Root Coverage With a Coronally Positioned Flap Used in Combination With Enamel Matrix Derivative: 18-Month Clinical Evaluation

Enhancing attachment of human gingival fibroblasts to periodontally compromised teeth: A comparative analysis of hyaluronic acid, EDTA, enamel matrix derivatives

Background

Gingival recession is a characteristic indicator of periodontitis and one of the factors that contributes to increased tooth clinical crown length. Patients with root exposure frequently undergo periodontal surgical procedures in addition to adjunctive therapy to increase root coverage area and soft tissue stability.

Purpose

This study aimed to evaluate fibroblast-root surface adhesion and determine whether periodontitis-damaged root surface microstructure can be restored using ethylenediaminetetraacetic acid (EDTA) and an enamel matrix derivative (EMD), individually or in combination.

Material and methods

Teeth extracted from patients with periodontal disease were used to create 60 samples, with each group containing six specimens. The test groups were provided root planing or root condition-specific materials (hyaluronic acid [HA], 24% EDTA, EMD, or EDTA/EMD) for varying treatment time periods. In contrast, the control group did not undergo any surface modifications. The samples and fibroblast cells were incubated for 72 h. The number of living cells on the root surface in each group was calculated using a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay (cell viability assessment).

Results

The control, root planing, and EMD groups showed that the root surfaces treated with EDTA for 4 min had significantly better cell adhesion. Surface EDTA treatment for 2 min significantly promoted cell attachment compared to root planing treatment. The root surfaces modified with EDTA/EMD for 2 and 4 min showed significantly improved cellular migration and adhesion compared to the root surface treated with root planing.

Conclusion

EDTA and EDTA/EMD substantially affected the root surface, which was related to the length of the treatment process. This effect shifts the surface properties, alters fibroblast interactions with the root surface, and recruits more cells to cover a larger area.

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.

Hyaluronic Acid as an Adjunct to Coronally Advanced Flap Procedures for Gingival Recessions: A Systematic Review and Meta—Analysis of Randomized Clinical Trials

Previous systematic reviews have reported that coronally advanced flap (CAF) + connective tissue graft (CTG) are the gold standard in root coverage procedures (RCP). Nevertheless, adjunctive treatment with hyaluronic acid (HA) has been proposed to aim at improving clinical outcomes and reducing patient morbidity. The aim of this systematic review and meta-analysis is to compare the use of HA as an adjunctive treatment to CAF procedures in Miller class I and II (recession type 1; RT1) gingival recession (GR) defects treatment with no adjunctive/other treatments. MEDLINE, The Cochrane Central Register of Controlled Trials, Web of Science, Scopus databases and gray literature were searched up to April 2022. The primary outcome variables were mean recession coverage (MRC) and reduction of the recession depth (RecRed). Weighted mean differences and 95% confidence intervals between treatments were estimated using a random-effect mode. From 264 titles identified, 3 RCTs reporting 90 GR defects in 60 patients were included. Overall analysis of MRC and RecRed were 0.27% (p = 0.01) and 0.40 mm (p = 0.45) in favor of CAF + HA compared to CAF alone/CAF + subepithelial connective tissue graft (SCTG), respectively, with a statistically significant difference only for MRC values. Nevertheless, due to the limited number and heterogeneity of the included studies, well-performed RCTs are needed to clarify a potential advantage of HA in RCPs in the future.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Coronally advanced flap with and without hyaluronic acid (HYALOSS) for the treatment of gingival recession – a randomized clinical trial

Objectives: To compare and evaluate the surgical outcome of gingival recession treatment using CAF alone or in conjunction with hyaluronic acid (HA) on Miller's Class I and class II gingival recession defects. Materials and methods: After randomisation, the control group (15 patients) received CAF alone and the test group (15 patients) received HA as an adjunct to CAF technique for an isolated gingival recession accompanied by an adequate width of keratinized gingiva on maxillary canines and premolars. All patients were evaluated at 7, 15, 30, 60 and 90 days interval post-operatively. Data obtained was subjected to statistical analysis and p value <0.05 was considered as statistically significant. Results: At 90 days interval statistically highly significant root coverage was obtained with mean gain of 66.1% in control group and 86.6% in test group. Statistically significant reduction in depth of gingival recession and gain in clinical attachment level was found for control and the test groups, and intergroup comparison showed statistically significant differences for root coverage and clinical attachment level between the groups (p = 0.000), however no significant differences were found for width of attached gingiva, keratinized gingiva and gingival thickness between the groups at 90 days (p > 005). Conclusion: HA has proven to be beneficial in the field of regenerative therapy. Our analysis suggested that HA can be used as a promising adjunct with CAF for root coverage, however further studies are required to imply the results on larger population.

Erbium, Chromium:Yttrium-Scandium-Gallium-Garnet Laser for Root Conditioning and Reduction of Postoperative Morbidity in the Treatment of Gingival Recession Defects: A Randomized Controlled Clinical Trial

Objective: This clinical trial evaluates the effect of erbium, chromium:yttrium-scandium-gallium-garnet (Er,Cr:YSGG) root surface biomodification and laser harvesting of de-epithelialized gingival graft (DGG) on root coverage clinical outcomes and postoperative morbidity, and compares this to the conventional blade-harvested DGG method without Er,Cr:YSGG root surface biomodification in treatment of Miller's class I, II gingival recessions (GR). Background: The application of laser technology to enhance tooth root coverage clinical outcomes as well as the impact of laser on postoperative morbidity after harvesting autogenous soft tissue grafts requires further research. Methods: This study is a randomized, single-blinded controlled trial, including 24 volunteers with isolated GR defects. They were allocated into three treatment groups to receive one of the following three interventions: blade-harvested DGG (control group: B-DGG); Er,Cr:YSGG-harvested DGG and root surface biomodified [test 1 group: L-laser-harvested DGG (L-DGG)/laser root biomodification (LRB)]; and B-DGG and Er,Cr:YSGG root surface biomodification (test 2 group: B-DGG/LRB). Clinical and radiographic parameters were recorded at baseline (1 week before surgery) and 3, 6, and 9 months postoperatively. Results: Root coverage did not show a statistically significant difference between control and test groups. Statistically significant differences were found for Visual Analog Scale on the day of surgery and day 3 and 4 postoperatively, as well as pain medication on the day of surgery favoring the L-DGG group. Conclusions: The use of Er,Cr:YSGG laser in root surface biomodification improved root coverage outcomes at 9 months. Even these changes were not statistically significant from the control group; the L-DGG technique was associated with decreased postoperative morbidity in the palatal donor site.

Regenerative Potential of Enamel Matrix Protein Derivative and Acellular Dermal Matrix for Gingival Recession: A Systematic Review and Meta-Analysis

Objective: The purpose of this study was to assess the clinical effectiveness of using a combination of enamel matrix protein derivative and acellular dermal matrix in comparison to acellular dermal matrix alone for treating gingival recessions. Methods: The Cochrane Library (Wiley), PubMed by Medline (NLM), Medline (EBSCO), and Embase (Ovid) databases were searched for entries up to April 2020. Only clinical trials were included. Primary outcomes were root coverage (%), changes in keratinized tissue width and recession (mm). Meta-analysis was conducted for root coverage, changes in keratinized tissue width, recession, clinical attachment level and probing depth. Results: Four studies were selected for the analysis. In primary outcomes, root coverage, change in keratinized tissue width and recession analysis showed a mean difference of 4.99% (p = 0.11), 0.20 mm (p = 0.14) and 0.13 mm (p = 0.23) respectively between the two groups. Secondary outcomes analysis also exhibited a statistically insignificant difference between the test and control group with mean difference of 0.11 mm (p = 0.32) in clinical attachment level gain and -0.03 mm (p = 0.29) in probing depth reduction analysis. Conclusions: Within the limits of this study, enamel matrix protein derivative combined with acellular dermal matrix used for treating gingival recession defects resulted in no beneficial effect clinically than acellular dermal matrix only.

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.

Efficacy of Enamel Derivatives to Improve Keratinized Tissue as Adjunct to Coverage of Gingival Recessions: A Systematic Review and Meta-Analysis

Background: The systematic review was designed to answer the following focused question: Are enamel matrix derivatives able to improve the quantity of keratinized tissue (KT) around natural dentition in patients with recessions defects after their treatment with periodontal plastic procedures? Methods: Only Randomized Clinical Trials (RCT) in English language evaluating root coverage procedures in combination with enamel matrix derivatives (commercially known as Emdogain^®—EMD), with at least 10 subjects and a minimum duration of six months, were included. The search was applied to PUBMED and SCOPUS and it consists of a combination of MeSH terms and free text words (from January 2000 to June 2019). Risk of bias in individual studies and across studies was also evaluated. Results: After the full text analysis and the exclusion of further 18 articles, 12 articles were finally included. In total 639 recessions were treated (334 tests and 305 control). The recessions defects were classified according to the classification of Miller (Class I, II, III, IV). Only one trial included Miller Class III recessions (7 in total). Enamel matrix derivatives were applied in conjunction with Coronally Advanced Flap (CAF), Coronally Advanced Flap + Sub Epithelial Connective Tissue Graft (CAF + CTG), Semilunar Flap (SF). For the group CAF vs CAF + EMD the mean difference between the keratinized tissue gain in the two procedures was 0.40 mm (95% Confindence Interval Lower/Upper: 0.014–0.81) (p < 0.058); for the comparison CAF + CTG + EMD vs. CAF + CTG the mean difference between the two groups resulted in −0.06 mm (95% Confindence Interval Lower Upper −0.45 to 0.33) (p = 0.7603). Discussion: Randomized clinical trials included medium-low quality evidence. The application of Enamel Matrix Derivatives to surgical procedures aimed to cover gingival recessions does not add robust clinical benefit to conventional plastic procedure alone.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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.

Effectiveness of adjunctive hyaluronic acid application in coronally advanced flap in Miller class I single gingival recession sites: a randomized controlled clinical trial

OBJECTIVES

The aim of this randomized controlled clinical trial was to evaluate the possible advantages of adjunctive hyaluronic acid (HA) application in the coronally advanced flap (CAF) procedure in single Miller class I/recession type 1 (RT1) gingival recession treatment.

MATERIAL AND METHODS

Thirty patients with one recession were enrolled; 15 were randomly assigned CAF + HA and 15 to CAF alone. The recession reduction (RecRed), clinical attachment level gain (CAL-gain), changes in probing pocket depth (PPD) and in the width of keratinized tissue (KT), complete root coverage (CRC), and mean root coverage (MRC) were calculated after 18 months. Post-operative morbidity (pain intensity, discomfort, and swelling) was recorded 7 days after treatment using visual analogue scale (VAS).

RESULTS

After 18 months, RecRed was statistically significantly higher in the test group (2.7 mm [1.0]) than in the control group (1.9 mm [1.0]; p = 0.007). PPD were found to be slightly but statistically significantly increased in both groups. No statistically significant difference was found for KT gain between treatments. CRC was 80% for test and 33.3% for control sites (p < 0.05). A MRC of 93.8 ± 13.0% for test and 73.1 ± 20.8% for control sites was calculated (p < 0.05). The test group reported lower swelling and discomfort values 7-days post-surgery (p < 0.05). Statistically significant difference was not found for pain intensity.

CONCLUSIONS

The adjunctive use of HA was effective in obtaining CRC for single Miller class I/RT1 gingival recession sites.

CLINICAL RELEVANCE

Adjunctive application of HA in the coronally advanced flap procedure may improve the reduction of the recessions and increase the probability of CRC in Miller class I recessions.

Comparative Evaluation of Treatment of Localized Gingival Recessions with Coronally Advanced Flap Using Microsurgical and Conventional Techniques

Background

Coverage of gingival recession is a very precision-oriented procedure. Employment of operating microscope has proved to be a boon in various surgical procedures and therefore can have positive benefits on the outcome of a procedure.

Aim

The aim of this study is to find out whether the use of an operating microscope in the surgical treatment of Millers Class I and Class II gingival recession defects could improve the outcome in terms of root coverage and final tissue appearance compared to those done by the conventional technique.

Materials and Methods

This clinical study was carried out on ten patients with the presence of bilateral isolated gingival recession classified as Miller's Class I or Class II recession defect. The split-mouth design was used where coronally advanced flap with the placement of platelet-rich fibrin was done in defects in test (microsurgical) and control (conventional) groups. Various clinical parameters were recorded at baseline and then postoperatively at 3-months and 6-month intervals.

Results

The visual analog scale scores showed a statistically significant difference between scores while all other parameters had no statistically significant difference in intergroup comparison after 3 and 6 months.

Conclusion

While microscope permitted less traumatic and minimally invasive procedure, both groups showed convincing improvement in clinical parameters.

Treatment of multiple maxillary adjacent class I and II gingival recessions with modified coronally advanced tunnel and a new xenogeneic acellular dermal matrix

OBJECTIVE

To evaluate the treatment of maxillary Miller Class I and II multiple adjacent gingival recessions using the modified coronally advanced tunnel technique (MCAT) combined with a new porcine acellular dermal matrix (PADM).

MATERIALS AND METHODS

Twelve patients exhibiting at least six adjacent maxillary Miller Class I and II gingival recessions were consecutively treated by means of MCAT and a PADM. Recession depth (RD), recession width (RW), probing pocket depth (PD), keratinized tissue height (KT), clinical attachment level (CAL), mean root coverage (RC), and complete root coverage (CRC) were recorded.

RESULTS

At 12 months, CRC was obtained in 43% of the 100 gingival recessions, while the mean RC measured 84.35%. Mean RD reduction was 3.16 ± 0.75 mm (P < 0.001), mean RW reduction was 1.73 ± 0.65 mm (P < 0.001), while the gain of CAL was 3.26 ± 1.33 mm (P < 0.001). All patients were satisfied with the esthetic appearance and would undergo the same surgery again.

CONCLUSION

Within their limits, the present results indicate that treatment of Miller Class I and II multiple gingival recessions using PADM in conjunction with the MCAT could be successfully used as an alternative to connective tissue grafts, with the advantage of avoiding the discomfort and morbidity of connective tissue harvesting.

CLINICAL SIGNIFICANCE

The modified coronally advanced tunnel technique using the new porcine acellular dermal matrix represents a clinically and esthetically satisfactory treatment of multiple Miller Class 1 and 2 recession defects.

Twenty years of enamel matrix derivative: the past, the present and the future

BACGROUND

On June 5th, 2015 at Europerio 8, a group of leading experts were gathered to discuss what has now been 20 years of documented evidence supporting the clinical use of enamel matrix derivative (EMD). Original experiments led by Lars Hammarström demonstrated that enamel matrix proteins could serve as key regenerative proteins capable of promoting periodontal regeneration including new cementum, with functionally oriented inserting new periodontal ligament fibres, and new alveolar bone formation. This pioneering work and vision by Lars Hammarström has paved the way to an enormous amount of publications related to its biological basis and clinical use. Twenty years later, it is clear that all these studies have greatly contributed to our understanding of how biologics can act as mediators for periodontal regeneration and have provided additional clinical means to support tissue regeneration of the periodontium.

AIMS

This review article aims to: (1) provide the biological background necessary to understand the rational for the use of EMD for periodontal regeneration, (2) present animal and human histological evidence of periodontal regeneration following EMD application, (3) provide clinically relevant indications for the use of EMD and (4) discuss future avenues of research including key early findings leading to the development of Osteogain, a new carrier system for EMD specifically developed with better protein adsorption to bone grafting materials.

Periodontal soft tissue root coverage procedures: a systematic review from the AAP Regeneration Workshop

BACKGROUND

This paper aims to create a "bridge" between research and practice by developing a practical, extensive, and clinically relevant study that translates evidence-based findings on soft tissue root coverage (RC) of recession-type defects to daily clinical practice.

METHODS

This review is prepared in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement based on the proposed focused questions. A literature search with no restrictions regarding status or the language of publication was performed for MEDLINE and EMBASE databases up to and including June 2013. Systematic reviews (SRs), randomized clinical trials, controlled clinical trials, case series, and case reports evaluating recession areas that were treated by means of RC procedures were considered eligible for inclusion through the three parts of the study (part I, an overview of the base of SRs; part II, an alternative random-effects meta-analyses on mean percentage of RC and sites exhibiting complete RC; and part III, an SR of non-randomized trials exploring other conditions not extensively evaluated by previous SRs). Data on Class I, II, III, and IV recessions, type of histologic attachment achieved with treatment, recipient- and donor-site anatomic characteristics, smoking-related outcomes, root surface conditions, tooth type and location, long-term effectiveness outcomes, unusual conditions that may be reported during conventional daily practice, and patient-centered outcomes were assessed as well.

RESULTS

Of the 2,456 potentially eligible trials, 234 were included. Data on Class I, II, III, and IV gingival recessions, histologic attachment achieved after treatment, recipient- and donor-site anatomic characteristics, smoking-related outcomes, root surface conditions/biomodification, tooth type and location, long-term effectiveness outcomes and unusual conditions that may be reported during conventional daily practice, and patient-centered outcomes (i.e., esthetic, visual analog scale, complications, hypersensitivity, patients perceptions) were assessed. Subepithelial connective tissue (CT)-based procedures and coronally advanced flap plus acellular dermal matrix grafts, enamel matrix derivative, or collagen matrix led to the best improvements of recession depth, clinical attachment level (CAL) gain, and keratinized tissue (KT). Some conditions, such as smoking and use of magnification, may affect RC outcomes.

CONCLUSIONS

All RC procedures can provide significant reduction in recession depth and CAL gain for Miller Class I and II recession-type defects. Subepithelial CT graft-based procedures provided the best outcomes for clinical practice because of their superior percentages of mean and complete RC, as well as significant increase of KT.

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

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

Amnion and Chorion Allografts in Combination with Coronally Advanced Flap in the Treatment of Gingival Recession: A Clinical Study

BACKGROUND

Guided tissue regeneration (GTR) based root coverage using different allograft membranes has been utilized to correct gingival recession defects with promising results. Amnion and chorion allograft membranes of alternative origin derived from human placental tissue has been advocated in the treatment of gingival recession. However, chorion membrane has been used in combination with amnion membrane no study has compared these allograft membranes in the treatment of gingival recession. Therefore, the purpose of this study was to clinically evaluate and compare the efficacy of amnion membrane and chorion membrane in combination with coronally advanced flap in the treatment of gingival recessions.

MATERIALS AND METHODS

Twelve systemically healthy patients having at least 2 bilateral Miller's Class I or Class II gingival recession were recruited and coronally advanced flap was performed with amnion membrane or chorion membrane. Clinical parameters such as gingival Index, plaque index, length of the recession, width of the recession, width of keratinized gingiva, relative attachment level were evaluated at baseline, 3 and 6 months post-surgery.

RESULTS

The mean decrease in length of recession (LR) for Chorion site was 2.00±1.54mm and amnion site was 1.58±1.14mm. The gain in attachment level for amnion site was 2.17±1.53mm and for chorion site was 1.58±1.22mm. The total mean percentage of root coverage was 34% for chorion site and 22% for amnion site.

CONCLUSION

Both amnion membrane and chorion membrane has shown to be versatile allograft material to be used in the treatment of root coverage.

Comparative clinical evaluation of coronally advanced flap with or without platelet rich fibrin membrane in the treatment of isolated gingival recession

Aim:

The aim of this study was to determine whether the addition of an autologous platelet rich fibrin (PRF) membrane to a coronally advanced flap (CAF) would improve the clinical outcome in terms of root coverage, in the treatment of isolated gingival recession.

Materials and Methods:

Systemically healthy 20 subjects each with single Miller's class I or II buccal recession defect were randomly assigned to control (CAF) or test (CAF + PRF) group. Clinical outcome was determined by measuring the following clinical parameters such as recession depth (RD), recession width (RW), probing depth (PD), clinical attachment level (CAL), width of keratinized tissue (WKT), gingival thickness (GTH), plaque index (PI), and gingival index (GI) at baseline, 3^rd, and 6^th month postsurgery.

Results:

The root coverage was 65.00 ± 44.47% in the control group and 74.16 ± 28.98% in the test group at 6^th month, with no statistically significant difference between them. Similarly, CAL, PD, and WKT between the groups were not statistically significant. Conversely, there was statistically significant increase in GTH in the test group.

Conclusion:

CAF is a predictable treatment for isolated Miller's class I and II recession defects. The addition of PRF to CAF provided no added advantage in terms of root coverage except for an increase in GTH.

An explorative study to develop a predictive model based on avascular exposed root surface area for root coverage after a laterally positioned flap

BACKGROUND

The aim of this study is to evaluate the reliability of the avascular exposed root surface area (AERSA) as a prognostic test for gingival recessions (GRs) and to compare the predictive value of the avascular root surface area calculation and Miller classification on the final root-coverage outcomes.

METHODS

Ninety-one patients with 91 isolated single GRs (32 Miller Class I, 29 Miller Class II, and 30 Miller Class III defects) located at the upper and lower incisors and canines were treated with a laterally positioned flap. Clinical parameters were recorded and correlated with the achievement of complete root coverage (CRC) after 6 months.

RESULTS

From all clinical parameters used, AERSA showed the highest sensitivity and specificity for predicting CRC. Receiver operating characteristic curves analyses revealed three acceptable cutoff points based on baseline AERSA for achieving CRC with higher sensitivity and specificity values compared to GR depth, GR width, and gingival thickness. Both univariate and multiple linear regression analyses reported that the models could explain the 86% of the mean root coverage with AERSA.

CONCLUSIONS

This prospective longitudinal study indicates that AERSA may be used to classify GR defects. The newly developed prognostic model may be used to predict the final root coverage outcomes.

Evaluation of recession defects treated with coronally advanced flaps and either recombinant human platelet-derived growth factor-BB plus β-tricalcium phosphate or connective tissue: comparison of clinical parameters at 5 years

BACKGROUND

In a previously reported split-mouth, randomized controlled trial, Miller Class II gingival recession defects were treated with either a connective tissue graft (CTG) (control) or recombinant human platelet-derived growth factor-BB + β-tricalcium phosphate (test), both in combination with a coronally advanced flap (CAF). At 6 months, multiple outcome measures were examined. The purpose of the current study is to examine the major efficacy parameters at 5 years.

METHODS

Twenty of the original 30 patients were available for follow-up 5 years after the original surgery. Outcomes examined were recession depth, probing depth, clinical attachment level (CAL), height of keratinized tissue (wKT), and percentage of root coverage. Within- and across-treatment group results at 6 months and 5 years were compared with original baseline values.

RESULTS

At 5 years, all quantitative parameters for both treatment protocols showed statistically significant improvements over baseline. The primary outcome parameter, change in recession depth at 5 years, demonstrated statistically significant improvements in recession over baseline, although intergroup comparisons favored the control group at both 6 months and 5 years. At 5 years, intergroup comparisons also favored the test group for percentage root coverage and change in wKT, whereas no statistically significant intergroup differences were seen for 100% root coverage and changes to CAL.

CONCLUSIONS

In the present 5-year investigation, treatment with either test or control treatments for Miller Class II recession defects appear to lead to stable, clinically effective results, although CTG + CAF resulted in greater reductions in recession, greater percentage of root coverage, and increased wKT.

Connective tissue graft vs. emdogain: A new approach to compare the outcomes

Background:

The aim of this clinical trial study was to clinically evaluate the use of enamel matrix protein derivative combined with the coronally positioned flap to treat gingival recession compared to the subepithelial connective tissue graft by a new method to obtain denuded root surface area.

Materials and Methods:

Thirteen patients, each with two or more similar bilateral Miller class I or II gingival recession (40 recessions) were randomly assigned to the test (enamel matrix protein derivative + coronally positioned flap) or control group (subepithelial connective tissue graft). Recession depth, width, probing depth, keratinized gingival, and plaque index were recorded at baseline and at one, three, and six months after treatment. A stent was used to measure the denuded root surface area at each examination session. Results were analyzed using Kolmogorov-Smirnov, Wilcoxon, Friedman, paired-sample t test.

Results:

The average percentages of root coverage for control and test groups were 63.3% and 55%, respectively. Both groups showed significant keratinized gingival increase (P < 0.05). Recession depth decreased significantly in both groups. Root surface area was improved significantly from baseline with no significant difference between the two study groups (P > 0.05). The results of Friedman test were significant for clinical indices (P < 0.05), except for probing depth in control group (P = 0.166).

Conclusion:

Enamel matrix protein derivative showed the same results as subepithelial connective tissue graft with relatively easy procedure to perform and low patient morbidity.

Surgical Approaches Based on Biological Objectives: GTR versus GBR Techniques

Guided tissue regenerative (GTR) therapies are performed to regenerate the previously lost tooth supporting structure, thus maintaining the aesthetics and masticatory function of the available dentition. Alveolar ridge augmentation procedures (GBR) intend to regain the alveolar bone lost following tooth extraction and/or periodontal disease. Several biomaterials and surgical approaches have been proposed. In this paper we report biomaterials and surgical techniques used for periodontal and bone regenerative procedures. Particular attention will be adopted to highlight the biological basis for the different therapeutic approaches.

Coronally advanced flap and combination therapy for root coverage. Clinical strategies based on scientific evidence and clinical experience

During the past three decades, several surgical techniques have been proposed to treat single and multiple gingival recessions. Evidence indicates that coronally advanced flap-based approaches result in the best clinical results. Among all the different techniques, the use of a graft under a coronally advanced flap results in the best short- and long-term outcomes in terms of root coverage and gain in keratinized tissue. The use of a coronally advanced flap + connective tissue graft would appear to be the best choice for root coverage. However, harvesting a graft from the palate adds morbidity, surgical chair-time and requires increased surgical skills. A potential alternative could be the use of enamel matrix derivatives under a coronally advanced flap, and this achieves similar clinical outcomes and is less invasive, but adds economic costs to the treatment. Evidence shows that a coronally advanced flap alone in many instances results in complete root coverage and is stable over time. A coronally advanced flap is less invasive for the patient, requires less chair-time and probably less surgical skill. It would therefore be desirable to use a coronally advanced flap approach when indicated. It has been hypothesized that a coronally advanced flap approach alone could be successfully applied when the residual gingiva is thick and wide, although existing evidence does not support this hypothesis in full. Accordingly, the adjunctive use of a graft or enamel matrix derivatives could be restricted to sites at which there is thin and narrow residual gingiva.

Ten-year results following treatment of intrabony defects with an enamel matrix protein derivative combined with either a natural bone mineral or a β-tricalcium phosphate

BACKGROUND

The purpose of the present study is to evaluate the 10-year results following treatment of intrabony defects treated with an enamel matrix protein derivative (EMD) combined with either a natural bone mineral (NBM) or β-tricalcium phosphate (β-TCP).

METHODS

Twenty-two patients with advanced chronic periodontitis and displaying one deep intrabony defect were randomly treated with a combination of either EMD + NBM or EMD + β-TCP. Clinical evaluations were performed at baseline and at 1 and 10 years. The following parameters were evaluated: plaque index, bleeding on probing, probing depth, gingival recession, and clinical attachment level (CAL). The primary outcome variable was CAL.

RESULTS

The defects treated with EMD + NBM demonstrated a mean CAL change from 8.9 ± 1.5 mm to 5.3 ± 0.9 mm (P <0.001) and to 5.8 ± 1.1 mm (P <0.001) at 1 and 10 years, respectively. The sites treated with EMD + β-TCP showed a mean CAL change from 9.1 ± 1.6 mm to 5.4 ± 1.1 mm (P <0.001) at 1 year and 6.1 ± 1.4 mm (P <0.001) at 10 years. At 10 years two defects in the EMD + NBM group had lost 2 mm, whereas two other defects had lost 1 mm of the CAL gained at 1 year. In the EMD + β-TCP group three defects had lost 2 mm, whereas two other defects had lost 1 mm of the CAL gained at 1 year. Compared with baseline, at 10 years, a CAL gain of ≥3 mm was measured in 64% (i.e., seven of 11) of the defects in the EMD + NBM group and in 82% (i.e., nine of 11) of the defects in the EMD + β-TCP group. No statistically significant differences were found between the 1- and 10-year values in either of the two groups. Between the treatment groups, no statistically significant differences in any of the investigated parameters were observed at 1 and 10 years.

CONCLUSION

Within their limitations, the present findings indicate that the clinical improvements obtained with regenerative surgery using EMD + NBM or EMD + β-TCP can be maintained over a period of 10 years.

A Randomized comparative clinical study of two surgical procedures to improve root coverage with the acellular dermal matrix graft

AIM

This randomized, controlled, clinical study compared two surgical techniques for root coverage with the acellular dermal matrix graft (ADMG) to evaluate which procedure could provide better root coverage and greater amounts of keratinized tissue.

MATERIALS AND METHODS

Fifteen pairs of bilateral Miller Class I or II gingival recessions were treated and assigned randomly to the test group, and the contra-lateral recessions were assigned to the control group. The ADMG was used in both groups. In the control group, the graft and flap were positioned at the level of the cemento-enamel junction (CEJ), and in the test group, the graft was positioned 1 mm apical to the CEJ and the flap 1 mm coronal to the CEJ. The clinical parameters were taken before the surgeries and after 6 months. The gingival recession area, a new parameter, was measured in standardized photographs through a special device and software.

RESULTS

There were statistically significant differences favouring the proposed technique for all parameters except for the amount of keratinized tissue at 6 months.

CONCLUSIONS

The proposed test technique is more suitable for root coverage procedures with ADMG, and the new parameter evaluated appears valuable for root coverage analysis. (Clinicaltrials.gov Identifier: NCT01175720).

Periodontal regeneration with enamel matrix derivative in reconstructive periodontal therapy: a systematic review

BACKGROUND

Enamel matrix derivative (EMD) is commonly used in periodontal therapy. The aim of this systematic review is to give an updated answer to the question of whether the additional use of EMD in periodontal therapy is more effective compared with a control or other regenerative procedures.

METHODS

A literature search in MEDLINE (PubMed) for the use of EMD in periodontal treatment was performed up to May 2010. The use of EMD in treatment of intrabony defects, furcations, and recessions was evaluated. Only randomized controlled trials with ≥1 year of follow-up were included. The primary outcome variable for intrabony defects was the change in clinical attachment level (CAL), for furcations the change in horizontal furcation depth, and for recession complete root coverage.

RESULTS

After screening, 27 studies (20 for intrabony defects, one for furcation, and six for recession) were eligible for the review. A meta-analysis was performed for intrabony defects and recession. The treatment of intrabony defects with EMD showed a significant additional gain in CAL of 1.30 mm compared with open-flap debridement, EDTA, or placebo, but no significant difference compared with resorbable membranes was shown. The use of EMD in combination with a coronally advanced flap compared with a coronally advanced flap alone showed significantly more complete root coverage (odds ratio of 3.5), but compared with a connective tissue graft, the result was not significantly different. The use of EMD in furcations (2.6 ± 1.8 mm) gave significantly more improvement in horizontal defect depth compared with resorbable membranes (1.9 ± 1.4 mm) as shown in one study.

CONCLUSIONS

In the treatment of intrabony defects, the use of EMD is superior to control treatments but as effective as resorbable membranes. The additional use of EMD with a coronally advanced flap for recession coverage will give superior results compared with a control but is as effective as a connective tissue graft. The use of EMD in furcations will give more reduction in horizontal furcation defect depth compared with resorbable membranes.