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1. Comparative outcome analysis of endodontic treatment and single implant restoration

2   Introduction to the SES Technique: Composite of Surgical Modifications
which Simplify the Subepithelial Connective Tissue Graft Technique

Comparative outcome analysis of endodontic treatment and single implant restoration
J. CARTER, D. JONES, E. SOLOMON, and J. HE, Baylor College of Dentistry, Dallas, TX, USA

Endodontic treatment and implant-supported restoration are both viable
treatment options to restore the functionality and esthetics of the
dentition. Both treatment modalities have high success rate and
predictability. Clinical decision making is often influenced by many
factors in addition to success rate such as cost, time, function, and
esthetics. Patient perception and preference play an important role in
the ultimate clinical decision making.

Objective: the purpose of this study was to compare endodontic treatment
(Endo) and single implant  restoration (Implant) regarding time to function,
cost, and patient  satisfaction. Materials and methods: 254 patient
satisfaction surveys  were sent to patients who received single implant
restoration or  endodontic treatment in the posterior mandible at Baylor
College of Dentistry. Survey questions included patient satisfaction towards
the cost, duration of the treatment, appearance and the ability to eat after
the treatment. 53 responses from Endo patients and 36 responses from
Implant patients were received. Treatment records of responded patients
were reviewed to record the duration of the treatment, number of visits,
treatment protocol, post-op intervention, and cost. Patient survey
results were evaluated using Pearson chi square analysis to determine
difference in the response to each question between the groups. Overall
satisfaction was analyzed by Student's t-test using a derived summative
score. Results: Time to function was significantly longer in Implant
patients compared to Endo. Implant also required more post-op
interventions. Endo patients were significantly more likely to report
satisfaction with treatment cost (p<0.05) and less likely to report
dissatisfaction regarding treatment duration, as compared to Implant
patients (p<0.05). However, there is no statistical difference in
overall satisfaction between the two groups.

Conclusion: Implant treatment requires more time and intervention to achieve
function  compared to Endo treatment. This delay causes significant
dissatisfaction among patients. However, Endo and Implant treatments
have similar overall patient satisfaction.

Introduction to the SES Technique: Composite of Surgical Modifications which
Simplify the Subepithelial Connective Tissue Graft Technique
Taeheon Kang, DDS, MS; and Matthew J. Fien, DDS


The subepithelial connective tissue graft has been a successful procedure hen wthe primary
goal of surgery is to obtain root coverage. A multitude of authors have described variations
of the original technique that have the potential to decrease morbidity and increase the
overall success of the procedure. This article describes the SES modifications, which consist
of scooping horizontal incisions, elevating an envelope flap, and closing with a sling suture.
Several cases demonstrate the potential of the SES technique to facilitate the connective
tissue graft procedure.

The esthetic and functional implications of gingival recession have led to the development
of various surgical techniques to treat these defects.1,2 Attempts to relate biologic
principles to clinical outcomes have created several modifications to the original connective
tissue graft technique.3-10 The authors have found the SES technique to be a simple and
predictable method to obtain root coverage. The SES modifications have been discussed in the
literature previously and will be reviewed herein.

SES Modifications

Scooping Incisions

Preparation of the recipient site is critical to the success of the subepithelial connective
tissue graft procedure. The original technique used horizontal incisions, which were butt
jointed at the level of the cementoenamel junction (CEJ) to preserve the interdental papilla.
11 The first modification of the subepithelial connective tissue graft technique involved
creating scooping horizontal incisions (Figure 1A View Figure and Figure 1B View Figure).
Scooping incisions produce beveled, split thickness, and concave interdental recipient beds,
while preserving the interdental papilla and respecting the biologic principles of healing.
Clinical and histological observations have revealed the benefits of beveled soft-tissue
incisions. They provide a wider soft-tissue interface, which decreases the presence of
gingival grooves and promotes a faster reorganization of wound margins.12 Furthermore,
scooping incisions allow for adequate thickness of the recipient flap while sufficient
underlying connective tissue is maintained for subsequent adaptation of the free connective
tissue graft and overlying flap.

Envelope Flap

In the original technique, elevation of the recipient flap to gain access to the surgical
site was completed with vertical incisions. While vertical incisions may not compromise the
success or predictability of the procedure, they seem to slow the healing process and have
the potential to interfere with the vascular supply to the overlying flap and, thus, the
connective tissue graft.5-9 Modification of the technique to eliminate the unnecessary
vertical incisions has the potential to reduce scar formation and increase the likelihood
of optimal tissue blending.7 When this modification is performed, the buccal sulcular
incisions are extended mesially and distally to create an envelope flap. Apical undermining
of the flap past the mucogingival junction provides adequate access to the recipient site.

Sling Suture

The adaptation of the connective tissue graft to the recipient bed and the subsequent
increase in the shear bulk of connective tissue at the site can make closure of the
overlying flap difficult to achieve. The sling suture has been added to the technique
for several reasons. In the authors’ experience, interrupted sutures placed interdentally
to stabilize the connective tissue graft can decrease the amount of tissue available for
suturing of the overlying flap. Sling sutures are used because they do not require
penetration into the narrow interdental periosteal bed, which is covered by the connective
tissue graft (Figure 1C View Figure and Figure 1D View Figure). Therefore, there is less
of a risk of damaging the graft and the residual interdental papilla. The sling suture
also can be used to help reposition the flap coronally, providing the tension required
to maintain the flap to cover as much of the connective tissue as desired.

Case Reports

The following three cases were treated with a subepithelial connective tissue graft.
As these cases illustrate, the SES modifications can be used to treat all three patients
despite fundamental differences in the clinical appearance of each case.

Case 1

A 28-year-old woman presented with the chief complaint of recession on her upper
right canine and first premolar, accompanied by sensitivity to cold liquids in
this quadrant (Figure 2A View Figure). The patient was unhappy with the unesthetic
appearance of the exposed roots and was motivated to have the defects corrected.
The patient was a nonsmoker and presented with no significant medical history.
She was not taking any medications and did not have allergies to any medications.
The patient did report a history of orthodontic treatment as a teenager.

Clinical examination revealed mild and moderate gingival recession
on teeth Nos. 5 and 6, respectively. The maxillary right first premolar had
recession measuring 3 mm in depth. The maxillary right canine had a root that
was prominent in the arch as well as a wide area of associated gingival recession
measuring 4 mm in depth. The patient pre-sented with 3 mm to 4 mm of keratinized
gingiva apical to the recession of teeth Nos. 5 and 6. Full-mouth charting
revealed probing depths within normal limits as well as an adequate plaque-control
regimen. Sounding of the palatal vault with a periodontal probe revealed an
adequate connective tissue donor site, with a depth > 3 mm.

Following evaluation of all clinical and radiographic data, the patient’s gingival
recession was classified as a Miller class I. Recession was not beyond the
mucogingival junction and there was no evidence of any interdental hard- or
soft-tissue deficiency in the area.13 Interdental papilla were intact and filled
the embrasure. The gingiva was 0.7-mm to 1-mm thick surrounding the recession
defects. A subepithelial connective tissue graft was chosen because of the width
of the area of recession apical to teeth Nos. 5 and 6 that required root coverage.
Complete root coverage was anticipated.

Local anesthetic, 2% lidocaine with 1:100,000 epinephrine, was administered via
maxillary infiltration at the level of the mucogingival junction buccal to
teeth Nos. 4 through 7. Palatal infiltration also was completed at this time,
taking care not to blanch the donor tissue. Interdental scooping incisions
0.5-mm to 1-mm coronal to the level of the CEJ were placed mesial and distal
to teeth Nos. 5 and 6 (Figure 2B View Figure). Buccal sulcular incisions to
connect the horizontal scooping incisions then were completed. Elevation of a
split-thickness envelope flap proximal to the recession with full-thickness
dissection apical to the recession easily was completed because of the presence
of the original beveled scooping incisions. Undermining of the recipient flap
beyond the mucogingival junction and into the buccal vestibule was performed,
followed by tension-releasing periosteal cutting incisions.

Elevation of the buccal flap revealed dehiscence defects of 3 mm and 4 mm on
teeth Nos. 5 and 6, respectively. The external layer of cementum covering the
exposed roots was planed with sharp curettes to remove all detectable deposits
of plaque and calculus. A high-speed handpiece and a finishing bur were used
to remove any gross convexities and irregularities of the root surfaces.
Ethylenediaminetetraacetic acid 24% was applied to the root surface for several
minutes to remove the superficial smear layer. Moistened gauze then was adapted
to the recipient flap to prevent dehydration and shrinkage of the flap during
donor site preparation.

Before harvesting the connective tissue graft, a periodontal probe was used
to measure the mesial–distal length of the recipient bed. Preparation of the
donor site was accomplished with a modification of the single incision
technique described by Hurtzeler.14,15 An initial incision with the blade
parallel to the curvature and contour of the palatal hard and soft tissues
was cut, followed by an incision perpendicular to the palate. Mesial, distal,
and apical periosteal releases then were completed. Periosteal elevation
released the graft medially. Firm pressure was applied to the donor site for
several minutes to achieve hemostasis. Resorbable sutures were used to
approximate the palatal tissues after a hemostatic agent
(oxidized regenerated cellulose) was trimmed and placed over the wound.16

After closure of the donor site, the graft was ready to be trimmed and adapted
for the recipient site. The graft measured 18 mm in length, 9 mm in width,
and 1.5 mm to 1.75 mm in thickness. A fresh blade was used to remove any
conspicuous fatty remnants and irregularities from the graft surface.
Careful modification of the graft was performed to create a uniform
thickness of 1 mm to 1.5 mm.

Then, the periosteal side of the graft was adapted to the denuded root surfaces
and prepared bed, and single interrupted sutures were placed interdentally with
resorbable suture material at the level of the CEJs of the involved teeth.

Final flap adaptation was simplified with strategic surgical instrumentation.
A significant amount of apical elevation and undermining was used to enhance
the mobility of the overlying flap. Coronal repositioning of the gingival tissues
in the absence of vertical incisions also required an additional release of tension
at the apical extent of the flap. These horizontal, periosteal cutting incisions
increase the likelihood of complete graft coverage. While no attempt was made to
completely cover the exposed graft, effort was made to prevent more than one
third of the graft’s size being exposed coronal to the free gingival margin.

A sling suture was placed, which helped maintain the flap in a more coronal
position (Figure 2C View Figure). The suture was initiated mesial to tooth No. 6
and was slung distally to the mesial of tooth No. 5 and back to the mesial of
tooth No. 6. A simple interrupted suture was placed distal to tooth No. 5.
No packing was placed and the patient was advised against brushing this quadrant
for the following week. Postoperative instructions were reviewed, and the patient
was given a prescription for ibuprofen 800 mg and amoxicillin 500 mg to be taken
every 8 hours for 7 days. Chlorhexidine gluconate 0.12% also was prescribed, and
the patient was advised to rinse for 30 seconds twice daily.

Postoperative healing of the recipient and donor sites occurred uneventfully
(Figure 2D View Figure). A thin layer of residual connective tissue at the donor
site, as well as increased tension of the donor site sutures, may be responsible
for a small zone of epithelial necrosis along the distal wound margins.
Nevertheless, the wound was almost undetectable 1 month after surgery. The 2-month
postoperative appearance of the recipient site revealed 100% root coverage
with a significant increase in the zone of keratinized tissue
(Figure 2E View Figure).

Case 2

A 33-year-old woman presented to the periodontal clinic with the chief complaint
of fear of losing her lower anterior teeth from advancing recession
(Figure 3A View Figure). The patient was not concerned with regaining complete
root coverage, but was determined to prevent further breakdown. The patient was a
nonsmoker, presented with no significant medical history, and reported minor
dental history with no history of orthodontic treatment.

Clinical examination revealed a classically thin periodontal biotype. Mild gingival
recession was visualized on teeth Nos. 22, 23, and 27. Teeth Nos. 22 and 27 had an
adequate band of associated keratinized tissue while the central and lateral incisors
had a thin, friable, and mobile zone of mucosa with < 1 mm of keratinized tissue
present surrounding tooth No. 23. Tooth No. 23 also presented with 3 mm of buccal
recession. The patient had lower anterior crowding and buccal displacement with
rotation of tooth No. 23.

On evaluation of all clinical and radiographic data, the patient’s gingival
recession was classified as a Miller class III. Marginal tissue recession extended
to the mucogingival junction, and there was hard- and soft-tissue deficiency along
with malpositioning of tooth No. 23. The papilla incompletely filled the embrasure,
and there were black triangles present interproximally. Because of these limiting
variables, 100% root coverage was not anticipated in this case. Nevertheless,
a connective tissue graft was used to increase the zone of keratinized tissue
and to obtain a reasonable amount of root coverage on tooth No. 23.

The surgical protocol was identical to the one described for Case 1. Scooping
incisions were made interdentally from the distal of tooth No. 22 to the distal
of tooth No. 26 (Figure 3B View Figure). On reflection of an envelope flap,
dehiscence defects were apparent on the surface of all anterior mandibular
teeth, ranging from 2 mm to 4 mm. The deficiency in buccal alveolar bone and
subsequent exposure of the avascular root surfaces justified the coronal
repositioning of the recipient flap to cover as much with the subepithelial
connective tissue graft as possible, using a sling suture (Figure 3C View Figure).

Healing of the donor and recipient sites was uneventful. The 2-month
postoperative appearance revealed 90% root coverage with a significant increase
in the zone of keratinized tissue (Figure 3D View Figure).

Case 3
An 18-year-old woman was referred to the periodontal clinic by her general
dentist for severe localized recession buccal to tooth No. 25 (Figure 4A View Figure).
The patient reported a dental history that included two failed root coverage
procedures. She also reported a history of orthodontic treatment as a teenager.
Her previous periodontist had recommended extraction of the tooth because of
the advancing recession, but the patient expressed a desire to save the tooth
for as long as possible. The patient had no significant medical history, was
taking no medications, and reported no allergies to any medications.

Clinical examination revealed gingival recession of 7 mm in depth on the buccal
surface of tooth No. 25. The defect was 2.5 mm to 3 mm in width and extended
apically to within 1 mm of the mucogingival junction. Tooth No. 25 appeared
to be supererupted 1 mm above the neighboring teeth, and there was a high
frenum pull in the area (Figure 4B View Figure). Probing depths were within
normal limits. Radiographs revealed moderate horizontal bone loss.

The patient presented with Miller class III recession, identified by recession
that extended past the mucogingival junction with associated hard-tissue
deficiency detected inter-proximally. The patient was informed that complete
root coverage would not be anticipated because of the advanced nature of the

The surgical procedure for this case was identical to the previous two cases,
except for two necessary modifications. A frenectomy was performed before the
subepithelial connective tissue graft procedure to remove the fibrous attachment
and to decrease the apical pull of the attached gingiva. Furthermore, scooping
incisions were placed only mesial and distal to tooth No. 25
(Figure 4C View Figure). Sulcular incisions, one tooth away in both the mesial
and distal directions, provided adequate access following elevation and
undermining of the envelope flap (Figure 4D View Figure).

Healing of the donor and recipient sites was uneventful. The 2-month
postoperative appearance revealed 100% root coverage with a significant
increase in the zone of keratinized tissue (Figure 4E View Figure).

Figure 1A Recession on lower central incisors. Figure 1B Scooping horizontal incisions and elevation of an envelope flap.
Figure 1C Sling sutures with a connective tissue graft adapted to the recipient site. Figure 1D Two-week postoperative appearance.
Figure 2A Severe recessions on upper right canine and first premolar. Figure 2B Scooping beveled incisions and elevation of an envelope flap.
Figure 2C Sling suture of overlying flap. Figure 2D One-week postoperative appearance.
Figure 2E Eight-week postoperative appearance. Figure 3A Recession and lack of keratinized gingiva on lower left lateral incisor.
Figure 3B Scooping incisions followed by extensive undermining of the envelope flap. Figure 3C Sling suture of overlying flap.
Figure 3D Eight-week postoperative appearance. Figure 4A Severe recession and lack of keratinized gingiva on lower right central incisor.
Figure 4B Frenectomy.
Figure 4C Scooping incisions and elevation of an envelope flap. Figure 4D Sutures to stabilize the graft and overlying flap.
Figure 4E Eight-week postoperative appearance. Figure 5 Analysis of the zone of keratinized gingiva and recession immediately before surgery, immediately after surgery, and 8 weeks after surgery.
Results Each patient presented at 1, 2, 4, and 8 weeks after surgery. The sling sutures were removed after 14 days. Oral hygiene instructions were reviewed at each postoperative visit and a prophylaxis was completed at 2, 4, and 8 weeks after surgery. Measurements of gingival recession (CEJ-free gingival margin [FGM]) and keratinized gingiva (FGM-mucogingival junction [MGJ]) were recorded at each visit (Figure 5 View Figure). Discussion Several advantages of the SES modifications have been identified. Scooping incisions facilitate the split-thickness elevation of the coronal extent of the recipient flap, and maintain a dual blood supply to the graft by preserving the underlying recipient connective tissue base as well as the overlying flap. The envelope flap provides the clinician adequate access to the site without the side effects and morbidity associated with vertical releasing incisions. Finally, the sling su-ture can be used to reposition the recipient flap coronally to cover the amount of the connective tissue graft desired. In the authors’ experience, the amount of graft necrosis has been directly related to the amount of graft supported by vascular tissue, including both the perfusion from the connective tissue bed as well as the circulation arising from the recipient flap. To counterbalance the effect of the avascular denuded root surfaces in direct contact with the graft, effort was made to cover as much of the grafts as possible. In the presented cases, a dramatic increase in the amount of keratinized gingiva occurred after surgery. As long as the graft survives the critical first weeks of healing, a large augmentation with keratinized gingiva can be anticipated.17 In the authors’ experience, it seems that the risk of necrosis of the subepithelial connective tissue graft is minimized when < 30% of the graft is left uncovered. Conclusion The use of the subepithelial connective tissue graft is a predictable method for obtaining root coverage. The technique has been modified by several clinicians since it was first introduced. To further simplify the procedure, a composite of surgical modifications has been introduced. The cases presented demonstrate the efficacy of the SES modifications and the wide range of conditions that can benefit from its use. Acknowledgment The authors would like to acknowledge Dr. R. Vuong for his surgical work and contribution to Case 3. REFERENCES 1. Oates TW, Robinson M, Gunsolley JC. Surgical therapies for the treatment of gingival recession. A systematic review. Ann Periodontol. 2003;8(1):303-320. 2. Greenstein G, Research, Science, and Therapy Committee of the American Academy of Periodontology. Position paper: the role of supra- and subgingival irrigation in the treatment of periodontal diseases. J Periodontol. 2005;76(11):2015-2027. 3. Nelson SW. The subpedicle connective tissue graft. A bilaminar reconstructive procedure for the coverage of denuded root surfaces. J Periodontol. 1987;58(2):95-102. 4. Harris RJ. The connective tissue and partial thickness double pedicle graft: a predictable method of obtaining root coverage. J Periodontol. 1992;63(5):477-486. 5. Raetzke PB. Covering localized areas of root exposure employing the “envelope” technique. J Periodontol. 1985;56(7):397-402. 6. Bruno JF. Connective tissue graft technique assuring wide root coverage. Int J Periodontics Restorative Dent. 1994;14(2):126-137. 7. Allen AL. Use of the supraperiosteal envelope in soft tissue grafting for root coverage. II. Clinical results. Int J Periodontics Restorative Dent. 1994;14(4):302-315. 8. Müller HP, Stahl M, Eger T. Root coverage employing an envelope technique or guided tissue regeneration with a bioabsorbable membrane. J Periodontol. 1999;70(7):743-751. 9. Zucchelli G, De Sanctis M. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol. 2000;71(9):1506-1514. 10. Goldstein M, Boyan BD, Cochran DL, et al. Human histology of new attachment after root coverage using subepithelial connective tissue graft. J Clin Periodontol. 2001;28(7):657-662. 11. Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol. 1985;56(12):715-720. 12. Kon S, Caffessee RG, Castelli WA. Vertical releasing incisions for flap design: clinical and histological study in monkeys. Int J Periodontics Restorative Dent. 1984;4(1):48-57. 13. Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent. 1985;5(2):8-13. 14. Blatz MB, Hurzeler MB, Strub JR. Reconstruction of the lost interproximal papilla—presentation of surgical and nonsurgical approaches. Int J Periodontics Restorative Dent. 1999;19(4):395-406. 15. Del Pizzo M, Modica F, Bethaz N, et al. The connective tissue graft: a comparative clinical evaluation of wound healing at the palatal donor site. A preliminary study. J Clin Periodontol. 2002;29(9): 848-854. 16. Rossmann JA, Rees TD. A comparative evaluation of hemostatic agents in the management of soft tissue graft donor site bleeding. J Periodontol. 1999;70(11): 1369-1375. 17. Bouchard P, Etienne D, Ouhayoun JP, et al. Subepithelial connective tissue grafts in the treatment of gingival recessions. A comparative study of 2 procedures. J Periodontol. 1994;65(10):929-936. -------------------------------------------------------------------------------- 1 Department of Periodontics, Nova Southeastern University, College of Dental Medicine, Davie, Florida 2 Department of Periodontics, Nova Southeastern University, College of Dental Medicine, Davie, Florida
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