More than clinical publications demonstrate predictable and natural-looking results, including up to ten years, as well as safe and effective stimulation of new periodontal attachment formation periodontal ligament, cementum and alveolar bone. Twenty years of enamel matrix derivative: the past, the present and the future. J Clin Periodontol. Ten-year results following treatment of intra-bony defects with enamel matrix proteins and guided tissue regeneration.
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The aim of this clinical trial study was to clinically evaluate the use of enamel matrix protein derivative combined with the coronally positioned flap to treat gingival recession compared to the subepithelial connective tissue graft by a new method to obtain denuded root surface area.
Recession depth, width, probing depth, keratinized gingival, and plaque index were recorded at baseline and at one, three, and six months after treatment. A stent was used to measure the denuded root surface area at each examination session.
Results were analyzed using Kolmogorov-Smirnov, Wilcoxon, Friedman, paired-sample t test. The average percentages of root coverage for control and test groups were Recession depth decreased significantly in both groups.
Enamel matrix protein derivative showed the same results as subepithelial connective tissue graft with relatively easy procedure to perform and low patient morbidity. Primary goals of mucogingival surgery have changed with time.
For many years, the free gingival graft was considered as a widely used, versatile and predictable mucogingival surgical procedure. Its main objective was to increase the apical-coronal dimension of keratinized tissue to extend the vestibular fornix, to dissipate muscle pull, and to provide an adequate zone of attached gingiva to maintain gingival health and to prevent gingival recession to occur.
The exposure of root surfaces maybe due to periodontal diseases, mechanical forces such as faulty tooth brushing, iatrogenic factors such as orthodontic movement, poor restorations, and anatomical factors such as tooth malposition and frenum pull. Several surgical techniques have been described to cover the root: Lateral or pedicle sliding flap that has several limitations there should be adequate dimension of gingival tissue lateral to the site of recession and the area to be treated should be localized.
The advantage of this procedure is in the esthetics because the color match is ideal. The coronally positioned flap CPF is another surgical technique used with many variations.
This technique is limited by the amount of height and thickness of the gingival tissues; however, the resulting esthetics are usually good and can be used to treat localized or generalized recession defects. This is a relatively easy procedure for the clinician to perform and for the patient due to reduced morbidity because donor tissue need not be procured.
The removal of a CTG results in only minor palatal denudation. This technique usually results in a good color blend of the augmented area and increased graft vascularization from the underlying periosteum and the overlying flap to the graft.
Sometimes a second surgery is needed to reduce thickness and obtain a good esthetic result. Guided tissue regeneration GTR is based on the principle of guiding various cells to proliferate and to form new periodontal tissues during healing through the use of resorbable or non-resorbable membrane.
This technique has been used to treat localized gingival recession defects. These included the technical difficulties in optimally placing the barrier, membrane exposure in the course of healing, and possible damage of the newly formed tissue due to membrane removal or absorption. Enamel matrix derivative EMD preparation consists of a group of proteins thought to be important in the development of the dental organ, particularly as it relates to the formation of cementum, periodontal ligament, and alveolar bone.
When mesenchymal cells of the dental follicle are exposed to the enamel matrix, a non-cellular hard tissue matrix is formed on the enamel surface. A commercially available product, Emdogain, consists of amelogenins that are extracted from developing embryonal tooth buds of porcine origin. It has also been tested as a periodontal regenerative treatment modality in animals and humans and was shown to be safe and effective on improving clinical attachment levels and radiographic bone fill.
Human biopsy reports revealed that true periodontal regeneration could be achieved with topical application of EMD. Root coverage outcomes in almost all studies are based on linear measurement of the recession depth and recession width obtained by a periodontal probe. Today, by use of different software programmes, a new horizon to diagnosis and treatment plan in periodontics has been opened. AutoCAD is a software programme that could be used for obtaining two-dimensional views in the treatment of gingival recession.
The aim of the present prospective, randomized, split-mouth, clinical study on teeth with Miller cl I or II gingival recession was to clinically evaluate the use of EMD in association with CPF to cover gingival recession compared to subepithelial CTG alone.
The covered surface area was obtained and compared by AutoCAD programme for the first time. Thirteen non-smoking patients eight females and five males aged years Twenty pairs of gingival recession were treated. Before therapy, all patients agreed to participate in the study signed a written informed consent according to ethical principles No Islamic Azad University-Dental branch.
Inclusion criteria were that vital teeth free from decay, crown, or buccal restorations, no radiographic signs of periapical infection, no occlusal trauma, no previous periodontal surgery in the area. All patients received oral hygiene instructions associated with full mouth scaling.
One patient refused to continue the study. Therefore, eighteen pairs of gingival recessions fulfilled the 6 months examination. One clinician blinded to the surgical procedure collected the pre-and post-operative data. The clinical parameters evaluated with Williams Probe at baseline, 1, 3, 6 months were as follows:. Distance between the cement enamel junction CEJ and the gingival margin measured at the mid-buccal aspect of the tooth.
Distance between the mesial and distal aspects of the gingival margins of the tooth measured in a horizontal direction at the level of the mid-buccal point of the CEJ. Distance between the CEJ and the bottom of the pocket measured at the mid-buccal aspect of the tooth.
Distance between the gingival margin and the bottom of the pocket measured at the level of the mid-buccal point of the CEJ. All measurements rounded up to the nearest millimeter.
The teeth surfaces which were coloured by the disclosing agent were calculated and divided by total teeth surfaces multiplied by An alginate impression was taken at baseline and an acrylic stent was made, according to mesial-distal dimension of the tooth under treatment, three to five grooves were made on the stent by a thin cylindric bur at mid-buccal, mesial and distal line angles and at 1.
This line showed the pre-operative gingival margin position. New gingival margin position at follow-up intervals 1, 3, 6 months were made by the aforementioned rules. In other words, these points were used to make an area of the recession defect by the Autocad programme and changes of the area over time could be assessed and calculated by overlapping the figures obtained at different follow-up examinations [ Figure 1 ].
Pre-operative photographs of the cases and surgical procedures were performed between September and June In each patient, the tooth with gingival recession was randomly assigned to one of the surgical procedures. Randomization was performed by coin toss. Surgical procedures were performed by one clinician with over 10 years of clinical experience in periodontal surgery.
Before elevation of the flap, the exposed and the intrasulcular root surfaces were gently scaled and planed with Gracy curettes. After local anesthesia with Lidocaine , a no. The incision was extended horizontally up to the adjacent tooth both mesial and distal to the involved tooth or teeth at the level of the CEJ. Two oblique releasing incisions were carried out from the mesial and distal extremities of the horizontal incisions across the mucogingival junction reaching the alveolar mucosa.
A trapezoidal partial thickness flap was raised and the root surface was scaled and debrided with hand instruments properly. The papillae adjacent to the involved tooth were deepithelialized to create a connective tissue bed.
The root surfaces was copiously rinsed with normal saline. EMD straumann, swiss was then applied, starting from the most apical bone level and covering the entire root surface. On the control tooth, a trapezoidal partial thickness flap with vertical incisions was elevated on the buccal surface of the tooth and the root was scaled and planed with curet. Suture removal was done after two weeks and after four weeks the patients were instructed to brush with a soft toothbrush.
Measurements and photographic documentation were obtained presurgically and after 1, 3, 6 months postoperatively. At these visits, oral hygiene instruction were reviewed and prophylaxis was performed.
Summary statistical measures mean, standard deviation were calculated for clinical indices. Distribution normality assumptions for clinical indices were assessed by the Kolmogorov-Smirnov test.
For comparison of clinical indices between groups paired-sample t test was used. In some comparisons when normality would not hold, non-parametric Wilcoxon and Friedman test were used. The value of clinical parameters at the baseline and 6-month examinations in both treatment groups are reporte in [ Table 1 ].
Percentage of root coverage obtained for control and test sites was evaluated. At the end of 6 months, The other width under investigation was the change in witz of the recession defects. In the test group, recession depth RD decreased from 3. At the test sites, PD changed from 1. In the control group, PD changed from 1. Equal to a reduction of 0. However, the values were slightly better for the control group at 6 months [ Table 3 ]. Both treatment groups presented with significant post-surgical improvement in gingival recession width, depth and surface area and keratinized gingiva [ Table 1 ].
The subepithelial CTG is preferred for treating most mucogingival recession defects and could be considered the gold standard. CPF, among other techniques is also a predictable surgical procedure in the treatment of Miller Cl I and II gingival recession[ 3 , 13 ] and dose not require a second surgical site.
EMD was avocate to promote new attachment to denuded root surfaces. The results of this study showed that the clinical efficacy of EMD placed under a CPF test was effective in covering recession defects, representing a simpler procedure for the clinician and a less invasive procedure for the patient. We performed each of the techniques without considering the amount of keratinized tissue at baseline. It seems EMD promoted new attachment to denuded root surfaces, based on biologic properties that have been described.
By means of EMD, periodontal regeneration may be achieved. CTG often results in periodontal repair. In a systematic review article by Koop and co-workers, there was a consensus of opinion on the results of root coverage by using these two techniques, although this review took place on two studies.
There was a significant increase in the mean width of KG 1. Data from this study demonstrated that a significant improvement was found in RD at six months 1. These percentages are less than the results of several studies. The reason to have better percentage of root coverage RD in the control group than in the test group, while the surface area of root coverage was similar between the groups, is not clear exactly.
This discrepancy maybe due to different methods of measurements. Surface area measures maybe more precise than one-point measurement. Source of Support: The study was self-funded by the authors and their institution. Conflict of Interest: None declared. National Center for Biotechnology Information , U.
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As a component of embryonic tissues it is designed to promote predictable regeneration of hard and soft tissues lost due to periodontal disease or trauma. The matrix has the proven ability to stimulate various cell types involved in the wound healing cascade of soft and hard tissues mesenchymal stem cells, osteoblasts, fibroblasts, periodontal ligament cells and cementoblasts towards a regenerative pattern. Heden, Karlstad, Sweden. Order your free printed copy here. Clin Oral Invest. J Periodontal Res  Heijl et al.
Clinical Use of Emdogain for Regeneration of Periodontal Defects
The aim of this clinical trial study was to clinically evaluate the use of enamel matrix protein derivative combined with the coronally positioned flap to treat gingival recession compared to the subepithelial connective tissue graft by a new method to obtain denuded root surface area. Recession depth, width, probing depth, keratinized gingival, and plaque index were recorded at baseline and at one, three, and six months after treatment. A stent was used to measure the denuded root surface area at each examination session. Results were analyzed using Kolmogorov-Smirnov, Wilcoxon, Friedman, paired-sample t test. The average percentages of root coverage for control and test groups were
Connective tissue graft vs. emdogain: A new approach to compare the outcomes
It is documented in over scientific publications including clinical publications 17 and 10 year data 14, J Periodontol. Clinical and histologic evaluation of human intrabony defects treated with an enamel matrix protein derivative Emdogain. Int J Periodontics Restorative Dent. Effects of enamel matrix derivative on vascular endothelial growth factor expression and microvessel density in gingival tissues of periodontal pocket: a comparative study.