Root coverage procedures for the treatment of localised recession-type defects

Treatment of Gingival Recession and Root Coverage Outcomes Using Fascia Lata Allograft: A Case Report with Two Years of Follow-Up

Mucogingival surgery is a procedure for the treatment of gingival recession, which is a shift of marginal gingival tissue to the cementoenamel junction (CEJ), exposing the surface of the root teeth. One treatment for gingival recession is the Langer and Langer bilaminar technique, which involves the use of the fascia lata (FL) membrane. This membrane is harvested from the aponeurosis of the external muscles. The purpose of this case report was to present the clinical results of a 2-year follow-up using the Langer and Langer bilaminar technique modified with FL in a patient with gingival recession. Recessions are a shift of marginal gingival tissue to the CEJ, which exposes the surface of the root teeth. At the 2-year follow-up, the patient presented with a gingival recession in tooth 41, which resulted in complete root coverage, reaching 83.3%; the amount of keratinized tissue increased to 3 mm in each tooth, changing the gingival biotype from thin to thick and scalloped. This case report supports the use of FL as a successful alternative treatment.

Treatment of Miller I Mandibular Gingival Recessions Using PRF vs. Connective Graft

Gingival recession (GR) can cause aesthetic and functional problems. Using connective tissue graft (CTG) and coronally advanced flap (CAF) is considered the technique of choice for treating GR. Considering the morbidity resulting from taking CTG, different alternative biomaterials have been described, including plasma-rich fibrin (PRF) membrane. Studies in lower teeth are few because of the complexity of the factors that can influence obtaining less predictable outcomes. Objective. To compare between CAF + PRF and CAF + CTG in the treatment of lower teeth Miller I gingival recession. Methodology. Split-mouth included 26 isolated GR (13 in each side of the mouth). The left side was treated with CAF + PRF and the right side with CAF + CTG. Clinical variables, probing depth (PD), GR, keratinized tissue (KT), vestibular soft tissue thickness (VSTT), and teeth sensitivity (TS), were assessed at the baseline. GR, KT, VSTT, extraoral inflammation (EI), and patient discomfort (PaD) were assessed at 45 days. Results. Statistically greater VSTT at 45 days was obtained using CAF + CTG (p < 0.05). Less EI and PaD were obtained using CAF + PRF (p < 0.05). No change was observed in GR, KT, and TS values in the intergroup or intragroup comparisons. Conclusion. Even with the limitations of this study, using PRF and CTG in lower teeth demonstrated an improvement in terms of root coverage, although it was without a total percentage of coverage. Regarding the VSTT, better results were obtained using the CTG + CAF, suggesting eventually long-term stable clinical results. We suggest a combined technique for future investigations.

Treating Public Health Dilemma of Gingival Recession by the Dehydrated Amnion Allograft: A 5-Year Longitudinal Study

Aim: This study aimed to evaluate the efficacy of dehydrated amnion allograft with coronally positioned flap procedure in paired Miller's class I recession defects.

Methods: A total of 51 subjects were included in the study with bilateral Miller's class I gingival recession defects. In the test group, patients were treated with an amniotic membrane (AM) with a coronally positioned flap, while in the control group, patients were treated with coronally positioned flap alone. Clinical parameters such as recession depth, recession width (RW), probing depth (PD), relative attachment level (RAL), width of keratinized gingiva (WKG), and thickness of keratinized gingiva (TKG) were recorded at baseline and after 5 years of follow-up.

Result: The mean baseline recession was 2.95 ± 0.89 in the test group and 2.70 ± 0.85 in the control group, and both were statically non-significant. At the end of 6 months, all the parameters, when compared with the baseline, showed a significant improvement. Intergroup comparison showed the non-significant difference in all settings except the TKG.

Conclusion: AM proved to help improve the TKG. This increase in thickness helps in the long-term maintenance of the gingival margin in Miller's class I recession defect.

Evaluation of root coverage with pedicled buccal fat pad in class III and class IV gingival recession defects

Background:

Gingival recession (GR) is a common clinical feature of periodontal disease and is an undesirable condition. More than 50% of the population has one or more sites with GR ≥ 1 mm.

Material and Methods:

In this study 15 subjects were subjected to initial periodontal therapy such as ultrasonic scaling and root planning with hand instruments and curettes. Patient is motivated for home care. The buccal fat pad is harvested and sutured in the gingival recession area and followed up for 6 months and root coverage was calculated.

Results:

At baseline mean recession of 5.60 ± 1.18 mm, probing depth of 0.73 ± 0.59 mm, clinical attachment loss of 6.40 ± 1.18 mm were recorded. At the end of 6 months, the mean recession was reduced from 5.60 ± 1.18 mm to 2.87 ± 0.74 mm, probing depth was increased from 0.73 ± 0.59 mm to 1.73 ± 0.70 mm and clinical attachment loss was decreased from 6.40 ± 1.18 mm to 4.53 ± 0.83 mm.The difference between baseline score and six months score for all three parameters are statistically significant.

Conclusion:

Buccal fat pad is a predictable procedure to cover Miller's class III and class IV gingival recession defects. There was a definitive improvement in clinical parameters (reduction in gingival recession, increased probing depth, gain in clinical attachment) after 6 months. There was 46.78% improvement in root coverage which was statistically significant.

Does the presence of unilateral gingival recession on maxillary canines influence smile esthetics?

OBJECTIVE

The objective of this study was to determine orthodontists', periodontists', and laypersons' perception of smile esthetics, regarding the presence of different levels of gingival recession on the maxillary left canine.

MATERIAL AND METHODS

Two close-up smile images (frontal and oblique) of a white female were selected for this study. The images were digitally altered to create different levels of gingival recession on maxillary left canine, in 0.5-mm increments. They were randomly arranged into a photo album that was shown to 135 evaluators: 45 orthodontists, 45 periodontists, and 45 laypersons. Each evaluator was asked to rate the smile attractiveness, using to a visual analog scale. Data were analyzed statistically using ANOVA, Tukey's post-hoc test, and Student t-test.

RESULTS

According to the orthodontists and periodontists, all levels of recession were considered as unesthetic in both types of images. According to the laypersons, gingival recession > 1.5 mm in the frontal image and > 1.0 mm in the oblique image were considered unesthetic.

CONCLUSION

The results showed that the presence of unilateral gingival recession on maxillary canines may negatively influence smile attractiveness, depending on the evaluator type and the level of the recession.

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.

Pain perception following epithelialized gingival graft harvesting: a randomized clinical trial

OBJECTIVES

The aim of this study was to compare the effects of a hemostatic collagen sponge and a collagen sponge sealed with a bio-adhesive material on the palatal donor sites with the purpose of minimizing postoperative pain after epithelialized gingival graft (EGG) harvesting.

MATERIAL AND METHODS

The present study consisted of 44 EGGs harvested in 44 patients. In the control group, a hemostatic collagen sponge was applied over the palatal wound, while the test group was treated with additional cyanoacrylate. Patients were observed for 14 days, evaluating the pain level by using the visual analogic scale. The consumption of analgesic during the postoperative period, the willingness for retreatment and the characteristic of the graft were also analyzed.

RESULTS

Statistically significant differences in pain perception were found between test and control groups in each of the studied days (p < 0.01). Analgesic consumption was lower in the test group (p < 0.01). Graft width < 14 mm was found to be associated with lower discomfort (p < 0.01).

CONCLUSIONS

Adding an additional layer of cyanoacrylate over a hemostatic collagen sponge on the palatal wound following EGG harvesting was found to be successful in minimizing the postoperative discomfort and the need for analgesics.

CLINICAL RELEVANCE

Postoperative pain after palatal tissue harvesting can be successfully minimized if the donor site open wound is protected with an external layer of cyanoacrylate over a collagen sponge.

Free Gingival Graft versus Mucograft: Histological Evaluation

INTRODUCTION:

The correction of the gingival recession is of esthetical and functional significance, but the tissue regeneration can only be confirmed by a histological examination.

AIM:

This study aims to make a comparison between the free gingival graft and the autograft.

MATERIAL AND METHODS:

This study included 24 patients with single and multiple gingival recessions. Twelve patients were treated with a free gingival graft and the other twelve with a micrograft. Six months after the surgical procedure, a micro-punch biopsy of the transplantation area was performed. The tissue was histologically evaluated, graded in 4 categories: immature, mature, fragmented and edematous collagen tissue. The elastic fibres were also examined and graded in three categories: with a normal structure, fragmented rare and fragmented multiplied.

RESULTS:

Regarding the type of collagen tissue that was present, there was a significant difference between the two groups of patients, with a larger number of patients treated with a micrograft showing a presence of mature tissue, compared to the patients treated with a free gingival graft. A larger number of patients in both of the groups displayed elastic fibres with a rare fragmented structure; 33.3% of the patients showed a normal structure; 50% demonstrated a normal structure.

CONCLUSION:

The patients treated with a free gingival graft showed a larger presence of fragmented collagen tissue and fragmented elastic fibres, whereas a mature tissue was predominantly present in the surgical area where a Geistlich Mucograft was placed.

Acellular dermal matrix and subepithelial connective tissue grafts for root coverage: A systematic review

BACKGROUND

The aim of this systematic review was to evaluate whether patients with gingival recession would benefit from an acellular dermal matrix graft (ADMG) in ways that are comparable to the gold standard of the subepithelial connective tissue graft (SCTG).

MATERIALS AND METHODS

A systematic review and meta-analysis comparing ADMG to SCTG for the treatment of Miller Class I and II recession defects was conducted according to PRISMA guidelines. PubMed, Excerpta Medica Database, and Cochrane Central Register of Controlled Trials databases were searched up to March 2016 for controlled trials with minimum 6 months duration. The primary outcome was root coverage; secondary outcomes included attachment level change, keratinized tissue (KT) change, and patient-based outcomes. Both authors independently assessed the quality of each included trial and extracted the relevant data.

RESULTS

From 158 potential titles, 17 controlled trials were included in the meta-analysis. There were no differences between ADMG and SCTG for mean root coverage, percent root coverage, and clinical attachment level gain. ADMG was statistically better than SCTG for gain in width of KT (-0.43 mm; 95% confidence interval: -0.72, -0.15). Only one study compared patient-based outcomes.

CONCLUSION

This review found that an ADMG would be a suitable root coverage substitute for an SCTG when avoidance of the second surgical site is preferred.

A Randomized Comparative Study of Two Techniques to Optimize the Root Coverage Using a Porcine Collagen Matrix

The aim of this randomized controlled clinical study was to compare the extended flap technique (EFT) with the coronally advanced flap technique (CAF) using a porcine collagen matrix (PCM) for root coverage. Twenty patients with two bilateral gingival recessions, Miller class I or II on non-molar teeth were treated with CAF+PCM (control group) or EFT+PCM (test group). Clinical measurements of probing pocket depth (PPD), clinical attachment level (CAL), recession height (RH), keratinized tissue height (KTH), keratinized mucosa thickness (KMT) were determined at baseline, 3 and 6 months post-surgery. At 6 months, the mean root coverage for test group was 81.89%, and for control group it was 62.80% (p<0.01). The change of recession depth from baseline was statistically significant between test and control groups, with an mean of 2.21 mm gained at the control sites and 2.84 mm gained at the test sites (p=0.02). There were no statistically significant differences for KTH, PPD or CAL comparing the two therapies. The extended flap technique presented better root coverage than the coronally advanced flap technique when PCM was used.

Bone-added periodontal plastic surgery: a new approach in esthetic dentistry

This article proposes a combined technique including bone grafting, connective tissue graft, and coronally advanced flap to create some space for simultaneous bone regrowth and root coverage.

A 23 year-old female was referred to our private clinic with a severe class II Miller recession and lack of attached gingiva. The suggested treatment plan comprised of root coverage combined with xenograft bone particles.

The grafted area healed well and full coverage was achieved at 12-month follow-up visit. Bone-added periodontal plastic surgery can be considered as a practical procedure for management of deep gingival recession without buccal bone plate.

Gingival unit transfer using in the Miller III recession defect treatment

The most significant factor for the success in soft tissue grafts is the synergistic relation between vascular configuration and involved tissues. In the soft tissue graft procedures, site specific donor tissue is assumed to have improved potential for function and aesthetic survive at recipient sites. On a clinical level, using site specific gingival unit graft that placed on traditionally prepared recipient site, results in predictable root coverage. In this case report the clinical effectiveness of gingival unit transfer (GUT) technique performed on Miller III recession was presented and a similar recession case treated with free gingival graft (FGG) technique for comparison. Probing depth, recession depth, keratinized tissue width and clinical attachment level clinical parameters were measured at baseline and postoperative 8 mo. Percentage of defect coverage was evaluated at postoperative 8 mo. Creeping attachment was assessed at postoperative 1, 3, 6 and 8 mo. The GUT revealed better defect coverage and creeping attachment results than the FGG in the treatment of Miller III defects.

Comparison of intervention effects in split-mouth and parallel-arm randomized controlled trials: a meta-epidemiological study

Background

Split-mouth randomized controlled trials (RCTs) are popular in oral health research. Meta-analyses frequently include trials of both split-mouth and parallel-arm designs to derive combined intervention effects. However, carry-over effects may induce bias in split- mouth RCTs. We aimed to assess whether intervention effect estimates differ between split- mouth and parallel-arm RCTs investigating the same questions.

Methods

We performed a meta-epidemiological study. We systematically reviewed meta- analyses including both split-mouth and parallel-arm RCTs with binary or continuous outcomes published up to February 2013. Two independent authors selected studies and extracted data. We used a two-step approach to quantify the differences between split-mouth and parallel-arm RCTs: for each meta-analysis. First, we derived ratios of odds ratios (ROR) for dichotomous data and differences in standardized mean differences (∆SMD) for continuous data; second, we pooled RORs or ∆SMDs across meta-analyses by random-effects meta-analysis models.

Results

We selected 18 systematic reviews, for 15 meta-analyses with binary outcomes (28 split-mouth and 28 parallel-arm RCTs) and 19 meta-analyses with continuous outcomes (28 split-mouth and 28 parallel-arm RCTs). Effect estimates did not differ between split-mouth and parallel-arm RCTs (mean ROR, 0.96, 95% confidence interval 0.52–1.80; mean ∆SMD, 0.08, -0.14–0.30).

Conclusions

Our study did not provide sufficient evidence for a difference in intervention effect estimates derived from split-mouth and parallel-arm RCTs. Authors should consider including split-mouth RCTs in their meta-analyses with suitable and appropriate analysis.

Lateral sliding bridge flap technique along with platelet rich fibrin and guided tissue regeneration for root coverage

Gingival recession is defined as the apical migration of the gingival margin with exposure of root surfaces. The etiology of the condition is multifactorial. Given the high rate of gingival recession defects among the general population, it is imperative that dental practitioners have an understanding of the etiology, complications and management of the condition. A recent innovation in dentistry is the preparation and use of platelet-rich fibrin (PRF) for recession defects. The article presents a case report, which highlights the use of lateral sliding bridge flap along with PRF in a collagen membrane carrier (guided tissue regeneration) for the treatment of multiple recession defects.

A comparative evaluation of subepithelial connective tissue graft (SCTG) versus platelet concentrate graft (PCG) in the treatment of gingival recession using coronally advanced flap technique: A 12-month study

OBJECTIVE

The objective of this study was to clinically evaluate and compare the efficacy of platelet concentrate graft (PCG) with that of subepithelial connective tissue graft (SCTG) using a coronally advanced flap technique in the treatment of gingival recession.

MATERIALS AND METHODS

Twelve patients with a total of 24 gingival recession defects were selected and randomly assigned either to experimental site-A (SCTG) or experimental site-B (PCG). The clinical parameters were recorded at baseline up to 12 months post-operatively and compared.

RESULTS

The mean vertical recession depth (VRD) statistically significantly decreased from 2.50 ± 0.48 mm to 0.54 ± 0.50 mm with PCG and from 2.75 ± 0.58 mm to 0.54 ± 0.45 mm with SCTG at 12 months. No statistically significant differences between the treatments were found for VRD and clinical attachment level (CAL), while keratinized tissue width (KTW) gain was statistically significant.

CONCLUSION

Both the SCTG and the PCG group resulted in a significant amount of root coverage. The PCG technique was less invasive and required minimal time and clinical maneuver. It resulted in superior aesthetic outcome and lower post-surgical discomfort at the 12 months follow-up.

A novel treatment of gingival recession using a botanical topical gingival patch and mouthrinse

BACKGROUND AND AIM

Current treatment of gingival recession (GR) is limited to surgical procedures. We describe a case series of 18 patients with GR who were treated with a botanical patch and rinse following standard conservative therapy. CASE SERIES DESCRIPTION: A total of 22 sites with GR > 1 mm were studied. Following scaling and root planing (SRP) and oral hygiene instruction, patients received two courses of patch treatment (3 days each) and botanical rinse administered twice daily throughout the treatment period. Outcome measures (GR, gingival index (GI) and gingival thickness (GT) were taken at baseline; at 1 to 2 weeks; 2 to 4 weeks; and at 6 to 8 weeks. Miller classifcation and plaque index (PI) were measured at baseline and at 6 to 8 weeks. At the end of the treatment period, mean GR decreased from 4.18 ± 1.74 mm to 3.31 ± 1.51 mm (20.8%); Miller grade from 1.86 ± 0.56 to 1.06 ± 0.43; GI scores from 1.45 ± 0.63 to 0.17 ± 0.38 (88.3%); and PI scores from 1.33 ± 0.59 to 0.78 ± 0.94. GT increased from 0.74 mm ± 0.40 to 1.21 ± 0.39 (63.5%). No adverse effects were reported with either the patch or rinse treatments.

CONCLUSION

We observed a decrease in GR and GI scores in 18 patients (22 sites) treated with the study patch and rinse, with increased GT.

CLINICAL SIGNIFICANCE

A combined botanical patch-rinse treatment may be effective as adjuvant treatment to standard conservative care for GR. Further research is needed to verify these fndings.