Periodontal Regeneration and Gingival Recession Management

Autogenous Bone Grafts

Intraoral Donor Sites

• Edentulous ridge
• Lingual ridge of mandible
• Retromolar area
• Maxillary tuberosity
• Extraction socket
• Ostectomy

Extraoral Donor Sites

• Hip marrow
• Iliac crest
• Tibia

Indications for GTR

1. Alveolar ridge augmentation
2. Alveolar ridge preservation
3. Augmenting maxillary sinus for implant
4. Augmenting bone to stabilize implant
5. Recession
6. Intrabony defect
7. Furcation class 2

Factors Influencing GTR Clinical Outcomes

• Patient health
• Patient compliance
• Smoking
• Tooth mobility
• Horizontal bone loss
• Medications or systemic disease

Requirements for GTR Materials

• Biocompatibility
• Tissue integration
• Cell separation
• Space maintenance
• Clinical manageability

Factors Affecting Clinical Outcome After GTR

Barrier Independent (Patient Factors)

• Plaque accumulation, smoking, occlusal trauma, inadequate tissue thickness

Barrier Dependent

• Inadequate root barrier adaptation, nonsterile technique, premature loss of barrier

Surgical Factors

• Poor incision placement, poor flap elevation, inadequate closure or suturing, excessive surgical time

Post-Surgical Factors

• Plaque recolonization, aggressive toothbrushing technique, loss of wound stability

Functions of Citric Acid

1. Accelerates healing and cementogenesis
2. Removes smear layer, widens dentinal tubules, makes them funnel-shaped
3. Removes bacterial endotoxins
4. Produces 4 mm of deep demineralized zone of exposed collagen fibers
5. Prevents apical migration of epithelium

Functions of Tetracycline

1. Anti-collagenolytic
2. Antimicrobial
3. Promotes fibroblast adhesion and growth
4. Applied as 125 mg tetracycline with 1 ml sterile saline for 3 minutes

Polypeptide Growth Factors

1. Platelet-derived GF
2. Fibroblast GF
3. Insulin-derived GF
4. Transforming GF

Etiology of Gingival Recession

1. Periodontal phenotype
2. Toothbrushing
3. Cervical restorative margin
4. High frenum
5. Traumatic occlusion
6. Periodontitis

Complications of Gingival Recession

• Esthetics
• Hypersensitivity
• Root caries
• Non-carious cervical lesions

Non-Surgical Treatment of Gingival Recession

• Monitoring
• Desensitizing agents
• Pink composite
• Removable gingival prosthetics
• Orthodontic treatment

Surgical Treatment of Gingival Recession

A) Pedicle Graft

• Laterally repositioned flap, double papilla flap, coronally advanced flap, semilunar

B) Free Gingival Graft

• Full thickness free graft, subepithelial connective tissue, acellular dermal matrix, platelet-rich fibrin

C) Regenerative Techniques

• GTR non-absorbable membrane, GTR absorbable

Goals of Free Gingival Graft

• Root coverage
• Prevent further recession
• Improve tissue quality

Factors Affecting Free Graft Success

• Graft too thick, graft too thin, incorrect choice of site, blood clot too thick

Free Gingival Graft Evaluation

• Advantages: Simplicity, treats multiple teeth
• Disadvantages: Compromised vascular supply & poor hemostasis, two operative sites, great discomfort, difficult retention

Advantages of Coronally Positioned Flap

• Multiple areas of root exposure, doesn’t increase existing problem, high degree of success, doesn’t involve adjacent teeth