Xenogenic collagen matrix or autologous connective tissue graft as adjunct to coronally advanced flaps for coverage of multiple adjacent gingival recession: Randomized trial assessing non-inferiority in root coverage and superiority in oral health-related quality of life

Stability of biomaterials used in adjunct to coronally advanced flap: A systematic review and network meta-analysis

AIM

The objective of this network meta-analysis was to rank different biomaterials used in adjunct to coronally advanced flap (CAF), based on their performance in root-coverage for Miller's Class I and II gingival recessions.

MATERIALS AND METHODS

An electronic database search was carried out in PUBMED, CENTRAL, SCOPUS, and EMBASE to identify the eligible articles and compiled into the citation manager to remove the duplicates. The primary outcome was keratinized gingival tissue width (KGW) and percentage of root coverage (%RC). The treatment effect of different biomaterials was estimated using predictive interval plots and ranked based on biomaterials performance, using multidimensional scale ranking.

RESULTS

CAF + connective tissue graft (CTG), CAF + platelet concentrate matrix (PCM) and acellular dermal matrix (ADM) ranked at the top positions in performance in improving KGW. The highest ranked materials in improving percentage of root coverage in gingival recession were CAF + collagen matrix (CM) + gingival fibroblasts (GF), CAF + ADM + platelet rich plasma (PRP) and CAF + ADM, as compared to CAF alone.

CONCLUSION

CTG, ADM, platelet concentrates, and CM + GFs, when used in adjunct to CAF, showed improved stability over ≥12 months of follow-up, better percentage of root coverage, and improved keratinized gingival width.

Polymeric Scaffolds for Dental, Oral, and Craniofacial Regenerative Medicine

Dental, oral, and craniofacial (DOC) regenerative medicine aims to repair or regenerate DOC tissues including teeth, dental pulp, periodontal tissues, salivary gland, temporomandibular joint (TMJ), hard (bone, cartilage), and soft (muscle, nerve, skin) tissues of the craniofacial complex. Polymeric materials have a broad range of applications in biomedical engineering and regenerative medicine functioning as tissue engineering scaffolds, carriers for cell-based therapies, and biomedical devices for delivery of drugs and biologics. The focus of this review is to discuss the properties and clinical indications of polymeric scaffold materials and extracellular matrix technologies for DOC regenerative medicine. More specifically, this review outlines the key properties, advantages and drawbacks of natural polymers including alginate, cellulose, chitosan, silk, collagen, gelatin, fibrin, laminin, decellularized extracellular matrix, and hyaluronic acid, as well as synthetic polymers including polylactic acid (PLA), polyglycolic acid (PGA), polycaprolactone (PCL), poly (ethylene glycol) (PEG), and Zwitterionic polymers. This review highlights key clinical applications of polymeric scaffolding materials to repair and/or regenerate various DOC tissues. Particularly, polymeric materials used in clinical procedures are discussed including alveolar ridge preservation, vertical and horizontal ridge augmentation, maxillary sinus augmentation, TMJ reconstruction, periodontal regeneration, periodontal/peri-implant plastic surgery, regenerative endodontics. In addition, polymeric scaffolds application in whole tooth and salivary gland regeneration are discussed.

Efficacy of keratinized mucosal augmentation with a collagen matrix concomitant to the surgical treatment of peri-implantitis: A dual-center randomized clinical trial

AIM

The aim of this study was to evaluate the efficacy of a xenogeneic collagen matrix to augment the width of keratinized mucosa (KM), concomitantly to the surgical treatment of peri-implantitis, when compared to the use of an autologous soft tissue graft.

MATERIAL AND METHODS

In this 12-month parallel-arm randomized controlled clinical trial, patients with peri-implantitis were randomly assigned, one month after non-surgical therapy, to surgical resective treatment of peri-implantitis consisting on an apically positioned flap (APF) in combination with a KM augmentation procedure, either with an autologous free gingival graft (FGG) or a collagen matrix (CM). Primary outcomes were the increase in the width of KM and probing pocket depth (PPD) reduction at 12 months. As secondary outcomes, peri-implant radiographic and patient-reported outcomes were assessed.

RESULTS

The intention-to-treat population consisted of 49 subjects, assigned to either the APF + FGG (n = 23) or APF + CM (n = 26) group. PPDs were reduced by 1.6 mm (SD 1.0) and 1.7 mm (SD 1.2), respectively, being these differences non statistically significant (p = .782). However, the increase in KM was significantly higher in the APF + FGG compared with APF + CM (2.5 mm [SD 1.6] vs. 1.6 mm [SD 1.2], respectively (p = .033).

CONCLUSION

The tested surgical modalities resulted in similar improvements of the clinical parameters. Both free gingival graft and collagen matrix significantly increased the peri-implant keratinized mucosa, but this KM gain was significantly higher with the free gingival graft. Use of CM, however, was better appreciated by the patients, in terms of pain perception and analgesic consumption, although the surgical time was similar.

Patient-reported outcome measures following soft-tissue grafting at implant sites: A systematic review

OBJECTIVES

To review the available literature on patient-reported outcome measures (PROMs) following soft tissue augmentation at implant sites.

MATERIALS AND METHODS

A comprehensive electronic and manual search was performed to identify clinical studies that involved soft tissue augmentation around dental implants and reported PROMs, including post-operative morbidity, painkillers intake, quality of life, aesthetics and satisfactions.

RESULTS

Nineteen articles were included in the qualitative analysis. Autogenous grafts (free gingival graft and connective tissue graft), acellular dermal matrix and xenogeneic collagen matrix were utilized, either with a bilaminar- or an apically positioned flap approach. PROMs reported in the literature included perceived hardship of the procedure and pain during the surgery, post-operative morbidity, painkillers intake, number of days with discomfort, satisfaction, aesthetic evaluation, quality of life and willingness to undergo the treatment again. Most of the included studies showed similar PROMs between autogenous grafts and substitutes, in terms of post-operative morbidity, painkillers intake, quality of life, aesthetic assessment and satisfaction. Nevertheless, a trend towards lower post-operative discomfort was observed for graft substitutes. High scores for patient satisfaction and aesthetic evaluation were observed in all the interventions compared to non-grafted sites.

CONCLUSIONS

PROMs represent a crucial endpoint of clinical studies evaluating the outcomes of soft tissue grafts at implant sites. Most of the studies did not find significant differences in terms of patient morbidity and painkillers between autogenous grafts and substitutes. Soft tissue grafting can enhance patient satisfaction and aesthetic evaluation compared to non-grafted sites.

Enamel matrix derivative effects on palatal mucosa wound healing: Randomized clinical trial

BACKGROUND

This study was conducted to evaluate the clinical, immunologic, and patient-centered outcomes of enamel matrix protein derivative (EMD) on excisional wounds in palatal mucosa.

MATERIALS

Forty-four patients in need of ridge preservation were randomly allocated into two groups: control group (n = 22): open palatal wound after free gingival graft (FGG) harvest and EMD group (n = 22): open palatal wound after FGG harvest that received 0.3 ml of EMD. Clinical and patient-centered parameters were analyzed for 3 months post-treatment. Wound fluid levels of inflammatory markers were assessed 3 and 7 days postoperatively.

RESULTS

No significant inter-group difference was observed in remaining wound area and re-epithelialization. EMD and control groups achieved wound closure and re-epithelialization 30 days postoperatively (p < .001), without inter-group differences. Similarly, number of analgesics and Oral Health Impact Profile scores did not present significant inter-group differences (p > .05). EMD appeared to selectively modulate wound fluid levels of monocyte chemoattractant protein-1, macrophage inflammatory protein-1α, matrix metallopeptidase 9, and tissue inhibitor of metalloproteinases-2.

CONCLUSION

Within the limits of the present study, it can be concluded that EMD application to excisional palatal wounds using the investigated protocol does not provide clinical healing benefits, despite an apparent modulation of selected inflammatory markers.

Assessment of Patients’ Satisfaction following Coverage of Gingival Recessions: Questionnaire-Based Case Series

Background/Aim: One of the most important goals of periodontal plastic surgery constitutes the predictable root coverage. Despite the thorough documentation that several surgical approaches can be implemented for the successful treatment of gingival recession (GR), only limited papers reported data on the evaluation according to patient’s opinion. Thus, the forthcoming study is aiming in the patient-based assessment of the outcome of root coverage procedures.

Material and Methods: Sixteen subjects (eight male, eight female; mean age 43.75 years, range: 23-73 years), with twenty one GRs, constituted the sample of this study and the root coverage procedures were executed in the period from 2011 to 2019. A patient-based questionnaire was used to assess the level of subjects’ concern on various aspects related to the GR, preand post-operatively. Patient’s overall post-operative satisfaction was evaluated with a VAS.

Results: After a period of at least 6 months of the surgical treatment, the majority of the subjects indicated that they were not concerned for all the examined criteria. The criteria with the highest improvement (reported as improvement by at least two levels of concern pre- and post-operatively) were the following: 1) fear to lose the involved teeth and 2) esthetics of the area of the recession defect. With regard to esthetics’ criteria, the majority of the patients indicated post-operatively the examined criteria as not important. The esthetics’ criteria yielding the highest improvement were: 1) position of the teeth and 2) the fact that the teeth showed longer. Mean patient’s overall post-operative satisfaction was 82,3 (range: 0-100).

Conclusions: The majority of the subjects were satisfied from the implemented root coverage procedures. Few studies on the international literature have evaluated patient satisfaction following therapy. Comprehensive, multi-center studies, comprised of a large sample and a using a standardized approach are needed in future research.

Clinical evaluation of xenogeneic collagen matrix versus free gingival grafts for keratinized mucosa augmentation around dental implants: A randomized controlled clinical trial

AIM

To evaluate the outcomes of an apically repositioned flap (ARF) plus xenogeneic collagen matrix (XCM) in augmenting keratinized mucosa width (KMW) around dental implants when compared with ARF plus free gingival grafts (FGG).

MATERIALS AND METHODS

Twenty-six participants with at least one site with KMW ≤2 mm were randomized into FGG or XCM group. Clinical examinations were performed at baseline and at 2 and 6 months after surgery, including KMW, keratinized mucosa thickness, gingival index (GI), and probing depth (PD). Post-operative pain and patient satisfaction were also evaluated.

RESULTS

At 6 months, FGG attained a greater increase of KMW and thicker mucosa than XCM (4.1 ± 1.6 mm vs. 1.8 ± 1.0 mm, p < .001; 1.7 ± 0.6 mm vs. 1.2 ± 0.3 mm, p < .01). Regarding GI, PD, post-operative pain, aesthetic outcomes, and patient satisfaction, no significant difference could be detected. Moreover, the operation time of XCM group was shorter (60 ± 9 min vs. 39 ± 8 min, p < .001).

CONCLUSIONS

FGG could result in greater increase of KMW than XCM, though both could increase KMW, maintain peri-implant health, and attain comparable aesthetic outcomes. The use of XCM was associated with reduced operation time.

Engaging a polylactide copolymer in oral tissue regeneration: first validation of Suprathel® for guided epithelial and osseous healing

The present study investigated the capacity of Suprathel^® (a copolymer membrane, so far validated for skin regeneration) to also regenerate oral tissue – mucosa and bone, by comparing this biomaterial, in a split-mouth rabbit model, to Mucoderm^®, a xenogeneic collagen matrix certified for keratinized oral mucosa healing. The clinical reason behind this experimental animal model was to determine whether the benefits of this advanced skin regeneration product (Suprathel^®) could be conveyed for future evaluation in clinical trials of oral tissue regeneration in humans. The outcomes of this study validated the use of Suprathel^®, a terpolymer of polylactide with trimethylene carbonate and ε-caprolactone, for stimulation of oral epithelium and alveolar bone regeneration in rabbits. Both Suprathel^® and Mucoderm^® exhibited comparable results and the null hypothesis stating a comparable regenerating effect of these two materials could not be rejected.

Collagen Matrix vs. Autogenous Connective Tissue Graft for Soft Tissue Augmentation: A Systematic Review and Meta-Analysis

Soft tissues have been shown to be critical for the maintenance of both teeth and implants. Currently, regenerative soft tissue techniques propose the use of collagen matrices, which can avoid the drawbacks derived from the obtainment of autogenous tissue graft. A systematic review and meta-analysis were conducted to ascertain the efficacy of collagen matrices (CM) compared to autogenous connective tissue graft (CTG) to improve soft tissue dimensions. An electronic and manual literature searches were performed to identify randomized clinical trials (RCT) or controlled clinical trials (CCT) that compared CTG and CM. Pooled data of width of keratinized tissue (KT) and mucosal thickness (MT) were collected and weighted means were calculated. Heterogeneity was determined using Higgins (I²). If I² > 50% a random-effects model was applied. Nineteen studies were included based on the eligibility criteria. When using CTG a higher MT gain (0.32 mm, ranging from 0.49 to 0.16 mm) was obtained than when employing CM. Similar result was obtained for the width of KT gain, that was 0.46 mm higher (ranging from 0.89 to 0.02 mm) when employing CTG. However, it can be stated that, although autogenous CTG achieves higher values, CM are an effective alternative in terms of total width of KT and MT gain.

Comparison between a xenogeneic dermal matrix and connective tissue graft for the treatment of multiple adjacent gingival recessions: a randomized controlled clinical trial

AIM

To compare the outcomes of modified coronally advanced flap (mCAF) combined with either xenogeneic dermal matrix (XDM) or connective tissue graft (CTG) for the treatment of multiple adjacent gingival recessions (MAGRs).

MATERIALS AND METHODS

Forty-two patients, in whom 130 maxillary (MAGRs) of type (RT1) were found, were randomly allocated to the two groups. Clinical, esthetic, and patient-centered outcomes were evaluated at baseline, 6, and 12 months post-treatment.

RESULT

Group CAF+ CTG exhibited a higher mean root coverage value (mRC) (91.79%) (primary outcome variable) than group CAF+XDM (80.19%) without statistically significant difference at 12 months (p=0.06). The control group also had significantly higher percentage of teeth in which complete root coverage (CRC) and mean gain of gingival thickness (GT) were achieved, than the test group (p<0.05). With respect to patient-centered outcomes, patients of the test group reported having experienced significantly less pain than those of the control group until 7 days (p<0.05). Both surgical approaches were capable of significantly decreasing dentin hypersensitivity (p<0.05). No difference between groups was found in the esthetic score analysis (p>0.05). Mean surgical time was lower in the test group (p<0.05).

CONCLUSION

The two treatments showed similar mRC. However, CAF+CTG was superior to CAF+XDM in providing CRC and in gaining GT. CAF+XDM demonstrated advantages over CAF+CTG with regard to patient morbidity and surgical time.

CLINICAL RELEVANCE

Application of XDM provided a better patient experience and shortened the time to recovery after coronally advanced flaps for coverage of multiple adjacent recessions. However, CTG resulted in improved percentages of complete root coverage.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry (REBEC) number: RBR-974c9j.

Autologous connective tissue graft or xenogenic collagen matrix with coronally advanced flaps for coverage of multiple adjacent gingival recession. 36-month follow-up of a randomized multicentre trial

AIM

To report the 36-month follow-up of a trial comparing the adjunct of a xenogenic collagen matrix (CMX) or connective tissue graft (CTG) to coronally advanced flaps (CAF) for coverage of multiple adjacent recessions.

MATERIAL AND METHODS

125 subjects (61 CMX) with 307 recessions in 8 centres from the parent trial were followed-up for 36 months. Primary outcome was change in position of the gingival margin. Multilevel analysis used centre, subject and tooth as levels and baseline parameters as covariates.

RESULTS

No differences were observed between the randomized and the follow-up population. Average baseline recession was 2.6 ± 1.0 mm. 3-year root coverage was 1.5 ± 1.5 mm for CMX and 2.0 ± 1.0 mm for CTG (difference of 0.32 mm, 95% CI from -0.02 to 0.65 mm). The upper limit of the confidence interval was over the non-inferiority margin of 0.25 mm. No treatment differences in position of the gingival margin were observed between 6- and 36-month follow-up (difference 0.06 mm, 95% CI -0.17 to 0.29 mm).

CONCLUSION

CMX was not non-inferior with respect to CTG in multiple adjacent recessions. No differences in stability of root coverage were observed between groups and in changes from 6 to 36 months. Previously reported shorter time to recovery, lower morbidity and more natural appearance of tissue texture and contour observed for CMX in this trial are also relevant in clinical decision-making.

Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivate for root coverage: 5-year results of an RCT using 3D digital measurement technology for volumetric comparison of soft tissue changes

AIM

Comparison of the clinical efficacy (digitally volumetric, aesthetic, patient-centred outcomes) of tunnel technique (TUN) with subepithelial connective tissue graft (CTG) versus coronally advanced flap (CAF) with enamel matrix derivate (EMD) 5 years after gingival recession therapy.

MATERIALS AND METHODS

In 18 patients contributing 36 RT1 recessions, study models were collected at baseline and follow-ups. Optical scans assessed recessions computer-assisted [recession depth, recession reduction (RECred), complete root coverage (CRC), percentage of root coverage (RC), pointwise (pTHK) and mean areal (aTHK) marginal soft tissue thickness]. Root coverage aesthetic Score (RES) was used for aesthetic evaluation and visual analogue scales for patient-centred data collection applied.

RESULTS

Sixty months after surgery, 50.0% (TUN+CTG) and 0.0% (CAF+EMD) of sites showed CRC (p = 0.0118), 82.2% (TUN+CTG) and 32.0% (CAF+EMD) achieved RC, respectively (p = 0.0023). CTG achieved significantly better RECred (TUN+CTG: 1.75±0.74 mm; CAF+EMD: 0.50 ± 0.39 mm; p = 0.0009) and aTHK (TUN+CTG: 0.95 ± 0.41 mm; CAF+EMD: 0.26 ± 0.28 mm; p = 0.0013). RES showed superior outcomes (p = 0.0533) for TUN+CTG (6.86 ± 2.31) compared to CAF+EMD (4.63 ± 1.99). The study failed to find significant differences related to patient-centred outcomes (TUN+CTG: 8.30 ± 2.21; CAF+EMD: 7.50 ± 1.51; p = 0.1136).

CONCLUSIONS

Five years after treatment, CTG resulted in better clinical and aesthetic outcomes than CAF+EMD. Increased THK was associated with improved outcomes for RECred and RC.

A Novel Volume-Stable Collagen Matrix Induces Changes in the Behavior of Primary Human Oral Fibroblasts, Periodontal Ligament, and Endothelial Cells

The aim of the present study was to investigate the influence of a novel volume-stable collagen matrix (vCM) on early wound healing events including cellular migration and adhesion, protein adsorption and release, and the dynamics of the hemostatic system. For this purpose, we utilized transwell migration and crystal violet adhesion assays, ELISAs for quantification of adsorbed and released from the matrix growth factors, and qRT-PCR for quantification of gene expression in cells grown on the matrix. Our results demonstrated that primary human oral fibroblasts, periodontal ligament, and endothelial cells exhibited increased migration toward vCM compared to control cells that migrated in the absence of the matrix. Cellular adhesive properties on vCM were significantly increased compared to controls. Growth factors TGF-β1, PDGF-BB, FGF-2, and GDF-5 were adsorbed on vCM with great efficiency and continuously delivered in the medium after an initial burst release within hours. We observed statistically significant upregulation of genes encoding the antifibrinolytic thrombomodulin, plasminogen activator inhibitor type 1, thrombospondin 1, and thromboplastin, as well as strong downregulation of genes encoding the profibrinolytic tissue plasminogen activator, urokinase-type plasminogen activator, its receptor, and the matrix metalloproteinase 14 in cells grown on vCM. As a general trend, the stimulatory effect of the vCM on the expression of antifibrinolytic genes was synergistically enhanced by TGF-β1, PDGF-BB, or FGF-2, whereas the strong inhibitory effect of the vCM on the expression of profibrinolytic genes was reversed by PDGF-BB, FGF-2, or GDF-5. Taken together, our data strongly support the effect of the novel vCM on fibrin clot stabilization and coagulation/fibrinolysis equilibrium, thus facilitating progression to the next stages of the soft tissue healing process.

Root coverage of multiple gingival recessions treated with coronally advanced flap associated with xenogeneic acellular dermal matrix or connective tissue graft: a 6-month split-mouth controlled and randomized clinical trial

OBJECTIVES

This study aimed to compare xenogeneic dermal matrix (XDM) to connective tissue graft (CTG) associated with coronally advanced flap (CAF) in treating Miller's class I and II (RT1) multiple gingival recession in a split-mouth randomized clinical trial.

MATERIALS AND METHODS

Fifteen patients with bilateral Miller's class I and II multiple recessions were selected. The patient's side receiving each treatment was randomly allocated to receive XDM or CTG. The clinical parameters were measured at baseline and 6 months of follow-up.

RESULTS

At 6 months, no significant difference in the root coverage (RC) (95.28 ± 6.89% for CTG and 92.68 ± 7.35% for XDM) and the keratinized tissue (KT) gain (0.91 ± 0.46 mm for CTG and 0.74 ± 0.39 mm for XDM) was observed between groups (p > 0.05). The CTG group presented higher complete root coverage (CRC) than XDM (60% and 33%, respectively) (p = 0.045). Multiple logistic regression indicated that the XDM (p = 0.01) and the XDM and KT interaction (p = 0.02) negatively interfered in the CRC. A 1-mm increase in the baseline KT when using XDM increases almost 6 times the chance of achieving CRC, and XDM reached a similar CRC probability to CTG when the receptor area presented at least 2 mm of KT.

CONCLUSIONS

Both treatments were effective for treating multiple gingival recession; similar KT gain, GR reduction, and RC were obtained for CTG and XDM, while CTG promoted higher CRC than XDM. Moreover, the amount of KT at baseline was determinant for CRC when treating multiple gingival recession with XDM.

CLINICAL RELEVANCE

XDM produces limited CRC in sites with a reduced amount of KT.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry (REBEC) number RBR-56NZQ6.

Treatment of Gingival Recession: When and How?

Gingival recession is a common finding in daily clinical practice. Several issues may be associated with the apical shift of the gingival margin such as dentine hypersensitivity, root caries, non-carious cervical lesions (NCCLs), and compromised aesthetics. The first step in an effective management and prevention program is to identify susceptibility factors and modifiable conditions associated with gingival recession. Non-surgical treatment options for gingival recession defects include establishment of optimal plaque control, removal of overhanging subgingival restorations, behaviour change interventions, and use of desensitising agents. In cases where a surgical approach is indicated, coronally advanced flap and tunnelling procedures combined with a connective tissue graft are considered the most predictable treatment options for single and multiple recession defects. If there is a contraindication for harvesting a connective tissue graft from the palate or the patient wants to avoid a donor site surgery, adjunctive use of acellular dermal matrices, collagen matrices, and/or enamel matrix derivatives can be a valuable treatment alternative. For gingival recession defects associated with NCCLs a combined restorative-surgical approach can provide favourable clinical outcomes. If a patient refuses a surgical intervention or there are other contraindications for an invasive approach, gingival conditions should be maintained with preventive measures. This paper gives a concise review on when and how to treat gingival recession defects.

Does enamel matrix derivative application provide additional clinical benefits in the treatment of maxillary Miller class I and II gingival recession? A systematic review and meta-analysis

OBJECTIVE

This review aimed to evaluate the effects of enamel matrix derivative (EMD) in association with coronally advanced flap (CAF) or CAF + connective tissue graft (CTG) when compared with CAF alone or CAF + CTG for the treatment of gingival recessions (GR) in maxillary teeth.

METHODS

Five databases and gray literature were searched up to April 2020, to find randomized clinical trials comparing the clinical effects of CAF + EMD versus CAF alone (first group) or CAF + CTG + EMD versus CAF + CTG (second group) in the treatment of Miller class I and II or Cairo type I gingival recessions (GR). Random effects model of mean differences was used to determine the GR reduction, gain in keratinized tissue width (KTW), and gain in clinical attachment level (CAL). The trial sequential analysis (TSA) was implemented to determine the optimal information size (OIS) and imprecision using the GRADE approach. Bayes factors were calculated as complementary statistical evidence of p value.

RESULTS

From 1349 titles identified, 9 trials representing 336 GR were included. The meta-analysis showed a statistically significant difference for GR reduction and CAL gain in favor CAF + EMD (p ≤ 0.05). The additional effect of EMD showed a statistically significant difference in GR reduction in favor CAF + CTG + EMD (p ≤ 0.05). The differences in KTW gain proved to be not statistically significant in both comparison groups. The OIS were not met among meta-analyses. Evidence certainty according the GRADE approach proved to be moderate for GR reduction and gain in CAL, but very low for gain in KTW.

CONCLUSION

The adjunctive application of EMD in the treatment of GR in maxillary teeth either with CAF or CTG provided moderate certainty evidence in favor of their use for reduction in GR and gain in CAL at 6 and 12 months. However, their effect on the increase in keratinized tissue band height showed very low evidence certainty for its use.

CLINICAL RELEVANCE

To know if EMD could improve the results for root coverage.

Treatment of multiple gingival recessions with xenogeneic acellular dermal matrix compared to connective tissue graft: a randomized split-mouth clinical trial

PURPOSE

The aim of this study was to compare the efficacy of the tunnel technique for root coverage using a new xenogeneic acellular dermal matrix vs. connective tissue grafting (CTG) for the treatment of multiple maxillary adjacent recessions (recession type 1) at 12 months postoperatively.

METHODS

This study enrolled 12 patients with at least 3 contiguous, bilateral, symmetrical maxillary gingival recessions (i.e., at least 6 recessions per patient). In total, 74 recessions were treated using the modified coronally advanced tunnel (MCAT) technique combined with a novel porcine-derived acellular dermal matrix (PADM) at 37 test sites or CTG at 37 control sites. The following clinical parameters were measured: recession height, clinical attachment level, width of keratinized tissue, probing depth, recession width, gingival thickness, mean root coverage (MRC), and complete root coverage (CRC). Comparisons between test and control groups were made for pain visual analog scale scores at 14 days.

RESULTS

At 12 months, the MCAT with PADM (test) yielded a statistically significant improvement in all clinical parameters studied. MRC was significantly higher on the control sides (80.6%±23.7%) than on the test sides (68.8%±23.4%). Similarly, CRC was 48.7%±6.8% on the control sides (CTG), in contrast to 24.3%±8.2% on the test sides (PADM). Statistically significant differences were observed in favor of the control sides for all clinical parameters studied. Nevertheless, the MCAT in adjunction with PADM was clearly superior at reducing mean and maximum patient-reported postoperative pain intensity and pain duration in the first week after surgery.

CONCLUSIONS

The use of PADM to treat multiple recessions improved clinical parameters at 12 months, but these outcomes were nevertheless poorer than those observed for CTG. However, PADM reduced morbidity, particularly the pain experienced by patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03162016.

Clinical comparison of a xenogeneic collagen matrix versus subepithelial autogenous connective tissue graft for augmentation of soft tissue around implants

Dental implant placement is a predictable therapy for replacing teeth. Nevertheless, mechanical, biological, and aesthetic complications frequently occur. The aim of this study was to compare the clinical outcomes of a xenogeneic collagen matrix (XCM) used at the time of implant placement as an alternative to a subepithelial connective tissue graft (SCTG), for soft tissue augmentation. This was a prospective clinical trial with 12 months of follow-up. In the control group, soft tissue augmentation at the time of implant placement was performed with a SCTG, while in the test group, a XCM was employed. At 12 months postoperative, all xenografts showed no postoperative complications. In both groups, a significantly greater thickness was observed on the buccal and occlusal sides from preoperative to 3 months postoperative (P<0.05). No statistically significant difference in pink aesthetic score (P=0.379, 6 months postoperative) or marginal bone loss (P=0.449 at 3 months postoperative, P=0.778 at 6 months postoperative) was observed between the groups. Statistically significant differences in pain perceived by the patients (P<0.0001) and the time to complete the surgical procedure (P=0.0008) were detected. At 12 months after surgery, XCM provided similar clinical results in terms of soft tissue augmentation on the buccal and occlusal sides as compared with the SCTG.

Partly deepithelialised palatal graft for the treatment of deep-wide palatal recession defect: simplified protocol with 18-month follow-up

Advances in periodontal plastic surgical procedures have led to achieve predictable root coverage outcomes for the recession defects. However, little has been reported and emphasised over management of palatal recession defects. The root coverage surgical procedures used for coverage of palatal recession defect are technically challenging in terms of accessibility and graft coverage. The purpose of this report is to describe a surgical technique used to manage deep-wide palatal recession defect. The technique uses partly deepithelialised palatal graft that is designed to approximately fit the defect site. This is employed for prolonged protection of the underlying healing process. This case report is unique in terms of treatment of deep (9.0 mm), wide (6.0 mm) palatal recession defect and its long-term follow-up for 18 months.

Aesthetic-And patient-related outcomes following root coverage procedures: A systematic review and network meta-analysis

BACKGROUND

Aim of this systematic review (SR) of randomized controlled trials (RCTs) was to evaluate effect of different flap designs and graft materials for root coverage, in terms of aesthetics, patient satisfaction and self-reported morbidity (post-operative pain/discomfort).

MATERIAL AND METHODS

A comprehensive literature search was performed. A mixed-modelling approach to network meta-analysis was utilized to formulate direct and indirect comparisons among treatments for Root Coverage Esthetic Score (RES), with its individual components, and for subjective patient-reported satisfaction and post-operative pain/discomfort (visual analogue scale (VAS) of 100).

RESULTS

Twenty-six RCTs with a total of 867 treated patients (1708 recessions) were included. Coronally Advanced Flap (CAF) + Connective Tissue Graft (CTG) (0.74 (95% CI [0.24, 1.26], p = .005)), Tunnel (TUN) + CTG (0.84 (95% CI [0.15, 1.53]), p = .01) and CAF + Graft substitutes (GS) (0.55 (95% CI [0.006, 1.094], p = .04)) were significantly associated with higher RES than CAF. No significant difference between CAF + CTG and TUN + CTG was detected (0.09 (95% CI [-0.54, 0.72], p = .77)). Addition of CTG resulted in less natural tissue texture (-0.21 (95% CI [-0.34, -0.08]), p = .003) and gingival colour (-0.06 (95% CI [-0.12, -0.03], p = .03)) than CAF. CTG techniques were associated with increased morbidity.

CONCLUSIONS

Connective tissue graft procedures showed highest overall aesthetic performance for root coverage, although graft integration might impair soft tissue colour and appearance. Additionally, CTG-based techniques were also correlated with a greater patient satisfaction and morbidity.

Patient experience of autogenous soft tissue grafting has an implication for future treatment: A 10- to 15-year cross-sectional study

BACKGROUND

Patient-reported outcomes have received a great deal of interest in periodontal plastic procedures. However, their evaluation has mainly been short-term. Thus, the aim of this study was to evaluate the impact of soft tissue grafting procedures conducted over a decade ago on the willingness of a patients to undergo the surgery again.

METHODS

Subjects that received an autogenous soft tissue graft over 10 years ago were screened and invited for a survey. Their response was only analyzed if they were able to correctly identify the sites of the surgical procedures. Dichotomous questions and visual analogue scales (VASs) were used to assess self-reported pain, willingness to retreat and satisfaction.

RESULTS

Fifty-two patients were included in the analyses. Higher pain was reported for mandibular sites, and treated areas including ≥ 3 teeth (P < 0.01). Willingness to retreatment was 84.6% and it was negatively associated with self-reported pain measures, the arch location (mandible), and number of treated sites (≥3 teeth) (P < 0.01). Mean satisfaction rate was 86.9 ± 13.65 (VAS) and showed a positive correlation with willingness to retreat (P < 0.01). Having a complete root coverage at the recall visit was also significantly associated with higher patient satisfaction scores (P < 0.01).

CONCLUSIONS

Patient experience of previous autogenous soft tissue grafting has an influence on their decision to undergo future treatment. Willingness to retreat was negatively affected by mandibular sites, larger treated areas and the perceived pain, while presenting with complete root coverage was significantly associated with patient satisfaction.

Effectiveness of connective tissue graft substitutes for the treatment of gingival recessions compared with coronally advanced flap: a network meta-analysis

OBJECTIVES

This study aimed to conduct a network comparison of the clinical effect of connective tissue graft (CTG) substitutes on the treatment of gingival recessions using coronally advanced flap.

MATERIALS AND METHODS

An electronic search without language or dates restrictions was performed in five databases and in Grey literature for articles published until May, 2020. The eligibility criteria comprised randomized controlled trials (RCTs) that analyzed the clinical outcomes of CTG substitutes when compared with coronally advanced flap (CAF) for the treatment of Miller class I and II (Cairo RT I) gingival recessions. A pairwise and network meta-analysis were conducted for each periodontal parameters to assess and compare the outcomes among different treatment arms for the primary and secondary outcomes. This systematic review (SR) was registered in INPLASY under number INPLASY202060075.

RESULTS

Twenty-seven studies were included in the present SR. All analyzed CTG substitutes showed superior results when comparing with CAF alone for all periodontal parameters. However, when compared in a network, the acellular dermal matrix (ADM) demonstrated the best treatment ranking of probability results, followed by platelet-rich fibrin (PRF), enamel matrix derivative (EMD), and xenogeneic collagen matrix (XCM) for root coverage (RC).

CONCLUSION

This SR observed that the association of biomaterials increases the effectiveness of RC in comparison with CAF alone. Based on the treatment ranking, although all the biomaterials analyzed showed a positive effect for RC, the ADM demonstrated the best results.

CLINICAL RELEVANCE

To know the effectiveness of CTG substitutes for the treatment of gingival recessions.

Effect of Different Timings of Implant Insertion on the Bone Remodeling Volume around Patients' Maxillary Single Implants: A 2-3 Years Follow-Up

Background: To investigate the middle-term effect on bone remodeling of different timings for different implant placement (immediate versus delayed). Methods: Patients with an anterior maxillary failing tooth were treated by single-crown supported by dental implant. Subjects were retrospectively analyzed for 3 years and assigned to one of two predictor groups: nine immediate versus 10 delayed implant placement (1-2 months after tooth extraction). The crestal bone loss around dental implants was measured with the cone beam computerized tomography by fusing pre-operative and post-operative data. Results: The percentage of volume loss registered at 1-year follow-up (%ΔV) was of 7.5% for the immediate group, which was significantly lower (p-values ≤ 0.0002) than the loss of 24.2% for the delayed group. At 3 years, there was a significant difference (p-values = 0.0291) between the two groups, respectively, with a volume loss of 14.6% and 27.1%. When different times were compared, the percentage of the volume loss for the immediate group was different (p-value = 0.0366) between the first and third year (7.5% and 14.6%, respectively). For the delayed group, no significant difference was registered between the 1- and 3-year follow-up. Conclusions: The bone loss around dental implant-supported single-crown with different timing of insertion appeared higher for the delayed group than the immediate group.

Oral Soft Tissue Grafting

The presence of healthy soft tissue at the tooth and implant interface correlates to long-term success and stability in function and esthetics. Grafting procedures utilizing various techniques can be performed during any stage of the implant or restorative therapy. Materials of autogenous, allogeneic, and xenogeneic sources are available for oral soft tissue grafting. This article describes the classifications of soft tissue defects, treatment modalities, and materials used to enhance soft tissue quality and quantity and to achieve optimal esthetics and function around teeth and implants.

An exploratory clinical study evaluating safety and performance of a volume-stable collagen matrix with coronally advanced flap for single gingival recession treatment

OBJECTIVE

To test the safety of a new volume-stable collagen matrix (VCMX) in combination with coronally advanced flap (CAF) for the treatment of single gingival recession.

MATERIAL AND METHODS

Ten patients were treated for single RT1 gingival recession. Complete and mean root coverage, gingival thickness and keratinized tissue height, patient-reported outcome measures (PROMs), and safety were assessed up to 180 days. Descriptive statistics were used to analyze the clinical parameters.

RESULTS

VCMX resulted to be safe with no serious adverse events in all patients. At 6 months, root coverage was 96.7% with 90% of defects exhibiting complete coverage. There was an increase in mean width of keratinized tissue (KT) (0.4 ± 0.8 mm) and in gingival thickness (GT) (0.4 ± 0.34 mm); however, the difference was not statistically significant compared to baseline parameters. Pain perception and pain-killer consumption were low and decreasing further at 7 days. Esthetic satisfaction for both patients and experts revealed excellent scores.

CONCLUSIONS

VCMX is a safe and well-tolerated device for the treatment of single gingival recessions. In combination with CAF, it resulted in a high performance in terms of mean and complete root coverage, KT width, and GT increase. VCMX may reduce patient discomfort and post-operative morbidity.

CLINICAL RELEVANCE

VCMX is a safe and stable substitute for the treatment of gingival recession in conjunction with coronally advanced technique.

Microcurrent electrotherapy improves palatal wound healing: Randomized clinical trial

BACKGROUND

This study was conducted to assess the clinical, immunological, and patient-centered outcomes of microcurrent electrotherapy on palatal wound healing.

METHODS

This was a parallel, double-masked randomized clinical trial, in which 53 patients with ridge preservation indications were selected and randomly assigned to one of two groups. In the control (sham) group (n = 27), palatal wounds, after free gingival grafts (FGG) harvest, received sham application of electrotherapy. In the test (electrotherapy treatment [EE]) group (n = 26), palatal wounds, after FGG harvest, received application of microcurrent electrotherapy protocol. Clinical parameters, patient-centered outcomes, and inflammatory markers were evaluated, up to 90 days postoperatively.

RESULTS

The EE group achieved earlier wound closure (P <0.001) and epithelialization (P <0.05; P = 0.03) at 7 and 14 days after harvest when compared with the sham group. Painful symptomatology was reported less frequently in the EE group than in the sham group at 3-day follow-up (P = 0.008). Likewise, an improvement in Oral Health Impact Profile was reported 2 days after the procedure by the EE group (P = 0.04). In addition, favorable modulation of inflammatory wound healing markers occurred when electrotherapy was applied.

CONCLUSION

Within the limits of the present study, it can be concluded that the use of a low-intensity electrotherapy protocol may accelerate palatal wound healing and decrease patient discomfort after FGG harvest.

Smile esthetic evaluation of mucogingival reconstructive surgery

To assess the difference in smile esthetic impact of Coronally Advanced Flap (CAF) with or without the adjunct of a collagen matrix (CMX) used as root coverage procedures. Subjects with esthetic demands showing multiple upper gingival recessions of at least 2 mm, without interproximal attachment loss and cervical abrasion no more than 1 mm were recruited and randomized to CAF plus CMX or CAF alone. The Smile Esthetic Index (SEI) was adopted to quantify the quality of the smile recorded at baseline and 12 months after treatment for each treatment group. In addition, between group difference in the SEI was calculated. 24 Patients were treated and analysed. At baseline, mean gingival recession depths were 2.3 ± 0.7 mm for Test group and 2.6 ± 1.0 mm for Control group. After 1 year, the residual recession depth was 0.3 ± 0.4 mm in the CAF + CMX group and 0.6 ± 0.3 mm in the control group. The SEI at baseline was 8.1 ± 1.0 and 7.9 ± 0.7 for Test and Control group, respectively. The between groups difference at 12 months in SEI was 0.4 (95% C.I. − 0.0 to 0.8, P = 0.0697). Twelve months after treatment, CAF + CMX provided a similar SEI compared to CAF alone and the adjunct of a collagen matrix did not show a different impact on the smile esthetic appearance.

Extrusion and Microfluidic-based Bioprinting to Fabricate Biomimetic Tissues and Organs

Next generation engineered tissue constructs with complex and ordered architectures aim to better mimic the native tissue structures, largely due to advances in three-dimensional (3D) bioprinting techniques. Extrusion bioprinting has drawn tremendous attention due to its widespread availability, cost-effectiveness, simplicity, and its facile and rapid processing. However, poor printing resolution and low speed have limited its fidelity and clinical implementation. To circumvent the downsides associated with extrusion printing, microfluidic technologies are increasingly being implemented in 3D bioprinting for engineering living constructs. These technologies enable biofabrication of heterogeneous biomimetic structures made of different types of cells, biomaterials, and biomolecules. Microfluiding bioprinting technology enables highly controlled fabrication of 3D constructs in high resolutions and it has been shown to be useful for building tubular structures and vascularized constructs, which may promote the survival and integration of implanted engineered tissues. Although this field is currently in its early development and the number of bioprinted implants is limited, it is envisioned that it will have a major impact on the production of customized clinical-grade tissue constructs. Further studies are, however, needed to fully demonstrate the effectiveness of the technology in the lab and its translation to the clinic.

Patient-based outcomes and quality of life

Patient-based outcomes complement clinical data with patients' self-evaluation of their physical, psychological, and social well-being, and as such facilitate clinical decision-making, assessing the quality of care provided, and evaluating practices and policies. Some validated generic oral health-related quality of life measures used in recent research indicated a high performance. There is a proportional relationship between the quality of life and periodontitis, ie, the higher the level of periodontitis, the poorer the oral health-related quality of life. This relationship is heightened by the presence of symptoms such as bleeding, halitosis, and mobility. On the other hand, periodontal treatment has demonstrated the capability to improve quality of life substantially. Future research should focus on questionnaires that are able to explain the interlinked pathways between periodontal conditions, approaches to treatment approaches, and patients' well-being. The acquisition of new knowledge in the field is essential for the whole community, as we treat people not millimeters.

Clinical efficacy of xenogeneic and allogeneic 3D matrix in the management of gingival recession: a systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis was thus conducted to answer the following focused question based on PICO strategy: Is there any 3D matrix biomaterial used for root coverage of human Miller class I and II defects equivalent with the connective tissue graft in localized defects of at least 2 mm and 3 mm?

MATERIAL AND METHODS

The search on electronic database included MEDLINE, Cochrane Central Register of Controlled Trials, Clinical Trials.gov, Web of Science, and New Zealand/Australian Clinical Trials. Only randomized clinical trials (RCTs) that compared connective tissue graft (CTG) with at least one 3D matrix alone for root coverage in Class I and II Miller localized defects of at least 2 mm, with at least 6 months follow-up, were included in this systematic review.

RESULTS

A total of 14 studies were included for meta-analysis (12 compared CTG with acellular dermal matrix allograft and 2 compared CTG with Xenogenic Collagen Matrix). Relative root coverage showed no significant difference among the materials, for either 2 or 3 mm minimal recessions. For keratinized tissue width, on 2 mm recessions, CTG showed superiority above other biomaterials, but on 3 mm recessions, it seemed to have the same results. The percentage of recessions with complete root coverage for both 2 and 3 mm recessions showed similar results for all biomaterials.

CONCLUSIONS

With their limits, the present data concluded that CTG, acellular dermal matrix allograft, and xenogenic collagen matrix provided similar results for root coverage.

CLINICAL RELEVANCE

To know if there is a 3D matrix with equivalent predictable results for root coverage, that we could avoid the morbidity of the connective tissue graft for these cases.

Root coverage using coronally advanced flap with porcine-derived acellular dermal matrix or subepithelial connective tissue graft: a randomized controlled clinical trial

OBJECTIVE

The aim of this study is to investigate the use of a porcine-derived acellular dermal matrix (MD) in root coverage procedures combined with extended coronally positioned flap (eCAF), in comparison to the subepithelial connective tissue graft (SCTG) associated with the eCAF.

MATERIAL AND METHODS

Eighteen adult patients presenting bilateral type 1 gingival recession were randomly assigned to SCTG or MD groups. Clinical and patient-based outcomes were recorded at 3 and 6 months after the surgical procedure.

RESULTS

Both groups showed a significant reduction in the mean recession height of 3.33 ± 0.89 mm to 1.24 ± 1.10 mm (MD) and 3.21 ± 0.8 mm to 0.83 ± 0.86 mm (SCTG) without difference between groups. Six patients in the test group and eight in the control group obtained complete root coverage. The keratinized tissue height and thickness (KTT) showed a significant increase after 3 and 6 months in both groups. The average KTT gains were 0.39 ± 0.4 mm (MD) and 0.51 ± 0.5 mm (SCTG) (p < 0.05). Performing multivariate analysis suggests that MD addition to coronally advanced flaps may be similar to SCTG.

CONCLUSION

The MD had similar results in comparison to SCTG and in the context of reducing patient morbidity it can be used as an alternative for the treatment of gingival recessions.

CLINICAL RELEVANCE

The SCTG is the gold standard therapy for root coverage. The MD has been widely used in mucogingival surgery as a substitute for SCTG and proposed similar results. A substitute is very important for clinicians and patients. It will give a better postoperative and possibilities to treat multiples recession. (Clinicaltrials.gov Identifier: NCT03675334).

Periodontal regeneration versus extraction and dental implant or prosthetic replacement of teeth severely compromised by attachment loss to the apex: A randomized controlled clinical trial reporting 10-year outcomes, survival analysis and mean cumulative cost of recurrence

Background

Periodontal regeneration can change tooth prognosis and represents an alternative to extraction in teeth compromised by severe intra‐bony defects. The aim of this study was to compare periodontal regeneration (PR) with tooth extraction and replacement (TER) in a population with attachment loss to or beyond the apex of the root in terms of professional, patient‐reported and economic outcomes.

Methods

This was a 10‐year randomized controlled clinical trial. 50 stage III or stage IV periodontitis subjects with a severely compromised tooth with attachment loss to or beyond the apex were randomized to PR or TER with either an implant‐ or a tooth‐supported fixed partial denture. Subjects were kept on a strict periodontal supportive care regimen every 3 months and examined yearly. Survival and recurrence analysis were performed.

Results

88% and 100% survival rates were observed in the PR and TER groups. Complication‐free survival was not significantly different: 6.7–9.1 years for PR and 7.3–9.1 years for TER (p = .788). In PR, the observed 10‐year attachment gain was 7.3 ± 2.3 mm and the residual probing depths were 3.4 ± 0.8 mm. Recurrence analysis showed that the 95% confidence interval of the costs was significantly lower for PR compared with TER throughout the whole 10‐year period. Patient‐reported outcomes and oral health‐related quality‐of‐life measurements improved in both groups.

Conclusions

Periodontal regeneration can change the prognosis of hopeless teeth and is a less costly alternative to tooth extraction and replacement. The complexity of the treatment limits widespread application to the most complex cases but provides powerful proof of principle for the benefits of PR in deep intra‐bony defect.

Treatment of multiple recessions with collagen matrix versus connective tissue: a randomized clinical trial

The objective of this study was to determine whether collagen matrix (CM) is an alternative to connective tissue graft technique (CTG) in the treatment of multiple gingival recessions (GR). The indication of CM for the treatment of multiple GR is not yet clear. More studies are needed to better understand this treatment modality, as an alternative to CTG. In this single-blind, split-mouth randomized clinical trial, fifteen patients with multiple Miller class I upper GR were selected and randomly assigned to control group (CTG) or test group (CM). Root coverage (RC) and patient-centered outcomes were evaluated at baseline and after 3, 6, and 12 months. A total of 82 GRs were treated. There was no significant difference regarding GR depth (GRD, primary outcome) between CTG (0.5 ± 0.9 mm) and CM groups (0.6 ± 1.0 mm) (p = 0.225). Percentage of RC was 82.14% in CTG and 77.7% in CM. Both groups demonstrated a gain in keratinized tissue width at 12 months (p < 0.05). Dentine hypersensitivity was effectively reduced in both groups. Postoperative pain was significantly higher in the CTG (p = 0.001). Esthetic satisfaction was high for both groups, with no significant difference (p > 0.05) between groups. After 12 months, both surgical treatments were able to promote RC, and GRD was similar in both CTG and CM groups.

Autogenous soft tissue grafting for periodontal and peri-implant plastic surgical reconstruction

This state-of-the-art review presents the latest evidence and the current status of autogenous soft tissue grafting for soft tissue augmentation and recession coverage at teeth and dental implant sites. The indications and predictability of the free gingival graft and connective tissue graft (CTG) techniques are highlighted, together with their expected clinical and esthetic outcomes. CTGs can be harvested from the maxillary tuberosity or from palate with different approaches that can have an impact on graft quality and patient morbidity. The influence of CTGs on soft tissue thickness and keratinized tissue width are also discussed.

Xenogeneic collagen matrix versus connective tissue graft for the treatment of multiple gingival recessions: A systematic review and meta-analysis

A systematic review and meta-analysis was performed to understand the efficacy of xenogeneic collagen matrix (CMX) compared with connective tissue graft (CTG) for the treatment of multiple adjacent gingival recessions (MAGRs). A literature search was performed for published randomized controlled trials in adult patients (≥18 years old) with Multiple Adjacent Miller class I and II gingival recessions (MAGRs). The assessments included recession depth, Recession width, complete root coverage, mean root coverage, probing depth, clinical attachment level, and keratinized tissue width. Pooled data were analyzed using fixed- and random-effects models, and Forest plots were constructed. Heterogeneity within studies was calculated to assess publication bias. Four randomized controlled trials were included based on the eligibility criteria. Although the recession depth, complete root coverage, and mean root coverage were significantly lower with CMX (p = .017 and p = .001, p = .001, respectively), there was no statistically significant difference in the Recession width between CMX and CTG (p = .203). CMX showed significantly lower Probing Depth than CTG (p = .023); however, no significant difference in clinical attachment level (p = .060) and keratinized tissue width (p = .052) was observed between the groups. Owing to the heterogeneity in the included studies, firm conclusions cannot be drawn regarding the noninferiority of CMX compared with CTG. Long-term studies are therefore needed to conclusively establish the relative efficacy of CMX in MAGR.

Extracellular matrix-based scaffolding technologies for periodontal and peri-implant soft tissue regeneration

The present article focuses on the properties and indications of scaffold-based extracellular matrix (ECM) technologies as alternatives to autogenous soft tissue grafts for periodontal and peri-implant plastic surgical reconstruction. The different processing methods for the creation of cell-free constructs resulting in preservation of the extracellular matrices influence the characteristics and behavior of scaffolding biomaterials. The aim of this review is to discuss the properties, clinical application, and limitations of ECM-based scaffold technologies in periodontal and peri-implant soft tissue augmentation when used as alternatives to autogenous soft tissue grafts.

Adjunctive benefit of a xenogenic collagen matrix associated with coronally advanced flap for the treatment of multiple gingival recessions: A superiority, assessor-blind, randomized clinical trial

AIM

To evaluate the superiority of coronally advanced flaps (CAFs) when used in combination with a xenogeneic collagen matrix (CMX) for root coverage of multiple adjacent gingival recessions.

MATERIALS AND METHODS

Participants with at least 2 upper adjacent teeth exhibiting gingival recession depth ≥2 mm were recruited and randomized to CAF with (test) or without (control) CMX, respectively. Mean and complete root coverage, amount of keratinized tissue (KTw), gingival thickness (GThick) and patient-reported outcomes (PROMs) were recorded at baseline, 3, 6 and 12 months.

RESULTS

Twenty-four patients providing 61 gingival recessions were analysed. After 1 year, gingival recession depth decreased from 2.3 ± 0.7 to 0.3 ± 0.4 mm in the CAF + CMX group (2.0 ± 0.8 mm meanRC) and from 2.6 ± 1.0 to 0.6 ± 0.3 mm in the control group (2.0 ± 1.1 mm meanRC). No difference was observed between the two groups (p = 0.2023). Nineteen (63%) of the test and 16 (52%) of control defects showed complete root coverage (p = 0.4919). GThick greatly increased in the test group (0.5 mm; 0.2-0.8 mm, 95% CI; p = 0.0057). No difference between the two groups was observed for KTw (p = 0.5668) and PROMs.

CONCLUSION

At 1 year, CAF + CMX provided similar root coverage to CAF alone, but a significant increase in gingival thickness.

Clinical efficacy of xenogeneic collagen matrix in the treatment of gingival recession: a systematic review and meta-analysis

Objective: The aim of this systematic review (SR) was to evaluate the effects of xenogenic collagen matrix (XCM) on the outcomes of clinical treatments of patients with Miller class-I or -II gingival recessions. Materials and methods: Articles that were published before March 2018 were electronically searched in four databases without any date or language restrictions and manually searched in regular journals and gray literature. The eligibility criteria comprised randomized controlled trials (RCTs) and prospective controlled trials with follow-up periods of 6 months or more that compared the performance of XCM in the treatment of Miller class-I or -II gingival recessions. This SR was registered in PROSPERO under number CRD42018106118. Results: Nine RCTs published between 2010 and 2018 were included in this SR. The percentage of root coverage (RC) was significantly higher (p = .0003) when gingival recessions were treated with XCM when compared to coronally advanced flap (CAF) alone. In addition, the parameters of keratinized mucosa width (KMW) (p = .006) and gingival thickness (GT) (p = .0003) were also improved when the XCM was used in comparison to the CAF alone. There was not a statistically significant difference (p = .22) between the clinical attachment level (CAL) achieved with the use of XCM and that achieved with CAF alone. RC with the use of XCM, when compared to connective tissue grafts (CTGs) (p = .09) and enamel matrix derivative (EMD) (p = .62), there was no significant difference; however, XCM yielded lower RC than CTG in the treatment of Miller class-I or -II gingival recessions. Conclusions: Based on both the individual studies' outcomes and the pooled estimates, it can be concluded that the use of XCM improves the RC, KMW and GT in the treatment of gingival recessions when compared to CAF alone and may be a viable alternative to use of CTG.

Acellular dermal matrix and coronally advanced flap or tunnel technique in the treatment of multiple adjacent gingival recessions. A 12-year follow-up from a randomized clinical trial

AIM

To evaluate the long-term outcomes of Acellular Dermal Matrix (ADM) with Coronally Advanced Flap (CAF) or Tunnel technique (TUN) in the treatment of multiple adjacent gingival recessions (MAGRs).

MATERIAL AND METHODS

Nineteen of the original 24 patients contributing to a total number of 33 sites for CAF and 34 for TUN were available for the 12 years follow-up examination. Recession depth, mean root coverage (mRC), keratinized tissue width (KTW), gingival thickness (GT) were evaluated and compared with baseline values and 6-months results. Regression analysis was performed to identify factors related to the stability of the gingival margin.

RESULTS

A highly significant drop in mRC was observed for both groups from the 6 months timepoint to the 12 years recall (p < .001). While there were no statistically significant differences between the two groups in terms of Clinical Attachment Level (CAL), KTW, GT changes and Root Coverage Esthetic Score at each timepoint (p > .05). KTW ≥ 2 mm and GT ≥ 1.2 mm at 6-months were two predictors for stability of the gingival margin (p = .03 and p = .01, respectively).

CONCLUSIONS

A significant relapse of the gingival margin of MAGRs treated with CAF or TUN + ADM was observed after 12 years.

Clinical evaluation of Miller class I and II recessions treatment with the use of modified coronally advanced tunnel technique with either collagen matrix or subepithelial connective tissue graft: A randomized clinical study

AIM

To compare outcomes of modified coronally advanced tunnel technique (MCAT) combined with either collagen matrix (CM) or subepithelial connective tissue graft (SCTG) in the treatment of Miller class I and II multiple gingival recessions in the mandible.

MATERIALS AND METHODS

The study encompassed 91 recessions in 29 patients for whom MCAT was combined with CM on one side of the mandible and SCTG on the contralateral one. The following clinical parameters were measured: gingival recession height (GR) and width (RW), probing depth (PD), clinical attachment level (CAL), width of keratinized tissue (KT), gingival thickness (GT), mean (MRC) and complete root coverage (CRC) and Root Coverage Esthetic Score (RES).

RESULTS

The MRC proportions on the CM- and SCTG-treated sides were 53.20% and 83.10%, respectively. CRC was achieved in 9 out of 45 (20%) gingival defects treated with CM and 31 out of 46 (67%) treated with SCTG. There were statistically significant differences in MRC, CRC, GR, RW, KT, GT and RES between CM- and CTG-treated sides.

CONCLUSIONS

Modified coronally advanced tunnel technique leads to reduction in gingival recession both when combined CM and SCTG, of which the latter is more efficient as far as root coverage and aesthetic parameters are concerned.

Root coverage procedures for treating localised and multiple recession-type defects

BACKGROUND

Gingival recession is defined as the oral exposure of the root surface due to a displacement of the gingival margin apical to the cemento-enamel junction and it is regularly linked to the deterioration of dental aesthetics. Successful treatment of recession-type defects is based on the use of predictable root coverage periodontal plastic surgery (RCPPS) procedures. This review is an update of the original version that was published in 2009.

OBJECTIVES

To evaluate the efficacy of different root coverage procedures in the treatment of single and multiple recession-type defects.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 12) in the Cochrane Library (searched 15 January 2018), MEDLINE Ovid (1946 to 15 January 2018), and Embase Ovid (1980 to 15 January 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 January 2018). No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) only of at least 6 months' duration evaluating recession areas (Miller's Class I or II ≥ 3 mm) and treated by means of RCPPS procedures.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, data extraction and risk of bias assessment were conducted independently and in duplicate. Authors were contacted for any missing information. We expressed results as random-effects models using mean differences (MD) for continuous outcomes and odds ratios (OR) for dichotomous outcomes with 95% confidence intervals (CI). We used GRADE methods to assess the quality of the body of evidence of our main comparisons.

MAIN RESULTS

We included 48 RCTs in the review. Of these, we assessed one as at low risk of bias, 12 as at high risk of bias and 35 as at unclear risk of bias. The results indicated a greater reduction in gingival recession for subepithelial connective tissue grafts (SCTG) + coronally advanced flap (CAF) compared to guided tissue regeneration with resorbable membranes (GTR rm) + CAF (MD -0.37 mm; 95% CI -0.60 to -0.13, P = 0.002; 3 studies; 98 participants; low-quality evidence). There was insufficient evidence of a difference in gingival recession reduction between acellular dermal matrix grafts (ADMG) + CAF and SCTG + CAF or between enamel matrix protein (EMP) + CAF and SCTG + CAF. Regarding clinical attachment level changes, GTR rm + CAF promoted additional gains compared to SCTG + CAF (MD 0.35; 95% CI 0.06 to 0.63, P = 0.02; 3 studies; 98 participants; low-quality evidence) but there was insufficient evidence of a difference between ADMG + CAF and SCTG + CAF or between EMP + CAF and SCTG + CAF. Greater gains in the keratinized tissue were found for SCTG + CAF when compared to EMP + CAF (MD -1.06 mm; 95% CI -1.36 to -0.76, P < 0.00001; 2 studies; 62 participants; low-quality evidence), and SCTG + CAF when compared to GTR rm + CAF (MD -1.77 mm; 95% CI -2.66 to -0.89, P < 0.0001; 3 studies; 98 participants; very low-quality evidence). There was insufficient evidence of a difference in keratinized tissue gain between ADMG + CAF and SCTG + CAF. Few data exist on aesthetic condition change related to patients' opinion and patients' preference for a specific procedure.

AUTHORS' CONCLUSIONS

Subepithelial connective tissue grafts, coronally advanced flap alone or associated with other biomaterial and guided tissue regeneration may be used as root coverage procedures for treating localised or multiple recession-type defects. The available evidence base indicates that in cases where both root coverage and gain in the width of keratinized tissue are expected, the use of subepithelial connective tissue grafts shows a slight improvement in outcome. There is also some weak evidence suggesting that acellular dermal matrix grafts appear as the soft tissue substitute that may provide the most similar outcomes to those achieved by subepithelial connective tissue grafts. RCTs are necessary to identify possible factors associated with the prognosis of each RCPPS procedure. The potential impact of bias on these outcomes is unclear.

Efficacy of xenogeneic collagen matrix in the treatment of gingival recessions: A systematic review and meta-analysis

OBJECTIVES

This review aims to evaluate the efficacy of xenogeneic collagen matrix (XCM) for the treatment of single or multiple gingival recessions in terms of clinical parameters and patient-related outcomes.

MATERIALS AND METHODS

Various electronic databases (The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, etc.) from 1966 to April 2018 and hand literatures were searched. Quality of the included studies was assessed through the Cochrane Collaboration's Risk of Bias tool. A meta-analysis was performed to calculate risk ratios and mean differences.

RESULTS

Nine randomized controlled trials were included. The results revealed a higher percentage of mean root coverage (MRC) and a greater recession reduction (RecRed) for single recessions for the combination of coronally advanced flap (CAF) with XCM compared to CAF alone (n = 3; MD = 10.00%; 95%CI [3.56%; 16.43%]; p = 0.002) (n = 3; MD = 0.35 mm; 95%CI [0.10 mm; 0.60 mm]; p = 0.005). Comparing XCM with connective tissue graft (CTG), no significant differences were detected in MRC or RecRed for single and multiple recessions.

CONCLUSIONS

The addition of XCM under CAF could improve MRC and RecRed at single tooth recessions. Initial data suggest that XCM shows promising results to improve the clinical efficacy of CAF for multiple recessions. In addition, XCM could be a valid alternative to CTG in terms of MRC and RecRed at both single and multiple recessions. Based on limited evidence, XCM may decrease postoperative morbidity and operation time compared to CTG.

[Periodontal optimization of the smile: choosing the right moment to achieve a maximum esthetic result]

INTRODUCTION

Today, esthetic enhancement is one of the main reasons why patients seek orthodontic treatment. Governed by the canons of beauty dictated by our society, the smile is a key component in this quest for perfect beauty. Hence, the orthodontist is often the first specialist to be consulted by adolescents, but also, more and more, by adults as well. Using simple tools, the practitioner must be able to make a precise analysis of the patient combining both orthodontic and periodontal examinations with an esthetic periodontal diagnosis.

OBJECTIVES

Using this analysis, the orthodontist must be able to identify his/her patient's periodontal morphotype and assess whether there is a risk of complications during treatment. One of the main complications that may arise is periodontal recession, which can both impact the esthetic result and give rise to patient anxiety, very soon leaving the orthodontist at a loss. If in doubt, it is essential to refer one's patient to the general dentist or to the periodontist.

MATERIALS AND METHODS

In this paper, the authors will describe a didactic decision-making tree, which will assist practitioners in learning how to manage their patients.

DISCUSSION

A synergistic approach to global patient management will ensure an optimal outcome by providing the patient with an appropriate and individualized treatment procedure.