how frequent are dehiscence seen in recession? what is the relationship to the underlying bone?
Lost 1984:
recession of 1mm is exceeded by 2.8mm towards the dehiscence
each additional 1mm of recession is followed by 1mm of dehiscence
how does inflammation contribute to recession (as your primary etiological factor)
inflammation, which is triggered by either plaque or mechanical trauma, causes a localized inflammatory response in the tissues, which if they are very thin (mostly thin gingiva and limited CT) due to phenotype and dehiscence and prominent roots, can lead to recession.
what factors did you consider for your overall prognosis as being fair
McGuire and Nunn
-age
-health
-individual tooth prognosis
-rate of progression
-compliance
-finances
-etiological factors
-oral habits
how long did you wait before re-attemtping the CTG and why
for harvest site:
Soileau - 9 weeks before reharvesting for adequate healing and maturation
Tavelli - 6months to gain volume back according to ultrasound study
for recipient site:
-up to 3-6m for CT maturation so it is recommended to wait 3-6m before revisions (Mazzoti)
when is the best time to do STA for ortho patients? before, during or after?
Rationale published by Chamberone 2024:
-if the tooth is within the alveolar housing and there is existing recession and/or lack of KT/thickness (ie. thin phenotype), the tissues should be augmented before ortho tx
-if the tooth is outside the alveolar housing, then ortho should be done first to position the tooth within the alveolar housing, then STA can be performed with better results
-otherwise, the sites should be monitored every 3-4m during ortho therapy
what factors affect root coverage outcomes
Patient:
1) smoking
Site:
2) RT classification
3) # of recessions
4) depth and width of the recession
5) periodontal phenotype
6) amount of KT
7) presence of NCCL
8) tooth position/root prominence
9) vestibular depth
10) frenum
Sx factors:
11) flap thickness (Baldi)
12) flap tension (Pini Prato)
13) flap position (Pini Prato)
how much blood supply to the CTG do you need
Should have 3mm laterally and apically on blood supply and aim to have the graft completely covered to improve the blood supply to the graft
is there a difference between tunnel and CAF
Tavelli 2018 meta analysis - CAF had better CRC compared to tunnel
what is the expected root coverage outcome?
(Cairo)
-RT1: 74% CRC
-RT2: 20%CRC
(Pini Prato 2018)
-RT1: 80%
-RT2: 60%
what is the ideal thickness of a CTG
ideally 1-2mm
Zuccheli 2003 (coronal and apical) 2014 (small versus big):
-small versus big grafts (<2mm versus >2mm) had NO difference in CRC, but the small graft group had better esthetics and less post op discomfort
-no difference in coronal or apical
-small grafts may allow for better blood flow and thus less shrinkage
how much do untreated recessions progress? is recession progressive?
Serino 1994:
-3mm of recession progresses 67% of the time
-4mm of recession progresses 98% of the time
Chamberone and Tatakis 2016:
78% of untreated recession defects tend to increase after a 2 year follow up esp if there is a lack of KT
Agudio 2016:
-48% of untreated sites progress
-83% of treated sites reduced (with FGG)
what are the risk factors of recession
1) thin phenotye
2) lack of KT
3) frenum
4) tooth position/ osseous dehiscence/root prominence
5) traumatic toothbrushing
6) ortho tx
7) plaque-induced inflammation
what is the relationship between ortho and KT
Coatoam 1981
-teeth with <2mm of KT had more loss of KT after ortho than those with >2mm
do you need root conditioning?
Oliveira 2012 - no additional benefit of root conditioning for for clinical outcomes of PD, CAL, or % root coverage
how stable is CTG long term
Pini Prato 2018 - 20 year follow up study shows that the gingival margins are stable. relapse occurs when you have <2mm KT, NCCL, and smoking.
how does a CTG heal
long JE and CT attachment (Guiha et al 2001)
what other techniques are there to cover recession?
-CTG with or without CAF
-FGG
-ADM
-EMD
-GTR
techniques:
-CAF
-tunnel
-VISTA
flaps:
-laterally positioned flap
-double papilla flap
-semilunar pedicle
how do the other techniques for RC compare to each other?
Chamberone/Tatakis 2015:
-CTG+CAF (gold standard) MRC of 97%, CRC 87%
how does ortho relate to recession
conflicting evidence on the relationship between ortho and recessions
Renkema 2013:
-5-12% prevalence of recession at the end of treatment and up to 47% after 5 year follow ups
-ortho proclination of incisiors is related to 5x more likely to have recession than no ortho tx
Bollen 2008 systematic review:
-ortho was only related to 0.03mm recession
factors that are important: thickness of tissue and the direction of tooth movement
Is there a minimum amount of KT needed for health
Lang and Loe previously believed that 2mm of KT and 1mm of attached tissue was required for gingival health, but its been demonstrated that health can be maintained without KT with good oral hygiene (Kennedy 1985)
is KT needed for gingival margin stability
yes, chamberone and tatakis 2016 demonstrated that, in the long term, untreated sites with <2mm of KT was sig associated with an increase in recession
why is thick phenotype more resistant to recession than thin phenotype
1) oral hygiene is easier (according to Agudio 2009)
2) theres more volume of dense, fibrous tissue
3) broader zone of attached gingiva
4) more blood supply
creeping attachment for CTG
Harris - 0.8mm at 6m
how frequently is hypersensitivity resolved after root coverage procedures
78% (De Oliverira 2013) but there is risk of bias in this systematic review and may not be very predictable
