Guided tissue regeneration in human gingival recessions. A 10-year follow-up study

Levels of smoking and outcome measures of root coverage procedures: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis was performed to investigate if there was a significant association between the number of cigarettes smoked per day and the results of root coverage procedures.

METHODS

Electronic search was performed through PubMed, Web of Science, Embase, and Scopus until January 2023. Studies were included if evaluated the outcomes of periodontal plastic surgery procedures for the treatment of gingival recession in smokers. Statistical evaluation was conducted using random-effects method to analyze the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CI).

RESULTS

From a total of 4494 references, 15 studies were considered relevant to be included in this study. The results showed that 44.39% sites had complete root coverage (CRC) at 6 months (non-smokers: 54.06%, < 10 cigarettes/day: 48%, 10-20 cigarettes/day: 19.56%, ≥ 20 cigarettes/day: 50%). Mean root coverage at 6 months were as follows: non-smokers: 74.94% ± 16.71%, < 10 cigarettes/day: 84.20% ± 2.24%, 10-20 cigarettes/day: 75.30% ± 14.69%, ≥ 20 cigarettes/day: 68.75% ± 26.51%. A significant difference was revealed between non-smokers and individuals who smoked 10-20 cigarettes/day in terms of CRC at 6 months: OR = 0.15 (95% CI = 0.03 to 0.71; P = .017). However, no significant difference was detected comparing 10-20 and ≥ 20 cigarettes/day.

CONCLUSION

As there was not enough data available, any definitive conclusions about the connection between an increase in the amount of cigarettes consumed per day and the results of root coverage procedures could not be reached. Further research is required with comparative studies involving individuals who smoke varying numbers of cigarettes.

Osteogenic cells transfer improving root coverage: A randomized clinical trial

BACKGROUND AND OBJECTIVE

The aim of this interventional, parallel-assignment, single-blinded, randomized, efficacy study was to investigate the efficacy of the treatment of gingival recessions by osteogenic cell transfer. This is the first randomized clinical trial of this nature.

MATERIAL AND METHODS

Treatment of Miller class I or II gingival recessions >4 mm was randomly defined by casual sorting and performed by newly forming bone graft (NFBG) and coronally advanced flap (CAF) or subepithelial connective tissue graft (SCTG) and CAF (control). Clinical examinations were performed by a single blinded examiner at baseline and at 3, 6, and 9 months after surgery. Parameters investigated were recession height (REC), probing depth (PD), clinical attachment level, gingival bleeding index (GBI), plaque index (PlI), and keratinized gingiva width (KGW).

RESULTS

Both techniques achieved similar percentage of root coverage, but NFBG was more effective in pocket depth reduction, attachment level gain, and reduction of plaque accumulation and of bleeding on probing.

CONCLUSIONS

These findings suggest that the transfer of osteogenic cells by NFBG is able to improve clinical attachment level and to cover denuded roots. NFBG can be used as an alternative treatment of deep recessions (≥4 mm), where the restoration of lost periodontal tissues is intended.

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.

Evaluation of efficacy of a novel resorbable collagen membrane for root coverage of Miller's Class I and Class II recession in the maxillary anteriors and premolars

Background:

There are several surgical techniques in literature that have been used to perform root coverage (RC). Currently, the use of a resorbable collagen membrane (RCM) as a guided tissue regenerative material is one of the highly sought treatment modalities. The present study aimed at evaluating the clinical outcome of RC in the treatment of Miller's Class I and II recession defects in maxillary anteriors and premolars by coronally advanced flap (CAF) with and without RCM.

Materials and Methods:

This split-mouth study (bilateral buccal recession defects) was randomized to include 15 test (CAF + membrane) and 15 control (CAF alone) sites. Clinical parameters included gingival recession depth (RD), probing pocket depth (PPD), clinical attachment level (CAL), and keratinized tissue height (KTH) measured at baseline and 9 months postoperatively.

Results:

Both test and control groups showed statistically significant (P < 0.05) reductions in RD (1.54 ± 0.46 mm and 1.60 ± 0.07 mm), PPD (0.53 ± 0.15 mm and 0.94 ± 0.10 mm), increase in KTH (0.67 ± 0.90 mm and 0.73 ± 0.14 mm) and CAL (1.94 ± 0.27 mm and 2.60 ± 0.19 mm) when comparing the 9-month data from baseline. The present study showed that mean improvement in RD was 1.60 ± 0.507 and 1.53 ± 0.64 mm in both test and control groups, respectively. Mean percent RC was 58.33% ±12.19% and 56.22% ±10.22% for test and control groups, respectively. However, there were no statistically significant differences between groups for RD, PPD, KTH, and CAL.

Conclusion:

The results of this study suggest that both the groups CAF (control) and CAF and RCM (test) could be successfully used to treat Miller's Class I and II gingival recession defects and also demonstrated an overall significant improvement in all the assessed clinical parameters. However, there was a greater reduction of gingival RD with the use of RCM when compared with the group of CAF alone.

Periodontal soft tissue root coverage procedures: a systematic review from the AAP Regeneration Workshop

BACKGROUND

This paper aims to create a "bridge" between research and practice by developing a practical, extensive, and clinically relevant study that translates evidence-based findings on soft tissue root coverage (RC) of recession-type defects to daily clinical practice.

METHODS

This review is prepared in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement based on the proposed focused questions. A literature search with no restrictions regarding status or the language of publication was performed for MEDLINE and EMBASE databases up to and including June 2013. Systematic reviews (SRs), randomized clinical trials, controlled clinical trials, case series, and case reports evaluating recession areas that were treated by means of RC procedures were considered eligible for inclusion through the three parts of the study (part I, an overview of the base of SRs; part II, an alternative random-effects meta-analyses on mean percentage of RC and sites exhibiting complete RC; and part III, an SR of non-randomized trials exploring other conditions not extensively evaluated by previous SRs). Data on Class I, II, III, and IV recessions, type of histologic attachment achieved with treatment, recipient- and donor-site anatomic characteristics, smoking-related outcomes, root surface conditions, tooth type and location, long-term effectiveness outcomes, unusual conditions that may be reported during conventional daily practice, and patient-centered outcomes were assessed as well.

RESULTS

Of the 2,456 potentially eligible trials, 234 were included. Data on Class I, II, III, and IV gingival recessions, histologic attachment achieved after treatment, recipient- and donor-site anatomic characteristics, smoking-related outcomes, root surface conditions/biomodification, tooth type and location, long-term effectiveness outcomes and unusual conditions that may be reported during conventional daily practice, and patient-centered outcomes (i.e., esthetic, visual analog scale, complications, hypersensitivity, patients perceptions) were assessed. Subepithelial connective tissue (CT)-based procedures and coronally advanced flap plus acellular dermal matrix grafts, enamel matrix derivative, or collagen matrix led to the best improvements of recession depth, clinical attachment level (CAL) gain, and keratinized tissue (KT). Some conditions, such as smoking and use of magnification, may affect RC outcomes.

CONCLUSIONS

All RC procedures can provide significant reduction in recession depth and CAL gain for Miller Class I and II recession-type defects. Subepithelial CT graft-based procedures provided the best outcomes for clinical practice because of their superior percentages of mean and complete RC, as well as significant increase of KT.

Surgical treatment of localized gingival recessions using coronally advanced flaps with or without subepithelial connective tissue graft

Background

A coronally advanced flap with subepithelial connective tissue graft is the gold standard surgical treatment of gingival recessions, since it offers a higher probability of achieving complete root coverage compared with other techniques. However, optimum short- and middle-term clinical results have also been obtained with coronally advanced flaps alone. The aim of the present study was to evaluate the results obtained by the surgical treatment of localized gingival recessions using coronally advanced flaps with or without subepithelial connective tissue graft.

Material and Methods

The reduction of recession height was assessed, together with the gain in gingival attachment apical to the recession, and total reduction of recession, in a comparative study of two techniques. Twenty-two gingival recessions were operated upon: 13 in the control group (coronally advanced flap) and 9 in the test group (coronally advanced flap associated to subepithelial connective tissue graft).

Results

After 18 months, the mean reduction of recession height was 2.2 ± 0.8 mm in the control group and 2.3 ± 0.7 mm in the test group, with a mean gain in gingival attachment of 1.3 ± 0.9 mm and 2.3 ± 1.3 mm, respectively. In percentage terms, the mean reduction of recession height was 84.6 ± 19.6% in the control group and 81.7 ± 17.8% in the test group, with a mean gain in gingival attachment of 20.5 ± 37.4% and 184.4 ± 135.5%, respectively.

Conclusions

Significant reduction of gingival recession was achieved with both techniques, though the mean gain in gingival attachment (in mm and as a %) was greater in test group.

Key words:Gingival recession, coronally advanced flap, subepthelial connective tissue graft.

A Randomized comparative clinical study of two surgical procedures to improve root coverage with the acellular dermal matrix graft

AIM

This randomized, controlled, clinical study compared two surgical techniques for root coverage with the acellular dermal matrix graft (ADMG) to evaluate which procedure could provide better root coverage and greater amounts of keratinized tissue.

MATERIALS AND METHODS

Fifteen pairs of bilateral Miller Class I or II gingival recessions were treated and assigned randomly to the test group, and the contra-lateral recessions were assigned to the control group. The ADMG was used in both groups. In the control group, the graft and flap were positioned at the level of the cemento-enamel junction (CEJ), and in the test group, the graft was positioned 1 mm apical to the CEJ and the flap 1 mm coronal to the CEJ. The clinical parameters were taken before the surgeries and after 6 months. The gingival recession area, a new parameter, was measured in standardized photographs through a special device and software.

RESULTS

There were statistically significant differences favouring the proposed technique for all parameters except for the amount of keratinized tissue at 6 months.

CONCLUSIONS

The proposed test technique is more suitable for root coverage procedures with ADMG, and the new parameter evaluated appears valuable for root coverage analysis. (Clinicaltrials.gov Identifier: NCT01175720).

Advanced reconstructive technologies for periodontal tissue repair

Reconstructive therapies to promote the regeneration of lost periodontal support have been investigated through both preclinical and clinical studies. Advanced regenerative technologies using new barrier-membrane techniques, cell-growth-stimulating proteins or gene-delivery applications have entered the clinical arena. Wound-healing approaches using growth factors to target the restoration of tooth-supporting bone, periodontal ligament and cementum are shown to significantly advance the field of periodontal-regenerative medicine. Topical delivery of growth factors, such as platelet-derived growth factor, fibroblast growth factor or bone morphogenetic proteins, to periodontal wounds has demonstrated promising results. Future directions in the delivery of growth factors or other signaling models involve the development of innovative scaffolding matrices, cell therapy and gene transfer, and these issues are discussed in this paper.

Guided tissue regeneration-based root coverage with a platelet concentrate graft: a 3-year follow-up case series

BACKGROUND

A platelet concentrate graft (PCG) was applied underneath the barrier membrane in guided tissue regeneration (GTR)-based root coverage procedures. The purpose of this case study was to assess the effectiveness of the technique and the long-term outcomes.

METHODS

Thirty-seven Miller Class I or II recession defects in six patients were treated using the PCG and a collagen membrane covered by an advanced mucogingival flap. Clinical parameters, such as vertical gingival recession depth (VRD), clinical attachment level (CAL), probing depth (PD), and width of keratinized tissue (WKT), were recorded presurgery (at baseline [BL]) and at 6 and 36 months of follow-up. The Wilcoxon signed-rank test and the Mann-Whitney test were used to assess statistical significance (alpha = 0.05).

RESULTS

Between BL and 6 months, there was a statistically significant reduction in VRD (from 2.81 +/- 0.88 mm to 0.30 +/- 0.48 mm) and PD (from 2.59 +/- 0.50 mm to 1.14 +/- 0.35 mm), as well as an improvement in CAL (from 5.41 +/- 0.86 mm to 1.43 +/- 0.66 mm). These results remained stable over the following 30 months. There was no statistically significant change in WKT during the initial 6 months; however, the increase in WKT was statistically significant at the 36-month follow-up. When comparing the healing between the maxillary and mandibular teeth at 6 months, the VRD reduction was statistically significantly greater in the maxillary teeth, but the difference was not statistically significant 30 months later. The average root coverage at 6 and 36 months was 89.86% +/- 15.85% and 85.86% +/- 18.16%, respectively, with complete root coverage in 24 (64.86%) and 21 (56.76%) of the 37 teeth.

CONCLUSIONS

The GTR-based technique using PCG was effective in reducing gingival recession. The outcomes remained stable for 3 years.

Root coverage procedures for the treatment of localised 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 periodontal plastic surgery (PPS) procedures.

OBJECTIVES

To evaluate the effectiveness of different root coverage procedures in the treatment of recession-type defects.

SEARCH STRATEGY

The Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE and EMBASE were searched up to October 2008. The main international periodontal journals were handsearched. There were no restrictions with regard to publication status or language of publication.

SELECTION CRITERIA

Only randomised controlled clinical trials (RCTs) of at least 6 months' duration evaluating recession areas (Miller's Class I or II > 3 mm) and that were treated by means of PPS procedures were included.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted independently and in duplicate. Authors were contacted for any missing information. Results were expressed as random-effects models using mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals.

MAIN RESULTS

Twenty-four RCTs provided data. Only one trial was considered to be at low risk of bias. The remaining trials were considered to be at high risk of bias. The results indicated a significant greater reduction in gingival recession and gain in keratinized tissue for subepithelial connective tissue grafts (SCTG) compared to guided tissue regeneration with resorbable membranes (GTR rm). A significant greater gain in the keratinized tissue was found for enamel matrix protein when compared to coronally advanced flap (0.40 mm) and for SCTG when compared to GTR rm plus bone substitutes. Limited 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 the treatment of localised recession-type defects. In cases where both root coverage and gain in the keratinized tissue are expected, the use of subepithelial connective tissue grafts seems to be more adequate. Randomised controlled clinical trials are necessary to identify possible factors associated with the prognosis of each PPS procedure. The potential impact of bias on these outcomes is unclear.

Coronally advanced flap: a modified surgical approach for isolated recession-type defects: Three-year results

BACKGROUND

Various modifications of the coronally displaced flap have been proposed in the literature with the attempt of treating gingival recession with uneven predictable results. The goal of the present study was to evaluate the effectiveness with respect to root coverage of a modification of the coronally advanced flap procedure for the treatment of isolated recession-type defects in the upper jaw.

METHODS

Forty isolated gingival recessions with at least 1 mm of keratinized tissue apical to the defects were treated with a modified approach to the coronally advanced flap. The main change in the surgical procedure consisted in the modification of flap thickness and dimension of surgical papillae during flap elevation. All recessions fall into Miller class I or II. The clinical re-evaluation was performed 1 year and 3 years after the surgery.

RESULTS

At the 1-year examination, the average root coverage was 3.72+/-1.0 mm (98.6% of the pre-operative recession depth) and 3.64+/-1.1 mm (96.7%) at 3 years. The gain in probing attachment amounted to 3.65+/-1.10 mm at 1 year and to 3.70+/-1.09 mm at 3 years. The average increase of keratinized tissue between the baseline and the 3-year follow-up amounted to 1.78+/-0.90 mm. All changes of keratinized tissue (difference between baseline and 1 year, baseline and 3 years, and between 1 and 3 years) were statistically significant.

CONCLUSION

The modified coronally advanced surgical technique is effective in the treatment of isolated gingival recession in the upper jaw.

The potential association between smoking and endodontic disease

The aim of this review was to analyse the literature to assess the possibility of an association between smoking and endodontic disease and the prognosis of endodontically treated teeth. The review of the prognosis of endodontically treated teeth involved taking account of any potential associations with smoking and endodontic disease and marginal periodontitis, and smoking and prosthodontic outcomes. In addition, the role of smoking in implant failure and surgical wound healing was analysed with a view to drawing parallels regarding the possible implications of smoking on the outcome of surgical endodontics. A MEDLINE and Cochrane library search including smoking and various endodontic keyword searches identified three papers which discussed the variables, and did not just mention them separately in the text. The literature demonstrates a paucity of evidence relating smoking with endodontic disease and prognosis, but nevertheless presents evidence of a possible influence on the prognosis of endodontically treated teeth in smokers and a likely increase in surgical complications. The possible merits of a smoking cessation protocol prior to surgical endodontics are also discussed.

Gene therapeutics for periodontal regenerative medicine

There has been significant advancement in the field of periodontal tissue engineering over the past decade for the repair of tooth-supporting structures. Although encouraging results for periodontal tissue regeneration have been found in numerous clinical investigations using recombinant growth factors, limitations exist with topical protein delivery. Newer approaches seek to develop methodologies that optimize growth factor targeting to maximize the therapeutic outcome of periodontal regenerative procedures. Genetic approaches in periodontal tissue engineering show early progress in achieving delivery of growth factor genes, such as platelet-derived growth factor or bone morphogenetic protein, to periodontal lesions. Ongoing investigations in ex vivo and in vivo gene transfer to periodontia seek to examine the extent of the potential effects in stimulating periodontal tissue engineering.