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Dental Tribune U.S. Edition

Dental Tribune U.S. Edition | February 2015A4 By David L. Hoexter, DMD, FACD, FICD, Editor in Chief This is a continuation of the fourth ar- ticle in a series of Dental Tribune clinical articles dealing with cosmetic periodon- tal surgery. As a follow-up to Part 4A, Part 4B in this series focuses on barriers used in cosmetic periodontal surgery. It also presents and deals with the predictable regenerative coverage of unesthetic root recession through cosmetic periodontal surgery, using the guided tissue regen- eration (GTR) technique with resorbable barriers. In Part 4A, I concentrated solely on the use of polylactic and polygalactic mem- branes used to regenerate gingival root coverage where root recession is clini- cally noted. While I presented clinical re- sults using the Guidor polylactic barrier to aid in achieving excellent results when covering recessed area of teeth for up to 10 years, it should be noted that a 10-year study published in the Journal of Peri- periodontia. Periodontal surgery to cor- rect this ideally hinges on proper se- quential regeneration of the lost tissue. Restoration of the lost periodontia in- volves regenerating the lost supporting structures, including alveolar bone, con- nective tissue, keratinized epithelium, periodontal ligament and cementum. By placing a barrier to inhibit the undesired cells and to enable the desired progeni- tor cells to procreate, we can selectively guide the desired restoration of the lost periodontia. For the past 40 or so years, regenera- tion of the periodontia — including os- seous as well as soft tissue — has been achieved successfully by the use of barri- ers. The most popular barrier used to date is a membrane, although there have been several others used throughout the his- tory of this type of treatment. A barrier should create and maintain a sufficient space where an adequate blood supply may form to enable regeneration to occur. The space must be preserved for a certain period of time, and the barrier should be immobile during that time pe- riod. It needs to preserve this space while preventing epithelial cells and connec- tive tissue cells from migrating into it. The barrier also must be porous so that metabolites can penetrate through to keep the underlying developing regrowth alive. By using the GTR technique popular- ized by Dr. S. Nieman, we can inhibit the causal factors of this periodontal disease and support proper cellular regenera- ” See BARRIERS, page A6 Ad Cosmetic periodontal surgery (Part 4B) Fig. 1: Note the obvious singular defect of recession at the gingival area of #11. Photos/Provided by Dr. David L. Hoexter Fig. 2: Final 10-year result. Using the collagen barrier with the coronal repositioned flap technique permits the regeneration of the attached gingiva, with its pinkish white color blending naturally with the healthy lateral tissue of the area. Also, note the complete covering of the previous recessed root, with its tan color, to a natural appearing healthy area and a glowing smile that can be maintained with good oral hygiene. Fig. 1 Fig. 2 Barriers of successodontology concluded that after 10 years, Guidor used for gingival recession cover- age, the same GTR technique as described in Part 4A, resulted in a larger recessed area than originally presented. The “pin-hole technique” treatment to cover recession — recently popular- ized via the Internet — is not new. This technique was used as early as 1953 and, as was true then, still does not use barri- ers to help regenerate a blood supply on the previously exposed recessed tooth, as this series of articles emphasizes. Without the newly regenerated con- nective tissue, the tissue covering the exposed root appears to be held in place by an adherence of a long junctional epi- thelium (not a regenerative attachment) and is thus doomed to repeated recession in the future. Barrier enables selective guidance of restoration of lost periodontia Periodontal disease leads to destruction that causes a void in which undesired cells have diminished the supportive tion. This technique involves forming a porous barrier membrane that excludes the undesired cells, yet allows nutriment through its porous membrane to aid the selective population by undifferentiated mesenchymal cells toward the regenera- tive goal. Nonresorbable membranes require second surgical procedure Historically, different materials were developed to act as barriers for the GTR technique. Initially, nonresorbable mem- branes were utilized. A porous Teflon barrier membrane, expanded polytetra- fluoroethylene (e-PTFE), was popularized by Gore. This e-PTFE and its more economical equal, Sartorious, along with other nonre- sorbable barriers, such as Millipore filters, worked well. However, being nonresorb- able, they required a second surgical pro- cedure after the healing process was com- plete (usually months later) to remove the nonresorbable membranes. This second procedure required the patient to receive another local anesthetic and go through another uncomfortable healing process. Other Teflon membranes that were nonporous and nonresorbable also were made available, but were not recom- mended for GTR because the lack of po- rosity inhibited essential nutrition from passing through — thus stopping newly forming blood supply from regenerating. Such membranes have, in fact, the same Clinical

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