EMD or subepithelial connective tissue graft for the treatment of single gingival recessions: a pilot study

From Basic Science to Clinical Practice: A Review of Current Periodontal/Mucogingival Regenerative Biomaterials

Periodontitis is a dysbiosis-driven inflammatory disease affecting the tooth-supporting tissues, characterized by their progressive resorption, which can ultimately lead to tooth loss. A step-wise therapeutic approach is employed for periodontitis. After an initial behavioral and non-surgical phase, intra-bony or furcation defects may be amenable to regenerative procedures. This review discusses the regenerative technologies employed for periodontal regeneration, highlighting the current limitations and future research areas. The search, performed on the MEDLINE database, has identified the available biomaterials, including biologicals (autologous platelet concentrates, hydrogels), bone grafts (pure or putty), and membranes. Biologicals and bone grafts have been critically analyzed in terms of composition, mechanism of action, and clinical applications. Although a certain degree of periodontal regeneration is predictable in intra-bony and class II furcation defects, complete defect closure is hardly achieved. Moreover, treating class III furcation defects remains challenging. The key properties required for functional regeneration are discussed, and none of the commercially available biomaterials possess all the ideal characteristics. Therefore, research is needed to promote the advancement of more effective and targeted regenerative therapies for periodontitis. Lastly, improving the design and reporting of clinical studies is suggested by strictly adhering to the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement.

Comparison of Root Coverage by the Subepithelial Connective Tissue Graft With and Without Root Biomodification: A Comprehensive Clinical Study

BACKGROUND

Being an autologous graft, a subepithelial connective tissue (SECT) graft shows more predictable root coverage better than other techniques. Hence, it is most likely to be widely used for recession treatment. During root planing, a smear layer forms on the root surface that cannot be removed by water or saline rinsing. To remove this smear layer, root biomodification agents are widely used. The present study was conducted to assess the efficacy of an SECT graft for root coverage with and without root biomodification.

METHODS

This study included 20 patients with no gender predilection, with an age range of 24-36 years and a mean age of 27.6 ± 4.24 years. The chosen range facilitated the acquisition of data in a relatively homogeneous population, minimizing the confounding effects of factors such as aging-related tissue changes or early-onset periodontal issues. All 40 sites were treated with the SECT and coronally advanced flap. Root conditioning in controls was done with distilled saline and tested using 24% ethylenediaminetetraacetic acid (EDTA) gel (Maquira; STM Meditech, Kerala). At baseline and at one, three, and six months postoperatively, pocket depth (PD) and clinical attachment levels (CALs) were assessed at four sites using a UNC-15 probe, and from the gingival margin to the cementoenamel junction (CEJ), the vertical recession was assessed.

RESULTS

For the buccal surface, CALs were reduced significantly (p < 0.001). Following root conditioning with 24% EDTA, no difference was seen in the CAL in the control and test group either buccally or interproximally with a p-value of greater than 0.05. For PD, following a SECT graft or root conditioning, no significant change was observed in the buccal or interproximal region (p > 0.05). The vertical recession was significantly reduced with a p-value of less than 0.001 and depth coverage of 97.5%. The difference between the two groups was statistically non-significant (p > 0.05). The root surface coverage decreased significantly from 16.6 ± 2.8 to 0.45 ± 0.4 from baseline to six months, which was statistically significant (p < 0.001). This intergroup difference was non-statistical (p > 0.05).

CONCLUSION

The present study concludes that the use of an SECT graft in root coverage can significantly improve the CAL, root surface area, and vertical recession both with and without root biomodification. We conclude that there is a significant decrease in the probing depth following SECT grafting and with root biomodification.

Efficacy of biologics in root coverage and gingival augmentation therapy: An American Academy of Periodontology best evidence systematic review and network meta-analysis

BACKGROUND

The aim of this systematic review was to assess the efficacy of three biologics, namely autologous blood-derived products (ABPs), enamel matrix derivatives (EMD) and recombinant human platelet-derived growth factor BB (rhPDGF-BB), in root coverage and gingival augmentation therapy.

METHODS

The protocol of this PRISMA 2020-compliant systematic review was registered in PROSPERO (CRD42021285917). After study selection, data of interest were extracted. A network meta-analysis (NMA) was conducted to assess the effect of different surgical interventions on the main clinical outcomes of interest (i.e., mean root coverage [MRC%], complete root coverage [CRC%], keratinized tissue width [KTW], gingival thickness [GT] change, and recession depth [RD] reduction).

RESULTS

A total of 48 trials reported in 55 articles were selected. All studies reported on the treatment of gingival recession defects for root coverage purposes. Forty-six treatment arms from 24 trials were included in the NMA. These arms consisted of treatment with coronally advanced flap (CAF) alone, EMD + CAF, platelet-rich fibrin (PRF) + CAF, and subepithelial connective tissue graft (SCTG) + CAF. Regarding MRC%, SCTG+CAF was associated with a significant higher estimate (13.41%, 95% CI [8.06-18.75], P <  0.01), while EMD+CAF (6.68%, 95% CI [-0.03 to 13.4], P = 0.061) and PRF+CAF (1.03%, 95% CI [-5.65 to 7.72], P = 0.71) failed to show statistically significant differences compared with CAF alone (control group) or with each other. Similarly, only SCTG+CAF led to a significantly higher CRC% (14.41%, 95% CI [4.21 to 24.61], P < 0.01), while treatment arms EMD + CAF (13.48%, 95% CI [-3.34 to 30.32], P = 0.11) and PRF+CAF (-0.91%, 95% CI [-15.38, 13.57], p = 0.81) did not show significant differences compared with CAF alone or with each other. Differences in the CI of PRF+CAF (symmetrical around a zero adjunctive effect) and EMD+CAF (non-symmetrical) suggest that EMD could have some additional value compared with PRF. Treatment with SCTG+CAF led to a statistically significant higher RD reduction (-0.39 mm, 95% CI [-0.55 to 0.22], P < 0.01), however EMD+CAF (-0.13 mm, 95% CI [-0.29 to 0.01], P = 0.08) and PRF+CAF (-0.06 mm, 95% CI [-0.23 to 0.09], P = 0.39) failed to show significant differences compared with CAF or with each other. While SCTG+CAF was associated with a statistically significant higher gain of KTW (0.71 mm, 95% CI [0.48 to 0.93], P < 0.01), EMD+CAF (0.24 mm, 95% CI [-0.02 to 0.51], P = 0.08) and PRF+CAF (0.08 mm, 95% CI [-0.23 to 0.41], P = 0.58) did not result into significant changes compared with CAF alone or with each other. Regarding the use of rhPDGF-BB+CAF, although available studies have reported equivalent results compared with SCTG+CAF, evidence is very limited.

CONCLUSIONS

The use of ABPs, EMD, or rhPDGF-BB in conjunction with a CAF for root coverage purposes is safe and generally promotes significant improvements respective to baseline clinical parameters. However, the adjunctive use of ABPs and EMD does not provide substantial additional improvements in terms of clinical outcomes and patient-reported outcome measures to those achieved using CAF alone, when baseline KTW is >2 mm. Both PRF+CAF and EMD+CAF rendered inferior MRC%, CRC%, RD reduction, and KTW gain compared with SCTG+CAF, which should still be considered the gold-standard in root coverage therapy. Although some studies have reported equivalent results for rhPDGF-BB+CAF compared with the gold-standard intervention, limited evidence precludes formal comparisons with CAF or SCTG+CAF that could be extrapolated to guide clinical practice.

Does the subepithelial connective tissue graft in conjunction with a coronally advanced flap remain as the gold standard therapy for the treatment of single gingival recession defects? A systematic review and network meta-analysis

BACKGROUND

The aim of this systematic review and network meta-analysis was to assess the efficacy of a bilaminar root coverage technique consisting of the combination of an autogenous subepithelial connective tissue graft (SCTG) and a coronally advanced flap (CAF) compared to the five most indicated alternative approaches for the treatment of single gingival recession defects (GRD).

METHODS

The protocol of this PRISMA 2020-compliant systematic review was registered in PROSPERO (CRD42020221362). Three electronic databases were searched up to September 30^th , 2021 to identify randomized controlled trials that involved the treatment of single GRD without interproximal tissue loss via root coverage procedures. A frequentist network meta-analysis was conducted for complete root coverage (CRC), mean root coverage (MRC) and keratinized tissue width (KTW) changes.

RESULTS

A total of 38 studies reporting on 830 patients and 1,265 GRD were included. SCTG+CAF was ranked as the most efficient treatment approach for MRC, CRC and KTW gain at 6 and 12 months after surgery, except for MRC at the 12-month follow-up where enamel matrix derivative (EMD) plus CAF exhibited superior results.

CONCLUSIONS

SCTG+CAF can be considered the gold standard for the treatment of single GRD. This article is protected by copyright. All rights reserved.

Stability of biomaterials used in adjunct to coronally advanced flap: A systematic review and network meta-analysis

AIM

The objective of this network meta-analysis was to rank different biomaterials used in adjunct to coronally advanced flap (CAF), based on their performance in root-coverage for Miller's Class I and II gingival recessions.

MATERIALS AND METHODS

An electronic database search was carried out in PUBMED, CENTRAL, SCOPUS, and EMBASE to identify the eligible articles and compiled into the citation manager to remove the duplicates. The primary outcome was keratinized gingival tissue width (KGW) and percentage of root coverage (%RC). The treatment effect of different biomaterials was estimated using predictive interval plots and ranked based on biomaterials performance, using multidimensional scale ranking.

RESULTS

CAF + connective tissue graft (CTG), CAF + platelet concentrate matrix (PCM) and acellular dermal matrix (ADM) ranked at the top positions in performance in improving KGW. The highest ranked materials in improving percentage of root coverage in gingival recession were CAF + collagen matrix (CM) + gingival fibroblasts (GF), CAF + ADM + platelet rich plasma (PRP) and CAF + ADM, as compared to CAF alone.

CONCLUSION

CTG, ADM, platelet concentrates, and CM + GFs, when used in adjunct to CAF, showed improved stability over ≥12 months of follow-up, better percentage of root coverage, and improved keratinized gingival width.

Root coverage procedures for treating localised and multiple recession-type defects

BACKGROUND

Gingival recession is defined as the oral exposure of the root surface due to a displacement of the gingival margin apical to the cemento-enamel junction and it is regularly linked to the deterioration of dental aesthetics. Successful treatment of recession-type defects is based on the use of predictable root coverage periodontal plastic surgery (RCPPS) procedures. This review is an update of the original version that was published in 2009.

OBJECTIVES

To evaluate the efficacy of different root coverage procedures in the treatment of single and multiple recession-type defects.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 12) in the Cochrane Library (searched 15 January 2018), MEDLINE Ovid (1946 to 15 January 2018), and Embase Ovid (1980 to 15 January 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 January 2018). No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) only of at least 6 months' duration evaluating recession areas (Miller's Class I or II ≥ 3 mm) and treated by means of RCPPS procedures.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, data extraction and risk of bias assessment were conducted independently and in duplicate. Authors were contacted for any missing information. We expressed results as random-effects models using mean differences (MD) for continuous outcomes and odds ratios (OR) for dichotomous outcomes with 95% confidence intervals (CI). We used GRADE methods to assess the quality of the body of evidence of our main comparisons.

MAIN RESULTS

We included 48 RCTs in the review. Of these, we assessed one as at low risk of bias, 12 as at high risk of bias and 35 as at unclear risk of bias. The results indicated a greater reduction in gingival recession for subepithelial connective tissue grafts (SCTG) + coronally advanced flap (CAF) compared to guided tissue regeneration with resorbable membranes (GTR rm) + CAF (MD -0.37 mm; 95% CI -0.60 to -0.13, P = 0.002; 3 studies; 98 participants; low-quality evidence). There was insufficient evidence of a difference in gingival recession reduction between acellular dermal matrix grafts (ADMG) + CAF and SCTG + CAF or between enamel matrix protein (EMP) + CAF and SCTG + CAF. Regarding clinical attachment level changes, GTR rm + CAF promoted additional gains compared to SCTG + CAF (MD 0.35; 95% CI 0.06 to 0.63, P = 0.02; 3 studies; 98 participants; low-quality evidence) but there was insufficient evidence of a difference between ADMG + CAF and SCTG + CAF or between EMP + CAF and SCTG + CAF. Greater gains in the keratinized tissue were found for SCTG + CAF when compared to EMP + CAF (MD -1.06 mm; 95% CI -1.36 to -0.76, P < 0.00001; 2 studies; 62 participants; low-quality evidence), and SCTG + CAF when compared to GTR rm + CAF (MD -1.77 mm; 95% CI -2.66 to -0.89, P < 0.0001; 3 studies; 98 participants; very low-quality evidence). There was insufficient evidence of a difference in keratinized tissue gain between ADMG + CAF and SCTG + CAF. Few data exist on aesthetic condition change related to patients' opinion and patients' preference for a specific procedure.

AUTHORS' CONCLUSIONS

Subepithelial connective tissue grafts, coronally advanced flap alone or associated with other biomaterial and guided tissue regeneration may be used as root coverage procedures for treating localised or multiple recession-type defects. The available evidence base indicates that in cases where both root coverage and gain in the width of keratinized tissue are expected, the use of subepithelial connective tissue grafts shows a slight improvement in outcome. There is also some weak evidence suggesting that acellular dermal matrix grafts appear as the soft tissue substitute that may provide the most similar outcomes to those achieved by subepithelial connective tissue grafts. RCTs are necessary to identify possible factors associated with the prognosis of each RCPPS procedure. The potential impact of bias on these outcomes is unclear.

Xenogenous Collagen Matrix and/or Enamel Matrix Derivative for Treatment of Localized Gingival Recessions: A Randomized Clinical Trial. Part I: Clinical Outcomes

BACKGROUND

Considering xenogeneic collagen matrix (CM) and enamel matrix derivative (EMD) characteristics, it is suggested that their combination could promote superior clinical outcomes in root coverage procedures. Thus, the aim of this parallel, double-masked, dual-center, randomized clinical trial is to evaluate clinical outcomes after treatment of localized gingival recession (GR) by a coronally advanced flap (CAF) combined with CM and/or EMD.

METHODS

Sixty-eight patients presenting one Miller Class I or II GRs were randomly assigned to receive either CAF (n = 17); CAF + CM (n = 17); CAF + EMD (n = 17), or CAF + CM + EMD (n = 17). Recession height, probing depth, clinical attachment level, and keratinized tissue width and thickness were measured at baseline and 90 days and 6 months after surgery.

RESULTS

The obtained root coverage was 68.04% ± 24.11% for CAF; 87.20% ± 15.01% for CAF + CM; 88.77% ± 20.66% for CAF + EMD; and 91.59% ± 11.08% for CAF + CM + EMD after 6 months. Groups that received biomaterials showed greater values (P <0.05). Complete root coverage (CRC) for CAF + EMD was 70.59%, significantly superior to CAF alone (23.53%); CAF + CM (52.94%), and CAF + CM + EMD (51.47%) (P <0.05). Keratinized tissue thickness gain was significant only in CM-treated groups (P <0.05).

CONCLUSIONS

The three approaches are superior to CAF alone for root coverage. EMD provides highest levels of CRC; however, the addition of CM increases gingival thickness. The combination approach does not seem justified.

Does Adjunctive Use of Growth Factors Improve Clinical Outcomes of Soft Tissue Grafting at Miller Class III Recession Defects? A Review of Current Evidence

Focused Clinical Question In patients with gingival recession that is classified as Miller Class III, does adjunctive use of local growth factors with gingival grafting procedures improve clinical outcomes? Clinical Scenario A 31-year-old female presents with a chief complaint of gingival recession (GR) at teeth #4 to #13 (Fig. 1). Interproximal bone loss coronal to the level of the buccal GR is present. She is concerned about esthetics and would like to maximize her chance for complete root coverage. Her medical history is non-contributory, and she has no contraindications to routine dental care. Because of the number of teeth involved and the difficulty in harvesting autogenous tissues, she is treated with acellular dermal matrix^§ and enamel matrix derivative^‖ with a coronally advanced flap at teeth #4 to #13 (Figs. 2 and 3). Final results reveal significant root coverage on all teeth and complete root coverage on teeth #7 to #10. This results in an esthetically acceptable result (Fig. 4).

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.

Coverage of Miller class I and II gingival recessions treated with subepithelial connective tissue graft, acellular dermal matrix, and enamel matrix proteins. Pilot study

Abstract Objective The aim of this study was to compare clinical findings obtained in the treatment of gingival recessions using subepithelial connective tissue graft (SECT), acellular dermal matrix (ADM), and enamel matrix proteins (EMP). Material and method Twelve patients with Miller class I and II recession in the canines or upper premolars were randomly divided into groups to receive treatments using SECT, ADM, or EMP. Clinical measurements were performed before and three months after surgical procedures. The data evaluated were as follows: percentage of root coverage, height and width of gingival recession, probe depth, clinical attachment level, and height and thickness of keratinized gingiva. The Kruskal-Wallis test complemented by Dunn’s test was used to perform the between-group, analysis and the Wilcoxon test was used to perform the within-groups analysis. The tests were applied at the 95% confidence level. Result The SECT and ADM groups had a higher percentage of root coverage and greater reduction in the height and width of gingival recessions compared to the EMP group (p<0.05). Conclusion The SECT and ADM are more effective in treating gingival recessions than EMP.

The Interplay of Orthodontics, Periodontics, and Restorative Dentistry to Achieve Aesthetic and Functional Success

Previously dentists focused on repair and maintenance of function. However, the emphasis of many patients and dentists is now on esthetics. Often there is a need for the disciplines of orthodontics, periodontics, restorative dentistry, and maxillofacial surgery to work together in order to achieve optimum results. Currently the sequencing planning process begins with esthetics and then function, structure, and ultimately biology.

Dimensional changes during early healing after a subepithelial connective tissue graft procedure

BACKGROUND

The subepithelial connective tissue graft (CTG) is a popular means to treat gingival recession and augment keratinized tissue. Studies exist that examine long-term outcomes of this procedure; however, changes in tissue dimensions during early healing (0 to 21 days postoperatively) are unknown. The aim of this study is to examine bucco-lingual tissue dimension (gingival tissue thickness [GT]) changes during early CTG healing using a non-invasive technique.

METHODS

Thirteen patients who had treatment planned for CTG on a single tooth were recruited for the study. Using a customized acrylic stent, GT was measured preoperatively, at surgery completion, and at 3, 7, 14, and 21 days postoperatively. CTG was performed using an envelope technique. GT changes were analyzed by repeated-measures analysis of variance.

RESULTS

All CTG procedures were considered successful with no postoperative complications. GT increased 1.5 mm immediately after surgery (baseline) compared to the preoperative measurement. GT increased on average 96%, 47%, and 2% compared to baseline at days 3, 7, and 14, respectively. Day 3 and day 7 measurements were significantly different from baseline (P <0.001). At day 21, GT decreased 15% compared to baseline, with an average increase of 1.29 mm from preoperative measurements.

CONCLUSIONS

The early postoperative healing of CTGs used for root coverage exhibits a significant but transient increase in bucco-lingual tissue dimension. The observed increase in bucco-lingual tissue dimension subsides by the end of the second postoperative week.