Flap Thickness as a Predictor of Root Coverage: A Systematic Review

Graduate Periodontics, University of Michigan School of Dentistry, Ann Arbor, MI, USA.
Journal of Periodontology (Impact Factor: 2.71). 11/2006; 77(10):1625-34. DOI: 10.1902/jop.2006.060107
Source: PubMed

ABSTRACT Thick gingival tissue eases manipulation, maintains vascularity, and promotes wound healing during and after surgery. A few recent case reports correlate greater flap thickness to mean and complete root coverage after mucogingival therapy for recession defects. The aim of this systematic review is to appraise the current literature on this subject and to combine existing data to verify the presence of any association between gingival thickness and root coverage outcomes.
Human studies that reported the number and class of recessions, measured flap thickness at a well-defined location, described the method of root coverage used, followed results for at least 3 months, and detailed mean root coverage underwent review and statistical analysis. Investigations were scored from 1 to 5 based on methodological quality. Weighted gingival thickness and weighted mean root coverage was calculated based on standard error. Statistical analysis used the Mann-Whitney test, analysis of variance (ANOVA), and linear regression to determine any correlation between a number of factors (i.e., thickness, treatment type, and follow-up time) and mean and complete root coverage. A significant P value was set at <0.05.
Fifteen investigations met the inclusion criteria. All of these reported at least 0.7 mm of flap thickness, although measurement locations varied. Treatment modalities included coronally advanced flap, connective tissue graft, and guided tissue regeneration with and without adjuncts. A significant moderate correlation occurred between weighted flap thickness and weighted mean root coverage and weighted complete root coverage (r = 0.646 and 0.454, respectively). According to Mann-Whitney analysis, a critical threshold thickness >1.1 mm existed for weighted mean and complete root coverage (P <0.02). The type of treatment rendered also influenced root coverage. Further simple linear regression revealed a high correlation between weighted thickness and weighted mean root coverage in connective tissue grafting and guided tissue regeneration (r = 0.909 and 0.714, respectively) but not coronally advanced flap therapy. Study score and follow-up time did not affect the percentage of root coverage.
Within the limits of this review, a positive association exists between weighted flap thickness and mean and complete root coverage.

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    • "In this respect, some factors of clinical relevance can be identified that should be respected to accomplish successful and predictable treatment outcomes if SCTGs are used in plastic periodontal and implant surgery. In the first place, the best possible blood supply from the recipient bed and the covering flap should be provided for graft survival: incisionand flap-design (Mormann & Ciancio 1977), thickness of the flap (Hwang & Wang 2006), complete graft coverage (Harris 1994, Studer et al. 2000) and an atraumatic surgical proceeding (Burkhardt & Lang 2005) seem to play an important role. Furthermore, it should be kept in mind that the risk of graft necrosis might increase with graft thickness (Miller 1985, Borghetti & Gardella 1990). "
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    ABSTRACT: Soft tissue replacement grafts have become a substantial element to increase tissue volume in plastic periodontal and implant surgery. Autogenous subepithelial connective tissue grafts are increasingly applied in aesthetic indications like soft tissue thickening, recession treatment, ridge preservation, soft tissue ridge augmentation and papilla re-construction. For the clinical performance of connective tissue graft harvesting and transplantation, a fundamental understanding of the anatomy at the donor sites and a sound knowledge of tissue integration and re-vascularization processes are required. Possible donor sites are the anterior and posterior palate including the maxillary tuberosity, providing grafts of distinct geometric shape and histologic composition. The selective clinical application of different grafts depends on the amount of required tissue, the indication and the personal preference of the treating surgeon. One of the main future challenges is to volumetrically evaluate and compare the efficacy and long-term stability of soft tissue autografts and their prospective substitutes. The aim of this review was to discuss the advantages and shortfalls of different donor sites, substitute materials and harvesting techniques. Although standardized recommendations regarding treatment choice and execution can hardly be given, guidelines for predictable and successful treatment outcomes are provided based on clinical experience and the available scientific data.
    Journal Of Clinical Periodontology 04/2014; 41 Suppl s15(s15):S123-S142. DOI:10.1111/jcpe.12185 · 4.01 Impact Factor
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    • "Even though in the above mentioned study, flap thickness appeared to be less influential on wound stability than flap tension, gingival thickness seemed to positively affect the outcome of flaps replaced on hard, non-shedding surfaces (Hwang & Wang 2006). The necessity of a minimal, optimal tissue thickness for complete root surface coverage remains a matter of debate although the systematic review presented identified a lower limit of 0.7 mm flap thickness (Hwang & Wang 2006). Although never substantiated, flap thickness was always assumed to affect the vascularity of the pedicle. "
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    ABSTRACT: To provide a narrative review of the current literature elaborating on fundamental principles of periodontal plastic surgical procedures. Based on a presumptive outline of the narrative review, MESH terms have been used to search the relevant literature electronically in the PubMed and Cochrane Collaboration databases. If possible, systematic reviews were included. The review is divided into three phases associated with periodontal plastic surgery: a) pre-operative phase, b) surgical procedures and c) post-surgical care. The surgical procedures were discussed in the light of a) flap design and preparation, b) flap mobilization and c) flap adaptation and stabilization. Pre-operative paradigms include the optimal plaque control and smoking counselling. Fundamental principles in surgical procedures address basic knowledge in anatomy and vascularity, leading to novel appropriate flap designs with papilla preservation. Flap mobilization based on releasing incisions can be performed up to 5 mm. Flap adaptation and stabilization depend on appropriate wound bed characteristics, undisturbed blood clot formation, revascularization and wound stability through adequate suturing. Delicate tissue handling and tension free wound closure represent prerequisites for optimal healing outcomes.
    Journal Of Clinical Periodontology 04/2014; 41 Suppl s15(s15):S98-S107. DOI:10.1111/jcpe.12193 · 4.01 Impact Factor
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    • "In cases where GT is less than 0.7 mm in recipient sites, the translation method should be avoided; preferably, a method using autogenous connective tissue grafting should be implemented (Huang et al., 2005). On the other hand, GT greater than 1.1 mm tends to a greater chance for successful coverage; namely, using the coronal positioned flap method (Hwang and Wang, 2006). In orthodontics, GT assessment prior to the application of orthodontic forces is important as such knowledge can prevent complications arising from gingival recession (Ackerman and Proffit, 1997) (Fig. 1). "
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    ABSTRACT: Knowledge of periodontal anatomy is essential when performing surgical and non-surgical procedures in the field of oral healthcare. Gingival thickness (GT) is often assessed for this purpose. A dental system prototype was recently developed for quantitative, non-invasive GT assessment by high-frequency (HF) ultrasound. Laboratory trials were conducted to validate system performance against a traditional method of assessment. A system with a 50MHz broadband, spherically-focused transducer was used. The transducer was housed in a small, hand-held probe equipped with a continuous water supply. A-scans were obtained and thickness at each location was determined. For comparison, the traditional method of transgingival probing through tissue with an endodontic k-file needle was also implemented. Preliminary experiments were performed on phantoms simulating the anatomical and acoustic properties of human periodontal tissues. A porcine cadaver was obtained for further laboratory trials. The speed of sound through porcine gingiva was determined to be 1564±21m/s. Finally, a multiple-point experiment involved GT assessment in an array of locations on the buccal gingival surface in the fourth quadrant. Ultrasonic measurements were found to yield similar GT values to those obtained from invasive methods. Results obtained in this experiment validate the applicability of ultrasound as a diagnostic tool for assessing periodontal anatomy.
    Annals of anatomy = Anatomischer Anzeiger: official organ of the Anatomische Gesellschaft 03/2014; 199. DOI:10.1016/j.aanat.2014.02.010 · 1.48 Impact Factor
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