Bone-added periodontal plastic surgery: a new approach in esthetic dentistry
© Gholami et al.; licensee BioMed Central. 2015
Received: 6 June 2014
Accepted: 21 January 2015
Published: 11 February 2015
This article proposes a combined technique including bone grafting, connective tissue graft, and coronally advanced flap to create some space for simultaneous bone regrowth and root coverage.
A 23 year-old female was referred to our private clinic with a severe class II Miller recession and lack of attached gingiva. The suggested treatment plan comprised of root coverage combined with xenograft bone particles.
The grafted area healed well and full coverage was achieved at 12-month follow-up visit. Bone-added periodontal plastic surgery can be considered as a practical procedure for management of deep gingival recession without buccal bone plate.
Marginal tissue recession is a mucogingival problem that is considered a major challenge for clinicians and patients. It is frequentlyassociated with esthetic concerns, fear of tooth loss, root caries, and dentin hypersensitivity. Manyprotocols are available for the management ofsuch defects including different types of soft tissue grafts. Several studies have confirmed thatthese recessions can be predictably covered by various surgical procedures like as pedicle flaps, subepithelial connective tissue grafts (CTG) with or without coronally positioned flap (CPF), and guided tissue regeneration (GTR), if the interdental papilla is not affected [1-5].
In spite of predictable clinical outcomes by using CTGs, its healingprocess and histological outcome still remain controversial. Evidence data of human histology after the use of these techniques are scarce. The histologic evidenceshave been mostly derived from animal studies or some case reportsconducted by the extraction of the treated teeth. It seems that CPF and CTG are associated with somedegrees of periodontal regeneration [6-8]. However, some authorshave reported that healing occurs primarily by a long junctional epithelium or to a limited extent by connective tissueadhesion of the graft [9,10]. The concern about the nature of the grafted tissue attachment is based on the concept that the ultimate goal of periodontal treatment is to fully restore the attachment apparatus. Current available therapies have shown limited and rather unpredictable results. The nature of connective tissue attachment seems to be stable over time, although, ultimate goal of a root coverage procedure should be new bone formation overthe denuded roots.
To our knowledge, there is no report of bone-added periodontal plastic surgery for root coverage procedures in humans. The aim of the present investigation was to present a technique with a combination of bone substitute, CTG, and CPF thatwas used to create some space for osteoconduction and soft tissue coverage over denuded roots.
Dehiscence bone defects over exposed root surfaces were overfilled with a mixture of deproteinized bovine bone (Bio-Oss Collagen, Geistlich AG, Wolhusen, Switzerland) and blood obtained froma peripheral vein. CTG was trimmed and sutured over the defect with a 5–0 bio-absorbable suture (Vicryl®, ETHICON, Johnson & Johnson, Livingston, Scotland) at the level of CEJs. Previously reflectedpartial-thickness flap was sutured as double papillary technique described by Harris , and then coronally positioned to cover the entire graft without tension . The flap was sutured in place with sling sutures (Figure 2).
The patient was instructed to discontinue tooth brushing for 3 weeks and to avoidtrauma at the surgical site. A 0.2% Chlorhexidine digluconate mouthwash (CHX mouthwash, Daroupakhsh Co, Iran) was prescribed twice daily. Professional cleaning was done by a hygienist every day until the sutures were removedon day14. The patients were recalled for prophylaxisat every month, postoperatively. The clinical measurements were recorded at baseline and every 3 months till the final recall visit at six years.
Subepithelial connective tissue grafts may be still considered the gold standard procedure for covering Miller Class I and II gingivalrecessions . One of the advantages of CG with a CAF over other procedures is that it produces a larger increase in the keratinized tissue compared to the repositioned flaps alone [14,16]. The presence of thick attached keratinized tissue may act as a protective factor against marginal inflammation or trauma.
Rosetti et al.  showed that both SCTG and GTR with a bioabsorbable membrane and bone graft demonstrated significant clinical and esthetic improvement in gingival recession coverage 18 months after surgery. The two procedures were statistically similar in root coverage (SCTG = 95.6%, GTR = 84.2%). In addition, they mentioned that the gingival recessions treated with the SCTG weresuperior in terms of GR, RC, and KT clinical parameters, while GTR demonstrated better PD reduction. The final esthetic results were similar using both techniques. However, occurrence of true regeneration after such procedures has been a controversial issue. McGuire et al.  showed that no histological evidence of cementum, bone, or periodontal ligament (PDL) and, therefore, regeneration could be determined using CTG + CPF. Thus, they recommended adding some regenerative materials to enhance the capacity of tissue regeneration.
There are some case reports that used different materials which were combined with CTG to achieve some regeneration over denuded root surfaces. For example, Maurer and Leone  used CTG coupled with enamel matrix derivative (Emdogain) to maximize the regenerative potential. Nozawa et al.  also described a case of gingival recession in which root coverage and coronal bone regrowth were achieved after treatment with a connective tissue-bone graft and enamel matrix derivative.
It can be concluded that connective tissue grafts are used successfully in periodontal therapy for root coverage. However, reports on the histologic interface between the root surface and the grafted tissue have been few in number [21-25]. Some studies have shown that the pedicle graft withor without CTG may heal by periodontal regeneration.Newconnective tissue attachment (3.9 mm), including periodontalligament was observed to be associated with aCAF with CTG . Histological evaluation of the CGrevealed a healing process characterized by one mm newbone formation, new periodontal fibers, new cementum, and new connective tissue attachment .
Summary of published data with histologic findings of different root coverage procedures
FGG+ tetracycline conditioning
4.4 mm of new attachment and 4.0 mm of new bone growth.
CTG+ Partial DPF
Two different healing patterns: first onewas a long junctional epithelial attachment with minimal connective tissue
The other pattern was a short junctional epithelium and predominately connective tissue.
No new bone or cementum was seen in any section.
Goldstein et al/2001 
Sulcular epithelium was keratinized; epithelium lining the dentin exhibited rete ridges projecting into the gingival connective tissue; and junctional epithelium extended over new cementum. New connective tissue attachment was also observed, including periodontal ligament.
Majzoub et al/2001 
Long junctional epithelium throughout the major portion. Only minimal signs of new cementum-like tissue
Carnio et al/2002 
CTG + EMD
Short junctional epithelium, dense CT fibers were found in close proximity to the root surface,
No insertion of fibers into the root was observed.
Newcementum and new bone in the most apical end of the grafted area.
McGuire et al/2003 
A connective tissue attachment
No histological evidence of cementum, bone, or PDL.
Cummings et al/2005 
Cementum deposition within the root notches, unaffected alveolar bone.
McGuire et al/2009 
CTG + rhPDGF + beta-TCP
Evidence of regeneration of cementum, PDL with inserting connective tissue fibers, and supporting alveolar bone, none of the CTG-treated sites exhibited any signs of periodontal regeneration.
Roman et al/2010 
No ligament or bone, no sign of a long junctional epithelium a long connective tissue attachment
a- Preparation of an extensive bed for sufficient blood supply,
b- Using xenograft bone particles over denuded root surfaces for space maintaining,
c- Adding own patients blood mixed with bone graft granules for accelerating the healing during initial phase,
d- Excellent stabilization od connective tissue graft over bone particles at the level of CEJs,
e- Using double pedicle and coronally positioned flaps for covering the connective tissue graft completely, and
f- Strict follow up protocol with optimal level of patient’s cooperation.
As shown in Figure 5, long term stability of xenograft particles was clearly shown in a cross sectional view of the treated sites via a cone beam computed tomography (CBCT) obtained 6 years later. Although this imaging method cannotbe used to indicate a true regeneration, the differences between treated and untreated sites revealed that it is more reasonable to use bone graft to cover the denuded root surfaces.
Bone added periodontal plastic surgery can be considered as a safe, efficient, and stable technique for complete root coverage ofsevere deep class II gingival recessions combined with lack of buccal plates. Clinical trials with sufficient cases are necessary to compare the results withthose of more conventional procedures.
The authors would like to thank Dr. T. Jalayer for taking and interpreting the initial and final imaging. The authors report no conflict of interest related to this case series.
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