Subepithelial Connective Tissue Graft for Root Coverage in Smokers and Non-Smokers: A Clinical and Histologic Controlled Study in Humans

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.

The effect of smoking on clinical and biochemical early healing outcomes of coronally advanced flap with connective tissue graft: Prospective cohort study

BACKGROUND

This study aimed to determine the effects of smoking on early (≤3 months) clinical outcomes and relevant molecular biomarkers following root coverage surgery.

METHODS

Eighteen smokers and 18 nonsmokers, status biochemically verified, with RT1 gingival recession defects were recruited and completed study procedures. All patients received coronally advanced flap plus connective tissue graft. Baseline and 3 month recession depth (RD), recession width (RW), keratinized tissue width (KTW), clinical attachment level (CAL), and gingival phenotype (GP) were recorded. Root coverage (RC) percentage and complete root coverage (CRC) were calculated. Recipient (gingival crevicular fluid) and donor (wound fluid) site VEGF-A, HIF-1α, 8-OHdG, and ANG levels were determined.

RESULTS

There were no significant intergroup differences for any baseline or postoperative clinical parameters (P > 0.05), except for whole mouth gingival index (increased in nonsmokers at 3 months; P < 0.05). Compared to baseline, RD, RW, CAL, KTW, and GP significantly improved postoperatively, without significant intergroup differences. There were no significant intergroup differences for RC (smokers = 83%, nonsmokers = 91%, P = 0.069), CRC (smokers = 50%, nonsmokers = 72%, P = 0.177), and CAL gain (P = 0.193). The four biomarker levels significantly increased postoperatively (day 7; P ≤ 0.042) in both groups and returned to baseline (day 28) without significant intergroup differences (P > 0.05). Similarly, donor site parameters were not different between groups. Strong correlations, consistent over time, were found between biomarkers implicated in angiogenesis (VEGF-A, HIF-1α, and ANG).

CONCLUSIONS

The early (3 month) clinical and molecular changes after root coverage surgery utilizing a coronally advanced flap plus connective tissue graft are similar between smokers and nonsmokers.

Experimental and clinical studies on plastic periodontal procedures

We have compiled, in this Periodontology 2000 review, all Latin American literature on experimental and clinical studies of periodontal plastic procedures. The body of literature on this subject has led to a discussion of the features and treatment outcomes of root-coverage procedures. Over time, knowledge on periodontal plastic procedures has become less empirical and more supportive of the clinical management of recession-type defects. Gingival recession etiology, animal studies, free gingival grafts, pedicle flaps (semilunar, laterally positioned, and coronally positioned), and subepithelial connective tissue grafts are extensively reviewed. The use of allografts as an alternative to subepithelial connective tissue grafts, the treatment of multiple gingival recessions, and the rationale for use of guided tissue regeneration and enamel matrix derivative in plastic periodontal procedure is discussed. We also assess how smoking can affect the treatment outcomes in plastic surgery procedures. Minimally invasive procedures are of great value in improving the features of the final tissues. The following aspects identified in this compilation were of great interest: (a) some factors, anatomical in nature, favor the formation of root recessions, but it is the inflammatory process (caused by the presence of biofilm and/or by traumatic toothbrushing) that is responsible for the development of root recessions; and (b) pedicle flap procedures (especially the coronally positioned flap) are extremely versatile and have the most predictable outcome of all root-coverage procedures, especially when combined with subepithelial connective tissue grafting and/or allogeneic grafts. In summary: subepithelial connective tissue grafting is considered as the first option to augment gingival width and thickness, and it may provide better long-term results; the same principles of root-coverage procedures in individual sites appear be used in clinical practice also for multiple-recession type defects; an allograft is an efficient alternative to a subepithelial connective tissue graft and, when it is the treatment option of choice, the use of wide, extended flaps should be considered; because of the superiority of plastic periodontal procedures over guided tissue regeneration and the technical difficulty of the latter, guided tissue regeneration has become obsolete for root-coverage procedures; there is rather a large body of evidence attesting that smoking negatively influences root-coverage procedures, especially subepithelial connective tissue grafts; and minimally invasive techniques may be of great value for improving the results obtained with plastic periodontal procedures, but these techniques need to be better addressed in clinical trials, both in terms of the quality and quantity of the new tissue generated.

Sub-epithelial connective tissue graft for the management of Miller's class I and class II isolated gingival recession defect: A systematic review of the factors influencing the outcome

The aim of the present systematic review was to analyze the factors that affect the outcome of subepithelial connective tissue graft (SCTG) for managing Miller's class I and class II isolated gingival recession defect. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for systematic reviews were used. Quality assessments of selected articles were performed. Data on root surface condition, recession type defect, flap thickness, different flap designs, different harvesting techniques, presence/absence of the epithelial collar, graft thickness, flap tension, suturing techniques, and smoking-related outcomes on root coverage were assessed. The SCTG procedure provides the best root coverage outcomes for Miller's class I and class II recession. The critical threshold of flap thickness was found to be 1 mm. Maximum root coverage was achieved by envelope and modified tunnel technique. SCTG with the epithelial collar does not provide additional gains than SCTG without the epithelial collar. The thickness of SCTG for root coverage was found to be 1.5-2 mm. Greater flap tension and smoking adversely affect root coverage outcomes. Analysis of the factors discussed would be of key importance for technique selection, and a combined approach involving factors favoring outcomes of SCTG could be of clinical relevance in recession coverage.

Free Gingival Graft versus Mucograft: Histological Evaluation

INTRODUCTION:

The correction of the gingival recession is of esthetical and functional significance, but the tissue regeneration can only be confirmed by a histological examination.

AIM:

This study aims to make a comparison between the free gingival graft and the autograft.

MATERIAL AND METHODS:

This study included 24 patients with single and multiple gingival recessions. Twelve patients were treated with a free gingival graft and the other twelve with a micrograft. Six months after the surgical procedure, a micro-punch biopsy of the transplantation area was performed. The tissue was histologically evaluated, graded in 4 categories: immature, mature, fragmented and edematous collagen tissue. The elastic fibres were also examined and graded in three categories: with a normal structure, fragmented rare and fragmented multiplied.

RESULTS:

Regarding the type of collagen tissue that was present, there was a significant difference between the two groups of patients, with a larger number of patients treated with a micrograft showing a presence of mature tissue, compared to the patients treated with a free gingival graft. A larger number of patients in both of the groups displayed elastic fibres with a rare fragmented structure; 33.3% of the patients showed a normal structure; 50% demonstrated a normal structure.

CONCLUSION:

The patients treated with a free gingival graft showed a larger presence of fragmented collagen tissue and fragmented elastic fibres, whereas a mature tissue was predominantly present in the surgical area where a Geistlich Mucograft was placed.

Sub-epithelial connective tissue graft for root coverage in nonsmokers and smokers: A pilot comparative clinical study

Background:

Gingival recession is a common condition and is more prevalent in smokers. It is widely believed that root coverage procedures in smokers result in less desirable outcome compared to nonsmokers', and there are few controlled studies in literature to support this finding. Therefore, the purpose of this study was to evaluate and compare the outcome of root coverage with sub-epithelial connective tissue graft (SCTG) in nonsmokers and smokers.

Materials and Methods:

A sample of twenty subjects, 10 nonsmokers and 10 smokers were selected each with at least 1 Miller's Class I or II recession on a single rooted tooth. Clinical measurements of probing depth, clinical attachment level (CAL), gingival recession total surface area (GRTSA), depth of recession (RD), width of recession (RW), and width of keratinized tissue were determined at baseline, 3, and 6 months after surgery.

Results:

The treatment of gingival recession with SCTG and coronally advanced flap showed a decrease in the GRTSA, RD, RW, and an increase in CAL and width of keratinized gingiva in both the groups. However, the intergroup comparison of the clinical parameters showed no statistical significance. About 6 out of 10 nonsmokers (60%) and 3 smokers (30%) showed complete root coverage. The mean percentage of root coverage of 71.2% in nonsmokers and 38% in smokers was observed.

Conclusion:

The results of the present study suggest that smoking may negatively influence gingival recession reduction and CAL gain. In addition, smokers may exhibit fewer chances of complete root coverage. Overall, nonsmokers showed better improvements in all the parameters compared to smokers at the end of 6 months.

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.

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.

Treatment of gingival recessions in heavy smokers using two surgical techniques: a controlled clinical trial

Smokers have small root coverage which is associated with bad vascularity of periodontal tissues. This study evaluated a technique that can increase the blood supply to the periodontal tissues compared with a traditional technique. Twenty heavy smokers (10 males and 10 females) with two bilateral Miller class I gingival recessions received coronally positioned flaps in one side (Control group)and extended flap technique in the other side (Test group). Clinical measurements (probing pocket depth, clinical attachment level, bleeding on probing, gingival recession height, gingival recession width, amount of keratinized tissue, and width and height of the papillae adjacent to the recession) were determined at baseline, 3 and 6 months postoperatively. Salivary cotinina samples were taken as an indicator of the nicotine exposure level. No statistically significant differences (p>0.05) were detected for the clinical measurements or smoke exposure. Both techniques promoted low root coverage (Control group: 43.18% and Test group: 44.52%). In conclusion, no difference was found in root coverage between the techniques. Root coverage is possible and uneventful even, if rather low, in heavy smoker patients with low plaque and bleeding indices.

[Effects of smoking on periodontal disease]

INTRODUCTION

Smoking is an independent risk factor for periodontal disease and tooth loss.

STATE OF THE ART

Smoking impairs inflammatory and immune responses to periodontal pathogens, and exerts both systemic and local effects. Periodontal disease is increased both in prevalence and severity in smokers. Smoking is a predisposing factor to acute necrotizing ulcerative gingivitis and is associated with an increased rate of periodontal disease in terms of pocket formation and attachment loss, as well as alveolar bone loss. Cigar, pipe, water-pipe and cannabis smoking have similar adverse effects on periodontal health as cigarette smoking. Passive smoking is also an independent periodontal disease risk factor. Smokeless tobacco is associated with localized periodontal disease. Smokers respond less favourably to both non-surgical and surgical treatments and have higher failure rates and complications following dental implantation. Smoking cessation may halt the disease progression and improve the outcome of periodontal treatment.

CONCLUSION

Smoking cessation counselling should be an integral part of periodontal therapy and prevention.

Surgical management of gingival recession: A clinical update

Gingival recession is defined as the apical migration of the junctional epithelium with exposure of root surfaces. It is a common condition seen in both dentally aware populations and those with limited access to dental care. The etiology of the condition is multifactorial but is commonly associated with underlying alveolar morphology, tooth brushing, mechanical trauma and periodontal disease. Given the high rate of gingival recession defects among the general population, it is imperative that dental practitioners have an understanding of the etiology, complications and the management of the condition. The following review describes the surgical techniques to treat gingival recession.