The use of collagen porcine dermal matrix and connective tissue graft with modified coronally advanced tunnel technique in the treatment of multiple adjacent type I gingival recessions: A randomized, controlled clinical trial

Levels of smoking and outcome measures of root coverage procedures: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis was performed to investigate if there was a significant association between the number of cigarettes smoked per day and the results of root coverage procedures.

METHODS

Electronic search was performed through PubMed, Web of Science, Embase, and Scopus until January 2023. Studies were included if evaluated the outcomes of periodontal plastic surgery procedures for the treatment of gingival recession in smokers. Statistical evaluation was conducted using random-effects method to analyze the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CI).

RESULTS

From a total of 4494 references, 15 studies were considered relevant to be included in this study. The results showed that 44.39% sites had complete root coverage (CRC) at 6 months (non-smokers: 54.06%, < 10 cigarettes/day: 48%, 10-20 cigarettes/day: 19.56%, ≥ 20 cigarettes/day: 50%). Mean root coverage at 6 months were as follows: non-smokers: 74.94% ± 16.71%, < 10 cigarettes/day: 84.20% ± 2.24%, 10-20 cigarettes/day: 75.30% ± 14.69%, ≥ 20 cigarettes/day: 68.75% ± 26.51%. A significant difference was revealed between non-smokers and individuals who smoked 10-20 cigarettes/day in terms of CRC at 6 months: OR = 0.15 (95% CI = 0.03 to 0.71; P = .017). However, no significant difference was detected comparing 10-20 and ≥ 20 cigarettes/day.

CONCLUSION

As there was not enough data available, any definitive conclusions about the connection between an increase in the amount of cigarettes consumed per day and the results of root coverage procedures could not be reached. Further research is required with comparative studies involving individuals who smoke varying numbers of cigarettes.

Allogenic Acellular Dermal Matrix and Xenogeneic Dermal Matrix as Connective Tissue Graft Substitutes for Long-Term Stability Gingival Recession Therapy: A Systematic Review and Meta-Analysis

Connective tissue graft (CTG) serves as a gold standard for gingival recession therapy. Yet the availability of CTG is limited, and it increases patient morbidity. Allogenic acellular dermal matrix (AADM) and xenogeneic dermal matrix (XDM) have been proven to be effective substitutes of CTG although the long-term stability is unclear. The aim of this study was to analyze the long-term stability outcome of gingival recession therapy using AADM and XDM compared to CTG. This study follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted independently from several online databases (PubMed, Scopus, and Embase). Five of 233 publications were included for final qualitative analysis and meta-analysis focusing on the mean difference of clinical parameters such as recession depth (RD), recession width (RW), probing depth (PD), clinical attachment loss (CAL), tissue thickness (TT), keratinized tissue width (KTW), and mean root coverage (MRC). Meta-analyses of RD, RW, CAL, TT, KTW, and MRC display an overall mean of 0.2 mm (95% confidence interval [CI]: -0.45 to -0.05), 0.29 mm (95% CI: -0.65 to 0.08), 0.2 mm (95% CI: -0.69 to 0.29), 0.25 mm (95% CI: -0.53 to 0.03), 0.26 mm (95% CI: -0.5 to 0.02), and 9.19% (95% CI: -13.95 to -4.43]), respectively, favoring the CTG. PD was the only parameter that favored the AADM or XDM with an overall mean of 0.03 mm (95% CI: -0.05 to 0.11). In all, if the long-term stability is the goal, the CTG is considered superior for gingival recession therapy. However, if it is contraindicated, the AADM and XDM might be considered as alternatives.

Xenogeneic collagen matrix vs. connective tissue graft for the treatment of multiple gingival recession: a systematic review and meta-analysis

The aim of this systematic review (SR) compared the effect of xenogeneic collagen matrix (XCM) vs. connective tissue graft (CTG) for the treatment of multiple gingival recession (MGR) Miller Class I and II or Cairo type I. Five databases were searched up to August 2022 for randomized clinical trials (RCTs) comparing the clinical effects of XCM vs. CTG in the treatment of MGR. The random effects model of mean differences was used to determine reduction of gingival recession (GR), gain in keratinized tissue width (KTW), gain in gingival thickness (GT) and gain in clinical attachment level (CAL). The risk ratio was used to complete root coverage (CRC) at 6 and 12 months. 10 RCTs, representing 1095 and 649 GR at 6 and 12 months, respectively, were included in this SR. The meta-analysis showed no statistically significant difference in GR reduction, KTW gain GT gain or CAL gain between groups at 6 months. However, at 12 months of follow-up, differences favoring the control group were observed (p < 0.05). CRC was significantly higher in the CTG group at 6 and 12 months. Regarding dentine hypersensitivity (DH), no statistically significant differences were found between groups at 6 and 12 months of follow-up (p < 0.05). At 12 months, CTG showed significantly superior clinical results in the treatment of MGR: however, this difference was not observed in the decrease of DH.

Soft Tissue Substitutes in Periodontal and Peri-Implant Soft Tissue Augmentation: A Systematic Review

BACKGROUND

Different extracellular matrix (ECM)-based technologies in periodontal and peri-implant soft tissue augmentation have been proposed in the market. The present review compared the efficacy of soft tissue substitutes (STSs) and autogenous free gingival grafts (FGGs) or connective tissue grafts (CTGs) in mucogingival procedures to increase keratinized tissue (KT) width around teeth and implants.

METHODS

Two independent examiners performed an electronic search on MEDLINE and the Cochrane Library based on the following PICOS format: (P) adult patients; (I) soft tissue substitutes and FGGs/CTGs; (C) STSs vs. CTGs; STSs vs. FGGs; STSs vs control; (O) KT width gain; (S) systematic reviews, randomized controlled trials. Studies published before November 2023 were included.

RESULTS

Around teeth, all biomaterials showed superior performance compared to a coronally advanced flap (CAF) alone for treating gingival recessions. However, when compared to CTGs, acellular dermal matrices (ADMs) yield the most similar outcomes to the gold standard (CTGs), even though in multiple recessions, CTGs continue to be considered the most favorable approach. The use of STSs (acellular matrix or tissue-engineered) in combination with apically positioned flaps (APF) resulted in significantly less gain in KT width compared to that achieved with FGGs and APFs. Around dental implants, free gingival grafts were deemed more effective than soft tissue substitutes in enhancing keratinized mucosa width.

CONCLUSIONS

Based on the available evidence, questions remain about the alternative use of soft tissue substitutes for conventional grafting procedures using free gingival grafts or connective tissue grafts around teeth and implants.

Efficacy of acellular xenogeneic dermal matrix graft in the treatment of multiple gingival recessions: systematic review and meta-analysis

OBJECTIVE

This study aimed to compare the efficacy of acellular xenogeneic dermal matrix graft (AXDM) compared to connective tissue graft (CTG) in treating multiple gingival recessions.

MATERIALS AND METHODS

A systematic search of electronic databases was conducted to identify randomized clinical trials (RCTs) that compared AXDM and CTG. The selected studies were subjected to bias risk assessment, data extraction, and meta-analyses. Parameters such as gingival recession height, width, mean percentage of root coverage, and complete root coverage were analyzed.

RESULTS

Seven RCTs involving 146 patients were included. The meta-analyses indicated that CTG was statistically superior to AXDM in reducing gingival recession height at the final follow-up (mean difference: -0.104 mm, 95% confidence interval [CI]: -0.180-0.028, p = 0.008) and width at the final follow-up (mean difference: -0.285 mm, 95% CI: -0.541-0.030, p = 0.029). CTG also demonstrated a significantly higher mean percentage of root coverage at the 6-month follow-up (difference in means: -2.761 mm, 95% CI: -4.932-0.590, p = 0.013) and a higher percentage of complete root coverage at the 6-month follow-up (odds Ratio [OR]: 0.598, 95% CI: 0.4-0.892, p = 0.012) compared to AXDM. However, there was no significant difference in the number of teeth with complete root coverage between CTG and AXDM (OR: 1.610, 95% CI: 0.983-2.636, p = 0.058) and aesthetic outcomes (mean difference: 0.148, 95% CI: -0.277-0.573, p = 0.494).

CONCLUSIONS

CTG is more effective than AXDM in treating multiple gingival recessions. This is evidenced by significant reductions in gingival recession height and width, a higher mean percentage of root coverage, and a greater percentage of complete root coverage at the 6-month follow-up.

CLINICAL RELEVANCE

In some clinical situations an alternative to CTG is required for the treatment of multiple gingival recessions. AXDM, despite presenting clinical outcomes that are not as satisfactory as CTG, can be used for this purpose.

Clinical outcomes of root coverage using porcine-derived collagen matrix with modified coronally advanced tunnel technique (MCAT) in multiple gingival recessions in smokers - a randomized controlled clinical trial

OBJECTIVES

Root coverage (RC) is an integral part in management of gingival recessions. Unlike isolated recessions, treating multiple recessions is the most challenging scenario especially in smokers who have reported reduced RC in terms of quantity and stability. Modified coronally advanced tunnel (MCAT) technique due to its improved vascularity along with use of porcine-derived collagen matrix (PDCM) (Mucograft™) with its bilayered dense collagen matrix may be a predictable alternative to conventional gold standard subepithelial connective tissue graft (SCTG). The purpose of this study was to compare the results of RC achieved using PDCM and SCTG with the MCAT approach in the treatment of multiple gingival recessions in smokers.

METHODOLOGY

This is a prospective randomized controlled clinical study registered under clinical trial registry (CTRI no. CTRI/2020/03/024238) including 28 patients with 64 recession defects. Smokers (≥ 10 cigarettes/day for ≥ 5 years) fulfilling the inclusion criteria were randomized into the SCTG and PDCM groups which were treated with SCTG using MCAT and PDCM using MCAT technique, respectively. Recession depth (RD), recession width (RW), width of keratinized tissue (WKT), thickness of keratinized gingiva (TKG), and %RC were assessed at baseline, 3, and 6 months. Complete RC (CRC) at 3 and 6 months, RC aesthetic scores (RCES) at 6 months.

RESULTS

Both groups showed significant improvement in all clinical parameters. Intergroup comparison of root coverage parameters in smokers showed better performance of the PDCM group in terms of RD, %RC, TKG, WKT, CRC (45.06%), and RCES (p < 0.001) compared to the SCTG group. Time taken for surgical procedure and visual analog pain scores were significantly lesser in the PDCM group.

CONCLUSION

PDCM showed good predictable results in terms of all RC parameters compared to SCTG and thus may be used as a predictable alternative to SCTG for RC in smokers.

CLINICAL SIGNIFICANCE

PDCM can be used as a potential alternative to gold standard subepithelial connective tissue graft in smokers with better patient compliance.

Bone Remodeling during Orthodontic Movement of Lower Incisors-Narrative Review

The tooth movement in the alveolus is possible due to bone remodeling. This process could be the risk factor for the formation of gingival recessions-the most common side effects of orthodontic therapy. Gingival recessions are found 5.8-11.5% more frequently among the orthodontically treated patients. What is more, anterior mandibular teeth are the ones most prone to gingival recession dehiscences and fenestrations. The aim of this narrative review was to evaluate, based on CBCT (Cone beam computed tomography) scans, the changes in the alveolar bone of lower incisors in adolescent and adult patients after orthodontic tooth movements. From the pool of 108 publications, a total of 15 fulfilled the criteria of this review. Both retrospective and prospective longitudinal studies-using CBCT or CT (Computed Topography) and evaluating alveolar bone changes in mandibular incisors during orthodontic treatment performed before and after teeth movement-were included. In the group of growing patients, either proclination or retroclination of mandibular incisors led to increase of the distance from CEJ (cementoenamel junction) to marginal bone crest. The difference in bone loss was greater on the lingual side of the incisors in both types of tooth movement. The results were similar for adults patients. The thickness of the alveolar bone was reduced after proclination (total bone thickness) among growing and non-growing patients and retraction (lingual and buccal) of lower anterior teeth in the group of growing patients. The only improvement was measured for buccal thickness of mandibular incisor in bimaxillary protrusion patients treated with extraction therapy. The control of retraction movement (more root than crown movement) enhanced preservation on bone height and thickness. In order to minimize possible deterioration and place teeth in the center of alveolus, CBCT monitoring and scrupulous clinical evaluation are recommended.

Comparison between connective tissue graft and xenogeneic acellular dermal matrix to treat single gingival recession: A data reanalysis of randomized clinical trials

OBJECTIVES

There are few studies comparing xenogeneic acellular dermal matrixes (XDMs) with connective tissue graft (CTG) to treat single gingival recession (GR). The present study involved a reanalysis of previous studies and comparison of CTG or XDM to treat single RT1/GR.

MATERIALS AND METHODS

Fifty patients from three previous randomized clinical trials treated either by CTG (n = 25) or XDM (n = 25) were evaluated after 6-month. Clinical, patient-centered, and esthetic parameters were assessed. Pearson's correlation and regression analyses were also performed.

RESULTS

Greater recession reduction (RecRed), percentage of root coverage (%RC), and complete root coverage (CRC) were observed in the CTG group (p ≤ 0.02). Gingival thickness (GT) and keratinized tissue width (KTW) gains were higher in the CTG group. The CTG group showed better esthetic at 6-month. Logistic analyses reported that GT([OR] = 1.647³ ) and papilla height (PH) (OR = 8.20) are predictors of CRC. GT*XDM interaction was a negative predictor of CRC (OR = 7.105^-5 ). GT at baseline acted as a predictor of RecRed in both groups (p = 0.03). The XDM graft impacted RecRed and %RC negatively. Baseline PH was a predictor of %RC for both grafts.

CONCLUSION

CTG was superior for treating RT1/GR, providing better root coverage outcomes and tissue gains over time. GT, PH, and graft type were classified as predictors of CRC.

CLINICAL SIGNIFICANCE

CTG presented better outcomes to treat single RT1 gingival recession when compared to the XDM.

Porcine Acellular Dermal Matrix: An Alternative to Connective Tissue Graft-A Narrative Review

Porcine acellular dermal matrix has recently been introduced in dentistry as an alternative to the gold standard connective tissue graft especially for the use in gingival recession treatments and soft tissue augmentation in implant surgery. Connective tissue grafts are inconvenient and require a second surgical site leading to greater morbidity, longer surgical procedures, and a more painful postoperative phase for the patient. Other options such as allografts have ethical concerns and are less available in Europe. Thus, dental professionals have sought other techniques and materials. Porcine acellular dermal matrix results in periodontal recession treatment with a gain in recession coverage as well as increased keratinized tissue and soft tissue augmentation. This leads to more keratinized mucosa and greater tissue thickness. Many studies have been published using collagen matrices, but a few strictly use porcine acellular dermal matrix, which have been studied in prospective randomized clinical trials with a large number of patients and longer follow-up periods (more than 5 years). Nevertheless, more data are needed to confirm that the porcine acellular dermal matrix is a suitable alternative although its favourable results to date suggest a positive future.

Collagen Matrix vs. Autogenous Connective Tissue Graft for Soft Tissue Augmentation: A Systematic Review and Meta-Analysis

Soft tissues have been shown to be critical for the maintenance of both teeth and implants. Currently, regenerative soft tissue techniques propose the use of collagen matrices, which can avoid the drawbacks derived from the obtainment of autogenous tissue graft. A systematic review and meta-analysis were conducted to ascertain the efficacy of collagen matrices (CM) compared to autogenous connective tissue graft (CTG) to improve soft tissue dimensions. An electronic and manual literature searches were performed to identify randomized clinical trials (RCT) or controlled clinical trials (CCT) that compared CTG and CM. Pooled data of width of keratinized tissue (KT) and mucosal thickness (MT) were collected and weighted means were calculated. Heterogeneity was determined using Higgins (I²). If I² > 50% a random-effects model was applied. Nineteen studies were included based on the eligibility criteria. When using CTG a higher MT gain (0.32 mm, ranging from 0.49 to 0.16 mm) was obtained than when employing CM. Similar result was obtained for the width of KT gain, that was 0.46 mm higher (ranging from 0.89 to 0.02 mm) when employing CTG. However, it can be stated that, although autogenous CTG achieves higher values, CM are an effective alternative in terms of total width of KT and MT gain.

Comparative assessment between bio-adhesive material and silk suture in regard to healing, clinical attachment level and width of keratinized gingiva in gingival recession defects cases

The objective of this study was to compare the silk suture with a cyanoacrylate adhesive to stabilize the free gingival graft in conjunction with Er: YAG laser-assisted recipient site preparation to augment the keratinized tissue in gingival recession cases. This randomized trial comprised of 300 recession defects patients. All the included patients were diagnosed using Miller class I and II gingival recession defects classification. Group I sites were treated with a free gingival graft (FGG) harvested using an Er: YAG laser and further sutured with silk. Group II sites were stabilized with isoamyl 2 cyanoacrylate bio-adhesive material. Clinical parameters, such as gingival recession depth, clinical attachment level, gain in gingival tissue thickness, and width of keratinized gingiva were recorded at baseline, and at third month, sixth month, and 12th month postoperatively. The mean changes in gingival recession from months 3 to 6 and months and 6 to 12 were significant (p < 0.05) in both groups. However, the improvement in recession depth was better in group II than in group I. The mean change in clinical attachment level did not differ significantly between the groups at the different time intervals. However, values tended to be higher in group II than in group I. The width of the keratinized gingiva tended to be higher from baseline to 3 months, baseline to 6 months, baseline to 12 months, 3 to 6 months, and from 6 to 12 months in group II as compared with group I (p > 0.05). Cyanoacrylate could be used as a substitute to silk sutures to stabilize FGGs. Cyanoacrylate was easy to apply, consumed less operating time, and was considered equally efficacious for stabilizing FGGs.

Root coverage of multiple gingival recessions treated with coronally advanced flap associated with xenogeneic acellular dermal matrix or connective tissue graft: a 6-month split-mouth controlled and randomized clinical trial

OBJECTIVES

This study aimed to compare xenogeneic dermal matrix (XDM) to connective tissue graft (CTG) associated with coronally advanced flap (CAF) in treating Miller's class I and II (RT1) multiple gingival recession in a split-mouth randomized clinical trial.

MATERIALS AND METHODS

Fifteen patients with bilateral Miller's class I and II multiple recessions were selected. The patient's side receiving each treatment was randomly allocated to receive XDM or CTG. The clinical parameters were measured at baseline and 6 months of follow-up.

RESULTS

At 6 months, no significant difference in the root coverage (RC) (95.28 ± 6.89% for CTG and 92.68 ± 7.35% for XDM) and the keratinized tissue (KT) gain (0.91 ± 0.46 mm for CTG and 0.74 ± 0.39 mm for XDM) was observed between groups (p > 0.05). The CTG group presented higher complete root coverage (CRC) than XDM (60% and 33%, respectively) (p = 0.045). Multiple logistic regression indicated that the XDM (p = 0.01) and the XDM and KT interaction (p = 0.02) negatively interfered in the CRC. A 1-mm increase in the baseline KT when using XDM increases almost 6 times the chance of achieving CRC, and XDM reached a similar CRC probability to CTG when the receptor area presented at least 2 mm of KT.

CONCLUSIONS

Both treatments were effective for treating multiple gingival recession; similar KT gain, GR reduction, and RC were obtained for CTG and XDM, while CTG promoted higher CRC than XDM. Moreover, the amount of KT at baseline was determinant for CRC when treating multiple gingival recession with XDM.

CLINICAL RELEVANCE

XDM produces limited CRC in sites with a reduced amount of KT.

TRIAL REGISTRATION

Brazilian Clinical Trials Registry (REBEC) number RBR-56NZQ6.