Newly forming bone graft: a novel surgical approach to the treatment of denuded roots
Identifieur interne : 001D57 ( Pmc/Corpus ); précédent : 001D56; suivant : 001D58Newly forming bone graft: a novel surgical approach to the treatment of denuded roots
Auteurs : Adriana Campos Passanezi Sant'Ana ; Bruna F. Rahal Ferraz ; Maria Lúcia Rubo De Rezende ; Sebastião Luiz Aguiar Greghi ; Carla Andreotti Damante ; Euloir PassaneziSource :
- Journal of Applied Oral Science [ 1678-7757 ] ; 2012.
Abstract
Many techniques have been proposed for root coverage. However, none of them presents predictable results in deep and wide recessions
The aim of this case series report is to describe an alternative technique for root coverage at sites showing deep recessions and attachment loss >4 mm at buccal sites.
Four patients presenting deep recession defects at buccal sites (≥4 mm) were treated by the newly forming bone graft technique, which consists in the creation of an alveolar socket at edentulous ridge and transferring of granulation tissue present in this socket to the recession defect after 21 days. Clinical periodontal parameters, including recession depth (RD), probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP), plaque index (PI) and keratinized gingiva width (KGW) were evaluated by a single examiner immediately before surgery and at 1, 3, 6 and 9 months postoperatively.
All cases showed reduction in RD and PD, along with CAL gain, although no increase in KGW could be observed. These findings suggest that the technique could favor periodontal regeneration along with root coverage, especially in areas showing deep recessions and attachment loss.
Url:
DOI: 10.1590/S1678-77572012000300016
PubMed: 22858709
PubMed Central: 3881776
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PMC:3881776Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Newly forming bone graft: a novel surgical approach to the treatment of
denuded roots</title><author><name sortKey="Sant Ana, Adriana Campos Passanezi" sort="Sant Ana, Adriana Campos Passanezi" uniqKey="Sant Ana A" first="Adriana Campos Passanezi" last="Sant'Ana">Adriana Campos Passanezi Sant'Ana</name><affiliation><nlm:aff id="aff01"> DDS, PhD, Associate Professor, Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil</nlm:aff></affiliation></author><author><name sortKey="Ferraz, Bruna F Rahal" sort="Ferraz, Bruna F Rahal" uniqKey="Ferraz B" first="Bruna F. Rahal" last="Ferraz">Bruna F. Rahal Ferraz</name><affiliation><nlm:aff id="aff02"> DDS, MSD, Graduate student, Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.</nlm:aff></affiliation></author><author><name sortKey="De Rezende, Maria Lucia Rubo" sort="De Rezende, Maria Lucia Rubo" uniqKey="De Rezende M" first="Maria Lúcia Rubo" last="De Rezende">Maria Lúcia Rubo De Rezende</name><affiliation><nlm:aff id="aff01"> DDS, PhD, Associate Professor, Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil</nlm:aff></affiliation></author><author><name sortKey="Greghi, Sebastiao Luiz Aguiar" sort="Greghi, Sebastiao Luiz Aguiar" uniqKey="Greghi S" first="Sebastião Luiz Aguiar" last="Greghi">Sebastião Luiz Aguiar Greghi</name><affiliation><nlm:aff id="aff01"> DDS, PhD, Associate Professor, Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil</nlm:aff></affiliation></author><author><name sortKey="Damante, Carla Andreotti" sort="Damante, Carla Andreotti" uniqKey="Damante C" first="Carla Andreotti" last="Damante">Carla Andreotti Damante</name><affiliation><nlm:aff id="aff03"> DDS, PhD, Assistant Professor, Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo. Bauru, SP, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Passanezi, Euloir" sort="Passanezi, Euloir" uniqKey="Passanezi E" first="Euloir" last="Passanezi">Euloir Passanezi</name><affiliation><nlm:aff id="aff04"> DDS, PhD, Head of the Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">22858709</idno><idno type="pmc">3881776</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881776</idno><idno type="RBID">PMC:3881776</idno><idno type="doi">10.1590/S1678-77572012000300016</idno><date when="2012">2012</date><idno type="wicri:Area/Pmc/Corpus">001D57</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001D57</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Newly forming bone graft: a novel surgical approach to the treatment of
denuded roots</title><author><name sortKey="Sant Ana, Adriana Campos Passanezi" sort="Sant Ana, Adriana Campos Passanezi" uniqKey="Sant Ana A" first="Adriana Campos Passanezi" last="Sant'Ana">Adriana Campos Passanezi Sant'Ana</name><affiliation><nlm:aff id="aff01"> DDS, PhD, Associate Professor, Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil</nlm:aff></affiliation></author><author><name sortKey="Ferraz, Bruna F Rahal" sort="Ferraz, Bruna F Rahal" uniqKey="Ferraz B" first="Bruna F. Rahal" last="Ferraz">Bruna F. Rahal Ferraz</name><affiliation><nlm:aff id="aff02"> DDS, MSD, Graduate student, Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.</nlm:aff></affiliation></author><author><name sortKey="De Rezende, Maria Lucia Rubo" sort="De Rezende, Maria Lucia Rubo" uniqKey="De Rezende M" first="Maria Lúcia Rubo" last="De Rezende">Maria Lúcia Rubo De Rezende</name><affiliation><nlm:aff id="aff01"> DDS, PhD, Associate Professor, Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil</nlm:aff></affiliation></author><author><name sortKey="Greghi, Sebastiao Luiz Aguiar" sort="Greghi, Sebastiao Luiz Aguiar" uniqKey="Greghi S" first="Sebastião Luiz Aguiar" last="Greghi">Sebastião Luiz Aguiar Greghi</name><affiliation><nlm:aff id="aff01"> DDS, PhD, Associate Professor, Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil</nlm:aff></affiliation></author><author><name sortKey="Damante, Carla Andreotti" sort="Damante, Carla Andreotti" uniqKey="Damante C" first="Carla Andreotti" last="Damante">Carla Andreotti Damante</name><affiliation><nlm:aff id="aff03"> DDS, PhD, Assistant Professor, Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo. Bauru, SP, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Passanezi, Euloir" sort="Passanezi, Euloir" uniqKey="Passanezi E" first="Euloir" last="Passanezi">Euloir Passanezi</name><affiliation><nlm:aff id="aff04"> DDS, PhD, Head of the Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Applied Oral Science</title><idno type="ISSN">1678-7757</idno><idno type="eISSN">1678-7765</idno><imprint><date when="2012">2012</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Many techniques have been proposed for root coverage. However, none of them presents
predictable results in deep and wide recessions</p><sec><title>Objective</title><p>The aim of this case series report is to describe an alternative technique for
root coverage at sites showing deep recessions and attachment loss >4 mm at
buccal sites. </p></sec><sec><title>Material and Methods</title><p>Four patients presenting deep recession defects at buccal sites (≥4 mm) were
treated by the newly forming bone graft technique, which consists in the creation
of an alveolar socket at edentulous ridge and transferring of granulation tissue
present in this socket to the recession defect after 21 days. Clinical periodontal
parameters, including recession depth (RD), probing depth (PD), clinical
attachment level (CAL), bleeding on probing (BOP), plaque index (PI) and
keratinized gingiva width (KGW) were evaluated by a single examiner immediately
before surgery and at 1, 3, 6 and 9 months postoperatively. </p></sec><sec><title>Results</title><p>All cases showed reduction in RD and PD, along with CAL gain, although no increase
in KGW could be observed. These findings suggest that the technique could favor
periodontal regeneration along with root coverage, especially in areas showing
deep recessions and attachment loss.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Al Hamdan, K" uniqKey="Al Hamdan K">K Al-Hamdan</name></author><author><name sortKey="Eber, R" uniqKey="Eber R">R Eber</name></author><author><name sortKey="Sarment, D" uniqKey="Sarment D">D Sarment</name></author><author><name sortKey="Kowalski, C" uniqKey="Kowalski C">C Kowalski</name></author><author><name sortKey="Wang, Hl" uniqKey="Wang H">HL Wang</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Baldi, C" uniqKey="Baldi C">C Baldi</name></author><author><name sortKey="Pini Prato, G" uniqKey="Pini Prato G">G Pini-Prato</name></author><author><name sortKey="Pagliaro, U" uniqKey="Pagliaro U">U Pagliaro</name></author><author><name sortKey="Nieri, M" uniqKey="Nieri M">M Nieri</name></author><author><name sortKey="Saletta, D" uniqKey="Saletta D">D Saletta</name></author><author><name sortKey="Muzzi, L" 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article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">J Appl Oral Sci</journal-id><journal-id journal-id-type="iso-abbrev">J Appl Oral Sci</journal-id><journal-id journal-id-type="publisher-id">J. Appl. Oral. Sci.</journal-id><journal-title-group><journal-title>Journal of Applied Oral Science</journal-title></journal-title-group><issn pub-type="ppub">1678-7757</issn><issn pub-type="epub">1678-7765</issn><publisher><publisher-name>Faculdade de Odontologia de Bauru da Universidade de São
Paulo</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">22858709</article-id><article-id pub-id-type="pmc">3881776</article-id><article-id pub-id-type="doi">10.1590/S1678-77572012000300016</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>Newly forming bone graft: a novel surgical approach to the treatment of
denuded roots</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>SANT'ANA</surname><given-names>Adriana Campos Passanezi</given-names></name><xref ref-type="aff" rid="aff01">1</xref><xref ref-type="corresp" rid="c01"></xref></contrib><contrib contrib-type="author"><name><surname>FERRAZ</surname><given-names>Bruna F. Rahal</given-names></name><xref ref-type="aff" rid="aff02">2</xref></contrib><contrib contrib-type="author"><name><surname>de REZENDE</surname><given-names>Maria Lúcia Rubo</given-names></name><xref ref-type="aff" rid="aff01">1</xref></contrib><contrib contrib-type="author"><name><surname>GREGHI</surname><given-names>Sebastião Luiz Aguiar</given-names></name><xref ref-type="aff" rid="aff01">1</xref></contrib><contrib contrib-type="author"><name><surname>DAMANTE</surname><given-names>Carla Andreotti</given-names></name><xref ref-type="aff" rid="aff03">3</xref></contrib><contrib contrib-type="author"><name><surname>PASSANEZI</surname><given-names>Euloir</given-names></name><xref ref-type="aff" rid="aff04">4</xref></contrib></contrib-group><aff id="aff01"><label>1</label> DDS, PhD, Associate Professor, Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil</aff><aff id="aff02"><label>2</label> DDS, MSD, Graduate student, Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.</aff><aff id="aff03"><label>3</label> DDS, PhD, Assistant Professor, Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo. Bauru, SP, Brazil.</aff><aff id="aff04"><label>4</label> DDS, PhD, Head of the Discipline of Periodontics, Department of Prosthodontics, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.</aff><author-notes><corresp id="c01"><bold>Corresponding address:</bold> Adriana Campos Passanezi Sant'Ana - Faculdade de
Odontologia de Bauru - USP - Departamento de Prótese - Disciplina de Periodontia -
Al. Otávio Pinheiro Brisolla 9-75 - 17012-901 - Bauru - SP - Brazil - Phone: 00 55
(14) 3235-8278 - Fax: 00 55 (14) 3227-5105 - e-mail: <email>acpsantana@usp.br</email></corresp></author-notes><pub-date pub-type="ppub"><season>May-Jun</season><year>2012</year></pub-date><volume>20</volume><issue>3</issue><fpage>392</fpage><lpage>398</lpage><history><date date-type="received"><day>13</day><month>10</month><year>2010</year></date><date date-type="rev-recd"><day>14</day><month>7</month><year>2011</year></date><date date-type="accepted"><day>15</day><month>8</month><year>2011</year></date></history><permissions><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/3.0/"><license-p>This is an open-access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly
cited.</license-p></license></permissions><abstract><p>Many techniques have been proposed for root coverage. However, none of them presents
predictable results in deep and wide recessions</p><sec><title>Objective</title><p>The aim of this case series report is to describe an alternative technique for
root coverage at sites showing deep recessions and attachment loss >4 mm at
buccal sites. </p></sec><sec><title>Material and Methods</title><p>Four patients presenting deep recession defects at buccal sites (≥4 mm) were
treated by the newly forming bone graft technique, which consists in the creation
of an alveolar socket at edentulous ridge and transferring of granulation tissue
present in this socket to the recession defect after 21 days. Clinical periodontal
parameters, including recession depth (RD), probing depth (PD), clinical
attachment level (CAL), bleeding on probing (BOP), plaque index (PI) and
keratinized gingiva width (KGW) were evaluated by a single examiner immediately
before surgery and at 1, 3, 6 and 9 months postoperatively. </p></sec><sec><title>Results</title><p>All cases showed reduction in RD and PD, along with CAL gain, although no increase
in KGW could be observed. These findings suggest that the technique could favor
periodontal regeneration along with root coverage, especially in areas showing
deep recessions and attachment loss.</p></sec></abstract><kwd-group><kwd>Gingival recession</kwd><kwd>Guided tissue regeneration</kwd><kwd>Citric acid</kwd><kwd>Grafts</kwd></kwd-group></article-meta></front><body><sec><title>INTRODUCTION</title><p>Coverage of denuded roots has been a main concern for both professionals and patients.
Many surgical techniques have been proposed to cover denuded roots, showing varying
rates of success depending on factors related to the surgical technique and anatomical
features of the lesions<sup><xref ref-type="bibr" rid="r13">13</xref>,<xref ref-type="bibr" rid="r14">14</xref>,<xref ref-type="bibr" rid="r17">17</xref>,<xref ref-type="bibr" rid="r26">26</xref></sup>. A greater reduction in
recession depth and width as well as a greater increase in the width of keratinized
gingiva are obtained by subepithelial connective tissue graft (SCTG) associated to
coronally positioned flap<sup><xref ref-type="bibr" rid="r05">5</xref>,<xref ref-type="bibr" rid="r13">13</xref>,<xref ref-type="bibr" rid="r19">19</xref></sup>. However, the success of such technique is limited in wide recession
defects presenting interproximal bone and soft tissue loss<sup><xref ref-type="bibr" rid="r17">17</xref></sup>.</p><p>To overcome these problems, the use of barrier membranes positioned over exposed root
surface (GTR) warranting a space for regeneration to occur along with root coverage has
been suggested<sup><xref ref-type="bibr" rid="r07">7</xref>,<xref ref-type="bibr" rid="r20">20</xref>,<xref ref-type="bibr" rid="r23">23</xref>,<xref ref-type="bibr" rid="r26">26</xref>,<xref ref-type="bibr" rid="r27">27</xref></sup>. This technique resulted in gain of attachment level, reduction of
probing depth, bleeding on probing and recession depth<sup><xref ref-type="bibr" rid="r19">19</xref>,<xref ref-type="bibr" rid="r23">23</xref>,<xref ref-type="bibr" rid="r26">26</xref></sup> in single, large, deep, localized
marginal tissue recessions showing ≥5 mm of depth<sup><xref ref-type="bibr" rid="r27">27</xref></sup>, in the presence of hypersensitivity<sup><xref ref-type="bibr" rid="r07">7</xref></sup>, cervical caries lesions or restorations<sup><xref ref-type="bibr" rid="r23">23</xref>,<xref ref-type="bibr" rid="r28">28</xref></sup>. Histological studies demonstrated that wound healing proceeded with
the formation of new cementum, periodontal ligament and alveolar bone coronal to the
pre-existent level, suggesting that root coverage was accomplished by regeneration of
periodontal tissues<sup><xref ref-type="bibr" rid="r07">7</xref>,<xref ref-type="bibr" rid="r20">20</xref></sup>. In turn, it is contra-indicated for the treatment of
multiple and shallow recessions<sup><xref ref-type="bibr" rid="r18">18</xref>,<xref ref-type="bibr" rid="r30">30</xref></sup> or in areas of thin gingival
tissue<sup><xref ref-type="bibr" rid="r11">11</xref></sup>.</p><p>To further improve these results, the use of allogenic bone grafts associated to GTR for
root coverage was proposed<sup><xref ref-type="bibr" rid="r08">8</xref>,<xref ref-type="bibr" rid="r12">12</xref>,<xref ref-type="bibr" rid="r24">24</xref>,<xref ref-type="bibr" rid="r25">25</xref></sup> to support the membrane
and to act as an osteoinductive/osteoconductive biomaterial, resulting in improved
reduction of recession and probing depth and gain of attachment level compared to the
use of barrier membranes alone<sup><xref ref-type="bibr" rid="r08">8</xref>,<xref ref-type="bibr" rid="r12">12</xref></sup>, as well as a slightly smaller - but not
significant - reduction in recession depth compared with subepithelial connective tissue
graft<sup><xref ref-type="bibr" rid="r24">24</xref></sup>.</p><p>Recently, the use of growth factors or stem cells under membranes has been proposed to
treat denuded areas<sup><xref ref-type="bibr" rid="r15">15</xref></sup> or missing
papillae<sup><xref ref-type="bibr" rid="r16">16</xref></sup>, with promising
results. Passanezi, et al.<sup><xref ref-type="bibr" rid="r21">21</xref></sup> (1989)
proposed a surgical technique based on the transfer of osteogenic cells to treat
infrabony periodontal defects with high rates of clinical success. The technique
consists in the transfer of healing bone from a surgically created alveolar socket to
infrabony periodontal defects approximately 21 days after. A substantial quantity of a
relatively mature newly forming bone containing a vast amount of osteoblasts with
osteogenic potential is observed in alveolar socket 4-12 weeks after tooth
extraction<sup><xref ref-type="bibr" rid="r09">9</xref></sup>. This material shows
positive staining against collagen I, osteocalcin, bone sialoprotein and alkaline
phosphatase activity<sup><xref ref-type="bibr" rid="r22">22</xref></sup>, which are
considered as markers of mesenchymal stem cells<sup><xref ref-type="bibr" rid="r03">3</xref>,<xref ref-type="bibr" rid="r06">6</xref></sup>, resulting in
regeneration of periodontal tissues in animal and human studies<sup><xref ref-type="bibr" rid="r21">21</xref></sup>.</p><p>The treatment of wide recession defects by the newly forming bone graft (NFBG) technique
would then be favored by the formation of a new periodontal attachment apparatus, even
in the presence of attachment loss or thin keratinized tissue. Considering that, the aim
of this case series report is to propose a new technique for coverage of denuded roots
in order to achieve root coverage along with successful regeneration of bone, cementum
and periodontal ligament, especially at deep and wide recession defects.</p></sec><sec><title>CASE SERIES REPORT</title><sec><title>Case 1</title><p>Patient #1 was a 44-year-old systemically healthy never-smoker female who presented
for treatment at the Clinics of the Discipline of Periodontics at Bauru School of
Dentistry, University of São Paulo, Brazil. Patient reported no use of antibiotics or
other medicines in the previous 6-month period. Treatment plan involved extraction of
the mandibular left central incisor and root coverage of the mandibular right second
premolar, which showed a 5 mm-deep and 4 mm-wide recession at baseline examination.
No tooth mobility was present. Clinical and radiographic examination suggested a
slight loss of soft and hard tissues at distal sites compatible with a Miller class
III recession defect, since the mandibular right second premolar was adjacent to an
edentulous ridge.</p></sec><sec><title>Case 2</title><p>Patient #2 presented for treatment at the Periodontics Clinics complaining of
recession at the mandibular left first premolar. Clinical examination revealed a 5
mm-deep recession defect. Patient reported no systemic disease, no smoking, no use of
antibiotics or any other medications or periodontal treatment in the 6-month period
previous to baseline examination. No tooth mobility was present. Clinical and
radiographic examination suggested a Miller's class III recession defect.</p></sec><sec><title>Case 3</title><p>Patient #3, a 35 year-old female, presented a deep recession defect (5 mm) at the
mandibular right second premolar. Patient was systemically healthy, never smoker, and
reported no use of any medication or periodontal treatment in the 6-month period
previous to baseline examination. There was no clinical sign of trauma from occlusion
or tooth mobility. Clinical and radiographic examination suggested a Miller's class
III recession defect.</p></sec><sec><title>Case 4</title><p>Patient #4 was a 32-year-old female with a 4-mm-deep recession defect at the
mandibular right second premolar. No tooth mobility was present, and there was no
clinical sign of trauma from occlusion. Patient reported to be systemically healthy
and never smoker. Additionally, patient reported no regular use of medications or
periodontal treatment during the past 6 months. Clinical and radiographic examination
suggested a Miller's class III recession defect.</p></sec><sec><title>Phase I therapy</title><p>All patients were submitted to a phase I therapy, which included removal of caries
and endodontic lesions, oral hygiene instruction and scaling and root planning aiming
at plaque control. Surgical treatment was performed after active treatment, when
resolution of inflammation was achieved, as observed by absence of bleeding on
probing and clinical signs of gingival health.</p></sec><sec><title>Clinical examination</title><p>Clinical examinations were performed by a single trained examiner immediately before
surgery and at 1, 3, 6 and 9 months post-operatively. Depth of marginal tissue
recession (DR), probing depth (PD), clinical attachment level (CAL), bleeding on
probing (BOP) and keratinized gingiva width (KGW) were determined using a millimeter
manual probe (HuFriedy, Chicago, IL, USA). DR was determined by the distance from
cementum-enamel junction to gingival margin. PD was determined by the distance from
gingival margin to the bottom of the sulcus. CAL was defined as the distance from
cementum-enamel junction to the bottom of sulcus (DR+PD). KGW was determined by the
distance from gingival margin to the mucogingival junction. The presence of bleeding
upon probing was recorded as 1 and its absence as 0. Plaque index was recorded as the
presence (1) or absence (0) of plaque after staining of tooth surface with a
plaque-evidencing solution. Percentage of root coverage was determined by the
application of the formula<sup><xref ref-type="bibr" rid="r11">11</xref></sup>:</p><p>% root coverage=(RD<sub>initial</sub>-RD<sub>final</sub>)x100/RD<sub>initial</sub></p></sec><sec><title>Description of NFBG for root coverage</title><sec><title>-Surgical creation of the alveolar socket</title><p>The alveolar socket was created by perforation of alveolar bone ridge with a
diamond bur, as previously described<sup><xref ref-type="bibr" rid="r21">21</xref></sup> (<xref ref-type="fig" rid="f01">Figure 1A</xref>-<xref ref-type="fig" rid="f01">B</xref>). A bovine type 1 collagen membrane (GenDerm,
Baumer, Bauru, SP, Brazil) was positioned over the socket (<xref ref-type="fig" rid="f01">Figure 1C</xref>) to prevent ingrowth of connective tissue or
epithelial cells. Flaps were sutured without tension with silk 4-0 (Ethicon,
Johnson & Johnson, São Paulo, SP, Brazil), as shown in <xref ref-type="fig" rid="f01">Figure 1D</xref>. Patients were prescribed antibiotics (Amoxicilin,
1500 mg, t.i.d, 7 days) and non-steroidal anti-inflammatory (Nimesulide, 100 mg,
b.i.d., 3 days) and instructed not to rinse during the first 48 h. Sutures were
removed after 7 days, with clinical evidence of uneventful wound healing.</p><fig id="f01" orientation="portrait" position="float"><label>Figure 1</label><caption><p>Prepare of donor site. (A) Occlusal view from edentulous ridge selected for
the creation of a surgical alveolus; (B) Rising of a full thickness flap and
creation of a surgical socket by perforation of alveolar ridge with a
diamond bur in high speed with vigorous irrigation; (C) Bovine type 1
collagen barrier membrane trimmed to overlap defects margins in 2-3 mm
positioned over the defect; (D) Primary closure of the flaps without tension
with 4-0 silk</p></caption><graphic xlink:href="jaos-20-03-0392-g01"></graphic></fig></sec><sec><title>-Surgical technique for root coverage</title><p>Root coverage procedure was carried out 21 days after (<xref ref-type="fig" rid="f02">Figure 2A</xref>, <xref ref-type="fig" rid="f02">B</xref>). After
appropriate anesthesia, a trapezoidal flap<sup><xref ref-type="bibr" rid="r07">7</xref></sup> was performed and a full thickness flap was raised (<xref ref-type="fig" rid="f02">Figure 2C</xref>). After debridement and scaling and
root planning, root surface was conditioned with a citric acid (pH 1) and a 50%
tetracycline solution (Discipline of Biochemistry, School of Dentistry at
Bauru-USP) during 3 minutes, followed by vigorous rinsing with saline solution.
Afterwards, a full thickness flap was raised at donor site (<xref ref-type="fig" rid="f02">Figure 2D</xref>). The healing tissue was removed from the alveolus
with a Lucas curette (Chinelatto, Ribeirão Preto, SP, Brazil) and transferred to
the receptor site (<xref ref-type="fig" rid="f02">Figure 2E</xref>). Flaps were
displaced coronally and sutured at cementoenamel junction (<xref ref-type="fig" rid="f02">Figure 2F</xref>). A periodontal dressing (CoePack, GC America INC,
Alsip, IL, U.S.A) protected the area for 14 days. Patient was prescribed a
non-steroidal anti-inflammatory and instructed not to rinse during the first 48 h.
Sutures were removed after 14 days. Patient was advised to carry out routine oral
hygiene procedures with dental floss and soft brush for the next 30 days.
Postoperative controls were performed at 1, 3, 6 and 9 months and included
instruction of oral hygiene and supra and subgingival plaque control, when
necessary.</p><fig id="f02" orientation="portrait" position="float"><label>Figure 2</label><caption><p>Treatment of recession defect by the newly forming bone technique. A: Buccal
view of the 5-mm-deep and 4-mm wide recession defect at the mandibular right
second premolar; B: Panoramic x-ray view of the area. A slight loss of
interproximal bone at distal site of the mandibular right second premolar
can be noticed; C: Trapezoidal full thickness flap at receptor site 21 days
after surgical creation of alveolar socket; D: Occlusal view of donor site
containing the healing tissue after rising of a full-thickness flap; E:
Positioning of the newly forming bone at the receptor site. A slight
compression with saline solution embedded gauze warranted a close contact
between the graft material and the root surface; F: Flaps displaced
coronally and sutured at the level of cementoenamel junction without
tension</p></caption><graphic xlink:href="jaos-20-03-0392-g02"></graphic></fig></sec></sec></sec><sec sec-type="results"><title>RESULTS</title><p><xref ref-type="table" rid="t01">Table 1</xref> describes RD, PD, CAL, BOP, PI, KGW and
the percentage of root coverage observed at buccal sites at baseline and at the
postoperative examinations for all cases described. A reduction in RD was observed for
all cases after 9 months, although Cases 2 and 3 showed a slight relapse from 3-month to
6- and 9-month examinations. All cases resulted in CAL gain and reduction or stability
of PD measures, as well as absence of plaque accumulation and BOP. Cases 2, 3 and 4
showed a slight increase in KGW, while no change was observed in Case 1. <xref ref-type="fig" rid="f03">Figure 3</xref> shows the results obtained in Case 1, in
which CAL gain was observed at interproximal and buccal sites, along with reduction of
RD from 5 mm at baseline to 2 mm after 9 months.</p><table-wrap id="t01" orientation="portrait" position="float"><label>Table 1</label><caption><p>Probing depth (PD), clinical attachment level (CAL), bleeding on probing (BOP),
plaque index (PI), recession depth (RD), keratinized gingiva width (KGW) and
percentage of root coverage (%RC) observed at baseline and postoperative
examinations</p></caption><table frame="hsides" rules="groups"><thead><tr><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>Case</bold></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>Examination</bold></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>PD</bold></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>CAL</bold></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>BOP</bold></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>PI</bold></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>RD</bold></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>KGW</bold></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>%RC</bold></td></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1">Case 1</td><td align="center" rowspan="1" colspan="1">Baseline</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">7</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">5</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">-</td></tr><tr style="background-color:#CCCCCC"><td align="center" rowspan="1" colspan="1"> </td><td align="center" rowspan="1" colspan="1">3 mouths</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">60</td></tr><tr><td align="center" rowspan="1" colspan="1"> </td><td align="center" rowspan="1" colspan="1">6 mouths</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">60</td></tr><tr><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"> </td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">9 mouths</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">1</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">3</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">0</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">0</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">60</td></tr><tr><td align="center" rowspan="1" colspan="1"> </td><td align="center" rowspan="1" colspan="1">Difference</td><td align="center" rowspan="1" colspan="1">-1</td><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">-</td><td align="center" rowspan="1" colspan="1">-</td><td align="center" rowspan="1" colspan="1">-3</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">-</td></tr><tr><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">Case 2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">Baseline</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">7</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">1</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">1</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">5</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">1</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">-</td></tr><tr><td align="center" rowspan="1" colspan="1"> </td><td align="center" rowspan="1" colspan="1">3 mouths</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">60</td></tr><tr><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"> </td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">6 mouths</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">5</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">1</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">0</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">3</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">40</td></tr><tr><td align="center" rowspan="1" colspan="1"> </td><td align="center" rowspan="1" colspan="1">9 mouths</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">5</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">40</td></tr><tr><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"> </td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">Difference</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">0</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">-</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">-</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">-2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">1</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">-</td></tr><tr><td align="center" rowspan="1" colspan="1">Case 3</td><td align="center" rowspan="1" colspan="1">Baseline</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">7</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">5</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">-</td></tr><tr><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"> </td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">3 mouths</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">1</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">4</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">0</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">0</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">3</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">60</td></tr><tr><td align="center" rowspan="1" colspan="1"> </td><td align="center" rowspan="1" colspan="1">6 mouths</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">4</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">40</td></tr><tr><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"> </td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">9 mouths</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">1</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">4</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">0</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">0</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">3</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">3</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">40</td></tr><tr><td align="center" rowspan="1" colspan="1"> </td><td align="center" rowspan="1" colspan="1">Difference</td><td align="center" rowspan="1" colspan="1">-1</td><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">-</td><td align="center" rowspan="1" colspan="1">-</td><td align="center" rowspan="1" colspan="1">-2</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">-</td></tr><tr><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">Case 4</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">Baseline</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">3</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">7</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">0</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">0</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">4</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">1</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">-</td></tr><tr><td align="center" rowspan="1" colspan="1"> </td><td align="center" rowspan="1" colspan="1">3 mouths</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">75</td></tr><tr><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"> </td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">6 mouths</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">1</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">0</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">0</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">1</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">75</td></tr><tr><td align="center" rowspan="1" colspan="1"> </td><td align="center" rowspan="1" colspan="1">9 mouths</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">0</td><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">2</td><td align="center" rowspan="1" colspan="1">75</td></tr><tr><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"> </td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">Difference</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">-2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">5</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">-</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">-</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">-3</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">1</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">-</td></tr></tbody></table></table-wrap><fig id="f03" orientation="portrait" position="float"><label>Figure 3</label><caption><p>Buccal view of the area 9 months after treatment, suggesting gingival health and
reduction of recession</p></caption><graphic xlink:href="jaos-20-03-0392-g03"></graphic></fig></sec><sec sec-type="discussion"><title>DISCUSSION</title><p>The aim of this case series report is to present a new surgical technique that could
favor both root coverage and periodontal regeneration, especially at sites showing deep
recession defects and attachment loss. The primary results obtained showed reduction of
PD, BOP and plaque index and gain of CAL after 9 months of follow-up. A slight increase
in KGW was observed after treatment.</p><p>These results are in agreement with other studies<sup><xref ref-type="bibr" rid="r01">1</xref>,<xref ref-type="bibr" rid="r05">5</xref>,<xref ref-type="bibr" rid="r07">7</xref>,<xref ref-type="bibr" rid="r08">8</xref>,<xref ref-type="bibr" rid="r19">19</xref>,<xref ref-type="bibr" rid="r23">23</xref>,<xref ref-type="bibr" rid="r24">24</xref>-<xref ref-type="bibr" rid="r29">29</xref></sup> which
suggested reduction of probing depth and gain of attachment level in wide and deep
recession defects treated by GTR associated to a coronal positioned flap. Similar
results were obtained by the use of β-TCP and 0.3 ng/mL rhPDGF-BB under a collagen
membrane for treatment of denuded roots, resulting in the formation of new cementum,
periodontal ligament and alveolar bone along with root coverage<sup><xref ref-type="bibr" rid="r15">15</xref></sup>.</p><p>The main advantage of this novel technique is the use of autograft material containing
osteogenic cells<sup><xref ref-type="bibr" rid="r09">9</xref>,<xref ref-type="bibr" rid="r22">22</xref></sup> capable of regenerating periodontal tissues<sup><xref ref-type="bibr" rid="r21">21</xref></sup> even in horizontal defects.
Disadvantages of the technique include the necessity of performing two surgical
procedures in a short period of time, as well as the existence of two surgical sites at
the graft surgery. Besides, patient is required to present at least one condemned tooth
or an alveolar ridge that allows the surgical creation of an alveolar socket.</p><p>An important issue was the difficulty in stabilizing the graft on the root surface, due
to the convexity of roots and the absence of remaining walls to support the graft. This
was at least partially solved by performing suture of apical portions of the flaps prior
to positioning of the graft, which allowed more stability of the graft.</p><p>The aim of the present technique is to achieve periodontal regeneration coronal to the
preexistent level along with root coverage. This is especially important at sites
showing deep recession and dehiscence defects, when conventional soft tissue grafts show
limited results<sup><xref ref-type="bibr" rid="r23">23</xref>,<xref ref-type="bibr" rid="r29">29</xref></sup>. Many studies<sup><xref ref-type="bibr" rid="r01">1</xref>,<xref ref-type="bibr" rid="r05">5</xref>,<xref ref-type="bibr" rid="r19">19</xref>,<xref ref-type="bibr" rid="r29">29</xref></sup> indicate that
subepithelial connective tissue results in greater complete and mean root coverage, and
a greater increase in KGW than GTR techniques, with long-term stability of the results
obtained. However, at sites showing interproximal bone loss or deep dehiscence defects
and severe attachment loss, regeneration of periodontal tissues may be required to
improve attachment support and, consequently, reduce recession depth<sup><xref ref-type="bibr" rid="r07">7</xref>,<xref ref-type="bibr" rid="r26">26</xref>,<xref ref-type="bibr" rid="r29">29</xref></sup> without the formation of a long
junctional epithelium, as observed when defects with such features are treated by
SCTGs<sup><xref ref-type="bibr" rid="r10">10</xref></sup>.</p><p>Periodontal regeneration can only be evaluated at the histologic level, which was not
performed at the present study. However, previous histological studies performed in
animal models showed that NFBG is capable of forming new alveolar bone, cementum and
periodontal ligament coronal to the base of the pre-existent defect<sup><xref ref-type="bibr" rid="r21">21</xref></sup>.</p><p>Since the healing tissue present at fresh alveolar sockets shows positive staining for
collagen I, osteonectin, bone sialoprotein and alkaline phosphatase activity<sup><xref ref-type="bibr" rid="r09">9</xref></sup>, it is possible that mesenchymal stem
cells are available at the material, as suggested by other studies investigating the
presence of mesenchymal stem cells in periodontal ligament by using the same panel of
markers<sup><xref ref-type="bibr" rid="r03">3</xref>,<xref ref-type="bibr" rid="r06">6</xref></sup>. Considering that one of the main features of mesenchymal
stem cells is plasticity<sup><xref ref-type="bibr" rid="r03">3</xref></sup> and the
healing tissue removed from alveolar sockets and transferred to periodontal defects are
able to form bone, periodontal ligament and cementum<sup><xref ref-type="bibr" rid="r21">21</xref></sup>, it seems reasonable to believe that mesenchymal stem cells are
present at the newly forming bone granulation tissue, which could explain its osteogenic
properties<sup><xref ref-type="bibr" rid="r09">9</xref>,<xref ref-type="bibr" rid="r21">21</xref>,<xref ref-type="bibr" rid="r22">22</xref></sup>.</p><p>The use of regenerative techniques to achieve root coverage has been used for many
years<sup><xref ref-type="bibr" rid="r26">26</xref></sup>. Trombelli, et
al.<sup><xref ref-type="bibr" rid="r27">27</xref></sup> (1995) showed that areas
of 4-6 mm recessions treated by guided tissue regeneration resulted in greater reduction
of recession and probing depth, as well as greater gain of attachment level than sites
treated by free gingival grafts and coronally advanced flap. Other researchers have also
demonstrated that the treatment of large recession defects by GTR results in the
formation of new alveolar bone, cementum and periodontal ligament coronal to the base of
the defect<sup><xref ref-type="bibr" rid="r05">5</xref>,<xref ref-type="bibr" rid="r07">7</xref>,<xref ref-type="bibr" rid="r13">13</xref>,<xref ref-type="bibr" rid="r27">27</xref>,<xref ref-type="bibr" rid="r28">28</xref></sup>, although
unsatisfactory results were observed in shallow recession defects<sup><xref ref-type="bibr" rid="r18">18</xref></sup>.</p><p>The percentage of root coverage obtained by GTR varies from 16.7%-100%<sup><xref ref-type="bibr" rid="r04">4</xref>,<xref ref-type="bibr" rid="r05">5</xref>,<xref ref-type="bibr" rid="r07">7</xref>,<xref ref-type="bibr" rid="r08">8</xref>,<xref ref-type="bibr" rid="r20">20</xref>,<xref ref-type="bibr" rid="r23">23</xref>,<xref ref-type="bibr" rid="r26">26</xref>,<xref ref-type="bibr" rid="r27">27</xref></sup>, which are in agreement with results presented in this
case report. In comparison with subepithelial connective tissue grafts, GTR shows better
results in reduction of probing depth and gain of attachment level, especially in areas
showing ≥5 mm of recession, and similar or slightly smaller reduction of
recession<sup><xref ref-type="bibr" rid="r01">1</xref>,<xref ref-type="bibr" rid="r19">19</xref>,<xref ref-type="bibr" rid="r24">24</xref>,<xref ref-type="bibr" rid="r29">29</xref></sup>. The main factors associated with
incomplete root coverage are related to early exposition of the membrane and wide
recessions<sup><xref ref-type="bibr" rid="r02">2</xref>,<xref ref-type="bibr" rid="r04">4</xref></sup>. These problems are overcome with the present technique,
since the use of barrier membranes is unnecessary due to the osteogenic properties of
the material<sup><xref ref-type="bibr" rid="r21">21</xref></sup>.</p><p>The use of allografts in combination with barrier membranes improves the results
obtained by the use of barrier membranes alone<sup><xref ref-type="bibr" rid="r08">8</xref>,<xref ref-type="bibr" rid="r12">12</xref></sup> or subepithelial
connective graft<sup><xref ref-type="bibr" rid="r01">1</xref>,<xref ref-type="bibr" rid="r24">24</xref>,<xref ref-type="bibr" rid="r29">29</xref></sup> in wide
recession defects. Cases treated by bone grafts and GTR showed decreased probing depth
at post-operative evaluations, suggesting a reconstitution of biological width, without
the formation of long junctional epithelium<sup><xref ref-type="bibr" rid="r01">1</xref>,<xref ref-type="bibr" rid="r08">8</xref>,<xref ref-type="bibr" rid="r12">12</xref>,<xref ref-type="bibr" rid="r24">24</xref>,<xref ref-type="bibr" rid="r29">29</xref></sup>. Considering that in the present case a histological
evaluation was not performed, reduction of probing depth and gain of attachment are
suggestive of regeneration of periodontal tissues.</p><p>The primary results obtained in the present case series suggest that the technique is
able to cover denuded areas, along with reconstitution of biological width and gain of
attachment level, especially in wide recession areas. Predictable and long-term well
succeeded cases of root coverage by the NFBT require a strict selection of patients and
sites to be treated. Further studies are necessary to compare the results obtained by
the proposed technique with other conventional reconstructive periodontal plastic
surgeries, such as subepithelial connective tissue grafts and guided bone
regeneration.</p></sec><sec sec-type="conclusions"><title>CONCLUSIONS</title><p>The results obtained in the present clinical case series suggest that NFBT can be an
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