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    Soft tissue Soft tissue Document Transcript

    • 307A Decision Tree for Soft Tissue GraftingDaylene Jack-Min Leong, BDS* “Mucogingival surgery” is a termHom-Lay Wang, DDS, MSD, PhD** first introduced in 1957 by Fried- man1 and was defined as ”surgical procedures designed to preserve gingiva, remove aberrant frenulumPeriodontal plastic surgery is commonly performed for esthetic and physiologic or muscular attachments, and in-reasons, such as alleviating root sensitivity, root caries, and cervical abrasion crease the depth of the vestibule.”and facilitating plaque control at the affected site. Currently, there is a lack These procedures were performedof information regarding the most appropriate treatment method for the to maintain an adequate mucogin-various clinical situations encountered. The aims of this paper are to review gival complex, with emphasis onand discuss the various clinical situations that require soft tissue grafting and the amount of attached gingiva.to attempt to provide recommendations for the most predictable technique. However, techniques were later de-Using MEDLINE and The Cochrane Library, a review of all available literature signed not only for health reasonswas performed. Papers published in peer-reviewed journals written in English but also for cosmetic purposes.were chosen and reviewed to validate the decision-making process when Subsequently, Miller not only intro-planning for soft tissue grafting. A decision tree was subsequently developed to duced a classification of marginalguide clinicians to choose the most appropriate soft tissue grafting procedure tissue recession,2 he also coined theby taking into consideration the following clinical parameters: etiology,purpose of the procedure, adjacent interproximal bone level, and overlying term ”periodontal plastic surgery”tissue thickness. The decision tree proposed serves as a guide for clinicians in 1988,3 which was accordinglyto select the most appropriate and predictable soft tissue grafting procedure defined at the Proceedings of theto minimize unnecessary mistakes while providing the ultimate desired World Workshop in Periodontics intreatment outcome. (Int J Periodontics Restorative Dent 2011;31:307–313.) 19964 as “surgical procedures per- formed to prevent or correct ana- tomic, developmental, traumatic or disease-induced defects of the gin-  * esident, Department of Periodontics and Oral Medicine, School of Dentistry, University R of Michigan, Ann Arbor, Michigan. giva, alveolar mucosa or bone.”** rofessor and Director of Graduate Periodontics, Department of Periodontics and Oral P Today, periodontal plastic sur- Medicine, School of Dentistry, University of Michigan, Ann Arbor, Michigan. gery is not only performed for physiologic reasons, but also for es- Correspondence to: Dr Hom-Lay Wang, Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, 1011 North University Avenue, Ann Arbor, MI thetic purposes. This paper focuses 48109-1078; fax: (734) 936-0374; email: homlay@umich.edu. on the management of soft tissue Volume 31, Number 3, 2011 © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 308defects and discusses situations in Etiology used, deepithelialization is requiredwhich a clinician would consider a at 12 weeks after healing so that thesoft tissue plastic surgery proce- First and foremost, it is of para- conversion of the overlying tissue todure. In addition, the authors at- mount importance to identify the keratinized tissue by the underlyingtempt to provide recommendations etiology of the soft tissue defect CT can occur.11,12 Some studies haveas to the appropriate technique in and remove the associated etiol- used acellular dermal matrix (ADM)different clinical scenarios to mini- ogy to achieve long-term stability as an alternative to an autogenousmize unnecessary mistakes through of the treatment outcome. Some palatal mucosal graft with a certainproviding the predictability and common etiologies for gingival re- degree of success,13,14 but the gainoverall success of treatment. cession include toothbrush trauma, in the width of KG and amount of tooth malalignment, calculus, gingi- root coverage using these allografts val inflammation, and orthodontic and other biologic agents or tissue-Decision tree for tooth movement.5,6 By addressing engineered products is generallysoft tissue grafting these etiologies, one can prevent not as predictable as compared to the problem from recurring. If mal­ CT grafts or FST graft.15,16Soft tissue grafting is a type of aligned teeth or orthodontic treat-periodontal plastic surgery, and a ment led to the gingival recession Increasing tissue thicknessdecision tree for performing soft and mucogingival problems, the On the other hand, if increasing tis-tissue grafting is herein proposed dentist or periodontist should com- sue thickness is the ultimate goal ofto guide clinicians in making a pru- municate with the orthodontist prior treatment, then procedures usingdent choice of the most appropri- to initiation of surgical correction to CT grafts, ADM, or bone augmenta-ate and predictable techniques in ensure proper treatment outcomes. tion techniques may be carried out.managing different goals and clini- Studies have reported that althoughcal situations (Fig 1). This decision both CT grafts and ADM producedtree takes into consideration the Treatment purpose an increase in gingival thickness,following important influencing greater improvement was observedfactors: identifying and removing Next, one should question the pur- when using the CT graft.17 Otherthe etiology of the problem, estab- pose of the procedure. Soft tissue experimental studies comparing alishing the purpose of treatment, grafting can be done for augment- coronally advanced flap (CAF) withand then determining the poten- ing the zone of keratinized gingiva or without ADM in the treatmenttial of root coverage by examining (KG), increasing tissue thickness, or of gingival recessions showed suc-the adjacent interproximal bone achieving root coverage. cessful outcomes in gaining gingivallevel and overlying tissue thick- thickness with the adjunctive use ofness. By adopting this decision- Augmenting the zone of KG ADM.18,19 However, the long-termmaking process, predictable treat- In situations where increasing the stability of both procedures remainsment outcomes would increase zone of KG is desired, procedures to be determined. For CT grafts,and unnecessary complications and such as the apically positioned deepithelialization is recommend-failures would be reduced. The ra- flap (APF),7 free soft tissue (FST) ed11,12; more studies are neededtionale and evidence in support of grafting,8,9 laterally positioned flap for ADM because of the lack of ca-this decision-making process are (LPF),10 and two-stage connective pacity of converting to KG.20 Bonediscussed. tissue (CT) grafts are all feasible, augmentation using nonresorbable with the possibility of using tissue- bone grafts has also been advocat- engineered or biologic agents as ed for this purpose and has shown well. When a two-stage CT graft is some success.21The International Journal of Periodontics & Restorative Dentistry © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 309 Identify etiology Remove etiology Purpose of procedure Increase KG Increase tissue thickness APF, free soft tissue, LPT, tissue engineering (biologic agents), CT, ADM, or CT graft first then deepithelialize at bone augmentation Root coverage 12 weeks after Check interproximal bone level No bone loss Bone loss (Miller Class I or II) (Miller Class III or IV) 100% root coverage possible Root coverage is unpredicatable Check tissue thickness Class III: Class IV: 70% to 75% No root root coverage coverage New attachment with Thin (< 1 mm) Thick (≥ 1 mm) root coverage CT graft preferably Any soft tissue procedures: GTRC, tissue (deepithelialization CT graft, CAF, GTR, ADM, engineeering at 12 weeks after) LPF, or combination (biologic agents)Fig 1    Decision tree for selecting a soft tissue grafting procedure. CT = connective tissue; CAF = coronally advanced flap; GTR = guidedtissue regeneration; ADM = acellular dermal matrix; KG = keratinized gingiva; LPF = laterally positioned flap; APF = apically positioned flap;GTRC = GTR-based root coverage. Volume 31, Number 3, 2011 © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 310 Root coverage While gingival thickness was If the goal of treatment is to attain not considered an influencing fac- root coverage so that esthetics can tor in achieving 100% root cov- be improved and hypersensitivity erage with the CT procedure, it can be reduced, factors to consider proved to be so for the CAF22–25 that can influence the predictabil- and GTR procedures.26 In a recent ity of root coverage procedures systematic review, a critical thresh- include the interproximal bone old flap thickness of > 1.1 mm was level of the involved tooth or teeth found to be associated with com- as well as gingival tissue thickness plete root coverage for GTR and (also known as tissue biotype). CT grafting.25 To predict the amount of root For a CAF procedure, an aver- coverage obtainable, it would be age thickness of 0.8 to 1.2 mm has useful to understand the type of been suggested as the minimal tis- gingival recession according to the sue thickness to achieve complete Miller classification.2 Based on the root coverage.22–-25 The thickness of Miller classification, one has to as- the marginal tissue (eg, ≥ 0.8 mm) sess the adjacent interproximal has been credited as a primary bone level for any bone loss before attribute for the success of root any soft tissue grafting procedure.2 coverage for a CAF procedure.24 In general, complete root coverage Another study investigating the can be achieved in Class I and II factors affecting the outcomes of defects, only partial root coverage CAF procedures reported that an (70% to 75%) can be accomplished initial gingival thickness > 1.2 mm in Class III defects, and Class IV de- was highly associated with com- fects are not amenable to root cov- plete root coverage.22 When the erage.2 As such, it was the authors’ criteria mentioned previously were objective to focus on the manage- adhered to or when a CT graft was ment of Miller Class I and II defects, placed under a CAF, the amount of while Miller Class III and IV defects mean defect coverage was almost are not described in this paper. 100%.22,27,28 Therefore, if the gingi- In deciding the soft tissue graft- val biotype is thick, root coverage ing procedure for root coverage, can be achieved with a CAF alone the next parameter to assess is gin- or other types of grafting proce- gival tissue thickness. In Miller Class dures (eg, GTR, ADM). On the oth- I and II recession defects with thin er hand, defects should be treated gingival thickness (< 1 mm), the in combination with a CT graft at treatment of choice would be a CT sites with a thin gingival biotype. graft. In the presence of thick tissue This is in agreement with a recent (≥ 1 mm), any soft tissue procedure multicenter, randomized, double- may be selected, such as a CT graft, blind clinical trial that showed that CAF, guided tissue regeneration additional placement of a CT graft (GTR), ADM, LPF, or a combination beneath a CAF increased the prob- of these procedures and materials. ability of achieving complete rootThe International Journal of Periodontics & Restorative Dentistry © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 311coverage in Miller Class I and II de- coverage for these studies.34 GTRfects in maxillary teeth.29 procedures using both absorbable Using GTR, sites with a tissue and nonresorbable membranesthickness of > 0.5 mm obtained have been performed for root cov-a mean root coverage of 95.6%; erage, with no apparent significantat thin areas of ≤ 0.5 mm, a mean differences in treatment outcome.38root coverage of only 26.7% was The mean root coverage has beenobtained.26 This may lead one found to be approximately 72% toto speculate that the membrane 73%, with a 35% to 39% predict-placed between the bone and full- ability of achieving ≥ 90% root cov-thickness flap may have acted as erage.34,39,40 Some factors affectinga barrier preventing blood circula- the success of root coverage in-tion. This is especially detrimental clude the initial recession depth,41for a thin flap. gingival thickness,25,26 and mem- Techniques used for root cov- brane exposure.42erage include CT grafts, FST grafts, In a recent systematic reviewpedicle autografts (rotational and comparing CT grafts, ADM, andadvanced flaps), GTR, and, more GTR with absorbable membranes,recently, acellular dermal matrix. results showed that CT grafts canThe use of a CT graft for root cov- be considered the ”gold standard”erage has been shown to be a in treating Miller Class I and II re-highly predictable and successful cession defects with respect to ob-procedure. Studies have shown a taining substantial root coverage,mean defect coverage of 84%30–32 clinical attachment, and keratinizedand a predictability of achieving tissue gain.43 Similar results in favor≥ 90% defect coverage 68% of of CT grafts were also reported inthe time.30,33,34 The CAF is another other systematic reviews.44,45technique often used alone or in Another factor that may influ-combination26 with other soft tis- ence the final treatment outcomesue grafting procedures to cover is the final position of the gingivalexposed roots. However, the re- margin. It has been demonstratedsults can only be predictable un- that the more coronal the level ofder specified conditions27,28: Miller the gingival margin postsuturing,Class I recession defect, shallow re- the higher the probability of achiev-cession ≤ 4 mm, keratinized tissue ing complete root coverage.35width ≥ 3 mm, gingival thickness ≥ Huang and Wang23 introduced a0.8,22,24,27 and overcorrection of the ”sling and tag” technique in 2007defect.23,35 The LPF technique has for the CAF procedure, and in thebeen advocated for coverage of lo- study, the flap was repositioned cor-calized recession defects. In gener- onally beyond the cementoenamelal, clinical studies on humans have junction by at least 1 mm. At 1 yearreported a range of 61% to 74% postsurgery, a mean root cover-reduction in recession depth,10,36,37 age of 93% ± 15% was obtained,representing a mean 67% defect indicating very successful results. Volume 31, Number 3, 2011 © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 312Therefore, to increase the predict- Acknowledgments 13. de Souza SL, Novaes AB Jr, Grisi DC, Taba M Jr, Grisi MF, de Andrade PF. Compara-ability of complete root coverage tive clinical study of a subepithelial con- This study was supported by the Periodontalwith a CAF procedure, it is gener- nective tissue graft and acellular dermal Graduate Student Research Fund, University matrix graft for the treatment of gingivalally recommended that the flap be of Michigan, Ann Arbor, Michigan. recessions: Six- to 12-month changes.repositioned at least 1 mm beyond J Int Acad Periodontol 2008;10(3):87–94.the cementoenamel junction. 14. Wei PC, Laurell L, Geivelis M, Lingen MW, Maddalozzo D. Acellular dermal If the objective of root coverage References matrix allografts to achieve increased at-is to obtain new attachment, proce- tached gingiva. Part 1. A clinical study.   1. Friedman N. Mucogingival surgery. Texas J Periodontol 2000;71:1297–1305.dures such as GTR-based root cov- Dent J 1957;75:358–362. 15. Harris RJ. A short-term and long-termerage and use of tissue-engineered  2. Miller PD Jr. A classification of marginal comparison of root coverage with an tissue recession. Int J Periodontics Re- acellular dermal matrix and a subepitheli-or biologic agents may be consid- storative Dent 1985;5:8–13. al graft. J Periodontol 2004;75:734–743.ered. GTR and other techniques,   3. Miller PD Jr. Regenerative and reconstruc- 16. McGuire MK, Scheyer ET, Nunn ME,such as root surface conditioning tive periodontal plastic surgery. Mucogin- Lavin PT. A pilot study to evaluate a tis- gival surgery. Dent Clin North Am 1988; sue-engineered bilayered cell therapy asprocedures and root biomodifi- 32:287–306. an alternative to tissue from the palate.cation with biologic agents (eg,  4. Proceedings of the World Workshop on J Periodontol 2008;79:1847–1856. Periodontics. Consensus report on muco- 17. Joly JC, Carvalho AM, da Silva RC, Ciottienamel matrix derivatives), have gingival therapy. Ann Periodontol 1996;1: DL, Curry PR. Root coverage in isolatedshown varying results with uncer- 702–706. gingival recessions using autograft ver-tain predictability in obtaining new   5. Gorman WJ. Prevalence and etiology of sus allograft: A pilot study. J Periodontol gingival recession. J Periodontol 1967;38: 2007;78:1017–1022.attachment and root coverage.46 316–322. 18. Woodyard JG, Greenwell H, Hill M, Dris-Histologic evidence showing re-  6. Hall WB. Pure Mucogingival Problems: ko C, Iasella JM, Scheetz J. The clinical Etiology, Treatment and Prevention. Chi- effect of acellular dermal matrix on gin-generation of the periodontium at cago: Quintessence, 1984. gival thickness and root coverage com-6 months has been shown in stud-  7. Friedman N. Mucogingival surgery. The pared to coronally positioned flap alone.ies using EMD and certain growth apically repositioned flap. J Periodontol J Periodontol 2004;75:44–56. 1962;33:328–340. 19. Sallum EA, Nogueira-Filho GR, Casatifactors.47,48 However, more studies  8. James WC, McFall WT Jr. Placement of MZ, Pimentel SP, Saldanha JB, Nociti FHare warranted in this area to ascer- free gingival grafts on denuded alveolar Jr. Coronally positioned flap with or with- bone. Part I: Clinical evaluations. J Peri- out acellular dermal matrix graft in gingi-tain the effectiveness and predict- odontol 1978;49:283–290. val recessions: A histometric study. Am Jability of attaining new attachment  9. Matter J, Cimasoni G. Creeping attach- Dent 2006;19:128–132.with various biologic agents. ment after free gingival grafts. J Peri- 20. Harris RJ. Gingival augmentation with an odontol 1976;47:574–579. acellular dermal matrix: Human histolog- 10. Guinard EA, Caffesse RG. Treatment of ic evaluation of a case—Placement of the localized gingival recessions. Part I. Lat- graft on periosteum. Int J Periodontics eral sliding flap. J Periodontol 1978;49:Conclusion 351–356. Restorative Dent 2004;24:378–385. 21. Seibert JS. Ridge augmentation to en- 11. Karring T, Cumming BR, Oliver RC, Löe hance esthetics in fixed prosthetic treat-The decision tree proposed serves H. The origin of granulation tissue and its ment. Compendium 1991;12:548–552. impact on postoperative results of muco- 22. Huang LH, Neiva RE, Wang HL. Factorsas a guide for clinicians to select gingival surgery. J Periodontol 1975;46: affecting the outcomes of coronally ad-the most appropriate and predict- 577–585. vanced flap root coverage procedure. 12. Cordioli G, Mortarino C, Chierico A, J Periodontol 2005;76:1729–1734.able soft tissue grafting procedure Grusovin MG, Majzoub Z. Comparison 23. Huang LH, Wang HL. Sling and tag su-to minimize unnecessary mistakes of 2 techniques of subepithelial connec- turing technique for coronally advancedwhile providing the ultimate de- tive tissue graft in the treatment of gin- flap. Int J Periodontics Restorative Dent gival recessions. J Periodontol 2001;72: 2007;27:379–385.sired treatment outcome. 1470–1476. 24. Baldi C, Pini Prato G, Pagliaro U, et al. Coronally advanced flap procedure for root coverage. Is flap thickness a relevant predictor to achieve root coverage? A 19-case series. J Periodontol 1999;70: 1077–1084.The International Journal of Periodontics & Restorative Dentistry © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
    • 31325. Hwang D, Wang HL. Flap thickness as a 36. Smukler H. Laterally positioned muco- 48. McGuire MK, Scheyer ET, Nevins M, predictor of root coverage: A systematic periosteal pedicle grafts in the treatment Schupbach P. Evaluation of human re- review. J Periodontol 2006;77:1625–1634. of denuded roots. A clinical and statistical cession defects treated with coronally26. Harris RJ. A comparative study of root study. J Periodontol 1976;47:590–595. advanced flaps and either purified recom- coverage obtained with guided tissue 37. Caffesse RG, Espinel M. Lateral sliding binant human platelet-derived growth regeneration utilizing a bioabsorbable flap with a free gingival graft technique in factor-BB with beta tricalcium phosphate membrane versus the connective tissue the treatment of localized gingival reces- or connective tissue: A histologic and with partial-thickness double pedicle sions. Int J Periodontics Restorative Dent microcomputed tomographic examina- graft. J Periodontol 1997;68:779–790. 1981;1:22–29. tion. Int J Periodontics Restorative Dent27. Allen MP, Miller PD Jr. Coronal position- 38. Roccuzzo M, Lungo M, Corrente G, Gan- 2009;29:7–21. ing of existing gingiva: Short term results dolfo S. Comparative study of a bioresorb- in the treatment of shallow marginal tis- able and a non-resorbable membrane in sue recession. J Periodontol 1989;60: the treatment of human buccal gingival 316–319. recessions. J Periodontol 1996;67:7–14.28. Harris RJ, Harris AW. The coronally po- 39. Shieh AT, Wang HL, O’Neal R, Glickman sitioned pedicle graft with inlaid mar- GN, MacNeil RL. Development and clini- gins: A predictable method of obtaining cal evaluation of a root coverage proce- root coverage of shallow defects. Int J dure using a collagen barrier membrane. Periodontics Restorative Dent 1994;14: J Periodontol 1997;68:770–778. 228–241. 40. Harris RJ. GTR for root coverage: A long-29. Cortellini P, Tonetti M, Baldi C, et al. Does term follow-up. Int J Periodontics Restor- placement of a connective tissue graft ative Dent 2002;22:55–61. improve the outcomes of coronally ad- 41. Pini Prato G, Tinti C, Vincenzi G, Magnani vanced flap for coverage of single gingi- C, Cortellini P, Clauser C. Guided tissue val recessions in upper anterior teeth? A regeneration versus mucogingival sur- multi-centre, randomized, double-blind, gery in the treatment of human buccal clinical trial. J Clin Periodontol 2009;36: gingival recession. J Periodontol 1992;63: 68–79. 919–928.30. Harris RJ. The connective tissue and 42. Trombelli L, Schincaglia GP, Scapoli C, partial thickness double pedicle graft: A Calura G. Healing response of human predictable method of obtaining root cov- buccal gingival recessions treated with erage. J Periodontol 1992;63:477–486. expanded polytetrafluoroethylene mem-31. Harris RJ. A comparative study of root branes. A retrospective report. J Peri- coverage obtained with an acellular der- odontol 1995;66:14–22. mal matrix versus a connective tissue 43. Chambrone L, Chambrone D, Pustiglioni graft: Results of 107 recession defects FE, Chambrone LA, Lima LA. Can subepi- in 50 consecutively treated patients. Int thelial connective tissue grafts be consid- J Periodontics Restorative Dent 2000;20: ered the gold standard procedure in the 51–59. treatment of Miller Class I and II recession-32. Wang HL, Bunyaratavej P, Labadie M, Shyr type defects? J Dent 2008;36:659–671. Y, MacNeil RL. Comparison of 2 clinical 44. Roccuzzo M, Bunion M, Needleman I, techniques for treatment of gingival reces- Sanz M. Periodontal plastic surgery for sion. J Periodontol 2001;72:1301–1311. treatment of localized gingival recessions:33. H, Moses O, Zohar R, Meir H, Nem- Tal A systematic review. J Clin Periodontol covsky C. Root coverage of advanced 2002;29(suppl 3):178–194. gingival recession: A comparative study 45. Oates TW, Robinson M, Gunsolley JC. between acellular dermal matrix allograft Surgical therapies for the treatment of and subepithelial connective tissue gingival recession. A systematic review. grafts. J Periodontol 2002;73:1405–1411. Ann Periodontol 2003;8:303–320.34. Greenwell H, Fiorellini J, Giannobile W, 46. Cheng YF, Chen JW, Lin SJ, Lu HK. Is cor- et al. Oral reconstructive and corrective onally positioned flap procedure adjunct considerations in periodontal therapy. with enamel matrix derivative or root con- J Periodontol 2005;76:1588–1600. ditioning a relevant predictor for achiev-35. Pini Prato GP, Baldi C, Nieri M, et al. ing root coverage? A systematic review. J Coronally advanced flap: The post-surgi- Periodontal Res 2007;42:474–485. cal position of the gingival margin is an 47. McGuire MK, Cochran DL. Evaluation of important factor for achieving complete human recession defects treated with cor- root coverage. J Periodontol 2005;76: onally advanced flaps and either enamel 713–722. matrix derivative or connective tissue. Part 2: Histological evaluation. J Peri- odontol 2003;74:1126–1135. Volume 31, Number 3, 2011 © 2011 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.. NO PART OF MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.