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 Table of Contents  
Year : 2016  |  Volume : 7  |  Issue : 2  |  Page : 258-261  

Calcium sulfate combined with guided tissue regeneration: A novel technique in treatment of gingival recessions

Department of Periodontology, Army Dental Centre Research and Referral, New Delhi, India

Date of Web Publication27-May-2016

Correspondence Address:
Arnav Mukherji
Flat 202, Block-15, Heritage Apartments, Near GC CRPF, On DBP Road, Yelahanka, Bengaluru - 560 064, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-237X.183073

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The presence of mucogingival problem around anterior teeth is a challenge to the clinician as not only biological and functional aspects has to be addressed but esthetic aspirations of the patient have to be met. The use of guided tissue regeneration (GTR) procedures for the treatment of gingival recession has shown encouraging results and is gaining clinical acceptance. However, maintenance of space under the membrane remains a problem for clinicians. Hence, this case study was an innovative attempt to evaluate the effect of adjunctive calcium sulfate placement along with collagen membrane GTR-based root coverage procedure.

Keywords: Calcium sulfate, coronally advanced flap, gingival recession, guided tissue regeneration

How to cite this article:
Mukherji A. Calcium sulfate combined with guided tissue regeneration: A novel technique in treatment of gingival recessions. Contemp Clin Dent 2016;7:258-61

How to cite this URL:
Mukherji A. Calcium sulfate combined with guided tissue regeneration: A novel technique in treatment of gingival recessions. Contemp Clin Dent [serial online] 2016 [cited 2021 Apr 14];7:258-61. Available from:

   Introduction Top

Gingival recession affects larger portion of adult population which is the apical shift of gingival margin beyond cementoenamel junction (CEJ).[1],[2],[3] The main factors contributing to this phenomenon are toothbrush trauma,[4] iatrogenic factors [5] (uncontrolled orthodontic movement in terms of force), improper restorations, oral habits, and viral infections of the gingiva.[6] Compromised esthetics, hypersensitivity, higher incidence of root caries, and poor plaque control are associated with gingival recession.[2] Predictable correction of gingival recession defects remains a challenge for clinician. Several techniques such as the laterally positioned pedicle graft, coronally advanced flap (CAF), free gingival graft, and subepithelial connective tissue graft are used which have yielded promising results.[7]

Investigators have reported successful root coverage using surgical techniques based on the principles of guided tissue regeneration (GTR).[8],[9],[10] GTR based root coverage, however, offers the additional potential benefit of new attachment formation (bone, cementum, periodontal ligament, and connective tissue) along the previously denuded root surface.[11]

It is very difficult to maintain the space under the membrane since the membrane tends to collapse against the root surface. The use of bone graft under a membrane can prevent this and enhance clot stability and cell proliferation.[12]

Unlike demineralized freeze-dried bone allograft (DFDBA), calcium sulfate does not possess osteogenic properties, but it has been used successfully as a binder/filler, functioning as a scaffold-type material in composite grafts and also as a resorbable barrier.[13]

Doxycycline application to the root surface enhances the binding of fibronectin, which in turn favors the attachment and growth of fibroblasts on the root surface.[14]

The purpose of this unique study was to check the effectiveness of barrier and graft especially calcium sulfate along with root conditioning for the treatment of Miller's Class I recession.

   Case Report Top

A 24-year-old male soldier reported to this establishment with the chief complaint of sensitivity and unsightly appearance in relation to 11 and 21. His medical history was noncontributory. He was a nonsmoker too. Periodontal evaluation was carried out using William's probe. The following measurements were noted: Recession depth (RD), recession width (RW), width of keratinized gingiva (KG), clinical attachment level (CAL), and probing depth (PD). RD and CAL were recorded relative to the CEJ. RD was measured at the midfacial aspect of the tooth, from CEJ to free gingival margin which was 3 mm. RW was measured 1 mm apical to the CEJ, which was 4 mm. KG was determined by subtracting RD from the CEJ-to–mucogingival junction (MGJ) measurement. CAL was 5 mm, and the PD was 2 mm. In addition, gingival thickness (GT) was measured at a buccal location 1 mm apical to bottom of sulcus using number 15 reamer endodontic instruments. No muscle pull affecting the area was present. Thus, diagnosis of Miller's Class I localized gingival recession was arrived upon [Figure 1].
Figure 1: Class I localized gingival recession recession in relation to 11

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Surgical protocol

Recession site was prepared according to the standard root coverage procedure described previously.[7] After achieving adequate local anesthesia, a sulcular incision was made from the mesiofacial line angle to the distofacial line angle of the teeth. The sulcular incision was extended horizontally into each adjacent papilla, at a level just coronal to the CEJ, to within 1 mm of the adjacent teeth. Starting at the terminal ends of the horizontal incision, two vertical incisions were extended apically well beyond the MGJ to allow adequate flap mobilization [Figure 2]. The vertical incisions diverged significantly while progressing apically to preserve blood supply to the flap. The trapezoidal pedicle flap was initially elevated split thickness in the papillary gingiva, then progressed full thickness from the osseous crest to the MGJ, and finally, split thickness again apical to the MGJ. Split-thickness dissection in the apical portion severed the periosteum to allow tension-free coronal positioning of the flap [Figure 3]. The accessible root surface was planned smooth with a hand instrument to eliminate any surface contamination. Subsequently, the root was conditioned with doxycycline hydrochloride (50 mg/5 ml in sterile solution) by light burnishing action using cotton tip applicator for 90 s followed by saline water irrigation. Next, papillae adjacent to the recipient tooth were deepithelialized with a 15C scalpel. Following flap reflection, intra-bone marrow perforations were made with a ½ round bur in the interproximal areas mesial and distal to the recipient teeth roots. A bovine collagen membrane (Guidor matrix barrier, Guidor AB, Huddinge, Sweden) was trimmed to cover 2–3 mm of bone surrounding the exposed root surface. The membrane was secured to the tooth at the level of the CEJ with one 6-0 resorbable monofilament (Ethicon/Johnson and Johnson) sling-tag suture engaging both membrane and papillae. The calcium sulfate graft (Capset, Lifecore Biomedical, Chaska, MN, USA) was mixed with saline to get a gel like consistency which was placed under the membrane using a sterile syringe. Finally, the pedicle flap was coronally positioned to cover the membrane and secured to the adjacent papillae with interrupted 6–0 resorbable monofilament sutures. Interrupted resorbable sutures were then used to close the vertical incisions [Figure 4]. Care was taken to ensure tension-free flap closure. No periodontal dressing was used. After surgery, routine postoperative instructions were given. A nonsteroidal anti-inflammatory analgesic was prescribed. No antibiotics were prescribed. Postoperative home care instructions included refraining from any mechanical cleaning of the surgical areas for 4 weeks. The patient was then instructed to rinse twice daily with a 0.12% chlorhexidine gluconate mouthrinse for the next 2 weeks. Healing was uneventful at the end of 3 weeks [Figure 5]. After 4 weeks, patients resumed gentle toothbrushing. Patients were seen at 1 week, 2 weeks, 3 weeks, 3 months, and 6 months [Figure 6]. Professional prophylaxis without prophy paste and reinforcement of oral hygiene instructions were also performed if indicated at each posttreatment visit.
Figure 2: Vertical incision given mesial and distal to 11 and 21

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Figure 3: Coronal advancement of flap done

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Figure 4: Sutures placed

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Figure 5: Postoperative healing after 3 weeks

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Figure 6: Postoerative view after 6 months

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   Results Top

After 6 months, 100% root coverage was achieved in 11 and 97% in 21. There was total reduction in both RD and width. Gain in CAL and KG was noted. No change was noted in PD. Slight increase in GT was also observed. During the healing period GTR was not exposed at any time.

   Discussion Top

The periodontal literature describes several surgical procedures and clinical variations to cover root surface exposed by facial gingival recessions. The purpose of this case study was to determine the feasibility of adding bone graft, in particular calcium sulfate, along with collagen membrane-based GTR root coverage procedures. Our results indicate that calcium sulfate plus a collagen barrier could be used to successfully treat gingival recession defects.

CAF presents several advantages with respect to other techniques: (a) Reduced discomfort and pain for the patient (avoidance of second surgical site); (b) easy-to-perform surgical technique; and (c) excellent esthetic results. According to the literature, the mean root coverage obtained by CAF in the treatment of Miller Class I and II defects ranges from 60% to 99%.[15],[16] Hence, in this study CAF was employed.

Collagen is a natural material that is well-tolerated by the host tissue. It is physiologically absorbable, and it behaves similarly to subepithelial connective tissue grafts by providing a collagenous scaffold for tissue repair. It may secondarily augment the volume of gingival tissues followingin vivo expansion, enzyme degradation, and eventual replacement by the surrounding connective tissue.[17] The creation and maintenance of space between the root surface and the overlying GTR barrier is considered critical to the success of all GTR procedures, including those aimed at achieving root coverage.[18]

Literature is replete with studies of the addition of DFDBA may create and maintain extra space that is needed for new attachment formation.[7] On similar lines calcium, sulfate was used as it is easily available, cheap, and biocompatible. The use of calcium sulfate as a graft/barrier may act as a binder, facilitating healing, and preventing loss of grafting material. It is well documented that calcium sulfate acts as a barrier, is tissue compatible, and does not interfere with the healing process.[19] As a barrier, it prevents the colonization of the defect by gingival cells, allowing selective repopulation of the defect by periodontal ligament cells. Calcium sulfate is biocompatible, and it completely resorbs within 4–10 weeks, depending on the vascularity of the grafted site.[13]

It is possible that the addition of calcium sulfate in the present study had a positive influence on healing. Thus, achieving satisfactory root coverage and reductions in RD and RW. The increase of KG may be due to a potential space created by calcium sulfate and by the collagen membrane itself. A study [17] reported that collagen membranes prevent apical migration and further support new connective tissue attachment. This often results in increased overlying flap thickness. The gain in clinical probing attachment with no change in PD suggests that a new attachment formed.[20] However, because of lack of histologic evidence, it is impossible to determine whether this gain in attachment resulted from the formation of a long junctional epithelium, a new connective tissue attachment, or a combination of both types of healing.

Doxycycline has been shown to retain its antimicrobial effect when combined with calcium sulfate; thus, the addition of the doxycycline may have improved the response to grafting. The doxycycline binds not only to the graft material but also to the root surface.[7] This study demonstrated that this binding may facilitate graft incorporation into the bone, resulting in an improved regenerative outcome over calcium sulfate alone.

   Conclusion Top

It is important to emphasize that this was a unique case study attempted to cover recession defects using a combination of principle of GTR and calcium sulfate. Though the result was encouraging, result needs to be interpreted with caution. A randomized controlled trial comparing collagen membranes with and without calcium sulfate is underway to evaluate the clinical efficacy of this combination approach. Results from this study indicate that use of calcium sulfate along with collagen membrane could be beneficial in promoting favorable clinical results.


I would like to extend my heartfelt thanks to Col (Retd.) M. K. Mukherji and Mrs. S. Mukherji for their valuable technical support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Susin C, Haas AN, Oppermann RV, Haugejorden O, Albandar JM. Gingival recession: Epidemiology and risk indicators in a representative urban Brazilian population. J Periodontol 2004;75:1377-86.  Back to cited text no. 1
Thomson WM, Hashim R, Pack AR. The prevalence and intraoral distribution of periodontal attachment loss in a birth cohort of 26-year-olds. J Periodontol 2000;71:1840-5.  Back to cited text no. 2
Albandar JM, Kingman A. Gingival recession, gingival bleeding, and dental calculus in adults 30 years of age and older in the United States, 1988-1994. J Periodontol 1999;70:30-43.  Back to cited text no. 3
Khocht A, Simon G, Person P, Denepitiya JL. Gingival recession in relation to history of hard toothbrush use. J Periodontol 1993;64:900-5.  Back to cited text no. 4
Coatoam GW, Behrents RG, Bissada NF. The width of keratinized gingiva during orthodontic treatment: Its significance and impact on periodontal status. J Periodontol 1981;52:307-13.  Back to cited text no. 5
Santarelli GA, Ciancaglini R, Campanari F, Dinoi C, Ferraris S. Connective tissue grafting employing the tunnel technique: A case report of complete root coverage in the anterior maxilla. Int J Periodontics Restorative Dent 2001;21:77-83.  Back to cited text no. 6
Wang HL, Kimble K, Eber R. Use of bone grafts for the enhancement of a GTR-based root coverage procedure: A pilot case study. Int J Periodontics Restorative Dent 2002;22:119-27.  Back to cited text no. 7
Trombelli L, Schincaglia GP, Scapoli C, Calura G. Healing response of human buccal gingival recessions treated with expanded polytetrafluoroethylene membranes. A retrospective report. J Periodontol 1995;66:14-22.  Back to cited text no. 8
Trombelli L, Schincaglia GP, Zangari F, Griselli A, Scabbia A, Calura G. Effects of tetracycline HCl conditioning and fibrin-fibronectin system application in the treatment of buccal gingival recession with guided tissue regeneration. J Periodontol 1995;66:313-20.  Back to cited text no. 9
Roccuzzo M, Lungo M, Corrente G, Gandolfo S. Comparative study of a bioresorbable and a non-resorbable membrane in the treatment of human buccal gingival recessions. J Periodontol 1996;67:7-14.  Back to cited text no. 10
Parma-Benfenati S, Tinti C. Histologic evaluation of new attachment utilizing a titanium-reinforced barrier membrane in a mucogingival recession defect. A case report. J Periodontol 1998;69:834-9.  Back to cited text no. 11
Kimble KM, Eber RM, Soehren S, Shyr Y, Wang HL. Treatment of gingival recession using a collagen membrane with or without the use of demineralized freeze-dried bone allograft for space maintenance. J Periodontol 2004;75:210-20.  Back to cited text no. 12
Maragos P, Bissada NF, Wang R, Cole BP. Comparison of three methods using calcium sulfate as a graft/barrier material for the treatment of class II mandibular molar furcation defects. Int J Periodontics Restorative Dent 2002;22:493-501.  Back to cited text no. 13
Terranova VP, Franzetti LC, Hic S, DiFlorio RM, Lyall RM, Wikesjö UM, et al. Abiochemical approach to periodontal regeneration: Tetracycline treatment of dentin promotes fibroblast adhesion and growth. J Periodontal Res 1986;21:330-7.  Back to cited text no. 14
Guinard EA, Caffesse RG. Treatment of localized gingival recessions. Part III. Comparison of results obtained with lateral sliding and coronally repositioned flaps. J Periodontol 1978;49:457-61.  Back to cited text no. 15
Langer B, Langer L. Subepithelial connective tissue graft technique for root coverage. J Periodontol 1985;56:715-20.  Back to cited text no. 16
Pitaru S, Tal H, Soldinger M, Noff M. Collagen membranes prevent apical migration of epithelium and support new connective tissue attachment during periodontal wound healing in dogs. J Periodontal Res 1989;24:247-53.  Back to cited text no. 17
Bunyaratavej P, Wang HL. Collagen membranes: A review. J Periodontol 2001;72:215-29.  Back to cited text no. 18
Sottosanti J. Calcium sulfate: A biodegradable and biocompatible barrier for GTR. Compend Contin Educ Dent 1992;13:226-34.  Back to cited text no. 19
Cardaropoli D, Cardaropoli G. Healing of gingival recessions using a collagen membrane with a hemineralized xenograft: A randomized controlled clinical trial. Int J Periodontics Restorative Dent 2009;29:59-67.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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