Complications and treatment errors in root coverage procedures.

Root coverage procedures have become very common in clinical dental practice. Even though these techniques are considered safe, the clinician may face several issues during the therapy due to their surgical nature. Some of these issues can be defined strictly as complications inherent to the procedure, whereas others are medical errors or treatment errors. This review will focus on describing treatment errors and complications that may arise during different phases of the root coverage therapeutic process and on how to prevent and manage them.

Difficulty score for the treatment of isolated gingival recessions with the coronally advanced flap: a preliminary reliability study.

OBJECTIVES: The treatment of gingival recessions (GRs) is operator-sensitive and dependent upon several local anatomical factors. The aim of this study was to introduce a difficulty score for the treatment of localized GRs with the coronally advanced flap (CAF) and to test its consistency among different operators. MATERIALS AND METHODS: A rubric (difficulty score) consisting of the assessment and grading of 8 anatomical parameters (anatomical papilla, apical and lateral keratinized tissue width, apical and lateral frenum, vestibulum depth, scar tissue, and mucosal invagination) is described based on the available evidence and the authors' experience. Inter-examiner agreement, with the score, was tested on 32 localized GRs among four different experienced practitioners. RESULTS: Minor discrepancies were observed in the total scores between the reviewers (intraclass correlation coefficient [ICC] 0.95). A good reproducibility, with ICCs ranging from 0.56 to 0.98, was found for the individual parameters. All models showed high absolute variance contribution conveying true differences among the cases, and small examiner variance, demonstrating minor systematic variability among the four reviewers and reproducible evaluations. CONCLUSIONS: The proposed difficulty score for the treatment of GRs with CAF was reproducible among different operators. Clinical interventional studies are the next step to validate the clinical magnitude of the present score. CLINICAL RELEVANCE: A novel tool for evaluating the difficulty of the treatment of isolated gingival recession using CAF was described. Clinicians can benefit from this score when assessing the expected level of complexity of the surgical case.

Patient-reported outcome measures after periodontal surgery.

OBJECTIVES: The present study aimed to explore the impact of different periodontal surgical treatments on the quality of life and postoperative morbidity. MATERIALS AND METHODS: The present study is a single-center, prospective, observational cohort trial. One hundred fifty-five patients, referred to the Periodontal Department of Bologna University who needed periodontal surgical treatment, were recruited. The self-reported perception of the postoperative course was assessed using the following anonymous questionnaires: Italian oral health impact profile (I-OHIP-14), visual analog scale (VAS) to evaluate the intensity of the pain, and 5-point Likert scale. RESULTS: Patients reported a mean OHIP-14 total score of 9.87±8.5 (range 0-42), significantly influenced by the female sex, flap extension, and periodontal dressing. A mean VAS score of 2.96±2.39 (range 0-9) was calculated, and was found to be influenced by the presence of vertical releasing incisions and palatal flap extension. Of the 155 subjects, 40 (25.8%) patients reported bleeding as a post-surgical complication, 96 (61.9%) swelling, 105 (67.7%) eating discomfort, and 44 (28.4%) reported speech discomfort. CONCLUSIONS: Within the limitations of the nature of the present study, periodontal surgical procedures have a low impact on patients' quality of life evaluated through the OHIP-14 and VAS pain questionnaires. CLINICAL RELEVANCE: Periodontal surgical procedures are safe procedures, with a limited duration of postoperative discomfort as well as the incidence of complications.

An exploratory clinical study evaluating safety and performance of a volume-stable collagen matrix with coronally advanced flap for single gingival recession treatment.

OBJECTIVE: To test the safety of a new volume-stable collagen matrix (VCMX) in combination with coronally advanced flap (CAF) for the treatment of single gingival recession. MATERIAL AND METHODS: Ten patients were treated for single RT1 gingival recession. Complete and mean root coverage, gingival thickness and keratinized tissue height, patient-reported outcome measures (PROMs), and safety were assessed up to 180 days. Descriptive statistics were used to analyze the clinical parameters. RESULTS: VCMX resulted to be safe with no serious adverse events in all patients. At 6 months, root coverage was 96.7% with 90% of defects exhibiting complete coverage. There was an increase in mean width of keratinized tissue (KT) (0.4 ± 0.8 mm) and in gingival thickness (GT) (0.4 ± 0.34 mm); however, the difference was not statistically significant compared to baseline parameters. Pain perception and pain-killer consumption were low and decreasing further at 7 days. Esthetic satisfaction for both patients and experts revealed excellent scores. CONCLUSIONS: VCMX is a safe and well-tolerated device for the treatment of single gingival recessions. In combination with CAF, it resulted in a high performance in terms of mean and complete root coverage, KT width, and GT increase. VCMX may reduce patient discomfort and post-operative morbidity. CLINICAL RELEVANCE: VCMX is a safe and stable substitute for the treatment of gingival recession in conjunction with coronally advanced technique.

Esthetics in periodontics and implantology.

Periodontal plastic surgery comprises an increasing part of clinical periodontology. Clinical trials have traditionally used professionals to judge esthetic outcome, and few studies have addressed patient needs and requests (true end points). Development of universally accepted and validated methods for professional esthetic assessment, together with standardized questionnaires for patient-perceived outcome, may help to provide better insights into the true needs and benefits of periodontal and implant-associated plastic surgery. In this volume of Periodontology 2000, experienced researchers and clinicians from different subdisciplines of periodontology evaluate: treatment of gingival recession with or without papilla elevation; clinical crown lengthening in the natural dentition and in prosthodontic preparative treatment; periodontal regeneration around natural teeth; and soft-tissue augmentation in edentulous areas. Similarly, experts in different areas of implant science address esthetic outcomes with single and multiple implant rehabilitation, alveolar ridge preservation, implant positioning and immediate implant placement in the esthetic zone.

Esthetic evaluation and patient-centered outcomes in single-tooth implant rehabilitation in the esthetic area.

Criteria for successful implants, in the rehabilitation of a single missing tooth in the esthetic area, should be determined by composite outcomes, including functional and esthetic aspects of soft tissues and the reconstruction, as well as patient-reported outcomes. This paper focuses on current methods in esthetic assessment and patient-centered/reported outcomes in single-tooth implant rehabilitation in the esthetic area. The relationship between subjective, patient-based esthetic evaluations and objective, professional-based esthetic evaluations is reviewed. In spite of increasing interest in the assessment of 'success' in implant dentistry, it is not yet possible to provide evidence-based conclusions because of the lack of consensus on a universal implant-supported crown esthetic index. There is also a need to standardize reporting of patient-centered outcomes in partially edentulous patients treated with implants.

Crown lengthening and restorative procedures in the esthetic zone.

Crown lengthening is one of the most common surgical procedures in periodontal practice. Its indications include subgingival caries, crown or root fractures, altered passive eruption, cervical root resorption and short clinical abutment, and its aim is to re-establish the biologic width in a more apical position. While the procedure in posterior areas of the dentition has been thoroughly investigated, crown lengthening performed for esthetic reasons in the anterior areas is still a matter of debate and an evidence-based technique is not available. This paper provides accurate descriptions of the surgical and restorative phases of the esthetic crown-lengthening procedure by answering the following questions: what is the ideal surgical flap design? how much supporting bone should be removed? how should the position of the flap margin relate to the alveolar bone at surgical closure? and how should the healing phase be managed in relation to the timing and the position of the provisional restoration with respect to the gingival margin?

Soft-tissue dehiscence coverage at peri-implant sites.

Soft-tissue dehiscence at the facial aspect of an osteointegrated implant is a common complication which impacts on the final esthetic result. The etiology and ways of diagnosing this condition are still controversial. Many factors seem to influence the position of the peri-implant soft-tissue margin, and some of these have been studied more carefully than others. Various surgical and combination surgical-prosthetic approaches have been described to treat soft-tissue dehiscence, with the latter appearing to be more predictable. This paper focuses on the factors affecting peri-implant soft-tissue margins and describes the different treatment approaches, reported in the literature, to treat buccal soft-tissue dehiscence, with more focus on the prosthetic-surgical-prosthetic approach.

Esthetic evaluation and patient-centered outcomes in root-coverage procedures.

Treatment of buccal gingival recession is performed for esthetic concerns, root sensitivity, root caries and cervical abrasion resulting from incorrect toothbrushing. Over the years, clinicians and researchers have improved surgical techniques to achieve surrogate end points, such as complete root coverage, gingival recession reduction or keratinized tissue increase, ignoring the input from the patient regarding the true indications for treatment. In the past few years there has been an emphasis to include patient-centered outcomes in the evaluation of root-coverage procedures. The aim of this narrative review is to describe the professional objective assessment of the esthetic results after root-coverage procedures and the patient perception of outcome in terms of esthetics, postoperative morbidity and dentinal hypersensitivity resolution after the treatment of gingival recessions. The need to align professional (surrogate) end points with patient-centered outcomes (true end points) in the future is emphasized.

Periodontal plastic surgery.

The aim of the present article is to summarize current knowledge in terms of the etiology, diagnosis, prognosis and surgical treatment of gingival recession. Whilst the main etiological factors (i.e. toothbrushing trauma and bacterial plaque) are well established, challenges still remain to be solved in the diagnostic, prognostic and classification processes of gingival recession, especially when the main reference parameter - the cemento-enamel junction - is no longer detectable on the affected tooth or when there is a slight loss of periodontal interdental attachment. Root coverage in single type gingival recession defects is a very predictable outcome following the use of various surgical techniques. The coronally advanced flap, with or without connective tissue grafting, is the technique of choice. The adjunctive use of connective tissue grafts improves the probability of achieving complete root coverage. Surgical coverage of multiple gingival recessions is also predictable with the coronally advanced flap and the coronally advanced flap plus the connective tissue graft, but no data are available indicating which, and how many, gingival recessions should be treated adjunctively with connective tissue grafting in order to limit patient morbidity and improve the esthetic outcome. None of the allograft materials currently available can be considered as a full substitute for the connective tissue graft, even if some recent results are encouraging. The need for future studies with patient-based outcomes (i.e. esthetics and morbidity) as primary objectives is emphasized in this review.

Coronally advanced flap + connective tissue graft techniques for the treatment of deep gingival recession in the lower incisors. A controlled randomized clinical trial.

AIM: The aim of this study was to compare the clinical and aesthetic outcomes of two different surgical approaches for the treatment of deep gingival recession affecting the mandibular incisors. METHODS: Fifty patients with Miller class I and II gingival recessions (≥ 3 mm) in the lower incisors were enrolled. Twenty-five patients were randomly assigned to the control group and the other 25 patients to the test group. All defects were treated with the coronally advanced flap + connective tissue graft (CAF + CTG) and in the test group the labial submucosal tissue (LST) was removed. Post-operative morbidity was evaluated at 1 week. Clinical and aesthetic evaluations were made at 1 year. RESULTS: Statistically greater recession reduction, probability of CRC (adjusted OR 7.94 95% CI = 1.88-33.50, p = 0.0024) and greater increase in GT were observed in the test group. Greater graft exposure and increase in KTH were demonstrated in the control group. Better aesthetics outcomes were observed in the test group. No statistically significant between groups differences were demonstrated in patient analgesic assumption and post-operative discomfort and bleeding. CONCLUSIONS: LST removal during CAF + CTG surgery is indicated to provide better root coverage and aesthetic outcomes in the treatment of gingival recessions affecting the lower incisors.

Does the dimension of the graft influence patient morbidity and root coverage outcomes? A randomized controlled clinical trial.

AIM: Primary aim of this study was to evaluate if patient morbidity was improved by diminishing graft thickness and height; secondary objective was to evaluate if such graft modifications influence root coverage and aesthetic outcomes. METHODS: 60 Miller class I and II gingival recessions (GR) (≥ 3 mm in depth) were treated with the coronally advanced flap plus extraoral de-epithelialized free gingival graft (FGG). In 30 randomly selected control GRs ("big graft group"), the FGG thickness was ≥ 2 mm and the height was equal to bone dehiscence (BD); in the other 30 test defects ("small graft group"), the thickness of the FGG was <2 mm and the height was 4 mm. The post-operative patient morbidity was assessed 1 week after the surgery. The clinical and aesthetic evaluations were performed 1 year after the surgery. RESULTS: Lower analgesic assumption, better post-operative course evaluations, better patient colour match scores and better periodontist aesthetic assessments were reported in the "small graft" group. No statistically significant differences were demonstrated between the two groups in terms of recession reduction, CRC and increase in KTH. Greater GT increase was obtained in the control-treated sites. CONCLUSIONS: Coronally advanced flap plus CTG of reduced thickness and height was associated with less patient morbidity, better aesthetic evaluations with no difference in RC outcomes.

Coronally advanced flap with and without connective tissue graft for the treatment of multiple gingival recessions: a comparative short- and long-term controlled randomized clinical trial.

AIM: The aim of this study was to compare short- and long-term root coverage and aesthetic outcomes of the coronally advanced flap (CAF) alone or in combination with a connective tissue graft (CTG) for the treatment of multiple gingival recessions. METHODS: Fifty patients with multiple (≥2) adjacent gingival recessions (≥2 mm) in the upper jaw were enrolled. Twenty-five patients were randomly assigned to the control group (CAF), and the other 25 patients to the test group (CAF + CTG). Clinical outcomes were evaluated at 6 months, 1 and 5 years. The aesthetic evaluations were made 1 and 5 years after the surgery. RESULTS: No statistically significant difference was demonstrated between the two groups in terms of Rec Red and complete root coverage (CRC) at 6 months and 1 year. At 5 years, statistically greater recession reduction and probability of CRC, greater increase in buccal KTH and better contour evaluation made by an independent periodontist were observed in the CAF + CTG group. Better post-operative course and better colour match were demonstrated in CAF-treated patients both at 1 and 5 years. CONCLUSIONS: CAF + CTG provided better CRC at 5 years; keloid formation due to graft exposure was responsible for the worse colour match evaluation.

A novel surgical-prosthetic approach for soft tissue dehiscence coverage around single implant.

OBJECTIVES: The aim of the study was to evaluate soft-tissue coverage and patient aesthetic satisfaction of a novel surgical-prosthetic approach to soft tissue dehiscence (STD) around single endosseous implant. MATERIAL AND METHODS: Twenty patients with buccal soft tissues dehiscence around single implants in the aesthetic area were consecutively enrolled. Treatment consisted in: removal of the implant supported crown, reduction in the implant abutment, coronally advanced flap in combination with connective tissue graft (CTG) and final restoration. The unrestored contralateral tooth normally positioned without recession defect was used as a reference. The soft tissue coverage and patient satisfaction were evaluated 1 year after the final restoration. RESULTS: One-year mean STD coverage was 96.3%, and complete coverage was achieved in 75% of the treated sites. The increase (1.54 ± 0.21 mm) in buccal soft tissue thickness (STT) at 1 year was significantly correlated with CTG thickness at time of the surgery. The mean difference between graft thickness and STT increase was 0.09 ± 0.14 mm, corresponding to the 5.8% of the original graft thickness. The aesthetic analysis showed a significant improvement between the baseline (median, 3.8; 95% CI, 2-4) and the 1-year (median, 8.0; 95% CI, 8-10) visual analogue scale (VAS) scores. CONCLUSION: The results from the present study demonstrated that the proposed bilaminar technique was effective in the coverage of buccal STD around single dental implant and the suggested prosthetic-surgical approach was aesthetically successful.

Vertically Coronally Advanced Flap (V-CAF) to Increase Vestibule Depth in Mandibular Incisors.

Treatment of gingival recessions affecting mandibular incisors is scarcely documented. Despite a shallow vestibule depth being considered a poor anatomical condition, it has never been measured nor deemed a clinical parameter affecting the outcome of root coverage procedures. This study describes a vertically and coronally advanced flap (V-CAF) + connective tissue graft (CTG) technique to obtain root coverage and increased vestibule depth in the treatment of gingival recessions affecting mandibular incisors. Twenty patients with single gingival recessions were treated. The results showed that V-CAF+CTG is effective in increasing residual vestibule depth and in reducing recession depth. Immediately after surgery, a vestibule-depth increase of 5.9 ± 1.2 mm was reported, which was statistically significant compared to baseline, and it remained stable after 12 months (4.8 ± 1.1 mm). The mean percentage of root coverage was 98.3% ± 5.2% for all treated recessions, and complete root coverage (CRC) was achieved in 90% of cases (18 of 20). V-CAF+CTG could be considered a successful technique in terms of vestibule depth increase and CRC for the treatment of single gingival recessions in the mandibular incisors.

5-year outcomes after coverage of soft tissue dehiscence around single implants: A prospective cohort study.

PURPOSE: To report the 5-year clinical and aesthetic outcomes of a novel surgical-prosthetic approach for the treatment of buccal soft tissue dehiscence around single dental implants. MATERIALS AND METHODS: Twenty patients with buccal soft tissues dehiscence around single implants in the aesthetic area were treated by removing the implant-supported crown, reducing the implant abutment, coronally advanced flap in combination with connective tissue graft and final restoration. After the first year, patients were recalled three times a year until the final clinical re-evaluation performed 5 years after the final prosthetic crown. Complications, bleeding on probing (BoP), peri-implant probing depth (PPD), clinical attachment level (CAL), keratinized tissue height (KTH), soft tissue coverage and thickness (STT), patient satisfaction (VAS) and aesthetic assessment (PES/WES) were evaluated 5 years after the final restoration. RESULTS: Of the 20 patients enrolled in the study, 19 completed the study at 5 years. A total of 99.2% mean soft tissue dehiscence coverage, with 79% of complete dehiscence coverage, was achieved at 5 years. A statistically significant increase in buccal soft tissue thickness (0.3 mm 0.1-0.4 P < 0.001) and keratinized tissue height (0.5 mm 0.0-1.0; P < 0.001) at 5 years with respect to 1 year was demonstrated. The patient aesthetic evaluation showed high VAS scores with no statistical difference between 1 year and 5 years (8.75 ± 1.02 and 8.95 ± 0.91 respectively). A statistical significant PES/WES score improvement was observed between baseline and 5 years (9.48 ± 2.68; P < 0.001), but not between 1 and 5 years. CONCLUSIONS: Successful aesthetic and soft tissue dehiscence coverage outcomes were well maintained at 5 years. The strict regimen of post-surgical control visits and the emphasis placed on the control of the toothbrushing technique could be critical for the successful long-term maintenance of soft tissue dehiscence coverage results.

Coronally Advanced Flap with Different Designs in the Treatment of Gingival Recession: A Comparative Controlled Randomized Clinical Trial.

The aim of this parallel double-blind randomized controlled clinical trial was to describe a modified approach using the coronally advanced flap (CAF) with triangular design and to compare its efficacy, in terms of root coverage and esthetics, with a trapezoidal type of CAF. A sample of 50 isolated Miller Class I and II gingival recessions with at least 1 mm of keratinized tissue apical to the defects were treated with CAF. Of these recessions, 25 were randomly treated with trapezoidal CAF (control group) while the other 25 (test group) were treated with a modified triangular CAF. The clinical and esthetic evaluations, made by the patient and an independent periodontist, were performed 3 months, 6 months, and 1 year after the surgery. No statistically significant difference was demonstrated between the two CAF groups in terms of recession reduction, complete root coverage, or 6-month and 1-year patient esthetic scores. Better 3-month patient esthetic evaluations and better periodontist root coverage, color match, and contiguity assessments were reported after triangular CAF. Trapezoidal CAF was associated with greater incidence of keloid formation. Single-type gingival recessions can be successfully covered with both types of CAF. The triangular CAF should be preferred for esthetically demanding patients.

The connective tissue graft wall technique and enamel matrix derivative to improve root coverage and clinical attachment levels in Miller Class IV gingival recession.

The case reports in this article describe a surgical approach for improving root coverage and clinical attachment levels in Miller Class IV gingival recessions. Two gingival recessions affecting maxillary and mandibular lateral incisors associated with severe interdental hard and soft tissue loss were treated. The surgical technique consisted of a connective tissue graft (CTG) that was placed below a coronally advanced envelope flap and acted as a buccal soft tissue wall of the bony defect treated with enamel matrix derivative (EMD). No palatal/lingual flap was elevated. In the first clinical case, 6 months after surgery a ceramic veneer was placed to correct tooth extrusion and improve the overall esthetic appearance. One year after the surgery in both cases, clinically significant root coverage, increase in buccal keratinized tissue height and thickness, improvement in the position of the interdental papilla, and clinical attachment level gain were achieved. The radiographs demonstrate bone fill of the intrabony components of the defects. This report encourages a novel application of CTG plus EMD to improve both root coverage and regenerative parameters in Miller Class IV gingival recessions.

Esthetic treatment of peri-implant soft tissue defects: a case report of a modified surgical-prosthetic approach.

A major esthetic concern is soft tissue defects around implant restorations, which often result in an extra long prosthetic crown. This report describes a modified prosthetic-surgical approach to the treatment of peri-implant horizontal and vertical soft tissue defects in an esthetically demanding patient. One month before surgery, the implant crown restoration was removed, the preexisting implant abutment was reduced, and a short provisional crown, at the level of the homologous contralateral incisor, was applied. A bilaminar technique, consisting of an envelope coronally advanced flap covering two connective tissue grafts, was used to treat the soft tissue defects around the implant site. Four months after surgery, a new implant abutment and provisional crown were applied for soft tissue conditioning before the final impression. Nine months after surgery, the peri-implant soft tissue margin was 4 mm more coronal compared with baseline and at the same soft tissue margin level of the right central incisor. A 2.2-mm increase in buccal soft tissue thickness measured 1.5 mm apical to the soft tissue margin was accomplished. The emergence profile of the replaced tooth faithfully reproduced that of the healthy homologous contralateral central incisor. Two years after surgery, the soft tissue margin was stable and the esthetic appearance of the implant site was well maintained. This report demonstrates the possibility of fully correcting severe vertical and horizontal peri-implant soft tissue defects and achieving high patient satisfaction through a combined mucogingival and prosthetic treatment.

The connective tissue platform technique for soft tissue augmentation.

The presence of a localized alveolar ridge defect, especially in the maxillary anterior dentition, may complicate an esthetic rehabilitation. The goal of this case report is to describe a novel subepithelial connective tissue graft technique for soft tissue augmentation in Class III ridge defects. Surgical intervention consisted of in situ maintenance of a connective tissue "platform" at the edentulous space, which facilitated the stabilization and suturing of the connective tissue grafts used for soft tissue augmentation. Adequate graft thickness to treat the deep horizontal soft tissue loss was obtained by doubling the width of a de-epithelialized free gingival graft that was subsequently folded on itself. The soft tissue conditioning at the level of the pontic began 9 months after surgery by shaping the soft tissue with a bur and filling the space with flowable composite resin applied above the pontic. The final prosthetic phase began 14 months after surgery. A reproduction of the anatomical cementoenamel junction in the provisional and definitive restorations was performed to improve the soft tissue emergence profile. Nine months after surgery, a soft tissue augmentation of 5 mm in the vertical and 4 mm in the horizontal dimension was accomplished. The suggested surgical technique was able to accomplish horizontal and vertical soft tissue augmentation in a single surgical step.