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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Coronally advanced flap and composite restoration of the enamel with or without connective tissue graft for the treatment of single maxillary gingival recession with non-carious cervical lesion. A randomized controlled clinical trial.

BACKGROUND: Aim of this study was to compare coronally advanced flap (CAF) and composite restoration of the cement-enamel junction (CEJ) with or without connective tissue graft (CTG) for treatment of single maxillary gingival recession with non-carious cervical lesion (NCCL). MATERIAL AND METHODS: Thirty patients with single gingival recessions and previously restored NCCL were randomly allocated to the two groups. A masked examiner evaluated recession reduction (RecRed), complete root coverage (CRC), keratinized tissue (KT) gain, increase in gingival thickness (GT), patient satisfaction and Root coverage Esthetic Score (RES). RESULTS: No significant difference for RecRed and CRC was detected at 12 months. CAF + CTG resulted in greater increase of KT width and thickness (p < .001). An interaction between baseline GT and type of treatment was reported, suggesting that when baseline GT was ≤0.84 mm adding CTG led to higher RecRed, while for values >0.84 mm the use of CAF was associated with better outcomes. Similarly, CAF alone provided better final RES score for baseline GT > 0.82 mm. CONCLUSION: Both procedures were effective for root coverage at single RT1 recession with previously restored CEJ. Adding a CTG under CAF should be considered for Rec with thin gingival phenotype.

Clinical and histological reaction of periodontal tissues to subgingival resin composite restorations.

OBJECTIVES: To compare the clinical and histological response of supracrestal periodontal tissues to subgingival composite restorations versus natural root surfaces MATERIAL AND METHODS: In 29 subjects with a single tooth requiring subgingival restorations, a deep margin elevation (DME) procedure with composite resin was applied. Full-mouth plaque score (FMPS), full-mouth bleeding score (FMBS), and focal probing depth (PD) were measured at baseline, before DME, and after 3 months. The distance between the coronal marked (CM) point to the apical margin of the composite reconstruction (AMR), at baseline, and to the tip of the periodontal probe inserted to reach the bottom of the sulcus (APP), 3 months later, was measured. An all-around secondary flap, harvested to ensure the subsequent single-crown prosthetic rehabilitation was histologically processed. The histological inflammation degree was evaluated in areas of gingival tissues adjacent to the composite (group B) and adjacent to the natural surface of each single tooth (group A). RESULTS: Significant FMPS, FMBS, and PD decreases were observed (p < 0.05). CM-AMR and CM-APP were significantly different (p < 0.05), suggesting an attachment gain after 3-months. The inflammation level of gingival tissue was similar in groups A and B (p > 0.05). CONCLUSIONS: For the first time, this topic was clinically and histologically studied in humans. Subgingival restorations resulted compatible with gingival health, with levels similar to that of untreated root surfaces. CLINICAL RELEVANCE: Deep margin elevation procedure produces favorable clinical and histological outcomes allowing a routine utilization in reconstructive dentistry.

The depth of the implant mucosal tunnel modifies the development and resolution of experimental peri-implant mucositis: A case-control study.

BACKGROUND: Resolution and prevention of peri-implant mucositis are a key in preventing peri-implantitis. This case-control study aims to assess the modifying effect of a deep mucosal tunnel (DMT) on the induction and resolution phases of experimental peri-implant mucositis. METHODS: Nineteen subjects with a tissue level implant were assigned to cases (DMT, depth ≥3 mm) or controls (shallow mucosal tunnel ≤1 mm, SMT). Subjects underwent a standard experimental peri-implant mucositis protocol characterized by an oral hygiene optimization phase, a 3-week induction phase using an acrylic stent to prevent self-performed oral hygiene at the experimental implant, and a 3 + 2 weeks resolution phase. Modified plaque (mPI), gingival index (mGI) and peri-implant sulcus fluid IL-1ß concentrations were measured over time. Differences between DMT and SMT were assessed with the Mann-Whitney test. RESULTS: Modified plaque index and mGI increased in parallel during the induction phase. After resumption of oral hygiene practice, mPI and mGI resolved towards baseline values in the SMT group. In DMT, mPI and mGI values diverged: plaque resolved but resolution of inflammation was delayed and of smaller magnitude during the first 3 weeks after resumption of oral hygiene. IL-1ß concentrations were significantly higher in DMT at 21 days (end of induction) and during the resolution phase corroborating the clinical findings. Removal of the crown and submucosal professional cleaning were needed to revert mGI to baseline values in DMT implants. CONCLUSIONS: The depth of the mucosal tunnel modifies the resolution of experimental peri-implant mucositis at transmucosal implants. This observation raises important questions on the effectiveness of self-performed oral hygiene in cases where implants are placed deeper and the ability to resolve mucositis and effectively prevent peri-implantitis in such situations.

Aesthetic assessment after root coverage of multiple adjacent recessions with coronally advanced flap with adjunctive collagen matrix or connective tissue graft: Randomized clinical trial.

BACKGROUND: Few studies have looked at professional assessment or patient perception of aesthetics after root coverage procedures. The addition of connective tissue grafts (CTG) seems to improve aesthetic outcomes. The objective of this a priori analysis was to compare aesthetics after addition of CTG or a collagen matrix (CMX) to coronally advanced flap (CAF). METHODS: Two independent, trained and calibrated assessors analysed baseline and 6-month post-operative Images from 183 subjects with 475 recessions from a previously reported multicentre multinational randomized clinical trial. The root coverage aesthetic score (RES) was assessed in its five constituent components after assessing the suitability of images blindly with regard to treatment assignment and centre. Data were analysed at the tooth and subject level. RESULTS: One hundred and fifty-five subjects (81 CTG) and 393 teeth (207 CTG) were included in the analysis. CTG control subjects had higher total RES scores (mean adjusted difference of 1.3 ± 0.8 RES units, p = 0.002). Analyses of RES subcomponents showed that the CTG group had higher scores in terms of gingival margin position but that better marginal tissue contour (OR 3.0, 95% CI 1.2-7.7) and soft tissue texture (OR 3.3, 95% CI 1.9-5.8) was observed for the CMX group. No significant differences were observed for mucogingival alignment and gingival colour. CONCLUSION: Better overall RES scores were observed for the CTG group. Better marginal tissue texture and marginal contour were observed in the CMX group. More research and development is needed to optimize materials to be used in conjunction with CAF to improve root coverage without negatively affecting tissue texture and marginal contour.

Mucogingival conditions in the natural dentition: Narrative review, case definitions, and diagnostic considerations.

BACKGROUND: Mucogingival deformities, and gingival recession in particular, are a group of conditions that affect a large number of patients. Since life expectancy is rising and people are retaining more teeth both gingival recession and the related damages to the root surface are likely to become more frequent. It is therefore important to define anatomic/morphologic characteristics of mucogingival lesions and other predisposing conditions or treatments that are likely to be associated with occurrence of gingival recession. OBJECTIVES: Mucogingival defects including gingival recession occur frequently in adults, have a tendency to increase with age, and occur in populations with both high and low standards of oral hygiene. The root surface exposure is frequently associated with impaired esthetics, dentinal hypersensitivity and carious and non-carious cervical lesions. The objectives of this review are as follows (1) to propose a clinically oriented classification of the main mucogingival conditions, recession in particular; (2) to define the impact of these conditions in the areas of esthetics, dentin hypersensitivity and root surface alterations at the cervical area; and (3) to discuss the impact of the clinical signs and symptoms associated with the development of gingival recessions on future periodontal health status. RESULTS: An extensive literature search revealed the following findings: 1) periodontal health can be maintained in most patients with optimal home care; 2) thin periodontal biotypes are at greater risk for developing gingival recession; 3) inadequate oral hygiene, orthodontic treatment, and cervical restorations might increase the risk for the development of gingival recession; 4) in the absence of pathosis, monitoring specific sites seems to be the proper approach; 5) surgical intervention, either to change the biotype and/or to cover roots, might be indicated when the risk for the development or progression of pathosis and associated root damages is increased and to satisfy the esthetic requirements of the patients. CONCLUSIONS: The clinical impact and the prevalence of conditions like root surface lesions, hypersensitivity, and patient esthetic concern associated with gingival recessions indicate the need to modify the 1999 classification. The new classification includes additional information, such as recession severity, dimension of the gingiva (gingival biotype), presence/absence of caries and non-carious cervical lesions, esthetic concern of the patient, and presence/absence of dentin hypersensitivity.

Predictor factors for long-term outcomes stability of coronally advanced flap with or without connective tissue graft in the treatment of single maxillary gingival recessions: 9 years results of a randomized controlled clinical trial.

AIM: To assess the clinical outcomes 9 years after the surgical treatment of single maxillary gingival recessions and identify predictors for long-term gingival margin stability. MATERIALS AND METHODS: Twenty-five gingival recessions (Miller Class I and II) were randomly treated with Coronally Advanced Flap (CAF) plus Connective Tissue Graft (CTG) or CAF alone. Outcomes included complete root coverage (CRC), recession reduction (REC), keratinized tissue (KT) gain and dentin hypersensitivity, and were evaluated at 6 months, 1 and 9 years. Multilevel analysis was performed to identify predictors for long-term gingival margin stability. RESULTS: Baseline gingival recession was 2.4 ± 0.8 mm and 2.4 ± 1.0 mm in the CAF + CTG and in the CAF-treated sites, respectively (p = 0.693). The chance to gain and preserve CRC over time is equal to 70% in the CAF + CTG group (Relative Risk [RR] = 1.70, 95% CI [0.84-3.45]; adjusted RR = 1.48, 95% CI [0.61-3.62]). Using the CTG, an increase in KT was recorded 9 years after the surgery (p = 0.019). An OR of 0.12 (p = 0.022) of not achieving CRC was observed in cases with non-carious cervical lesions (NCCL) compared to cases without NCCL. CONCLUSION: Both treatment modalities demonstrated stability over time. Additional use of CTG provided a greater increase in KT. The presence of NCCL negatively affected CRC and REC.

Xenogenic collagen matrix or autologous connective tissue graft as adjunct to coronally advanced flaps for coverage of multiple adjacent gingival recession: Randomized trial assessing non-inferiority in root coverage and superiority in oral health-related quality of life.

AIM: To evaluate the non-inferiority of the adjunct of a xenogeneic collagen matrix (CMX) or connective tissue graft (CTG) to coronally advanced flaps (CAF) for coverage of multiple adjacent recessions and compare superiority in patient-reported outcomes (PROM). MATERIAL AND METHODS: One hundred and eighty-seven subjects (92 CMX) with 485 recessions in 14 centres were randomized and followed up for 6 months. Patients filled daily diaries for 15 days to monitor patient-reported experience. The primary outcome was changed in position of the gingival margin. Multilevel analysis used centre, subject and tooth as levels and baseline parameters as covariates. RESULTS: Average baseline recession was 2.5 ± 1.0 mm. The surgery was 15.7 min shorter (95%CI from 11.9 to 19.6, p < .0001) and perceived lighter (11.9 VAS units, 95%CI from 4.6 to 19.1, p = .0014) in CMX subjects. Time to recovery was 1.8 days shorter in CMX. Six-month root coverage was 1.7 ± 1.1 mm for CMX and 2.1 ± 1.0 mm for CTG (difference of 0.44 mm, 95%CI from 0.25 to 0.63 mm). The upper limit of the confidence interval was over the non-inferiority margin of 0.25 mm. Odds of complete root coverage were significantly higher for CTG (OR = 4.0, 95% CI 1.8-8.8). CONCLUSION: Replacing CTG with CMX shortens time to recovery and decreases morbidity, but the tested generation of devices is probably inferior to autologous CTG in terms of root coverage. Significant variability in PROMs was observed among centres.

Periodontal manifestations of systemic diseases and developmental and acquired conditions: Consensus report of workgroup 3 of the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

BACKGROUND: A variety of systemic diseases and conditions can affect the course of periodontitis or have a negative impact on the periodontal attachment apparatus. Gingival recessions are highly prevalent and often associated with hypersensitivity, the development of caries and non-carious cervical lesions on the exposed root surface and impaired esthetics. Occlusal forces can result in injury of teeth and periodontal attachment apparatus. Several developmental or acquired conditions associated with teeth or prostheses may predispose to diseases of the periodontium. The aim of this working group was to review and update the 1999 classification with regard to these diseases and conditions, and to develop case definitions and diagnostic considerations. METHODS: Discussions were informed by four reviews on 1) periodontal manifestions of systemic diseases and conditions; 2) mucogingival conditions around natural teeth; 3) traumatic occlusal forces and occlusal trauma; and 4) dental prostheses and tooth related factors. This consensus report is based on the results of these reviews and on expert opinion of the participants. RESULTS: Key findings included the following: 1) there are mainly rare systemic conditions (such as Papillon-Lefevre Syndrome, leucocyte adhesion deficiency, and others) with a major effect on the course of periodontitis and more common conditions (such as diabetes mellitus) with variable effects, as well as conditions affecting the periodontal apparatus independently of dental plaque biofilm-induced inflammation (such as neoplastic diseases); 2) diabetes-associated periodontitis should not be regarded as a distinct diagnosis, but diabetes should be recognized as an important modifying factor and included in a clinical diagnosis of periodontitis as a descriptor; 3) likewise, tobacco smoking - now considered a dependence to nicotine and a chronic relapsing medical disorder with major adverse effects on the periodontal supporting tissues - is an important modifier to be included in a clinical diagnosis of periodontitis as a descriptor; 4) the importance of the gingival phenotype, encompassing gingival thickness and width in the context of mucogingival conditions, is recognized and a novel classification for gingival recessions is introduced; 5) there is no evidence that traumatic occlusal forces lead to periodontal attachment loss, non-carious cervical lesions, or gingival recessions; 6) traumatic occlusal forces lead to adaptive mobility in teeth with normal support, whereas they lead to progressive mobility in teeth with reduced support, usually requiring splinting; 7) the term biologic width is replaced by supracrestal tissue attachment consisting of junctional epithelium and supracrestal connective tissue; 8) infringement of restorative margins within the supracrestal connective tissue attachment is associated with inflammation and/or loss of periodontal supporting tissue. However, it is not evident whether the negative effects on the periodontium are caused by dental plaque biofilm, trauma, toxicity of dental materials or a combination of these factors; 9) tooth anatomical factors are related to dental plaque biofilm-induced gingival inflammation and loss of periodontal supporting tissues. CONCLUSION: An updated classification of the periodontal manifestations and conditions affecting the course of periodontitis and the periodontal attachment apparatus, as well as of developmental and acquired conditions, is introduced. Case definitions and diagnostic considerations are also presented.

Gingival tissue reaction to direct adhesive restoration: A preliminary study.

INTRODUCTION: It is debated whether composite resin marginal/submarginal direct restoration can be usefully performed without inflammatory consequences. This histological study is the first human analysis aimed to compare, in the same tooth, the gingival tissue close to composite resin restorations with gingival tissue close to hard tissue. METHODS: Eight healthy patients with almost a residual strategic tooth needing endodontic therapy, and post-and-core restoration, then indirect prosthetic restoration, were selected. Direct margin relocation with composite resin was necessary to perform endodontic treatment. The crown lengthening with a secondary flap harvested was necessary to perform prosthetic rehabilitation. Three months after marginal relocation, the secondary flap was harvested, embedded in PMMA, 4-µm sectioned, and stained to analyze the inflammation degree. RESULTS: All patients completed post-and-core reconstruction and the planned prosthetic therapy, maintaining the stringent hygienic protocol plan. The inflammation level comparison, slightly lower in gingiva close to the teeth (3.62 ± 0.38) than in gingiva close to the composite (3.75 ± 0.26), results in a p-value of 0.11 after Wilcoxon test. CONCLUSIONS: Results highlight a minimal, statistically not significant difference in the inflammation degree after margin relocation, conceivably due to patients, teeth and cases selection, together with adopted stringent methodological and supportive measures.