Gingival recession: review and strategies in treatment of recession

Correlation between Gingival Thickness and Occurrence of Gingival Recession

Background

Gingival recession (GR) has become a common problem among patients. GR is associated with increased accumulation of plaque, root caries, abrasion and cervical wear, and dentinal hypersensitivity. The present study aimed to examine the correlation between gingival biotypes and the occurrence of GR.

Methods

The study initially recruited 94 subjects; however, 54 of them did not have any recession sites, and hence were discarded. Therefore, the analysis was performed on 40 subjects. The study particularly compared the relationship between the recession length (RL) and width along with the gingival thickness (GT). As such, different clinical parameters were analyzed, namely, RL, recession width (RW), keratinized gingival width (KGW), and GT.

Results

Based on the statistical analysis (descriptive statistics and Pearson's correlation) conducted on the collected data, the study established that the gingival RL has a significant negative relationship with GT, which implied that the amount of thickness is inversely proportional to the RL. The study also found a significant positive correlation between RW and RL as well as between GT and KGW.

Conclusion

Based on the findings, the study thus concluded that the gingival biotype (thickness) significantly determines the occurrence and extent of GR.

Clinical Evaluation of Coronally Advanced Flap With or Without Advance-Platelet Rich Fibrin Membrane in the Treatment of Miller's Class-II Localized Gingival Recession: A Clinical Study

INTRODUCTION

 Periodontal treatment focuses on maintaining a patient's natural teeth and gums. The gingival margin recedes to a point apical to the tooth in 20%-100% of people. Coronally advanced flap (CAF) is one of several effective treatments for this condition. This surgery covers the tooth root with gingiva. The predictability of this surgery depends on the blood supply, donor tissue, and surgical skills. Platelet concentrates, which include platelet-rich fibrin (PRF), majority of the time is used for various regenerative therapies. Since no bovine thrombin or anticoagulant is needed, its manufacturing is simpler, cheaper, and less biochemically modified than PRP. Platelet-rich fibrin (PRF) is a fibrin matrix that progressively releases platelet cells and cytokines.

AIM

The present study aimed to evaluate the efficacy of CAF with and without A-PRF in the treatment of Miller's class-II localized gingival recession.

MATERIALS AND METHODS

Twenty patients were chosen who had Miller's class-II localized gingival recession. A random number generator was used to place patients into either the "test" or "control" group. Treatment for both Groups A and B included a coronally advanced flap, but only Group A additionally got autologous platelet-rich fibrin (A-PRF). After receiving a detailed explanation of the treatment process, the patient signed an informed consent form. Complete medical and dental histories were taken to see whether there were any absolute or relative contraindications.

RESULTS

 Following treatment with either method in the current study, gingival thickness improved considerably. The percentage of root coverage did not change considerably between the two groups. The clinical result might likely have been different if other factors, such as platelet concentration and PRF consistency, had been examined in the current investigation. Furthermore, there was no histological examination of the healing process. As a result, we are unsure of the extent to which PRF affects how effectively connective tissue attaches.

CONCLUSION

The additional use of A-PRF membrane did not provide additional benefits in terms of root coverage outcomes compared with CAF alone. The use of A-PRF membranes significantly reduced the recession depth.

Minimally invasive intrasulcular tunneling technique for treatment of gingival recessions: A case series

Coronally advanced flap (CAF) by tunneling procedure was applied on four cases of gingival recession. Post-operative follow-up, at different time breaks, recorded full coverage of almost all receded root surfaces. The technique and the clinical outcome of this technique will be demonstrated in this case series report.

A Review of the Effects of Collagen Treatment in Clinical Studies

Collagen, an abundant extracellular matrix protein, has been found to have a lot of pharmaceuticals, medicine, food, and cosmetics applications. Increased knowledge of collagen sources, extraction techniques, structure, and properties in the last decades has helped develop more collagen-based products and tissue engineering biomaterials. Collagen products have been playing an important role in benefiting the health of the human body, especially for aging people. In this paper, the effects of collagen treatment in different clinical studies including skin regeneration, bone defects, sarcopenia, wound healing, dental therapy, gastroesophageal reflux, osteoarthritis, and rheumatoid arthritis have been reviewed. The collagen treatments were significant in these clinical studies. In addition, the associations between these diseases were discussed. The comorbidity of these diseases might be closely related to collagen deficiency, and collagen treatment might be a good choice when a patient has more than one of these diseases, including the coronavirus disease 2019 (COVID-19). It concludes that collagen-based medication is useful in treating comorbid diseases and preventing complications.

A Comparative Evaluation of Silk Suture and Cyanoacrylate Adhesive in the Stabilization of Free Gingival Graft Harvested with Erbium: Yttrium-Aluminum-Garnet Laser: A Clinical Study

BACKGROUND

The most common technique for gingival augmentation is free gingival graft (FGG). The aim of this study is to clinically compare the efficacy of FGG harvested with erbium: yttrium-aluminum-garnet (Er: YAG) laser stabilized with 5-0 silk suture in comparison to N-butyl-2-cyanoacrylate tissue adhesive in increasing the width of keratinized gingiva (WK) for the management of Miller's Class I and II gingival recession.

METHODOLOGY

Forty-eight gingival recession defects were divided into two Groups I and II. Group I sites were treated with FGG harvested using Er: YAG laser stabilized with 5-0 silk suture and Group II sites were treated with FGG harvested using Er: YAG laser stabilized with N-butyl-2-cyanoacrylate tissue adhesive. Clinical parameters such as gingival recession depth, clinical attachment level (CAL), gain in gingival tissue thickness, and WK were recorded at baseline and 3 and 6 months postoperatively.

RESULTS

A significant reduction in gingival recession defects, gain in CAL, increase in WK, and gain in gingival tissue thickness were observed in both the groups. Intergroup comparison of gingival recession defects, CAL, WK, and gingival tissue thickness yielded nonsignificant differences.

CONCLUSION

Within the limits of this study, it can be concluded that both 5-0 silk suture and n-butyl-2-cyanoacrylate were equally efficacious in the stabilization of FGG. N-butyl-2-cyanoacrylate was easy to apply, consumed less operating time, and had no adverse effect. Hence, cyanoacrylate can be used as an alternative to suture in stabilization of FGG.

Localization of cementoenamel junction in intraoral ultrasonographs with machine learning

OBJECTIVE

Our goal was to automatically identify the cementoenamel junction (CEJ) location in ultrasound images using deep convolution neural networks (CNNs).

METHODS

Three CNNs were evaluated using 1400 images and data augmentation. The training and validation were performed by an experienced nonclinical rater with 1000 and 200 images, respectively. Four clinical raters with different levels of experience with ultrasound tested the networks using the other 200 images. In addition to the comparison of the best approach with each rater, we also employed the simultaneous truth and performance level estimation (STAPLE) algorithm to estimate a ground truth based on all labelings by four clinical raters. The final CEJ location estimate was obtained by taking the first moment of the posterior probability computed using the STAPLE algorithm. The study also computed the machine learning-measured CEJ-alveolar bone crest distance.

RESULTS

Quantitative evaluations of the 200 images showed that the comparison of the best approach with the STAPLE-estimate yielded a mean difference (MD) of 0.26 mm, which is close to the comparison with the most experienced nonclinical rater (MD=0.25 mm) but far better than the comparison with clinical raters (MD=0.27-0.33 mm). The machine learning-measured CEJ-alveolar bone crest distances correlated strongly (R = 0.933, p < 0.001) with the manual clinical labeling and the measurements were in good agreement with the 95% Bland-Altman's lines of agreement between -0.68 and 0.57 mm.

CONCLUSIONS

The study demonstrated the feasible use of machine learning methodology to localize CEJ in ultrasound images with clinically acceptable accuracy and reliability. Likelihood-weighted ground truth by combining multiple labels by the clinical experts compared favorably with the predictions by the best deep CNN approach.

CLINICAL SIGNIFICANCE

Identification of CEJ and its distance from the alveolar bone crest play an important role in the evaluation of periodontal status. Machine learning algorithms can learn from complex features in ultrasound images and have potential to provide a reliable and accurate identification in subsecond. This will greatly assist dental practitioners to provide better point-of-care to patients and enhance the throughput of dental care.

Biocompatibility Evaluation of Human and Porcine Acellular Dermal Matrix on Human Primary Gingival Fibroblasts: In Vitro Comparative Study

Objective  Allogeneic and xenogeneic acellular dermal matrix (ADM) grafts have been used to treat periodontal soft tissue defects. The purpose of the current study was to compare the effect of human ADM (AlloDerm) and porcine ADM (Derma) on human primary gingival fibroblasts in vitro regarding the biocompatibility test.

Materials and Methods  Gingival fibroblasts were obtained from healthy adult gingiva and seeded on AlloDerm or Derma ADM in 96-well plate. The control cells were grown on a surface-treated polystyrene cell-culture plate without matrix. The cells were cultured for 3, 7, and 14 days. The fibroblasts morphology was examined using inverted microscopy, and the cell viability of fibroblasts adherent to the dermal matrix was evaluated using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell viability assay after 3, 7, and 14 days in culture. The data were statistically evaluated by one-way analysis of variance. p -Value of 0.05 was considered significant.

Results  Gingival fibroblasts adjacent to the AlloDerm and Derma matrices were healthy, attached to the well, and did not exhibit any cytopathic changes similar to control. There were no statistically significant differences in the cell viability between the gingival fibroblasts attached to Derma and AlloDerm on day 3 ( p = 0.841), day 7 ( p = 0.198), and day 14 ( p = 0.788).

Conclusion  Considering this in vitro study’s limitations, both human and porcine ADM were compatible with the surrounding human primary gingival fibroblasts. No significant differences were observed in the cell viability between the gingival fibroblasts that were attached to Derma and AlloDerm.

The Concept of Sustainable Development of Modern Dentistry

This paper concerns the assessment of the current state of dentistry in the world and the prospects of its sustainable development. A traditional Chinese censer was adopted as the pattern, with a strong and stable support on three legs. The dominant diseases of the oral cavity are caries and periodontal diseases, with the inevitable consequence of toothlessness. From the caries 3.5–5 billion people suffer. Moreover, each of these diseases has a wide influence on the development of systemic complications. The territorial range of these diseases and their significant differentiation in severity in different countries and their impact on disability-adjusted life years index are presented (DALY). Edentulousness has a significant impact on the oral health-related quality of life (OHRQoL). The etiology of these diseases is presented, as well as the preventive and therapeutic strategies undertaken as a result of modifying the Deming circle through the fives’ rules idea. The state of development of Dentistry 4.0 is an element of the current stage of the industrial revolution Industry 4.0 and the great achievements of modern dental engineering. Dental treatment examples from the authors’ own clinical practice are given. The systemic safety of a huge number of dentists in the world is discussed, in place of the passive strategy of using more and more advanced personal protective equipment (PPE), introducing our own strategy for the active prevention of the spread of pathogenic microorganisms, including SARS-CoV-2. The ethical aspects of dentists’ activity towards their own patients and the ethical obligations of the dentist community towards society are discussed in detail. This paper is a polemic arguing against the view presented by a group of eminent specialists in the middle of last year in The Lancet. It is impossible to disagree with these views when it comes to waiting for egalitarianism in dental care, increasing the scope of prevention and eliminating discrimination in this area on the basis of scarcity and poverty. The views on the discrimination of dentistry in relation to other branches of medicine are far more debatable. Therefore, relevant world statistics for other branches of medicine are presented. The authors of this paper do not agree with the thesis that interventional dental treatment can be replaced with properly implemented prophylaxis. The final remarks, therefore, present a discussion of the prospects for the development of dentistry based on three pillars, analogous to the traditional Chinese censer obtaining a stable balance thanks to its three legs. The Dentistry Sustainable Development (DSD) > 2020 model, consisting of Global Dental Prevention (GDP), Advanced Interventionist Dentistry 4.0 (AID 4.0), and Dentistry Safety System (DSS), is presented.

Current Insight of Collagen Biomatrix for Gingival Recession: An Evidence-Based Systematic Review

Collagen (Col) is a naturally available material and is widely used in the tissue engineering and medical field owing to its high biocompatibility and malleability. Promising results on the use of Col were observed in the periodontal application and many attempts have been carried out to inculcate Col for gingival recession (GR). Col is found to be an excellent provisional bioscaffold for the current treatment in GR. Therefore, the aim of this paper is to scrutinize an overview of the reported Col effect focusing on in vitro, in vivo, and clinical trials in GR application. A comprehensive literature search was performed using EBSCOhost, Science Direct, Springer Link, and Medline & Ovid databases to identify the potential articles on particular topics. The search query was accomplished based on the Boolean operators involving keywords such as (1) collagen OR scaffold OR hybrid scaffold OR biomaterial AND (2) gingiva recession OR tissue regeneration OR dental tissue OR healing mechanism OR gingiva. Only articles published from 2015 onwards were selected for further analysis. This review includes the physicochemical properties of Col scaffold and the outcome for GR. The comprehensive literature search retrieved a total of 3077 articles using the appropriate keywords. However, on the basis of the inclusion and exclusion criteria, only 15 articles were chosen for further review. The results from these articles indicated that Col promoted gingival tissue regeneration for GR healing. Therefore, this systematic review recapitulated that Col enhances regeneration of gingival tissue either through a slow or rapid process with no sign of cytotoxicity or adverse effect.

Re-invigoration of Pink Esthetics by a Novel Minimally Invasive Technique: A Report of Two Cases

The importance of pink esthetics as well as increased patient comfort has been gaining its pace in dentistry. Moreover, when it comes to the treatment of gingival recession, the ideologies of the periodontists have changed over time, i.e., from “extension to prevention;” it has now become “conserve to preserve.” Utilizing this same principle, pinhole technique was introduced comprising sutureless surgery with minimal surgical intervention, thus providing maximum comfort to the patient while undergoing treatment and postoperatively. This article presents a case report of two cases who were treated with a minimally invasive pinhole surgical technique, with complete root coverage and minimal complications.

The reproducibility of electronic color measurements of the marginal gingiva

INTRODUCTION

This study evaluated the reproducibility of electronic color determination system evaluations of the marginal gingiva, which could be important for adhesive cervical fillings or prosthetic restorations that imitate the gingiva.

MATERIAL AND METHODS

In 50 subjects, the L*, a*, and b* color coordinates were evaluated five times at a point in the marginal area of a central incisor using different electronic color determination systems: (SP) Shadepilot, (ES) Easyshade, (CE) Crystaleye, and (SV) X-Rite. The mean color difference (ΔE) and its standard deviation between the five measurements from each participant were calculated separately for each device. Further ICC for interdevice reliability was determined.

RESULTS

The L*, a*, and b* color coordinates and ΔE values differed significantly among the systems (p < 0.001). Within each patient and measurement system, ΔE ranged from 1.4 to 3.2 (SD 1.1-2.5), L* from 2.6 to 5.7 (SD 2.6-5.7), a* from 11.9 to 21.3 (SD 3.6-3.9), and b* from 15.1 to 28.9 (SD 1.7-4.3). Interdevice reliability ranged between 0.675 and 0.807.

CONCLUSIONS

Color determination of the marginal gingiva using the electronic tooth color determination systems tested herein showed limited reproducibility. The results obtained with the different measurement systems differed enormously.

CLINICAL RELEVANCE

These results show that the electronic color measurement devices tested allow no high reproducible determination of color coordinates of the marginal gingiva.

Coronally Advanced Flap with Amniotic Membrane in the Treatment of Gingival Recession: Three Case Reports

Gingival recession is defined as an apical displacement of soft tissues to the cementoenamel junction. Various treatment options for the management of gingival recessions include laterally positioned flap, double papillae flap, coronally advanced flap (CAF) with or without guided tissue regeneration, free gingival autografts, and autogenous subepithelial connective tissue grafts. Three patients with multiple adjacent gingival recessions in the upper jaw were treated utilizing amniotic membrane (Tata memorial) with CAF. The results of this procedure show that amniotic membrane can be used in the treatment of gingival recession defects with significant root coverage and to increase the thickness of keratinized gingiva. There was an increase in height and thickness of keratinized gingiva from 3 to 3.5 mm and 1.5 to 2 mm, respectively. The present results suggest that the combined approach of CAF and amniotic membrane can be considered as a treatment option for multiple adjacent gingival recessions.

Comparative evaluation of human chorion membrane and platelet-rich fibrin membrane with coronally advanced flap in treatment of Miller's class I and II recession defects: A randomized controlled study

BACKGROUND

Root coverage procedures have gained much popularity in recent years, due to increasing esthetic demands of patients. Coronally advanced flap (CAF) is a predictable technique for treating gingival recessions. Platelet-rich fibrin (PRF), an autologous platelet concentrate, has properties to enhance soft-tissue wound healing. A current method in dentistry is the use of human chorion membrane, a placental derivative, having biologic properties that help in healing and regeneration. Thus, the aim of the study was evaluation and comparison of the efficacy of chorion membrane and PRF membrane in the treatment of Miller's Class I and Class II recession defects.

MATERIALS AND METHODS

This was a randomized controlled clinical study. Totally 30 sites with Miller's Class I and Class II recession were taken and randomly allocated to chorion membrane (test) PRF membrane (control) group. The clinical parameters recorded were clinical attachment level (CAL), recession height (REC-HT), recession width (REC-WD), width of keratinized gingiva (WKG) and gingival tissue thickness (GTH).

RESULTS

Significant differences were seen from baseline to 6 months in test group regarding gain in CAL (P < 0.001), reduction in REC-HT (P < 0.001), decrease in REC-WD (P = 0.02), increase in WKG (P < 0.001), and increase in GTH (P < 0.001). In the control group also, significant difference was noted at the end of 6 months i regarding gain in CAL (P < 0.001), reduction in REC-HT (P < 0.001), decrease in REC-WD (P = 0.029), increase in WKG (P < 0.001), and increase in GTH (P < 0.001). Intergroup analysis showed significant differences between test and control groups at the end of 6 months, with CAL, REC-HT, WKG, and GTH showing statistically significant differences with P = 0.002, 0.001, 0.001, and 0.026, respectively. No significant difference was seen regarding REC-WD (P = 0.39).

CONCLUSIONS

Both are effective materials in root coverage, but chorion membrane showed better and more stable results at the end of 6 months as compared to PRF membrane in treating gingival recession.

Rhodoptilometrin, a Crinoid-Derived Anthraquinone, Induces Cell Regeneration by Promoting Wound Healing and Oxidative Phosphorylation in Human Gingival Fibroblast Cells

Gingival recession (GR) potentially leads to the exposure of tooth root to the oral cavity microenvironment and increases susceptibility to dental caries, dentin hypersensitivity, and other dental diseases. Even though many etiological factors were reported, the specific mechanism of GR is yet to be elucidated. Given the species richness concerning marine biodiversity, it could be a treasure trove for drug discovery. In this study, we demonstrate the effects of a marine compound, (+)-rhodoptilometrin from crinoid, on gingival cell migration, wound healing, and oxidative phosphorylation (OXPHOS). Experimental results showed that (+)-rhodoptilometrin can significantly increase wound healing, migration, and proliferation of human gingival fibroblast cells, and it does not have effects on oral mucosa fibroblast cells. In addition, (+)-rhodoptilometrin increases the gene and protein expression levels of focal adhesion kinase (FAK), fibronectin, and type I collagen, changes the intracellular distribution of FAK and F-actin, and increases OXPHOS and the expression levels of complexes I~V in the mitochondria. Based on our results, we believe that (+)-rhodoptilometrin might increase FAK expression and promote mitochondrial function to affect cell migration and promote gingival regeneration. Therefore, (+)-rhodoptilometrin may be a promising therapeutic agent for GR.

Efficacy of xenogeneic collagen matrix in the treatment of gingival recessions: A systematic review and meta-analysis

OBJECTIVES

This review aims to evaluate the efficacy of xenogeneic collagen matrix (XCM) for the treatment of single or multiple gingival recessions in terms of clinical parameters and patient-related outcomes.

MATERIALS AND METHODS

Various electronic databases (The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, etc.) from 1966 to April 2018 and hand literatures were searched. Quality of the included studies was assessed through the Cochrane Collaboration's Risk of Bias tool. A meta-analysis was performed to calculate risk ratios and mean differences.

RESULTS

Nine randomized controlled trials were included. The results revealed a higher percentage of mean root coverage (MRC) and a greater recession reduction (RecRed) for single recessions for the combination of coronally advanced flap (CAF) with XCM compared to CAF alone (n = 3; MD = 10.00%; 95%CI [3.56%; 16.43%]; p = 0.002) (n = 3; MD = 0.35 mm; 95%CI [0.10 mm; 0.60 mm]; p = 0.005). Comparing XCM with connective tissue graft (CTG), no significant differences were detected in MRC or RecRed for single and multiple recessions.

CONCLUSIONS

The addition of XCM under CAF could improve MRC and RecRed at single tooth recessions. Initial data suggest that XCM shows promising results to improve the clinical efficacy of CAF for multiple recessions. In addition, XCM could be a valid alternative to CTG in terms of MRC and RecRed at both single and multiple recessions. Based on limited evidence, XCM may decrease postoperative morbidity and operation time compared to CTG.

Colored Gingiva Composite Used for the Rehabilitation of Gingiva Recessions and Non-Carious Cervical Lesions

In this case of extensive gingival recession (Miller’s Class II) and mild physiologic pigmentation, an alternative method for the placement of Amaris Gingiva-Colored Composite was used to produce a non-invasive, aesthetic result acceptable to the patient. In restoring the defects in the entire maxilla of this patient, the opaquers were not mixed, but applied individually, directly to various areas of the teeth. Multiple opaquers were placed in a pattern mimicking the coloring of the patient’s gingiva. These were then covered with the base shade for a more aesthetic result to the patient’s satisfaction. The restorations resulting from the alternative method were highly aesthetic and at an eleven (11) month review showed no signs of failure giving rise to the conclusion that this method proposed for application of Amaris Gingiva-Colored Composite is viable for producing highly-aesthetic restorations in cases of gingival recession.

Exploring the versatility of gingiva-colored composite

Gingival recession has a diverse etiology. The consequences may include gingivitis, periodontitis, and hypersensitivity. Whereas the management can include surgical treatment options, sometimes a more conservative, yet still esthetic approach may be required. The use of gingiva-colored composites provides one such alternative and can be applied to varying presentations of the problem. While surgical treatment can be successful in re-creating favorable esthetic anatomy as well as achieving accurate tissue contour in cases when minor amounts of tissue are reconstructed, long-term results vary because of the vascularity and complexity of the interdental space. Factors such as cost, healing time, discomfort, and variable long-term results make surgery an unpopular choice. If tooth-colored restorative materials are utilized to restore cervical tooth exposure as a result of severe recession, the disproportionate appearance of the visible crown may give a dissatisfying result. Gingiva-colored composite provides dental practitioners with a versatile material that can be used to directly restore cervical defects caused by gingival recession, thus correcting the appearance of the gingival anatomy. It offers a treatment option that may increase patient satisfaction through the provision of a cost-effective, minimally invasive solution with highly esthetic results.

Multidisciplinary Treatment of a Fenestration-type Defect

The case report aimed at treating a fenestration-type defect with multidisciplinary conventional and advanced surgical techniques. Fenestrations are isolated areas in which the exposed root surface is covered only by the periosteum and gingiva, but the remaining cortical bone remains intact. Root coverage is indicated in cases of root hypersensitivity, treatment of shallow caries lesions, cervical abrasions, and esthetic and cosmetic needs. In this case report, after proper hygiene instruction and dental biofilm control, a fenestration-type defect was treated using guided tissue regeneration (anorganic bovine matrix and resorbable membrane) and a connective tissue grafts, associated to an endodontic apicoectomy. After reevaluation, the remaining gingival recession was treated with a second gingival connective tissue graft covered with q double papillae type in order to reconstruct the periodontal tissues of the involved tooth. In this clinical case, the interaction between the different areas of dentistry has made it possible to correct a fenestration-type defect, following procedures based on scientific evidence, restoring periodontal health, esthetics, self-esteem, and meeting the patient's expectations regarding her initial complaint. This case report shows the important role of interdisciplinary approach to treating a patient with a complex periodontal defect that required different types of knowledge and abilities to achieve the best results based on the current status of dentistry possibilities.