Predictor factors for long-term outcomes stability of coronally advanced flap with or without connective tissue graft in the treatment of single maxillary gingival recessions: 9 years results of a randomized controlled clinical trial

Effect of Coenzyme Q10 on early wound healing after recession coverage surgery with the modified coronally advanced tunnel technique and a connective tissue graft: A 6-month, triple-blinded, randomized, placebo-controlled pilot trial

OBJECTIVES

Coenzyme Q10 (CoQ10) or ubiquinone is one of a cell's most important electron carriers during oxidative phosphorylation and many other cellular processes. As a strong anti-oxidant with further anti-inflammatory effects CoQ10 is of potential therapeutical value. The aim of this randomized controlled clinical trial was to investigate the effect of topical CoQ10 on early wound healing after recession coverage surgery using the modified coronally advanced tunnel (MCAT) and palatal connective tissue graft (CTG).

MATERIALS AND METHODS

Thirty patients with buccal gingival recessions were evaluated after being randomly allocated to: 1) MCAT and CTG with topical application of a coenzyme Q10 spray for 21 days or 2) MCAT and CTG with placebo spray. Wound healing was evaluated by the early wound healing index (EHI). Patient-reported pain was analyzed by a 100-mm visual analogue scale (VAS) at day 2, 7, 14 and 21 post-surgically. Mean recession coverage, gain of keratinized tissue and esthetic outcomes were assessed at 6 months.

RESULTS

EHI and pain scores showed no significant differences. Time to recovery defined as VAS<10 mm was shorter in the test group. Mean root coverage after 6 months was 84.62 ± 26.57% and 72.19 ± 26.30% for test and placebo, p=0.052. Complete root coverage was obtained in 9 (60%) test and in 2 (13.3%) placebo patients. Increase in keratinized tissue width and esthetical outcomes were similar for both groups.

CONCLUSION

CoQ10 had no significant effect on early wound healing and on mean root coverage after 6 months.

CLINICAL RELEVANCE

Early wound healing: in young healthy patients with no inflammatory oral conditions topical CoQ10 does not improve early healing.

Treatment of Multiple RT1 Gingival Recessions Using a Coronally Advanced Flap Associated with L-PRF or Subgingival Connective Tissue Graft from Maxillary Tuberosity: A Randomized, Controlled Clinical Trial

The goal of plastic periodontal surgery is to obtain complete root coverage, increasing gingival thickness (GT), a positive prognostic factor for gingival margin stability over time. The aim of this study was to compare the effectiveness of the Coronally Advanced Flap (CAF) in RT1 (GR; gingival recession with no loss of interproximal attachment) when associated with a connective tissue graft from the maxillary tuberosity (tCTG) or with leukocyte and platelet-rich fibrin (L-PRF) membranes in obtaining root coverage and increasing the thickness and width of the keratinized tissue, along with aesthetic improvement, taking into account a number of patient-related outcomes. Thirty patients with two adjacent RT1 GRs (GRs with no loss of interproximal attachment) were each treated using CAF associated with tCTG (15 patients) or L-PRF. The main outcome was a GT increase; secondary outcomes were keratinized tissue width (KT), gingival recession (GR), probing depth (PD), clinical attachment level (CAL), root coverage percentage (RC%), complete root coverage (CRC), and root coverage esthetic score (RES). Patient-reported outcomes were discomfort (D), dentine hypersensitivity (DH), patient-related esthetic score (PRES), and overall treatment satisfaction (OTS). After 12 months, clinical and patient-reported parameters did not show significant differences between groups, with the only exception being a GT gain, which was significantly greater in the CAF + tCTG group. Our results showed that both techniques were effective in treating RT1 GRs, with comparable patient-related outcomes. However, the use of tCTG produces significantly thicker tissue, covering the exposed root surface.

Long-term stability of gingival margin and periodontal soft-tissue phenotype achieved after mucogingival therapy: A systematic review

BACKGROUND

The aim of this systematic review was two-fold: (i) to evaluate the long-term (≥5 years) stability of the gingival margin position, keratinized tissue width (KTW) and gingival thickness (GT) in sites that underwent root coverage (RC) or gingival augmentation (GA); and (ii) to assess the influence of different local variables on the long-term stability of dental and gingival tissues.

MATERIALS AND METHODS

Randomized controlled trials (RCTs) and non-RCTs reporting short-term (i.e., 6-12 months after baseline surgical intervention) and long-term (≥5 years) follow-up data after surgical treatment of adult patients presenting single or multiple mucogingival deformities, defined as sites presenting gingival recession defects (GRDs) and/or (KTW) deficiency (i.e., <2 mm), were considered eligible for inclusion. MEDLINE-PubMed, EMBASE and Cochrane Central Register of Controlled Trials databases were searched for articles published up to 15 May 2023. Mixed-effects multiple linear regression was used to assess the association between KTW, type of surgical procedure and time (i.e., independent variables) on the stability of the gingival margin in sites that received RC or GA therapy.

RESULTS

Of the 2569 potentially eligible records, 41 (reporting 40 studies) met the eligibility criteria. Graphical estimates including data from all RC procedures found an upward trend in recession depth (RD) increase over time. Conversely, it was observed that in 63.63% of RC studies and in 59.32% of RC treatment arms KTW increased over time, particularly in sites treated with subepithelial connective tissue grafts (SCTGs). Conversely, sites that underwent GA procedures generally exhibited an overall reduction of KTW over time. However, sites treated with free gingival grafts (FGGs) showed a decrease in RD after 10 years of follow-up. Three main findings derived from the pooled estimates were identified: (i) Gingival margin stability was associated with the amount of KTW present during short-term assessment (i.e. the greater the KTW at 6-12 months after treatment, the more stable the gingival margin). (ii) The use of autogenous soft-tissue grafts was associated with lower RD increase over time. (iii) Treatment approaches that contribute to the three-dimensional enhancement of the gingival phenotype, as clearly demonstrated by FGG, were associated with gingival margin stability.

CONCLUSIONS

The extent of apical migration of the gingival margin appears to be directly related to the amount of KTW and GT upon tissue maturation. Interventions involving the use of autogenous grafts, either SCTG or FGG, are associated with greater short-term KTW gain and lower RD increase over time.

Coverage stability of peri-implant soft tissue dehiscence: A systematic review and meta-analysis

OBJECTIVE

The occurrence of peri-implant soft tissue dehiscence, especially in the esthetic zone, can be challenging. This study sought to investigate how the passage of time affects the outcomes of treatment for peri-implant soft tissue dehiscence coverage.

MATERIALS AND METHODS

A literature search was performed up to April 2023 via PubMed, Scopus, and Web of Science to retrieve studies reporting the data on peri-implant soft tissue dehiscence of at least 2-time points (baseline and follow-up). Clinical trials with a minimum of 5 participants, reporting at least 1 primary outcome, and with a minimum follow-up of 3 months were included. The primary outcomes were the changes in dehiscence depth, complete coverage, and mean coverage at different time points.

RESULTS

Seven studies with 112 participants and 119 implants were included. Dehiscence depth increased insignificantly between 3 to 6 months. Although the dehiscence depth increased from 6 to 12 months in the tunnel group, it decreased in the coronally advanced group, and a slight decrease was observed from 12 to 72 months. Soft tissue thickness was the predictor for soft tissue margin stability. However, no significant relationship was found between the baseline dehiscence depth and complete coverage.

CONCLUSIONS

Within the limitations of this study, it seems prudent to wait at least 6 months to achieve a stable soft tissue margin.

CLINICAL SIGNIFICANCE

The occurrence of peri-implant soft tissue dehiscence, especially in the esthetic zone, can be a challenging complication. It is important not only to achieve coverage but also to ensure that the treatment results remain stable in the long term, in order to satisfy both patients and clinicians. A reasonable approach would be to wait for at least 6 months to achieve a stable soft tissue margin.

Long-term stability (21-30 years) of root coverage outcomes using sub-epithelial connective tissue grafts at single or multiple gingival recessions: A longitudinal case series

AIM

To evaluate outcomes and predictive factors for the long-term stability of root coverage using a sub-epithelial connective tissue graft.

MATERIALS AND METHODS

One-hundred and two healthy subjects (221 gingival recessions, GRs) were treated from 1987 to 1996. Keratinized tissue width (KTW), GR depth (RD), GR width (RW) and GR area (RA) were evaluated at baseline (M0) and at 1 month (M1), 1 year (M2), 11 years (M3), 21 years (M4) and 27 years (M5) after surgery. Primary outcomes consisted of complete root coverage (cRC) and relative dimensional changes in recession depth (measured in mm [c%-RD]), recession width (measured in mm [c%-RW]) and recession area (measured in mm2 [c%-RA]).

RESULTS

cRC was 88.7% at 1 year (M2), 59.8% at M3, 44.4% at M4 and 51.9% at M5. Average c%-RD was 95.2% at 1 year, 81.9% at M3, 71.5% at M4 and 81.7% at M5. KTW increased after surgery and over time and was positively correlated with favourable outcomes. Increased baseline RA was associated with less favourable clinical outcomes.

CONCLUSIONS

The sub-epithelial connective tissue graft is effective in the treatment of GRs and facilitates long-term stability of clinical outcomes. Wider baseline RA was a strong predictor of unfavourable short- and long-term RC outcomes.

Challenges and success in periodontal plastic surgery

To truly understand a field of study, one must delve into its past and examine the challenges and successes that have shaped its current practices. In the case of periodontal plastic surgery, recognizing how challenges induced changes over the last 70 years-from the 1950s to today-is essential to fully comprehend its evolution. This editorial provides a perspective on the field, highlighting the interrelationships between influential surgical techniques and advancements in research methodology. With each event building upon the last, the evolution of periodontal plastic surgery is a story of scientific progress and ongoing research, fostering a sense of community and shared knowledge.

Living cellular constructs for keratinized tissue augmentation: A 13-year follow-up from a split-mouth randomized, controlled, clinical trial

BACKGROUND

A 13-year follow-up was conducted of a short-term investigation of the use of living cellular construct (LCC) versus free gingival graft (FGG) for keratinized tissue width (KTW) augmentation in natural dentition, to evaluate the long-term outcomes and assess the changes occurring since the end of the original 6-month study.

METHODS

Twenty-four subjects out of the original 29 enrolled participants were available at the 13-year follow-up. The primary endpoint was the number of sites demonstrating stable clinical outcomes from 6 months to 13 years (defined as KTW gain, stability, or ≤0.5 mm of KTW loss, together with reduction, stability, or increase of probing depth, and recession depth [REC] ≤0.5 mm). Secondary outcomes included the assessment of KTW, attached gingiva width (AGW), REC, clinical attachment level, esthetics, and patient-reported outcomes at the 13-year visit, assessing the changes from baseline to 6 months.

RESULTS

Nine sites per group (42.9%) were found to have maintained stable (≤0.5 mm or improved) clinical outcomes from 6 months to 13 years. No significant differences were observed for the clinical parameters between LCC and FGG from 6 months to 13 years. However, the longitudinal mixed model analysis showed that FGG delivered significantly better clinical outcomes over 13 years (p < 0.01). LCC-treated sites exhibited superior esthetic outcomes compared to FGG-treated sites at 6 months and 13 years (p < 0.01). Patient-evaluated esthetics were significantly higher for LCC over FGG (p < 0.01). Patient overall treatment preference was also in favor of LCC (p < 0.01).

CONCLUSIONS

A similar stability of the treatment outcomes from 6 months to 13 years was found for LCC- and FGG-treated sites, with both approaches shown to be effective in augmenting KTW and AGW. However, superior clinical outcomes were found for FGG over 13 years, while LCC was associated with better esthetics and patient-reported outcomes than FGG.

Influence of immediate postoperative gingival thickness and gingival margin position on the outcomes of root coverage therapy: A 6 months prospective case series study using 3D digital measuring methods

BACKGROUND

To assess linear and volumetric changes following the treatment of gingival recessions (GRs) by means of a modified coronally advanced tunnel technique combined with acellular dermal matrix (MTUN + ADM).

MATERIALS AND METHODS

Patients presenting GR type 1 (RT1) GRs underwent root coverage surgery consisting of MTUN + ADM. Clinical measurements were made, and intraoral scans were obtained at baseline, postoperatively, and 6 weeks, 3 and 6 months after surgery, to evaluate changes in probing depth (PD), keratinized tissue width (KTW), recession depth (RD), recession area (RA), marginal gingival thickness (MGT), and mucosal volume (MV). The impact of patient-level and surgical-site variables upon percentage root coverage (% RC) and the likelihood of achieving complete root coverage (CRC) were explored.

RESULTS

A total of 20 patients (n = 47 teeth) were treated. After 6 months, RD and RA decreased, while KTW, MGT, and MV increased. The mean % RC was 93% at 6 months and CRC was found on 72.3% of the sites at 6 months. The postoperative MGT changes at 1.5 and 3 mm were significantly correlated to % RC and CRC at 6 months. Each additional mm of postoperative gain of gingival thickness resulted in a 4-fold increase in the probability of achieving CRC. Additionally, gingival margin positioned ≥0.5 mm coronal to the cementoenamel junction immediately after surgery was a strong predictor of CRC.

CONCLUSIONS

The MGT gain at 1.5 and 3 mm achieved in the immediate postoperative period is a significant predictor of CRC at 6 months when treating multiple GRs via MTUN + ADM.

CLINICAL SIGNIFICANCE

The Scientific rationale for the study relies on the lack of 3D digital measuring tools in the assessment of soft tissue healing dynamics after root coverage therapy. The principal findings of this study can be summarized as follows: tooth type, tooth position, and post-operative gingival margin position and gingival thickness and volume changes are predictors of CRC. Therefore, the practical implications are that the more thickness and more coronal advancement achieved immediately after root coverage surgery, the higher chance of achieving CRC.

Current state about root coverage using soft-tissue substitutes in the presence of noncarious cervical lesions: A literature review

About half of the cases of gingival recession are associated with the noncarious cervical lesion (NCCL), resulting in combined defects (CDs). NCCL negatively affects the root coverage outcomes. In addition, considering the morbidity associated with graft harvesting, soft-tissue substitutes (STSs) appeared as a suitable option for connective tissue grafts for surgical root coverage. Currently, the literature addressing the therapy of CDs employing STSs is scarce. Thus, the present review aimed to update the literature and outline the future perspectives about root coverage of CDs using STSs. A detailed literature search was conducted on MEDLINE, Web of Science, EMBASE, LILACS, Scopus, and Google Scholar databases using keywords and Boolean operators. Randomized clinical trials (2) and case reports (6) were included. None of the selected studies reported any adverse effect using STSs. Based on the limited evidence available, we cannot state that STSs may benefit the periodontal clinical and patient-centered outcomes. Randomized controlled trials are needed to assess the long-term outcomes, surgical approaches, and restorative protocols.

Long-term comparison of root coverage procedures at single RT2 maxillary gingival recessions: Ten-year extension results from a randomized, controlled clinical trial

AIM

The purpose of the present study was to assess root coverage outcomes 10 years after connective tissue graft plus coronally advanced flap (CTG + CAF) or CAF alone, at single RT2 maxillary gingival recession.

MATERIALS AND METHODS

Twenty-one of the original 29 patients (11 treated with CAF + CTG and 10 with CAF alone) were available for the 10-year follow-up. A blinded and calibrated examiner performed all the measurements. Outcome measures included complete root coverage (CRC), recession reduction (RecRed), root coverage aesthetic score (RES), and keratinized tissue (KT) gain. A visual analogue scale was used to evaluate patient satisfaction.

RESULTS

CRC was maintained in 63% of the test group and 20% of the control group after 10 years, with a significant difference favouring CAF + CTG (p = .030). Furthermore, the addition of CTG was associated with greater KT gain (p = .0002) and greater papilla tip recession (p = .023) than with CAF at the last follow-up. No difference was detected regarding RecRed, RES, and patient satisfaction.

CONCLUSIONS

Adding CTG under CAF improved the probability of maintaining complete root coverage 10 years after single maxillary RT2 recession treatment.

Gingival phenotype changes after different periodontal plastic surgical techniques: a single-masked randomized controlled clinical trial

ABSTRACT: OBJECTIVES: Aim of this clinical study was to evaluate the effects on gingival thickness of three surgical techniques for root coverage: the coronally advanced flap (CAF) alone, with a sub-epithelial connective tissue graft (SCTG) or with leukocyte- and platelet-rich fibrin (L-PRF) membranes.

METHODS

Sixty patients with RT1 single maxillary gingival recession were treated with CAF + L-PRF (20 patients), CAF + SCTG (20 patients) or CAF alone (20 patients). At baseline and 6-month after treatment, gingival thickness (GT), keratinized tissue width (KT), gingival recession (GR), clinical attachment level (CAL), probing depth (PD), PROMs, and the aesthetic outcome were recorded.

RESULTS

CAF + SCTG and CAF + L-PRF groups showed a significantly greater mean GT increase than CAF alone (0.31 ± 0.10 mm) with no significant differences between CAF + SCTG (0.99 ± 0.02 mm) and CAF + L-PRF (0.92 ± 0.52 mm) groups (p = 0.55). CAF + SCTG was associated with a significantly greater KT gain (3.85 ± 1.04 mm), while in CAF + L-PRF (2.03 ± 0.53 mm) and CAF (1.50 ± 0.69 mm) groups, KT was not significantly increased. Both GR and CAL showed a significant within groups' improvement, without among-groups differences. No significant among-groups difference for the aesthetic outcome but greater discomfort and pain-killer consumption in CAF + SCTG group was detected.

CONCLUSION

All investigated surgical techniques produced significant GR reduction and CAL gain. GT was similarly augmented by CAF + L-PRF and CAF + SCTG techniques; however, the CAF + SCTG technique produced a more predictable KT and GT increase.

CLINICAL RELEVANCE

The results of our study suggest that the CAF + SCTG technique represents the most predictable method for the clinician to improve the gingival phenotype, an important factor for long term gingival margin stability.

Minimal invasiveness in gingival augmentation and root coverage procedures

Minimally invasive surgical procedures aim at optimal wound healing, a reduction of postoperative morbidity and, thus, at increased patient satisfaction. The present article reviews the concept of minimal invasiveness in gingival augmentation and root coverage procedures, and critically discusses the influencing factors, technical and nontechnical ones, and relates them to the underlying biological mechanisms. Furthermore, the corresponding outcomes of the respective procedures are assessed and evaluated in relation to a possible impact of a minimized surgical invasiveness on the clinical, aesthetic, and patient-related results.

Recession coverage using the modified coronally advanced tunnel and connective tissue graft with or without enamel matrix derivative: 5-year results of a randomised clinical trial

OBJECTIVES

To evaluate the 5-year results of single and multiple recession type (RT) 1 and 2 (Miller I to III) recessions treated with the modified coronally advanced tunnel (MCAT) and connective tissue graft (CTG) with or without an enamel matrix derivative (EMD). The main outcome variable was the stability of obtained root coverage from 6 months to 5 years.

MATERIALS AND METHODS

In 24 patients, both complete and mean root coverage (CRC and MRC) and gain of keratinised tissue (KT) were assessed at 6 months and 5 years after recession coverage by means of MCAT and CTG with or without EMD. Aesthetic outcomes after 5 years were evaluated using the root coverage aesthetic score (RES).

RESULTS

At 5 years, 24 patients with a total of 43 recessions were evaluated. Eight patients (57.14%) of the test and 6 (60.0%) of the control group showed complete root coverage. MRC revealed no statistically significant differences between the two groups, with 73.87 ± 26.83% (test) and 75.04 ± 22.06% (control), respectively. KT increased from 1.14 ± 0.57 mm to 3.07 ± 2.27 mm in the test group and from 1.24 ± 0.92 mm to 3.02 ± 1.55 mm in the control group, respectively.

CONCLUSION

Treatment of single and multiple RT 1 and 2 recessions by means of MCAT and CTG with or without EMD yielded comparable clinical improvements which could be maintained over a period of 5 years. The additional use of EMD did not influence the clinical outcomes.

CLINICAL RELEVANCE

The use of MCAT + CTG yielded successful coverage of single and multiple RT 1 and 2 gingival recessions, while the additional application of EMD did not seem to influence the results.

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.

Soft tissue phenotype modification predicts gingival margin long-term (10-year) stability: Longitudinal analysis of six randomized clinical trials

Aim

To assess the prognostic value of soft tissue phenotype modification following root coverage procedures for predicting the long‐term (10‐year) behaviour of the gingival margin.

Materials and Methods

Participants from six randomized clinical trials on root coverage procedures at the University of Michigan were re‐invited for a longitudinal evaluation. Clinical measurements were obtained by two calibrated examiners. A data‐driven approach to model selection with Akaike information criterion (AIC) was carried out via multilevel regression analyses and partial regression plotting for changes in the level of the gingival margin over time and interactions with the early (6‐month) results of soft tissue phenotypic modification.

Results

One‐hundred and fifty‐seven treated sites in 83 patients were re‐assessed at the long‐term recall. AIC‐driven model selection and regression analyses demonstrated that 6‐month keratinized tissue width (KTW) and gingival thickness (GT) influenced the trajectory of the gingival margin similarly in a concave manner; however, GT was the driving determinant that predicted significantly less relapse in the treatments, with stability of the treated gingival margin obtained beyond values of 1.46 mm.

Conclusions

Among a compliant patient cohort, irrespective of the rendered therapy, the presence of at least 1.5 mm KTW and 1.46 mm GT was correlated with the long‐term stability of the gingival margin.

Effectiveness of surgical root coverage on dentin hypersensitivity: A systematic review and meta-analysis

AIM

To assess the effect of surgical root coverage (RC) on dentin hypersensitivity (DH) associated with gingival recession.

MATERIALS AND METHODS

Two independent reviewers conducted electronic literature searches in MEDLINE (PubMed), EMBASE, Cochrane Library, Web Of Science, Dentistry & Oral Sciences Source, ScienceDirect, and ClinicalTrials.gov databases as well as a manual search to identify eligible clinical studies from January 2000 to March 2022. Randomized controlled trials (RCTs) comparing two surgical RC techniques or a surgical RC technique with or without adjuvant were included. Meta-analyses were performed on data provided by RCTs.

RESULTS

Thirteen RCTs with a total of 701 patients (1086 recessions) were included. The percentage of DH suppression was 70.8% (95% confidence interval [CI] [64.4-76.6]; I²  = 39.2% [3.5-61.8], Q-test = 0.02) after surgical RC. Recession reduction and percentage of RC were both statistically significantly associated with DH suppression (estimate = 0.66 [0.10-1.23], p = .022, R²  = 14.45% and estimate = 0.04 [0.01-0.08], p = .012, R²  = 29.54%, respectively). Coronally advanced flap (CAF) + connective tissue graft showed results statistically more effective than CAF + xenogeneic collagen matrix in DH suppression (73.3% [65.6-79.8] and 61.4% [51.7-70.3], respectively; p = .048).

CONCLUSIONS

Success of surgical RC is associated with DH suppression.

Effectiveness of acellular dermal matrix graft with a coronally advanced flap for the treatment of Miller Class I/II single gingival recession with thin gingival phenotype: study protocol for a split-mouth randomised controlled trial

INTRODUCTION

Gingival recession is one of the most common mucogingival deformities requiring surgical correction. The American Academy of Periodontology Regeneration Workshop recommended connective tissue graft (CTG) combined with coronally advanced flap (CAF) for the treatment of Miller Class I and II single-tooth gingival recession. The disadvantages of harvesting autogenous tissue include postoperative bleeding, pain and discomfort at the donor site, restricted tissue supply, increased morbidity and prolonged operative times. Acellular dermal matrix (ADM) contains undamaged collagen and elastin matrices that can be used as a substitute for CTG during root coverage procedures. However, the use of ADM is still controversial. The objective of this split-mouth; randomised, controlled, clinical study is to evaluate the long-term effects of ADM graft (ADMG) combined with CAF on root coverage, aesthetics and patient satisfaction for the treatment of single gingival recession with thin gingival phenotype.

METHODS AND ANALYSIS

Forty participants with bilateral Miller Class I/II gingival recession will be randomised to receive an ADMG on one side and CTG on the contralateral side, combined with CAF. Gingival recession depth, gingival recession width and keratinised tissue width will be measured at baseline, 2 weeks and 1, 3, 6, 12 and 24 months. Mean root coverage, complete root coverage, root coverage aesthetic score, colour change (∆E) and patient satisfaction will be assessed during follow-up visits.

ETHICS AND DISSEMINATION

The present study has received approval from the Ethics Committee of Peking University School and Hospital of Stomatology (PKUSSIRB-202054029). Data of this study will be registered with the International Clinical Trials Registry Platform. Additionally, we will disseminate the results through scientific journal.

TRIAL REGISTRATION NUMBER

ChiCTR2000033230.

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.

Effects of autologous concentrated growth factor on gingival thickness in periodontal accelerated osteogenic orthodontics: a 6-month randomized controlled trial

Background

Earlier studies have not given clear results of concentrated growth factor (CGF) on gingival thickness (GT) in periodontal accelerated osteogenic orthodontics (PAOO). This randomized controlled trial aimed to evaluate the effects of CGF on GT in patients with thin gingival phenotype undergoing PAOO.

Methods

Forty four patients presenting 264 anterior mandibular teeth were recruited and randomly allocated to one of the groups: test—positioning of autologous CGF after PAOO or control—positioning of a collagen membrane after PAOO. GT, gingival height (GH), buccal alveolar bone thickness (BT), and buccal alveolar bone height (BH) were evaluated depending on cross-sectional CBCT images at t0 (before surgery) and t1(6 months after surgery).

Results

GT were increased in both groups at t1 compared to t0. Yet, higher values were observed in the test group (from 0.94 ± 0.23 to 1.31 ± 0.33 mm) compared to the control group (from 0.94 ± 0.19 to 1.02 ± 0.16 mm) (p < 0.05). Moreover, in the intergroup comparison, GT at t1 in the test group was significantly higher compared to the control group (p < 0.01). Furthermore, the GT of central incisors, lateral incisors and canine teeth all showed significantly changes compared with baseline and the test group showed higher increase (p < 0.01). No statistically significant difference were found in GH, BT, BH and all clinical parameters between two groups at t1 (p > 0.05).

Conclusions

Within the limitation of this study, gingival thickness could be increased by using CGF in PAOO for the patients with thin gingival phenotype.

Trial registration The study was registered in Chinese Clinical Trial Registry (http://www.chictr.org.cn/index.aspx) under the number ChiCTRINR17013346, Registered 11 November 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01967-5.

Soft Tissue Regeneration at Natural Teeth

This article provides an overview of the best-documented surgical techniques for recession coverage and draws conclusions for the clinician. Use of a connective tissue graft with either coronally advanced flap (CAF) or tunnel is the most predictable technique for the treatment of single and multiple gingival recessions. Long-term results exist only for CAF with/without connective tissue graft providing evidence for long-term stability with only minor relapses. Soft tissue replacement materials and biologics may represent a valuable modality to additionally improve the clinical outcomes obtained with CAF alone or, in certain clinical situations, to serve as an alternative to autogenous tissue.

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.

Laterally closed tunnel technique with and without adjunctive photobiomodulation therapy for the management of isolated gingival recession-a randomized controlled assessor-blinded clinical trial

The objective of this prospective randomized controlled single-center clinical trial was to prove the efficacy of adjunctive photobiomodulation in improving selected outcomes following the use of laterally closed tunnel technique for the management of isolated gingival recession. Nineteen participants (with isolated gingival recession) each treated by laterally closed tunnel technique were randomized to either add on treatment with control (sham laser application) or test group (photobiomodulation with 660 nm diode, 3.5 J/cm² per point of application). The primary outcome variable was change in recession depth and secondary variables included recession width, width of keratinized gingiva, periodontal biotype, and VAS score for pain assessment and EHS index for early wound healing assessment. Analysis was performed using a linear mixed effects model. There were no significant differences in the gingival recession depth (p = 0.8324) and recession width (p-0.969) at 3-month follow-up. The VAS scores were significantly lower for the test (laterally closed tunnel technique + photobiomodulation) group as compared to control (laterally closed tunnel technique + sham laser) over time (p =  < 0.0001) as well as per site (p = 0.0006) The Early Wound Healing Index scores were significantly higher in the test (laterally closed tunnel technique + photobiomodulation) group as compared to control (laterally closed tunnel technique + sham laser) group (p < 0.0001). The adjunctive use of photobiomodulation did not show a better outcome concerning recession depth but appears to provide faster healing of the surgical wounds and better patient comfort. The result needs further evaluation in particular with respect to long-term effect and due to limitation in sample size. Clinical Trial Registry of India: CTRI/2019/11/022012.

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).

Comparison between a xenogeneic dermal matrix and connective tissue graft for the treatment of multiple adjacent gingival recessions: a randomized controlled clinical trial

AIM

To compare the outcomes of modified coronally advanced flap (mCAF) combined with either xenogeneic dermal matrix (XDM) or connective tissue graft (CTG) for the treatment of multiple adjacent gingival recessions (MAGRs).

MATERIALS AND METHODS

Forty-two patients, in whom 130 maxillary (MAGRs) of type (RT1) were found, were randomly allocated to the two groups. Clinical, esthetic, and patient-centered outcomes were evaluated at baseline, 6, and 12 months post-treatment.

RESULT

Group CAF+ CTG exhibited a higher mean root coverage value (mRC) (91.79%) (primary outcome variable) than group CAF+XDM (80.19%) without statistically significant difference at 12 months (p=0.06). The control group also had significantly higher percentage of teeth in which complete root coverage (CRC) and mean gain of gingival thickness (GT) were achieved, than the test group (p<0.05). With respect to patient-centered outcomes, patients of the test group reported having experienced significantly less pain than those of the control group until 7 days (p<0.05). Both surgical approaches were capable of significantly decreasing dentin hypersensitivity (p<0.05). No difference between groups was found in the esthetic score analysis (p>0.05). Mean surgical time was lower in the test group (p<0.05).

CONCLUSION

The two treatments showed similar mRC. However, CAF+CTG was superior to CAF+XDM in providing CRC and in gaining GT. CAF+XDM demonstrated advantages over CAF+CTG with regard to patient morbidity and surgical time.

CLINICAL RELEVANCE

Application of XDM provided a better patient experience and shortened the time to recovery after coronally advanced flaps for coverage of multiple adjacent recessions. However, CTG resulted in improved percentages of complete root coverage.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry (REBEC) number: RBR-974c9j.

Treatment of Miller I Mandibular Gingival Recessions Using PRF vs. Connective Graft

Gingival recession (GR) can cause aesthetic and functional problems. Using connective tissue graft (CTG) and coronally advanced flap (CAF) is considered the technique of choice for treating GR. Considering the morbidity resulting from taking CTG, different alternative biomaterials have been described, including plasma-rich fibrin (PRF) membrane. Studies in lower teeth are few because of the complexity of the factors that can influence obtaining less predictable outcomes. Objective. To compare between CAF + PRF and CAF + CTG in the treatment of lower teeth Miller I gingival recession. Methodology. Split-mouth included 26 isolated GR (13 in each side of the mouth). The left side was treated with CAF + PRF and the right side with CAF + CTG. Clinical variables, probing depth (PD), GR, keratinized tissue (KT), vestibular soft tissue thickness (VSTT), and teeth sensitivity (TS), were assessed at the baseline. GR, KT, VSTT, extraoral inflammation (EI), and patient discomfort (PaD) were assessed at 45 days. Results. Statistically greater VSTT at 45 days was obtained using CAF + CTG (p < 0.05). Less EI and PaD were obtained using CAF + PRF (p < 0.05). No change was observed in GR, KT, and TS values in the intergroup or intragroup comparisons. Conclusion. Even with the limitations of this study, using PRF and CTG in lower teeth demonstrated an improvement in terms of root coverage, although it was without a total percentage of coverage. Regarding the VSTT, better results were obtained using the CTG + CAF, suggesting eventually long-term stable clinical results. We suggest a combined technique for future investigations.

De-epithelialized gingival graft versus subepithelial connective tissue graft in the treatment of multiple adjacent gingival recessions using the tunnel technique: 1-year results of a randomized clinical trial

AIM

To compare the clinical efficacy and postoperative morbidity of de-epithelialized gingival graft (DGG) with subepithelial connective tissue graft (SCTG) on treatment of multiple adjacent gingival recessions (MAGRs) with tunnel technique (TUN) and to evaluate histological characteristics of the palatal grafts.

MATERIALS AND METHODS

Twenty-seven patients with MAGRs affecting at least 2 adjacent teeth were treated with either DGG + TUN or SCTG + TUN. Recession depth(RD) and width(RW), probing depth(PD), clinical attachment level(CAL), keratinized tissue height(KTH), gingival thickness(GT), and complete and mean root coverage(CRC, MRC) were evaluated at 6 and 12 months postoperatively. Multilevel analysis was performed to identify patient- and tooth/site-related predictors for the 12-month MRC outcomes. Postoperative patient morbidity and histological characteristics of palatal graft samples obtained during harvesting were investigated.

RESULTS

At the 12-month follow-up, MRC was 91.72% ± 16.59% and 84.72% ± 19.72% in DGG + TUN and SCTG + TUN groups (p = .001). Multilevel regression analysis identified RD, KTH and GT as variables associated with MRC. No significant difference between the groups was observed regarding postoperative patient morbidity parameters. Cellularity was found significantly higher in the SCTG samples compared to the DGG samples (p < .05).

CONCLUSIONS

Although DGG + TUN presented higher MRC and CRC compared to SCTG + TUN in the treatment of MAGRs, treatment method was not a significant predictive factor for the amount of MRC outcomes while RD, KTH and GT were significant predictive factors.

Root coverage stability: A systematic overview of controlled clinical trials with at least 5 years of follow-up

Objectives

To systematically assess the long‐term outcome (≥5 years) of root coverage procedures reported in controlled clinical trials.

Material and Methods

Literature search was performed according to the PRISMA guidelines with the following eligibility criteria: (a) English or German language; (b) controlled (CT) or randomised controlled clinical trials (RCT); (c) root coverage procedure with ≥5 years follow‐up; and (d) clinical treatment effect size and/or patient‐related outcome measures (PROMs) reported.

Results

Four CT and 14 RCT with a follow‐up of 5–20 years fulfilled the eligibility criteria; sample size per study ranged from 8 to 70 patients contributing with 18–149 sites. Coronally advanced flap (CAF) and CAF + connective tissue graft (CTG) were the prevalent treatments (i.e., in 24 and 38% of the groups, respectively), while other flap designs and adjuncts (i.e., enamel matrix derivative, bone graft, collagen membrane) were represented only once. For single Miller class I/II gingival recessions (GR), CAF + CTG appeared advantageous compared to other techniques, and provided low residual recession depths (i.e., ≤0.5 mm), and complete root coverage in ≥2/3 of the patients; similar tendency was observed for multiple GR. No data on Miller class III/IV GR is available. No meta‐analysis was feasible due to lack of similarity in the clinical and methodological characteristics across the trials and observed comparisons of interventions.

Conclusions

CAF + CTG appears to be the ‘gold standard’ technique for the treatment of single and multiple Miller class I/II GR also in regard to long‐term (i.e., ≥5 years of follow‐up) treatment outcomes. There is little information regarding the performance, on the long‐term, of other techniques and adjuncts.

Does enamel matrix derivative application provide additional clinical benefits in the treatment of maxillary Miller class I and II gingival recession? A systematic review and meta-analysis

OBJECTIVE

This review aimed to evaluate the effects of enamel matrix derivative (EMD) in association with coronally advanced flap (CAF) or CAF + connective tissue graft (CTG) when compared with CAF alone or CAF + CTG for the treatment of gingival recessions (GR) in maxillary teeth.

METHODS

Five databases and gray literature were searched up to April 2020, to find randomized clinical trials comparing the clinical effects of CAF + EMD versus CAF alone (first group) or CAF + CTG + EMD versus CAF + CTG (second group) in the treatment of Miller class I and II or Cairo type I gingival recessions (GR). Random effects model of mean differences was used to determine the GR reduction, gain in keratinized tissue width (KTW), and gain in clinical attachment level (CAL). The trial sequential analysis (TSA) was implemented to determine the optimal information size (OIS) and imprecision using the GRADE approach. Bayes factors were calculated as complementary statistical evidence of p value.

RESULTS

From 1349 titles identified, 9 trials representing 336 GR were included. The meta-analysis showed a statistically significant difference for GR reduction and CAL gain in favor CAF + EMD (p ≤ 0.05). The additional effect of EMD showed a statistically significant difference in GR reduction in favor CAF + CTG + EMD (p ≤ 0.05). The differences in KTW gain proved to be not statistically significant in both comparison groups. The OIS were not met among meta-analyses. Evidence certainty according the GRADE approach proved to be moderate for GR reduction and gain in CAL, but very low for gain in KTW.

CONCLUSION

The adjunctive application of EMD in the treatment of GR in maxillary teeth either with CAF or CTG provided moderate certainty evidence in favor of their use for reduction in GR and gain in CAL at 6 and 12 months. However, their effect on the increase in keratinized tissue band height showed very low evidence certainty for its use.

CLINICAL RELEVANCE

To know if EMD could improve the results for root coverage.

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.

Periodontal plastic surgery for the management of an ankylosed permanent maxillary lateral incisor: A clinical report with 5-year follow-up

Anterior maxillary tooth ankylosis disturbs the development of the alveolar bone process, leading to discrepancies between the cervical gingival margin and incisal edge position of the affected tooth, and therefore, the esthetics is compromised. Proposed treatments in adults and growing patients have been used successfully, but they have disadvantages and are contraindicated in some circumstances. This article proposes an alternative treatment for an ankylosed permanent maxillary anterior tooth with a slow replacement resorption rate in an adult patient, for whom a combination of a periodontal plastic surgery procedure and a fixed dental prosthesis was used to correct the esthetics. This treatment has less risk of complications, preserves the ankylosed tooth as long as possible, creates an optimal gingival contour, and maintains the alveolar bone for further treatment should the tooth be lost.

Coronally advanced flap achieved higher esthetic outcomes without a connective tissue graft for the treatment of single gingival recessions: a 4-year randomized clinical trial

OBJECTIVES

Limited long-term data are available when comparing the esthetic outcomes of coronally advanced flap (CAF) with or without a connective tissue graft (CTG). The aim of this study was to compare the 4-year esthetic outcomes of CAF vs CAF + CTG for the treatment of isolated maxillary gingival recessions.

MATERIAL AND METHODS

Forty-eight patients were randomly assigned for treatment either with CAF (control; N = 24) or to CAF + CTG (test group; N = 24). Patients were followed after the surgery until the final evaluation. A professional esthetic evaluation was performed using the Root coverage Esthetic Score (RES). Recession reduction, mean root coverage, and complete root coverage were also evaluated.

RESULTS

Forty-two patients completed the study at the 4-year recall. A significant recession reduction was evident at 4 years, without significant intergroup differences. The CAF group showed a statistically significant higher final RES compared with the CAF + CTG group (9.14 ± 1.08 vs 7.25 ± 1.29, respectively, p < 0.001). Regarding the individual components of RES, gingival margin and marginal tissue contour were significantly higher in the CAF group compared with that in the CAF + CTG group.

CONCLUSIONS

CAF presented with a significantly higher overall esthetic score than CAF + CTG, and in the individual RES components of marginal tissue contour and gingival margin after 4 years.

CLINICAL RELEVANCE

CAF without the addition of CTG provided higher esthetic outcomes for the treatment of isolated gingival recessions.

Acellular dermal matrix for root coverage procedures: 9-year assessment of treated isolated gingival recessions and their adjacent untreated sites

BACKGROUND

The long-term outcomes of acellular dermal matrix (ADM) for the treatment of isolated gingival recessions has not yet been evaluated. Thus, the aim of this study was to observe the root coverage outcomes of coronally advanced flap with ADM over time, and compare them with their adjacent untreated sites.

METHODS

Twelve patients (from 20) were available at the 9-year recall. Clinical parameters (recession depth, mean root coverage [mRC], keratinized tissue width [KTW], and gingival thickness) were evaluated and compared with the 1-year results, and the ADM-adjacent untreated sites (on mesial and distal) via mixed-modeling regression analyses.

RESULTS

From 1 to 9 years, the ADM-treated isolated recessions showed a relapse from 77% to 62% mRC (P <0.05). A similar pattern toward apical shift of the gingival margin was noticed for the ADM-adjacent untreated sites without baseline recession. However, ADM-adjacent untreated sites which had presented with recession at baseline but were not treated showed a significantly more apical shift of the gingival margin (almost two-fold). A significant increase in KTW was noted for all sites. Baseline KTW ≥2 mm was a significant predictor for the stability of the gingival margin at the ADM-treated, and the ADM-adjacent sites with baseline recession.

CONCLUSIONS

ADM-treated sites displayed recession relapse from 1 to 9 years. The untreated adjacent sites with a recession at baseline, showed a higher apical displacement of the gingival margin compared with the ADM-treated sites, and ADM-adjacent sites without a recession at baseline.

Tunnel/Pouch versus Coronally Advanced Flap Combined with a Connective Tissue Graft for the Treatment of Maxillary Gingival Recessions: Four-Year Follow-Up of a Randomized Controlled Trial

BACKGROUND

The long-term stability after soft tissue graft for covering gingival recession remains a pivotal goal for both patient and periodontist. Therefore, the aim of this study was to compare the four-year outcomes of the coronally advanced flap (CAF) versus the pouch/tunnel (POT) technique, both combined with connective tissue graft (CTG), for gingival recession treatment.

METHODS

Forty patients were initially randomly assigned to the control group (CAF + CTG; N = 20) and the test group (POT + CTG; N = 20). Clinical outcomes included mean root coverage (MRC) and complete root coverage (CRC), gingival thickness (GT), and keratinized tissue (KT) gain. Esthetic outcomes were also analyzed using the pink esthetic score (PES) and patient-reported outcome measures (PROMs). All outcomes initially assessed at six months were extended to four years post-surgery.

RESULTS

No significant differences were observed between the two patient groups in terms of MRC and CRC. At four years, significantly greater GT and KT gain were noted in the POT + CTG group, and tissue texture enhancement was also more prominent in the test group.

CONCLUSIONS

The POT + CTG technique allows for long-term clinical coverage of gingival recessions comparable to that of the CAF + CTG technique, but it potentially improves gingival thickness, keratinized tissue and esthetic results.

Extrusion and Microfluidic-based Bioprinting to Fabricate Biomimetic Tissues and Organs

Next generation engineered tissue constructs with complex and ordered architectures aim to better mimic the native tissue structures, largely due to advances in three-dimensional (3D) bioprinting techniques. Extrusion bioprinting has drawn tremendous attention due to its widespread availability, cost-effectiveness, simplicity, and its facile and rapid processing. However, poor printing resolution and low speed have limited its fidelity and clinical implementation. To circumvent the downsides associated with extrusion printing, microfluidic technologies are increasingly being implemented in 3D bioprinting for engineering living constructs. These technologies enable biofabrication of heterogeneous biomimetic structures made of different types of cells, biomaterials, and biomolecules. Microfluiding bioprinting technology enables highly controlled fabrication of 3D constructs in high resolutions and it has been shown to be useful for building tubular structures and vascularized constructs, which may promote the survival and integration of implanted engineered tissues. Although this field is currently in its early development and the number of bioprinted implants is limited, it is envisioned that it will have a major impact on the production of customized clinical-grade tissue constructs. Further studies are, however, needed to fully demonstrate the effectiveness of the technology in the lab and its translation to the clinic.

Autogenous soft tissue grafting for periodontal and peri-implant plastic surgical reconstruction

This state-of-the-art review presents the latest evidence and the current status of autogenous soft tissue grafting for soft tissue augmentation and recession coverage at teeth and dental implant sites. The indications and predictability of the free gingival graft and connective tissue graft (CTG) techniques are highlighted, together with their expected clinical and esthetic outcomes. CTGs can be harvested from the maxillary tuberosity or from palate with different approaches that can have an impact on graft quality and patient morbidity. The influence of CTGs on soft tissue thickness and keratinized tissue width are also discussed.

Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

This comprehensive review of the 2018 dental literature is provided to inform busy dentists about progress in the profession. Developed by the Committee on Scientific Investigation of the American Academy of Restorative Dentistry, each author brings discipline-specific expertise to one of the 8 sections of the report including (1) prosthodontics; (2) periodontics, alveolar bone, and peri-implant tissues; (3) implant dentistry; (4) dental materials and therapeutics; (5) occlusion and temporomandibular disorders; (6) sleep-related breathing disorders; (7) oral medicine and oral and maxillofacial surgery; and (8) dental caries and cariology. The report targets important information that will likely influence day-to-day treatment decisions. Each review is not intended to stand alone but to update interested readers so that they may visit source materials if greater detail is desired. As the profession continues its march toward evidence-based clinical decision-making, an already voluminous library of potentially valuable dental literature continues to grow. It is the intention of this review and its authors to provide assistance in navigating the extensive dental literature published in 2018. It is our hope that readers find this work useful in the clinical management of patients moving forward.

The Effect of Time on Root Coverage Outcomes: A Network Meta-analysis

The stability of root coverage outcomes has gained a great deal of interest. However, insufficient evidence is available, mainly due to limited direct comparisons among different techniques and the small sample size among clinical trials. Therefore, the aim of this study was to propose a mixed-models network meta-analysis (NMA) that includes the novelty of assessing time on root coverage outcomes while simultaneously comparing different surgical approaches. A literature search was performed by 2 individual reviewers to identify randomized clinical trials (RCTs) reporting the outcomes of root coverage procedures of at least 2 time points to estimate the slopes of different treatment approaches. The primary outcomes were the changes in slopes for recession depth (REC), keratinized tissue width (KTW), and clinical attachment level. Sixty RCTs with a total of 2,554 gingival recessions (1,864 patients) were included in the NMA. Connective tissue graft (CTG) and enamel matrix derivative (EMD) approaches provided superior initial REC reduction compared to flap advancement alone. However, only CTG-based procedures were effective in maintaining the stability of the gingival margin over time, while EMD, acellular dermal matrix, collagen matrix, and flap alone showed a similar tendency for gingival recession recurrence. Baseline REC and KTW at the earliest postoperative recall were predictors for the stability of the gingival margin. In addition, a geographic center effect on the treatment slopes was observed for REC and KTW. While limitations of the present linear mixed-modeling approach should be considered as it refers to estimation and comparison of time slopes based on an examined while linear framework, the designed NMA showed to be an effective tool for the simultaneous comparison of multiple treatment approaches while taking into account the critical element of time.

Acellular dermal matrix and coronally advanced flap or tunnel technique in the treatment of multiple adjacent gingival recessions. A 12-year follow-up from a randomized clinical trial

AIM

To evaluate the long-term outcomes of Acellular Dermal Matrix (ADM) with Coronally Advanced Flap (CAF) or Tunnel technique (TUN) in the treatment of multiple adjacent gingival recessions (MAGRs).

MATERIAL AND METHODS

Nineteen of the original 24 patients contributing to a total number of 33 sites for CAF and 34 for TUN were available for the 12 years follow-up examination. Recession depth, mean root coverage (mRC), keratinized tissue width (KTW), gingival thickness (GT) were evaluated and compared with baseline values and 6-months results. Regression analysis was performed to identify factors related to the stability of the gingival margin.

RESULTS

A highly significant drop in mRC was observed for both groups from the 6 months timepoint to the 12 years recall (p < .001). While there were no statistically significant differences between the two groups in terms of Clinical Attachment Level (CAL), KTW, GT changes and Root Coverage Esthetic Score at each timepoint (p > .05). KTW ≥ 2 mm and GT ≥ 1.2 mm at 6-months were two predictors for stability of the gingival margin (p = .03 and p = .01, respectively).

CONCLUSIONS

A significant relapse of the gingival margin of MAGRs treated with CAF or TUN + ADM was observed after 12 years.

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.