CASE REPORT
Clinical comparison of coronary displaced flap and sub-epithelial connective tissue graft with or without enamel matrix protein derivative for gingival recession coverage. Clinical case presentation
Comparación clínica del uso del colgajo de avance coronal e injerto de tejido conectivo subepitelial con o sin proteínas derivadas de la matriz del esmalte para la cobertura de recesiones gingivales. Caso clínico
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Patient handling at the «Licenciado Adolfo López Mateos» Hospital Mexico City" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e254" "paginaFinal" => "e258" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 849 "Ancho" => 829 "Tamanyo" => 105351 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Postoperative, lateral image showing surgical wound scar</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Gerardo Romero Jasso, Ana María Nieto Munguía, Alejandro Ricardo Sánchez Amador" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Gerardo Romero" "apellidos" => "Jasso" ] 1 => array:2 [ "nombre" => "Ana María Nieto" "apellidos" => "Munguía" ] 2 => array:2 [ "nombre" => "Alejandro Ricardo Sánchez" "apellidos" => "Amador" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1870199X15000555?idApp=UINPBA00004N" "url" => "/1870199X/0000001900000004/v1_201511290022/S1870199X15000555/v1_201511290022/en/main.assets" ] "asociados" => array:1 [ 0 => array:18 [ "pii" => "S1870199X15000476" "issn" => "1870199X" "doi" => "10.1016/j.rodmex.2015.10.009" "estado" => "S300" "fechaPublicacion" => "2015-10-01" "aid" => "27" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "crp" "cita" => "Rev Odont Mex. 2015;19:263-72" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4447 "formatos" => array:3 [ "EPUB" => 35 "HTML" => 3801 "PDF" => 611 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">CASO CLÍNICO</span>" "titulo" => "Comparación clínica del uso del colgajo de avance coronal e injerto de tejido conectivo subepitelial con o sin proteínas derivadas de la matriz del esmalte para la cobertura de recesiones gingivales. Caso clínico" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "263" "paginaFinal" => "272" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Clinical comparison of coronary displaced flap and sub-epithelial connective tissue graft with or without enamel matrix protein derivative for gingival recession coverage. Clinical case presentation" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figura 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1247 "Ancho" => 1367 "Tamanyo" => 240018 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">CAC + ITCSE + DME en el cuadrante inferior izquierdo. <span class="elsevierStyleBold">(A)</span> Recesiones gingivales previo la cirugía. <span class="elsevierStyleBold">(B)</span> Colocación del DME sobre las superficies radiculares. <span class="elsevierStyleBold">(C)</span> Adaptación y sutura del injerto. <span class="elsevierStyleBold">(D)</span> Sutura del colgajo cubriendo totalmente al injerto. <span class="elsevierStyleBold">(E)</span> Cicatrización a los seis meses.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Patricia Vargas Casillas, Blanca Itzel Mendoza Espinosa, Socorro Aída Borges Yáñez" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Ana Patricia Vargas" "apellidos" => "Casillas" ] 1 => array:2 [ "nombre" => "Blanca Itzel Mendoza" "apellidos" => "Espinosa" ] 2 => array:2 [ "nombre" => "Socorro Aída Borges" "apellidos" => "Yáñez" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1870199X15000476?idApp=UINPBA00004N" "url" => "/1870199X/0000001900000004/v1_201511290022/S1870199X15000476/v1_201511290022/es/main.assets" ] ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">CASE REPORT</span>" "titulo" => "Clinical comparison of coronary displaced flap and sub-epithelial connective tissue graft with or without enamel matrix protein derivative for gingival recession coverage. Clinical case presentation" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "e259" "paginaFinal" => "e268" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ana Patricia Vargas Casillas, Blanca Itzel Mendoza Espinosa, Socorro Aída Borges Yáñez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Ana Patricia Vargas" "apellidos" => "Casillas" "email" => array:1 [ 0 => "anapvargas@aol.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "fn1" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Blanca Itzel Mendoza" "apellidos" => "Espinosa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Socorro Aída Borges" "apellidos" => "Yáñez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "DDS, Masters Degree in Periodontics, Periodontics and Implantology Professor" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "DDS, Student at the Implantology and Periodontics Specialty" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "DDS, Masters Degree in Public Health, PhD in Dentistry, Coordinator of Public Oral Health" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comparación clínica del uso del colgajo de avance coronal e injerto de tejido conectivo subepitelial con o sin proteínas derivadas de la matriz del esmalte para la cobertura de recesiones gingivales. Caso clínico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1511 "Ancho" => 1430 "Tamanyo" => 293032 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">CAF + SCTG + EMD in upper right quadrant. <span class="elsevierStyleBold">(A)</span> Gingival recessions before surgery. <span class="elsevierStyleBold">(B)</span> Flap lifting underneath oblique incisions. <span class="elsevierStyleBold">(C)</span> Placement of PrefGel on root surfaces. <span class="elsevierStyleBold">(D)</span> Abundant irrigation with physiological solution to remove PrefGel. <span class="elsevierStyleBold">(E)</span> Application of EMD on root surfaces. <span class="elsevierStyleBold">(F)</span> Graft placed immediately after EMD application on root surfaces. <span class="elsevierStyleBold">(G)</span> Flap sutured above the enamel-cement junction. <span class="elsevierStyleBold">(H)</span> Healing at six months.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">INTRODUCTION</span><p id="par0005" class="elsevierStylePara elsevierViewall">Gingival recession is defined as exposition of a part of the tooth's root due to the displacement of the gingival margin.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is not considered a disease, but rather a defect which prompts the patient to complain about root hypersensitivity,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> poor esthetics<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and root caries.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It is a trait frequently found in subjects with suitable or deficient oral hygiene,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> it can appear isolated or in several contiguous teeth.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Self-induced trauma due to vigorous brushing is the main etiologic factor in patients with good oral hygiene, it generally appears in the oral surface in young subjects.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In patients with inflammation induced by bacterial plaque, gingival recession mainly affects inter-proximal zones.6 Several factors might enhance the presence of gingival recession, such as high muscle insertion, frenum traction and iatrogenic factors related to restorative and periodontal procedures.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Isolated gingival recession or multiple recessions can be treated with periodontal plastic surgery procedures aimed at placing soft tissue grafts to cover root surfaces, to thus restore acceptable esthetics and decrease root sensitivity.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">According to Miller's classification of gingival recessions,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> class I and II gingival recessions are more predictable to achieve root coverage, since in these recessions, inter-proximal tissues remain intact, blood supply for the survival of the graft will be provided from these locations. Success rate is unpredictable for Miller's class II and IV recessions, since there is a loss of inter-proximal tissues which will limit or prevent blood supply to the graft.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Several surgical procedures have been undertaken to achieve root coverage of multiple gingival recessions, among them we can mention coronary-advanced flaps, <a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> sub-epithelial connective tissue grafts<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> connective tissue grafts with tunnel flap,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> all of which provide different rates of success and predictability.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Nevertheless, the procedure involving a coronary-advanced flap combined with sub-epithelial connective tissue graft (CAF + SCTG), can be considered the gold standard, since this procedure exhibits greater root coverage predictability and greater color homogeneity with surrounding tissues.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Recently, the use of enamel matrix derivative (EMD) has been applied as clinical treatment to promote periodontal tissues regeneration.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a> It is a derivative from porcine embryonic enamel and is based on the high homology found between human and porcine enamel proteins, since they mimic the sequence of events involved in root cement formation, favoring thus new insertion of periodontal ligament.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20</span></a> This regenerative concept has also been demonstrated when used in root coverage procedures.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Topical EMD application in CAF procedures has exhibited suitable results with respect to root coverage, clinical insertion gain and increase of apex-coronal dimension of keratinized tissue.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22,23</span></a> Nevertheless, other studies could not demonstrate clinical improvement when compared with solely coronal advanced flap.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,25</span></a> There are a few studies on EMD application along with CAF + SCTG, where contradictory results have equally been found. Better results have been reported in a controlled clinical study in Miller's class I and II<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> recessions, as well as in another study conducted on Miller's<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> class III recessions, whereas other studies have reported no benefit whatsoever.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28,29</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The purpose of the present clinical case was to study whether EMD application during coronal-advanced flap procedures with sub-epithelial connective tissue graft (CAF + SCTG) exerted an additional effect on root coverage of Miller's class I and II recessions in a patient afflicted with multiple gingival recessions.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">CLINICAL CASE</span><p id="par0045" class="elsevierStylePara elsevierViewall">37 year old female attending the Implantology and Periodontics Clinic at the Graduate and Research School, National School of Dentistry, National University of Mexico (UNAM), due to multiple gingival recessions. She requested coverage of said recessions due to hypersensitivity and esthetic problems. Clinical history did not reveal any systemic condition. During pathological personal history recording, the patient revealed orthodontic treatment with bilateral mandibular orthognatic surgery three years before. Clinical exploration showed Miller's type I, II and III recessions in all quadrants and edge to edge occlusion (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). X-ray examination showed intact inter-proximal bone crests, periodontal examination revealed plaque-induced gingivitis. The patient exhibited a 22% plaque index and bleeding upon probing in 34% of all sites.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The patient was subjected to initial therapy which consisted on oral hygiene advice, calculi removal, tooth polishing, as well as inter-consultation with the Orthodontics Clinic at the same institution in order to correct dental malposition. Three weeks later another assessment was undertaken which revealed a plaque index under 10%.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Surgical treatment plan consisted on root coverage with coronal advanced flap with sub-epithelial connective tissue graft (CAF + SCTG) in the left upper and right lower quadrants and coronal advanced flap with sub-epithelial connective tissue graft along with application of enamel matrix derivative (CAF + SCTG + EMD) in the upper right and lower left quadrants.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient was advised on risks and procedures inherent to sub-epithelial connective tissue graft with and without use of EMD when undertaking root coverage. The patient signed an informed consent form before initiating therapy, and was treated in the time span ranging from August 2013 to May 2014.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Clinical measures</span><p id="par0065" class="elsevierStylePara elsevierViewall">Clinical measures used as success criteria for root coverage of gingival recession defects were: recession depth (RD) measured from the dentin-enamel junction to the gingival margin, probing depth (PD) measured from the gingival margin distance to the depth of the gingival sulcus, clinical insertion level (CIL) measured from the distance of the enamel cement junction to the sulcus depth and width of keratinized tissue (KT) measured from the distance of the muco-gingival line to the gingival margin. Location of muco-gingival line was determined visually. Clinical measures were observed immediately before as well as 6 months after surgery at the middle vestibular site of each treated tooth. To this effect, a millimeter Michigan periodontal probe (Hu-Friedy<span class="elsevierStyleSup">®</span>, Chicago III. USA) was used. All measurements were recorded by one of the authors and were rounded to the lower millimeter. Photographs were taken at treatment initiation, during surgery and at follow-up appointments up to 6 months post-operatively.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Included teeth were four canines and six premolars (upper and lower) giving a total of 12 gingival recessions. Seven gingival recessions were Miller's class I and five were Miller's class II. Six gingival recessions were treated with CAF + SCTG and six with CAF + SCTG + EMD.</p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Surgical procedure with CAF + SCTG in upper left and lower right quadrants</span></p><p id="par0080" class="elsevierStylePara elsevierViewall">After local anesthesia with 2% lidocaine with 1:100,000 epinephrine, root surfaces were scraped and smoothed with Gracey curettes (Hu-Friedy<span class="elsevierStyleSup">®</span>, Chicago Illinois, USA) in order to remove calculi and plaque deposits, leaving smooth surfaces and removing any protuberance. For surgery the Zucchelli G and De Sanctis M12 bilaminar technique for multiple recessions was used.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Oblique incisions were performed in the interproximal papillae, followed by intra-sulcus incisions around the gingival recessions. A flap of partial-total-partial thickness was lifted in coronal-apical direction. Oblique incisions created surgical papillae which were de-epithelialized. The flap was freed from underlying periostium so as to be able to be freely displaced in a coronal direction towards the level of the cementenamel junction.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The sub-epithelial connective tissue flap was obtained from the palate area, performing the trapdoor incision described by Langer.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Treatment was initiated with infiltrative blocking with 2% lidocaine anesthetic with epinephrine 1:100,000 at the level of premolars and mesial aspect of first molar. A horizontal incision was performed at approximately 5<span class="elsevierStyleHsp" style=""></span>mm from the gingival margin in apical direction. Two vertical incisions were undertaken at both sides of this horizontal incision. A partial thickness flap was raised thus obtaining sub-epithelial connective tissue. The area was sutured with cross-wise sutures, using absorbable 4-0 suture (PGA<span class="elsevierStyleSup">®</span> Atramat, Internacional Farmacéutica, Mexico City Mexico).</p><p id="par0095" class="elsevierStylePara elsevierViewall">The graft was partially sectioned so as to achieve greater extension and was then placed and adapted to exposed root surfaces. It was fixated to the receptor site with single isolated sutures. After this, the flap was placed in position and sutured at 2<span class="elsevierStyleHsp" style=""></span>mm in a coronal direction from the enamel-cement junction, fully covering the graft. To this effect, 4-0 absorbable sutures were used with horizontal suspensory sutures in all inter-proximal papillae (<a class="elsevierStyleCrossRefs" href="#fig0010">Figures 2 and 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CAF + SCTG + EMD surgical procedure in upper right and lower left quadrants</span></p><p id="par0105" class="elsevierStylePara elsevierViewall">Sites were treated as previously described with the exception of EMD gel (Emdogain<span class="elsevierStyleSup">®</span> Straumann, Switzerland) placement, following manufacturer's instructions.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Before placing SCTG, root surfaces were primed for 2<span class="elsevierStyleHsp" style=""></span>minutes with 24% PrefGel<span class="elsevierStyleSup">®</span> of EDTA (ethylenediaminetetraacetic acid) (Straumann Basel Switzerland). After this time, rinsing abundantly with pressured sterile saline physiological solution, they were lightly dried with sterile gauze. EMD was applied (Emdogain<span class="elsevierStyleSup">®</span>) on exposed root surfaces, starting at the base of the recession and covering the whole root surface. Immediately after this, the graft was placed on the gel at the level of the cement-enamel junction, and it was stabilized with absorbable 4-0 suture (PGA® Atramat, Internacional Farmacéutica, D.F., Mexico). The flap was coronally displaced l and sutured, using the same 4-0 absorbable suture with horizontal suspensory points at all inter-proximal papillae (<a class="elsevierStyleCrossRefs" href="#fig0020">Figures 4 and 5</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">POSTOPERATIVE CARE</span><p id="par0115" class="elsevierStylePara elsevierViewall">Following surgeries, 600<span class="elsevierStyleHsp" style=""></span>mg ibuprofen (Siegfried Rhein® D.F., Mexico) was prescribed to the patient, every 8<span class="elsevierStyleHsp" style=""></span>hours for four days. The patient was instructed to forego oral hygiene practices on treated zones, as well as use of 0.12% chlorhexidine oral rinse (Siegfried Rhein® D.F., Mexico) twice a day for two weeks. The patient was instructed not to brush the affected area and to avoid trauma and food impaction in the operated area for duration of two weeks. Sutures were removed after 15 days and the patient was instructed to resume brushing and use of dental floss. The patient was examined once a week for six weeks, and after that, every 2 months until 6 months had elapsed. At all appointments, the patient received reinforcement of oral hygiene instructions and was subjected to professional cleansing.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">STATISTICAL ANALYSIS</span><p id="par0120" class="elsevierStylePara elsevierViewall">Clinical results were assessed at the beginning of treatment and 6 months after treatment completion. Standard deviation mean was estimated for all four measurements, and these values were compared between both groups at basal measurement and at six months. In all groups, differences in before-after measurements were compared. T student test was used for independent samples, as well as for paired samples as hypothesis proof. p < 0.05 values were considered statistically significant. Results were analyzed through SPSS Software (version 17.0).</p><p id="par0125" class="elsevierStylePara elsevierViewall">Root coverage percentage was estimated after 6 months according to the following formula:<elsevierMultimedia ident="eq0005"></elsevierMultimedia></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">RESULTS</span><p id="par0130" class="elsevierStylePara elsevierViewall">After six months, all gingival recessions clinically presented soft tissue coverage whose color suitably matched surrounding tissues. None of the surgical procedures caused post-operative complications (<a class="elsevierStyleCrossRef" href="#fig0010">Figures 2</a> to 5).</p><p id="par0135" class="elsevierStylePara elsevierViewall">In all groups, means of measurements were compared at beginning of treatment as well as 6 months after treatment. It was found that both procedures, CAF + SCTG + EMD and CAF + SCTG caused significant root coverage, at an average of 2.83 ± 1.16<span class="elsevierStyleHsp" style=""></span>mm and 2.50 ± 0.83<span class="elsevierStyleHsp" style=""></span>mm respectively. This is to say that the root coverage increase (in millimeters) when comparing measurement at beginning of treatment and six months after completion was statistically significant in both methods. (p = .001 and p = .002).</p><p id="par0140" class="elsevierStylePara elsevierViewall">Averages of initial clinical measurements of gingival recession depth (RD), probing depth (PD), clinical insertion level (CIL) and keratinized tissue (KT) among teeth of both treatment groups were similar, since no statistically significant differences were found between both groups (p > .05) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table I</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">Six months after treatment, a new clinical evaluation was undertaken in order to identify which one of both treatments had achieved better clinical results. It was observed that gingival recessions treated with CAF + SCTG + EMD exhibited average gingival recession depth (RD) of 0.00<span class="elsevierStyleHsp" style=""></span>mm, this is to say 100% coverage was achieved, whereas recessions treated with CAF + SCTG exhibited an average of 1.33 ± 1.50 GR, and achieved 65.3% coverage, these differences were not statistically significant (p = 0.06). Nevertheless, when average clinical insertion level (CIL) was compared, it was found that the group with CAF + SCTG + EMD showed lower insertion average (2.00 ± 0.00) than the CAF + SCTG group (3.50 ± 1.05<span class="elsevierStyleHsp" style=""></span>mm). These differences were statistically significant (p = 0.02) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table I</a>)</p><p id="par0150" class="elsevierStylePara elsevierViewall">Probing depth averages did not exhibit differences between both groups after 6 months, since the CAF+ SCTG + EMD group exhibited 2.00 ± 0.00<span class="elsevierStyleHsp" style=""></span>mm and the CAF + SCTG group showed 2.17 ± 0.75<span class="elsevierStyleHsp" style=""></span>mm (p = 0.61). No statistically significant differences were found for keratinized tissue between groups, which respectively exhibited 3.17 ± 1.47<span class="elsevierStyleHsp" style=""></span>mm and 2.50 ± 1.05<span class="elsevierStyleHsp" style=""></span>mm (p = 0.39).</p><p id="par0155" class="elsevierStylePara elsevierViewall">Likewise, no statistically significant differences were found when comparing differences among before-after probing depth, clinical insertion level and keratinized tissue measurements in the two groups (p > 0.05).</p><p id="par0160" class="elsevierStylePara elsevierViewall">It was not possible to establish comparisons among class I and II gingival recessions, since their number was not similar in both groups.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">DISCUSSION</span><p id="par0165" class="elsevierStylePara elsevierViewall">The main objectives of surgical procedures for root coverage are the complete coverage and restoration of normal gingival anatomy, achieving thus eradication of root hypersensitivity and restoration of esthetics.</p><p id="par0170" class="elsevierStylePara elsevierViewall">Several techniques have been developed to achieve this goal; predictability has improved as a result of modifications undertaken through the years. It has been shown that the coronally-advanced flap without liberating incisions created by Zucchelli G and De Sanctis M<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> conferred abundant blood supply to the sub-epithelial connective tissue graft, improving thus the probabilities to achieve full root coverage in Miller's class I and II gingival recessions.</p><p id="par0175" class="elsevierStylePara elsevierViewall">The thin gingival phenotype present in this patient as well as keratinized tissue absence in apical location with respect to gingival recessions justified the CAF + SCTG procedure, since this procedure is indicated in these biotypes and in canine and premolar areas, with the aim of increasing marginal tissue thickness, avoiding contraction and favoring root coverage stability through time.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">In recent years, periodontal plastic surgery has focused not only on soft tissue coverage, but also on periodontal tissue coverage with the use of EMD; it has shown it can induce growth factor production, which in turn promotes migration of osteoblasts and periodontal ligament cells favoring thus periodontal regeneration in periodontal defects<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31,32</span></a> as well as in gingival recession defects.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,33</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">The present clinical case compared multiple gingival recessions coverage using the technique of coronally advanced flap with connective tissue graft (CAF + SCTG) with and without application of matrix enamel derivative (EMD). Results revealed that both procedures were effective to reduce gingival recession depth since both techniques produced a high percentage of root coverage (100% in CAF + SCTG + EMD and 65.3% in the group CAF + SCTG).</p><p id="par0190" class="elsevierStylePara elsevierViewall">The group CAF + SCTG + EMD statistically showed better results in the increase of clinical insertion after 6 months, when compared with the CAF + SCTG group. Likewise, it exhibited greater gain of root coverage, which furthermore was found at the limit of significance level (p = 0.06). Nevertheless, when comparing differences, none of both measurements resulted statistically significant. These results concur with those of Rasperini et al<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> who established greater rate of root coverage in the CAF + SCTG + EMD group (90%) than that of the CAF + SCTG group (80%), but this did not represent a significant statistical relevance. Other studies have not found additional clinical benefits of including EMD in CAF+SCTG<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">29,34,35</span></a> and suggest that, from a clinical point of view, its application is not necessary. Nevertheless, use of EMD could enhance early healing of periodontal tissues as well as new insertion of connective tissue towards the root surface.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> These benefits can only be histologically confirmed.</p><p id="par0195" class="elsevierStylePara elsevierViewall">This study did not prove additional KT gain when EMD was used combined with CAF + SCTG. Similarly, Aroca et al<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> study did not report noticeable KT increase after CAF + SCTG + EMD treatment. Nevertheless, other studies<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,37</span></a> have shown KT gain when EMD was applied with coronal-advanced flap for root coverage. This might suggest presence of an altered expression of keratinocytes stimulated by enamel matrix derivative.</p><p id="par0200" class="elsevierStylePara elsevierViewall">The patient was satisfied with the excellent esthetic results obtained, which were characterized by full root coverage in most gingival recessions and color similarity to surrounding tissues. Nevertheless, one of the disadvantages of this technique was the lengthy treatment time, since complete healing of palate is required in order to once more obtain sub-epithelial connective tissue graft.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">CONCLUSION</span><p id="par0205" class="elsevierStylePara elsevierViewall">Results of the present clinical case did not show that EMD use provided additional effect to achieve root coverage, or CIL decrease when a coronally advanced flap and sub-epithelial connective tissue graft were applied as treatment for root coverage in multiple Miller's class I and II recessions; neither did the other two clinical measurements reveal statistically significant differences. Nevertheless, it must be borne in mind that the small size of the sample could have prevented observation of greater differences in both treatments.</p><p id="par0210" class="elsevierStylePara elsevierViewall">Graduate and Research School, National School of Dentistry, National University of Mexico (UNAM).</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres583744" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec599931" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres583743" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec599932" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "INTRODUCTION" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "CLINICAL CASE" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Clinical measures" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "POSTOPERATIVE CARE" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "STATISTICAL ANALYSIS" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "RESULTS" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "DISCUSSION" ] 10 => array:2 [ "identificador" => "sec0040" "titulo" => "CONCLUSION" ] 11 => array:1 [ "titulo" => "REFERENCES" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec599931" "palabras" => array:5 [ 0 => "Gingival recession" 1 => "coronary-advanced flap" 2 => "connective tissue sub-epithelial graft" 3 => "enamel matrix derivatives" 4 => "periodontal regeneration." ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec599932" "palabras" => array:5 [ 0 => "Recesión gingival" 1 => "colgajo de avance coronal" 2 => "injerto subepitelial de tejido conectivo" 3 => "derivado de la matriz del esmalte" 4 => "regeneración periodontal." ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The present article described a clinical case where it was assessed whether aggregation of enamel matrix derivative (EMD) to the procedure of coronary-advanced flap with sub-epithelial connective tissue graft (CAF + SCTG) would improve the amount of root coverage in Miller's class I and II gingival recessions when compared to the same isolated procedure in a patient suffering multiple gingival recessions, in a 6 month time-span. Twelve gingival recessions were included in the study: six treated with (CAF + SCTG + EMD) and six treated with (CAF + SCTG) in different quadrants. At beginning of procedure as well as six months later, the following clinical parameters were measured: gingival recession depth (RD), depth to probing (PD), clinical insertion level (CIL) and width of keratinized tissue (KT) in apex-coronary direction. A p < 0.05 was considered statistically significant. Results established that after a six month procedure CAF + SCTG + EMD and CAF + SCTG produced significant root coverage, respective averages were 2.83 ± 1.16<span class="elsevierStyleHsp" style=""></span>mm (p = 0.001) and 2.50 ± 0.83<span class="elsevierStyleHsp" style=""></span>mm (p = .002). All gingival recessions treated with EMD experienced 100% root coverage, sites treated with CAF + SCTG + EMD exhibited coverage of only 65.3%. When comparing results at six months, better results were observed with CAF + SCTG + EMD with respect to clinical insertion level (p = .02) and root coverage (p = .06). Nevertheless, neither the difference of clinical level insertion nor the gain in root coverage resulted significant. Additionally, no significant differences were observed between PD and KT. <span class="elsevierStyleBold">Conclusion:</span> The present clinical case did not show additional benefits when EMD were aggregated to the CAF + SCTG in the coverage of multiple Miller's class I and class II gingival recessions.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Se presenta un caso clínico donde se evaluó si la agregación del derivado de la matriz del esmalte (DME) al procedimiento del colgajo de avance coronal con injerto de tejido conectivo subepitelial (CDC + ITCS) mejorarían la cantidad de cobertura radicular en recesiones gingivales clase I y II de Miller comparados con el mismo procedimiento solo, en un paciente con recesiones gingivales múltiples a seis meses. Se incluyeron 12 recesiones gingivales, seis tratadas con (CAC + ITCSE + DME) y seis con (CAC + ITCSE) en diferentes cuadrantes. Al inicio y a los seis meses se midieron los parámetros clínicos tal como profundidad de la recesión gingival (PR), profundidad al sondeo (PS), nivel de inserción clínica (NIC), y ancho de tejido queratinizado en dirección apico-coronal (TQ). Un valor p < 0.05 se consideró significativo. Los resultados mostraron que a los seis meses ambos procedimientos, CAC + ITCSE+ DME y CAC + ITCSE produjeron una significativa cobertura radicular en promedio 2.83 ± 1.16<span class="elsevierStyleHsp" style=""></span>mm (p = 0.001) y 2.50 ± 0.83<span class="elsevierStyleHsp" style=""></span>mm (p = .002), respectivamente. Todas las recesiones gingivales tratadas con el DME tuvieron el 100% de cobertura radicular y sólo el 65.3% de cobertura para los sitios tratados con CAC + ITCSE. Al comparar ambos procedimientos a los seis meses se observaron mejores resultados con CAC + ITCSE + DME en cuanto al nivel de inserción clínica (p = .02) y la cobertura radicular (p = .06); sin embargo, la diferencia del nivel de inserción clínico ni la ganancia en la cobertura radicular mostraron ser significativos. Por otro lado, no se observaron diferencias significativas en la PS y TQ. <span class="elsevierStyleBold">Conclusión:</span> El presente caso clínico no mostró beneficio adicional cuando se agregó el DME al procedimiento de CAC + ITCSE para la cobertura de recesiones gingivales múltiples clase I y II de Miller.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">This article can be read in its full version in the following page: http://www.medigraphic.com/facultadodontologiaunam.</p>" "identificador" => "fn1" ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 386 "Ancho" => 2101 "Tamanyo" => 120569 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Initial photographs. <span class="elsevierStyleBold">(A)</span> Right lateral side with multiple Miller's class I and II recessions. <span class="elsevierStyleBold">(B)</span> The anterior area presented ridge to ridge occlusion and gingival recessions in lateral teeth and upper canines as well as in lower teeth. <span class="elsevierStyleBold">(C)</span> Left lateral view with class I and II gingival recessions.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1704 "Ancho" => 1425 "Tamanyo" => 313163 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Surgical procedure with CAF + SCTG in left upper quadrant. <span class="elsevierStyleBold">(A)</span> Gingival recessions before surgery.<span class="elsevierStyleBold">(B)</span> Oblique incisions beginning from the largest recession. <span class="elsevierStyleBold">(C)</span>, <span class="elsevierStyleBold">(D)</span> and <span class="elsevierStyleBold">(E)</span> Graft cut in order to obtain greater extension. <span class="elsevierStyleBold">(F)</span> Graft placement and adaptation. <span class="elsevierStyleBold">(G)</span> Sutured, coronally displaced flap. <span class="elsevierStyleBold">(H)</span> Postoperative results six months after treatment completion.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1852 "Ancho" => 1434 "Tamanyo" => 375852 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">CAF + SCTG in lower right quadrant. <span class="elsevierStyleBold">(A)</span> Gingival recessions before surgery. <span class="elsevierStyleBold">(B)</span> Oblique incisions and de-epithelialization of interproximal papillae. <span class="elsevierStyleBold">(C)</span> Partial-totalpartial thickness fl ap lifting. <span class="elsevierStyleBold">(D)</span> Flap released from underlying periostium.<span class="elsevierStyleBold">(E)</span> Palate graft harvesting. <span class="elsevierStyleBold">(F).</span>Graft placement on root surfaces.<span class="elsevierStyleBold">(G)</span> Sutured displaced flap. <span class="elsevierStyleBold">(H)</span> Postoperative results six months after treatment completion.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1511 "Ancho" => 1430 "Tamanyo" => 293032 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">CAF + SCTG + EMD in upper right quadrant. <span class="elsevierStyleBold">(A)</span> Gingival recessions before surgery. <span class="elsevierStyleBold">(B)</span> Flap lifting underneath oblique incisions. <span class="elsevierStyleBold">(C)</span> Placement of PrefGel on root surfaces. <span class="elsevierStyleBold">(D)</span> Abundant irrigation with physiological solution to remove PrefGel. <span class="elsevierStyleBold">(E)</span> Application of EMD on root surfaces. <span class="elsevierStyleBold">(F)</span> Graft placed immediately after EMD application on root surfaces. <span class="elsevierStyleBold">(G)</span> Flap sutured above the enamel-cement junction. <span class="elsevierStyleBold">(H)</span> Healing at six months.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1248 "Ancho" => 1362 "Tamanyo" => 219848 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">CAF + SCTG + EMD in lower left quadrant. <span class="elsevierStyleBold">(A)</span> Gingival recessions before surgery. <span class="elsevierStyleBold">(B)</span> EMD placement on root surfaces. <span class="elsevierStyleBold">(C)</span> Graft adaptation and suture.(<span class="elsevierStyleBold">D</span>) Flap suture fully covering the graft. (E) Healing six months after treatment.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table I" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">CAF + SCTG + EMD= coronally advanced flap and sub-epithelial connective tissue graft with enamel matrix derivative, CAF + SCTG = coronally advanced flap and sub-epithelial connective tissue graft, RD = gingival recession depth, PD = probing depth, CIL = clinical insertion level, KT = keratinized tissue, RCA = root coverage average, CRC = complete root coverage.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">T Student test for independent and paired samples.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group CAF + SCTG + EMD (n = 6) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group CAF + EMD (n = 6) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RD average (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beginning \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.83 ± 1.17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.83 ± 1.47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.00 ± 0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.33 ± 1.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.06<span class="elsevierStyleSup">*</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Difference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.83 ± 1.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.50 ± 0.83 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.58 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PD average (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beginning \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.33 ± 0.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.83 ± 0.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.00 ± 0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.17 ± 0.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.61 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Difference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.66 ± 0.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.33 ± 1.21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.56 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CIL average (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beginning \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4.17 ± 1.33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.67 ± 2.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.00 ± 0.00 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.50 ± 1.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.02<span class="elsevierStyleSup">*</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Difference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.16 ± 1.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.16 ± 1.47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">KT average (mm) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Beginning \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.50 ± 1.23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.83 ± 0.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.32 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.17 ± 1.47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.50 ± 1.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.39 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Difference \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.67 ± 0.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.67 ± 0.51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">RCA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">65.3% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab952313.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Base measurements and measurements at six months and difference between base and six month measurements according to treatment group.</p>" ] ] 6 => array:5 [ "identificador" => "eq0005" "tipo" => "MULTIMEDIAFORMULA" "mostrarFloat" => false "mostrarDisplay" => true "Formula" => array:1 [ "imagen" => array:1 [ 0 => array:4 [ "Fichero" => "fx1.jpeg" "Tamanyo" => 103684 "Alto" => 322 "Ancho" => 3025 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "REFERENCES" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:37 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "American Academy of Periodontology. <span class="elsevierStyleItalic">Glossary of periodontal terms</span>. 3rd ed. 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| 2023 November | 100 | 2 | 102 |
| 2023 October | 123 | 13 | 136 |
| 2023 September | 73 | 2 | 75 |
| 2023 August | 93 | 6 | 99 |
| 2023 July | 128 | 4 | 132 |
| 2023 June | 98 | 10 | 108 |
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| 2020 September | 77 | 11 | 88 |
| 2020 August | 72 | 12 | 84 |
| 2020 July | 49 | 14 | 63 |
| 2020 June | 50 | 10 | 60 |
| 2020 May | 36 | 5 | 41 |
| 2020 April | 36 | 5 | 41 |
| 2020 March | 41 | 2 | 43 |
| 2020 February | 47 | 6 | 53 |
| 2020 January | 45 | 7 | 52 |
| 2019 December | 51 | 12 | 63 |
| 2019 November | 35 | 2 | 37 |
| 2019 October | 40 | 3 | 43 |
| 2019 September | 52 | 9 | 61 |
| 2019 August | 52 | 1 | 53 |
| 2019 July | 44 | 6 | 50 |
| 2019 June | 96 | 26 | 122 |
| 2019 May | 141 | 36 | 177 |
| 2019 April | 103 | 8 | 111 |
| 2019 March | 33 | 5 | 38 |
| 2019 February | 34 | 3 | 37 |
| 2019 January | 16 | 3 | 19 |
| 2018 December | 17 | 3 | 20 |
| 2018 November | 41 | 3 | 44 |
| 2018 October | 35 | 5 | 40 |
| 2018 September | 60 | 11 | 71 |
| 2018 August | 61 | 3 | 64 |
| 2018 July | 55 | 0 | 55 |
| 2018 June | 56 | 2 | 58 |
| 2018 May | 74 | 4 | 78 |
| 2018 April | 52 | 2 | 54 |
| 2018 March | 54 | 1 | 55 |
| 2018 February | 28 | 1 | 29 |
| 2018 January | 24 | 0 | 24 |
| 2017 December | 47 | 2 | 49 |
| 2017 November | 12 | 1 | 13 |
| 2017 October | 31 | 10 | 41 |
| 2017 September | 14 | 5 | 19 |
| 2017 August | 30 | 4 | 34 |
| 2017 July | 24 | 2 | 26 |
| 2017 June | 34 | 15 | 49 |
| 2017 May | 52 | 9 | 61 |
| 2017 April | 29 | 29 | 58 |
| 2017 March | 22 | 55 | 77 |
| 2017 February | 49 | 6 | 55 |
| 2017 January | 17 | 4 | 21 |
| 2016 December | 29 | 6 | 35 |
| 2016 November | 41 | 2 | 43 |
| 2016 October | 54 | 11 | 65 |
| 2016 September | 82 | 5 | 87 |
| 2016 August | 40 | 4 | 44 |
| 2016 July | 33 | 1 | 34 |
| 2016 June | 38 | 10 | 48 |
| 2016 May | 35 | 23 | 58 |
| 2016 April | 37 | 22 | 59 |
| 2016 March | 61 | 26 | 87 |
| 2016 February | 43 | 33 | 76 |
| 2016 January | 29 | 24 | 53 |
| 2015 December | 23 | 13 | 36 |
Show all