Does Gingival Recession Require Surgical Treatment?

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.

A Review of Gingival Recession and the Surgical Managements According to Their Classification and Etiologic Backgrounds: A Clinical Case Study

Mucogingival deformities are a group of defects that occur around the cervical area of the teeth. Gingival recession is the most common type of these deformities. It might happen separately or with other related deformities like thin gingival biotypes, shallow vestibule, high frenal attachment, and cervical dental steps. Recent classification of mucogingival deformity matrix has collectively grouped gingival recession types with other mucogingival deformities and dental steps to establish the proper diagnosis and evaluate surgical/restorative management and prognosis of the treatment outcomes. The following case presentations have presented with a technical review, clinical evaluation, and surgical and/or restorative treatment according to the recent matrix.

Knowledge, Awareness, and Practice of Gingival Veneer Prosthesis Among Dental Students, Interns, and Practitioners in the Riyadh Region: A Cross-Sectional Questionnaire-Based Survey

Background:

The treatment modality of using gingival veneer prosthesis for anterior gingival recession is not widely known even in the dental fraternity. This survey has been conducted considering its essential nature and absence of data on its awareness in the Riyadh region.

Aims:

The aim of the study was to assess the knowledge, awareness, and practice of gingival veneer prosthesis among dental students, interns, and practitioners in the Riyadh region.

Materials and Methods:

A descriptive cross-sectional electronic survey was conducted on dental students, interns, and practitioners of both genders in Saudi Arabia, using a convenient sampling method. The final questionnaire consisted of 12 questions. The percentage of various responses, with reference to the demographics, and statistical significance, were tested by independent sample t-test and p-value <0.05. The responses/data of 446 participants were tabulated and processed in SPSS (version 21.0).

Results:

The preferred treatment option for an anterior gingival recession proposed by prosthodontists was prosthetic correction (p<0.05), and for other groups, it was periodontal surgery (p<0.05). 66% of general practitioners’ group and 56% of dental students and interns’ group, respectively, were not sure about the ideal treatment option for Miller’s class III & IV gingival defects, while 70% of general practitioners’ group and 65% of the students and interns’ group, respectively, were not sure about the ideal treatment option for the management of gingival tissue loss between implants,.

Conclusion:

There is a significant lack of knowledge on using gingival veneer prosthesis as a treatment option for anterior gingival defects among general dental practitioners, interns, and dental students (p˂0.05).

Minimally invasive treatment of gingival recession by vestibular incision subperiosteal tunnel access technique with collagen membrane and advanced platelet-rich fibrin: A 6-month comparative clinical study

AIM

The study aimed to assess the minimally invasive Vestibular Incision Subperiosteal Tunnel Access (VISTA) technique for treatment of Millers Class I or Class II buccal gingival recession defects and to compare the effectiveness of a bioresorbable collagen membrane or advanced platelet rich fibrin (A-PRF).

METHODS AND MATERIAL

20 sites with Millers Class I or II gingival recession were recruited and allocated into 2 groups with 10 sites each. Group 1: VISTA with A-PRF, Group 2: VISTA with with bioresorbable collagen membrane (Healiguide)®.

STANDARDIZED CLINICAL PARAMETERS

Plaque Index (PI), Gingival Index (GI), Clinical attachment level (CAL )Pocket Probing Depth (PPD) Recession Height (RH ) and width of keratinized gingiva (WKG) were measured at baseline 3 months and 6 months.

RESULTS

Both groups showed significant improvement in clinical parameters. However reduction in recession height and mean root coverage percentage was greater in A-PRF group after 6 months.

CONCLUSIONS

VISTA with both A-PRF and Healiguide showed good clinical outcomes but better results were obtained when A-PRF was used.

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.

Diode versus CO2 Laser Therapy in the Treatment of High Labial Frenulum Attachment: A Pilot Randomized, Double-Blinded Clinical Trial

Background: The labial frenula are triangular plicas departing from the alveolar mucosa and attaching themselves at different heights of the gingiva. Sometimes a high attachment can determine a gingival recession. The most suitable surgical resolution is the use of laser devices. The aim of this study was to compare the labial frenulectomy through the use of Diode and CO₂ laser techniques in pediatric patients with a high labial frenulum attachment, clarifying at the same time the preventive role of the surgical treatment to avoid further recession. Methods: A pilot randomized, double-blinded clinical trial was conducted to compare both the surgical advantages and the preventive treatment of laser technology using two different wavelengths within a population of pediatric patients with a high labial frenulum attachment. Different parameters intra and post-surgery were taken into account (Bleeding, Wound Healing, Gingival Recession, Periodontal pocket and Numerical Scale Value for pain) to compare Diode versus CO₂ laser therapy. Results: Although both the laser devices provide a good performance in the post-operative period, the Diode laser shows better results (p < 0.001) in three of the five parameters evaluated. Conclusions: From the results it was found that the Diode Laser device is more suitable compared to the CO₂ device.

A randomized split mouth clinical study to compare the clinical outcomes of subepithelial connective graft and acellular dermal matrix in Miller's Class I recession coverage therapy

Background:

According to the American Association of Periodontology, subepithelial connective tissue graft (SCTG) is one the most reliable surgical technique available for the treatment of gingival recession (GR) with Miller's Class I defect. However, due to its various disadvantages, alternate grafts such as acellular dermal matrix (ADM) grafts have been introduced for recession coverage. The present study compares the clinical outcome of these two grafts in treating Miller's Class I GR.

Materials and Methods:

All the 15 patients participated in the study who had totally 30 bilateral Miller's Class I GR were divided randomly into SCTG group and ADM group each containing 15 defects. In the SCTG group, coronally advanced flap (CAF) with SCTG was performed, and in ADM group, CAF with ADM was done. Clinical parameters were measured on the day of surgery (baseline) and after 6 months. Data collected were statistically analyzed using paired and unpaired t-tests.

Results:

The analysis of the data collected at the baseline and 6 months later showed that there were no statistically significant differences in the recorded clinical parameters such as probing pocket depth, clinical attachment loss, and GR depth. ADM group showed a better color match than the SCTG group, while SCTG group achieved more keratinized tissue width than ADM group.

Conclusion:

From the outcome of the current study, we can conclude that ADM is an efficient substitute for SCTG for treating Miller's Class I GR. However, additional studies with greater number of samples and lengthier follow-up periods are necessary to validate the present inference.

Ultrasonography for chairside evaluation of periodontal structures: A pilot study

BACKGROUND

The crestal bone level and soft tissue dimension are essential for periodontal diagnosis and phenotype determination; yet, existing measurement methods have limitations. The aim of this clinical study was to evaluate the correlation and accuracy of ultrasound in measuring periodontal dimensions, compared to direct clinical and cone-beam computed tomography (CBCT) methods.

METHODS

A 24-MHz ultrasound probe prototype, specifically designed for intraoral use, was employed. Periodontal soft tissue dimensions and crestal bone levels were measured at 40 teeth and 20 single missing tooth gaps from 20 patients scheduled to receive a dental implant surgery. The ultrasound images were interpreted by two calibrated examiners. Inter-rater agreement was calculated by using inter-rater correlation coefficient (ICC). Ultrasound readings were compared with direct clinical and CBCT readings by using ICC and Bland-Altman analysis.

RESULTS

The following six parameters were measured: 1) interdental papilla height (tooth), 2) mid-facial soft tissue height (tooth), 3) mucosal thickness (tooth), 4) soft tissue height (edentulous ridge), 5) mucosal thickness (edentulous ridge), and 6) crestal bone level (tooth). Intra-examiner calibrations were exercised to achieve an agreement of at least 0.8. ICC between the two readers ranged from 0.482 to 0.881. ICC between ultrasound and direct readings ranged from 0.667 to 0.957. The mean difference in mucosal thickness (tooth) between the ultrasound and direct readings was -0.015 mm (95% CI: -0.655 to 0.624 mm) without statistical significance. ICC between ultrasound and CBCT ranged from 0.654 to 0.849 among the measured parameters. The mean differences between ultrasound and CBCT range from -0.213 to 0.455 mm, without statistical significance.

CONCLUSION

Ultrasonic imaging can be valuable for accurate and real-time periodontal diagnosis without concerns about ionizing radiation.

Topical application of phenytoin or nifedipine-loaded PLGA microspheres promotes periodontal regeneration in vivo

OBJECTIVES

Gingival recession and alveolar bone loss are common manifestations of periodontitis. Periodontal regeneration is the ideal strategy for rehabilitating periodontal tissue defects and preventing tooth loss. The present study examined whether localized, topical application of gingival overgrowth-inducing drugs, phenytoin, nifedipine or cyclosporine, induces periodontal regeneration.

METHODS

Polylactic-co-glycolic acid (PLGA) was used as the carrier for preparation of phenytoin, nifedipine or cyclosporine-loaded PLGA microspheres, using an oil-in-water emulsification technique. The drug-loaded microspheres were delivered to periodontal defects created on alveolar ridges mesial to the first maxillary molars of Sprague-Dawley rats. After eight weeks, the operation area in each rat, including the maxillary molars and periodontal tissues, was harvested and evaluated by micro-computed tomography, histochemical and immunohistochemical analyses.

RESULTS

Physical parameters representative of periodontal regeneration, including the length of new alveolar bone (p < 0.01) and the area of new alveolar bone (p < 0.01) were significantly improved in the phenytoin group. Compared to other groups, the phenytoin group demonstrated increased expression of COL-1, VEGF-A, osteoblast and osteoclast markers (BMP-2, TGF-β1, OCN and TRAP staining), as well as decreased expression of MMP-8.

CONCLUSIONS

Results of the present study provided new evidence that localized, controlled release of phenytoin confers therapeutic benefits toward gingival recession and alveolar bone loss. Phenytoin appears to be a promising drug that promotes periodontal regeneration.

Periodontal microsurgery for management of multiple marginal tissue recession using Zucchelli's modification of coronally advanced flap and pericardium membrane in an esthetic zone

Marginal tissue recession (MTR) by definition is an apical shift of gingival margin, which leads to exposure of root surface. Patients affected with MTR often complain of sensitivity to cold on exposed root surfaces apart from esthetic concerns. In this article, a case of multiple Miller's class I MTR who presented with sensitivity to cold in relation to maxillary anterior teeth region was treated using Zucchelli's coronally advanced flap with pericardium membrane under operating microscope. The application of principles of periodontal microsurgery and guided tissue regeneration results in significant root coverage with reduction/elimination of sensitivity. Long-term success of root coverage procedures depends on the removal of etiology and maintenance therapy.

[Periodontal status assessment before orthodontic treatment and opportune moment selection for orthodontic treatment]

The aesthetic demands of teeth by the public have improved with the increase in the living standard. Orthodontics, which is a method of aesthetic dentistry, is becoming increasingly important. Orthodontic treatment mainly involves the application of orthodontic force to the teeth and guides the reconstruction of the periodontal tissue, thereby changing the position of the teeth at the occlusal bone. Orthodontic treatment can also improve the dental occlusion caused by dentition crowding and teeth mobility to achieve long-term stability of periodontal tissue. The number of patients with periodontal disease is high in China, and the number of patients with periodontal disease that are eager to receive orthodontic treatment is increasing. Hence, the periodontal status during the orthodontic therapy should be explored along with periodontal therapy and orthodontic treatment. This article briefly demonstrates the assessment criteria of periodontal status before orthodontic treatment, the opportune moment selection for orthodontic treatment, and the supportive periodontal therapy. This study helps dentists develop individualized treatment programs and win a balanced, stable, and aesthetic impression.

Non-invasive evaluation of facial crestal bone with ultrasonography

Purpose

Facial crestal bone level and dimension determine function and esthetics of dentition and dental implants. We have previously demonstrated that ultrasound can identify bony and soft tissue structures in the oral cavity. The aim of this study is to evaluate the accuracy of using ultrasound to measure facial crestal bone level and thickness.

Materials and methods

A commercially available medical ultrasound scanner, paired with a 14 MHz imaging probe was used to scan dental and periodontal tissues at the mid-facial site of each tooth on 6 fresh cadavers. The alveolar crest level in relation to the cemento-enamel junction and its thickness on ultrasound images were measured and compared to those on cone-beam computed tomography (CBCT) scans and/or direct measurements on a total of 144 teeth.

Results

The mean crestal bone level measured by means of ultrasound, CBCT and direct measures was 2.66 ± 0.86 mm, 2.51 ± 0.82 mm, and 2.71 ± 1.04 mm, respectively. The mean crestal bone thickness was 0.71 ± 0.44 mm and 0.74 ± 0.34 mm, measured by means of ultrasound and CBCT, respectively. The correlations of the ultrasound readings to the other two methods were between 0.78 and 0.88. The mean absolute differences in crestal bone height and thickness between ultrasound and CBCT were 0.09 mm (-1.20 to 1.00 mm, p = 0.06) and 0.03 mm (-0.48 to 0.54 mm, p = 0.03), respectively.

Conclusion

Ultrasound was as accurate in determining alveolar bone level and its thickness as CBCT and direct measurements. Clinical trials will be required to further validate this non-ionizing and non-invasive method for determining facial crestal bone position and dimension.

Multiple Gingival Recession Coverage Treated with Vestibular Incision Subperiosteal Tunnel Access Approach with or without Platelet-Rich Fibrin - A Case Series

Background:

Gingival recession involves both soft tissue and hard tissue loss. In this evolutionary era of dentistry, newer techniques have evolved for complete coverage of isolated recession defects. Since 2012, vestibular incision subperiosteal tunnel access (VISTA) technique was used with various regenerative membranes to treat multiple recession defects (MRDs). Platelet-rich fibrin (PRF) membrane, a pool of growth factors but have any added advantage to recession coverage techniques is controversial. Thus, in this case series, we compare the effect of VISTA with or without PRF-membrane for the treatment of Classes I and III MRDs.

Subjects and Methods:

Four patients between of age 30 and 40 years (two patients having bilateral Class I and another two having bilateral Class III MRDs) were selected from the Department of Periodontics, ITS Dental College, Greater Noida and designated as Case I–IV simultaneously. Recession defects at antagonist sites in each patient were corrected by VISTA approach with or without PRF-membrane. Recorded clinical parameters included recession depth, recession width, pocket probing depth, and clinical attachment level (CAL) at baseline and 6 months postoperatively.

Results:

Patients having Class I recession defects showed almost complete root coverage with VISTA technique alone and reflected no added advantage of PRF-membrane. However, patients with Class III recession defects treated with VISTA + PRF-membrane showed more reduction in recession depth and gain in CAL as compared to sites treated with VISTA only.

Conclusion:

VISTA alone is a convenient technique for treatment of Class I MRDs. Addition of PRF-membrane for Class III recession defects give better outcome in term of reduction of recession depth and gain in CAL 6 month postoperatively.

Root Coverage Procedure With Connective Tissue Graft Harvested From a Distal Wedge: A Case Report

INTRODUCTION

This case report illustrates the use of a connective tissue (CT) graft harvested from a distal wedge procedure for root coverage. The retromolar area could be an alternative donor site, especially when a distal wedge procedure is planned. This approach offers an alternative CT donor site for the treatment of a localized gingival recession (GR).

CASE PRESENTATION

A healthy 22-year-old female patient presented with a localized Miller Class II GR defect on a mandibular incisor (tooth #25) caused by trauma from a lip piercing. Probing depths of 6 mm were also noted bilaterally over the distal aspect of the mandibular second molars. A root coverage procedure was performed, together with a distal wedge procedure for pseudopocket reduction. A CT graft harvested from a distal wedge was used for the root coverage. Complete root coverage with stable follow-up was documented up to 2 years, 5 months. Tissue from a contralateral distal wedge was submitted for histologic evaluation. Histopathologic examination showed dense collagenous fibrous tissue with no inflammatory infiltrates.

CONCLUSIONS

Localized GR can be treated with a CT graft harvested from a distal wedge without significant inflammation. The mandibular retromolar area may serve as an alternative viable donor site in selected cases.