Periodontal Osseous Defects: A Treatment-Oriented Classification to Guide Regenerative Treatment Planning.

Periodontal bony defects are classified into 'supraosseous' ('suprabony') or 'infraosseous' ('infrabony') according to the location of the base of the defect compared to the coronal part of the residual alveolar crest. Infraosseous defects are generally considered more challenging to treat and are thought to be associated with a higher risk of periodontal progression. The emergence and advancement of periodontal regenerative procedures have improved the clinician's ability to manage infraosseous defects. However, limitations still exist. This paper reviews the definitions of periodontal osseous defects and provides a new classification framework for infraosseous defects, relating them to the chances of success of regenerative procedures and therefore to their treatment planning options. Infraosseous defects are hereby divided into intrabony and inter-root defects. Factors affecting treatment response, such as number of walls, depth and extension into buccal and lingual surfaces are added to the classification framework.

Long-term stability (21-30 years) of root coverage outcomes using sub-epithelial connective tissue grafts at single or multiple gingival recessions: A longitudinal case series.

AIM: To evaluate outcomes and predictive factors for the long-term stability of root coverage using a sub-epithelial connective tissue graft. MATERIALS AND METHODS: One-hundred and two healthy subjects (221 gingival recessions, GRs) were treated from 1987 to 1996. Keratinized tissue width (KTW), GR depth (RD), GR width (RW) and GR area (RA) were evaluated at baseline (M0) and at 1 month (M1), 1 year (M2), 11 years (M3), 21 years (M4) and 27 years (M5) after surgery. Primary outcomes consisted of complete root coverage (cRC) and relative dimensional changes in recession depth (measured in mm [c%-RD]), recession width (measured in mm [c%-RW]) and recession area (measured in mm2 [c%-RA]). RESULTS: cRC was 88.7% at 1 year (M2), 59.8% at M3, 44.4% at M4 and 51.9% at M5. Average c%-RD was 95.2% at 1 year, 81.9% at M3, 71.5% at M4 and 81.7% at M5. KTW increased after surgery and over time and was positively correlated with favourable outcomes. Increased baseline RA was associated with less favourable clinical outcomes. CONCLUSIONS: The sub-epithelial connective tissue graft is effective in the treatment of GRs and facilitates long-term stability of clinical outcomes. Wider baseline RA was a strong predictor of unfavourable short- and long-term RC outcomes.

The influence of interradicular anatomy on the predictability of periodontal regenerative therapy of furcation defects: a retrospective, multicenter clinical study.

BACKGROUND: The relationship between the anatomy of the interradicular space and success in regenerative therapy of furcation defects is discussed in this paper. The goal of this retrospective, multicenter clinical study is to clinically evaluate the relationship between the interradicular conformation and regenerative therapy success with the use of a novel measurement method. METHODS: One hundred thirty-eight radiographs of mandibular molars with furcation defects that had been treated with regenerative therapy were collected from six clinical centers. Data on the type of therapy and clinical parameters before and after treatment (follow-up of at least 12 months) were collected. The radiographs (before surgery and at least 12 months postoperatively) were measured with a visual evaluation method by a blind operator using graphics software. RESULTS: Success, defined as a reduction in horizontal and vertical furcation involvement, decrease in probing depths, and increase in clinical attachment level, was statistically assessed on 138 regenerated molars sites and were related to clinical variables such as age, sex, center, and treatment. No correlation was found between success in regenerative therapy and the conformation of the interradicular space, measured with a visual ratio method and a standard linear measurement. At the univariate analysis, the parameters that had a correlation with success were center, extent of furcation involvement, treatment, and sex. The use of enamel matrix derivative (EMD) seemed to be the most favorable therapy, with increase in CAL gain and reduction of vertical or horizontal furcation involvement. CONCLUSIONS: The regenerative outcome was not significantly influenced by the anatomy of furcation. The center, the degree of furcation involvement, sex, and treatment (EMD) were significantly associated with higher success of periodontal regeneration.

Long-term comparison of root coverage procedures at single RT2 maxillary gingival recessions: Ten-year extension results from a randomized, controlled clinical trial.

AIM: The purpose of the present study was to assess root coverage outcomes 10 years after connective tissue graft plus coronally advanced flap (CTG + CAF) or CAF alone, at single RT2 maxillary gingival recession. MATERIALS AND METHODS: Twenty-one of the original 29 patients (11 treated with CAF + CTG and 10 with CAF alone) were available for the 10-year follow-up. A blinded and calibrated examiner performed all the measurements. Outcome measures included complete root coverage (CRC), recession reduction (RecRed), root coverage aesthetic score (RES), and keratinized tissue (KT) gain. A visual analogue scale was used to evaluate patient satisfaction. RESULTS: CRC was maintained in 63% of the test group and 20% of the control group after 10 years, with a significant difference favouring CAF + CTG (p = .030). Furthermore, the addition of CTG was associated with greater KT gain (p = .0002) and greater papilla tip recession (p = .023) than with CAF at the last follow-up. No difference was detected regarding RecRed, RES, and patient satisfaction. CONCLUSIONS: Adding CTG under CAF improved the probability of maintaining complete root coverage 10 years after single maxillary RT2 recession treatment.

Longevity of teeth in patients susceptible to periodontitis: Clinical outcomes and risk factors associated with tooth loss after active therapy and 30 years of supportive periodontal care.

AIM: (i) To evaluate the efficacy of active periodontal therapy supplemented by supportive periodontal care (SPC) in retaining dentition during a 30-year follow-up period in patients susceptible to periodontitis, and (ii) to assess the prognostic factors associated with tooth loss. MATERIALS AND METHODS: One-hundred and fifty-four patients with periodontitis, retrospectively classified as stage I-IV and grade B-C periodontitis, treated between 1984 and 1986 in a private practice, were enrolled in this study. After periodontal assessment, patients received non-surgical treatment followed by surgical periodontal therapy, orthodontic treatment, and tooth-splinting, where appropriate. SPC consisted of a strict recall programme every 3-6 months over a 30-year period. Recurrences were treated either with subgingival root planing or flap surgery. Dental and periodontal variables were measured at baseline (T0), end of active therapy (T1), and after 25 (T2) and 30 (T3) years. Generalized mixed models were analysed to assess the prognostic factors associated with and survival analyses for tooth loss. RESULTS: Data on 154 patients (4083 teeth) were available at baseline (T0). Teeth considered unworthy of treatment were extracted during active therapy (160, 3.9%) and at re-assessment (13, 0.3%; T1). After 25 years of SPC, 140 teeth out of 3910 in 154 patients (3.6%) were lost (24 in 18 patients for periodontal reasons). Between 25 and 30 years, 20 patients (482 teeth) dropped out, and 61 teeth (2%) were lost (15 in 14 patients for periodontal reasons). Overall, 201 teeth (5.1%) were lost (39 for periodontal reasons) in 30 years of SPC. Generalized mixed models showed that stage III or stage IV periodontitis was associated with greater tooth loss during SPC compared to stage I or stage II (OR = 2.10; p = .048). Generalized periodontitis showed a statistically significant OR = 3.24 (p = .016) compared to the localized one. In SPC (T1-T3), age (p = .011), gender (male; p = .038), molar teeth (p = < .001), T0 and T1 pocket depth (p = < .001), tooth mobility grades 2 (p = .018) and 3 (p = .050), T0 and T1 bone loss (p = < .001), and presence of a root canal treatment (p = < .001) and a crown (p = .009) were statistically significantly associated with tooth loss. CONCLUSION: (i) Periodontal therapy and a stringent SPC are effective in maintaining most of the teeth in patients with moderate/advanced periodontitis for 30 years, and (ii) age, gender, molar teeth, pocket depth, bone loss, and the presence of a root canal treatment and a crown are prognostic factors associated with tooth loss.

Diagnostic reproducibility of the 2018 Classification of Gingival Recession Defects and Gingival Phenotype: A multicenter inter- and intra-examiner agreement study.

BACKGROUND: The aim of this study was to investigate the inter- and intra-examiner agreement among international experts on the diagnosis of gingival recession defects using the 2018 Classification of Gingival Recession Defects and Gingival Phenotype as proposed in the 2017 World Workshop. METHODS: Standardized intraoral photographs from 28 gingival recession defects were evaluated twice by 16 expert periodontists. Recession type (RT), recession depth (RD), keratinized tissue width (KTW), gingival thickness (GT), detectability of the cemento-enamel junction (CEJ), and presence of root steps (RS) were recorded and used for the analysis. Intra- and inter-examiner agreements were calculated for individual variables and for the overall classification. Intraclass correlation coefficient with 95% CI was used for RD and KTW; Kappa with 95% CI was used for GT, CEJ, and RS; quadratic weighted Kappa with 95% CI was used for RT. RESULTS: Overall intra- and inter-examiner agreements were highest for KTW (0.95 and 0.90), lowest for GT (0.75 and 0.41), with the other variables in between (RD: 0.93 and 0.68, RS: 0.87 and 0.65, RT: 0.79 and 0.64, CEJ: 0.75 and 0.57). Overall intra- and inter-examiner agreements for the matrix were 62% and 28%, respectively. Significant effects existed between one variable's measurement and other variables' agreements. CONCLUSIONS: The 2018 Classification of Gingival Recession Defects and Gingival Phenotype is clinically reproducible within the examiners, and when the variables forming the matrix are analyzed individually. The between-examiner agreement for the complete matrix showed lower reproducibility. The agreement was highest for KTW and RD, and least for GT.

Introduction of a Novel Anatomic Recession Ratio in the Treatment of Gingival Recession: A Proof-of-Principle Study.

The present study introduces a novel "anatomic recession ratio" (ARR) and evaluates the clinical outcomes of using a tunnel technique (TUN) with a connective tissue graft (CTG) for root coverage (RC). Sixteen systemically healthy patients contributing a total of 33 recession types 1 and 2 were treated with TUN + CTG. The predictive value of a panel of baseline clinical parameters (ARR) on RC was evaluated 12 months postoperatively. At 12 months, mean recession depth decreased from 2.74 ± 0.22 mm to 0.46 ± 0.13 mm (P < .0001); 19 sites (58%) showed complete RC, and the mean RC rate was 88.85% ± 2.73%. The mean ARR value was 0.74 ± 0.3, revealing a positive correlation with RC (r2: 0.73, P < .0001). The 12-month esthetic evaluation resulted in a score of 8.52 ± 1.75 using the root coverage esthetic score. TUN + CTG is effective in reducing recession depth and obtaining good esthetic outcomes. Within the limits of the present study, it may be suggested that ARR has potential as an analytical baseline parameter for RC outcomes with TUN + CTG.

Modified minimally invasive surgical technique in human intrabony defects with or without regenerative materials-10-year follow-up of a randomized clinical trial: Tooth retention, periodontitis recurrence, and costs.

AIM: The modified minimally invasive surgical technique (M-MIST) optimizes wound stability in the treatment of intrabony defects. Short-term observations show similar results as with flap alone or adjunctive regenerative materials. This study aims to compare the stability of the long-term outcomes, complication-free survival, and costs of the three treatment options. MATERIALS AND METHODS: Forty-five intrabony defects in 45 patients were randomized to M-MIST alone (N = 15), combined with enamel matrix derivative (M-MIST + EMD, N = 15), or EMD plus bone-mineral-derived xenograph (M-MIST + EMD + BMDX, N = 15). Supportive periodontal care (SPC) and necessary re-treatment were provided for 10 years. RESULTS: Three subjects were lost to follow-up. Clinical attachment level differences between 1 and 10 years were -0.1 ± 0.7 mm for M-MIST, -0.1 ± 0.8 mm for M-MIST + EMD, and -0.3 ± 0.6 mm for M-MIST + EMD + BMDX (p > .05 for within- and between-group differences). Four episodes of recurrence occurred in the M-MIST group, four in the M-MIST + EMD group, and five in the M-MIST + EMD + BMDX group. No significant differences in complication-free survival were observed between the three groups (p = .47). Complication-free survival was 7.46 years (95% confidence interval: 7.05-7.87) for the whole population. The M-MIST + EMD + BMDX group lost one treated tooth. Data indicated no significant inter-group difference of the total cost of recurrence over 10 years. When the baseline cost of treatment was considered, the total cost was lower for M-MIST alone. CONCLUSIONS: Teeth with deep pockets associated with intrabony defects can be successfully maintained over the long term with either M-MIST alone or by adding a regenerative material in the context of a careful SPC programme. M-MIST alone provided similar short- and long-term benefits as regeneration, at a lower cost. These findings need to be confirmed in larger, independent studies.

Treatment planning of teeth with compromised clinical crowns: endodontic, reconstructive, and surgical strategy.

The present article describes a treatment planning clinical strategy based on a flowchart developed to facilitate the treatment of teeth with severely compromised clinical crowns. The study comprised a group of 978 patients presenting with 2327 teeth needing clinical crown reconstruction. The patients were screened, diagnosed, and treated with a multidisciplinary approach according to a flowchart structure. A subgroup of 75 teeth in 62 patients was considered irrational to treat when a composite risk-evaluation model was applied. Another subgroup of 168 teeth in 126 patients required periodontal surgery and received a minimally invasive crown lengthening (MICL) procedure. Endodontic treatment was necessary for 73 teeth, and retreatment for 51. Most of the teeth (124 in 94 patients) received a full crown, while the remaining 44 teeth received a direct (24 teeth) or an indirect (20 teeth) reconstruction. Six teeth were orthodontically extruded before surgery. The 1-year average probing depth and clinical attachment level at the treated teeth was 2.5 ± 0.5 mm and 2.7 ± 0.6 mm, respectively. Bleeding on probing was detected in 19 sites (11.3%). No side effects or short-term recurrences were detected in 168 treated sites. Patients described function and esthetics as extremely satisfactory, very satisfactory, or satisfactory. In conclusion, an accurate screening based on a flowchart supported the clinical decision to treat 168 teeth with MICL and to replace 75 out of 2327 teeth presented at our clinic for restorations. The use of MICL and the high-quality restorations resulted in a healthy periodontal and dental condition of all the treated teeth as well as patient satisfaction at the 1-year follow-up.

Treatment of Teeth with an Insufficient Clinical Crown. Part 2: Treatment Cost and Time and Patient Outcomes.

This study involves a group of 168 teeth in 126 patients treated with crown lengthening and tooth reconstruction (experimental group), and a group of 75 teeth from 62 patients that were judged irrational to treat, extracted, and replaced (control group). In the control group, 13 teeth in 12 patients were not replaced; 37 were replaced with an implant-supported crown, 14 with a tooth-supported partial denture, 2 with a Maryland partial denture; and 9 patients requested a removable prosthesis. In the experimental group, 44 teeth in 37 patients received a conservative restoration (24 direct and 20 indirect), while 124 teeth in 94 patients received a full crown. All 168 teeth were surgically treated with minimally invasive crown lengthening. Endodontic treatment and orthodontic extrusion were applied when necessary. Treatment resulted in healthy periodontal and dental/implant conditions at the 1-year follow-up in both groups. Function and esthetics were described from satisfactory to extremely satisfactory by patients of both groups, with the exception of three patients in the control group who received a mobile prosthesis restoration and reported some difficulties in chewing. When comparing treatment cost and duration of the reconstructed teeth (experimental group) to the treatment cost and duration of extracted and replaced teeth (control group), the difference is significantly in favor of the preservation of natural teeth, both monetarily and in terms treatment time. Saving a tooth with a compromised crown is more favorable for the patient than extraction and replacement. This conservative approach is advisable to clinicians whenever the clinical conditions enable treatment.

Papilla preservation and minimally invasive surgery for the treatment of peri-implant osseous defects. Clinical and radiographic outcomes of a 5-year retrospective study.

OBJECTIVES: Evaluate in a case series the clinical applicability of a regenerative approach for treatment of peri-implant lesions based on papilla preservation flaps (PPF) and minimally invasive surgery (MIST). MATERIAL AND METHODS: Twenty-one deep peri-implant defects in 21 patients were surgically accessed applying PPF and MIST. The exposed implant surface was decontaminated with the sequential application of mechanical devices and chemical agents. Bone substitutes alone or in combination with a collagen barrier were applied, according to the anatomy of the peri-implant lesion. Clinical and radiographic measurements were collected at baseline, post-surgery, 1 and 5 years. RESULTS: Primary wound closure was obtained in 100% of the sites and maintained in 90% of the sites at 1 week. Bleeding on probing (BOP) was reduced from 100% at baseline to 28.6% at 1 year and to 42.8% at 5 years. The 1-year pocket reduction was 3.9 ± 1 mm. Residual probing depths (PD) were 4.1 ± 0.9 mm. PD remained stable up to 5 years. The radiographic bone gain was 2.5 ± 1.2 mm (mesial) and 2.5 ± 1.1 (distal) at 1-year and 2.3 ± 1.3 mm (mesial) and 2.6 ± 1.4 mm (distal) at 5 years. The radiographic resolution of the defect was 70.4% ± 19% (mesial) and 70.2% ± 22% (distal) at 1 year and 64.2% ± 21% (mesial) and 67.7% ± 21% (distal) at 5 years. All implants survived up to 5 years. A composite outcome of disease resolution shows consistent 1-year clinical improvements at all the treated sites and substantial 5-year stability. CONCLUSIONS: PPF and MIST can be successfully applied for the regenerative treatment of peri-implant defects.

Treatment of Teeth with Insufficient Clinical Crown. Part 1: One-Year Clinical Outcomes of a Minimally Invasive Crown-Lengthening Approach.

This study describes a clinical strategy based on a flowchart developed to facilitate the treatment of teeth with a severely compromised clinical crown. A group of 168 teeth in 126 patients required periodontal surgery and received a minimally invasive crown-lengthening procedure with the aim to reach a minimal supracrestal tissue attachment width of 2.5 mm, including a free space between the cervical margin of the restoration and the bottom of the sulcus. Surgery was performed with the aid of an operating microscope and microsurgical instruments, trying to reduce bone surgery and invasiveness as much as possible. An average postsurgical radiographic bone resection of 1 ± 0.6 mm was measured. Endodontic treatment was necessary in 73 teeth, re-treatment in 51. Most of the teeth (124 in 94 patients) received a full crown, while the remaining 44 received a direct (24 teeth) or an indirect (20 teeth) reconstruction. Six teeth were orthodontically extruded before surgery. The 1-year average pocket depth at the treated units was 2.5 ± 0.5 mm, resulting in a reduction of 0.7 ± 0.9 mm compared to the preoperative measurement (P < .0001). Bleeding on probing was detected in 19 sites (11.3%) and was significantly reduced from the preoperative condition (57 sites, 33.9%). The distance between the apical margin of the restoration and the gingival margin was 0.2 ± 0.4 mm (range: 0 to 1 mm); clinical attachment level was 2.7 ± 0.6 mm. A clinical approach based on minimally invasive crown lengthening with minimal or no ostectomy and high-quality restorative dentistry resulted in healthy periodontal and dental condition of all the treated units at the 1-year follow-up.

Influence of Tooth-Brushing on Early Healing after Access Flap Surgery: A Randomized Controlled Preliminary Study.

In the present study, the clinical outcomes obtained using three different protocols of post-operative plaque control for the 4 weeks after surgery were compared. Thirty healthy subjects, presenting at least one periodontal pocket requiring resective surgery, were selected and randomly distributed to three different groups corresponding to respective post-surgical protocols: (A) toothbrushes + chlorhexidine + anti-discoloration system (ADS + CHX); (B) toothbrushes + chlorhexidine (CHX); (C) only toothbrushes. The full-mouth plaque score (FMPS), full-mouth bleeding score (FMBS), probing pocket depth (PPD), recession depth (REC), clinical attachment level (CAL), and bleeding on probing (BoP) were measured in six aspects per tooth (mesio-buccal (MB), buccal (B), disto-buccal (DB), disto-lingual (DL), lingual (L), and mesio-lingual (ML)) at baseline, 3 months, and 6 months after surgery. FMPS and FMBS did not significantly change (p > 0.05), whereas PPD and CAL significantly decreased, and REC significantly increased in all groups during the study (p < 0.05). Clinical results were satisfactory in all cases, with no significant differences between groups 3 months after surgery. Six months after surgery, only PPD-MB was significantly different in the three groups (p < 0.05). Nevertheless, this value was not clinically relevant because the value of PPD-B (about 2 mm) in group C was physiologic. The mechanical plaque control was proven to be fundamental and sufficient in all the six aspects per tooth to guarantee an excellent clinical outcome without the need of chemical plaque control.

Autologous connective tissue graft or xenogenic collagen matrix with coronally advanced flaps for coverage of multiple adjacent gingival recession. 36-month follow-up of a randomized multicentre trial.

AIM: To report the 36-month follow-up of a trial comparing the adjunct of a xenogenic collagen matrix (CMX) or connective tissue graft (CTG) to coronally advanced flaps (CAF) for coverage of multiple adjacent recessions. MATERIAL AND METHODS: 125 subjects (61 CMX) with 307 recessions in 8 centres from the parent trial were followed-up for 36 months. Primary outcome was change in position of the gingival margin. Multilevel analysis used centre, subject and tooth as levels and baseline parameters as covariates. RESULTS: No differences were observed between the randomized and the follow-up population. Average baseline recession was 2.6 ± 1.0 mm. 3-year root coverage was 1.5 ± 1.5 mm for CMX and 2.0 ± 1.0 mm for CTG (difference of 0.32 mm, 95% CI from -0.02 to 0.65 mm). The upper limit of the confidence interval was over the non-inferiority margin of 0.25 mm. No treatment differences in position of the gingival margin were observed between 6- and 36-month follow-up (difference 0.06 mm, 95% CI -0.17 to 0.29 mm). CONCLUSION: CMX was not non-inferior with respect to CTG in multiple adjacent recessions. No differences in stability of root coverage were observed between groups and in changes from 6 to 36 months. Previously reported shorter time to recovery, lower morbidity and more natural appearance of tissue texture and contour observed for CMX in this trial are also relevant in clinical decision-making.

Reconstructive surgical treatment of isolated deep intrabony defects with guided tissue regeneration using entire papilla preservation technique: A prospective case series.

BACKGROUND: The aim of this prospective study is to evaluate the clinical applicability of the entire papilla preservation (EPP) technique in the regenerative treatment of isolated deep intrabony defects using native collagen membrane and bone grafting materials. METHODS: Fifteen healthy and non-smoker patients (nine males and six females; mean age: 47.73 ± 12.18; range 21 to 63 years) with one isolated deep intrabony defect each (baseline probing depth (PD): 9.03 ± 1.62 mm; clinical attachment level (CAL): 11.16 ± 1.81 mm) were treated with guided tissue regeneration. Surgical access to the defect was provided by a single buccal vertical incision with an interdental tunneling flap. Following the granulation tissue removal, intrabony defect was filled with bone substitutes. A collagen barrier was trimmed and placed under the intact defect-associated papilla with palatal positioning suture. Microsurgical sutures were used for primary closure. RESULTS: At 1 week, healing of the 15 sites was uneventful. During the study, all sites showed 100% primary closure rate. At 1-year follow-up, an average CAL gain of 5.86 ± 1.28 mm (P < 0.0001), PD reduction of 6.1 ± 1.47 mm (P < 0.0001), and minimal increase in gingival recession of 0.23 ± 0.62 mm (P = 0.168) were observed. CONCLUSION: This novel surgical technique, that keeps the interdental papilla intact, seems promising to provide optimal biomaterial protection and healing conditions, even when a collagen barrier and bone substitutes are applied.

Medium- and long-term clinical benefits of periodontal regenerative/reconstructive procedures in intrabony defects: Systematic review and network meta-analysis of randomized controlled clinical studies.

BACKGROUND: Systematic reviews have established the short-term improvements of periodontal regenerative/reconstructive procedures compared to conventional surgical treatment in intrabony defects. However, a hierarchy of periodontal regenerative/reconstructive procedures regarding the medium- to long-term results of treatment does not exist. AIM: To systematically assess the literature to answer the focused question "In periodontitis patients with intrabony defects, what are the medium- and long-term benefits of periodontal regenerative/reconstructive procedures compared with open flap debridement (OFD), in terms of clinical and/or radiographic outcome parameters and tooth retention?". MATERIAL & METHODS: Randomized controlled clinical trials (RCTs), reporting on clinical and/or radiographic outcome parameters of periodontal regenerative/reconstructive procedures ≥3 years post-operatively, were systematically assessed. Clinical [residual probing pocket depth (PD) and clinical attachment level (CAL) gain, tooth loss] and radiographic [residual defect depth (RDD), bone gain (RBL)] outcome parameters were assessed. Descriptive statistics were calculated, and Bayesian random-effects network meta-analyses (NMA) were performed where possible. RESULTS: Thirty RCTs, presenting data 3 to 20 years after treatment with grafting, GTR, EMD, as monotherapies, combinations thereof, and/or adjunctive use of blood-derived growth factor constructs or with OFD only, were included. NMA based on 21 RCTs showed that OFD was clearly the least efficacious treatment; regenerative/reconstructive treatments resulted in significantly shallower residual PD in 4 out 8 comparisons [range of mean differences (MD): -2.37 to -0.60 mm] and larger CAL gain in 6 out 8 comparisons (range of MD: 1.26 to 2.66 mm), and combination approaches appeared as the most efficacious. Tooth loss after regenerative/reconstructive treatment was less frequent (0.4%) compared to OFD (2.8%), but the evidence was sparse. There were only sparse radiographic data not allowing any relevant comparisons. CONCLUSION: Periodontal regenerative/reconstructive therapy in intrabony defects results, in general, in shallower residual PD and larger CAL gain compared with OFD, translating in high rates of tooth survival, on a medium (3-5 years) to long-term basis (5-20 years). Combination approaches appear, in general, more efficacious compared to monotherapy in terms of shallower residual PD and larger CAL gain. A clear hierarchy could, however, not be established due to limited evidence.

Clinical Remarks on the Significance of Tooth Malposition and Papillae Dimension on the Prediction of Root Coverage.

When it comes to complete root coverage of exposed root surfaces, several limiting factors have been suggested. Although tooth malposition and papillae dimension are capable of influencing root coverage, they have not received sufficient emphasis in the literature. Therefore, the aim of the present commentary is to discuss the impact of tooth malposition and papillae dimension on root-coverage outcomes. This commentary combines evidence from the literature with the authors' experience. Limited evidence is available in the literature regarding the influence of tooth malposition on root-coverage outcomes. Severe buccal displacement and tooth extrusion and/or rotation may limit the amount of achievable root coverage, and the cementoenamel junction should no longer be considered the landmark for root coverage in these cases. The relationship between papillae dimension and root coverage has been tested in different clinical conditions and by applying different root-coverage approaches, thereby resulting in contradictory outcomes. The clinical experience of the authors suggests that having wider papillae is advantageous for coronally advanced flap and tunnel flap preparations and connective tissue graft stabilization. Although scientific evidence and the authors' clinical experience suggest that papillae dimension can play a major role in determining the surgical management of soft tissues and the amount of achievable root coverage, further studies are necessary to evaluate to which extent papillae dimensions contribute to treatment outcomes.

Self-reported bleeding on brushing as a predictor of bleeding on probing: Early observations from the deployment of an internet of things network of intelligent power-driven toothbrushes in a supportive periodontal care population.

BACKGROUND: Bleeding on brushing (BoB) is an important sign of gingival inflammation. Recently, the use of intelligent toothbrushes and oral health Apps has shown potential to improve oral and periodontal health. In the context of the introduction of an Internet of things network of intelligent power-driven toothbrushes in a supportive periodontal care programme, the aim of this study was (a) to audit the adoption and retention of this new technology; and (b) to preliminarily assess the feasibility to gather data on BoB and associate them with clinical periodontal parameters. METHODS: 100 subjects with different periodontal case diagnoses participating in supportive periodontal care (SPC) were provided with and instructed on the use of an intelligent power-driven toothbrush connected with an App (I-Brush). Brushing sessions and occurrence of BoB were recorded through the App and stored in a data protection compliant backend. Subject retention was audited over time. BoB recorded in the two weeks before the SPC appointment was associated with clinical parameters observed by the clinician blind to App data. RESULTS: 75% of subjects provided data from using the power toothbrush and the App for a minimum of 10 brushing sessions over an average period of 362 days. Compared with baseline, subjects' oral hygiene, bleeding on probing and prevalence of residual pockets improved gradually while using the I-Brush. The number of BoB episodes in the two weeks leading to the SPC appointment and the number of residual pockets predicted BOP (p < .001) detected during the examination. App use in the previous two weeks was associated with lower plaque scores at SPC. CONCLUSIONS: These preliminary observations indicate good adoption and retention of a mobile health system built around an intelligent power toothbrush in a SPC population. The App was able to gather clinically relevant information predicting the observed degree of gingival inflammation. Deployment of mHealth systems seems feasible in dental practice and may bring significant oral health benefits. More investigations are needed in this area.

Periodontal regeneration versus extraction and dental implant or prosthetic replacement of teeth severely compromised by attachment loss to the apex: A randomized controlled clinical trial reporting 10-year outcomes, survival analysis and mean cumulative cost of recurrence.

BACKGROUND: Periodontal regeneration can change tooth prognosis and represents an alternative to extraction in teeth compromised by severe intra-bony defects. The aim of this study was to compare periodontal regeneration (PR) with tooth extraction and replacement (TER) in a population with attachment loss to or beyond the apex of the root in terms of professional, patient-reported and economic outcomes. METHODS: This was a 10-year randomized controlled clinical trial. 50 stage III or stage IV periodontitis subjects with a severely compromised tooth with attachment loss to or beyond the apex were randomized to PR or TER with either an implant- or a tooth-supported fixed partial denture. Subjects were kept on a strict periodontal supportive care regimen every 3 months and examined yearly. Survival and recurrence analysis were performed. RESULTS: 88% and 100% survival rates were observed in the PR and TER groups. Complication-free survival was not significantly different: 6.7-9.1 years for PR and 7.3-9.1 years for TER (p = .788). In PR, the observed 10-year attachment gain was 7.3 ± 2.3 mm and the residual probing depths were 3.4 ± 0.8 mm. Recurrence analysis showed that the 95% confidence interval of the costs was significantly lower for PR compared with TER throughout the whole 10-year period. Patient-reported outcomes and oral health-related quality-of-life measurements improved in both groups. CONCLUSIONS: Periodontal regeneration can change the prognosis of hopeless teeth and is a less costly alternative to tooth extraction and replacement. The complexity of the treatment limits widespread application to the most complex cases but provides powerful proof of principle for the benefits of PR in deep intra-bony defect.

Clinical outcomes of the entire papilla preservation technique with and without biomaterials in the treatment of isolated intrabony defects: A randomized controlled clinical trial.

AIM: This study compared the clinical efficacy of the entire papilla preservation technique (EPP) alone and in combination with enamel matrix proteins plus bovine-derived bone substitutes (EPP EMD + BS) in the treatment of isolated inter-dental intrabony defects. MATERIAL AND METHODS: Thirty patients, each with one isolated intrabony defect, were randomly assigned to EPP EMD + BS or EPP alone. Clinical outcomes were assessed 1-year post-surgery. RESULTS: Early healing phase was uneventful in all cases, and 100% primary wound closure was maintained throughout the study period. Intragroup differences between baseline and 1-year were statistically significant in both groups in terms of clinical attachment level (CAL) gain and probing depth (PD) reduction (p ≤ .001). No statistically significant differences were detected in gingival recession (REC) (p > .05). No statistically significant differences were detected in terms of CAL gain (6.3 ± 2.5 mm vs. 5.83 ± 1.12 mm), PD reduction (6.5 ± 2.65 mm vs. 6.2 ± 1.33 mm) or increase in gingival recession (0.2 ± 0.25 mm vs. 0.36 ± 0.54 mm) between the groups treated with EPP EMD + BS or EPP alone. CONCLUSIONS: Application of EPP with and without regenerative biomaterials resulted in significant amounts of CAL gain and PD reduction, with negligible increase in gingival recession. Within the limits of the present study, it can be concluded that the addition of regenerative biomaterials does not improve the clinical outcomes of EPP alone. NCT03923465.