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A retrospective analysis of the outcome of three methods used for the treatment of multiple gingival recession defects

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A retrospective analysis of the outcome of three methods used for the treatment of multiple gingival recession defects

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1

A retrospective analysis of the outcome of three methods used for the treatment of multiple
gingival recession defects

==================================================================

A Thesis Presented to the
FACULTY OF THE OSTROW SCHOOL OF DENTISTRY OF UNIVERSITY OF
SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
(CRANIOFACIAL BIOLOGY)

Dec 2014

Author
Shoko Sato DDS
Department of Advanced periodontology program; Herman Ostrow School of Dentistry of USC;
Loa Angeles, California, 90089-0641 USA

Contact
shokosatodds@gmail.com

2

Table of Contents

Title …………………………………………………………….. 1
Abstract
…………………………………………………………….. 3
Introduction …………………………………………………………….. 4
Materials and Methods …………………………………………………. 6
Results …………………………………………………………….. 8
Discussion …………………………………………………………….. 11
Figures and tables …………………...…………………………………….. 14
References …………………………………………………………….. 24

3

Abstract
Background: Many surgical interventions have been utilized for correcting gingival recession
defects. Some of the most common treatment options include the coronally advanced flap (CAF)
and intrasulcular tunneling technique (IST). Another technique recently introduced is the
Vestibular Incision Subperiosteal Tunnel Access (VISTA), The purpose of this retrospective
study was to compare the efficacy of these three modalities (CAF, IST, and VISTA) used to treat
gingival recession defects.

Methods: A retrospective study was conducted to evaluate the outcome of the most common
methods used for the treatment of multiple-teeth recession defects. Pre- and post-operative
intraoral photographs of patients treated at the Post-doctoral Clinic of the University of Southern
California Ostrow School of Dentistry were obtained. The pre-operative photographs were
digitally superimposed over the corresponding post-operative images using the Adobe Photoshop
graphics editing program. The surface area of the exposed roots that were treated with
connective tissue grafts was calculated, using tools provided by the software. The area was
expressed as an arbitrary unit of area (AUA). The relative proportion of the AUA before and
after treatment were compared.

Results: Of the 136 sites in 59 patients, 74 sites in 31 patients were treated using IST, 24 sites in
13 patients were treated with CAF, and 38 sites in 15 patients were treated using the VISTA
technique. Complete root coverage (CRC) was achieved for 31 of the 74 IST sites (41.8%); 29 of
the 38 VISTA sites (76.3%), and 5 of the 24 (20.8%) CAF sites. The mean root coverage
achieved was 66% for IST (median=67.4%), 90.1% (median 100%) for VISTA, and 72.9%
(median 77.5%) for CAF. The percentage of coverage achieved was stratified according to the
initial Miller classification, as well as the anatomic location of the recession in the mouth.

Conclusions: Using a novel method for assessing the percentage of root coverage achieved by
three different surgical techniques, VISTA was found to be the most effective intervention
modality. In challenging situations such as anterior mandibular sites or those with severe
gingival defects (Miller class III), VISTA demonstrated significantly higher efficacy than CAF
or IST.

4

Introduction
Gingival recession is one of the most common manifestations of periodontal disease; it has been
estimated to occur in more than 50% of individuals (Albandar and Kingman, 1999), (Al-
Wahadni and Linden, 2002), (Kassab and Cohen, 2003). Recession defects adversely affect
patients’ esthetics (Al-Wahadni and Linden, 2002), lead to dental hypersensitivity (Andrade et
al., 2010), and cause difficulty in biofilm removal due to discrepant gingival margins (Kassab
and Cohen, 2003) (Kassab & Cohen 2002). A variety of periodontal plastic surgical (PPS)
procedures have been introduced to treat gingival recession defects (Miller, 1993; Oates et al.,
2003; Roccuzzo et al., 2002). Subepithelial connective tissue grafts have been the gold standard
procedure in the treatment of Miller Class I and II recession-type defects (Chambrone et al.,
2008).

Initial attempts at root coverage of gingival recession defects entailed laterally positioned flaps
(Grupe HE, 1956), (Staffileno, 1964) and free gingival grafts (Sullivan and Atkins, 1968).
Coronally advanced flaps (CAF) were first reported by Bernimoulin et al (1975) (Bernimoulin et
al., 1975) and later modified (Allen 1988, Miller 1988, Tarnow 1986). CAF has also been used
in conjunction with connective tissue grafts (CTGs) in an attempt to increase the root coverage
(Allen, 1988; Langer and Langer, 1985) reported that CAF can result in better esthetic outcomes
than free autogenous grafts when the dimensions of the keratinized gingiva are adequate. It was
asserted that the color and form of healed CAF surgical sites are almost indistinguishable from
the native tissue. After planing and repositioning of the flap over the exposed root surfaces,
releasing incisions are made obliquely on each interdental papilla at a distance from the tip of
papilla equal to the amount of root exposure. A split-thickness flap is raised by sharp dissection
close to the periosteum. Then the interdental papilla surfaces are de-epithelialized in preparation
for overlaying the papillae with the flap. The flap is secured at or slightly coronal to the CEJ
using sling sutures. Interrupted sutures are also used to stabilize the flap to the periosteum, to
reduce flap tension.

In an effort to minimize surface incision, an intrasulcular tunneling (IST) technique, also known
as the pouch technique, was described by (Raetzke, 1985) and Allen (1994). To maintain
papillary integrity and avoid vertical releasing incisions while at the same time allowing for

5

treatment of multiple recession defects, various tunneling techniques have been developed.
(Harris et al., 2005; Ribeiro et al., 2008; Tozum and Dini, 2003; Tozum et al., 2005; Zabalegui et
al., 1999) These primarily use an intrasulcular approach to create either a sub- or supraperiosteal
space that extends beyond the mucogingival junction. CTGs or allograft can then be inserted
under the gingival collar. Sling sutures are typically utilized to adapt the buccal flap precisely to
the exposed root surfaces and stabilize the papillae over the interdental connective tissue bed.
More apically, a horizontal double mattress suture can also be performed to reduce the lip
tension on the marginal portion of the flap.

Because of the need to obtain access through a small sulcular access point and the increased risk
of traumatizing and perforating the marginal gingiva, sulcular tunnel access techniques tend to be
technically challenging. To avoid some of the potential complications, an alternative tunneling
technique has been described, termed vestibular incision subperiosteal tunnel access (VISTA)
(Zadeh, 2011). Treatment begins with creation of a vestibular vertical incision; its location
depends on the site(s) being treated. In the maxillary anterior, the midline frenum is typically
optimal, whereas the typical location of the incision for posterior access is anterior to the canine.
Using a series of elevators, a subperiosteal tunnel is created to provide access to the facial
osseous plate and root dehiscences. To mobilize the gingival margins and coronally position the
mucoperiosteal flap, this tunnel extends at least one or two teeth beyond the teeth requiring root
coverage. Using an elevator, the tunnel is also extended interproximally under each papilla as far
as possible while avoiding making any surface incisions through the papilla. A connective tissue
graft is then inserted into the subperiosteal tunnel and carefully repositioned 2-3mm beyond each
tooth’s CEJ (Pini Prato et al., 2005). The flap is stabilized with “suspensory sutures.” These are
polypropylene sutures that are secured to the facial aspect of each tooth with flowable composite
resin. The suspensory sutures are kept in place for approximately three weeks to immobilize the
tissues during initial healing.

Published studies have found a great deal of variability in the outcome of various PPS
procedures employed for the treatment of recession defects. The variability in outcomes has been
attributed to patient-related, site-specific, and technique-related factors (Cortellini and Pini Prato,
2012). Few studies have compared the outcomes achieved by multiple methodologies. Moreover,

6

most of the published studies are limited to the treatment of single teeth and mostly in the
maxillary canine and premolar regions. Therefore, there is a paucity of studies that have
investigated the outcome of root coverage procedures for multiple teeth, as well as in various
anatomic locations of the mouth.

The objective of the present retrospective study was to evaluate the relative efficacy of ISF,
CAF, and VISTA techniques used for the treatment of multiple gingival recession defects.
Previous efforts to quantify the amount of root coverage have used a periodontal probe to
measure the linear height of the exposed root surface (before and after treatment) at the deepest
point of the gingival recession. This methodology of measurement introduces a number of
confounding variables, since most recession defects have complex configurations, making linear
measurement unrepresentative of the degree of original recession or the efficacy of the root
coverage. To address some of the limitations of existing methodologies, a new method of
measuring these areas before and after treatment was developed for the present study.

Materials and Methods
The protocol for this retrospective study was reviewed and approved by the Institutional Review
Board (IRB) of the University of Southern California. A query was made into the dental records
of all patients who had received soft tissue augmentation at the University of Southern California
Post-doctoral Periodontology Clinic between January 1, 2010 and January 31, 2014. All dental
records were reviewed to identify patients who had received soft tissue augmentation for the
treatment of recession defects. Patients who had received soft tissue augmentation for other
reasons such as in pontic sites or around dental implants were excluded. The treating provider for
those patients were identified in order to obtain digital pre-operative and post-operative
photographs.

Inclusion criteria consisted of:
n Availability of pre-operative photographs of sufficient quality (angulation and exposure).
n A clear view of the CEJ in the photographs.

7

Exclusion criteria were:
n An inability to clearly identify the CEJ in photographs.
n Orthodontic treatment in the root-coverage treatment site during the interval between
taking of the pre- and post-operative photographs.
n A restoration of the root-coverage treatment site that interfered with detection of the CEJ.
n A lack of availability of pre-operative photographs.

Included treated sites were divided according the three modes of therapy provided, namely
coronally advanced flaps (CAFs) ( (Zucchelli and De Sanctis, 2000), instrasulcular tunneling
(IST) (Allen, 1988),

or vestibular incision subperiosteal tunnel access (VISTA) (Zadeh, 2011).
The digital pre-operative photographs of the surgical site(s) were taken on the day of surgery and
again post-operatively.

The pre- and post-operative photographs for each site were imported into Adobe Photoshop CS6.
The program’s “overlay” tool was used to superimpose the two images to adjust their overall
proportions using various anatomic landmarks such as the cusp tips and embrasure spaces. To
ensure that the placement on the second image was accurate, the opacity of the second (post-
operative) photograph was changed to enable simultaneous viewing of both images.

After the two images were overlaid and their proportions were adjusted, the recession surface
area in the pre-operative image was outlined using the lasso tool. After outlining the area of
exposed roots, the “Record Measurements” tool was used to count the number of pixels within
that region. The remaining area of recession was outlined with a second line, and the pixels
within the remaining area of recession were counted. The resultant measurements of pre- and
post-operative recession represent a quantification of the exposed root surfaces, expressed as an
arbitrary unit of area (AUA) (Figures 1A-E). The same investigator [SS] performed all the image
manipulation and measurement, taking care to use the same protocol for every pair of images
measured. To avoid any bias, the surgical procedure that was used was concealed from the
investigator during the measurement phase of the investigations.

8

The percentage of root coverage achieved for each technique was calculated using the formula
100 X (post-op AUA/pre-op initial AUA). Median and mean coverage achieved by using each of
the three modalities were calculated. The initial Miller classification was determined, and results
were tabulated according to the initial Miller class of recession defects. The sites included
represented Miller Class I, II and III recession defects. No cases for the treatment of Miller class
IV were identified. Outcomes for the three modalities relative to the treatment site location
(maxillary anterior or posterior, mandibular anterior and posterior) were compared.

The outcomes for the different methods were compared by pair-wise comparison of methods
using Student’s T-Test. Statistical significance was considered when p-values were equal to or
less than 0.05.

Results
A total of 136 teeth were included in the present study; 74, 24, and 38 sites were treated using
IST, CAF, and VISTA techniques, respectively. Table 1 shows the characteristics of study
subjects included. The mean age of the study subjects was 37.0 (range 19-74), 46.8 (range 26-81),
and 40.4 (range 22-74) for IST, VISTA, and IST, respectively. Gender (male/ female) was 15/16
(IST), 9/6 (VISTA), and 5/8 (CAF.) The mean follow-up days were: IST 122.4 days (range 30-
365), VISTA 200.6 days (range 48-500), and CAF 141.6 days (range 21-455). The site treated
with VISTA had the longest follow-up data.

The effectiveness of root coverage achieved using each of the techniques was examined by
comparing the digital photographs taken at pre- and post-operative visits to quantify the exposed
root surface. To minimize the confounding effects of the distortion of photographic images, pre-
and post-operative photographs were digitally superimposed in Photoshop utilizing dental
landmarks such as cusp tips, marginal ridges, and embrasure line angles. The surface area of
exposed roots at pre- and post-operative visits were compared in order to calculate the percent
root coverage. Figure 2 shows the mean overall percentage of root surface area coverage
achieved for CAF (72%), IST (66%), and VISTA (90%). The highest mean root coverage was
achieved with the VISTA technique, and this was statistically significant (p<0.05) when
compared with the IST and CAF techniques.

9

To gain a better understanding of the outcome of individual cases, dot plots of individual sites
treated by IST, CAF, and VISTA are shown in Figure 3. The distribution of individual case
outcomes was used to calculate the median root surface area coverage, which was 67.4% (IST),
100% (VISTA), and 77.5% (CAF).

The percentage of root surface area coverage achieved by each of the three techniques in sites
according to the initial Miller classification is shown in Figure 4. In sites with initial Miller Class
I defects, the mean root surface coverage achieved was 88.2% (+ 23.2) by IST, 98.9% (+4.2)
using VISTA, and 79.1% (+26.7) by CAF. The VISTA technique showed the highest root
coverage, which was statistically significant when compared with CAF (p<0.05).

In sites with initial Miller Class II defects, the mean root surface coverage achieved using IST
was 60.2% (+ 33.2), with VISTA it was 100% (+ 0), and using CAF it was 76.7% (+18.8). Again,
the VISTA technique showed the highest degree of root surface coverage with the lowest
variance. The root surface coverage achieved with VISTA was statistically significantly higher,
when compared with CAF (p<0.05) and IST (p<0.05).

In Miller Class III sites, the mean root surface coverage achieved using IST was 34.7% (+24.0),
using VISTA it was 73% (+ 27.3), and using CAF it was 55.7% (+13.9). The VISTA technique
showed the highest root coverage, and it was statistically significantly higher when compared
with IST (p < 0.05) but not CAF.

Figure 5 shows the percentage of root surface area coverage achieved in the four anatomic
regions, using the CAF, IST, and VISTA techniques. When gingival recessions in the maxillary
sites were treated with each of the three methods, higher root coverage was achieved in
comparison with the mandibular sites. VISTA was the most effective modality for the treatment
of mandibular posterior sites (100% + 0). VISTA achieved statistically significantly higher root
surface coverage when compared with CAF (p<0.05) and IST (p<0.05). There were no sites
treated with CAF in the mandibular anterior area in the present study.

10

Using the IST and CAF techniques, the outcomes of the root coverage surgical procedures for
maxillary gingival recession were more favorable than the outcomes of procedures for
mandibular gingival recession. However with the VISTA technique it is clear that the outcomes
for the mandibular recession were as equally effective as the outcomes for the maxillary
recession.

When the 136 total sites were classified according to their location, 31sites were located in the
maxillary posterior, 39 sites were located in the maxillary anterior, 25 sites were located in the
mandibular posterior, and 41 sites were located in the mandibular anterior. Table 5 displays the
mean percentage of root surface coverage achieved using each technique in each quadrant except
the mandibular anterior. (No sites there were treated using a CAF.) The only quadrant in which
the technique resulted in statistically significantly better root coverage was the mandibular
posterior, where 100% coverage was achieved by the VISTA sites, compared to 62.7% and
65.6% achieved by the IST and CAF techniques, respectively Figure 6 (A,B,C) shows the
percentage of root surface area coverage achieved in the Maxilla and Mandible regions using
IST,VISTA and CAF techniques.
Figure 6 (A) In IST group, the percentage of root surface area coverage achieved in the Maxilla
was 83.0% (+29.7).Mandibular was 52.3%( +31.8) Maxilla shows higher percentage of root
surface area coverage compared to Mandibular sites (p<0.05).
Figure6 (B) In VISTA group, the percentage of root surface area coverage achieved in the
Maxilla was 93.1%(+ 13.1) Mandibular was 87.0%(+ 26.0). Maxilla shows higher percentage of
root surface area coverage compared to Mandibular sites however it was not statistically
significant.
Figure6 (C) In CAF group, the percentage of root surface area coverage achieved in the Maxilla
was 78.0%(+ 23.2),Mandibular was65.6%(+ 15.5). Maxilla shows higher percentage of root
surface area coverage compared to Mandibular sites however it was not statistically significant.
It should be noted that the result of CAF group was not statistically significant because the
number of the sites which have been included in this study were 8sites in Mandibular CAF group.
This may have been affected in statistics.
Figure 7 shows complete root coverage (CRC) was achieved for 31 of the 74 IST sites (41.4%),
29 of the 38 VISTA sites,(76.3%), and 5 of the 24 sites treated with CAF (20.8%)

11

Discussion
A variety of methods have been described for the treatment of gingival recession defects.
However, most of the available evidence for root coverage procedures has been presented on the
treatment of single-tooth recession defects. Moreover, most of the studies have reported on the
treatment of maxillary canines and premolars. There has been a paucity of available data on the
treatment of multiple-teeth gingival recession defects in oral sites other than the maxillary canine
and premolar region.

Achieving CRC in multiple-teeth recession defects is more challenging than in single recession
type defects. Chambrone et al. (Chambrone et al., 2009) conducted a systematic review of the
literature to evaluate the results of using different periodontal plastic surgery procedures to treat
multiple recession-type defects. Although an initial database search retrieved 632 articles, only
16 were found to be suitable for more detailed analysis. Of these, only four case series met the
inclusion criteria (at least 6 months of follow up for patients with multiple recession-type defects
who were treated with PPS). Over the four studies, mean root coverage ranged from 94% to 98%,
while in the three trials that reported CRC results, it was achieved for 68% to 90% of the patients.
Other clinical parameters also improved, including mean recession, clinical attachment levels,
and probing depths.

Esteiber et al (Esteibar et al., 2011), noting the unpredictability of achieving CRC following
surgery for Miller Class III recession sites, sought to identify pre-surgical variables that could
affect such results. They studied presurgical, surgical, and postsurgical conditions for 121 Class
III recessions in 50 patients, 47% of which achieved CRC. Statistical analysis using linear
regression techniques led them to conclude that the variables which best explained those results
were soft tissue interproximal integrity, the use of grafts with a thickness of greater than 2 mm,
interproximal bone loss that did not exceed 3 mm, and an initial recession width of 3 mm or less.
They reported no clear difference among three surgical procedures: free gingival grafts,
(Holbrook and Ochsenbein, 1983), subepithelial connective tissue grafts, (Langer and Langer,
1985), and connective tissue double pedicle flaps (Nelson, 1987).

The outcome of CTG in conjunction with CAF for the treatment of Miller Class I or Class II

12

multiple-teeth recession defects has been studied (Cetiner et al., 2004). The 12-month post-
surgical results showed a mean root coverage of 96%, with 80% of the sites achieving complete
root coverage. Chambrone et al (Chambrone and Chambrone, 2006) further reported the result of
treating Miller Class I or Class II multiple recession-type defects. The mean percentage root
coverage was 96% and CRC was 71%. The results of the current study regarding treatment of
Miller Class I and II gingival recession are consistent with these previous publications,
demonstrating a high degree of root coverage after using all three techniques.

Most of the previous published studies have limited their therapy to the maxillary arch.
Zabalegui et al. (Zabalegui et al., 1999) found mean root coverage and complete root coverage of
92% and 67%, respectively. Zucchelli and De Sanctis (Zucchelli and De Sanctis, 2000) found
mean root coverage and complete root coverage of 97% and 88%, respectively. The respective
findings of Tözum and Dini (Tozum and Dini, 2003) were 95% and 92%, while Cetiner et al
(Cetiner, Bodur et al 2004) found 96% and 80%, respectively.

Connective tissue grafts, when used in conjunction with coronally advanced flaps for the
treatment of Class I and Class II multiple gingival recession, have been found to achieve better
outcomes in the maxilla than the mandible (Chambrone and Chambrone, 2006).

Dembowska et al. (Dembowska and Drozdzik, 2007), noting the dearth of data regarding
coverage of multiple recessions, compared the clinical outcomes (recession height and width,
keratinized tissue width, and probing depth) after treatment of 28 Miller Class I and 20 Miller
Class II adjacent gingival recessions in 18 patients. They found mean recession coverage to be
99.1% and 98.9% (for the Class I and Class II sites, respectively) six months after connective
tissue grafts combined with tunnel surgical techniques. At 12 months post-surgery, 79.2% for the
Class I sites and 72.2% of the Class II sites were completely covered. Keratinized gingival width
also increased.

Previous investigations of root coverage procedures have primarily used linear measurement of
recession depth and width.(Oates et al., 2003; Roccuzzo et al., 2002) In contrast, the present
study utilized photographic images to quantify recession surface areas while evaluating the

13

outcome of root coverage procedures. This approach enables much more precise measurement of
the typically geometrically complex recession areas. A permanent record can be created of each
area measured, offering the possibility of independent confirmation. Disadvantages include the
fact that photographic images are subject to distortion. Use of the Adobe Photoshop software
also is more complicated than measurement with a periodontal probe, and errors could
potentially be introduced while aligning the before and after images. However, when measuring
the recession on the computer screen, the size of the tooth on the screen was adjusted so that the
image was 16-20 times larger than the actual tooth. At this increased size, even if the line that
traced the gingival margins and the CEJs was not perfectly positioned, the discrepancy caused by
any difference between the actual gingival and CEJ margins and the drawn margins should be
minimal, and any resulting error insignificant.

Nonetheless, to conclusively demonstrate the validity of the present method of evaluating the
outcome of root coverage procedures, experimental evidence will be required. There are future
plans to validate this measurement method.

14

Table 1. Characteristics of study subjects included.
IST VISTA CAF
Age mean (range) 37.0(19-74) 46.8(26-81)

40.4(22-74)
Gender (male/ female) 15/16

9/6 5/8
Sites included 74 38 24
Follow-up days mean
(range)
122.4(30-365) 200.6(48-500) 141.6(21-455)
Miller Class I 8.7-100 83.6-100 40.2-100
Miller Class II 6.8-100 100-100 39.7-100
Miller Class III 0.5-65.5 27.5-100 41.6-86.4
Max anterior 97.3% (Range
0.9-100,SD 34.4)
89.2% (Range
55.4-100, SD
17.1)
75.3% (Range 39.7-
100,SD26.4)
Max Posterior 97.1%(Range
63.1-100 (SD
10.2)
96.0%(Range
72.5-100, SD9.1)
81.8% (Range 43.7-100,SD
19.0)
Mand anterior 50.1% (Range
0.5-100 (SD
31.9)
72.6% (Range
27.5-100,SD32.9)
N/A
Mand Posterior 62.7%(Range
10.0-100(SD31.2)
100% (Range
100-100,SD 0)
65.6% (Range 40.2-86.4,SD
15.5)

Table 2. Characteristics of study subjects included.
Maxilla Mandible
IST 83.0%(Range0.94-100, SD29.7) 52.3%(Range0.55-100, SD31.8)
VISTA 93.1%(Range55.4-100, SD13.1) 87.0%(Range27.5-100 SD26.0)
CAF 78.0%(Range39.7-100, SD23.2) 65.6%(Range40.2-86.4 SD15.5)

15

Figures

Figure 1A
Example of a pre-operative photograph, after importation into Photoshop.

Figure 1B
Each post-operative photograph was superimposed on the corresponding pre-operative
photograph. In the combined image shown here, the proportions have not yet been adjusted.

16

Figure 1C
Using dental landmarks, the proportions of the pre- and post-operative images were adjusted to
make them as equivalent as possible.

Figure 1D
After adjusting the pre-operative and post-operative images to make them the same size, the root
recession evident in the pre-operative image was outlined. The number of pixels within the
outlined area was then counted, using the software program.

17

Figure 1E
The residual root recession was also outlined on the post-operative image (adjusted to match the
size of the pre-operative image), and the number of pixels within the outlined area was calculated.
Adjusting the proportions of the pre- and post-operative images thus allowed for calculation of
the proportion of remaining root recession.

Figure 2. The mean overall percentage of root surface area coverage achieved for IST, VISTA,
0"
20"
40"
60"
80"
100"
120"
IST" VISTA" CAF"
IST"
VISTA"
CAF"
* *
*: P<0.05, Student T test

18

and CAF.

Figure 3(A)

Figure 3(B)

Figure 3(C)

Figure 3. The root surface area coverage achieved for individual sites treated by IST, VISTA,
and CAF. The median root surface area coverage was 67.4%, 100%, and 77.5% for IST (A),
CAF (B) and VISTA (C),respectively. Complete root coverage was achieved by 41.4%, 76.3%,
and 20.8% of the IST, VISTA, and CAF sites, respectively.

0"
20"
40"
60"
80"
100"
120"
0" 10" 20" 30" 40" 50" 60" 70" 80"
IST
% of complete RC: 41.4%
Median 67.4
0"
20"
40"
60"
80"
100"
120"
0" 10" 20" 30" 40" 50" 60" 70" 80"
VISTA
% of complete RC: 76.3%
Median 100
0"
20"
40"
60"
80"
100"
120"
0" 10" 20" 30" 40" 50" 60" 70" 80"
CAF
% of complete RC: 20.8%
Median 77.5

19

60#
70#
80#
90#
100#
110#
120#
IST# VISTA# CAF#
Class%I%
IST#
VISTA#
CAF#
*: P<0.05, Student T test
*
40#
50#
60#
70#
80#
90#
100#
110#
IST# VISTA# CAF#
Class%II%
IST#
VISTA#
CAF#
* *
*: P<0.05, Student T test

20

Figure 4. The percentage of root surface area coverage achieved in Miller class I, II and III sites,
using the IST, VISTA, and CAF techniques. In Class I sites, the VISTA technique showed the
highest root coverage with the lowest standard deviation, a finding that was statistically
significant when compared with the CAF technique. In Miller Class II sites, the VISTA
technique showed the highest root coverage with the lowest standard deviation, a statistically
significant finding compared to that for Class II sites treated with the CAF and IST techniques.
In the Miller Class III sites, the VISTA technique showed the highest root coverage with the
lowest standard deviation. This was statistically significant when compared with Class III sites
treated with the IST technique.

20#
30#
40#
50#
60#
70#
80#
90#
100#
110#
IST# VISTA# CAF#
Class%III%
IST#
VISTA#
CAF#
*
*: P<0.05, Student T test

21

Figure 5. The percentage of root surface area coverage achieved in the four anatomic regions,
using the IST, VISTA, and CAF techniques.

40#
50#
60#
70#
80#
90#
100#
110#
120#
Max#pos# Max#Ant# Mand#pos# Mand#Ant#
IST#
VISTA#
CAF#
* *
*: P<0.05, Student T test
0"
20"
40"
60"
80"
100"
120"
Maxilla" Mandible"
*: P<0.05, Student T test
*

22

Figure 6(A)

Figure 6 (B)

Figure 6 (C)
0"
20"
40"
60"
80"
100"
120"
Maxilla" Mandible"
0"
20"
40"
60"
80"
100"
120"
Maxilla" Mandible"

23

Figure 6 The percentage of root surface area coverage achieved in Maxilla and Mandible using
IST(A),CAF(C) and VISTA(C) technique.

Figure 7
The percentage of complete root coverage (CRC) achieved using IST,VISTA and CAF.

0"
20"
40"
60"
80"
100"
120"
IST" VISTA" CAF"
IST"
VISTA"
CAF"
* *
*: P<0.05, Student T test

24

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Abstract (if available)

Abstract Background: Many surgical interventions have been utilized for correcting gingival recession defects. Some of the most common treatment options include the coronally advanced flap (CAF) and intrasulcular tunneling technique (IST). Another technique recently introduced is the Vestibular Incision Subperiosteal Tunnel Access (VISTA), The purpose of this retrospective study was to compare the efficacy of these three modalities (CAF, IST, and VISTA) used to treat gingival recession defects. ❧ Methods: A retrospective study was conducted to evaluate the outcome of the most common methods used for the treatment of multiple-teeth recession defects. Pre- and post-operative intraoral photographs of patients treated at the Post-doctoral Clinic of the University of Southern California Ostrow School of Dentistry were obtained. The pre-operative photographs were digitally superimposed over the corresponding post-operative images using the Adobe Photoshop graphics editing program. The surface area of the exposed roots that were treated with connective tissue grafts was calculated, using tools provided by the software. The area was expressed as an arbitrary unit of area (AUA). The relative proportion of the AUA before and after treatment were compared. ❧ Results: Of the 136 sites in 59 patients, 74 sites in 31 patients were treated using IST, 24 sites in 13 patients were treated with CAF, and 38 sites in 15 patients were treated using the VISTA technique. Complete root coverage (CRC) was achieved for 31 of the 74 IST sites (41.8%)

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Asset Metadata

Creator Sato, Shoko (author)

Core Title A retrospective analysis of the outcome of three methods used for the treatment of multiple gingival recession defects

School School of Dentistry

Degree Master of Science

Degree Program Craniofacial Biology

Publication Date 09/09/2014

Defense Date 07/29/2014

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag CAF,connective tissue graft,coronally advanced flap,esthetic,gingiva,gingival recession,intrasulcular tunneling technique,IST,Miller class III,multiple gingival recession defects,multiple gingival recessions,OAI-PMH Harvest,root coverage,root coverage procedures,subepithelial connective tissue graft,surface area,vestibular incision subperiosteal tunnel access,Vista

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Language English

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Advisor Zadeh, Homayoun H. (committee chair), Navazesh, Mahvash (committee member), Paine, Michael L. (committee member)

Creator Email shokosat@usc.edu,shokosatodds@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-471550

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