Effect of gingival augmentation procedure (free gingival graft) on reducing the risk of non-carious cervical lesions: A 25- to 30-year follow-up study

Risk factors for noncarious cervical lesions: A case-control study

OBJECTIVES

Noncarious cervical lesions (NCCLs) are multifactorial and can be caused by the anatomical structure of the teeth, erosion, abrasion and abnormal occlusion. The aim of this case-control study was to explore the risk factors for NCCLs.

METHODS

Cone-beam computed tomography was used to determine whether a wedge-shaped defect existed at the cementoenamel junction. We compared 63 participants with NCCLs with 63 controls without NCCLs, matched for sex, age (±1 year) and toothbrushing-related factors (e.g., type of bristle and brushing patterns, frequency and strength). All participants were asked to complete a questionnaire about self-administered daily diet habits and health condition. Univariate and multivariate logistic regression analyses were conducted to determine the risk factors for NCCLs.

RESULTS

Significant variables in the univariate analysis (i.e., p < .2) included frequency of carbonated beverage consumption, sella-nasion-point B angle (SNB) and Frankfort-mandibular plane angle (FMA). Multivariate logistic regression demonstrated that the consumption frequency of carbonated beverages (odds ratio [OR] = 3.147; 95% confidence interval [CI], 1.039-9.532), FMA (OR = 1.100; 95% CI, 1.004-1.204) and SNB (OR = 0.896; 95% CI, 0.813-0.988) was independent influencing factors. The area under the receiver operating characteristic curve (AUC) value of regression Model 1 (established with the frequency of carbonated beverage consumption, FMA, SNB and sleep bruxism) was 0.700 (95% CI, 0.607-0.792; p < .001), and that of regression Model 2 (established using the frequency of carbonated beverage consumption, FMA and SNB) was 0.704 (95% CI, 0.612-0.796; p < .001).

CONCLUSIONS

The consumption frequency of carbonated beverages and FMA was risk factors for NCCLs; the higher the frequency of carbonated beverage consumption and FMA, the higher was the probability of NCCLs. SNB was a protective factor for NCCL occurrence; the larger the SNB, the lower was the probability of NCCL occurrence. These findings have further clarified the aetiology of NCCLs and provided clinicians with valuable insights into strategies for preventing the loss of dental tissue.

Risk indicators for gingival recession in the esthetic zone: A cross-sectional clinical, tomographic, and ultrasonographic study

BACKGROUND

To evaluate the risk indicators associated with midfacial gingival recessions (GR) in the natural dentition esthetic regions.

METHODS

Cone-beam computed tomography (CBCT) results of thirty-seven subjects presenting with 268 eligible teeth were included in the cross-sectional study. Clinical measurements included presence/absence of midfacial GR; the depth of the midfacial, mesial, and distal gingival recession; the recession type (RT); keratinized tissue width (KT); and attached gingiva width (AG). Questionnaires were utilized to capture patient-reported esthetics and dental hypersensitivity for each study tooth. Buccal bone dehiscence (cBBD) and buccal bone thickness (cBBT) were measured on the CBCT scans. High-frequency ultrasonography was performed to assess gingival thickness (GT) and buccal bone dehiscence (uBBD). Intraoral optical scanning was obtained to quantify the buccolingual position of each study site (3D profile analysis). Multilevel logistic regression analyses with generalized estimation equations were performed to assess the factors associated with the conditions of interest.

RESULTS

The presence of midfacial GR was significantly associated with the history of periodontal treatment for pocket reduction (OR 7.99, p = 0.006), KT (OR 0.62, p < 0.001), cBBD (OR 2.30, p = 0.015), GT 1.5 mm from the gingival margin (OR 0.18, p = 0.04) and 3D profile 1 mm from the gingival margin (OR 1.04, p = 0.001). The depth of midfacial GR was significantly correlated to previous history of periodontal treatment (OR 0.96, p = 0.001), KT (OR -0.18, p < 0.001), presence of bone fenestration (OR 0.24, p = 0.044), and cBBD (OR 0.43, p < 0.001). The depth of midfacial GR was also the only factor associated with patient-reported esthetics (OR -3.38, p = 0.022), while KT (OR 0.77, p = 0.018) and AG (OR 0.82, p = 0.047) were significantly correlated with patient-reported dental hypersensitivity.

CONCLUSIONS

Several risk indicators of midfacial and interproximal GR in the esthetic region were identified. The use of imaging technologies allowed for detection of parameters associated with the conditions of interest, and, therefore, their incorporation in future clinical studies is advocated. Ultrasonography could be preferred over CBCT for a noninvasive assessment of periodontal phenotype.

Long-term stability of gingival margin and periodontal soft-tissue phenotype achieved after mucogingival therapy: A systematic review

BACKGROUND

The aim of this systematic review was two-fold: (i) to evaluate the long-term (≥5 years) stability of the gingival margin position, keratinized tissue width (KTW) and gingival thickness (GT) in sites that underwent root coverage (RC) or gingival augmentation (GA); and (ii) to assess the influence of different local variables on the long-term stability of dental and gingival tissues.

MATERIALS AND METHODS

Randomized controlled trials (RCTs) and non-RCTs reporting short-term (i.e., 6-12 months after baseline surgical intervention) and long-term (≥5 years) follow-up data after surgical treatment of adult patients presenting single or multiple mucogingival deformities, defined as sites presenting gingival recession defects (GRDs) and/or (KTW) deficiency (i.e., <2 mm), were considered eligible for inclusion. MEDLINE-PubMed, EMBASE and Cochrane Central Register of Controlled Trials databases were searched for articles published up to 15 May 2023. Mixed-effects multiple linear regression was used to assess the association between KTW, type of surgical procedure and time (i.e., independent variables) on the stability of the gingival margin in sites that received RC or GA therapy.

RESULTS

Of the 2569 potentially eligible records, 41 (reporting 40 studies) met the eligibility criteria. Graphical estimates including data from all RC procedures found an upward trend in recession depth (RD) increase over time. Conversely, it was observed that in 63.63% of RC studies and in 59.32% of RC treatment arms KTW increased over time, particularly in sites treated with subepithelial connective tissue grafts (SCTGs). Conversely, sites that underwent GA procedures generally exhibited an overall reduction of KTW over time. However, sites treated with free gingival grafts (FGGs) showed a decrease in RD after 10 years of follow-up. Three main findings derived from the pooled estimates were identified: (i) Gingival margin stability was associated with the amount of KTW present during short-term assessment (i.e. the greater the KTW at 6-12 months after treatment, the more stable the gingival margin). (ii) The use of autogenous soft-tissue grafts was associated with lower RD increase over time. (iii) Treatment approaches that contribute to the three-dimensional enhancement of the gingival phenotype, as clearly demonstrated by FGG, were associated with gingival margin stability.

CONCLUSIONS

The extent of apical migration of the gingival margin appears to be directly related to the amount of KTW and GT upon tissue maturation. Interventions involving the use of autogenous grafts, either SCTG or FGG, are associated with greater short-term KTW gain and lower RD increase over time.

Importance of periodontal phenotype in periodontics and restorative dentistry: a systematic review

BACKGROUND

Periodontal phenotype is regarded to be one of the key factors influencing the efficacy of restorative therapies in dental practice. The objective of the systematic review was to explore the importance of thin and thick periodontal phenotypes and how they affect the outcome of periodontal and restorative therapies by looking at a number of academic publications from various online databases.

METHODS

Following the PRISMA guidelines (Preferred Reporting Items for Systematic Review standards), relevant data will be searched and retrieved from three significant scientific databases, including PubMed, EBSCO, and Scopus. The articles with full texts that matched the keywords and published in English between 2018 and 2023 were taken into consideration.

RESULTS

The majorities of these articles were based on the type of periodontal phenotype and their impact on periodontal and restorative treatment outcomes were selected. The initial search yielded a total of 530 articles. Only 273 were relevant to the review's objectives, and these were considered for determining eligibility. Only 20 publications were eligible for analysis.

CONCLUSION

Understanding these anatomical aspects of periodontal phenotype is crucial to both periodontology and restorative dentistry. The clinical outcome of restorative, prosthetic, orthodontic, surgical, and periodontal therapies is determined in large part by the periodontal phenotype, which also plays a significant role in clinical failure or success in dental treatments.

TRIAL REGISTRATION

This study protocol registered with the International Prospective Register of Systematic Reviews (PROSPERO) dated 16th June 2023 with the registration ID CRD42023432568.

Living cellular constructs for keratinized tissue augmentation: A 13-year follow-up from a split-mouth randomized, controlled, clinical trial

BACKGROUND

A 13-year follow-up was conducted of a short-term investigation of the use of living cellular construct (LCC) versus free gingival graft (FGG) for keratinized tissue width (KTW) augmentation in natural dentition, to evaluate the long-term outcomes and assess the changes occurring since the end of the original 6-month study.

METHODS

Twenty-four subjects out of the original 29 enrolled participants were available at the 13-year follow-up. The primary endpoint was the number of sites demonstrating stable clinical outcomes from 6 months to 13 years (defined as KTW gain, stability, or ≤0.5 mm of KTW loss, together with reduction, stability, or increase of probing depth, and recession depth [REC] ≤0.5 mm). Secondary outcomes included the assessment of KTW, attached gingiva width (AGW), REC, clinical attachment level, esthetics, and patient-reported outcomes at the 13-year visit, assessing the changes from baseline to 6 months.

RESULTS

Nine sites per group (42.9%) were found to have maintained stable (≤0.5 mm or improved) clinical outcomes from 6 months to 13 years. No significant differences were observed for the clinical parameters between LCC and FGG from 6 months to 13 years. However, the longitudinal mixed model analysis showed that FGG delivered significantly better clinical outcomes over 13 years (p < 0.01). LCC-treated sites exhibited superior esthetic outcomes compared to FGG-treated sites at 6 months and 13 years (p < 0.01). Patient-evaluated esthetics were significantly higher for LCC over FGG (p < 0.01). Patient overall treatment preference was also in favor of LCC (p < 0.01).

CONCLUSIONS

A similar stability of the treatment outcomes from 6 months to 13 years was found for LCC- and FGG-treated sites, with both approaches shown to be effective in augmenting KTW and AGW. However, superior clinical outcomes were found for FGG over 13 years, while LCC was associated with better esthetics and patient-reported outcomes than FGG.

Soft-Tissue Augmentation around Dental Implants with a Connective Tissue Graft (CTG) and Xenogeneic Collagen Matrix (CMX)-5-Year Follow-Up

Proper horizontal and vertical thickness of the gingival connective tissue has been proven to be one of the success criteria in dental implant and reconstructive surgery. When thin tissue is found, gingiva augmentation methods can be used to increase the quality and volume of the tissue. Many methods have been described, among them pedicle soft-tissue flaps or autogenic tissue grafts. As an alternative to patients' own tissue, xenogenic materials can be used for grafting. The fundamental issue is to choose a material that will ensure the maximum therapeutic effect, while also minimizing the negative influence on the patient's health. The aim of this study was to compare gingival augmentation procedures using a palatal connective tissue graft (CTG) and an xenogenic soft-tissue substitute, Geistlich Mucograft (xenogeneic collagen matrix; CMX), and assess whether the timing of the graft surgery influences the clinical outcomes. The original study was a randomized control trial with a total of 75 implants placed. The patients received the soft-tissue thickening 3 months before the implant placement or 3 months after the implant placement (depending on the group). A connective tissue graft (CTG) or Geistlich Mucograft were used (depending on the group). For both the CTG and Geistlich Mucograft, better clinical outcomes were observed for maintaining the alveolar bone level and the thickness of the attached gingiva compared to the control group with no gingival augmentation. The Geistlich Mucograft showed good clinical performance in comparison to the control. Soft-tissue augmentation with the CTG before the implant placement was found to be most efficient method in terms of a stable increase of the tissue thickness since, throughout the entire observation period, the greatest increase of 1.035 mm (SD = 0.73 mm) in thickness was observed. Statistically important differences in the tissue thickness baseline compared after 5 years were observed for groups G1 vs. G2b (no augmentation vs. CTG before), G1 vs. G3b (no augmentation vs. CTG after) and for groups G2b vs. G3a (CTG before vs. CMX after).

Periodontal phenotype modification of complexes periodontal-orthodontic case scenarios: A clinical review on the applications of allogenous dermal matrix as an alternative to subepithelial connective tissue graft

OBJECTIVES

The aim of this review is to address the potential applications of allogenous dermal matrix (ADM), as an alternative to subepithelial connective tissue graft (SCTG), in promoting periodontal phenotype modification (PPM) of challenging periodontal-orthodontic clinical scenarios.

OVERVIEW

The rationale behind the need of changing thin to thick gingival tissues is associated to the superior and more stable treatment outcomes promoted by PPM therapy. PPM, via soft tissue grafting, leads to clinical and histological changes of the pre-established original genetic conditions of the gingiva. Although SCTG-based procedures are recognized as the "gold standard" for the treatment of sites requiring root coverage and gingival augmentation, ADM has been recognized as the most suitable alternative to SCTG, particularly in clinical scenarios where the use of autogenous grafts is not possible. Thus, ADM is considered an optimal option for the treatment of patients with a history (or in need) of orthodontic tooth movement, due its two-fold potential indication: (1) the promotion of periodontal soft tissue phenotype modification; and (2) its use, as a barrier membrane, in hard tissues augmentation procedures.

CONCLUSIONS

ADM is a viable option for soft tissue augmentation, as well as for treatment approaches involving buccal bone gain.

CLINICAL SIGNIFICANCE

Periodontal phenotype modification therapy, when applied in challenging periodontal-orthodontic clinical scenarios, promotes root coverage and prevents the onset and development clinical attachment loss.

Impact of peri-implant soft tissue characteristics on health and esthetics

OBJECTIVE

To review the impact of key peri-implant soft tissue characteristics on health and esthetics.

MAIN CONSIDERATIONS

The keratinized mucosa width (KMW), the mucosal thickness (MT), and the supracrestal tissue height (STH) are essential components of the peri-implant soft tissue phenotype. An inadequate KMW (<2 mm) has been associated with local discomfort upon oral hygiene performance and increased risk for the onset of peri-implant diseases. A minimum buccal MT (≥2 mm) is generally required to prevent esthetic issues related to the effect of transmucosal prosthetic elements on the color of the mucosa and can also contribute to long-term mucosal stability. STH is directly related to marginal bone remodeling patterns during the early healing process that follows the connection of transmucosal prosthetic components. Short STH, generally defined as <3 mm, has been consistently associated with marginal bone loss resulting from the physiologic establishment of the mucosal seal. Insufficient STH may also derive into the fabrication of unfavorable transmucosal prosthetic contours, which frequently results in unpleasing esthetic outcomes and predisposes to submarginal biofilm accumulation. Peri-implant soft tissue dehiscences (PISTDs) are a type of peri-implant deformity that are associated with esthetic issues and often occur in sites presenting KMW, MT, and/or STH deficiencies. PISTDs should be correctly diagnosed and treated accordingly, usually by means of multidisciplinary therapy.

CONCLUSION

Understanding the impact of different dimensional and morphologic features of the peri-implant mucosa on health and esthetic outcomes is fundamental to make appropriate clinical decisions in the context of tooth replacement therapy with implant-supported prostheses.

Efficacy of biologics in root coverage and gingival augmentation therapy: An American Academy of Periodontology best evidence systematic review and network meta-analysis

BACKGROUND

The aim of this systematic review was to assess the efficacy of three biologics, namely autologous blood-derived products (ABPs), enamel matrix derivatives (EMD) and recombinant human platelet-derived growth factor BB (rhPDGF-BB), in root coverage and gingival augmentation therapy.

METHODS

The protocol of this PRISMA 2020-compliant systematic review was registered in PROSPERO (CRD42021285917). After study selection, data of interest were extracted. A network meta-analysis (NMA) was conducted to assess the effect of different surgical interventions on the main clinical outcomes of interest (i.e., mean root coverage [MRC%], complete root coverage [CRC%], keratinized tissue width [KTW], gingival thickness [GT] change, and recession depth [RD] reduction).

RESULTS

A total of 48 trials reported in 55 articles were selected. All studies reported on the treatment of gingival recession defects for root coverage purposes. Forty-six treatment arms from 24 trials were included in the NMA. These arms consisted of treatment with coronally advanced flap (CAF) alone, EMD + CAF, platelet-rich fibrin (PRF) + CAF, and subepithelial connective tissue graft (SCTG) + CAF. Regarding MRC%, SCTG+CAF was associated with a significant higher estimate (13.41%, 95% CI [8.06-18.75], P <  0.01), while EMD+CAF (6.68%, 95% CI [-0.03 to 13.4], P = 0.061) and PRF+CAF (1.03%, 95% CI [-5.65 to 7.72], P = 0.71) failed to show statistically significant differences compared with CAF alone (control group) or with each other. Similarly, only SCTG+CAF led to a significantly higher CRC% (14.41%, 95% CI [4.21 to 24.61], P < 0.01), while treatment arms EMD + CAF (13.48%, 95% CI [-3.34 to 30.32], P = 0.11) and PRF+CAF (-0.91%, 95% CI [-15.38, 13.57], p = 0.81) did not show significant differences compared with CAF alone or with each other. Differences in the CI of PRF+CAF (symmetrical around a zero adjunctive effect) and EMD+CAF (non-symmetrical) suggest that EMD could have some additional value compared with PRF. Treatment with SCTG+CAF led to a statistically significant higher RD reduction (-0.39 mm, 95% CI [-0.55 to 0.22], P < 0.01), however EMD+CAF (-0.13 mm, 95% CI [-0.29 to 0.01], P = 0.08) and PRF+CAF (-0.06 mm, 95% CI [-0.23 to 0.09], P = 0.39) failed to show significant differences compared with CAF or with each other. While SCTG+CAF was associated with a statistically significant higher gain of KTW (0.71 mm, 95% CI [0.48 to 0.93], P < 0.01), EMD+CAF (0.24 mm, 95% CI [-0.02 to 0.51], P = 0.08) and PRF+CAF (0.08 mm, 95% CI [-0.23 to 0.41], P = 0.58) did not result into significant changes compared with CAF alone or with each other. Regarding the use of rhPDGF-BB+CAF, although available studies have reported equivalent results compared with SCTG+CAF, evidence is very limited.

CONCLUSIONS

The use of ABPs, EMD, or rhPDGF-BB in conjunction with a CAF for root coverage purposes is safe and generally promotes significant improvements respective to baseline clinical parameters. However, the adjunctive use of ABPs and EMD does not provide substantial additional improvements in terms of clinical outcomes and patient-reported outcome measures to those achieved using CAF alone, when baseline KTW is >2 mm. Both PRF+CAF and EMD+CAF rendered inferior MRC%, CRC%, RD reduction, and KTW gain compared with SCTG+CAF, which should still be considered the gold-standard in root coverage therapy. Although some studies have reported equivalent results for rhPDGF-BB+CAF compared with the gold-standard intervention, limited evidence precludes formal comparisons with CAF or SCTG+CAF that could be extrapolated to guide clinical practice.

[Efficacy of tunnel technique for treatment of gingival recession of upper adjacent teeth with noncarious cervical defect]

OBJECTIVE

To evaluate the efficacy of tunnel technique (TUN) in treatment of teeth with adjacent gingival regression (GR) combined with noncarious cervical lesions (NCCL).

METHODS

We collected data from 21 patients (79 teeth) undergoing TUN surgery for GR combined with NCCL. According to GR depth (GRD) and lesion depth (LD) of NCCL, the teeth were divided into group 1 with GRD≤3 mm and LD≤1 mm; group 2 with GRD≤3 mm and LD>1mm; group 3 with GRD>3 mm and LD≤1 mm; and group 4 with GRD>3 mm and LD>1 mm. The mean root coverage (MRC) rate, complete root coverage (CRC) rate, keratinized gingival width, and keratinized gingival thickness were compared among the 4 groups after TUN surgery.

RESULTS

The keratinized gingival width and thickness were significantly improved after the surgery in the 4 groups. When the GRD was below 3 mm, the MRC was not significantly different between group 1 and group 2 (8.55% vs 95.45%, P>0.05); When the GRD was beyond 3 mm, the MRC and CRC rates were both decreased in group 3 and group 4, especially in group 4, where the CRC rate (25%) was significantly lower than those in the other 3 groups (P < 0.01).

CONCLUSION

In patients with GR combined with NCCL, TUN surgery can obviously improve keratinized gingival width and thickness. GRD has a greater effect on the outcome of root coverage than LD, suggesting that NCCL restoration before TUN surgery may not be necessary. Both GRD and LD should be considered in the evaluation of the clinical efficacy of TUN surgery.

Rethinking the decision-making process to treat gingival recession associated with non-carious cervical lesions

The presence of a tooth-surface defect, such as a non-carious cervical lesion (NCCL), associated with sites of gingival recession (GR) defects creates a combined soft tissue/tooth defect (CD) that requires a different treatment plan. This study aimed to critically review the literature regarding the available treatment protocols for CDs and suggest a new decision-making process. NCCLs were classified as Class A-: the cementoenamel junction (CEJ) was visible and the root surface discrepancy was < 0.5 mm (no step); Class A+: CEJ was visible and the root surface discrepancy was > 0.5 mm (with a step); Class B-: unidentifiable CEJ without a step; Class B+: unidentifiable CEJ with a step. NCCLs affecting both root and crown surfaces (Class B) lead to CEJ destruction and consequently eliminate an important landmark used before and after root coverage procedures. The depth of the root surface discrepancy is vital owing to its possible impact on soft tissue adaptation after healing, which, in turn, may influence the treatment options, namely the use of graft and/or composites to compensate for the discrepancy. Clinically, a step with horizontal depth greater than 0.5 mm should be recognized as the minimum threshold value to define this condition. Extremely deep defects tend to assume a V-shaped topography. Therefore, extremely deep V-shaped defects were classified into subclasses A+V, a V-shaped defect, and B+V, a V-shaped defect with loss of CEJ, for management considerations. The treatment options, supported by the literature, and a decision-making process to deal with each condition are presented.

Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

This comprehensive review of the 2019 restorative dental literature is offered to inform busy dentists regarding remarkable publications and noteworthy progress made in the profession. Developed by the Scientific Investigation Committee of the American Academy of Restorative Dentistry, each author brings discipline-specific expertise to 1 of 8 sections of the report: (1) prosthodontics; (2) periodontics, alveolar bone, and peri-implant tissues; (3) implant dentistry; (4) dental materials and therapeutics; (5) occlusion and temporomandibular disorders; (6) sleep-related breathing disorders; (7) oral medicine and oral and maxillofacial surgery; and (8) dental caries and cariology. The report targets important information likely to influence day-to-day dental treatment decisions. Each review is not intended to stand alone but to update interested readers so that they may visit source material when greater detail is desired. As the profession moves toward evidence-based clinical decision-making, an incredible volume of potentially valuable dental literature continues to increase. It is the intention of this review and its authors to provide assistance in negotiating the extensive dental literature published in 2019. It is our hope that readers find this work useful in the clinical management of dental patients.