Periodontal regeneration in gingival recession defects

Clinical effectiveness of periosteal pedicle graft for the management of gingival recession defects-a systematic review and meta-analysis

OBJECTIVE

The purpose of this systematic review and meta-analysis was to evaluate the effectiveness of periosteal pedicle graft (PPG) in terms of root coverage and patient related outcomes. To the best of our knowledge this is the first systematic review with meta-analysis on PPG.

MATERIAL AND METHODS

A comprehensive search was performed using electronic and hand searches upto January 2023. Primary outcomes were Recession depth Reduction (Rec Red), mean root coverage (mRC) and complete root coverage (CRC). Secondary outcomes were gain in width of keratinized gingiva (WKG) and patient reported outcome measures (PROMs). Meta-analysis was performed when possible. The risk bias assessment was done using RevMan5.4.1 and Joanna Briggs institute scale for the included RCTs and case series respectively.

RESULTS

A total of 8 RCTs and 2 case series (538 recession sites) were included based upon the predefined inclusion and exclusion criteria. The follow up period ranged from 6 months to 18 months. Results demonstrated that mRC of PPG + Coronally advanced flap (CAF) was 87.7% for localized gingival recession defects (GRDs) and 84.83% for multiple GRDs. An overall gain in WKG (Weighted Mean =1.49 ± 0.27 mm) was observed among all the included studies in the PPG + CAF group with mean difference (-0.10 (95% CI [-0.52, 0.33], p = 0.66)). Sub-group meta-analysis comparing PPG + CAF with sub-epithelial connective tissue graft (SCTG) + CAF resulted in similar outcomes in terms of Rec Red (0.10 (95% CI [-0.56 to 0.77], p = 0.76)) and gain in WKG (-0.03 (95% CI [-0.25 to 0.18], p = 0.76)). In terms of PROMs systematic review revealed better patient satisfaction with PPG + CAF than SCTG + CAF.

CONCLUSION

PPG + CAF is a viable treatment modality for management of GRDs. The primary and secondary outcomes achieved utilizing PPG + CAF were found to be comparable to other conventional techniques including the gold standard i.e., SCTG.

Comparison of chorion allograft and subepithelial connective tissue autograft in the treatment of gingival recession- A randomized controlled clinical trial

Background

To compare the clinical outcomes of subepithelial connective tissue graft and chorion membrane along with coronally advanced flap in the treatment of gingival recession.

Methods

A total of 12 patients with 24 sites showing isolated bilateral Miller's class I and II gingival recessions were randomly allocated into two treatment sites. One site, connective tissue graft, (n = 12 sites) while on the contra-lateral site, chorion membrane (n = 12 sites) was used with coronally advanced flap. Clinical parameters: probing depth, recession depth, recession width, width of keratinized gingiva, relative attachment level, thickness of keratinized gingiva were recorded at the baseline, 3 months, and 6 months. The amount of root coverage was evaluated after 6 months.

Results

Statistically significant differences were observed between test and control sites in terms of recession depth, recession width, width of keratinized gingiva and thickness of keratinized gingiva at 6 months. The test sites presented 66.17 ± 18.85% and the control site showed 87.17 ± 18.33% of root coverage at 6 months.

Conclusion

Very limited amount of recession coverage with chorion membrane and did not serve as an alternative to connective tissue graft.

Trial registration

CTRI/2017/12/010964.

The treatment of multiple gingival recession defects with connective tissue grafting and enamel matrix derivative in a private practice setting: Two case reports

BACKGROUND

Dentofacial esthetics has become a mainstay treatment in periodontics. For a periodontal private practice to succeed in a referral-based environment, predictability and stability in treatment results are crucial. The scientific literature provides a guide to successfully treating multiple recession defects with non-carious cervical lesions and lingual recession. These case reports show how the use of biologic mediators, proper case selection, and proper surgical technique may provide a better treatment outcome for our patients.

METHODS

Two patients with multiple gingival recession defects were treated with autogenous tissue grafting in conjunction with the application of enamel matrix derivative (EMD) to attempt root coverage. Based on the Cairo classification, the recession defects were classified as type I in the maxillary buccal and lingual recession in the mandibular anterior. There were areas of no attached gingiva, loss of enamel, and the presence of non-carious cervical lesions.

RESULTS

At 3-month post-treatment in case #1 and 6-month post-treatment in case #2, satisfactory esthetic results for the patients and clinician were achieved. These short-term follow-ups were favorable for root coverage and soft tissue healing, especially at the 1-week visit. There was noticeably less edema and erythema. Additionally, dental hypersensitivity was no longer reported for both patients.

CONCLUSION

By using biologic mediators, such as an EMD combined with connective tissue grafting, both multiple recession defects with non-carious cervical lesions, and lingual recession cases, can be treated successfully in a private practice setting. Using an EMD provides no additional risks to patients, may result in faster healing, and would afford stability of long-term success by influencing true periodontal regeneration.

3D-printed bi-layered polymer/hydrogel construct for interfacial tissue regeneration in a canine model

OBJECTIVES

There are complications in applying regenerative strategies at the interface of hard and soft tissues due to the limited designs of constructs that can accommodate different cell types in different sites. The problem originates from the challenges in the adhesion of dissimilar materials, such as polymers and hydrogels, that can be suitable for regenerating different tissues such as bone and soft tissues. This paper presents a design of a new hybrid construct in which a polymer (polycaprolactone (PCL)) membrane firmly adheres to a layer of hydrogen (gelatin).

METHODS

PCL membranes with defined size and porosity were fabricated using 3D printing. The gelatin layer was attached to the PCL membranes using the aminolysis procedure. We have examined this construct for the application of Guided Bone Regeneration (GBR) as a typical surgical regenerative procedure of the oral cavity at the interface of bone and soft tissue. Complete in vitro and in vivo investigations on canine tibia bone defects have been performed. Histological analyses for fibrosis morphometric and bone morphometric evaluation, as well as bone-fibrosis histological grading and CBCT imaging, were conducted.

RESULTS

Chemical and morphological studies of the membrane proved that gelatin was uniformly attached to the aminolyzed PCL membranes. The in vitro and in vivo studies indicated the membrane's biocompatibility, mechanical stability, and barrier function for the GBR application. Furthermore, in vitro study showed that the membranes could improve osteogenesis and the regeneration of bone defects. The results illustrated that the mean bone density in the membrane groups was about three times more than that of the control group.

SIGNIFICANCE

The fabricated 3D-printed hybrid Gelatin/PCL bi-layered membrane can be a good candidate for interfacial tissue engineering and a promising membrane for GBR procedure.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Assessment of Patients’ Satisfaction following Coverage of Gingival Recessions: Questionnaire-Based Case Series

Background/Aim: One of the most important goals of periodontal plastic surgery constitutes the predictable root coverage. Despite the thorough documentation that several surgical approaches can be implemented for the successful treatment of gingival recession (GR), only limited papers reported data on the evaluation according to patient’s opinion. Thus, the forthcoming study is aiming in the patient-based assessment of the outcome of root coverage procedures.

Material and Methods: Sixteen subjects (eight male, eight female; mean age 43.75 years, range: 23-73 years), with twenty one GRs, constituted the sample of this study and the root coverage procedures were executed in the period from 2011 to 2019. A patient-based questionnaire was used to assess the level of subjects’ concern on various aspects related to the GR, preand post-operatively. Patient’s overall post-operative satisfaction was evaluated with a VAS.

Results: After a period of at least 6 months of the surgical treatment, the majority of the subjects indicated that they were not concerned for all the examined criteria. The criteria with the highest improvement (reported as improvement by at least two levels of concern pre- and post-operatively) were the following: 1) fear to lose the involved teeth and 2) esthetics of the area of the recession defect. With regard to esthetics’ criteria, the majority of the patients indicated post-operatively the examined criteria as not important. The esthetics’ criteria yielding the highest improvement were: 1) position of the teeth and 2) the fact that the teeth showed longer. Mean patient’s overall post-operative satisfaction was 82,3 (range: 0-100).

Conclusions: The majority of the subjects were satisfied from the implemented root coverage procedures. Few studies on the international literature have evaluated patient satisfaction following therapy. Comprehensive, multi-center studies, comprised of a large sample and a using a standardized approach are needed in future research.

Clinical efficacy of xenogeneic and allogeneic 3D matrix in the management of gingival recession: a systematic review and meta-analysis

OBJECTIVE

A systematic review and meta-analysis was thus conducted to answer the following focused question based on PICO strategy: Is there any 3D matrix biomaterial used for root coverage of human Miller class I and II defects equivalent with the connective tissue graft in localized defects of at least 2 mm and 3 mm?

MATERIAL AND METHODS

The search on electronic database included MEDLINE, Cochrane Central Register of Controlled Trials, Clinical Trials.gov, Web of Science, and New Zealand/Australian Clinical Trials. Only randomized clinical trials (RCTs) that compared connective tissue graft (CTG) with at least one 3D matrix alone for root coverage in Class I and II Miller localized defects of at least 2 mm, with at least 6 months follow-up, were included in this systematic review.

RESULTS

A total of 14 studies were included for meta-analysis (12 compared CTG with acellular dermal matrix allograft and 2 compared CTG with Xenogenic Collagen Matrix). Relative root coverage showed no significant difference among the materials, for either 2 or 3 mm minimal recessions. For keratinized tissue width, on 2 mm recessions, CTG showed superiority above other biomaterials, but on 3 mm recessions, it seemed to have the same results. The percentage of recessions with complete root coverage for both 2 and 3 mm recessions showed similar results for all biomaterials.

CONCLUSIONS

With their limits, the present data concluded that CTG, acellular dermal matrix allograft, and xenogenic collagen matrix provided similar results for root coverage.

CLINICAL RELEVANCE

To know if there is a 3D matrix with equivalent predictable results for root coverage, that we could avoid the morbidity of the connective tissue graft for these cases.

Experimental and clinical studies on regenerative periodontal therapy

The recognition of a periodontal therapy as a regenerative procedure requires the demonstration of new cementum, periodontal ligament, and bone coronal to the base of the defect. A diversity of regenerative strategies has been evaluated, including root surface conditioning, bone grafts and bone substitute materials, guided tissue regeneration, enamel matrix proteins, growth/differentiation factors, combined therapies and, more recently, tissue-engineering approaches. The aim of this chapter of Periodontology 2000 is to review the research carried out in Latin America in the field of periodontal regeneration, focusing mainly on studies using preclinical models (animal models) and randomized controlled clinical trials. This review may help clinicians and researchers to evaluate the current status of the therapies available and to discuss the challenges that must be faced in order to achieve predictable periodontal regeneration in clinical practice.

Peripheral Giant Cell Granuloma Associated With Periodontal Intrabony Defect

INTRODUCTION

The peripheral giant cell granuloma (PGCG) is associated with periodontal bony lesions in several situations and excision results in a soft papilla defect and an intrabony defect without soft tissue protection.

CASE PRESENTATION

A PGCG associated with loss of periodontal support is described. Following the lesion excision, a specific flap design outlining a surgical papilla in the adjacent area was proposed. The aim of this flap design was to obtain an optimal condition for periodontal regeneration, to treat the lesion excision associated with soft tissue defect, and to avoid a second surgical area. Complete periodontal defect resolution without soft tissue contraction or lesion recurrence was obtained at 2-year follow-up.

CONCLUSION

Early diagnosis and treatment are essential to prevent greater loss of periodontal attachment.

A Prospective, Case-Controlled Study Evaluating the Use of Enamel Matrix Derivative on Human Buccal Recession Defects: A Human Histologic Examination

BACKGROUND

Connective tissue grafts (CTGs) and coronally advanced flaps (CAFs) do not regenerate periodontal attachment apparatus when used to treat gingival recessions (GRs). Instead of generating new bone, cementum, and inserting periodontal ligament fibers, CTG+CAF repairs through a long epithelial junction and connective tissue attachment. Enamel matrix derivatives (EMDs) have demonstrated proof-of-principle that periodontal regeneration can be achieved, although data are limited.

METHODS

Three patients, each requiring extraction of four premolars before orthodontic treatment, were enrolled in a randomized, open-label study. Two months after induction of Miller Class I and II GR, each patient received EMD+CAF for three teeth and CTG+CAF for one tooth for root coverage. Nine months after root coverage, all four premolars from each of the three patients were surgically extracted en bloc for histologic and microcomputed tomography (micro-CT) analysis, looking for evidence of periodontal regeneration. Standard clinical measurements, radiographs, and intraoral photographs were taken over prescribed time points.

RESULTS

Seven of the nine teeth treated with EMD+CAF demonstrated varying degrees of periodontal regeneration, detailed through histology with new bone, cementum, and inserting fibers. Micro-CT corroborated these findings. None of the three teeth treated with CTG+CAF showed periodontal regeneration. Clinical measurements were comparable for both treatments. One instance of root resorption and ankylosis was noted with EMD+CAF.

CONCLUSIONS

EMD+CAF continues to show histologic evidence of periodontal regeneration via human histology, this being the largest study (nine teeth) examining its effect when treating GR. The mechanism of action, ideal patient profile, and criteria leading to predictable regeneration are in need of further exploration.

Vascularization after treatment of gingival recession defects with platelet-rich fibrin or connective tissue graft

OBJECTIVE

The aim of this study was to evaluate histologically the following treatment of bilateral localized gingival recessions with coronally advanced flap (CAF) combined with platelet-rich fibrin (PRF) or subepithelial connective tissue graft (SCTG).

MATERIALS AND METHODS

Tissue samples were harvested from 14 subjects either 1 or 6 months after the surgeries. The 2-mm punch biopsies were obtained from the mid-portion of the grafted sites. Neutral buffered formalin fixed, paraffin-embedded 5-μm thick tissue sections were stained with hematoxylin eosin and Masson's trichrome in order to analyze the collagen framework, epithelium thickness and rete-peg length. Multiple sequential sections were cut from paraffin-embedded blocks of tissue and immunohistochemically prepared for detection of vascular endothelial growth factor, CD31 and CD34, for the assessment of vascularization.

RESULTS

Rete peg formation was significantly increased in the sites treated with PRF compared to the SCTG group after 6 months (p < 0.05). On the contrary, the number of vessels was increased in the SCTG group compared to the PRF group after 6 months (p < 0.05). No statistically significant differences were observed in the collagen density. Staining intensity of CD31 increased in submucosal area of PRF group than SCTG group after 1 month. Higher staining intensity of CD34 was observed in the submucosal area of PRF group compared with SCTG group after 6 months.

CONCLUSIONS

The results of the present study suggest that in histological evaluation because of its biological compounds, PRF results earlier vessel formation and tissue maturation compared to connective tissue graft.

CLINICAL RELEVANCE

PRF regulated the vascular response associated with an earlier wound healing.

Dental stem cells: a future asset of ocular cell therapy

Regenerative medicine using patient's own stem cells (SCs) to repair dysfunctional tissues is an attractive approach to complement surgical and pharmacological treatments for aging and degenerative disorders. Recently, dental SCs have drawn much attention owing to their accessibility, plasticity and applicability for regenerative use not only for dental, but also other body tissues. In ophthalmology, there has been increasing interest to differentiate dental pulp SC and periodontal ligament SC (PDLSC) towards ocular lineage. Both can commit to retinal fate expressing eye field transcription factors and generate rhodopsin-positive photoreceptor-like cells. This proposes a novel therapeutic alternative for retinal degeneration diseases. Moreover, as PDLSC shares similar cranial neural crest origin and proteoglycan secretion with corneal stromal keratoctyes and corneal endothelial cells, this offers the possibility of differentiating PDLSC to these corneal cell types. The advance could lead to a shift in the medical management of corneal opacities and endothelial disorders from highly invasive corneal transplantation using limited donor tissue to cell therapy utilizing autologous cells. This article provides an overview of dental SC research and the perspective of utilizing dental SCs for ocular regenerative medicine.

The Adjunctive Effect of Platelet-Rich Fibrin to Connective Tissue Graft in the Treatment of Buccal Recession Defects: Results of a Randomized, Parallel-Group Controlled Trial

BACKGROUND

Platelet-rich fibrin (PRF) is an autologous preparation that has encouraging effects in healing and regeneration. The aim of this trial is to evaluate the effectiveness of coronally advanced flap (CAF) + connective tissue graft (CTG) + PRF in Miller Class I and II recession treatment compared to CAF + CTG.

METHODS

Forty patients were treated surgically with either CAF + CTG + PRF (test group) or CAF + CTG (control group). Clinical parameters of plaque index, gingival index, vertical recession (VR), probing depth, clinical attachment level (CAL), keratinized tissue width (KTW), horizontal recession (HR), mucogingival junction localization, and tissue thickness (TT) were recorded at baseline and 3 and 6 months after surgery. Root coverage (RC), complete RC (CRC), attachment gain (AG), and keratinized tissue change (KTC) were also calculated.

RESULTS

All individuals completed the entire study period. At baseline, mean VR, HR, CAL, KTW, and TT values were similar (P >0.05). In both groups, all parameters showed significant improvement after treatment (P <0.001), and except TT (P <0.05), no intergroup difference was observed at 6 months after surgery. The amount of RC and AG, but not KTC and CRC, was higher in the PRF-applied group (P <0.05).

CONCLUSIONS

According to the results, the addition of PRF did not further develop the outcomes of CAF + CTG treatment except increasing the TT. However, this single trial is not sufficient to advocate the true clinical effect of PRF on recession treatment with CAF + CTG, and additional trials are needed.

Comparative evaluation of envelope type of advanced flap with and without type I collagen membrane (NEOMEM™) in the treatment of multiple buccal gingival recession defects: A clinical study

BACKGROUND

The aim of this study is to compare and evaluate the clinical outcome of the envelope-type of coronally advanced flap (CAF) alone versus envelope type of coronally advanced flap plus type I collagen membrane (NEOMEM) in the treatment of multiple buccal gingival recessions, using the split mouth study.

MATERIALS AND METHODS

Ten patients in the age group of 20-50 years showing bilateral gingival recessions were treated. The defects in each patient were randomly assigned as Group A, which were treated with the envelope type of CAF, and those in Group B were treated with envelope type of CAF along with the Type I collagen membrane (NEOMEM). The recession depth (RD), probing depth (PD), clinical attachment level (CAL), and width of the keratinized tissue (KT) were measured at baseline, at three and six month intervals.

RESULTS

Forty-six Miller's class I and II gingival recessions were treated. In the CAF + Type I collagen membrane (NEOMEM)-treated (Group B) sites the baseline gingival recession was 2.34 ± 0.48 mm, while in the CAFtreated (Group A) sites it was 2.52 ± 0.84 mm. Both the treatments resulted in significant recession depth reduction (P < 0.001), but the reduction was significantly greater (P < 0.01) for Group B than Group A. The probing depth changes were significant (P < 0.01) for both groups, but the difference was nonsignificant. Similarly, a significant gain of CAL was seen in Group B (2.23 ± 0.75 mm, P < 0.001) as well as in group A (1.60 ± 0.86 mm, P < 0.001) showing a significant difference (P < 0.01) between the two groups. The width of keratinized tissue was also significantly (P < 0.001) increased in both groups, but the increase was significantly greater (P < 0.001) in group B (2.30 ± 1.06 mm) than in group A (1.21 ± 0.67 mm).

CONCLUSION

The envelope type of CAF along with Type I collagen membrane (NEOMEM) was more effective than envelope type of CAF alone, in producing root coverage in multiple gingival recession defects, associated with gain in CAL as also in the width of KT.

Regenerative Treatment for Recession Defects Using Purified Human Platelet-Derived Growth Factor-BB, Particulate Grafts, and Coronally Repositioned Flaps

INTRODUCTION

Recession defects are typically characterized by loss of periodontal attachment, including gingiva, periodontal ligament, alveolar bone, and cementum. Numerous techniques have been developed for treatment of these defects using soft-tissue grafting procedures with autogenous and allograft materials that generally heal with root coverage and repair of the defects. This case presentation illustrates a technique using a particulate carrier saturated with recombinant human platelet-derived growth factor-BB (rhPDGF-BB) and coronally advanced gingival flaps to cover recession defects. Additionally, other scientific evidence from previous studies suggests that this technique may lead to periodontal regeneration, including cementum, periodontal ligament, and alveolar bone over previously exposed roots, which might be preferable to other methods that lead to periodontal repair.

CASE PRESENTATION

This article illustrates a technique to coronally position flaps in combination with rhPDGF-BB-saturated particulate graft material. Results show significant root coverage with excellent color and texture match to adjacent tissues. Additionally, the alveolus appeared thicker than non-treated areas, suggesting appositional augmentation of the sites. Human histologic investigation of this technique in other studies confirms that periodontal regeneration can occur with this technique.

CONCLUSIONS

Coronally positioned flaps over rhPDGF-BB-soaked human freeze-dried bone allograft, termed "recession regeneration," can result in significant root coverage with excellent esthetics, even in demanding cases. Surgical reentry of one case shows significant regeneration of buccal alveolar bone over the previously exposed root surfaces, consistent with periodontal regeneration that is not ordinarily observed with other root coverage techniques unless biologic modifiers or cell occlusive barrier membranes are used.

Clinical evaluation of the efficacy of a GTR membrane (HEALIGUIDE) and demineralised bone matrix (OSSEOGRAFT) as a space maintainer in the treatment of Miller's Class I gingival recession

Background:

Periodontal plastic surgical procedures aimed at coverage of exposed root surface have evolved into routine treatment modalities. The present study was designed to evaluate the effectiveness and predictability of using a collagen barrier along with a demineralized bone matrix in the treatment of recession defects in a single surgical procedure.

Materials and Methods:

Seventeen patients with Miller's class I recession were treated with a combination of a collagen barrier used along with a bone graft and coronally advanced flap technique. Clinical parameters were recorded at baseline, 3 months, 6 months, and 9 months.

Results:

The study showed a highly significant reduction in the recession depth (70.29 ± 21.96%) at the end of the study. This study showed that the use of this technique for recession coverage is highly predictable and highly esthetic root coverage can be obtained.

[Therapeutic efficacy of guided tissue regeneration and connective tissue autotransplants with periosteum in the management of gingival recession]

BACKGROUND/AIM

Gingival recession progression in clinical practice as an ethiological factor of periodontal diseases, and symptoms of the disease have caused the development of various surgical procedures and techniques of the reconstruction of periodontal defects. The aim of this study was to verify efficacy of surgical procedures that include connective tissue autotransplants with periosteum and guided tissue regeneration for the treatment of gingival recession.

METHODS

The study included 20 teeth with gingival recession, Müller class II and III. Ten teeth with gingival recession were treated with resorptive membrane and coronary guided surgical flap (GTR group). On the contralateral side 10 teeth with gingival recession were treated with connective tissue autotransplants with periosteum in combination with coronary guided surgical flap (TVT group). We measured the degree of epithelial attachment (DEA), width of subgingival curettage (WGC) and vertical deepness of recession (VDR). For statistical significance we used Student's t-test.

RESULTS

The study revealed statistical significance in reducing VDR by both used treatments. Root deepness in GTR and TVT group was 63.5%, and 90%, respectively. With both surgical techniques we achieved coronary dislocation of the epithelial attachment, larger zone of gingival curettage, and better oral hygiene.

CONCLUSION

Current surgical techniques are effective in the regeneration of deep periodontal spaces and the treatment of gingival recession. Significantly better results were achieved with the used coronary guided surgical flap than with guided tissue regeneration.

[Clinical impact of platelet rich plasma in treatment of gingival recessions]

INTRODUCTION

Root coverage supported with complete regeneration of lost periodontal tissues represents the ultimate goal of gingival recession treatment.

OBJECTIVE

This study was designed to evaluate clinical effectiveness of platelet rich plasma gel (PRP) with connective tissue graft (CTG) in the treatment of gingival recession.

METHOD

15 gingival recessions Miller class I or II were treated with CTG and PRP (group PRP). Connective tissue graft was harvested from the premolar region using trap door technique. After elevation of the flap, the regional bone and root surface were smeared with activated PRP gel. CTG was also irrigated with PRP gel before placement over the exposed root surface and local bone. Fixed CTG was covered with a coronally advanced flap. The same number of gingival recessions were treated with CTG in combination with the coronally advanced flap with no PRP gel (group TVT). Clinical recordings included recession depth (RD), probing depth (PD), clinical attachment level (CAL) and keratinized tissue width (KT) before and 1 year after mucogingival surgical treatment.

RESULTS

Mean value of RD was significantly decreased from 4.93 +/- 0.86 mm to 0.60 +/- 0.37 (p < 0.01) with CTG and PRP and from 4.76 +/- 0.74 mm to 0.63 +/- 0.29 mm (p < 0.01) in CTG group. This difference was not statistically significant. Results of the keratinized tissue width showed significant increase from 0.88 +/- 0.30 mm presurgery to 3.78 +/- 0.49 mm (p < 0.01) six months after treatment in PRP group and from 0.90 +/- 0.34 mm to 3.15 +/- 0.41 in TVT group (p < 0.01). This difference was statistically significant (p > 0.05). No statistically significant differences were observed between treatment groups in CAL and PD.

CONCLUSION

Clinical results validate both procedures as effective and highly predictable surgical techniques in solving gingival recession problem. Histological evaluation may confirm advantage of PRP use related to regeneration of periodontal tissues.

Coverage of Miller Class I and II Recession Defects Using Enamel Matrix Proteins Versus Coronally Advanced Flap Technique: A 2-Year Report

BACKGROUND

The aim of this study was to evaluate a comparison of the coronally advanced flap procedure with or without the use of enamel matrix proteins in the treatment of recession defects.

METHODS

This 2-year study was conducted as a blinded, split-mouth, placebo-controlled, and randomized design. Thirty patients from two dental schools with two paired buccal recession defects were chosen. Surgical recession coverage was performed as the coronally advanced flap technique. One site was additionally treated with derivative (EMD) and the other site with a placebo (propylene glycol alginate [PGA]). A blinded examiner assessed pre- and post-surgical measurements. Measurements comprised the height and width of the gingival recession, height of keratinized tissue, probing attachment level, probing depth, and alveolar bone level.

RESULTS

Twenty-four months after therapy, both treatment modalities showed significant root coverage and probing attachment gain. The mean gingival recession decreased from 3.6 to 0.8 mm for the EMD-treated sites and from 3.8 to 1.4 mm for the control sites. However, this difference was not statistically significant (P = 0.122). Similarly, all other clinical parameters did not differ significantly in the between-group comparison except for the recession width (P = 0.027) and probing depth (P = 0.046) exhibiting higher reductions in the EMD group. Complete root coverage could be maintained over 2 years in 53% of the EMD versus merely 23% in the control group. A total of 47% of the treated recessions in the control group deteriorated again in the second year after therapy compared to 22% in the EMD group.

CONCLUSION

Enamel matrix derivative seems to provide better long-term results.

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

OBJECTIVE

The aim of the present study was to evaluate the changes of the mucogingival complex of guided tissue regeneration (GTR)-treated gingival recession defects over a 10-year follow-up.

METHODS

The study population consisted of 20 patients, 11 males and nine females, mean age: 44.3+/-10.4 years, each contributing one recession defect treated with a polytetrafluoroethylene membrane. Eight patients were smokers at the time of surgery and at 10 years post-surgery. Recession depth (RD), probing depth clinical attachment level (CAL), and width of keratinized gingiva (KG) were assessed immediately before surgery, at 6 months, 4 years and 10 years post-surgery.

RESULTS

RD was 0.9+/-0.6 mm at 6 months, 1.0+/-1.3 mm at 4 years and 1.3+/-1.6 mm at 10 years. CAL amounted to 1.9+/-1.0 mm at 6 months and shifted to 2.2+/-1.4 and 2.6+/-1.6 mm at 4 years and 10 years, respectively. KG significantly increased following surgery and remained stable thereafter. At 10-year examination, no significant changes from 4-year evaluation were observed. Differences in periodontal parameters between smokers and non-smokers were not statistically significant.

CONCLUSION

In conclusion, the results of the present study failed to demonstrate changes over time in the clinical outcome achieved following GTR procedure in gingival recession defects over a period between 4 and 10 years post-surgery.

Guided Tissue Regeneration-Based Root Coverage: Meta-Analysis

BACKGROUND

The goal of guided tissue regeneration-based root coverage (GTRC) is to repair gingival recession via new attachment formation. Numerous clinical trials have been conducted utilizing the concept of GTR to promote root coverage. Most GTRC studies have had relatively small sample sizes and have not utilized power calculations to determine appropriate sample size; therefore, it is difficult to draw strong conclusions from them. Hence, the purpose of this study is to combine data from currently available GTRC studies and to use meta-analysis to determine whether GTRC provides significantly improved clinical outcomes compared to conventional periodontal plastic surgical approaches for the treatment of marginal tissue recession.

METHODS

Studies were identified that used GTR approaches to treat gingival recession from January 1990 to October 2001. Information from each study was entered into a database. Data were analyzed according to the following criteria: GTRC versus conventional mucogingival surgery (CMGS); membrane type; root conditioning; pretreatment recession depth; adjunctive use of bone replacement graft (BRG); and source of funding. Studies were ranked independently, and mean data from each were weighted accordingly. Meta-analysis was performed using the weighted means for each group. Paired t tests were used to determine statistical significance between each pair of groups.

RESULTS

Forty papers were included for analysis. GTRC resulted in an average of 74% recession depth reduction, 41% complete root coverage, 3 mm AL gain, and 1 mm KG gain. Both GTRC and CMGS produced significant (P < 0.05) improvement compared to baseline measurements. Compared to GTRC, CMGS resulted in significantly (P < 0.05) increased KG (2.1 mm vs. 1.1 mm), root coverage (81% vs. 74%), and percentage of defects with complete root coverage (55% vs. 41 %). Use of absorbable membranes, root conditioning, shallow pretreatment recession (< 4 mm), and corporate sponsorship all resulted in significantly (P < 0.05) improved percentages of sites with complete root coverage but had no effect on other parameters.

CONCLUSIONS

Based on this meta-analysis, guided tissue regeneration-based root coverage can be used successfully to repair gingival recession defects. Conventional mucogingival surgery, however, resulted in statistically better root coverage, width of keratinized gingiva, and complete root coverage.

Evaluation of Human Recession Defects Treated with Coronally Advanced Flaps and Either Enamel Matrix Derivative or Connective Tissue. Part 1: Comparison of Clinical Parameters

BACKGROUND

Recession defects around teeth have been treated with a variety of surgical techniques. Most of the literature suggests that the subepithelial connective tissue graft has the highest percentage of mean root coverage with the least variability. Previous studies have demonstrated that enamel matrix derivative (EMD) has the ability to improve clinical parameters. The purpose of this study was to compare the clinical efficacy of enamel matrix derivative placed under a coronally advanced flap to subepithelial connective tissue placed under a coronally advanced flap in patients with recession type defects.

METHODS

Twenty patients with incisors or premolars presenting with a facial recession of > or = 4 mm in contralateral quadrants of the same jaw were treated; 17 patients completed the study. One tooth in each patient was randomized to receive either a coronally advanced flap with a subepithelial connective tissue graft (control) or a coronally advanced flap with EMD (test). Clinical parameters measured at baseline and at 6, 9, and 12 months included amount of recession; width at the coronal extent of the gingival defect; width of keratinized tissue; probing depth; clinical attachment level; inflammation score; plaque score; plaque index; alveolar bone level; tissue texture and color; and patient perception of pain, bleeding, swelling, and sensitivity.

RESULTS

Results for both the test and control groups were similar for all measured clinical parameters with the exception of early healing, self-reported discomfort, and the amount of keratinized tissue obtained. The coronally advanced flap with EMD was superior to the subepithelial connective tissue graft with regard to early healing and patient-reported discomfort, whereas the subepithelial connective tissue graft demonstrated greater amount of keratinized tissue during the 12-month evaluation period. However, both the test and control showed a significant increase in the amount of keratinized tissue at 9 and 12 months compared to baseline. No significant difference in the amount of root coverage was found between the test and control groups (n = 19; P = 0.82). On average, a gain of 4.5 mm (range 4 to 8 mm) tissue covering the previously exposed root surfaces was achieved with both treatment groups. The average percentages of root coverage for control and test groups were 93.8% and 95.1%, respectively. One hundred percent root coverage was obtained 89.5% of the time with the coronally advanced flap with EMD and 79% of the time with the subepithelial connective tissue graft.

CONCLUSION

Based on the results of this investigation, the addition of EMD to the coronally advanced flap resulted in root coverage similar to the subepithelial connective tissue graft but without the morbidity and potential clinical difficulties associated with the donor site surgery.

Evaluation of Human Recession Defects Treated with Coronally Advanced Flaps and Either Enamel Matrix Derivative or Connective Tissue. Part 2: Histological Evaluation

BACKGROUND

A number of surgical procedures are effective in covering denuded root surfaces. The first paper in this series evaluated the subepithelial connective tissue graft and the coronally advanced flap with enamel matrix derivative (EMD). That paper revealed no significant difference in the percent of root coverage between the two treatments (P = 0.82). There is limited human histological evidence of the type of attachment achieved with these types of procedures. This paper presents a human case report detailing the histological nature of the attachment of these two treatments to the root surfaces previously exposed by recession.

METHODS

One patient presented with two hopeless teeth that were randomized to receive either a subepithelial connective tissue graft or a coronally advanced flap plus EMD. The surgery was accomplished in accordance to the protocol previously described. The teeth and a small collar of tissue were removed at 6 months and underwent histological analysis.

RESULTS

Histological evaluation of the subepithelial connective tissue graft revealed a connective tissue attachment between the tooth and graft, and no histological evidence of cementum, bone, or periodontal ligament (PDL) and, therefore, regeneration. In addition, there appeared to be some resorption of the dentin adjacent to the graft. Histological evaluation of the coronally advanced flap with EMD revealed new cementum, organizing PDL fibers and islands of condensing bone at a constant distance from the root surface.

CONCLUSIONS

The subepithelial connective tissue graft in this study was found to have adhered to the root surface primarily by a connective tissue attachment with some evidence of root resorption. The coronally advanced flap with EMD was found histologically to have all the tissues necessary for regeneration: new cementum, organizing PDL fibers, and islands of condensing bone. These histologic sections strongly suggest that enamel matrix derivative works in a biomimetic fashion by mimicking the natural process of tooth development.

Evidence-based mucogingival therapy. Part 1: A critical review of the literature on root coverage procedures

BACKGROUND

Systematic reviews of the literature are an increasingly important tool for providing evidence-based guidance to the practitioner. This review article and a companion paper deal with the surgical coverage of exposed root surfaces, but their aim is to promote a more up-to-date way of writing and publishing scientific articles in this field. This article presents the published data about surgical root coverage in table form and its aim is to identify updated minimum standards for data presentation.

METHODS

Manual and computer-assisted searches were conducted to find the articles published on this topic during the 30-year period from 1970 to 2000. Articles that described the surgical procedure and reported at least the number of treated recessions and the duration of the follow-up, including case series, controlled studies, and randomized trials were selected and data were arranged in tables.

RESULTS

Only 90 of the 290 articles that dealt with root coverage met the entry criteria; 25 of these were found only through manual searching. The overall clinical outcomes of different techniques appear to be satisfactory, but the published evidence is of little help in deciding which procedure is best suited for each clinical situation. Only a more homogeneous way of collecting and reporting clinical data and especially outcome measures will allow for an effective reanalysis which could help in everyday clinical decision making. Perhaps studies should be carried out and presented keeping in mind that the published results of sound clinical studies will, sooner or later, be reviewed and compared with other studies.

CONCLUSION

A standard format with minimum requirements for data collection and presentation should be established and imposed by international journals in order to provide readers and researchers with more useful information.

Labial piercing resulting in gingival recession. A case series

Several complications of oral piercing have been recently reported in the medical and dental literature. Even though few people have had problems related to oral piercing, dentists should familiarise themselves with the potential associated oral and dental problems. We present three cases of young people with gingival recession in the mandibular incisor area related to labial piercing. The clinical examination and the dental history of the three cases revealed the relationship between the gingival recession and the presence of labial piercing. In particular, a stud in the lower lip was held in place by a metal disk on the inner labial mucosa in each case. The metal disk was in close proximity to the mandibular front teeth and it would appear that it was responsible for local trauma and recession. This case series reinforces previously reported concerns regarding the practice of piercing and the role of the dentist, both in advising patients with oral or facial piercing and in the treatment of related oral, gingival and dental problems.

Supracrestal soft tissue preservation with enamel matrix proteins in treatment of deep intrabony defects

BACKGROUND/AIMS

The purpose of the present study was to investigate the effectiveness of a regenerative procedure based on supracrestal soft tissue preservation in association with enamel matrix proteins (EMP) in the treatment of deep intrabony defects.

METHODS

The subjects included 35 consecutively treated patients, 23 females and 12 males, aged 28-61 years, 11 of whom were smokers. Patients presented with at least one intrabony defect with probing pocket depth > or = 6 mm and a radiographic depth of the defect > or = 4 mm at the initial visit. Immediately before surgery and 9-12 months after surgery, Local Plaque Score (LPS), Local Bleeding Score (LBS), probing pocket depth (PPD), clinical attachment level (CAL), gingival recession (REC), and radiographic depth of the defect (DEPTH) were recorded.

RESULTS

Thirty-one (88.6%) defects were LPS-negative presurgery, while 29 (82.9%) defects presented with no plaque postsurgery. The prevalence of LBS-positive defects shifted from 94.3% presurgery to 8.4% postsurgery (p < 0.0000). PPD was 8.9 mm before surgery, and decreased to 3.5 mm postsurgery (p < 0.0000). CAL varied from 10.1 mm presurgery to 5.4 mm postsurgery (p < 0.0000), with an average improvement (gain) of 4.7 +/- 1.7 mm. Twenty-six (74.3%) defects presented a gain of least 4 mm. Regression analysis showed a positive correlation between CAL gain as a dependent variable, and presurgery PPD and amount of supracrestal soft tissues as predictors. DEPTH improvement (gain) was 3.9 +/- 1.8 mm, which represented 65% of defect fill. Twenty (57.1%) defects presented a DEPTH gain of at least 4 mm. DEPTH gain was significantly correlated to presurgery PPD (p < 0.000). No significant differences were found between smokers and non-smokers in terms of CAL and DEPTH gain.

CONCLUSIONS

Results from the present study indicated that the regenerative procedure based on supracrestal soft tissue preservation and EMP application leads to clinically and statistically significant improvement of hard and soft tissue conditions of deep intrabony defects.

Influence of anti-CD49f and anti-CD29 monoclonal antibodies on mitotic activity of epithelial cells (HaCaT) and gingival fibroblasts in vitro

A major complication in the treatment of periodontitis marginalis is the reepithelization of periodontal defects inhibiting collagen fiber attachment and periodontal regeneration. In this study we investigated the possibility of a molecular blockade of epithelial mitosis in vitro. Monoclonal antibodies against the VLA-6 laminin receptor subunit alpha6 interrupted interactions between epithelial cells (HaCaT cells) and their extracellular matrix and thus resulted in reduction of proliferation rates by more than 50%. The same effect was observed with anti alpha1-antibodies. In contrast, collagen-producing and -secreting gingival fibroblasts, which play an important role in periodontal regeneration, remained unaffected by the applied anti alpha6 antibodies. Correspondingly, these cells were found to lack VLA-6 laminin receptors. Selective molecular inhibition of epithelial proliferation and apical migration by monoclonal anti alpha6 antibody application may provide an adjuvant periodontitis therapy resulting in an enhanced periodontal regeneration.

Comparison of 2 techniques of subepithelial connective tissue graft in the treatment of gingival recessions

BACKGROUND

The clinical outcome of connective tissue grafts in the treatment of gingival recessions has been documented in numerous studies. However, no attempt has been made to correlate the postoperative mucogingival changes with the surgical parameters. The present retrospective clinical study was undertaken to 1) evaluate root coverage and mucogingival changes 1 to 1.5 years following treatment of Miller's Class I and II recession defects using 2 variants of the subepithelial connective tissue graft (SCTG) procedure, and 2) assess the effect of the surgical parameters on the postoperative gingival width.

METHODS

Thirty-one recessions in 10 patients treated with the envelope technique (E) and 31 recessions in 11 patients treated with coronally positioned flap combined with connective tissue graft (CP) were retrospectively analyzed to evaluate: 1) percentage of root coverage obtained with the 2 procedures and variations in width of keratinized tissue (KT) 1 to 1.5 years postsurgery, and 2) the effect of the surgical parameters on the postoperative gingival width.

RESULTS

Results showed a mean root coverage percentage of 89.6 +/- 15% for the E group and 94.7 +/- 11.4% for the CP group; the difference between groups was statistically insignificant (P = 0.1388). Mean KT increased significantly from 1.4 +/- 1.1 mm presurgery to 4.5 +/- 1.1 mm postsurgery for the E group while a minor increase in KT was observed in the CP group (2 +/- 1.5 mm presurgery versus 2.7 +/- 1.6 mm postsurgery). For both treatment groups, the mean postsurgical width of keratinized tissue (POSTKT) was found to be mathematically correlated with the mean presurgical width of keratinized tissue (PREKT) and the corono-apical height of the graft that remained exposed (GE) coronal to the flap margin in the recipient site.

CONCLUSIONS

Treatment of human gingival recession defects by the 2 variants of SCTG resulted in significant recession reduction. When SCTG is grafted beneath alveolar mucosa using the combined technique (CP), transformation of the mucosa into keratinized tissue does not seem to occur, at least within 1 to 1.5 years postsurgery. The treatment outcome in terms of keratinized tissue width seems to be correlated with the presurgical gingival dimensions and the height of the graft that remains exposed at the end of the surgical procedure.

The use of a bioabsorbable barrier for regenerative management of marginal tissue recession. I. Report of 100 consecutively treated teeth

BACKGROUND

Periodontal plastic surgical procedures aimed at coverage of exposed root surfaces have evolved into routine treatment modalities. The present study was designed to assess the effectiveness and the predictability of a bioabsorbable barrier in the treatment of human recession defects utilizing a single-step surgical procedure.

METHODS

One hundred consecutive single and multiple adjacent Miller Class I, II, and III buccal recession defects in 41 patients were treated with a combination of a bioabsorbable barrier and coronally advanced flap technique. Clinical parameters were recorded immediately prior to surgery, at 3 months, and after a minimum of 6 months.

RESULTS

A highly significant reduction in recession depth from a mean value of 3.2 +/- 0.9 mm preoperatively to 0.3 +/- 0.5 mm postoperatively, corresponding to a mean root coverage of 92. 7% +/- 14.1%, was obtained. Complete (100%) root coverage was obtained in 75% of the sites. Factors adversely affecting root coverage were membrane exposure postoperatively and preoperative recession depth > or =4 mm. In addition, inferior results were achieved at mandibular incisor and maxillary molar sites. Factors having no effect on root coverage included maxillary versus mandibular sites and single versus multiple adjacent sites.

CONCLUSIONS

The use of guided tissue regeneration in periodontal plastic surgery is highly predictable, and highly esthetic root coverage can be gained without requiring a second surgical procedure or a second surgical site and is, therefore, an attractive alternative to conventional grafting techniques.