement of the gingival displacement at baseline using a periodontal probe. 3 mm of recession are measured at the level of the ideal cemento-enamel junction.

Fig. 3 Surgical incisions design in order to create a coronally advanced flap. An intrasulcular buccal incision is connected with two vertical release incisions.

3. Surgical procedure

Fig. 7 The trimmed Geistlich Mucograft® collagen matrix is presutured with a single-loop sling suture.

Fig. 8 The collagen matrix is fixed with a single-loop sling suture around the cemento-enamel junction, and two single sutures at the mesial and distal sides of the flap.

Fig. 9 The pedicle flap is positioned to the cemento-enamel junction by means of a double-loop sling suture, and the releasing incisions are sutured to complete primary closure of the area.

Fig. 10 Primary closure maintained after 2 weeks, on the day of suture removal. No signs of inflammation are present.

Fig. 11 Clinical observation 3-months post-opera-tively. Uneventful healing is observed, with perfect color-match and root-coverage.

Fig. 12 Occlusal view 3-months post-operatively. An amount of gingival tissue surrounding the canine, and a thick gingival biotype are present.

Fig. 4 A combined (from coronal to apical) split-thickness, full-thickness and split-thickness flap is elevated. Split-thickness mesially and distally to the root surface, full-thickness apical to the recession and split-thickness above the muco-gin-gival junction.

Fig. 5 Both mesial and distal papillae are de-epitheli-alised in order to secure anchorage of the flap onto a connective bed. The root surface is scaled and planed with ultrasonic, rotary burs and hand inst-ruments to produce a decontaminated, smooth and flattened surface.

Fig. 6 The Geistlich Mucograft® collagen matrix is trimmed to conform to the surgical field in a dry state.

Fig. 13 Presentation at 6-month follow-up. The gingival margin is located at the cemento- enamel junction. A proper amount of keratinised tissue is present, with perfect colour-match.

Fig. 14a Clinical situation 11 months post-opera-tively. Optimal outcomes after 6 months are main-tained at long-term follow-up.

Fig. 14b Occlusal view at 11 month follow-up.

2

Dr. Daniele Cardaropoli:Gingival recession is defined as the displacement of the marginal tissue apical to the cemento- e namel junction with exposure of the root surface1,2. Problems commonly associated with the presence of gingival recessions are compromised aesthetics, root hypersensitivity, higher inci-dence of root caries, and compromised plaque control.

Treatment of gingival recession is performed via mucogingival therapy, which includes surgical and nonsurgical procedures (periodontal plastic surgery, oral hygiene, orthodontic therapy) for correction of soft-tissue defects3-5. The treatment of buccal soft-tissue defects is mainly concerned with reshaping of the gingival architecture, and in some cases concomitant efforts to increase the amount of keratinised tissue is indicated6-11. Thus, the rationale for treating gingival recessions is related to aesthetics and root hypersensitivity. Patient: Male, 59 years old, referred to the practice for gingival and orthodontic therapy.

Chief complaints: Root sensitivity on tooth 13. The patient was concerned with function and aesthetics.

Anamnesis: Good general health, no family history of periodontitis, never smoker.

Intraoral examination: Slight generalised gingival inflammation associated with the presence of deposits of plaque and calculus.

Initial treatment plan: Cause-related therapy, motivation and oral hygiene instructions.

Treatment objectives: Root coverage and gain in gingival thickness on tooth 13, in order to resolve root sensitivity and improve both function and aesthetics.

Surgical treatment plan: Coronally advanced flap in Class I Miller‘s type defect5, associated with the use of a resorbable collagen matrix (Geistlich Mucograft®).

Background information

2. Aims of the therapy > Aim of the therapy is to resolve root hypersensitivity and, at the same time, improve the aesthetic appearance. Periodontal plastic surgery will be performed.> A 3 mm Class I Miller‘s type defect present on tooth 13 will be treated via a coronally advanced flap. Using the principles of Guided Tissue Regeneration, a collagen matrix (Geistlich Mucograft®) will be inserted under the flap in order to obtain a gain in gingival thickness.

3

Fig. 1 Photograph at baseline: clinical evidence of gingival recession affecting upper right canine.

Fig. 2 Measurement of the gingival displacement at baseline using a periodontal probe. 3 mm of recession are measured at the level of the ideal cemento-enamel junction.

Fig. 3 Surgical incisions design in order to create a coronally advanced flap. An intrasulcular buccal incision is connected with two vertical release incisions.

3. Surgical procedure

Fig. 7 The trimmed Geistlich Mucograft® collagen matrix is presutured with a single-loop sling suture.

Fig. 8 The collagen matrix is fixed with a single-loop sling suture around the cemento-enamel junction, and two single sutures at the mesial and distal sides of the flap.

Fig. 9 The pedicle flap is positioned to the cemento-enamel junction by means of a double-loop sling suture, and the releasing incisions are sutured to complete primary closure of the area.

Fig. 10 Primary closure maintained after 2 weeks, on the day of suture removal. No signs of inflammation are present.

Fig. 11 Clinical observation 3-months post-opera-tively. Uneventful healing is observed, with perfect color-match and root-coverage.

Fig. 12 Occlusal view 3-months post-operatively. An amount of gingival tissue surrounding the canine, and a thick gingival biotype are present.

Fig. 4 A combined (from coronal to apical) split-thickness, full-thickness and split-thickness flap is elevated. Split-thickness mesially and distally to the root surface, full-thickness apical to the recession and split-thickness above the muco-gin-gival junction.

Fig. 5 Both mesial and distal papillae are de-epitheli-alised in order to secure anchorage of the flap onto a connective bed. The root surface is scaled and planed with ultrasonic, rotary burs and hand inst-ruments to produce a decontaminated, smooth and flattened surface.

Fig. 6 The Geistlich Mucograft® collagen matrix is trimmed to conform to the surgical field in a dry state.

Fig. 13 Presentation at 6-month follow-up. The gingival margin is located at the cemento- enamel junction. A proper amount of keratinised tissue is present, with perfect colour-match.

Fig. 14a Clinical situation 11 months post-opera-tively. Optimal outcomes after 6 months are main-tained at long-term follow-up.

Fig. 14b Occlusal view at 11 month follow-up.

Region

Bony situation

Soft-tissue situation

n aesthetic region nnon-aesthetic regionn single tooth gap nmultiple tooth gapn single tooth

n bone defect present nno bone defect present

n recession nno recession

n inflamed ninfected

n thick biotype nthin biotype

n primary wound closure possible nprimary wound closure not possible

n intact papillae nimpaired, missing papillae

n adequate keratinised mucosa n inadequate keratinised mucosa n uneventful

1 Wennström J, Pini Prato G. Mucogingival therapy-periodontal plastic surgery. In: Lindhe J, Karring T, Lang N (eds). Clinical Periodontology and Implant Dentistry. Copen-hagen: Munksgaard, 2003:576–649.

2 Wennström J. Mucogingival therapy. Ann Periodontol 1996;1:671–706.3 Cortellini P, Clauser C, Prato GP. Histologic assessment of new attachment following the treatment of a human buccal recession by means of a guided tissue regeneration

procedure. J Periodontol 1993;64:387–391. 4 Wang HL, Bunyaratavej P, Labadie M, Shyr Y, MacNeil RL. Comparison of 2 clinical techniques for treatment of gingival recession. J Periodontol 2001;72:1301–1311.5 Miller PD. A classification of marginal tissue recession. Int J Periodontics Restorative Dent 1985;5:8–13.6 Pini Prato G, Clauser C, Cortellini P, Tinti C, Vincenzi G, Pagliaro U. Guided tissue regeneration versus mucogingival surgery in the treatment of human buccal recessions.

A 4-year follow-up study. J Periodontol 1996;67:1216–1223.7 Tatakis DN, Trombelli L. Gingival recession treatment: Guided tissue regeneration with bioabsorbable membrane versus connective tissue graft. J Periodontol

2000;71: 299–307.8 Ainamo A, Bergenholtz A, Hugoson A, Ainamo J. Location of the mucogingival junction 18 years after apically repositioned flap surgery. J Clin Periodontol 1992;19:49–52.9 Matarasso S, Cafiero C, Coraggio F, Vaia E, de Paoli S. Guided tissue regeneration versus coronally repositioned flap in the treatment of recession with double papillae.

Int J Periodontics Restorative Dent 1998;18:444–453.10 Amarante ES, Leknes KN, Skavland J, LieT. Coronally positioned flap procedures with or without a bioabsorbable membrane in the treatment of human gingival recession.

J Periodontol 2000;71:989–998. 11 Cardaropoli D, Cardaropoli G. Healing of Gingival Recessions Using a Collagen Membrane with a Demineralized Xenograft: A Randomized Controlled Clinical Trial. Int J

Periodontics Restorative Dent. 2009 Feb;29(1):59-67.

4

© Geistlich Pharma AG Business Unit Biomaterials CH-6110 Wolhusen phone +41 41 492 56 30 fax +41 41 492 56 39 www.geistlich-pharma.com

1

3141

3.1/

1012

/e

Literature references

Suppliers > Sutures: Resopren 5/0 (Resorba, Germany) and Glycolon 5/0 (Resorba, Germany)

Contact > Dr. Daniele Cardaropoli, Corso Galileo Ferraris 148, 10129 Turin, Italy telephone: +39.011.323683, fax: +39.011.323683, e-mail: dacardar@tin.it, website: www.cardaropoli.it

Further Indication Sheets> For free delivery please contact: www.geistlich.com/indicationsheets> If you no longer wish to collect Indication Sheets, please unsubscribe with your local distribution partner

Treatment concept by Dr. Daniele Cardaropoli, Private Practice, Turin, Italy

> Gingival recession coverage > Gingival biotype modification> Coronally advanced flap

Soft-Tissue RegenerationIndication Sheet STR-1

1. Indication profile