Evaluation of Human Recession Defects Treated With Coronally Advanced Flaps and Either Enamel Matrix Derivative or Connective Tissue: Comparison of Clinical Parameters at 10 Years

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Minimal invasiveness in gingival augmentation and root coverage procedures

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

Efficacy of biologics in root coverage and gingival augmentation therapy: An American Academy of Periodontology best evidence systematic review and network meta-analysis

BACKGROUND

The aim of this systematic review was to assess the efficacy of three biologics, namely autologous blood-derived products (ABPs), enamel matrix derivatives (EMD) and recombinant human platelet-derived growth factor BB (rhPDGF-BB), in root coverage and gingival augmentation therapy.

METHODS

The protocol of this PRISMA 2020-compliant systematic review was registered in PROSPERO (CRD42021285917). After study selection, data of interest were extracted. A network meta-analysis (NMA) was conducted to assess the effect of different surgical interventions on the main clinical outcomes of interest (i.e., mean root coverage [MRC%], complete root coverage [CRC%], keratinized tissue width [KTW], gingival thickness [GT] change, and recession depth [RD] reduction).

RESULTS

A total of 48 trials reported in 55 articles were selected. All studies reported on the treatment of gingival recession defects for root coverage purposes. Forty-six treatment arms from 24 trials were included in the NMA. These arms consisted of treatment with coronally advanced flap (CAF) alone, EMD + CAF, platelet-rich fibrin (PRF) + CAF, and subepithelial connective tissue graft (SCTG) + CAF. Regarding MRC%, SCTG+CAF was associated with a significant higher estimate (13.41%, 95% CI [8.06-18.75], P <  0.01), while EMD+CAF (6.68%, 95% CI [-0.03 to 13.4], P = 0.061) and PRF+CAF (1.03%, 95% CI [-5.65 to 7.72], P = 0.71) failed to show statistically significant differences compared with CAF alone (control group) or with each other. Similarly, only SCTG+CAF led to a significantly higher CRC% (14.41%, 95% CI [4.21 to 24.61], P < 0.01), while treatment arms EMD + CAF (13.48%, 95% CI [-3.34 to 30.32], P = 0.11) and PRF+CAF (-0.91%, 95% CI [-15.38, 13.57], p = 0.81) did not show significant differences compared with CAF alone or with each other. Differences in the CI of PRF+CAF (symmetrical around a zero adjunctive effect) and EMD+CAF (non-symmetrical) suggest that EMD could have some additional value compared with PRF. Treatment with SCTG+CAF led to a statistically significant higher RD reduction (-0.39 mm, 95% CI [-0.55 to 0.22], P < 0.01), however EMD+CAF (-0.13 mm, 95% CI [-0.29 to 0.01], P = 0.08) and PRF+CAF (-0.06 mm, 95% CI [-0.23 to 0.09], P = 0.39) failed to show significant differences compared with CAF or with each other. While SCTG+CAF was associated with a statistically significant higher gain of KTW (0.71 mm, 95% CI [0.48 to 0.93], P < 0.01), EMD+CAF (0.24 mm, 95% CI [-0.02 to 0.51], P = 0.08) and PRF+CAF (0.08 mm, 95% CI [-0.23 to 0.41], P = 0.58) did not result into significant changes compared with CAF alone or with each other. Regarding the use of rhPDGF-BB+CAF, although available studies have reported equivalent results compared with SCTG+CAF, evidence is very limited.

CONCLUSIONS

The use of ABPs, EMD, or rhPDGF-BB in conjunction with a CAF for root coverage purposes is safe and generally promotes significant improvements respective to baseline clinical parameters. However, the adjunctive use of ABPs and EMD does not provide substantial additional improvements in terms of clinical outcomes and patient-reported outcome measures to those achieved using CAF alone, when baseline KTW is >2 mm. Both PRF+CAF and EMD+CAF rendered inferior MRC%, CRC%, RD reduction, and KTW gain compared with SCTG+CAF, which should still be considered the gold-standard in root coverage therapy. Although some studies have reported equivalent results for rhPDGF-BB+CAF compared with the gold-standard intervention, limited evidence precludes formal comparisons with CAF or SCTG+CAF that could be extrapolated to guide clinical practice.

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.

The Progress of Decellularized Scaffold in Stomatology

The oral and maxillofacial region contains oral organs and facial soft tissues. Due to the complexity of the structures and functions of this region, the repair of related defects is complicated. Different degrees of defects require different repair methods, which involve a great combination of medicine and art, and the material requirements are extremely high. Hence, clinicians are plagued by contemporary oral repair materials due to the limitations of bone harvesting, immune rejection, low osteogenic activity and other problems. Decellularized extracellular matrix has attracted much attention as a bioactive scaffold material because of its nonimmunogenic properties, good osteogenic properties, slow release of growth factors, promotion of seed cell adhesion and maintenance of stem cell characteristics. This article reviews the sources, preparation methods, application and research progress of extracellular matrix materials in the repair of oral and maxillofacial defects to provide an overview for fundamental research and clinical development.

Stability of biomaterials used in adjunct to coronally advanced flap: A systematic review and network meta-analysis

AIM

The objective of this network meta-analysis was to rank different biomaterials used in adjunct to coronally advanced flap (CAF), based on their performance in root-coverage for Miller's Class I and II gingival recessions.

MATERIALS AND METHODS

An electronic database search was carried out in PUBMED, CENTRAL, SCOPUS, and EMBASE to identify the eligible articles and compiled into the citation manager to remove the duplicates. The primary outcome was keratinized gingival tissue width (KGW) and percentage of root coverage (%RC). The treatment effect of different biomaterials was estimated using predictive interval plots and ranked based on biomaterials performance, using multidimensional scale ranking.

RESULTS

CAF + connective tissue graft (CTG), CAF + platelet concentrate matrix (PCM) and acellular dermal matrix (ADM) ranked at the top positions in performance in improving KGW. The highest ranked materials in improving percentage of root coverage in gingival recession were CAF + collagen matrix (CM) + gingival fibroblasts (GF), CAF + ADM + platelet rich plasma (PRP) and CAF + ADM, as compared to CAF alone.

CONCLUSION

CTG, ADM, platelet concentrates, and CM + GFs, when used in adjunct to CAF, showed improved stability over ≥12 months of follow-up, better percentage of root coverage, and improved keratinized gingival width.

Efficacy of a harvest graft substitute for recession coverage and soft tissue volume augmentation: A randomized controlled trial

BACKGROUND

The autogenous connective tissue graft (CTG) with coronally advanced flap (CTG+CAF) is the "gold standard" for recession defect coverage; however, researchers continue to pursue lower morbidity, more convenient and unlimited supply harvest graft substitutes, including those that could provide soft tissue volume augmentation.

METHODS

A randomized, controlled, double-masked comparison of a volume-stable collagen matrix (VCMX) versus CTG was conducted at four clinical investigation sites. Single, contralateral, within patient matched-pair, RT1 recession defects were treated with VCMX+CAF (test) and CTG+CAF (control). The primary efficacy end point was percent root coverage at 6 months. Secondary efficacy end points included clinical measures such as soft tissue volume, attachment level, and keratinized tissue width. Patient-reported outcomes included measures such as discomfort, esthetics, and overall satisfaction; 6-month end point results were followed for 1 year.

RESULTS

Thirty patients received control and test therapies, and all patients were available for follow-up measures. Average percent root coverage for CTG+CAF was 90.5% ± 14.87% versus 70.7% ± 28.26% for VCMX+CAF, P <0.0001. Both therapies produced significant soft tissue volume increases (84.8 ± 47.43 mm² control versus 48.90 ± 35.58 mm² test, P = 0.0006). The test, harvest graft substitute produced less postoperative pain and was preferred by patients at the 6-month end point. All other end point measures were not significantly different.

CONCLUSIONS

VCMX+CAF root coverage was inferior to CTG+CAF but produced less morbidity and was preferred by patients. Case/patient selection and surgical technique appear key to achieving successful results with the harvest graft alternative.

Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivate for root coverage: 5-year results of an RCT using 3D digital measurement technology for volumetric comparison of soft tissue changes

AIM

Comparison of the clinical efficacy (digitally volumetric, aesthetic, patient-centred outcomes) of tunnel technique (TUN) with subepithelial connective tissue graft (CTG) versus coronally advanced flap (CAF) with enamel matrix derivate (EMD) 5 years after gingival recession therapy.

MATERIALS AND METHODS

In 18 patients contributing 36 RT1 recessions, study models were collected at baseline and follow-ups. Optical scans assessed recessions computer-assisted [recession depth, recession reduction (RECred), complete root coverage (CRC), percentage of root coverage (RC), pointwise (pTHK) and mean areal (aTHK) marginal soft tissue thickness]. Root coverage aesthetic Score (RES) was used for aesthetic evaluation and visual analogue scales for patient-centred data collection applied.

RESULTS

Sixty months after surgery, 50.0% (TUN+CTG) and 0.0% (CAF+EMD) of sites showed CRC (p = 0.0118), 82.2% (TUN+CTG) and 32.0% (CAF+EMD) achieved RC, respectively (p = 0.0023). CTG achieved significantly better RECred (TUN+CTG: 1.75±0.74 mm; CAF+EMD: 0.50 ± 0.39 mm; p = 0.0009) and aTHK (TUN+CTG: 0.95 ± 0.41 mm; CAF+EMD: 0.26 ± 0.28 mm; p = 0.0013). RES showed superior outcomes (p = 0.0533) for TUN+CTG (6.86 ± 2.31) compared to CAF+EMD (4.63 ± 1.99). The study failed to find significant differences related to patient-centred outcomes (TUN+CTG: 8.30 ± 2.21; CAF+EMD: 7.50 ± 1.51; p = 0.1136).

CONCLUSIONS

Five years after treatment, CTG resulted in better clinical and aesthetic outcomes than CAF+EMD. Increased THK was associated with improved outcomes for RECred and RC.

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

Objectives

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

Material and Methods

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

Results

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

Conclusions

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Randomized clinical trial evaluating single maxillary gingival recession treatment with connective tissue graft and tunnel or trapezoidal flap: 2-year follow-up

BACKGROUND

The literature lacks long-term evidence regarding outcomes of the coronally advanced tunnel flap (TUN) combined with connective tissue graft (CTG) when compared to the trapezoidal coronally advanced flap (CAF) and CTG combination. This study presents 2-year results of a randomized clinical trial comparing CTG combined with either CAF or TUN in the treatment of single maxillary gingival recession (GR) defects.

METHODS

Thirty-nine patients, each contributing a single Miller Class I or II GR defect, were treated by CAF+CTG (control; n = 19) or TUN+CTG (test; n = 20) and completed the 2-year follow up. Clinical, patient centered, and esthetic evaluations were performed and differences among groups were analyzed.

RESULTS

At 2 years, mean root coverage for control and test group was 89.5% ± 14.6% and 87.7% ± 18.4%, respectively (P = 0.5). The corresponding complete root coverage prevalence was 68.4% and 50% (P = 0.4). Dentin hypersensitivity significantly decreased for both groups. The two groups showed improvement in esthetics, as assessed by both professionals and patients, without significant intergroup differences (P > 0.5). TUN+CTG sites were much more likely to present improvement in root coverage between 6 months and 2 years, exhibiting creeping attachment of 0.7 ± 0.6 mm.

CONCLUSIONS

At 2 years of follow up, both CAF+CTG and TUN+CTG resulted in significant clinical and esthetic improvements and provided similar results in the treatment of single maxillary GRs.

Three-dimensional cell printing of gingival fibroblast/acellular dermal matrix/gelatin-sodium alginate scaffolds and their biocompatibility evaluation in vitro

Tissue engineering has emerged as a promising approach for soft tissue regeneration. Three-dimensional (3D) cell printing showed great potential for producing cell-encapsulated scaffolds to repair tissue defects. The advantage of 3D cell printing technology is precise cell loading in scaffolds to achieve tissue regeneration instead of only relying on the cells from surrounding tissue or blood. A new acellular dermal matrix/gelatin-sodium alginate (ADM/A/G) scaffold with living gingival fibroblasts was constructed by 3D cell printing technology for potential oral soft tissue regeneration in this study, and the biological characteristics of the 3D cell printing scaffolds were evaluated. The residue of nucleic acid and growth factors in ADM were detected. Three biomaterials were mixed at an appropriate radio with human gingival fibroblasts (hGFs) to prepare bioinks. Two kinds of layer scaffolds were fabricated by 3D cell printing technology. The mechanical strength and degradability of the scaffolds were determined by measuring their compressive modulus and mass loss. CCK-8 assay and calcein-AM/PI staining were conducted to detect the cell proliferation and viability in 3D cell printing scaffolds. The morphology of the hGFs in the scaffolds were observed using SEM and FITC-phalloidin staining. The expression of COL1A1, PECAM1, and VEGF-A of hGFs in the scaffolds were quantified by qRT-PCR. The gelatin-sodium alginate (A/G) scaffolds were used as control group in all experiments. Compared with the control group, 3D cell printing ADM/A/G scaffolds showed better mechanical strength and longer degradation time. The ADM/A/G scaffolds obviously had a better promotion effect on cell proliferation and viability. Most of the hGFs observed had a fully extended spindle morphology in the ADM/A/G scaffolds but oval morphology in the control group. The expression of COL1A1 was significantly higher than in the control group with time, and the expression of PECAM1 and VEGF-A was slightly higher in ADM/A/G scaffolds on day 14. 3D cell printing gingival fibroblast-ADM/A/G scaffolds showed excellent biological properties, which could be potentially useful in oral soft tissue regeneration.

A 3-year prospective clinical and patient-centered trial on subepithelial connective tissue graft with or without enamel matrix derivative in Class I-II Miller recessions

BACKGROUND AND OBJECTIVE

The study compared clinical and patient-centered outcomes of subepithelial connective tissue graft (CTG) with and without enamel matrix derivative (EMD) in the treatment of Class I-II Miller periodontal recession defects.

MATERIAL AND METHODS

This prospective clinical study evaluated 80 patients over a 3 years follow-up in a private periodontal practice. A total of 144 maxillary and mandibular anterior teeth were divided into two groups: group 1 (CTG with EMD-80 teeth) and group 2 (CTG only-64 teeth). Recession (REC), keratinized tissue (KT) width, % root overage, patient-centered outcomes, and pain visual analog scale (P-VAS) were compared between the two groups.

RESULTS

At 3 years follow-up at a patient level, statistically significant changes in REC were achieved in both group 1 (4.65 ± 1.84 to 0.39 ± 0.19 mm) and group 2 (4.43 ± 1.11 to 0.92 ± 0.43 mm). Complete root coverage (CRC) was achieved in 66.4% of group 1 and 50.1% of group 2. At both patient and tooth level, the 3-year outcomes were superior for group 1 compared with group 2 in terms of % root coverage, REC, and KT width. Clinical attachment loss (CAL) was reduced in group 1 compared with group 2 at the tooth level analysis only (<.01). Significantly less pain was reported using the pain visual analog Scale (P < .001) at the two weeks follow-up post-surgery in group 1.

CONCLUSIONS

Addition of EMD results in improved root coverage outcomes and higher amounts of keratinized tissue width 36 months after treatment of multiple adjacent recessions on maxillary and mandibular anterior teeth. The adjunctive use of EMD also resulted in significantly reduced pain 14 days after the surgery.

Subepithelial connective tissue graft with or without enamel matrix derivative for the treatment of multiple Class III-IV recessions in lower anterior teeth: A 3-year randomized clinical trial

BACKGROUND

This study compared clinical and patient-centered outcomes of subepithelial connective tissue graft (CTG) with and without enamel matrix derivative (EMD) in the treatment of multiple Class III-IV Miller periodontal recession (REC) defects on mandibular anterior teeth.

METHODS

This randomized clinical study evaluated 41 patients at 3 years follow-up. One hundred and fifty-six teeth were divided into two groups: test (CTG-EMD, 79 teeth) and control (CTG only, 77 teeth). Clinical REC, keratinized tissue (KT) width, percentage of root coverage, patient-centered outcomes were compared between the two groups.

RESULTS

At 36 months follow-up, patient level analysis showed that REC in the test group reduced significantly (5.71 ± 0.58 mm to 1.57 ± 0.85 mm) compared with the control group (5.94 ± 0.46 mm to 2.51 ± 0.62 mm) (P < 0.001), while KT width increased in the test group (1.51 ± 0.26 mm to 4.18 ± 0.34 mm) and was significantly greater than the control group (1.65 ± 0.21 mm to 2.90 ± 0.20 mm) (P < 0.001). At 36 months, tooth level analysis (Class III and Class IV groups) found less residual REC and increased KT in the test group compared with the control group (P < 0.01). Significantly less pain was reported at 2, 7, and 14 days follow-up post-surgery in the test group (P < 0.001).

CONCLUSIONS

The addition of EMD to CTG results in improved root coverage outcomes and higher amounts of KT width 36 months after treatment of Class III-IV REC on mandibular anterior teeth. The adjunctive use of EMD also resulted in significantly reduced pain 14 days post-surgery.

Comparison of two soft tissue substitutes for the treatment of gingival recession defects: an animal histological study

Objectives:

This study aimed to compare two different soft tissue replacement grafts in their ability to treat gingival recession defects and successfully integrate with the surrounding tissues.

Methodology:

Nine beagle dogs were included and followed up to 10 weeks. Sites for intervention were allocated to one of the grafting materials investigated. Treatment consisted of coronally advanced flap combined with one of the two soft tissue substitutes on a previous surgically created defect. Materials employed were porcine-derived acellular dermal matrix (ADM) [Novomatrix^™ (Test)] and collagen-based matrix (CBM) [Mucograft^® (Control)]. Animals were sacrificed at 2, 6, and 10 weeks postoperatively and compared using descriptive histology and histomorphometric outcomes.

Results:

Macroscopic findings were similar between test and control groups at all intervals. After 10 weeks, both groups demonstrated successful incorporation of the grafting materials without signs of rejection and with comparable tissue integration. The histomorphometric data were similar between groups at 2 weeks; however, the test group provided greater root coverage and increase in tissue thickness than the control at 6- and 10-weeks post surgically.

Conclusions:

Both porcine-derived ADM and CBM revealed similar histological outcomes with successful integration and absence of adverse events. Test group provided superior outcomes regarding root coverage and increase in tissue thickness.

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

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

Effect of gingival augmentation procedure (free gingival graft) on reducing the risk of non-carious cervical lesions: A 25- to 30-year follow-up study

BACKGROUND

The aim of this long-term case series was to assess the development/prevalence of non-carious cervical lesions (NCCLs) at sites that have and have not been treated with gingival augmentation following free gingival graft (FGG).

METHODS

Fifty-two patients had at least one test and one control site: 1) test site showing absence of attached gingiva (AG) associated with gingival recession (GR) treated with FGG; and 2) contralateral site with or without AG. Patient/tooth/site-associated variables were recorded for each tooth/site at baseline (T0), 12 months after surgery (T1), during the follow-up period (T2) (15 to 20 years), and at the end of the follow-up period (T3) over 25 to 30 years. Mixed-effects logistic regression was used throughout the study.

RESULTS

Forty-nine patients/130 sites were available for analysis at T2 whereas 44 patients/120 sites at T3. Twenty-two NCCLs >0.5 mm were restored in the test sites and in 35 in the untreated sites. The development of NCCL over time appeared associated with sites with attached KT <2 mm (i.e., odds ratio [OR]: 3.80 [P = 0.045] and 3.47 [P = 0.046], 15- to 20- and 20- to 30-year follow-ups, respectively), as well as to teeth presenting a thin/non-modified periodontal phenotype (i.e., OR: 3.53 [P = 0.037] and 5.51 [P = 0.008], 15- to 20- and 20- to 30-year follow-ups, respectively).

CONCLUSIONS

Periodontal phenotype modification achieved by FGG may prevent the development/progression of NCCL. Evidence suggests that the thickness and width of the AG had a direct influence on the need of restoring these lesions during the 25- to 30-year observation period.

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.

Exploring the Gingival Recession Surgical Treatment Modalities: A Literature Review

Gingival recessions present complex soft tissue pathology, with a multiple aetiology and a high prevalence which increases with age. They are defined as an exposure of the root surface of the teeth as a result of the apical migration of the gingival margin beyond the cementum-enamel junction, causing functional and aesthetic disturbances to the affected individuals. Aiming to ensure complete root coverage and satisfying aesthetic outcomes, a wide range of surgical techniques have been proposed through the decades for the treatment of the gingival recessions. The following literature review attempts to provide a comprehensive, structured and up-to-date summary of the relevant literature regarding these surgical techniques, aiming to emphasise for each technique its indications, its long-term success and predictability, its advantages and disadvantages about each other.

Xenogenous Collagen Matrix and/or Enamel Matrix Derivative for Treatment of Localized Gingival Recessions: A Randomized Clinical Trial. Part I: Clinical Outcomes

BACKGROUND

Considering xenogeneic collagen matrix (CM) and enamel matrix derivative (EMD) characteristics, it is suggested that their combination could promote superior clinical outcomes in root coverage procedures. Thus, the aim of this parallel, double-masked, dual-center, randomized clinical trial is to evaluate clinical outcomes after treatment of localized gingival recession (GR) by a coronally advanced flap (CAF) combined with CM and/or EMD.

METHODS

Sixty-eight patients presenting one Miller Class I or II GRs were randomly assigned to receive either CAF (n = 17); CAF + CM (n = 17); CAF + EMD (n = 17), or CAF + CM + EMD (n = 17). Recession height, probing depth, clinical attachment level, and keratinized tissue width and thickness were measured at baseline and 90 days and 6 months after surgery.

RESULTS

The obtained root coverage was 68.04% ± 24.11% for CAF; 87.20% ± 15.01% for CAF + CM; 88.77% ± 20.66% for CAF + EMD; and 91.59% ± 11.08% for CAF + CM + EMD after 6 months. Groups that received biomaterials showed greater values (P <0.05). Complete root coverage (CRC) for CAF + EMD was 70.59%, significantly superior to CAF alone (23.53%); CAF + CM (52.94%), and CAF + CM + EMD (51.47%) (P <0.05). Keratinized tissue thickness gain was significant only in CM-treated groups (P <0.05).

CONCLUSIONS

The three approaches are superior to CAF alone for root coverage. EMD provides highest levels of CRC; however, the addition of CM increases gingival thickness. The combination approach does not seem justified.

Biofunctionalization of porcine-derived collagen matrix using enamel matrix derivative and platelet-rich fibrin: influence on mature endothelial cell characteristics in vitro

OBJECTIVES

The present study evaluated the effect of an enamel matrix derivative (EMD) and platelet-rich fibrin (PRF)-modified porcine-derived collagen matrix (PDCM) on human umbilical vein endothelial cells (HUVEC) in vitro.

MATERIALS AND METHODS

PDCM (mucoderm®) was prepared to 6 mm (±0.1 mm) diameter discs. PDCM samples were incubated with either EMD, PRF, or control solutions for 100 min at 4 °C before the experiments. Cell-inducing properties of test materials on HUVEC cells were tested with cell proliferation assays (MTT, PrestoBlue®), a cytotoxicity assay (ToxiLight®), a Boyden chamber migration assay, and a cell attachment assay. Scanning electron microscopy (SEM) imaging was performed to determine the surface and the architecture of the modified matrices.

RESULTS

Cell proliferation was elevated in the EMD and PRF groups compared with control (p each ≤0.046). PRF modification increased HUVEC migration ability by 8-fold compared with both control and EMD groups (p each <0.001). Both treatments significantly promoted the cell attachment of HUVEC to PDCM, as assessed by direct cell counts on the matrices (p each <0.001).

CONCLUSIONS

HUVEC cell characteristics were overall improved by EMD- and PRF- modified PDCM. Adsorbed bioactive molecules to the PDCM surface may have contributed to a more preferable environment to surrounding cells.

CLINICAL RELEVANCE

The results may give evidence that PDCM modification with EMD or PRF, respectively, might be a useful approach to improve clinical outcomes, to prevent inflammatory reactions and wound-healing disturbances, and to expand the clinical application area of PDCM.

Root coverage procedures improve patient aesthetics. A systematic review and Bayesian network meta-analysis

BACKGROUND

The aim of this study was to perform a systematic review (SR) of randomized controlled trials (RCTs) to explore if periodontal plastic surgery procedures for the treatment of single and multiple gingival recessions (Rec) may improve aesthetics at patient and professional levels.

MATERIAL AND METHODS

In order to combine evidence from direct and indirect comparisons by different trials a Bayesian network meta-analysis (BNM) was planned. A literature search on PubMed, Cochrane libraries, EMBASE, and hand-searched journals until January 2016 was conducted to identify RCTs presenting aesthetic outcomes after root coverage using standardized evaluations at patient and professional level.

RESULTS

A total of 16 RCTs were selected in the SR; three RTCs presenting professional aesthetic evaluation with Root coverage Aesthetic Score (RES) and three showing final self-perception using the Visual Analogue Scale (VAS Est) could be included in a BNM model. Coronally Advanced Flap plus Connective Tissue Graft (CAF + CTG) and CAF + Acellular Dermal Matrix (ADM) and Autologous Fibroblasts (AF) were associated with the best RES outcomes (best probability = 24% and 64%, respectively), while CAF + CTG and CAF + CTG + Enamel matrix Derivatives (EMD) obtained highest values of VAS Est score (best probability = 44% and 26%, respectively).

CONCLUSIONS

Periodontal Plastic Surgery (PPS) techniques applying grafts underneath CAF with or without the adding of EMD are associated with improved aesthetics assessed by final patient perception and RES as professional evaluation system.

Does Adjunctive Use of Growth Factors Improve Clinical Outcomes of Soft Tissue Grafting at Miller Class III Recession Defects? A Review of Current Evidence

Focused Clinical Question In patients with gingival recession that is classified as Miller Class III, does adjunctive use of local growth factors with gingival grafting procedures improve clinical outcomes? Clinical Scenario A 31-year-old female presents with a chief complaint of gingival recession (GR) at teeth #4 to #13 (Fig. 1). Interproximal bone loss coronal to the level of the buccal GR is present. She is concerned about esthetics and would like to maximize her chance for complete root coverage. Her medical history is non-contributory, and she has no contraindications to routine dental care. Because of the number of teeth involved and the difficulty in harvesting autogenous tissues, she is treated with acellular dermal matrix^§ and enamel matrix derivative^‖ with a coronally advanced flap at teeth #4 to #13 (Figs. 2 and 3). Final results reveal significant root coverage on all teeth and complete root coverage on teeth #7 to #10. This results in an esthetically acceptable result (Fig. 4).

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.

A Prospective, Case-Controlled Study Evaluating the Use of Enamel Matrix Derivative on Human Buccal Recession Defects: A Human Histologic Examination

BACKGROUND

Connective tissue grafts (CTGs) and coronally advanced flaps (CAFs) do not regenerate periodontal attachment apparatus when used to treat gingival recessions (GRs). Instead of generating new bone, cementum, and inserting periodontal ligament fibers, CTG+CAF repairs through a long epithelial junction and connective tissue attachment. Enamel matrix derivatives (EMDs) have demonstrated proof-of-principle that periodontal regeneration can be achieved, although data are limited.

METHODS

Three patients, each requiring extraction of four premolars before orthodontic treatment, were enrolled in a randomized, open-label study. Two months after induction of Miller Class I and II GR, each patient received EMD+CAF for three teeth and CTG+CAF for one tooth for root coverage. Nine months after root coverage, all four premolars from each of the three patients were surgically extracted en bloc for histologic and microcomputed tomography (micro-CT) analysis, looking for evidence of periodontal regeneration. Standard clinical measurements, radiographs, and intraoral photographs were taken over prescribed time points.

RESULTS

Seven of the nine teeth treated with EMD+CAF demonstrated varying degrees of periodontal regeneration, detailed through histology with new bone, cementum, and inserting fibers. Micro-CT corroborated these findings. None of the three teeth treated with CTG+CAF showed periodontal regeneration. Clinical measurements were comparable for both treatments. One instance of root resorption and ankylosis was noted with EMD+CAF.

CONCLUSIONS

EMD+CAF continues to show histologic evidence of periodontal regeneration via human histology, this being the largest study (nine teeth) examining its effect when treating GR. The mechanism of action, ideal patient profile, and criteria leading to predictable regeneration are in need of further exploration.

Bifunctional bioceramics stimulating osteogenic differentiation of a gingival fibroblast and inhibiting plaque biofilm formation

A bifunctional Ca–Mg–Si bioceramic induces osteogenic differentiation of gingival fibroblasts and inhibits plaque biofilm formation.

Biologic Agents for Periodontal Regeneration and Implant Site Development

The advancement of molecular mediators or biologic agents has increased tremendously during the last decade in periodontology and dental implantology. Implant site development and reconstruction of the lost periodontium represent main fields in which these molecular mediators have been employed and investigated. Different growth factors trigger different reactions in the tissues of the periodontium at various cellular levels. Proliferation, migration, and differentiation constitute the main target areas of these molecular mediators. It was the purpose of this comprehensive review to describe the origin and rationale, evidence, and the most current understanding of the following biologic agents: Recombinant Human Platelet-Derived Growth Factor-BB (rhPDGF-BB), Enamel Matrix Derivate (EMD), Platelet-Rich Plasma (PRP) and Platelet-Rich Fibrin (PRF), Recombinant Human Fibroblast Growth Factor-2 (rhFGF-2), Bone Morphogenic Proteins (BMPs, BMP-2 and BMP-7), Teriparatide PTH, and Growth Differential Factor-5 (GDF-5).

The Interplay of Orthodontics, Periodontics, and Restorative Dentistry to Achieve Aesthetic and Functional Success

Previously dentists focused on repair and maintenance of function. However, the emphasis of many patients and dentists is now on esthetics. Often there is a need for the disciplines of orthodontics, periodontics, restorative dentistry, and maxillofacial surgery to work together in order to achieve optimum results. Currently the sequencing planning process begins with esthetics and then function, structure, and ultimately biology.