Cervical restoration and the amount of soft tissue coverage achieved by coronally advanced flap: A 2-year follow-up randomized-controlled clinical trial

Digital and analog techniques for cemento-enamel junction reconstruction: A case study

BACKGROUND

Non-carious cervical lesions (NCCLs) refer to the loss of dental hard tissue in the cervical region due to physical and/or chemical factors, often associated with the disappearance of the cemento-enamel junction (CEJ), posing challenges in both diagnosis and treatment of gingival recessions (GR). This case study introduces two protocols for multidisciplinary CEJ reconstruction prior to the root coverage therapy (RCT).

METHODS

Two patients with GR and NCCLs were treated using two CEJ reconstruction techniques: both, analogically and digitally guided. For each case, the position of the therapeutic CEJ was predetermined using a combination of the methods described by Zucchelli and Cairo. Then, an analog or digital diagnostic wax-up was performed accordingly. In the analogically guided technique, a transparent silicone guide matrix was used to transfer information from the dental wax-up. In contrast, the digitally guided technique employed a rigid, translucent resin prosthetic guide matrix that was designed and printed. Restorations were fabricated using direct composite resin and RCT was performed 1 week later in both techniques.

RESULTS

At 6 months, both cases demonstrated complete root coverage and effective healing of the soft tissues surrounding the restorations.

CONCLUSIONS

Dimensional changes in materials and precise guide adjustment in the analog technique are operator-dependent and can affect the outcomes. Digital procedures, though effective, are costly and may limit their use. The usage of these two CEJ reconstruction techniques enhances communication within the multidisciplinary team and ensures optimal aesthetic outcomes and precise placement of the gingival margin.

KEY POINTS

There are no established clinical protocols described in the literature for reconstructing the cemento-enamel junction (CEJ) once the position of a therapeutic CEJ has been predetermined and prior root coverage therapy (RCT). Performing a diagnostic wax-up (analogically or digitally) to reconstruct the therapeutic CEJ is crucial and facilitates the creation of a prosthetic guide that accurately reproduces the defined CEJ position. The reconstruction of the CEJ may improve the prognosis of RCT.

PLAIN LANGUAGE SUMMARY

This study looked at a dental issue called non-carious cervical lesions, which happens when the hard tissue near the gum line of a tooth wears away, making it harder to treat gum recession. Two different approaches were tested to rebuild the lost tissue in the gum area before performing a procedure to cover the exposed roots. One approach used traditional methods with physical guides to help place the new tissue, while the other used advanced digital techniques to create a precise guide using 3D printing. After 6 months, both methods successfully covered the exposed roots and helped the gums heal properly. However, the traditional method's results can vary depending on the dentist's skill, while the digital method, although more accurate, can be expensive. Using these methods can improve teamwork among dental specialists and lead to better-looking results by ensuring the gum line is placed exactly where it should be.

Effect of collagen sponge and flowable resin composite on pain management after free gingival graft harvesting: A randomized controlled clinical trial

The aim of this study was to compare the effect of the application of a flowable resin composite coating, over a collagen sponge stabilized with suture, on postoperative pain after free gingival graft harvesting. Thirty-two free gingival grafts were harvested from the palate in 32 patients, who were subsequently randomized to have only a collagen sponge stabilized with sutures applied to the palatal wound (control), or to have the collagen sponge coated with a flowable resin composite (test). Patients were observed for 14 days, and the pain level was evaluated by using a numerical rating scale. The consumption of analgesics during the postoperative period and the characteristic of the graft were also analyzed. The patients in the test group reported having experienced significantly less pain statistically than the patients in the control group throughout the study. The consumption of analgesics was lower in the test group. The dimensions of harvested grafts in the control and test groups showed no significant differences in height, width, and thickness. In conclusion, the addition of flowable resin composite coating to the hemostatic collagen sponge on the palatal wound following free gingival graft harvesting helped to minimize postoperative pain.

Evaluation of a novel restorative protocol to treat non-carious cervical lesion associated with gingival recession: a 2-year follow-up randomized clinical trial

OBJECTIVE

To compare 2 different resin composites and 2 adhesive systems used in a new restorative protocol (partial restoration) to treat non-carious cervical lesions associated with gingival recession type 1 (RT1).

MATERIAL AND METHODS

Eighty combined defects (CDs) were treated with a partial restoration and periodontal plastic surgery for root coverage. The CDs were randomly assigned to one of the following groups: NP + TE (n = 20), nanofilled composite and 2-step total-etch adhesive system; NP + UA (n = 20), nanofilled composite and universal adhesive system; MH + TE (n = 20), microhybrid composite and 2-step total-etch adhesive; MH + UA (n = 20), microhybrid composite and universal adhesive. Restorations were assessed using the United States Public Health Service (USPHS) criteria at 1 week (baseline) and 6, 12, and 24 months. Survival rate, periodontal parameters, dentin hypersensitivity (DH), and aesthetics were also evaluated.

RESULTS

After 24 months, only the MH + TE group did not lose any restoration, with no significant differences between groups. For surface roughness parameter, MH presented 83.3% of the restorations scoring Bravo, whereas NP presented 48.5% of the restorations scoring Bravo. All groups presented restorations with marginal discoloration. All periodontal parameters behaved similarly, regardless of the restorative material. All groups presented significant reductions of dentin hypersensitivity and improved aesthetic perceptions (p < 0.05).

CONCLUSION

Both resin composites and adhesives tested can be combined for partial restorations to treat CDs.

CLINICAL RELEVANCE

This new restorative-surgical protocol to treat CDs presents satisfactory outcomes. The partial restorations can be successfully executed with both combinations of adhesives and resin composites evaluated in this investigation. TRN : ClinicalTrial.gov: NCT03215615; registration date July 12, 2017.

The influence of non-carious lesions in the surgical treatment of gingival recession: A systematic review & meta-analysis

BACKGROUND

The presence of a non-carious cervical lesion (NCCL) is a complicating factor for tooth coverage following gingival recession. It is generally associated with disappearance of the enamel-cementum junction, a key landmark, and a surface discrepancy requiring restoration or compensation using a connective tissue graft (CTG). The aim of this systematic review is to study the efficacy of periodontal plastic surgery on recession defects associated with a NCCL, with or without restorative treatment.

MATERIALS AND METHODS

RCT assessing the root coverage of teeth with Miller's class I and class II isolated gingival recession with an NCCL published up to April 2020, with at least 10 patients per group and a follow-up longer than 6 months, were included through electronic databases and hand-searched journals.

RESULTS

Seven articles were finally included. Treatment systematically consisted of a coronally advanced flap in association with partial or complete restorative treatment ± CTG. Meta-analyses showed that periodontal plastic procedures are less effective in terms of complete root coverage in cases of teeth with an NCCL. Overall Mean Recession Reduction was 2.00 mm (CI: [1.72, 2.28]), and overall mean complete root coverage was 5% (CI: [2,8]).

CONCLUSION

The presence of an NCCL is a complicating factor in plastic surgery. The use of CTG without NCCL restoration provides better outcomes except for the reduction of dental hypersensitivity for which the combined treatment (restoration + CTG) is the most effective.

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.

Single gingival recession associated with non-carious cervical lesion treated by partial restoration and coronally advanced flap with or without xenogenous collagen matrix: A randomized clinical trial evaluating the coverage procedures and restorative protocol

BACKGROUND

Evaluate the use of collagen matrix (CM) as adjunctive to coronally advanced flap (CAF versus CAF + CM) to treat gingival recession (GR) associated with non-carious cervical lesion-combined defects (CDs).

METHODS

Sixty-two patients presenting 62 CDs (RT1 GR and non-carious cervical lesion (NCCLs) were randomly allocated to either CAF group (n = 31): partial restoration of the NCCL and CAF; or to CAF + CM group (n = 31): partial restoration of the NCCL and CAF associated with CM. Clinical, esthetic, patient-centered outcomes, and restorative parameters were assessed.

RESULTS

After 12 months, CD coverage were 55.2% for CAF and 54.4% for CAF + CM (P = 0.8). Recession reduction were 1.9 ± 0.8 mm for CAF and 2.0 ± 0.7 mm for CAF + CM (P = 0.6). CAF+CM resulted in higher increase in keratinized tissue (KT) width (CAF: 0.3 ± 0.7 mm; CAF + CM: 0.9 ± 0.8 mm; P = 0.004) and KT thickness gain (CAF: 0.1 ± 0.3 mm; CAF + CM: 0.7 ± 0.2 mm; P = 0.001). Both treatments presented low postoperative pain and resulted in esthetics improvements. In addition, no restoration was lost, 27.4% showed a reduction of the superficial polishing, and 8% showed marginal staining, but still clinically acceptable.

CONCLUSION

Partial resin composite restoration (with the apical limit up to 1 mm of the estimated CEJ) and CAF alone or combined with CM are suitable for treating CDs. The use of CM provided additional benefits in terms of KT width and thickness gain. (NCT03341598).

Complete root coverage in the treatment of Miller class III or RT2 gingival recessions: a systematic review and meta-analysis

Background

The primary objective of this systematic review and meta-analysis was to assess the evidence on complete root coverage (CRC) achieved by periodontal plastic techniques in the treatment of Miller class III/RT2 gingival recessions, comparing techniques developed along the twentieth century (pre-twenty-first) versus surgical approaches of the twenty-first century (21st).

Methods

An electronic bibliographic search was carried out in four databases up to December 2019, focusing on studies that reported CRC results in Miller class III or RT2 recessions treatment with at least a six-month follow-up. In addition, a random-effects models’ meta-analysis was performed for the CRC, comparing pre-twenty-first versus twenty-first century techniques at 6 months, 12 months and more than 12 months.

Results

Thirty-seven publications were included. A total of 933 gingival recessions were treated, 298 with pre-twenty-first century surgical techniques and 635 with techniques from the twenty-first century. CRC was achieved at 6 months on half of the recessions (pre-twenty-first: 57.60% vs. 21st: 51.11%), but decreased markedly for twenty-first century techniques at 12 months (pre-twenty-first: 63.82% vs. 21st: 32.87%). Thereafter, this difference was the other way around (> 12 months: pre-twenty-first: 5.26% vs. 21st: 19.65%). The meta-analysis showed a high heterogeneity, with no significant differences amongst the techniques.

Conclusions

Although CRC might be achievable by treating Miller class III or RT2 recessions with any of the described techniques, its long-term stability is not predictable. More randomized clinical trials with longer follow-ups and several visits, are needed. In addition, the patient’s satisfaction should also be assessed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01494-3.

Treatment of Gingival Recession: When and How?

Gingival recession is a common finding in daily clinical practice. Several issues may be associated with the apical shift of the gingival margin such as dentine hypersensitivity, root caries, non-carious cervical lesions (NCCLs), and compromised aesthetics. The first step in an effective management and prevention program is to identify susceptibility factors and modifiable conditions associated with gingival recession. Non-surgical treatment options for gingival recession defects include establishment of optimal plaque control, removal of overhanging subgingival restorations, behaviour change interventions, and use of desensitising agents. In cases where a surgical approach is indicated, coronally advanced flap and tunnelling procedures combined with a connective tissue graft are considered the most predictable treatment options for single and multiple recession defects. If there is a contraindication for harvesting a connective tissue graft from the palate or the patient wants to avoid a donor site surgery, adjunctive use of acellular dermal matrices, collagen matrices, and/or enamel matrix derivatives can be a valuable treatment alternative. For gingival recession defects associated with NCCLs a combined restorative-surgical approach can provide favourable clinical outcomes. If a patient refuses a surgical intervention or there are other contraindications for an invasive approach, gingival conditions should be maintained with preventive measures. This paper gives a concise review on when and how to treat gingival recession defects.

Treatment efficacy of gingival recession defects associated with non-carious cervical lesions: a systematic review

Purpose

This systematic review aimed to compare the efficacy, defined in terms of the mean percentage of root coverage (mRC), of surgical treatment approaches combined with adhesive restorations of non-carious cervical lesions (NCCLs) to that of root coverage alone in patients with a single gingival recession (GR) and NCCL.

Methods

A literature search was conducted to identify longitudinal studies reporting the mRC following treatment for the correction of GR defects associated with NCCLs using a combination of surgical and restorative techniques in systemically and periodontally healthy patients.

Results

The search resulted in the retrieval of 12,409 records. Seven publications met the inclusion criteria for the qualitative synthesis of data. The mRCs ranged from 69% to 97%. In the medium term, the gingival margin position was more stable when a connective tissue graft (CTG) was used, independently of whether restoration of teeth with NCCLs was performed.

Conclusions

The strength of the evidence was limited by methodological heterogeneity in terms of study design as well as the unit and period of analysis, which precluded a meta-analysis. Although no definitive conclusion could be drawn due to the lack of sufficient evidence to estimate the effectiveness of the interventions, CTG-based procedures contributed to gingival margin stability regardless of the performance of restoration to treat NCCLs.

The Relationships Between Tooth-Supported Fixed Dental Prostheses and Restorations and the Periodontium

PURPOSE

To search the literature and to critically evaluate the findings on the periodontal outcomes of restorations and tooth-supported fixed prostheses.

MATERIALS AND METHODS

PubMed was searched according to a systematic methodology, previously reported, but updated to include a larger database. Filters applied were: Case reports, clinical trial, review, guideline, randomized controlled trial, meta-analysis, systematic reviews, and English. A narrative review was then synthesized to discuss periodontal outcomes related to restorations and tooth-supported fixed prostheses. Relevant data was organized into four sections: Direct restorations, indirect restorations, biologic width or supracrestal tissue attachment and tooth preparation/finish line design.

RESULTS

While increased gingival index, bleeding on probing, probing depth and clinical attachment loss have been associated with subgingival restorations, intracrevicular margins do not cause periodontal diseases. Inflammation and bone loss occur, for both direct and indirect restorations, only with large overhangs. Different restorative materials are associated with different clinical responses when placed in the gingival sulcus or within the epithelial and connective tissue attachments. When the connective tissue attachment is removed, histological changes occur causing its apical shift and subsequent re-establishment. Gingival displacement during impression procedures can cause gingival recession. Emergence profile can have a range of values, not associated with periodontal diseases. Periodontal response appears to be clinically not different when compared among different finish line designs.

CONCLUSIONS

Contemporary procedures and materials used for the placement and fabrication of tooth-supported restorations and fixed prostheses are compatible with periodontal health when adequate patient education and motivation in self-performed oral hygiene are present. Periodontal diagnostic criteria should be thoroughly reviewed before fixed restorative treatments are planned and executed.

The Disease Process, Diagnosis and Treatment of Invasive Cervical Resorption: A Review

Invasive cervical resorption (ICR) is a localized, subepithelial, supra-osseous resorptive process of the tooth. Although there are several predisposing factors associated with ICR, its etiology and pathogenesis are poorly understood. The damage to the protective layer on the external root surface appears to allow for the attachment of clastic cells and initiate the resorptive process, which is confined by the inner protective pericanalar resorption-resistant sheet surrounding the root canal space. The use of cone-beam computed tomography (CBCT) is recommended for the diagnosis and assessment of a resorptive lesion. Based on the thorough evaluation of the size and location of the ICR lesion using CBCT, surgical or nonsurgical treatment can be chosen to address the source of the resorption. This review discusses the current status of knowledge regarding the biology of ICR lesions as well as their external or internal treatment using hydraulic calcium silicate-based materials. Future clinical outcome studies are necessary to evaluate the impact of hydraulic calcium silicate-based materials on the healing of ICR lesions.

Cytotoxicity of Different Nano Composite Resins on Human Gingival and Periodontal Ligament Fibroblast Cell Lines: An In Vitro Study

The aim of this study is to determine the cytotoxicity of three different nano composite resins (CRs) on human gingival fibroblast (hGF) and periodontal ligament fibroblast (hPDLF) cell lines. These CRs selected were nanohybrid organic monomer-based Admira Fusion (AF), nanohybrid Bis-(acryloyloxymethyl) tricyclo [5.2.1.0.sup.2,6] decane-based Charisma Topaz (CT), and supra nano filled resin-based Estelite Quick Sigma (EQS). MTT assay was performed to assess the cytotoxicity of CRs at 24 h and one week. AF and EQS applied on hGF cells at 24 h and one week demonstrated similar cytotoxic outcomes. Cytotoxicity of CT on hGF cells at one week was higher than 24 h (p = 0.04). Cytotoxicity of CT on hGF cells was higher at 24 h (p = 0.002) and one week (p = 0.009) compared to control. All composites showed higher cytotoxicity on hPDLF cells at one week than the 24 h (AF; p = 0.02, CT; p = 0.02, EQS; p = 0.04). AF and EQS demonstrated lower cytotoxicity on hPDLF cells than the control group at 24 h (AF; p = 0.01, EQS; p = 0.001). CT was found more cytotoxic on hPDLF cells than the control (p = 0.01) and EQS group (p = 0.008) at one week. The cytotoxicity of CRs on hGF and hPDLF cells vary, according to the type of composites, cell types, and exposure time.

Experimental and clinical studies on plastic periodontal procedures

We have compiled, in this Periodontology 2000 review, all Latin American literature on experimental and clinical studies of periodontal plastic procedures. The body of literature on this subject has led to a discussion of the features and treatment outcomes of root-coverage procedures. Over time, knowledge on periodontal plastic procedures has become less empirical and more supportive of the clinical management of recession-type defects. Gingival recession etiology, animal studies, free gingival grafts, pedicle flaps (semilunar, laterally positioned, and coronally positioned), and subepithelial connective tissue grafts are extensively reviewed. The use of allografts as an alternative to subepithelial connective tissue grafts, the treatment of multiple gingival recessions, and the rationale for use of guided tissue regeneration and enamel matrix derivative in plastic periodontal procedure is discussed. We also assess how smoking can affect the treatment outcomes in plastic surgery procedures. Minimally invasive procedures are of great value in improving the features of the final tissues. The following aspects identified in this compilation were of great interest: (a) some factors, anatomical in nature, favor the formation of root recessions, but it is the inflammatory process (caused by the presence of biofilm and/or by traumatic toothbrushing) that is responsible for the development of root recessions; and (b) pedicle flap procedures (especially the coronally positioned flap) are extremely versatile and have the most predictable outcome of all root-coverage procedures, especially when combined with subepithelial connective tissue grafting and/or allogeneic grafts. In summary: subepithelial connective tissue grafting is considered as the first option to augment gingival width and thickness, and it may provide better long-term results; the same principles of root-coverage procedures in individual sites appear be used in clinical practice also for multiple-recession type defects; an allograft is an efficient alternative to a subepithelial connective tissue graft and, when it is the treatment option of choice, the use of wide, extended flaps should be considered; because of the superiority of plastic periodontal procedures over guided tissue regeneration and the technical difficulty of the latter, guided tissue regeneration has become obsolete for root-coverage procedures; there is rather a large body of evidence attesting that smoking negatively influences root-coverage procedures, especially subepithelial connective tissue grafts; and minimally invasive techniques may be of great value for improving the results obtained with plastic periodontal procedures, but these techniques need to be better addressed in clinical trials, both in terms of the quality and quantity of the new tissue generated.

Clinical and histological reaction of periodontal tissues to subgingival resin composite restorations

OBJECTIVES

To compare the clinical and histological response of supracrestal periodontal tissues to subgingival composite restorations versus natural root surfaces MATERIAL AND METHODS: In 29 subjects with a single tooth requiring subgingival restorations, a deep margin elevation (DME) procedure with composite resin was applied. Full-mouth plaque score (FMPS), full-mouth bleeding score (FMBS), and focal probing depth (PD) were measured at baseline, before DME, and after 3 months. The distance between the coronal marked (CM) point to the apical margin of the composite reconstruction (AMR), at baseline, and to the tip of the periodontal probe inserted to reach the bottom of the sulcus (APP), 3 months later, was measured. An all-around secondary flap, harvested to ensure the subsequent single-crown prosthetic rehabilitation was histologically processed. The histological inflammation degree was evaluated in areas of gingival tissues adjacent to the composite (group B) and adjacent to the natural surface of each single tooth (group A).

RESULTS

Significant FMPS, FMBS, and PD decreases were observed (p < 0.05). CM-AMR and CM-APP were significantly different (p < 0.05), suggesting an attachment gain after 3-months. The inflammation level of gingival tissue was similar in groups A and B (p > 0.05).

CONCLUSIONS

For the first time, this topic was clinically and histologically studied in humans. Subgingival restorations resulted compatible with gingival health, with levels similar to that of untreated root surfaces.

CLINICAL RELEVANCE

Deep margin elevation procedure produces favorable clinical and histological outcomes allowing a routine utilization in reconstructive dentistry.

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

BACKGROUND

The aim of this long-term case series was to assess the development/prevalence of non-carious cervical lesions (NCCLs) at sites that have and have not been treated with gingival augmentation following free gingival graft (FGG).

METHODS

Fifty-two patients had at least one test and one control site: 1) test site showing absence of attached gingiva (AG) associated with gingival recession (GR) treated with FGG; and 2) contralateral site with or without AG. Patient/tooth/site-associated variables were recorded for each tooth/site at baseline (T0), 12 months after surgery (T1), during the follow-up period (T2) (15 to 20 years), and at the end of the follow-up period (T3) over 25 to 30 years. Mixed-effects logistic regression was used throughout the study.

RESULTS

Forty-nine patients/130 sites were available for analysis at T2 whereas 44 patients/120 sites at T3. Twenty-two NCCLs >0.5 mm were restored in the test sites and in 35 in the untreated sites. The development of NCCL over time appeared associated with sites with attached KT <2 mm (i.e., odds ratio [OR]: 3.80 [P = 0.045] and 3.47 [P = 0.046], 15- to 20- and 20- to 30-year follow-ups, respectively), as well as to teeth presenting a thin/non-modified periodontal phenotype (i.e., OR: 3.53 [P = 0.037] and 5.51 [P = 0.008], 15- to 20- and 20- to 30-year follow-ups, respectively).

CONCLUSIONS

Periodontal phenotype modification achieved by FGG may prevent the development/progression of NCCL. Evidence suggests that the thickness and width of the AG had a direct influence on the need of restoring these lesions during the 25- to 30-year observation period.

Clinical evaluation of combined surgical/ restorative treatment of gingival recession-type defects using different restorative materials: A randomized clinical trial

Background/purpose

An ideal therapeutic procedure for the treatment of gingival recession associated with an NCCL has presented a challenge to clinicians. Various dental materials and surgical approaches have been used to manage gingival recessions associated with NCCLs for the most predictable combined surgical/restorative treatment. The objective of this study was to evaluate the treatment of gingival recessions associated with non-carious cervical lesions (NCCL) using a modified coronally advanced flap (MCAF) in combination with a connective tissue graft (CTG) on restored root surfaces.

Materials and methods

Twenty-three systemically healthy subjects, who were positive for the presence of three cervical lesions associated with gingival recessions in three different adjacent teeth, were enrolled in the study. The NCCL were each restored prior to surgery by using one of three different materials: nanofilled composite resin (NCR), resin-modified glass ionomer cement (RMGI) or giomer. The gingival recession defects were treated by CTG.

Results

Inter-group differences were not statistically significant for probing depth (PD), relative recession height (rRH), relative clinical attachment level (rCAL), keratinized tissue width (KTW) or keratinized tissue thickness (KTT) (p > 0.05) among the groups at any time. The mean percentage of defect coverage was 71.18 ± 23.16% for NCR + CTG group; 71.33 ± 22.33% for RMGI + CTG group; and 64.23 ± 20.33% for giomer + CTG group at 1 year postoperatively (p > 0.05).

Conclusion

The combined surgical/restorative treatments provided successful clinical results. Giomer + CTG may be less effective compared to other groups for treatment of gingival recession associated with NCCL.

Gingival tissue reaction to direct adhesive restoration: A preliminary study

INTRODUCTION

It is debated whether composite resin marginal/submarginal direct restoration can be usefully performed without inflammatory consequences. This histological study is the first human analysis aimed to compare, in the same tooth, the gingival tissue close to composite resin restorations with gingival tissue close to hard tissue.

METHODS

Eight healthy patients with almost a residual strategic tooth needing endodontic therapy, and post-and-core restoration, then indirect prosthetic restoration, were selected. Direct margin relocation with composite resin was necessary to perform endodontic treatment. The crown lengthening with a secondary flap harvested was necessary to perform prosthetic rehabilitation. Three months after marginal relocation, the secondary flap was harvested, embedded in PMMA, 4-μm sectioned, and stained to analyze the inflammation degree.

RESULTS

All patients completed post-and-core reconstruction and the planned prosthetic therapy, maintaining the stringent hygienic protocol plan. The inflammation level comparison, slightly lower in gingiva close to the teeth (3.62 ± 0.38) than in gingiva close to the composite (3.75 ± 0.26), results in a p-value of 0.11 after Wilcoxon test.

CONCLUSIONS

Results highlight a minimal, statistically not significant difference in the inflammation degree after margin relocation, conceivably due to patients, teeth and cases selection, together with adopted stringent methodological and supportive measures.

Does Evidence Support a Combined Restorative Surgical Approach for the Treatment of Gingival Recessions Associated With Noncarious Cervical Lesions?

OBJECTIVES

Gingival recessions are frequently associated with noncarious cervical lesions. Combined restorative surgical approaches have been suggested for the management of these combined defects. The aim of this review was to analyze the current evidence on the effectiveness of these combined restorative surgical approaches.

METHODS

A systematic review of randomized controlled studies published from January 2006 to June 2016 was performed.

RESULTS

Ten articles comparing combined restorative surgical approaches to surgery alone were included. Both the procedures showed similar outcomes in term of root coverage but the combined restorative surgical approach achieved better result in the reduction of dentin hypersensitivity. In combined restorative surgical treatments, resin-modified glass ionomers showed better antimicrobial properties but poorer esthetic outcome than resin composites.

CONCLUSION

Data to support or refute definitely the interest of combined approaches for the treatment of gingival recessions associated with noncarious cervical lesions are limited.

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.

Flap approaches in plastic periodontal and implant surgery: critical elements in design and execution

AIM

To identify critical elements in design and execution of coronally advanced flap, lateral positioned flap and their variations for the treatment of facial gingival recessions or peri-implant soft tissue dehiscences.

MATERIALS AND METHODS

Clinical studies were identified with both electronic and hand searches, and examined for the following aspects: flap design and incision techniques, flap elevation, root conditioning, flap mobility, flap stability and suturing. Moreover, prognostic factors for complete recession coverage were identified.

RESULTS

Some critical elements are evident in flap design and execution: the dimension and the thickness of tissue positioned over the denuded roots; the use on root surface of enamel matrix derivate; the stability and suturing of the flap in a position coronal to the cemento-enamel junction. The pre-determination of the clinical cemento-enamel junction, smoking status, operator surgical skills and the compliance to a supportive care programme have a role in obtaining and maintaining a complete root coverage.

CONCLUSIONS

Different flap approaches are available when performing periodontal plastic surgery, resulting in a great variability in clinical outcomes. The possibility of using pedicle flaps alone to achieve complete soft tissue coverage of facial implant dehiscence has not yet been investigated.

Classification & prevalence of dental surface defects in areas of gingival recession- a clinical study

BACKGROUND

Apical migration of the gingival margin beyond the cement-enamel junction (CEJ) is called as gingival recession. Various classifications of gingival recession have been proposed to evaluate different degrees of damage to periodontal tissues, but do not consider the condition of the exposed root surface: presence of an identifiable CEJ and presence of root abrasion. Sometimes these lesions may be associated with enamel abrasion. Therefore, the aim of this paper is to propose the new classification of dental surface defects in gingival recession area.

METHODS

Two factors were evaluated to set up a classification system: presence (A) or absence (B) of CEJ and presence (+) or absence (-) of dental surface discrepancy caused by abrasion (step). Four classes (A+, A-, B+, and B-) were identified on the basis of these variables. The classification was used on 1,000 gingival recessions to examine the distribution of the four classes.

RESULTS

Out of 1,000 exposed root surfaces, 380 showed an identifiable CEJ associated with step (Class A+, 38%); 280 an identifiable CEJ without any associated step (Class A-, 28%); 200 an unidentifiable CEJ with a step (Class B+, 20%); and 140 an unidentifiable CEJ without any associated step (Class B-, 14%).

CONCLUSION

The proposed classification describes the dental surface defects that are of paramount importance in diagnosing gingival recession areas which might help in selecting the definite treatment approach.

Clinical attachment level gain and bone regeneration around a glass ionomer restoration on root surface wall of periodontal pocket

A case describing perio-restorative management of an accidental trauma in the mid portion of root on an upper left canine tooth following an ostectomy surgery is presented here. The traumatized root area was undergoing fast resorption and a chronic periodontal abscess had developed in relation to the lesion. The article illustrates the clinical and radiographic photo series of a periodontal flap surgery done to gain access into a subgingival region for the placement of Glass ionomer restoration on the root and its periodic follow up. The clinical condition of the area suggests 8 mm clinical attachment gain over the restoration and the review radiographs at definite intervals up to 18 months revealed evidence of consistent bone regeneration around the restoration. The article also highlights the various other possibilities, where this restorative material can be effectively used in conjunction with periodontal surgical procedures.

Coronally advanced flap and combination therapy for root coverage. Clinical strategies based on scientific evidence and clinical experience

During the past three decades, several surgical techniques have been proposed to treat single and multiple gingival recessions. Evidence indicates that coronally advanced flap-based approaches result in the best clinical results. Among all the different techniques, the use of a graft under a coronally advanced flap results in the best short- and long-term outcomes in terms of root coverage and gain in keratinized tissue. The use of a coronally advanced flap + connective tissue graft would appear to be the best choice for root coverage. However, harvesting a graft from the palate adds morbidity, surgical chair-time and requires increased surgical skills. A potential alternative could be the use of enamel matrix derivatives under a coronally advanced flap, and this achieves similar clinical outcomes and is less invasive, but adds economic costs to the treatment. Evidence shows that a coronally advanced flap alone in many instances results in complete root coverage and is stable over time. A coronally advanced flap is less invasive for the patient, requires less chair-time and probably less surgical skill. It would therefore be desirable to use a coronally advanced flap approach when indicated. It has been hypothesized that a coronally advanced flap approach alone could be successfully applied when the residual gingiva is thick and wide, although existing evidence does not support this hypothesis in full. Accordingly, the adjunctive use of a graft or enamel matrix derivatives could be restricted to sites at which there is thin and narrow residual gingiva.

A clinical comparison of two flap designs for coronal advancement of the gingival margin: semilunar versus coronally advanced flap

BACKGROUND

The semilunar incision was introduced in oral surgery more than a century ago. The semilunar coronally re-positioned flap (SLCRF) is one of the variants of this procedure; however, no previous controlled clinical study has evaluated the SLCRF performed as originally described. The objective of the present study was to compare the clinical outcomes of the SLCRF and coronally advanced flap (CAF) procedure in the treatment of maxillary Miller class I recession (GR) defects.

MATERIALS AND METHODS

Twenty-two patients, with 22 contra-lateral Miller class I GR defects, were randomly assigned to CAF or SLCRF. Clinical parameters assessed included recession height, width of keratinized tissue, probing depth, vertical clinical attachment level, visual plaque score and bleeding on probing. Clinical recordings were performed at baseline and 6 months later. Inter-measurements differences were analysed with a chi(2) or a paired t-test, with significance set at alpha<0.05.

RESULTS

Both flap designs were effective in obtaining and maintaining a coronal displacement of the gingival margin. The CAF resulted in clinical improvements significantly better than SLCRF for percentage of root coverage (RC), frequency of complete RC and gain in clinical attachment level. RC obtained in the immediate post-surgical period of SLCRF-treated sites was not maintained throughout the subsequent evaluations.

CONCLUSION

RC is significantly better with CAF compared with the original SLCRF technique in the treatment of shallow maxillary Miller class I GR defects.

Root coverage in an HIV-positive individual: combined use of a lateral sliding flap and resin-modified glass ionomer for the management of an isolated severe recession defect

BACKGROUND

Gingival recession is a frequent clinical finding in the general population. Exposed root surfaces are more likely to develop root sensitivity and root caries and pose esthetic concerns for the patient. Most root coverage procedures have been described on non-restored root surfaces. Limited data are available that describe root coverage procedures on restored root surfaces. To our knowledge, this is the first case report in which a severe recession defect and its associated carious lesion were managed using the combination of a lateral sliding flap and a resin-modified glass ionomer restoration in an HIV-positive individual.

METHODS

A 53-year-old male patient with a 25-year history of HIV infection presented for comprehensive care. The facial surface of tooth #22 had a fractured composite restoration, recurrent decay, and a Miller Class III recession defect. The lesion was restored with resin-modified glass ionomer and root coverage was obtained by a lateral sliding flap mobilized from the adjacent edentulous ridge. After 8 weeks, surgical access was used to correct a previously undetected void in the restoration.

RESULTS

Uneventful healing was observed at the 1-, 4-, 8-, 10-, 12-, and 24-week postoperative visits. Root coverage of 5 mm along with a 2-mm band of keratinized tissue was obtained at 24 weeks. The gingiva displayed no signs of inflammation and was tightly adapted to the root surface with minimal probing depths circumferentially.

CONCLUSION

Successful root coverage was obtained on a resin-modified glass ionomer-restored surface in an HIV-positive individual.