Influence of tooth location on coronally advanced flap procedures for root coverage

Evaluation of Postoperative Complications Following Modified Coronally Advanced Flap as Root Coverage Procedure - A Prospective Clinical Study

BACKGROUND

Root coverage procedures are very technique sensitive and require patients' compliance for successful treatment outcomes. Post operative complications can influence patients' acceptance of treatment and compromise further periodontal maintenance.

AIM

The aim of this study was to evaluate the frequency and severity of complications after a modified coronally advanced flap procedure.

METHODS AND MATERIALS

A total of 78 modified coronally advanced flap procedures were performed in 42 patients for root coverage. Duration of surgical procedure, history of smoking, gender, and age were recorded for each patient. A questionnaire was given to every patient to fill in at first post operative week regarding their experience of postoperative pain, swelling, and bleeding.

RESULTS

Pain and duration of surgery had a correlation (OR: 1.05, P < 0.05). Post operative bleeding was significantly correlated with duration of surgery (OR: 1.03, P < 0.05). Current smokers experienced post operative swelling (P < 0.05). However, post operative pain in current smokers was not significantly different (P > 0.05) as compared to nonsmokers. Descriptive statistics were expressed as mean and standard deviations. Odd's ratio was obtained to evaluate risk indicators for moderate to severe types of complications. P < 0.05 was considered as significant.

CONCLUSIONS

The duration of the surgery, long duration, and the presence of smoking can increase the frequency and severity of post operative complications.

Guided coronally advanced flap to treat gingival recession: Digital workflow and case report

BACKGROUND

The inherently technique-sensitive nature of periodontal plastic procedures demands a significant level of skill and expertise. The incorporation of three-dimensional (3D) printing technologies emerges as a potential strategy to optimize and simplify surgical procedures. This case report describes the digital workflow and presents the clinical outcomes achieved using a guided coronally advanced flap for the treatment of a single gingival recession (GR).

METHODS AND RESULTS

A female patient with a gingival recession type 1 (RT1 B-) defect on the mandibular second left premolar underwent successful treatment using a guided coronally advanced flap (g-CAF) and de-epithelized connective tissue graft (CTG). The digital planning included intraoral scanning of the mandible and hard palate using an intraoral scanner, with resulting polygon format (PLY) files exported for virtual model creation. The CAF guide was meticulously designed to orient horizontal and vertical incisions at the papillae base adjacent to the GR defect. For the donor site, a guide was specifically created, positioning the graft area 2 mm apically to the premolars' gingival margins. The delineation of this area involved two horizontal and vertical incisions, meticulously based on the dimensions of the GR. The digitally designed guides were then 3D-printed using a surgical guide-specific resin, contributing to the precise execution of the innovative surgical approach. Complete root coverage was achieved.

CONCLUSION

This case report demonstrates that g-CAF can be a promising approach for the treatment of single GR.

HIGHLIGHTS

Why is this case new information? To the best of the authors' knowledge, this is the first manuscript to report a guided procedure for the treatment of gingival recession. This report provides the digital workflow for the fabrication of a guide to perform the coronally advanced flap for single recession defects. What are the keys to successfully manage this case? It is necessary to adequately scan the recession defect area and palate. Properly not only design the guide using specific software but also print it. The guide has to be stable when in position for the surgical procedure. What are the primary limitations of this technique? This guide was designed to help surgeons during the incisions. However, it does not provide aid to split and release the flap and suture.

Essential training variables of arm-hand training in people with cervical spinal cord injury: a systematic review

OBJECTIVE

To identify and evaluate 3 training variables of motor training programmes involving people with a cervical spinal cord injury: i.e. motor training strategies, therapy dosage, and persons' motivation for arm-hand functioning in subacute and chronic phases.

METHODS

PubMed, Cochrane, CINAHL, EMBASE, and DARE databases were searched for active arm-hand motor training programmes. Two independent reviewers assessed methodological quality. Pre-post effect sizes were calculated using Hedge's g, and mean effect sizes were calculated to compare outcomes on the International Classification of Functioning, Disability, and Health levels of function and activity.

RESULTS

Twelve training programmes integrated mainly skill training alone or combined with strength and/or endurance training. Task-oriented training components included: multiple movement planes, functional movements, clear functional goals, and bimanual practice. Training duration of 8 weeks was common. Quantitative analyses of 8 training programmes showed an overall small effect (0.34) on function level and an overall moderate effect (0.55) on activity level. In depth-analysis of activity level showed moderate effects of skill training only (0.55) or combined with strength and endurance training (0.53). Moderate effects (0.53-0.60) were found for integrating functional movements, clear functional goals, real-life object manipulation, multiple movement planes, total skill practice, context-specific environment, exercise variety, and bimanual practice. Training of minimum 8 weeks showed a moderate effect (0.60-0.69).

CONCLUSION

Based on limited studies, arm-hand functioning aiming to improve activity level can be improved using skill training with at least 8 task-oriented training components, additional strength and endurance training, with a minimum training duration of 8 weeks.

Gingival pedicle with split-thickness tunnel technique: A retrospective case series for single mandibular anterior recessions

INTRODUCTION

Gingival recessions in the mandibular anterior sextant are a common clinical finding, but mucogingival treatment in this location is particularly challenging, due to several anatomical and surgical difficulties. In the present case series, a novel technique, called gingival pedicle with split-thickness tunnel (GPST), was retrospectively evaluated.

CASE SERIES

Fifteen patients presenting with a single buccal RT1 or RT2 gingival recession of a depth of ≥3 mm in the mandibular anterior sextant were treated by means of the GPST technique. Clinical periodontal parameters at baseline and at the last follow-up evaluation visit (6-84 months) were compared. Early healing was uneventful in all cases, and no complications such as flap dehiscence or loss of connective tissue graft were observed. Mean root coverage (mRC) was 98.1% ± 7.38%, corresponding to a statistically significant recession reduction (ΔRD) of 4.53 ± 1.19 mm. Complete root coverage was achieved in 14 of 15 cases. The gain in keratinized tissue width amounted to 3.13 ± 0.99 mm and was statistically significant, whereas no significant change in periodontal probing depth was observed after treatment.

CONCLUSION

In conclusion, treatment with GPST technique seems to achieve a favorable and predictable clinical improvement in gingival recessions on mandibular anterior teeth. Why are these cases new information? Limited information is available about the management of isolated deep labial recessions in the mandibular anterior teeth. A novel surgical approach, called GPST technique, is described in a case series to specifically address this type of defect. What are the keys to successful management of these cases? Horizontal incision ≥ RECwidth Cut-back preparation helps to mobilize the flap without tension. CTG width ≥ 3 times RECwidth CTG height ≥ RECdepth Proper graft and flap stabilization need to be achieved. What are the primary limitations to success in these cases? Limited mesio-distal dimensions, which do not allow to obtain a pedicle with adequate horizontal width Very thin biotype may not be suitable because of the risk of inadequate flap vascularization.

Complications and treatment errors in root coverage procedures

Root coverage procedures have become very common in clinical dental practice. Even though these techniques are considered safe, the clinician may face several issues during the therapy due to their surgical nature. Some of these issues can be defined strictly as complications inherent to the procedure, whereas others are medical errors or treatment errors. This review will focus on describing treatment errors and complications that may arise during different phases of the root coverage therapeutic process and on how to prevent and manage them.

Comparing the safety profiles of implants and autologous fat grafting in gluteal augmentation: A systematic review

Gluteal augmentation has become a popular esthetic procedure since its inception. The main methods are augmentation using implants or autologous fat grafting, which is the harvesting and grafting of patients' own fat tissue. The last review comparing the safety of these methods was written 7 years ago, which warrants the writing of a new one. PubMed, Cochrane, and Medline were searched for studies focusing on the methods of gluteal augmentation listed previously. Five search terms were used and 15 studies fulfilled the criteria. The data were cataloged according to the method described and outcomes compared. Seven articles focused on gluteal implants and another seven assessed autologous fat grafting, whereas one detailed both. The most common complications in 524 implant procedures were wound dehiscence (9.16%), excessive implant palpability (5.92%), and seroma (3.82%), with an overall complication rate of 25%. The most common complications in 1788 gluteal fat augmentation procedures were seroma (6.9%), infection (3.0%), and transient sciatic paresthesia (1.0%), with an overall complication rate of 13%. Several articles listed satisfaction figures, but these were not assessed because this article was not powered to assess this outcome. Overall, gluteal augmentation using autologous fat grafting leads to fewer postoperative complications than implants and allows greater contouring of the buttocks and the surrounding areas. However, it can also be a far more dangerous procedure if certain recommendations are not followed.

Comparison of the clinical efficacy of concentrated growth factor and advanced platelet-rich fibrin in the treatment of type I multiple gingival recessions: a controlled randomized clinical trial

OBJECTIVES

The purpose of this randomized controlled clinical trial was to compare and evaluate the clinical effects of concentrated growth factor (CGF) and advanced platelet-rich fibrin (A-PRF) applied together with coronally advanced flap (CAF) technique using a microsurgical approach in the treatment of type I multiple gingival recessions (GR).

MATERIALS AND METHODS

Sixteen patients with multiple recession defects (Cairo type I) were included in this randomized and controlled study. Forty-five gingival recession defects were randomly equally divided into three groups (n = 15): CAF + CGF (test site); CAF + A-PRF (test site), and CAF alone (control site). Clinical attachment level (CAL), vertical gingival recession (VGR), horizontal gingival recession (HGR), gingival thickness (GT), width of keratinized gingiva (KGW), percentages of the mean (MRC), and complete root coverage (CRC), patient esthetic score (PES), and hypersensitivity score (HS) were recorded at baseline and 6 months after surgery. Patient comfort score (PCS) was evaluated at the day of surgery.

RESULTS

Significant improvements were determined in CAL, VGR, HGR, KGW, and GT at 6 months when compared to baseline levels in intra-group comparisons for all groups, and also GT was increased in CAF + A-PRF and CAF + CGF compared to CAF alone at 6 months in intergroup comparisons (p < 0.05). At 6 months, MRC was detected 85.66 ± 22.68% in the CAF + CGF, 90.88 ± 20.87% in the CAF + A-PRF, and 75.10 ± 32,37% in the CAF alone, and a significant increase was detected in the CAF + A-PRF group compared to CAF alone (p < 0.05). CRC in CAF + CGF was 66.66%, in CAF + A-PRF 80% and in CAF alone was 53.33% (p > 0.05). PES and HS values showed significant improvement from baseline to 6 months for all groups and also in CAF + CGF and CAF + A-PRF compared to CAF alone at 6 months in intergroup comparisons (p < 0.05).

CONCLUSIONS

The present study showed that the use of A-PRF and CGF membranes in GR therapy may have an additional benefit in GT increase and also A-PRF may increase the percentages of MRC. The use of A-PRF and CGF membranes may be beneficial in terms of improving patient-related parameters.

CLINICAL RELEVANCE

A-PRF and CGF may be superior to CAF alone in terms of patient-related parameters and GT increase in multiple recession defects.

TRIAL REGISTRATION NUMBER

17578e02-00a9-4a41-8c8d-42a637143531.

The nature of malpractice claims related to nerve damage after dental implants insertion in Israel during 2005-2020: A descriptive study

INTRODUCTION

Dental implant placement is a routine practice in dentistry, with a possible uncommon risk of neurosensory injury. The present study analyzed all dental implant claims involving sensory nerve disturbances between 2005 and 2020 in Israel. The study was conducted to understand implant risk management better and improve the patient's safety.

MATERIALS AND METHODS

All legal claims registered by Medical Consultant International (MCI) involving nerve damage claims between 2005 and 2020 were included in the study. The data included demographic details such as age, sex, event date, claim delivery date, and treatment settings. Information on the nerve damage included the damaged nerve, side of injury, and the number of implants performed in the same surgery.

RESULTS

There were 218 claims regarding nerve damage out of 1154 claims for dental implant therapy. The mean age for nerve damage claims was 54.1 ± 11 years. There were more female than male claims (p = 0.02), with 87% of cases concerning damage to the inferior alveolar nerve (p < 0.0001), out of those molar areas being more frequently involved in nerve damage (64.3%, p < 0.0001). The left side was 1.4 times more frequent than the right side (p = 0.043). The risk for nerve injury was 7.4 times higher when placing multiple implants compared to single dental implant (p < 0.0001).

CONCLUSIONS

Clinicians should be aware that placement of multiple implants, left-side implant placement, and patient gender may increase risk for a malpractice claim for neurosensory disturbances.

Estimates and multivariable risk assessment of mid-buccal gingival recessions in an Italian adult population according to the 2018 World Workshop Classification System

OBJECTIVES

The aim of this cross-sectional study was to provide estimate of mid-buccal gingival recession (GR) according to the 2018 World Workshop Classification System and to explore GR risk indicators in a representative urban population in North-West of Italy.

MATERIAL AND METHODS

This is a secondary analysis using data collected in an epidemiological study enrolling a representative sample of 736 adults, living in Turin. GR prevalence was defined as the presence of at least one mid-buccal GR ≥ 1 mm. GRs were categorized according to the 2018 classification system (RT1, RT2, RT3) and to different severity cutoffs. Logistic regression analysis was performed to identify RT GR risk indicators.

RESULTS

Mid-buccal GR ≥ 1 mm affected 57.20% of subjects and 14.56% of teeth. When considering RT1 GRs, their prevalence was 40.90% and 6.29% at the patient and tooth level. RT2 and RT3 GRs affected 25.82% and 36.68% of the study population, respectively. RT1 GRs occurred mostly on maxillary and mandibular premolars and maxillary canines, while RT2 and RT3 GRs on maxillary molars and mandibular incisors. Older age, high education, and full-mouth plaque score (FMPS) < 30% were risk indicators for RT1 GRs, while older age, poor education, periodontitis, and FMPS > 60% were significant contributors to RT2 and RT3 GRs.

CONCLUSIONS

RT1 and RT3 are fairly common findings in this Italian population and are significantly associated to different contributing factors and tooth type distribution pattern.

CLINICAL RELEVANCE

Prevention strategies should target different socio-demographic, behavioral, and clinical risk indicators based on the RT classes.

Clinical Outcomes of the Double Lateral Sliding Bridge Flap Technique with Simultaneous Connective Tissue Graft in Sextant V Recessions: Three-Year Follow-Up Study

The presence of isolated or multiple gingival recessions in the mandibular anterior region is a challenge for the clinician, as they may be associated with a shallow vestibule, high frenum insertion and/or little or no attached gingiva. Only limited evidence is available on the use of the double lateral sliding bridge flap technique with connective tissue graft (CTG) technique for treating gingival recessions in the mandibular anterior region. The aim of this study was to describe and evaluate the clinical and esthetic outcomes of the double lateral sliding bridge flap technique with CTG on isolated and multiple gingival recessions at the level of the mandibular incisors. Nine patients required treatment of gingival recessions in the mandibular incisors at the University of Salamanca (Spain) (seven females, two males; mean age: 27.9 ± 6.9) with a total of 14 isolated (42.9%) and multiple (57.1%) Miller class II and III gingival recessions. After a mean follow-up of 36 months, the mean percentage of root coverage was 80.5% for all treated recessions. Statistically significant differences (p < 0.05), were observed for reduction in recession depth, increased width of keratinized tissue and increased gingival thickness, this being dependent on the Miller class. The esthetic outcome was acceptable, with a final mean esthetic score of 7.4 out of 10. The double lateral sliding bridge flap surgical technique with CTG is an effective procedure for the coverage of isolated and multiple gingival recessions in the anterior mandibular region, as it offers satisfactory esthetic results.

Periodontal treatment outcomes in smokers: A narrative review

Smoking is considered as the major environmental risk factor for periodontal diseases. Smokers have a higher risk for severe periodontitis with more periodontal tissue destruction, more gingival recession, and more susceptibility for tooth loss. The aim of this narrative review is to provide up-to-date evidence on the clinical outcomes of periodontal treatment in smokers. Electronic databases were searched for studies that compare the clinical outcomes in smokers and non-smokers following non-surgical and surgical periodontal treatment modalities and also during the supportive periodontal treatment. Clinical studies published before May 2021 were included in the review. Smokers have a higher risk for recurrence of periodontal disease and the response to non-surgical as well as surgical periodontal treatment is not as good as that of non-smokers. Moreover, there is a dose-response effect in the adverse effects of smoking on periodontal health. Compared to non-smokers, smoker patients with periodontitis tend to respond less favorably to non-surgical and surgical periodontal treatment, and exhibit recurrence more frequently during supportive periodontal treatment. Along with the periodontal treatment, smokers may be encouraged to quit. Long follow-up and the communication between the dentist and the patient give a great opportunity for such counseling.

Comparison of two types of xenogeneic matrices to treat single gingival recessions: A randomized clinical trial

BACKGROUND

Xenogeneic matrices (XMs) have been increasingly used for root coverage procedures. This study compared the use of two types of XM (collagen matrix [CM] and xenogeneic acellular dermal matrix [XDM]) associated with the coronally advanced flap technique (CAF) to treat single gingival recessions.

METHODS

Seventy-five patients presenting single RT1 gingival recession were treated by CAF (control group, n = 25), CAF+CM (test group 1, n = 25), or CAF+XDM (test group 2, n = 25) and completed 6-month follow-up. Clinical, patient-centered, and esthetic assessments were performed and intra- and intergroup differences were analyzed.

RESULTS

At 6 months, the mean recession reduction for CAF, CAF+CM, and CAF+XDM was 2.4 ± 0.8 mm, 2.4 ± 0.9 mm and 2.1 ± 0.8 mm, respectively (P > 0.05). The corresponding mean percentage of root coverage was 78.9% ± 26.2% for CAF, 78.0% ± 28.5% for CAF+CM, and 65.6% ± 26.9% for CAF+XDM (P > 0.05). Dentin hypersensitivity and esthetic conditions showed significantly improvements in all groups. Test groups presented significant gains in gingival thickness (GT; CAF+CM: 0.4 ± 0.3 mm; CAF+XDM: 0.4 ± 0.2 mm) compared to the control group (CAF: 0.0 ± 0.1 mm; P < 0.05).

CONCLUSION

The CAF, CAF+CM, and CAF+XDM treatments each provided similar results in the treatment of single gingival recessions. The addition of either CM or XDM to CAF increases the GT.

Design of customized soft-tissue substitutes for posterior single-tooth defects: A proof-of-concept in-vitro study

OBJECTIVES

Soft-tissue volume augmentation treatments do not provide the satisfactory long-term functional and esthetic outcomes. The aim of the study was to develop a standardized digital procedure to design individual soft-tissue substitutes (STS) and apply mathematical modeling to obtain average shape STS for single posterior tooth defects.

MATERIAL AND METHODS

Thirty-three casts from 30 patients were scanned. STS were designed with a computer-aided design software and a systematic procedure standardized the measurements across all STS using 3D-analysis software. The occlusal, mesial-distal, and buccal-lingual planes were defined to partition, each STS and produce a mesh. The thickness values of each 3D slice were documented in a coordinate system chart to generate a scatter graph. Graphs were embedded into images (Orange software) and images were analyzed via hierarchical clustering.

RESULTS

Three STS groups were identified according to shape. Two shapes corresponded to the maxilla defects: a square (n = 13) with dimensions of 10 mm in a lingual-buccal (length) and 7-10 mm in a mesial-distal (width) direction; a rectangle (n = 11) of 11 mm in length and 4-7 mm in width. The average shape for mandible defects (n = 9) was smaller (6-8 mm in length, 5-10 mm in width). The highest thickness in all STS was in the buccal portion, above the alveolar ridge, with median values of 2 mm. The lowest thickness of 0.2 mm was at the edges.

CONCLUSIONS

The study developed novel methodology to design customized, as well as average shape STS for volume augmentation. Future STS harboring adapted geometry might increase volume augmentation efficiency and accuracy, while reducing surgical time.

Methodological quality of case series studies: an introduction to the JBI critical appraisal tool

INTRODUCTION

Systematic reviews provide a rigorous synthesis of the best available evidence regarding a certain question. Where high-quality evidence is lacking, systematic reviewers may choose to rely on case series studies to provide information in relation to their question. However, to date there has been limited guidance on how to incorporate case series studies within systematic reviews assessing the effectiveness of an intervention, particularly with reference to assessing the methodological quality or risk of bias of these studies.

METHODS

An international working group was formed to review the methodological literature regarding case series as a form of evidence for inclusion in systematic reviews. The group then developed a critical appraisal tool based on the epidemiological literature relating to bias within these studies. This was then piloted, reviewed, and approved by JBI's international Scientific Committee.

RESULTS

The JBI critical appraisal tool for case series studies includes 10 questions addressing the internal validity and risk of bias of case series designs, particularly confounding, selection, and information bias, in addition to the importance of clear reporting.

CONCLUSION

In certain situations, case series designs may represent the best available evidence to inform clinical practice. The JBI critical appraisal tool for case series offers systematic reviewers an approved method to assess the methodological quality of these studies.

Root Coverage Predictability in the Treatment of Gingival Recessions on Mandibular Anterior Teeth

INTRODUCTION

Mandibular anterior teeth are most frequently affected by gingival recession. However, data regarding mucogingival treatment aimed at root coverage in this specific location are limited.

OBJECTIVE

The purpose of this study was to systematically review the scientific literature and to use the meta-analytic approach to address the following focused question: "What is the effectiveness of different surgical approaches on clinical and patient-related outcomes in the treatment of buccal gingival recessions on mandibular anterior teeth?"

METHODS

Studies were located by searching 3 electronic databases (Medline, Scopus, and Cochrane databases) and cross-referencing. Randomized and nonrandomized studies including at least 1 arm involving the use of pedicle flaps and/or free soft tissue grafts in the treatment of gingival recessions (recession type [RT] 1 and RT2) located on the buccal aspects of mandibular centrals, laterals and canines, were included in the analysis. Primary outcome was mean root coverage (mRC), expressed in percentage, based on a 3- to 12-mo follow-up observation. A Bayesian single-arm network meta-analysis was performed to identify a treatment hierarchy of the different surgical techniques.

RESULTS

Sixteen studies, with a total of 23 arms, were included in the quantitative analysis. The greatest mRC is associated with laterally positioned flap (LPF) + connective tissue graft (CTG) (91.2%) and tunnel (TUN) + CTG (89.4%), whereas LPF alone, coronally advanced flap (CAF) + CTG, and free gingival graft (FGG) showed lower mRC (79.1%, 78.9%, and 68.5% respectively). TUN + CTG provides significantly greater mRC compared to CAF+CTG. No difference among the procedures could be observed in terms of keratinized tissue width gain.

CONCLUSIONS

Treatment hierarchy generated by an arm-based network meta-analysis model suggested that tunnel and laterally positioned flap, both in combination with connective tissue graft, may provide the greatest mean root coverage in the treatment of mandibular anterior recessions.

KNOWLEDGE TRANSFER STATEMENT

The results of the present systematic review can be used by clinicians when deciding which approach to adopt when treating buccal gingival recessions on mandibular anterior teeth. In particular, procedures based on a laterally positioned flap or a tunneling technique, both in combination with connective tissue graft, seem to be the most predictable therapeutic decision.

Root coverage stability: A systematic overview of controlled clinical trials with at least 5 years of follow-up

Objectives

To systematically assess the long‐term outcome (≥5 years) of root coverage procedures reported in controlled clinical trials.

Material and Methods

Literature search was performed according to the PRISMA guidelines with the following eligibility criteria: (a) English or German language; (b) controlled (CT) or randomised controlled clinical trials (RCT); (c) root coverage procedure with ≥5 years follow‐up; and (d) clinical treatment effect size and/or patient‐related outcome measures (PROMs) reported.

Results

Four CT and 14 RCT with a follow‐up of 5–20 years fulfilled the eligibility criteria; sample size per study ranged from 8 to 70 patients contributing with 18–149 sites. Coronally advanced flap (CAF) and CAF + connective tissue graft (CTG) were the prevalent treatments (i.e., in 24 and 38% of the groups, respectively), while other flap designs and adjuncts (i.e., enamel matrix derivative, bone graft, collagen membrane) were represented only once. For single Miller class I/II gingival recessions (GR), CAF + CTG appeared advantageous compared to other techniques, and provided low residual recession depths (i.e., ≤0.5 mm), and complete root coverage in ≥2/3 of the patients; similar tendency was observed for multiple GR. No data on Miller class III/IV GR is available. No meta‐analysis was feasible due to lack of similarity in the clinical and methodological characteristics across the trials and observed comparisons of interventions.

Conclusions

CAF + CTG appears to be the ‘gold standard’ technique for the treatment of single and multiple Miller class I/II GR also in regard to long‐term (i.e., ≥5 years of follow‐up) treatment outcomes. There is little information regarding the performance, on the long‐term, of other techniques and adjuncts.

Platelet-Rich Fibrin in Single and Multiple Coronally Advanced Flap for Type 1 Recession: An Updated Systematic Review and Meta-Analysis

Background and Objectives: The aim of the present systematic review and meta-analysis was to investigate the efficacy of leukocyte–platelet-rich fibrin (L-PRF) in addition to coronally advanced flap (CAF) for the treatment of both single and multiple gingival recessions (GRs) compared to the CAF alone and to the adjunct of connective tissue graft (CTG). Root coverage outcomes using platelet concentrates have gained increased interest. In particular, it has been suggested that adding L-PRF to CAF may provide further benefits in the treatment of GRs. Materials and Methods: An electronic and manual literature search was conducted to identify randomized controlled trials (RTCs) investigating root coverage outcomes with CAF + L-PRF. The outcomes of interest included mean root coverage (mRC), recession reduction, keratinized tissue width (KTW) gain, gingival thickness (GT) gain, and patient-reported outcome measures (PROms) such as pain perception and discomfort. Results: A total of 275 patients and 611 surgical sites were analyzed. L-PRF in adjunct to single CAF seems to show statistically significant results regarding clinical attachment level (CAL) with a weighted means (WM) 0.43 95% CI (−0.04, 0.91), p < 0.0001, GT (WM 0.17 95% CI (−0.02, 0.36), p < 0.0001, and mRC (WM 13.95 95% CI (−1.99, 29.88) p < 0.0001, compared to single CAF alone. Interesting results were obtained from the adjunct of PRF to multiple CAF with respect to multiple CAF alone with an increase in the mRC WM 0.07 95% CI (−30.22, 30.35), p = 0.0001, and PPD change WM 0.26 95% CI (−0.06, 0.58), p < 00001. On the other hand, no statistically significant data were obtained when L-PRF was added to single or multiple CAF combined with CTG according to the included outcomes such as mRC (p = 0.03 overall). Conclusions: L-PRF is a valid alternative to CAF alone. L-PRF compared to CTG in single and multiple CAF showed statistically significant results regarding pain perception and discomfort PROms (p < 0.0001). However, CTG remains the gold standard for treating gingival recession.

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.

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.

Coronally advanced flap achieved higher esthetic outcomes without a connective tissue graft for the treatment of single gingival recessions: a 4-year randomized clinical trial

OBJECTIVES

Limited long-term data are available when comparing the esthetic outcomes of coronally advanced flap (CAF) with or without a connective tissue graft (CTG). The aim of this study was to compare the 4-year esthetic outcomes of CAF vs CAF + CTG for the treatment of isolated maxillary gingival recessions.

MATERIAL AND METHODS

Forty-eight patients were randomly assigned for treatment either with CAF (control; N = 24) or to CAF + CTG (test group; N = 24). Patients were followed after the surgery until the final evaluation. A professional esthetic evaluation was performed using the Root coverage Esthetic Score (RES). Recession reduction, mean root coverage, and complete root coverage were also evaluated.

RESULTS

Forty-two patients completed the study at the 4-year recall. A significant recession reduction was evident at 4 years, without significant intergroup differences. The CAF group showed a statistically significant higher final RES compared with the CAF + CTG group (9.14 ± 1.08 vs 7.25 ± 1.29, respectively, p < 0.001). Regarding the individual components of RES, gingival margin and marginal tissue contour were significantly higher in the CAF group compared with that in the CAF + CTG group.

CONCLUSIONS

CAF presented with a significantly higher overall esthetic score than CAF + CTG, and in the individual RES components of marginal tissue contour and gingival margin after 4 years.

CLINICAL RELEVANCE

CAF without the addition of CTG provided higher esthetic outcomes for the treatment of isolated gingival recessions.

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.

Root coverage with coronally advanced flap:6-year follow-up

AIM

The aim of this study was to evaluate the long-term stability of root coverage without a regular control programme after coronally advanced flap (CAF) procedures in isolated gingival recessions.

MATERIAL AND METHODS

Recession defects were treated with CAF using microsurgery technique. Probing depth, clinical attachment level, keratinized gingival width, plaque index, papilla bleeding index, recession depth, recession width and root surface area was evaluated at baseline, and then postoperative 6-month and 6-year follow-up sessions. Percentages of root coverage and complete root coverage rates were also calculated.

RESULTS

In total, 12 defects in 12 patients of the 36 defects in 30 patients were available for analysis at the 6-year follow-up examination (66.7% of the initial sites could be reached). Percentage of mean root coverage was 95.06% at 6-month and 69.27% at 6-year and the difference was statistically significant (P < 0.05). Complete root coverage rate decreased from 75% (at 6-month) to 50% (at 6-year), but the difference was not statistically significant (P > 0.05).

CONCLUSION

Within the limits of this long-term follow-up study, there seems to be a rather high risk for relapse after root coverage with CAF possibly due to the lack of regular recalls and persistent traumatic tooth brushing habits.