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Modified Tunnel Technique Combined with Enamel Matrix Derivative: A Minimally Invasive Treatment for Single or Multiple Class I Recession Defects

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  Modified Tunnel Technique Combined with Enamel Matrix Derivative: A Minimally Invasive Treatment for Single or Multiple Class I Recession Defects SÉVERINE VINCENT-BUGNAS, DDS, PHD *, YVES CHARBIT, DDS, PHD † , JULIE LAMURE, DDS, MSC ‡ , PATRICK MAHLER, DDS, PHD § , MICHEL M. DARD, DDS, PHD ¶ (J Esthet Restor Dent 27:145  – 154, 2015) INTRODUCTION Gingival recession (GR) is an important challenge in creating a natural-looking smile. Several techniques have been proposed for root coverage, such as free gingival grafts, 1 guided tissue regeneration, 2  subepithelial connective tissue grafts (SCTG), 3 lateral pedicle grafts, 4 double papillae flaps, 5 coronally advanced flaps (CAF), 6 and acellular dermal matrix grafts. 7  Among them, the tunnel connective tissue graft was presented as an alternative due to its less invasive approach and quick healing aspects for root coverage. 8  However, this procedure requires a second surgical site to harvest the tissue and therefore is associated with undesirable side effects like post-operative pain, discomfort, and potential post-operative bleeding. Currently, quantitative root coverage is no longer the ultimate treatment goal of recession defects: qualitativecriteria of success, such as the chromatic and texture integration of the covering tissues, the marginal tissue contour or scar tissue formation, and the satisfaction of patients, are parameters to be considered andevaluated. 9 In fact, a good result is now described as complete root coverage associated with minimal probing depths (PDs) and pleasing esthetics. 10  – 12 In order to perform surgery in the treatment of GR as atraumatically as possible at the recipient and donor site, the use of enamel matrix derivative (EMD) (Emdogain®, Straumann, Basel, Switzerland) has been reported as an adjunct to periodontal plastic surgery. This device is composed of freeze-dried enamel matrix proteins obtained from the developing crown of a 6-month-old piglet. These proteins are industrially isolated, treated, and, after their final purification stage, solubilized under the form called EMD within a hydrogel. This proteins complex is reported to stimulate and promote the formation of new connective tissue, alveolar bone, periodontal ligament. and cementum. 13 Periodontal regeneration through the application of EMD is thought to occur by mimicking the embryological events leading to the normal development of periodontal tissues. 14,15 The application of EMD on root surfaces, in surgical therapy, results in substantial regeneration of periodontal tissues thus improving the clinical outcomes in intrabony defects, recessions, and Class II furcation defects. 16 Recent characterization of the molecular composition of EMD confirms that amelogenin proteins, including their enzymatically cleaved and alternatively spliced fragments, dominate the protein complex (>95%). A small presence of ameloblastin fragments has been reported too, and cumulative evidence indicates that EMD can affect and enhance gene expression, protein production, proliferation, and differentiation of various cell types, particularly for periodontal ligament and osteoblastic cells. 17 Moreover, EMD may promote superoxide production and chemotaxis but reduces matrix metalloproteinase-8 expression by polymorphonuclear leukocytes that suggest potential for enhancement of wound healing, bacterial and tissue debris clearance, and suppress tissue damage and degradation. 18 The bioactive component EMD results in significant stimulation of microvascular primary endothelial cell proliferation and so acts as a proangiogenic factor in vitro and, as such, might contribute to periodontal tissue healing and regeneration by stimulation of vessel formation. It is likely that EMD stimulates angiogenesis directly by affecting the production of angiogenic  factors via periodontal ligament cells. 19  A recent in vivo study confirmed the angiogenic activity of EMD on wound-healing sites. 20 The following study describes minimally invasive plastic surgery using the tunnel technique, complemented by the application of EMD in the treatment of Miller Class I single or multiple recession defects, with a clinical follow-up of 24 months post-operatively. MATERIALS AND METHODS Fourteen patients, eight females, and six males (22  – 58 years old), in good general health and all non-smokers, were recruited in the Department of Periodontology at the Nice University Hospital, from January 2010 to January 2012. After giving informed consent, the procedure was conducted in accordance with the Helsinki declaration of 1975, as revised in 2000. All patients selected for the study had from Miller Class I recession defects and requested surgical root coverage procedure for esthetic reasons, and sometimes hypersensitivity. None of them showed signs of destructive periodontal diseases and all received oral hygiene instructions. Clinical Measurements Before surgery, supragingival plaque was calculated according to the plaque index (PI) systems, and only patients with a PI lower than 0.6 qualified for the operation. All clinical examinations were performed by the same periodontist at baseline (immediately before surgery) and at 6, 12 and 24 months post-surgery (Table 1). The following measurements were recorded using a UNC probe to nearest 0.5 mm. The height of GR was measured from the cementoenamel junction to the gingival margin. The PD of the buccal side of the teeth was measured between the gingival margin and the bottom of the pocket. The clinical attachment level (CAL) was the distance between the cementoenamel junction and the bottom of the pocket. The width of keratinized tissue (KT) was measured between the gingival margin and the mucogingival junction.  Surgical Procedure  All the patients were treated with the same procedure,which is illustrated by the clinical case in Figure 1. After local infiltration of 2% lidocaine containing 1:200,000 epinephrine (Astra, Westborough, MA, USA), the exposed root was scaled and planed with periodontal curettes and ultrasonic hand instruments. If necessary, the root surfaces were reshaped with a smooth diamond bur and polished. The preparation of the recipient bed for adjacent areas of recession was based on the construction of a tunnel under the gingival tissue with minimal trauma. The sole incision at each recession site was made through the sulcus with a 15°C surgical blade, without any external incisions, thus without affecting the gingival papillae. The tunnel was formed by partial thickness dissection apical to the mucogingival junction in order to coronally advance the flap. It was then extended laterally through the papillae with a papilla elevator, 3 mm mesially and distally from the lateral teeth, while keeping the tip of the interproximal papillae attached to the teeth apical to the proximal contact point. The exposed root surface was treated with a 24% ethylenediaminetetracetic acid gel for 2 minutes (PrefGel®, Straumann, Basel, Switzerland) and rinsed copiously with sterile saline solution. Then suspended pre-sutures, using 5.0 bioabsorbable sutures (Vicryl®, Ethicon, Inc., Somerville, NJ, USA), were placed for each recession area. The sites were carefully dried by inserting small pieces of gauze in the pouch created by the flap (Figure 2). The gauze was then removed just before applying EMD on the root surface, inside the tunnel, and in an apico-coronal direction so that no blood was then present (Figure 3). The flap was advanced to the cementoenamel  junction level and the suspension pre-sutures were tied (Figure 4). Patients were subsequently examined at 3, 6, 12, and 24 months post-surgically (Figures 5 and 6). At 6 and 24 months post-operatively, the treated areas were evaluated for GR, PD, CAL, and width of KT just as performed at baseline. Patients were asked if they were satisfied with the appearance of the operated site, and if they would undergo the same surgery again. RESULTS In our study, five patients had single tooth recession, six patients had two adjacent teeth recessions, and three patients needed coverage for three adjacent teeth. For the five patients with only one recession, we performed a pouch technique, and for the other nine, a tunnel technique. We pooled the results because of the similarity of the two procedures (the tunnel is  only the succession of several pouches), and the homogeneity of the initial recessions: 3.2 mm ± 0.6 mm. The values and changes for the clinical parameters at baseline and 24 months post-operatively are reported in Table 2. Height of GR The baseline mean recession depth of 3.2 mm ± 0.6 mm was reduced to 0.3 mm ± 0.4 mm at 24 months (  p < 0.0001). This indicates a reduction of 2.9 mm ± 0.6 mm at 24 months, with mean root coverage of 93% at the end of the study. PD PD remained shallow over time. It changed from 1.6 mm ± 0.5 mm to 1.2 mm ± 0.3 mm at 24 months with a mean reduction of 0.4 mm ± 0.4 mm (  p = 0.05). CAL The mean value at baseline was 4.7 mm ± 0.9 mm and 1.6 mm ± 0.6 mm at 24 months. So there was a statistically significant gain in CAL of 3.1 mm ± 0.9 mm at the end of the study (  p < 0.0001). CONCLUSIONS This study deals with the use of an srcinal, minimally invasive, periodontal plastic surgery variation of the tunnel technique, with the addition of EMD in the treatment of Miller Class I recession defects. This single procedure provides root coverage and gain of clinical attachment with esthetic results at 24 months. Moreover, it does not require a second surgical site. Avoiding harvesting from the palatal donor site decreases post-operative morbidity; therefore, recovery is simplified, with minimal pain reported by patients. Lastly, chair time is decreased for the surgeon because of the ease of this procedure. Within the limits of this study, this technique could be successfully used as an alternative to connective tissue grafts to cover Class I single or multiple recession defects. Although only a few cases were treated using this procedure, the results are encouraging. Further studies that compare results of this technique with already established protocols are necessary to support its regular use.
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