A Retrospective study of root coverage procedures using an image analysis system

The effect of smoking on clinical and biochemical early healing outcomes of coronally advanced flap with connective tissue graft: Prospective cohort study

BACKGROUND

This study aimed to determine the effects of smoking on early (≤3 months) clinical outcomes and relevant molecular biomarkers following root coverage surgery.

METHODS

Eighteen smokers and 18 nonsmokers, status biochemically verified, with RT1 gingival recession defects were recruited and completed study procedures. All patients received coronally advanced flap plus connective tissue graft. Baseline and 3 month recession depth (RD), recession width (RW), keratinized tissue width (KTW), clinical attachment level (CAL), and gingival phenotype (GP) were recorded. Root coverage (RC) percentage and complete root coverage (CRC) were calculated. Recipient (gingival crevicular fluid) and donor (wound fluid) site VEGF-A, HIF-1α, 8-OHdG, and ANG levels were determined.

RESULTS

There were no significant intergroup differences for any baseline or postoperative clinical parameters (P > 0.05), except for whole mouth gingival index (increased in nonsmokers at 3 months; P < 0.05). Compared to baseline, RD, RW, CAL, KTW, and GP significantly improved postoperatively, without significant intergroup differences. There were no significant intergroup differences for RC (smokers = 83%, nonsmokers = 91%, P = 0.069), CRC (smokers = 50%, nonsmokers = 72%, P = 0.177), and CAL gain (P = 0.193). The four biomarker levels significantly increased postoperatively (day 7; P ≤ 0.042) in both groups and returned to baseline (day 28) without significant intergroup differences (P > 0.05). Similarly, donor site parameters were not different between groups. Strong correlations, consistent over time, were found between biomarkers implicated in angiogenesis (VEGF-A, HIF-1α, and ANG).

CONCLUSIONS

The early (3 month) clinical and molecular changes after root coverage surgery utilizing a coronally advanced flap plus connective tissue graft are similar between smokers and nonsmokers.

Methods and parameters for digital evaluation of gingival recession: a critical review

OBJECTIVES

The aim of the present review was to find, compare, and critically discuss digital methods for quantitative evaluation of gingival recessions dimensions.

DATA

Collection of articles and classification related to digital evaluation of gingival recessions.

SOURCES

A search of PubMed, Web of Science, Scopus, and reference lists of articles was conducted up to April 2021 STUDY SELECTION: Twenty-two articles used digital evaluation of gingival recessions dimensions. The methods in the included articles were extracted, compared, and categorized.

RESULTS

Digital measurements were performed on 2D intraoral photographs, 3D models, or cross-sections obtained from 3D models. Baseline measurement were performed for diagnostic and treatment planning and categorised into distance and area measurements. Follow-up evaluation of treatment was based either on repeating the "baseline" measurements and calculating differences or measuring differences directly on composite images, composed from two superimposed images obtained at two time-points. Direct measurements were categorised into distance, area, and volume measurements.

CONCLUSIONS

Digital evaluation predominantly means just digitalization of the established evaluation methods; therefore, increasing measurements accuracy and maintaining comparability with past studies. At present, a large variability of digital evaluation workflow among the included studies renders the comparison among different studies difficult if not impossible. The potential of digital evaluation seems not to have been fully exploited as only a few novel measurements and parameters introduced, i.e., volumetric evaluation of soft tissue dynamics. For reproducible and comparable studies in the future, the research should be aimed at evaluation, optimization and standardization of all phases of the digital evaluation.

CLINICAL SIGNIFICANCE

Digital evaluation, based on 3D image superimposition is a promising approach as it increases measurements accuracy, maintains compatibility with past studies and simultaneously introduces novel evaluation possibilities.

European survey on criteria of aesthetics for periodontal evaluation: The ESCAPE study

OBJECTIVE

The ESCAPE multicentre survey was designed to (a) compare the agreement of three relevant aesthetic scoring systems among different centres, and (b) evaluate the reproducibility of each question of the questionnaires.

MATERIALS AND METHODS

EFP centres (n = 14) were involved in an e-survey. Forty-two participants (28 teachers, 14 postgraduate students) were asked to score the one-year aesthetic outcomes of photographs using the Before-After Scoring System (BASS), the Pink Esthetic Score (PES) and the Root coverage Esthetic Score (RES). Mean values of kappa statistics performed on each question were provided to resume global agreement of each method.

RESULTS

Between teachers, a difference of kappa ≥ 0.41 (p = .01) was found for BASS (75%) and PES (57%). Similarly, RES (84%) and PES (57%) were different (p < .001). No difference was found between BASS (75%) and RES (84%). No difference was found between students, whatever the scoring system. Questions of each scoring system showed differences in their reproducibility.

CONCLUSIONS

The outcomes of this study indicate that BASS and RES scoring systems are reproducible tools to evaluate aesthetic after root coverage therapies between different centres. Among the various variables, lack of scar, degree of root coverage, colour match and gingival margin that follows the CEJ show the best reliability.

Effectiveness of laser adjunctive therapy for surgical treatment of gingival recession with flap graft techniques: a systematic review and meta-analysis

Various flap graft techniques in the treatment of gingival recession have already been reported in the literatures for root coverage. Laser therapy has effects of ablative, hemostatic, and decontamination. Therefore, we performed a meta-analysis of randomized controlled trials (RCTs) to compare the efficacy of flap surgery combined with laser with surgery alone for treating gingival recession. The studies were searched from PubMed, Embase, Web of science, and the Cochrane Central Register of Controlled Trials by two reviewers up to August 2017. The quality of RCTs was assessed by Cochrane Handbook. Data were extracted from studies and analyzed by Review Manager 5.3. 95% confidence interval (CI) and risk ratio (RR) were calculated for dichotomous data. Seven RCTs with 173 patients and 296 teeth were included in the meta-analysis. We found no statistically significant differences between two groups in GRD (gingival recession depth) (P = 0.21), GRW (gingival recession width) (P = 0.92), RES (root esthetic score) (P = 0.21), and CRC (complete root coverage) (P = 0.09). Statistically significant differences were found between two groups in the WKT (width of keratinized tissue) (P < 0.0001) and 1-year follow-up of PD (probing depth) (P = 0.03) and CAL (clinical attachment level) (P < 0.00001). The meta-analysis found that surgery with laser therapy provided clinical advantages in terms of WKT and 1-year follow-up of PD and CAL. However, flap graft associated with laser did not offer additional benefit to root coverage and esthetics in treating gingival recession. More long-term studies are required to assess these parameters.

Conservative treatment of a large facial midroot perforation

Aim. To report on the endodontic and periodontal management of a root and alveolar process perforation in a maxillary front tooth. Summary. Perforation during access cavity preparation is an infrequent complication during endodontic therapy, leading to potential periodontal tissue breakdown. The case described the two-stage management of a massive facial root perforation requiring a connective tissue graft to correct a mucosal fenestration persisting after orthograde repair of the root defect with MTA.

Micro- and macrosurgical techniques in the coverage of gingival recession using connective tissue graft: 2 years follow-up

OBJECTIVE

The aim was to evaluate the clinical results of micro- and macrosurgical approaches in the coverage of gingival recession using connective tissue graft.

MATERIAL AND METHODS

Twenty-one teeth in microsurgical group (test group) and 21 in macrosurgical group (control group) were treated using coronally positioned flap and subgingival connective tissue graft. Recession depth (RD), recession width (RW), root surface area (RSA), keratinized tissue width (KTW), probing depth, clinical attachment level, pain level during healing, and aesthetic results were evaluated for 24 months.

RESULTS

RD, RW, and RSA were significantly lower at 1, 3, 6, and 24th months compared with baseline in both groups. RD was also significantly lower in the 1st month compared with 24th month in control group. RD and RSA at 24th month were significantly lower in microsurgical group. KTW significantly and similarly increased by 6th month in both groups. The pain levels in the donor and the recipient area decreased earlier in the microsurgical group, and aesthetic scores improved similarly in both groups.

CONCLUSION

A microsurgical approach to root coverage with gingival recession is likely to preserve the clinical outcomes longer than macrosurgical approach, at least for 24 months. Healing appears to be faster using microsurgery, but aesthetic outcomes are similar.

CLINICAL SIGNIFICANCE

This study evaluated the clinical results of microsurgical versus macrosurgical approaches to root coverage in cases of gingival recession. Based on the results of the study, pain levels in the donor and the recipient areas decreased earlier in the microsurgical group, and microsurgical approach resulted in significantly greater amount of root coverage at 24 months.

The role of smoking and gingival crevicular fluid markers on coronally advanced flap outcomes

BACKGROUND

This study evaluates possible effects of smoking on the following: 1) biochemical content in gingival crevicular fluid (GCF) samples from sites of gingival recession and saliva; and 2) clinical outcomes of coronally advanced flap (CAF) for root coverage.

METHODS

Eighteen defects in 15 patients were included in each of the smoker and non-smoker groups. Baseline cotinine, basic fibroblast growth factor, vascular endothelial growth factor, platelet-derived growth factor, interleukin (IL)-8, IL-10, IL-12, tumor necrosis factor-α, matrix metalloproteinase (MMP)-8, MMP-9, and plasminogen activator inhibitor-1 levels were determined in GCF and saliva samples. CAF with microsurgery technique was applied. Plaque index, papilla bleeding index, recession depth (RD), recession width (RW), and root surface area were evaluated at baseline and postoperative months 1, 3, and 6. Probing depth, clinical attachment level (CAL), and keratinized gingival width (KGW) was recorded at baseline and month 6. Percentage of root coverage and complete root coverage were calculated at postoperative months 1, 3, and 6.

RESULTS

All biochemical parameters were similar in the two groups apart from the definite difference in salivary cotinine concentrations (P = 0.000). Compared with the baseline values, RD, RW, CAL, and root surface area decreased, and KGW increased, with no significant difference between the study groups. CAL gain, percentage of root coverage, and complete root-coverage rates were similar in the study groups.

CONCLUSION

Similar baseline biochemical data and comparably high success rates of root coverage with CAF in systemically and periodontally healthy smokers versus non-smokers suggest lack of adverse effects of smoking on clinical outcomes.

Decision Making in Gingival Recession Treatment: Scientific Evidence and Clinical Experience

Focused Clinical Question: What are the key considerations for selecting the best surgical approach in mucogingival plastic surgery? Summary: Treatment of gingival recession has become an important therapeutic issue due to the increasing number of cosmetic requests from patients. The dual goals of mucogingival treatment include complete root coverage, up to the cemento-enamel junction, and blending of tissue color between the treated area and non-treated adjacent tissues. Even though the connective tissue graft is commonly considered the "gold standard" for treatment of recession defects, it may not always be the best surgical option for every case. Conclusions: Under non-experimental conditions, all root coverage procedures may be effective in terms of complete root coverage and excellent esthetics. Careful analyses of patient- and defect-related factors, however, are key considerations prior to selecting an appropriate surgical technique.

Qualitative cosmetic evaluation after root-coverage procedures

BACKGROUND

The purpose of the present study was to evaluate the esthetic outcome using four categories of root-coverage procedures (pedicle soft tissue grafts, non-submerged grafts, submerged grafts, and envelope techniques) and to identify factors associated with esthetic assessment.

METHODS

A professional panel of three observers (two periodontists and one control) used a before-after panel scoring system to evaluate the esthetics of 162 root-coverage surgeries. A five-point ordinal scale was used to evaluate the overall esthetic improvement and seven variables that may be considered in the assessment.

RESULTS

The intraobserver agreement of the two trained periodontists for the overall cosmetic assessment was almost perfect (kappa = 0.83), and substantial agreement was found between them (kappa = 0.68). Good to excellent overall esthetic results were found by the professionals and control in >70% of the surgical procedures. Analysis of variance indicated a statistical difference between the non-submerged grafts category and the three other surgical categories (P <10(-3)). Multivariate analysis showed that the degree of root coverage was not a significant predictive factor, whereas soft tissue appearance variables and the follow-up were significantly associated with cosmetic assessment.

CONCLUSIONS

The present study demonstrated that non-submerged grafts are not recommended in cases of esthetic demand. Future root-coverage trials, basing their justification on esthetics, should include overall qualitative evaluation as the primary variable. The follow-up period should not be <12 months. The before-after panel scoring system is a tool that can be used to evaluate cosmetic outcomes.