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ePaper created 2015-03-23, 09:31:36 | version 1.33.01
XXXXX regenerative properties as a rubber dam and should not be used or considered for GTR. These various challenges ultimately led to the development of resorbable barrier membranes that eliminated the necessity of a second surgical procedure — appreci- ated by patient and practitioner alike. The resorbable membrane barriers that companies started to develop had all of the desired qualities of the nonresorbable group but did not need a second surgi- cal procedure to be removed. Different materials led to different rates of absorb- tion time, resulting in different amounts of time for inhibition of epithelium and/ or connective tissue invagination. There- fore, different materials may result in dif- ferent consistency of results. The resorbable membrane barriers that are used most often in cosmetic root re- cession coverage are divided into three main groups, based on the type of mate- rial: 1) polylactic acid, 2) polygalactic acid and 3) collagen. The polylactic and polygalactic mem- branes are similar except that polylactic acid membrane contains a citric acid, es- ter, which enables it to be malleable. Resorbable polygalactic barrier mem- branes were the first popular resorb- able membranes approved by the FDA. Produced under the commercial name of Guidor, and developed for GTR proce- dures, they were made of polylactic acid with a citric-acid ester to enable malle- ability and easier clinical handling. The resorption of this material is through hydrolysis. Results show no soft-tissue reactions during healing. Yet, there are reduced probing depths during healing and a definite gain of clinical attach- ments. Options: Human, bovine or porcine This article concentrates on collagen re- sorbable membrane barriers, which are made from three sources: human, bo- vine and porcine. While all three are ade- quate, my personal preference is human. Bovine has been used quite successfully, but it and porcine are xenografts (from different species). Additionally, I do not use porcine in my private practice out of respect for the religious preferences of many of my patients. The specific acellular barrier that is used in these presentations is distributed through TBI (Tissue Banks International) under the brand name TranZgraft® ACD. There are several popular companies, but this company’s product is a sterilized graft, compared with Alloderm, which is not. Once again, it must be emphasized that before commencing any surgical correc- tion, the practitioner must relieve the initiating factors that led to the reces- sion. Case No. 1 The patient presented with an obvious singular defect of recession at the gingi- val area of tooth #11 (Fig. 1). Using a collagen barrier with the coro- nal repositioned flap technique enabled regeneration of the attached gingiva with a pinkish white color blending naturally with the healthy lateral tissue of the area. In follow-up 10 years later, it was ob- Fig. 4: Surgical mucogingival flap exposing recession areas of #11 and #12. Fig. 5: Placement of connective-tissue barrier on only #11. Fig. 3: Pretreatment view of #11 and#12. Note the large recessed gingival area exposing their respective roots. Fig. 6: Sutured coronal repositioned flap to desired level covering all exposed recession. “ BARRIERS, page A4 Fig. 3 Fig. 4 Fig. 5 Fig. 6 served that the complete covering of the previous recessed root was natural and healthy appearing and would continue to be able to be maintained with good oral hygiene. Case No. 2 This case describes two areas of reces- sion in a single mouth, thus influenced by identical saliva and oral habits. I used the same cosmetic surgery technique on both areas but used a barrier on only one of the areas (Figs. 3–6). The 10-plus year outcome (Fig. 7) shows complete root coverage of gingiva on tooth #11, where the barrier collagen TranZgraft was used. The adjacent bi- cuspid #12 had the same coronal repo- sitioned gingival flap procedure at the same time but without use of the connec- tive tissue barrier. The results clinically demonstrate that use of a barrier helped achieve complete restoration of gingiva tissue on previ- ously recessed root. The same technique in this case, without the use of a barrier membrane, results in no root coverage (Fig. 7). This particular case would appear to confirm that barriers aid in predictability of root coverage when using this cosmetic surgery technique. Editorial Note: Part 1 in this series ap- peared in the Dental Tribune U.S. Edition, Vol. 4, No. 13/14; Part 2 ran in Vol. 6, No. 17; Part 3 ran in Vol. 7, No. 11; and Part 4A ran in Vol. 8, No. 11. These editions can be ac- cessed as e-papers or PDF files through the “E-Paper” link in the top navigation menu on www.dental-tribune.com. David L. Hoexter, DMD, FICD, FACD, is director of the International Acad- emy for Dental Facial Esthetics and a clinical professor in the department of periodontics and implantology at Temple University, Philadelphia. He is a diplomate of implantology in the International Congress of Oral Implanto- logists as well as the American Society of Osseointegration and a diplomate of the American Board of Aesthetic Dentistry. He lectures throughout the world and has published nationally and internationally. He has been award- ed 12 fellowships, including FACD, FICD and Pierre Fauchard. He maintains a practice at 654 Madison Ave., New York City, limited to periodontics, im- plantology and esthetic surgery. He can be reached at (212) 355-0004 or drdavidlh@gmail.com. Clinical Fig. 7: Final result at 10-plus years. Complete recession coverage on #11. But note that root recession exposure on #12 returns as it was before surgery. Fig. 7 Dental Tribune U.S. Edition | February 2015A6 Clinical Ad