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Predictibility of fibrin-assisted soft tissue promotion (FASTP) in treatment of multiple gingival recession defects: a retrospective 2-D analysis

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Predictibility of fibrin-assisted soft tissue promotion (FASTP) in treatment of multiple gingival recession defects: a retrospective 2-D analysis

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Content PREDICTIBILITY OF FIBRIN-ASSISTED SOFT TISSUE PROMOTION (FASTP)
IN TREATMENT OF MULTIPLE GINGIVAL RECESSION DEFECTS:
A RETROSPECTIVE 2-D ANALYSIS
By
Shahriar H. Agahi, DMD
A Thesis Presented to the
FACULTY OF THE USC HERMAN OSTROW SCHOOL OF DENTISTRY
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE
BIOMEDICAL IMPLANTS AND TISSUE ENGINEERING
August 2021
ii
TABLE OF CONTENTS:
List of Tables……………………………………………………………………………………..iii
List of Figures………………………………………………………………………………….....iv
Abstract…………………………………………………………………………………………....v
1. Background……………………………………………………………………………………..1
2. Objectives………………………………………………………………………………………8
3. Materials & Methods …………………………………………………………………………..9
4. Results…………………………………………………………………………………………17
5. Discussion……………………………………………………………………………………..22
6. Conclusions……………………………………………………………………………………30
References………………………………………………………………………………………..31
Tables…………………………………………………………………………………………….41
Figures……………………………………………………………………………………………54

iii
List of Tables:
Table 1: Demographic of the sample population (N = 13) ……………………………………..41
Table 2: Number of recession defects for recession type, tooth type, and anatomic location…..42
Table 3: Characteristics of defect sites and associated outcomes (n =122) …………………….43
Table 4: Comparison of outcome measures for RT1 (n = 16) versus RT2 (n = 106) defects…...44
Table 5: Comparison of outcome measures for different tooth types (32 Incisors, 16 Canines, 40
Premolars, 34 Molars).…………………………………………………………………………...45
Table 6: Comparison of outcome measures for different tooth positions (14 maxillary incisors,
11 maxillary canines, 22 maxillary premolars, 17 maxillary molars, 18 mandibular incisors, 5
mandibular canines, 18 mandibular premolars, 18 mandibular molars)………………….……...48
Table 7: Comparison of outcome measures for different anatomical locations (25 Maxillary
Anterior, 23 Mandibular Anterior, 39 Maxillary Posterior, and 35 Mandibula Posterior, 48
Anterior versus 74 Posterior, 64 Maxillary versus 58 Mandibular)……………………………..51

iv
List of Figures:
Figure 1: Advanced Platelet Rich Fibrin (A-PRF) membrane preparation……………………..54
Figure 2: Treatment of multiple adjacent gingival recession defects (RT1 & RT2) with FASTP
protocol…………………………………………………………………………………………..55
Figure 3: The pre and post-operative STL files were transferred into Geomagic
®
software……56
Figure 4: Illustration of the trimming process of the digitized study models…….……………..57
Figure 5: Illustration of linear measurements and surface area selection after cropping the
scans…………………………………………………………………………………………...…58
Figure 6: Comparison of outcome measures for RT1 (n = 16) versus RT2 (n = 106) defects…..59
Figure 7: Scatter plot illustrating the correlation between pre-operative initial recession depth
(IRD) and outcome measures…………………………………………………………………….60
Figure 8: Scatter plot illustrating the correlation between pre-operative initial recession width
(IRW) and outcome measures……………………………………………………………………61
Figure 9: Comparison of outcome measures for different tooth types (32 Incisors, 16 Canines, 40
Premolars, 34 Molars)……………………………………………………………………………62
Figure 10: Comparison of outcome measures for different tooth positions (14 maxillary incisors,
11 maxillary canines, 22 maxillary premolars, 17 maxillary molars, 18 mandibular incisors, 5
mandibular canines, 18 mandibular premolars, 18 mandibular molars)………………………….63
Figure 11: Comparison of outcome measures for different anatomical locations (25 Maxillary
Anterior, 23 Mandibular Anterior, 39 Maxillary Posterior, and 35 Mandibula Posterior, 48
Anterior versus 74 Posterior, 64 Maxillary versus 58 Mandibular)………………………………64

v
ABSTRACT
Background: Multiple contiguous gingival recession defects may be treated using a variety of
therapeutic techniques with varying degrees of success depending on the initial presentation and
treatment approach. The primary aim of this retrospective study was to determine the efficacy of
the Fibrin-Assisted Soft Tissue Promotion (FASTP) technique for root coverage of multiple
gingival recession defects by measuring the following outcomes: percentage mean root coverage
(%mRC), percentage of teeth with complete root coverage (CRC), and linear mean root coverage
(mRC) at a follow up period of 10.1 ± 1.5 months (range 6-18) after surgery. Secondary aim of
the study was to determine the influence of the following independent factors; recession type (RT),
initial recession depth (IRD), initial recession width (IRW), tooth type, and anatomic location on
the outcome measures.
Methods: Retrospective data from thirteen patients (122 teeth) who were treated with FASTP
technique for multiple gingival recession defects were collected. Pre- and post-therapy intraoral
scans were superimposed using the Geomagic
®
software to allow for comparison of 2-dimensional
surface changes. Each of the outcome measures were further compared by independent factors
using linear mixed effects regression.
Results: A total of 122 recession defects in 13 patients were included in this retrospective study.
The percentage mean root coverage (%mRC) achieved were 100% (100.0, 100.0) for RT1 and
48.87% (36.37, 61.36) for RT2 recession defects (p <0.001). Complete root coverage (CRC) was
100% (100.0, 100.0) for RT1 and 18.87% (11.92, 27.62) for RT2 recession defects (p<0.001) and
linear mean root coverage (mRC) was -1.598mm (-1.952, -1.243) for RT1 and -1.005mm (-1.210,
-0.800) for RT2 recession defects (p=0.001). Initial recession depth (IRD) showed a statistically
significant negative correlation with linear mean root coverage (mRC) (p <0.001). Initial recession
vi
width (IRW) showed no statistically significant difference in any of the parameters measured. With
respect to different tooth types, statistically significant overall difference was only observed in
percentage of teeth achieving complete root coverage (CRC). In a descending order CRC was
achieve in 53.1% (38.8, 67.4), 31.2% (15.1, 47.4), 17.5% (2.5, 32.5), and 20.6% (4.3, 36.9) of
incisors, canines, premolars, and molars respectively (p <0.001). Anatomic location of the tooth
(Anterior vs. posterior and maxillary vs. mandibular) showed statistically significant difference in
all of the parameters measured (p<0.05) except for percentage mean root coverage (%mRC) in
anterior vs. posterior (p=0.058). With respect to a combination of tooth type and anatomical
location, maxillary canines achieved a statistically significant higher %mRC of 69.57% (57.99,
81.16) compared to mandibular canines 36.11% (22.29, 49.93) (p<0.001) and a statistically
significant higher proportion of maxillary incisors achieved CRC 78.6% (58.3, 98.9) compared to
maxillary premolars 22.7% (5.5, 39.9) (p<0.001). Finally, maxillary anterior teeth achieved a
statistically significant higher %mRC of 80.43% (73.24, 87.62) compared to both maxillary
posterior 49.16% (33.69, 64.62) and mandibular posterior 49.39% (37.41, 61.37) teeth (p<0.001).
Conclusions: It can therefore be concluded that FASTP technique for the purpose of root coverage
shows favorable outcomes after a mean follow up period of 10.1 ± 1.5 months (range 6-18).
Randomized controlled clinical trial will be required to compare the efficacy of FASTP to other
periodontal root coverage methods, as well as to examine the predictive value of the independent
factors identified in the present study.

1
BACKGROUND:
Apical migration of the gingival margin in relationship to cementoenamel junction (CEJ) is defined
as gingival recession (1). This clinical condition can present on one single tooth or multiple teeth
which further categorizes the extend of the disease to either localized or generalized respectively.
Gingival recession is regarded as one of the most common periodontal findings in the population.
In a 1967 study, Gormon reported that 22-53% of the teeth in 78-100% of middle-aged individuals
in the USA present with gingival recession (2). In more recent studies, this high level of prevalence
has further been confirmed when in 2003 Kassab reported that more than 50% of the US population
and more than 85% of the population 65 and older present with gingival recession with varying
types and extents (3). Reports now indicate that in the US alone, over 90% of the population has
at least 1 tooth with 1mm recession, with up to 40% of the same population presenting with
recessions greater than 3mm (4,5,6).
The high incidence of this condition can be attributed to multiple predisposing and precipitating
factors such as plaque-induced inflammation and periodontal disease or trauma inducing factors
such and traumatic tooth brushing and orthodontic treatment (7,8,9,10,11). Multiple factors have
also been reported as contributing to the progression of recession defects. Tooth malposition, high
frenum attachment, thin tissue biotype, presence of non-carious cervical lesions, prior history of
periodontal surgery, orthodontic movement, defective restorations, and history of smoking have
all been reported to influence the progression of gingival recession defects (12,13).
Different classification systems have been introduced and reported in the literature to categorize
gingival recession defects. One of the most commonly used systems was introduced by Miller in
1985. In this classification, four classes of gingival recessions were defined based on the level of
2
gingival margin, mucogingival junction, and interproximal alveolar bone. Both class I and II
defects could be identified with no interproximal periodontal tissue loss with class I defects not
extending to the mucogingival junction versus class II defects extending to or beyond the
mucogingival junction. In class III defects the marginal tissue recession would extend to or beyond
the mucogingival junction with presence of interproximal periodontal tissue loss. Class IV was
defined as marginal recession extended to or beyond the mucogingival junction with severe
interproximal periodontal tissue loss. As part of the same study, Miller suggested that complete
root coverage could be expected for Miller class I and II defects, whereas partial and no root
coverage could be expected for miller class III and IV defects, respectively (14). A more recent
classification system was introduced by Cairo in 2011 in which he defined three classes of gingival
recession types based on primarily the interproximal attachment level. Recession type 1 (RT1) was
associated with no loss of interproximal attachment and a nondetectable interproximal
cementoenamel junction. Recession type 2 (RT2) was associated with loss of interproximal
attachment less than or equal to buccal attachment loss. The most severe type, recession type 3
(RT3) was associated with greater interproximal attachment loss than buccal attachment loss (15).
In a 2018 study, Cortellini reported that 100% root coverage can be predicted in RT1 defects.
Several randomized clinical trials have also shown that 100% root coverage can be predicted even
with RT2 defects when certain procedures are applied. However, with respect to RT3 defects,
complete root coverage is not reported to be achievable (16).
In 2010, Chambrone reported aesthetic problems and dentinal hypersensitivity to be associated
with gingival recessions (17). Moreover, the irregularities caused by gingival recession defects can
pose patients with difficulty to perform adequate oral hygiene, leading to accumulation of plaque
and gingival inflammation. A 1994 study by Srino et al, reported that sites with gingival recession
3
have increased susceptibility to future gingival recession (18). A more recent study by Chambrone
further confirmed that untreated recession defects in individuals with good oral hygiene have a
high probability of progressing during long term follow up (19). The negative consequences
associated with gingival recession defects including compromised aesthetic appearance and/or
dental hypersensitivity along with the high probability of progression if left untreated, provide an
indication for treatment of certain gingival recessions.
A wide variety of surgical techniques for treatment of localized and generalized recession defects
have been introduced in the literature throughout the past few decades, each with specific
indications as well as strengths and limitations of their own. Initially epositioned periodontal flaps
were used for the treatment of gingival recessions between years 1950s to the 1970s. In this
technique a partial thickness pedicle graft was displaced to the recession site in a lateral/oblique
manner to cover the root surface (20,21,22,23). Repositioned flaps were then modified by
Bernimoulin in 1975 to substitute lateral sliding flaps for coronally advanced flap procedures. In
this technique periosteal releasing incisions was utilized to mobilize the flap in a coronal direction
to cover denuded roots (24). Almost a decade later, Miller described the use of free epithelized
graft for gingival augmentation and root coverage. In this technique the free graft would be
stabilized with sutures over the recipient site which would be dissected with a partial thickness
flap and apically positioned (25). The limitations of this latest technique remained to be the
aesthetic problems due to lack of color match with the recipient area and the patient morbidity due
to the secondary intention healing in the palate (26).
In 1985 Langer and Langer introduced the sub epithelial connective tissue graft (SCTG) for
mucogingival therapy and root coverage. In this technique, after raising a split thickness flap, the
4
connective tissue graft would be stabilized with sutures over the denuded root surface and would
then be left uncovered (27). The strengths of this technique included decreased morbidity and
improved clinical results. More recent systematic reviews have widely reported the coronally
advanced flap (CAF) in combination with a connective tissue graft as the gold standard for soft
tissue augmentation and periodontal root coverage (28,29).
To meet the high aesthetic demand of patients, root coverage procedures that would preserve the
integrity of the papillae were introduced beginning in 1985 by Raetzke. He was the first to use an
envelope flap technique for covering isolated gingival recessions (30). Allen modified this
approach by creating a partial thickness supraperiosteal envelope to treat multiple gingival
recession defects (31) what was later named the “tunnel approach” by Zabalegui (32). In addition
to different names suggested for this technique, further modifications of the tunnel approach have
been proposed since its introduction (33,34,35,36,37).
Vestibular Incision Subperiosteal Tunnel Access (VISTA), yet another modified version of the
tunnel approach was proposed by Zadeh in 2011. VISTA consists of a vertical incision done in the
vestibule, remote from the recession area. Through this incision, a subperiosteal tunnel is created
using a series of specially designed elevators, extending towards the vestibular depth as well as
the gingival margin and papillae. As part of this technique the whole mucogingival complex is
coronally displaced with the help of bonded sutures to the buccal surface of the tooth. Then, an
autogenous connective tissue graft or graft substitute is inserted inside the tunnel and the vertical
incision is approximated with suture (34).
Another area that has been widely investigated in the literature when it comes to treatment of
gingival recession defects is the identification and management of risk factors affecting the
5
outcome of the procedures. These factors can be generally classified into patient centric factors
(medical history, smoking status, periodontal health), anatomical specifications (interproximal
bone level, dimensions of the papilla, recession defect size, soft tissue phenotype, location of the
tooth), and surgical considerations (surgeon’s experience, surgical technique, choice of
biomaterials) (38,39,40).
While connective tissue graft is widely accepted as the gold standard for the treatment of gingival
recession defects, it has a number of disadvantages that include the need for harvesting at a distant
donor site, limited tissue availability, and increased potential for post harvesting morbidity (29,34).
Such disadvantages have led to the use of substitutes for autogenous connective tissue such as
allograft (41,42), xenograft (43,44), enamel matrix derivative (45) and collagen bilayer matrix
(46).
In addition to the abovementioned substitutes, in year 2009 Hollander introduced the concept of
utilizing three dimensional scaffolds fabricated from the patient’s own peripheral blood as an
alternative to connective tissue graft (47). This new approach was built upon the concept that was
introduced by Choukroun about a decade earlier. Choukroun had proposed the idea of developing
a platelet concentrate without the use of anticoagulants, which led to the introduction of Platelet-
rich fibrin (PRF) as an improved formulation of the previously widely utilized platelet-rich plasma
(PRP) (48). This fibrin matrix contains platelets and leukocytes as well as a variety of growth
factors and cytokines including transforming growth factor-beta1 (TGF-β1), platelet-derived
growth factor (PDGF), vascular endothelial growth factor (VEGF), interleukin (IL)-1β, IL-4, and
IL-6 (49). In 2014, Choukroun introduced advanced platelet-rich fibrin (A-PRF) which gained
wide popularity due to its ease of preparation, presence of bone morphogenic protein, and
6
beneficial physical properties (50). Ghanaati et al. also investigated the properties of L-PRF and
A-PRF. Their study showed that A-PRF clots had superior properties compared to L-PRF clots
including a looser structure, more interfibrous space, and more living cells. In addition, they found
that these cells were more evenly distributed throughout the A-PRF clots (51). More recently in a
2017 systematic review, Miron concluded that the combination of PRF with regenerative therapy
has been shown to be most promising for periodontal repair of intrabony and furcation defects, as
well as soft tissue root coverage of gingival recessions (52).
There is not an abundance of evidence in the literature surrounding the use of PRF in periodontal
plastic surgeries. However, in 2009 Aroca et al compared 20 patients receiving treatment with a
coronally positioned flap with and without PRF membranes. At 6 months, the test group benefited
from an increased zone of keratinized tissue but a lower percentage of complete root coverage
(53). Few years later in 2012 Jankovic compared the connective tissue graft to the PRF as graft
material for the treatment of Miller Class 1 and Class 2 recession defects in 19 patients. At 6
months, no statistical difference was found between the groups when comparing the amount of
root coverage and increased zone of keratinized tissue. He further concluded that the increased
comfort of the procedure and reduced post operatory complications were statistically significant
when compared with the CTG group because no intraoral donor site was used (54). In a more
recent study Tunali and Ozdemir conducted a prospective split-mouth design study comparing
PRF and connective tissue graft in 20 patients with 12-month follow-up. Both treatment methods
significantly reduced the amount of recession (76% and 77%, respectively) and increased the
clinical attachment levels (2.90 mm and 3.04 mm, respectively) with no statistically significant
difference between the two treatment modalities (55).
7
In 2017, Aalam et al. published a new technique known as “Fibrin Assisted Soft Tissue Promotion
(FASTP)” to promote soft tissue regeneration of muco-gingival recessions utilizing Advanced
Leukocyte Platelet Rich Fibrin (APRF) (56). The technique was described as a simplification of
the vestibular incision subperiosteal technique access (VISTA) (34) and an improvement of the
tunnel technique (57). Placement of multiple vestibular incisions to improve access and visibility,
addition of apical mattress sutures to stabilize the PRF membranes coronally, and the use of
interproximal contact area composites in place of facial composites to eliminate the risk of
compromising facial esthetics of these teeth are some of those modifications that make FASTP a
safer and more predictable tunneling approach. The primary aim of this retrospective study was
to determine the efficacy of FASTP technique for root coverage of multiple gingival recession
defects by measuring the following outcomes: percentage mean root coverage (%mRC),
percentage of teeth with complete root coverage (CRC), and linear mean root coverage (mRC) at
a follow up period of 10.1 ± 1.5 months (range 6-18) after surgery. Secondary aim of the study
was to determine the influence of the following independent factors; recession type (RT), initial
recession depth (IRD), initial recession width (IRW), tooth type, and anatomic location on the
outcome measures.
This work was supported by grants UL1TR001855 and UL1TR000130 from the National Center
for Advancing Translational Science (NCATS) of the U.S. National Institutes of Health. The
content is solely the responsibility of the authors and does not necessarily represent the official
views of the National Institutes of Health.

8
OBJECTIVES:
The aim of this retrospective study is to evaluate the efficacy of FASTP as a treatment modality
for root coverage in multiple adjacent gingival recession defects in clinical setting and to determine
the role of various risk factors on the outcome of FASTP.
Our primary null hypothesis was: There is no change in mean percentage root coverage (%mRC),
percentage of teeth with complete root coverage (CRC), and linear mean root coverage (mRC)
after treatment of multiple adjacent recession defects with FASTP.
Our secondary null hypothesis was: There is no correlation between recession type (RT), initial
recession depth (IRD), initial recession width (IRW), tooth type, anatomical location and our
outcome measures; mean percentage root coverage (%mRC), percentage of teeth with complete
root coverage (CRC), and linear mean root coverage (mRC).
To test these hypotheses, we developed two specific aims:
1. Quantifying the 2-dimentional surface changes around each recession defect after
treatment utilizing the 3-D rendering software Geomagic
®
.
2. Analyze the correlation between baseline parameters including recession type (RT), initial
recession depth (IRD), initial recession width (IRW), tooth type, anatomical location, and
our outcome measure; mean percentage root coverage (%mRC), percentage of teeth with
complete root coverage (CRC), and linear mean root coverage (mRC).

9
MATERIALS AND METHODS:
STUDY DESIGN:
This retrospective study was reviewed and exempted by the Institutional Review Board (IRB) of
the University of Southern California. The study was conducted by a resident in the advanced
periodontology department based on the 2-D analysis of the pre- and post-treatment intraoral scans
of patients who underwent FASTP gingival recession treatment between years 2017-2019 at the
private practice of one of the co-investigators of the study (A.A.A.). All patients were treated by
the same experienced periodontist. For each patient, a comprehensive medical history and
demographic report along with the pre and post-treatment intra oral scans were collected. All the
measurements were calculated using the reverse engineering software, Geomagic
®
. The main
outcome variables were percentage mean root coverage (%mRC), percentage of teeth with
complete root coverage (CRC), and linear mean root coverage (mRC). Furthermore, influence of
the following independent variables; recession type (RT), initial recession depth (IRD), initial
recession width (IRW), tooth type, and anatomic location on the outcome measures was also
evaluated.
INCLUSION CRITERIA:
Age > 18 years
Patients with ambulatory medical history (ASA 1 and ASA 2)
Multiple (≥2) recession type (RT) 1 or 2 defects on adjacent teeth
Gingival recession defects treated with FASTP surgical protocol and A-PRF
Availability of diagnostic quality pre- and post-treatment intraoral scans
Presence of identifiable CEJ
Initial recession depth ≥ 1mm
10
EXCLUSION CRITERIA:
Patients with untreated periodontal disease or with contraindications for periodontal surgery
Patients taking medication that could affect gingival health or anatomy
Non-diagnostic intraoral scans
Second and third molars
Recession type (RT) 3 defects
Smoking
Sites treated with sub-epithelial palatal/tuberosity connective tissue graft
STUDY POPULATION:
Based on the inclusion and exclusion criteria, 13 patients were qualified for the study, contributing
122 recession defects that could be used for 2-dimentional analysis. The mean follow-up period
was 10.1 ± 1.5 months (range 6-18). Table 1 summarizes the demographics of the 13 studied
patients.
PLATELET RICH FIBRIN MEMBRANE PREPARATION PROTOCOL:
A total of ten to twenty 10ml tubes of blood were drawn from the antecubital fossa of each patient
based on the number of recession defects to be treated. Three to four A-PRF membranes are
recommended for each pair of treated teeth. The A-PRF tubes were spun in a centrifuge (Process
Ltd.; Nice, France) at 1300 rpm (200G) for eight minutes based on the proposed A-PRF protocol
by Choukroun (50). Fibrin clots were then removed and compressed in a special container (PRF
box, Process Ltd.) and formed into membranes to be applied as part of the surgical protocol (Figure
1).
SURGICAL PROTOCOL:
11
All patients were treated by the same experienced periodontist in a private practice setting and
under IV conscious moderate sedation. Proper anesthesia through block and/or infiltration was
administered, and scaling and root planning was performed to remove all plaque, calculus and
stains. Flowable composite (Elegance, Henry Schein) was used between the teeth without any
preparation (no etching or primer). The shrinkage after light-curing physically locks the composite
material between the teeth and provides support for the sutures. This step is performed at the
beginning of the procedure to avoid any fluid contamination interfering with the bonding.
Odontoplasty was performed over the teeth with root prominence to create a flat or negative root
surface allowing for more volume of A-PRF to be inserted and so decrease flap tension. Vertical
incisions were made in the vestibular fornix away from the teeth to be treated. The typical location
for the vertical incisions included midline frenum for maxillary anterior teeth or between canine
and lateral incisors for maxillary posterior and all mandibular teeth. A subperiosteal tunnel was
created using specially designed elevators (VISTA elevators, DoWell Dental Products, USA). The
tunnel was then extended from the vestibule to the gingival margin and interproximal papillae.
This would result in total flap relaxation and passive coronal displacement of the mucogingival-
papillary complex 1-2mm coronal to the CEJ of the teeth. Roots were conditioned using
ethylenediaminetetraacetic acid (EDTA) 17% (double application for two-and-a-half minutes) to
remove the smear layer. The A-PRF membranes were inserted in the tunnel from distal to mesial.
Three to four membranes were used per pair of teeth. If a minimum of 2-3 mm of keratinized tissue
was not present at the recession site, a sub-epithelial palatal/tuberosity connective tissue graft was
sutured at the site in the tunnel to optimize the clinical outcome. These sites were excluded from
the analysis. Apical periosteal mattress sutures, Polypropylene 5.0 (Prolene, Henry Schein;
Chatsworth, CA), were placed to avoid marginal suture tension on the APRF membranes, and to
12
stabilize and maintain the membranes on the root surfaces and avoid any displacement of the
membranes into the mucosal area. Interproximal Polypropylene 6.0 sutures sling sutures were used
to position the flap coronally. Approximation and suture of the initial access vertical incision(s)
were performed by interrupted Polypropylene 6.0 sutures. Patients were then prescribed antibiotics
(Amoxicillin or clindamycin), naproxen sodium 550 mg every 12 hours when needed and
Chlorhexidine rinse 0.12% twice a day for three weeks. Approximately two-and-a-half weeks later,
the sutures were removed, and the composites were separated from the incisal edges of the teeth
with a curette. Figure 2 illustrates the steps described earlier.
INTRAORAL SCAN EVALUATION:
Patients were seen for routine maintenance care on a 6-month interval after complete healing.
Intraoral scans were taken at pre- and post-therapy periods using an optical scanner (3Shape Trios)
and saved in Standard Tessellation Language (STL) format. The STL files were imported into a
reverse engineering software, Geomagic
®
(Figure 3). Quantitative 2-dimentional analysis of the
scans was performed by a single examiner (S.A.). Pre and post-operative digitized images were
initially cropped in order to facilitate image manipulation. This step was performed by cropping
the image one tooth adjacent to the treated tooth (Figure 4). The first three cases were measured
three times at three different time positions for calibration and intra-examiner analysis.
DESCRIPTION OF PARAMETERS MEASURED:
INDEPENDENT VARIABLES:
• Recession type (RT): Each recession defect was either diagnosed with recession type 1
(RT1) or recession type 2 (RT2) according to Cairo’s 2011 classification and definition
(15).
13
• Initial recession depth (IRD): IRD was calculated by performing a linear measurement
from the identifiable CEJ of the tooth to the most apical location of the gingival margin
(zenith) in the recession area in millimeter. The digital software was able to identify the
CEJ in all of the cases. If there was a cervical restoration, the margin of the restoration was
used as the reference (Figure 5).
• Initial recession width (IRW): IRW was calculated by performing linear measurement from
the most mesial to the most distal point on the defect of the marginal gingiva in millimeter
(Figure 5).
• Recession surface area: Surface area was calculated using the “Manual Select” tool to
carefully and segmentally outline the initial and post-operative surface of the exposed root.
Following the selection, “Surface Area” tool was used to measure the surface area of the
outlined segments in squared millimeters (Figure 5).
• Tooth type: Defects were categorized according to the type of the tooth associated with
(incisor, canine, premolar, molar).
• Anatomical location: Defects were categorized according to the anatomical location of the
tooth associated with (anterior, posterior, maxillary, mandibular).
OUTCOME MEASURES:
• Mean percentage root coverage (%mRC): (100* (pre surface area – post surface area)/pre
surface area) in percentage
• Percentage of teeth with complete root coverage (CRC): (100* SUM (0 if %mRC<100; 1
if %mRC=100)/total number of subjects) in percentage
• Linear mean root coverage (mRC): (post – pre) in millimeter
STATISTICAL ANALYSIS:
14
Descriptive statistics and pre- and post- treatment mean and standard deviations were calculated
for all continuous descriptors. Categorial measures were summarized using counts and
percentages. To address the primary aim, we reported the mean + standard deviation of all three
outcome measures (%mRC, CRC, and mRC) for the entire study population.
To address the secondary aim, we evaluated the following research questions:
(1) Does recession type predict the treatment outcome?
(2) Are there correlations between outcome measures and baseline measures (IRD and IRW)?
(3) Does tooth type or anatomical location predict treatment outcome?
To address the first question, mean percentage change in root coverage (%mRC) was compared
by recession type using fractional regression with a logit function, that allowed modeling of the
outcome variable ranging from 0 (no change in root coverage) to 1 (100% change in root
coverage). The variance-covariance matrix was calculated with clustering at the patient level.
Results were then presented as regression model-estimated mean change (with 95% confidence
interval) by recession type. Percentage of teeth with complete root coverage (CRC) were compared
by recession type using exact testing; results were presented as proportions with Clopper-Pearson
exact confidence intervals. Finally, linear mean root coverage (mRC) were compared by recession
type using linear mixed effects regression. To account for correlated outcomes due to assessment
of multiple teeth within patient, a random intercept term was specified at the patient level.
To address the second question, the association of percentage change in root coverage (%mRC)
with initial recession depth and width was tested using fractional regression with a logit function,
that allowed modeling of the outcome variable ranging from 0 (no change in root coverage) to 1
(100% change in root coverage). The variance-covariance matrix was calculated with clustering
at the patient level. The association of the binary outcome of achieved complete root coverage
15
(CRC) with initial recession depth and width was tested using mixed effects logistic regression.
Finally, the association of linear mean root coverage (mRC) with initial recession depth and width
was tested using linear mixed effects regression. To account for correlated outcomes due to
assessment of multiple teeth within patient, a random intercept term was specified at the patient
level. All regression models were evaluated for the assumption of linearity of associations using
initial lowess plots. Results were presented as regression model estimate (regression coefficient,
standard error, and p-value).
To address the third question, percentage mean root coverage (%mRC) was compared by tooth
type and anatomical location using fractional regression with a logit function, that allowed
modeling of the outcome variable ranging from 0 (no change in root coverage) to 1 (100% change
in root coverage). The variance-covariance matrix was calculated with clustering at the patient
level. Results were presented as regression model-estimated mean change (with 95% confidence
interval) by tooth type and anatomical location. Percentage of teeth achieving complete root
coverage (CRC) were compared by tooth type and anatomical location using logistic regression,
with the variance-covariance matrix specified with clustering at the patient level; results were
presented as proportions with 95% confidence intervals. Finally, linear mean root coverage (mRC)
were compared by the tooth type and anatomical location categories using linear mixed effects
regression. To account for correlated outcomes due to assessment of multiple teeth within patient,
a random intercept term was specified at the patient level. The unadjusted p-values are not
accounting for the fact that many pairwise hypothesis tests are being conducted. The adjusted p-
values account for the multiple hypothesis testing to control to overall type 1 error at 0.05.
We used Stata 15.0 (Statacorp, College Station, TX) for all data management and to calculate and
test predicted marginal mean differences. To assess correlations between pre-measurements and
16
the primary outcome, we used the R package rmcorr (3.6.3 GUI 1.70 El Capitan build (7735), The
R Foundation for Statistical Computing) to calculate and test correlation coefficients, adjusted for
repeated measures.

17
RESULTS:
The study sample consisted of 13 patients with the mean age of 50.1 ± 5.9 years old. Subjects
included 7 females and 6 males and consisted of 11 Caucasians and 2 Asians. Average healing
time at the time of the post-operative scans was 10.1 ± 1.5 months (range 6-18) (Table 1). All
patients were non-smokers and classified as either ASA type I or II. All 13 patients were treated
for mucogingival deformities by the same experienced periodontist in a periodontal private
practice setting during years 2017-2019. All 13 surgeries followed the same protocol of FASTP
technique with A-PRF membranes. No complications were reported during the healing period.
A total of 122 (range 8-24 per patient) gingival recession defects were included in this retrospective
study. Out of the 122 recession defects, 13% were classified as RT1 (n=16) versus 87% that were
classified as RT2 (n=106). The proportions of incisors, canines, premolars, and molars were 26%
(n=32), 13% (n=16), 33% (n=40), and 28% (n=34) respectively. Finally, 52% (n=64) of the defects
were in the maxilla versus 48% (n=58) in the mandible and 40% (n=48) were located in the anterior
teeth versus 60% (n=74) in the posterior teeth (Table 2).
The mean initial recession depth (IRD), mean initial recession width (IRW), percentage mean root
coverage (%mRC), linear mean root coverage (mRC), and percentage of teeth with complete root
coverage (CRC) for the population of subjects were 1.9 ± 0.7 mm (1–4.8), 4.8± 0.3 mm (0.4-9.6),
55.2 ± 6.2 % (-32.6-100), -1.1± 0.1 mm (-3.5-0.3), and 30%, respectively (Table 3).
Table 4 exhibits the percentage mean root coverage (%mRC), percentage of teeth with complete
root coverage (CRC), and linear mean root coverage (mRC) in different recession types. RT1
defects yielded 100.0 %mRC while RT2 defects exhibited 48.9 %mRC (p <0.001). 100% of RT1
defects yielded CRC while only 18.9% of RT2 defects yielded CRC (p <0.001). Linear mean root
18
coverage was -1.6 mm (-1.9, -1.2) for RT1 and -1 mm (-1.2, -0.8) for RT2 defects (p =0.001)
(Figure 6).
Figure 7 illustrates the correlation between initial linear recession depth (IRD) and outcome
measures achieved. Initial recession depth showed no statistically significant correlation with
mean percentage mean root coverage (%mRC). However, IRD showed statistically significant
negative correlation with linear mean root coverage (mRC) as well as percentage of teeth with
complete root coverage (CRC).
Figure 8 illustrates the correlation between initial linear recession width (IRW) and outcome
measures achieved. Initial recession depth showed no statistically significant correlation with any
of the three outcome measures.
Table 5 exhibits the outcome measures achieved for different tooth types. The %mRC in a
descending order was found to be 68.4% for incisors, 59.1% for canines, 51.5% for premolars, and
46.6% for molars. Overall p-value for difference among groups was statistically significant (p
=0.022). The percentage of teeth with CRC in a descending order was found to be 53.1% for
incisors, 31.2% for canines, 20.6% for molars, and 17.5% for premolars. Overall p-value for
difference among groups was statistically significant (p =0.0003). The mRC in a descending order
was found to be -1.43 mm for canines, -1.2 mm for incisors, -0.98 mm for molars, and -0.93 mm
for premolars. Overall p-value for difference among groups was statistically significant (p =0.032).
In an unadjusted pairwise comparison incisors achieved statistically significant higher %mRC than
premolar and molars. In an unadjusted pairwise comparison, statistically significant higher
percentage of incisor teeth achieved CRC than canines, premolars and molars. The adjusted
pairwise comparison was significantly higher for incisors when compared with premolars. Lastly,
19
in an unadjusted pairwise comparison canines achieved statistically significant higher mRC than
premolars and molars (Figure 9).
Table 6 exhibits the outcome measures achieved for different tooth positions. The %mRC in a
descending order was found to be 88.96% for maxillary incisors, 69.57% for maxillary canines,
55.83% for maxillary premolars, 52.79% for mandibular molars, 52.36% for mandibular incisors,
46.17% for mandibular premolars, 40.51% for maxillary molars, and 36.11% for mandibular
canines. Overall p-value for difference among groups was statistically significant (p <0.0001).
In an unadjusted pairwise comparison maxillary incisors achieved statistically significant higher
%mRC than maxillary premolar, maxillary molar, and all mandibular tooth positions. In an
unadjusted pairwise comparison maxillary canines achieved statistically significant higher %mRC
than maxillary molar, mandibular canine, and mandibular premolars. The adjusted pairwise
comparison was significantly higher when comparing %mRC in maxillary canines compared to
mandibular canines.
The percentage of teeth with CRC in a descending order was found to be 78.6% for maxillary
incisors, 45.5% for maxillary canines, 33.3% for mandibular incisors, 29.4% for mandibular
molars, 22.7% for maxillary premolars, 11.8% for maxillary molars, 11.1% for mandibular
premolars, and 0% for mandibular canines. Overall p-value for difference among groups was
statistically significant (p =0.0002).
In an unadjusted pairwise comparison, statistically significant higher percentage of maxillary
incisor teeth achieved CRC than maxillary and mandibular premolar, maxillary and mandibular
molar, and mandibular incisor teeth. The adjusted pairwise comparison was significantly higher
when comparing CRC in maxillary incisors compared to maxillary premolars. In an unadjusted
20
pairwise comparison, statistically significant higher percentage of maxillary canine teeth achieved
CRC than maxillary molar, and mandibular premolar teeth.
The linear mRC in a descending order was found to be -1.56 mm for maxillary canines, -1.47 mm
for maxillary incisors, 5-1.09 mm for maxillary canines, -1.04 mm for maxillary premolars, -1.03
mm for mandibular incisors, -1 mm for maxillary molars, -0.95 mm for mandibular molars, and -
0.83 mm for mandibular premolars. Overall p-value for difference among groups was statistically
significant (p = 0.036).
In an unadjusted pairwise comparison maxillary incisors achieved statistically significant higher
mRC than maxillary and mandibular premolar and molar teeth. Lastly, in an unadjusted pairwise
comparison maxillary canines achieved statistically significant higher mRC than maxillary and
mandibular premolar and molar teeth as well as mandibular incisors (Figure 10).
Table 7 exhibits the outcome measures achieved for different anatomical locations. The %mRC
was 65.29% and 49.27% in anterior versus posterior defects respectively and the pairwise
comparison was not statistically significant (p =0.058). The %mRC was 61.37% and 49.17% in
maxillary versus mandibular defects respectively and the pairwise comparison was statistically
significant (p =0.031). The %mRC in a descending order was 80.43% for maxillary anterior,
49.39% for mandibular posterior, 49.16% for maxillary posterior, and 48.83% for mandibular
anterior defects. The overall p-value for difference among groups was statistically significant (p
<0.0001). In both unadjusted and adjusted pairwise comparisons maxillary anterior teeth achieved
statistically significant higher %mRC than maxillary and mandibular posterior teeth as well as
mandibular anterior teeth.
The percentage of teeth that achieved CRC was 45.8% and 18.9% in anterior versus posterior
defects respectively and the pairwise comparison was statistically significant (p =0.003). The
21
percentage of teeth that achieved CRC was 35.9% and 22.4% in maxillary versus mandibular
defects respectively and the pairwise comparison was statistically significant (p =0.04). The
percentage of teeth that achieved CRC in a descending order was 64.0% for maxillary anterior,
26.1% for mandibular anterior, 20.0% for mandibular posterior, and 17.9% for maxillary posterior
defects. The overall p-value for difference among groups was statistically significant (p = 0.0001).
The adjusted pairwise comparison was significantly higher when comparing CRC in maxillary
anterior teeth compared to maxillary and mandibular posterior teeth as well as mandibular anterior
teeth.
The linear mean root coverage (mRC) was -1.30 mm and -0.96 mm in anterior versus posterior
defects respectively and the pairwise comparison was statistically significant (p =0.006). The
linear mean root coverage (mRC) was -1.21 mm and -0.93 mm in maxillary versus mandibular
defects respectively and the pairwise comparison was statistically significant (p =0.027). The
linear mean root coverage (mRC) in a descending order was -1.52 mm for maxillary anterior, -
1.04 mm for mandibular anterior, -1.02 mm for maxillary posterior, and -0.89 mm for mandibular
posterior defects. The overall p-value for difference among groups was statistically significant (p
=0.002). In an unadjusted pairwise comparison maxillary anterior teeth achieved statistically
significant higher mRC than maxillary and mandibular posterior teeth as well as mandibular
anterior teeth. Finally, in an adjusted pairwise comparison, maxillary anterior teeth achieved
statistically significant higher mRC than maxillary and mandibular posterior teeth (Figure 11).

22
DISCUSSION:
A review of literature reveals that different techniques have been utilized to aid in quantification
of pre- and post- gingival defects for the purpose of treatment outcome evaluations. Such
techniques include periodontal probes, endodontic files, and optical scans. While periodontal
probe might seem to be the most common tool for measurement of recession defects, its accuracy
has been questioned and deemed limited. Badersten et al. in a 1984 study revealed that due to the
incremental markings on the periodontal probes, the accuracy of the readings is decreased.
Moreover, the limited access and visualization of the sites provide another limitation in using
periodontal probes for accurate quantitative measurements (58).
Our study utilized the digitalized images provided by an intraoral scanner to overcome such
limitations. The rendering and 2-D analysis of the scans were accomplished through a reverse
engineering software (Geomagic
®
). Through digital rendering and evaluation, measurements can
be performed in a nonclinical environment and as many times as needed without the need to have
the patient present. Digitally rendered images can be visualized in different angles and
magnifications which can significantly increase the accuracy of the measurements. Finally, digital
rulers can be used which can accurately calculate linear or areal measurements (59). In their 2014
study, Schneider et al. concluded that digital measurements of papilla height and amount of gingiva
were more reproducible compared to clinical intraoral measures performed by different
investigators or the even same investigator (59).
The negative consequences associated with gingival recession defects including compromised
aesthetic appearance and/or dental hypersensitivity along with the high probability of progression
if left untreated provide an indication for treatment of certain gingival recessions. A wide variety
23
of surgical techniques for treatment of localized and generalized recession defects have been
introduced in the literature throughout the past few decades each with specific indications,
strengths and limitations of their own.
The ultimate goal of recession therapy is to achieve predictable and esthetically pleasing root
coverage. Studies on this topic mostly include multiple gingival recessions of Miller Class I and
II or RT1. A review of the literature reveals that mean root coverage for the CTG (gold standard)
in combination with CAF ranges from 70% to 98% (60,61,62,63,64). Furthermore, Zucchekki and
Sanctis in a 2000 study showed a mean root coverage of 97.1% with a CAF and sling sutures after
1 year while 88% of defects obtaining complete root coverage at the 12-month time point (65).
A 6-month postoperative measurement period is sufficient to evaluate the stability of the gingival
margin after a CAF (66). The outcomes of the present study revealed that FASTP technique using
A-PRF membrane resulted in an overall percentage mean root coverage (%mRC) of 55.2% and
linear mean root coverage (mRC) of -1.1 ± 0.1 mm in a total of 122 recession defects, 10.1 ± 1.5
months postoperatively. Complete root coverage (CRC) was obtained in 30% of cases. These
parameters were respectively 100%, -1.6 mm, and 100% for RT1 (n=16) and 48.9%, -1 mm, and
18.9% for RT2 (n=106) defects. One can attribute the higher %mRC reported in literature to the
fact that most of the literature is focused on RT1 (miller class I and II) defects as well as the use
of subepithelial connective tissue graft along with coronally advanced flap. A possible explanation
may be that root coverage outcome benefit from improving the thickness of the marginal gingiva,
and PRF membranes do not act as a solid scaffold leading to such increase in thickness. On the
other hand, this inferior result may be due to cofounding factors such as morphology of the defects,
24
initial recession depth and width, initial gingival thickness, number of treated defects, tooth
location, different PRF protocols, or the provided surgical technique.
In the present study, 100% of the RT1 defects achieved CRC which is comparable to the 2018
study by Cortellini, where he concluded that 100% root coverage can be predicted in RT1 defects
(16). The high degree of root coverage achieved for RT1 defects was possible because FASTP
allows coronally advancing the gingival margins of teeth beyond the CEJ and maintaining such
position during the healing by coronal anchoring of sutures utilizing interproximal composites.
The significance of coronally advancing the gingival margin during surgery at least 2 mm past the
CEJ has been demonstrated (67), where 100% complete root coverage was achieved only in cases
where the gingival margin was advanced 2 mm past the CEJ. This was achieved in all the RT1
gingival recession defects treated in this study. With respect to RT2 defects, where loss of
interproximal bone and attachment exists, previous studies where alternatives to CTG (gold
standard) were used, have demonstrated that the percentage of root coverage is around 60%
(68,69). This occurs due to the limited blood supply to the area having reduced bone and
attachment apparatus. Our study showed a mean percentage root coverage (%mRC) of 48.9% for
RT2 defects which again could be explained by the inferior efficacy of PRF in substituting other
grafting materials such as acellular dermal matrix which was used in both studies mentioned earlier
in RT2 defects.
In terms of recession type, the results of this study correlate with other publications on root
coverage, where statistically significant difference in root coverage has been reported between
RT1 versus RT2 gingival recession defects (29). The presence of interproximal periodontal
attachment provides the required vascular supply to support the survival of a gingival graft.
Recessions with no interdental tissue loss typically yield better root coverage outcomes (4).
25
In a 2016 systematic review and meta-analysis, Moraschini et al. investigated the effects of
platelet-rich fibrin (PRF) membranes on the outcomes of clinical treatments in patients with
gingival recession. Six randomized clinical trials with follow-up period of greater or equal to 6
months and one clinical trial were included in the study. The results of the meta-analysis suggested
that the use of PRF membranes did not improve the root coverage, keratinized mucosa width, or
clinical attachment level of miller class I and II gingival recessions compared with the other
treatment modalities which included sites treated with CAF, CAF+CTG, and CAF+EMD (70).
The design of our study does not allow the comparison of FASTP technique with any other
modality however our clinical experience and observatory findings are in line with Moraschini
where he demonstrated that the use of PRF had several advantages including low cost, relatively
simple acquisition, and no donor site morbidity.

In a more recent systematic review and meta-analysis, Rodas et al. investigated the efficacy of
platelet rich fibrin (PRF) membranes versus subepithelial connective tissue grafts (SCTGs) in the
coverage of Miller class I and II gingival recessions. Rodas revealed that gingival recession,
clinical attachment level, and probing depth parameters in the PRF group were found to be equal
to those of the SCTG group and only the keratinized mucosal width was statistically more
significant in the SCTG group. Therefore, they concluded that PRF membranes were determined
to be promising alternatives to autogenous gingival grafts in the treatment of Miller class I and II
gingival recessions (71). The findings of this 2020 systematic review and metanalysis is in line
with our findings where 100% of our RT1(Miller class I and II) defects achieved CRC through the
FASTP treatment protocol.
26
Neither one of the systematic reviews investigated the effect of PRF in treatment of RT2 (Miller
class III) defects and that is because most of the literature on this topic involves RT1 defects and
there is a substantial lack of evidence when it comes to studying RT2 defects. In that sense, our
study is unique in a way that 87% of treated defects were classified as RT2 (n=106) versus only
13% were RT1 (n=16). Disproportional distribution of RT2 to RT1 recession diffects could be the
reason why the overall %mRC in our study was only 55.2 %. This can further indicate that the use
of PRF as a substitute to other grafting materials in RT2 (Miller class I and II) defects would not
yield predictable outcomes.
Surgical technique may influences efficacy of a root coverage. In a 2019 study, Chambrone and
Pini Prato investigated the evolution of root coverage procedures. They concluded that coroally
advanced flap (CAF), intrasulcular tunneling (IST) and vestibular tunneling (VISTA) are the most
common techniques used in root coverage; however, each technique may have some specific
limitations and indications. In another recent systematic review and meta-analysis, Tevelli et al.
compared the efficacy of IST versus CAF in treatment of gingival recession defects. They
concluded that CAF may lead to superior results in terms of root coverage however may not be
the treatment of choice in the esthetic zone due to the scarring that it leaves behind at the incisions
sites (72). Both IST and VISTA techniques were developed to overcome this exact issue. In
addition to that, tunneling technique has shown superiority to other modalities due to undisturbed
blood supply to papillae and the underlying graft, faster healing, and reduced post-operative
discomfort (31).
Some of the limitations of the tunneling technique however include limited access and visibility
when it comes to instrumentation and placement and stabilization of the graft material.
Furthermore, the facial composites that suspend the sutures in the VISTA protocol can jeopardize
27
the esthetics of those teeth upon removal and polishing of those sites. Another limitation is existing
restorations that will challenge the bonding of the composite to the facial surface.
FASTP technique involves some modifications of the VISTA protocol to overcome some of the
abovementioned limitations. Placement of multiple vestibular incisions to improve access and
visibility, addition of apical mattress sutures to stabilize the PRF membranes coronally, and the
use of interproximal contact area composites in place of facial composites to eliminate the risk of
compromising facial esthetics of these teeth are some of those modifications that make FASTP a
safer and more predictable tunneling approach.

As part of the secondary aim of our study we looked at the influence of initial recession depth
(IRD) and initial recession width (IRW) on %mRC, CRC, and mRC. In a 2005 study, Berlucchi
showed that 94.7% mean root coverage can be expected in recession depth less than 4mm versus
85% mean root coverage in recession depth of more than 4mm (73). In a more recent study, the
2015 consensus report from the AAP regeneration workshop demonstrated that initial recession
depth negatively influenced the degree of root coverage achieved (74). In other words, the deeper
the initial recession depth the more surface area that needs to be covered and the harder it is to
achieve CRC. This finding is in line with our study where we observe a statistically significant
negative correlation between initial recession depth and percentage of teeth with complete root
coverage (CRC) as well as linear mean root coverage (mRC) (Figure 7). Nevertheless, these results
should be interpreted with caution due to the fact of the limited number of recession defects deeper
than 4 mm and the number of variables included in the study. Our study did not find any
statistically significant correlation between initial recession width and outcome measures.
28
We further evaluated tooth type and anatomical location of the site being treated for root coverage
as cofounding factors and investigated any possible trend or correlation. Our study has shown tooth
type and anatomical location may be important predictive factors for root coverage and achieving
complete root coverage. Incisors were the teeth that showed greatest percentage mean root
coverage (%mRC) followed by canines, premolars and molars. This could be explained by the
increased surface area in posterior teeth compared to anterior teeth which will require more surface
area to be covered by the graft (75). In a more recent study, Zucchelli et al. also evaluated the
influence of tooth location on determining amount of root coverage with CAF. They concluded
that the second sextant is associated with the highest root coverage outcomes compared with other
sextants. Moreover, they demonstrated that mandibular anterior teeth showed the least amount of
root coverage (72). These results are in line with our findings in which maxillary anterior teeth
showed the highest level of %mRC and mandibular anterior teeth showed the lowest level of
%mRC. A practical explanation may be the unfavorable anatomical conditions and features in the
mandibular anterior area. High frenal attachment, strong mentalis muscle pull, and shallow
vestibules are often present in this sextant which can increase the flap tension and compromise the
clinical outcome.
In 2006, Chambrone et al. reported that when maxillary and mandibular sited were compared,
there was a trend favoring the maxillary teeth (76). Few years later, in a 2010 study, Aroca et al.
showed that the distance from the tip of papilla to the contact point and tooth location are the key
root coverage determining factors. They further showed that maxillary teeth are more likely to
have better root coverage than mandibular teeth (77). Our findings are in line with the results of
previous studies as we also demonstrated statistically significant higher %mRC in maxillary versus
29
mandibular sites. The increased muscle pull and decreased thickness of the gingival tissue in the
mandible could negatively affect the outcome of the mucogingival surgery.
The present investigation had a series of limitations, which included: a) the retrospective nature of
the study, b) lack of negative control to evaluate the efficacy of FASTP technique alone, c) lack
of positive control group with the use of CTG or other alternatives, d) small sample size, e)
disproportional sample distribution between RT1 and RT2, and f) The difficulty of identifying the
CEJ in some of the cases, especially if the teeth presented with full contour restorations. In these
cases, the restoration margin was used as the reference for measurement.
The implications of the present data for the future studies include: a) Randomized control clinical
trials with a negative control and larger patient pool will be required in order to examine the
efficacy of FASTP and validate the risk factors identified in this study, b) Digital measurements
have to be compared with conventional clinical measurements to validate these measurements,
3) If the risk factors identified in the present study are validated in future randomized control
clinical trials, these factors can be incorporated as part of risk assessment to predict outcome of
therapy, 4) The risk factors (recession type, Initial recession depth and width, tooth type, and
anatomic location) may potentially be incorporated into a classification system to predict clinical
outcomes, and 5) No histological evaluation was performed in the present study; therefore, the
effect of APRF on overall regenerative capacity remains to be determined.

30
CONCLUSION:
1- Within the limitations of this study, FASTP protocol was assessed to be a predictable technique
in treatment of multiple adjacent RT1 defects with 100% of the subjects achieving CRC.
2- Initial Recession Depth (IRD) was an important negative predictor of CRC and mRC outcome
measures.
3- Additional predictors of outcome included tooth type (incisor, canine, premolar or molar),
anatomic location (anterior, posterior, maxillary, mandibular), and interproximal tissue loss (RT1
vs RT2).
4- Randomized controlled clinical trial will be required to compare the efficacy of FASTP to other
periodontal root coverage methods, as well as to examine the predictive value of the risk factors
identified in the present study.

31
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41
TABLES:
Table 1: Demographic of the sample population (N = 13)
Age (year)
Mean ± SD
Range

50.1 ± 5.9
25 - 65
Sex
Female
Male

n = 7 (54%)
n = 6 (46%)
Race
Caucasian
Asian

n = 11 (84%)
n = 2 (16%)
Medical Status
ASA I
ASA II
n = 5 (38%)
n = 8 (62%)
Average healing time (month)
Mean ± SD
Range

10.1 ± 1.5
6-18

42
Table 2: Number of recession defects for recession type, tooth type, and anatomic location.
Recession type (RT)
RT 1
RT 2

n =16 (13%)
n =106 (87%)
Tooth type
Incisor
Canine
Premolar
Molar

n = 32 (26%)
n = 16 (13%)
n = 40 (33%)
n = 34 (28%)
Anatomic location
Maxillary
Mandibular

n = 64 (52%)
n = 58 (48%)
Anterior
Posterior
n = 48 (40%)
n = 74 (60%)

43
Table 3: Characteristics of defect sites and associated outcomes (n =122)

Mean ± SD
Initial recession depth (IRD) (mm)
(Range)
1.9 ± 0.7
(1–4.8)
Initial recession width (IRW) (mm)
(Range)
4.8 ± 0.3
(0.4-9.6)
Percentage mean root coverage (%mRC)
(Range)
55.2 ± 6.2
(-32.6-100)
Linear mean root coverage (mRC) (mm)
(Range)
-1.1 ± 0.1
(-3.5-0.3)
Percentage of teeth with complete root coverage (CRC) (%) 30 (n = 36)

44
Table 4: Comparison of outcome measures for RT1 (n = 16) versus RT2 (n = 106) defects.

Outcome Measures RT1 RT2 p-value
Mean Initial Recession Width (IRW) ± SD (mm) 1.6 ± 0.2 2 ± 0.1
< 0.001
Mean Initial Recession Depth (IRD) ± SD (mm) 3.8 ± 0.5 5 ± 0.4
< 0.001
Percentage mean Root Coverage (%mRC)
(Range)
100
(100, 100)
48.9
(36.4, 61.4)
< 0.001
Percentage of teeth with Complete Root
Coverage (CRC) (%)
(Range)
100
(100,100)
18.9
(11.9,27.6)
< 0.001
Linear mean root coverage (mRC) (mm)
(Range)
-1.6
(-1.9, -1.2)
-1
(-1.2, -0.8)
0.001

45
Table 5: Comparison of outcome measures for different tooth types (32 Incisors, 16 Canines, 40
Premolars, 34 Molars).
Percentage Mean Root Coverage
Tooth
Position
%mRC Unadjusted
Significantly
Different
from:
Unadjusted
p-value for
pairwise
group
difference
Adjusted
Significantly
Different
from:
Adjusted
p-value
for
pairwise
group
difference
N Mean
(95%CI)

Incisor 32 68.4
(50.7,86.1)
Premolar
Molar
0.037
0.049

Canine
16
59.1
(43.7,74.5)

Premolar 40 51.5
(37.6,65.3)

Molar 34 46.6
(32.4,60.9)

Overall p-value for differences among groups = 0.022. P-values for pairwise group differences
are presented: (1) unadjusted for multiple comparisons; (2) adjusted for multiple comparisons
using Scheffe procedure.

46

Percentage of Teeth with Complete Root Coverage (CRC)
Tooth
Position
CRC Unadjusted
Significantly
Different
from:
Unadjusted
p-value for
pairwise
group
difference
Adjusted
Significantly
Different
from:
Adjusted
p-value
for
pairwise
group
difference
N Proportion
(95%CI)

Incisor 32 53.1
(38.8,67.4)
Canine
Premolar
Molar
0.044
0.002
0.007

Premolar

0.025
Canine
16
31.2
(15.1,47.4)

Premolar 40 17.5
(2.5,32.5)

Molar 34 20.6
(4.3,36.9)

Overall p-value for differences among groups = 0.0003. P-values for pairwise group differences
are presented: (1) unadjusted for multiple comparisons; (2) adjusted for multiple comparisons
using Scheffe procedure.

47

Linear Mean Root Coverage (mRC)
Tooth
Position
mRC Unadjusted
Significantly
Different
from:
Unadjusted
p-value for
pairwise
group
difference
Adjusted
Significantly
Different
from:
Adjusted
p-value
for
pairwise
group
difference
N Mean
(95%CI)

Incisor 32 -1.2
(-1.5,-0.9)

Canine
16
-1.43
(-1.8,-1.07)
Premolar
Molar
0.009
0.021

Premolar 40 -0.93
(-1.2,-0.6)

Molar 34 -0.98
(-1.25,-0.7)

Overall p-value for differences among groups = 0.022. P-values for pairwise group differences
are presented: (1) unadjusted for multiple comparisons; (2) adjusted for multiple comparisons
using Scheffe procedure.

48
Table 6: Comparison of outcome measures for different tooth positions (14 maxillary incisors, 11
maxillary canines, 22 maxillary premolars, 17 maxillary molars, 18 mandibular incisors, 5
mandibular canines, 18 mandibular premolars, 18 mandibular molars).
Percentage Mean Root Coverage
Tooth category Mean (95% CI) Unadjusted
Significantly
different from:
Unadjusted
p-value for
pairwise
group
difference
Adjusted
Significantly
different
from:
Adjusted
p-value
for
pairwise
group
difference
Maxillary incisor 88.96 (75.05,
100.03)
Maxillary
premolar
0.001
Maxillary
molar
0.001
Mandibular
incisor
0.021
Mandibular
canine
0.006
Mandibular
premolar
0.005
Mandibular
molar
0.006
Maxillary canine 69.57 (57.99,
81.16)
Maxillary
molar
0.012 Mandibular
canine
< 0.001
Mandibular
canine
< 0.001
Mandibular
premolar
0.003
Maxillary premolar 55.83 (38.57,
73.09)

Maxillary molar 40.51 (25.29,
55.74)

Mandibular incisor 52.36 (25.24,
79.49)

Mandibular canine 36.11 (22.29,
49.93)

Mandibular
premolar
46.17 (32.91,
59.43)

Mandibular molar 52.79 (32.73,
72.86)

Overall p-value for differences among groups <0.0001. P-values for pairwise group differences
are presented: (1) unadjusted for multiple comparisons; (2) adjusted for multiple comparisons
using Scheffe procedure.
49
Percentage of Teeth with Complete Root Coverage (CRC)
Tooth category Proportion (95%
CI)
Unadjusted
Significantly
different from:
Unadjusted
p-value for
pairwise
group
difference
Adjusted
Significantly
different
from:
Adjusted
p-value
for
pairwise
group
difference
Maxillary incisor 78.6 (58.3, 98.9) Maxillary
premolar
<0.001 Maxillary
premolar
0.026
Maxillary
molar
0.001
Mandibular
incisor
0.013
Mandibular
premolar
0.001
Mandibular
molar
0.001
Maxillary canine 45.5 (25.5, 65.4) Maxillary
molar
0.045
Mandibular
premolar
0.039
Maxillary premolar 22.7 (5.5, 39.9)
Maxillary molar 11.8 (-4.9, 28.4)
Mandibular incisor 33.3 (14.1, 52.6)
Mandibular canine 0 (0, 52.2)
Mandibular premolar 11.1 (-4.3, 26.5)
Mandibular molar 29.4 (4.3, 54.5)

Overall p-value for differences among groups = 0.0002. P-values for pairwise group differences
are presented: (1) unadjusted for multiple comparisons; (2) adjusted for multiple comparisons
using Scheffe procedure. Confidence interval for mandibular canine is an exact Clopper-
Pearson one-sided 97.5% confidence interval.

50
Linear Mean Root Coverage (mRC)
Tooth category Mean (95% CI) Unadjusted
Significantly
different from:
Unadjusted
p-value for
pairwise
group
difference
Adjusted
Significantly
different
from:
Adjusted
p-value
for
pairwise
group
difference
Maxillary incisor -1.47 (-1.85, -
1.09)
Maxillary
premolar
0.049
Maxillary
molar
0.045
Mandibular
premolar
0.005
Mandibular
molar
0.024
Maxillary canine -1.59 (-2.01, -
1.17)
Maxillary
premolar
0.019
Maxillary
molar
0.019
Mandibular
incisor
0.025
Mandibular
premolar
0.002
Mandibular
molar
0.01
Maxillary premolar -1.04 (-1.36, -
0.72)

Maxillary molar -1.00 (-1.34, -
0.66)

Mandibular incisor -1.03 (-1.38, -
0.67)

Mandibular canine -1.09 (-1.69, -
0.49)

Mandibular premolar -0.83 (-1.17, -
0.49)

Mandibular molar -0.95 (-1.30, -
0.60)

Overall p-value for differences among groups = 0.036. P-values for pairwise group differences
are presented: (1) unadjusted for multiple comparisons; (2) adjusted for multiple comparisons
using Scheffe procedure.

51
Table 7: Comparison of outcome measures for different anatomical locations (25 Maxillary
Anterior, 23 Mandibular Anterior, 39 Maxillary Posterior, and 35 Mandibula Posterior, 48
Anterior versus 74 Posterior, 64 Maxillary versus 58 Mandibular).
Percentage Mean Root Coverage
Tooth category Mean (95% CI) p-value
Anterior 65.29 (5013, 80.44) 0.058
Posterior 49.27 (37.06,
61.48)

Percentage Mean Root Coverage
Tooth category Mean (95% CI) p-value
Maxillary 61.37 (52.19,
70.56)
0.031
Mandibular 49.17 (35.53,
62.80)

Percentage Mean Root Coverage
Tooth category Mean (95% CI) Unadjusted
Significantly
different from:
Unadjusted
p-value for
pairwise
group
difference
Adjusted
Significantly
different
from:
Adjusted
p-value
for
pairwise
group
difference
Maxillary anterior 80.43 (73.24,
87.62)
Mandibular
anterior
0.001 Mandibular
anterior
0.008
Maxillary
posterior
< 0.001 Maxillary
posterior
0.001
Mandibular
posterior
< 0.001 Mandibular
posterior
0.001
Mandibular anterior 48.83 (24.63,
87.2)

Maxillary posterior 49.16 (33.69,
64.62)

Mandibular posterior 49.39 (37.41,
61.37)

52
Overall p-value for differences among groups < 0.0001. P-values for pairwise group differences
are presented: (1) unadjusted for multiple comparisons; (2) adjusted for multiple comparisons
using Scheffe procedure.

Percentage of Teeth with Complete Root Coverage (CRC)
Tooth category Proportion (95%
CI)
p-value
Anterior 45.8 (34.2, 57.5) 0.003
Posterior 18.9 (7.9, 30.0)

Percentage of Teeth with Complete Root Coverage (CRC)
Tooth category Proportion (95%
CI)
p-value
Maxillary 35.9 (27.2, 44.7) 0.04
Posterior 22.4 (11.5, 33.3)

Percentage of Teeth with Complete Root Coverage (CRC)
Tooth category Proportion (95%
CI)
Unadjusted
Significantly
different from:
Unadjusted
p-value for
pairwise
group
difference
Adjusted
Significantly
different
from:
Adjusted
p-value
for
pairwise
group
difference
Maxillary anterior 64.0 (52.6, 75.4) Mandibular
anterior
0.036
Maxillary
posterior
0.001
Mandibular
posterior
0.004
Mandibular anterior 26.1 (8.2, 43.9)
Maxillary posterior 17.9 (4.2, 31.7)
Mandibular posterior 20.0 (5.9, 34.1)

Overall p-value for differences among groups = 0.0001. P-values for pairwise group differences
are presented: (1) unadjusted for multiple comparisons; (2) adjusted for multiple comparisons
using Scheffe procedure.

53
Linear Mean Root Coverage (mRC)
Tooth category Mean (95% CI) p-value
Anterior -1.30 (-1.56, -1.04) 0.006
Posterior -0.96 (-1.18, -0.73)

Linear Mean Root Coverage (mRC)
Tooth category Mean (95% CI) p-value
Maxillary -1.21 (-1.43, -0.98) 0.027
Mandibular -0.93 (-1.16, -0.69)

Linear Mean Root Coverage (mRC)
Tooth category Mean (95% CI) Unadjusted
Significantly
different from:
Unadjusted
p-value for
pairwise
group
difference
Adjusted
Significantly
different
from:
Adjusted
p-value
for
pairwise
group
difference
Maxillary anterior -1.52 (-1.83, -
1.22)
Mandibular
anterior
0.01 Maxillary
posterior
0.023
Maxillary
posterior
0.002 Mandibular
posterior
0.002
Mandibular
posterior
<0.002
Mandibular anterior -1.04 (-1.36, -
0.72)

Maxillary posterior -1.02 (-1.28, -
0.77)

Mandibular posterior -0.89 (-1.15, -
0.62)

Overall p-value for differences among groups = 0.002. P-values for pairwise group differences
are presented: (1) unadjusted for multiple comparisons; (2) adjusted for multiple comparisons
using Scheffe procedure.

54
FIGURES:
Figure 1: Advanced Platelet Rich Fibrin (A-PRF) membrane preparation. A: fibrin clot
dissociation from red blood cells after centrifugation, B: fibrin clots, C: fibrin membranes after
compression

55
Figure 2: Treatment of multiple adjacent gingival recession defects (RT1 & RT2) with FASTP
protocol. A: Baseline, B: vestibular incision, C: Tension-free coronal advancement through
vestibular incision, D: root surface preparation with 17% EDTA, E: introduction of A-PRF
membranes through the vestibular incision, F: clinical presentation after placing 3-4 A-PRF
membranes per pair of treated teeth, G: apical periosteal mattress sutures, H: interproximal resin
assisted sutures, I: 24-month postoperative presentation

56
Figure 3: The pre and post-operative STL files were transferred into Geomagic
®
software.

57
Figure 4: Illustration of the trimming process of the digitized study models. A: Pre-operative and
B: post-operative scans were trimmed to limit the file size to the region of interest Cropped C:
pre-operative and D: post-operative intraoral scans are illustrated.

58
Figure 5: Illustration of linear measurements and surface area selection after cropping the scans.
A: Cropped pre-op scan, B: Pre-op IRD and IRW linear measurements utilizing “Ruler” tool as
well as surface area selected in red utilizing “Manual Select” and “Surface Area” tools, C: Cropped
post-op scan with complete root coverage

59
Figure 6: Comparison of outcome measures for RT1 (n = 16) versus RT2 (n = 106) defects.

60
Figure 7: Scatter plot illustrating the correlation between pre-operative initial recession depth
(IRD) and outcome measures: percentage mean root coverage (%mRC), percentage of teeth with
complete root coverage (CRC) and linear mean root coverage (mRC).

61

Figure 8: Scatter plot illustrating the correlation between pre-operative initial recession width
(IRW) and outcome measures: percentage mean root coverage (%mRC), percentage of teeth with
complete root coverage (CRC) and linear mean root coverage (mRC).

62
Figure 9: Comparison of outcome measures for different tooth types (32 Incisors, 16 Canines, 40
Premolars, 34 Molars).

63
Figure 10: Comparison of outcome measures for different tooth positions (14 maxillary incisors,
11 maxillary canines, 22 maxillary premolars, 17 maxillary molars, 18 mandibular incisors, 5
mandibular canines, 18 mandibular premolars, 18 mandibular molars).

64
Figure 11: Comparison of outcome measures for different anatomical locations (25 Maxillary
Anterior, 23 Mandibular Anterior, 39 Maxillary Posterior, and 35 Mandibula Posterior, 48
Anterior versus 74 Posterior, 64 Maxillary versus 58 Mandibular).

65

66

Abstract (if available)

Abstract Background: Multiple contiguous gingival recession defects may be treated using a variety of therapeutic techniques with varying degrees of success depending on the initial presentation and treatment approach. The primary aim of this retrospective study was to determine the efficacy of the Fibrin-Assisted Soft Tissue Promotion (FASTP) technique for root coverage of multiple gingival recession defects by measuring the following outcomes: percentage mean root coverage (%mRC), percentage of teeth with complete root coverage (CRC), and linear mean root coverage (mRC) at a follow up period of 10.1 ± 1.5 months (range 6–18) after surgery. Secondary aim of the study was to determine the influence of the following independent factors; recession type (RT), initial recession depth (IRD), initial recession width (IRW), tooth type, and anatomic location on the outcome measures. ? Methods: Retrospective data from thirteen patients (122 teeth) who were treated with FASTP technique for multiple gingival recession defects were collected. Pre- and post-therapy intraoral scans were superimposed using the Geomagic® software to allow for comparison of 2-dimensional surface changes. Each of the outcome measures were further compared by independent factors using linear mixed effects regression. ? Results: A total of 122 recession defects in 13 patients were included in this retrospective study. The percentage mean root coverage (%mRC) achieved were 100% (100.0, 100.0) for RT1 and 48.87% (36.37, 61.36) for RT2 recession defects (p <0.001). Complete root coverage (CRC) was 100% (100.0, 100.0) for RT1 and 18.87% (11.92, 27.62) for RT2 recession defects (p<0.001) and linear mean root coverage (mRC) was ?1.598mm (?1.952, ?1.243) for RT1 and ?1.005mm (?1.210, ?0.800) for RT2 recession defects (p=0.001). Initial recession depth (IRD) showed a statistically significant negative correlation with linear mean root coverage (mRC) (p <0.001). Initial recession width (IRW) showed no statistically significant difference in any of the parameters measured. With respect to different tooth types, statistically significant overall difference was only observed in percentage of teeth achieving complete root coverage (CRC). In a descending order CRC was achieve in 53.1% (38.8, 67.4), 31.2% (15.1, 47.4), 17.5% (2.5, 32.5), and 20.6% (4.3, 36.9) of incisors, canines, premolars, and molars respectively (p <0.001). Anatomic location of the tooth (Anterior vs. posterior and maxillary vs. mandibular) showed statistically significant difference in all of the parameters measured (p<0.05) except for percentage mean root coverage (%mRC) in anterior vs. posterior (p=0.058). With respect to a combination of tooth type and anatomical location, maxillary canines achieved a statistically significant higher %mRC of 69.57% (57.99, 81.16) compared to mandibular canines 36.11% (22.29, 49.93) (p<0.001) and a statistically significant higher proportion of maxillary incisors achieved CRC 78.6% (58.3, 98.9) compared to maxillary premolars 22.7% (5.5, 39.9) (p<0.001). Finally, maxillary anterior teeth achieved a statistically significant higher %mRC of 80.43% (73.24, 87.62) compared to both maxillary posterior 49.16% (33.69, 64.62) and mandibular posterior 49.39% (37.41, 61.37) teeth (p<0.001). ? Conclusions: It can therefore be concluded that FASTP technique for the purpose of root coverage shows favorable outcomes after a mean follow up period of 10.1 ± 1.5 months (range 6–18). Randomized controlled clinical trial will be required to compare the efficacy of FASTP to other periodontal root coverage methods, as well as to examine the predictive value of the independent factors identified in the present study.

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Asset Metadata

Creator Agahi, Shahriar H. (author)

Core Title Predictibility of fibrin-assisted soft tissue promotion (FASTP) in treatment of multiple gingival recession defects: a retrospective 2-D analysis

School School of Dentistry

Degree Master of Science

Degree Program Biomedical Implants and Tissue Engineering

Degree Conferral Date 2021-08

Publication Date 07/24/2021

Defense Date 05/11/2021

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

Tag advanced platelet rich fibrin,APRF,A-PRF,FASTP,fibrin-assisted soft tissue promotion,LPRF,L-PRF,OAI-PMH Harvest,platelet-rich fibrin,PRF,recession,root coverage

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Bakhshalian, Neema (committee chair), Kar, Kian (committee member), Navazesh, Mahvash (committee member)

Creator Email Shahriaa@usc.edu,sharagahi@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC15621180

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