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.

Xenogeneic collagen matrix versus connective tissue graft for buccal soft tissue augmentation at implant site. A randomized, controlled clinical trial.

BACKGROUND: Peri-implant soft tissue may be critical to prevent inflammation and promote gingival margin stability. The purpose of this randomized clinical trial (RCT) is to compare xenogeneic collagen matrix (XCM) versus connective tissue graft (CTG) to increase buccal soft tissue thickness at implant site. MATERIALS AND METHODS: Soft tissue augmentation with XCM (test) or CTG (control) was performed at 60 implants in 60 patients at the time of implant uncovering. Measurements were performed by a blinded examiner at baseline, 3 and 6 months. Outcome measures included buccal soft tissue thickness (GT), apico-coronal keratinized tissue (KT), chair time and post-operative discomfort. Visual Analogue Scale (VAS) was used to evaluate patient satisfaction. RESULTS: After 6 months, the final GT increase was 0.9 ± 0.2 in the XCM group and 1.2 ± 0.3 mm in the CTG group, with a significant difference favouring the control group (0.3 mm; p = .0001). Both procedures resulted in similar final KT amount with no significant difference between treatments. XCM was associated with significant less chair-time (p < .0001), less post-operative pain (p < .0001), painkillers intake (p < .0001) and higher final satisfaction than CTG (p = .0195). CONCLUSION: CTG was more effective than XCM to increase buccal peri-implant soft tissue thickness.

Clinical efficacy of coronally advanced flap with or without connective tissue graft for the treatment of multiple adjacent gingival recessions in the aesthetic area: a randomized controlled clinical trial.

BACKGROUND: The aim of this study was to assess the clinical efficacy of coronally advanced flap (CAF) with or without connective tissue graft (CTG) for the treatment of multiple adjacent gingival recessions in the upper arch. MATERIAL AND METHODS: Thirty-two patients with a total of 74 gingival recessions were randomly allocated to the two groups. Outcome measures, collected by a blind examiner, included complete root coverage (CRC), recession reduction (RecRed), keratinized tissue (KT) gain, increase in gingival thickness (GT), patient satisfaction and root coverage esthetic score (RES). RESULTS: An interaction between treatment and baseline GT was detected. At 1 year, CAF + CTG resulted in better outcomes in terms of CRC (p = 0.0016) and RecRed (p < 0.0001) than CAF alone at sites with thin gingiva (thickness ≤ 0.8 mm). No difference was found between CAF alone and CAF + CTG at sites with thick gingiva (>0.8 mm). CAF resulted in higher aesthetic scores (RES) than CAF + CTG at sites with thick gingiva. CAF + CTG was associated with greater KT gain (p < 0.0001) and greater post-operative morbidity (p < 0.0001). CONCLUSION: Connective tissue graft under CAF results in increased probability of CRC only at sites with thin baseline gingiva. CAF alone is associated with similar clinical outcomes and better aesthetics at sites with thick baseline gingiva.

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

BACKGROUND: The aim of this study was to perform a systematic review (SR) of randomized controlled trials (RCTs) to explore if periodontal plastic surgery procedures for the treatment of single and multiple gingival recessions (Rec) may improve aesthetics at patient and professional levels. MATERIAL AND METHODS: In order to combine evidence from direct and indirect comparisons by different trials a Bayesian network meta-analysis (BNM) was planned. A literature search on PubMed, Cochrane libraries, EMBASE, and hand-searched journals until January 2016 was conducted to identify RCTs presenting aesthetic outcomes after root coverage using standardized evaluations at patient and professional level. RESULTS: A total of 16 RCTs were selected in the SR; three RTCs presenting professional aesthetic evaluation with Root coverage Aesthetic Score (RES) and three showing final self-perception using the Visual Analogue Scale (VAS Est) could be included in a BNM model. Coronally Advanced Flap plus Connective Tissue Graft (CAF + CTG) and CAF + Acellular Dermal Matrix (ADM) and Autologous Fibroblasts (AF) were associated with the best RES outcomes (best probability = 24% and 64%, respectively), while CAF + CTG and CAF + CTG + Enamel matrix Derivatives (EMD) obtained highest values of VAS Est score (best probability = 44% and 26%, respectively). CONCLUSIONS: Periodontal Plastic Surgery (PPS) techniques applying grafts underneath CAF with or without the adding of EMD are associated with improved aesthetics assessed by final patient perception and RES as professional evaluation system.

Soft-tissue re-growth following fibre retention osseous resective surgery or osseous resective surgery: a multilevel analysis.

BACKGROUND: The aim of this study was to assess soft-tissue re-growth following Fibre Retention Osseous Resective Surgery (FibReORS) or Osseous Resective Surgery (ORS) over a 12-month healing period. MATERIAL AND METHODS: Thirty patients with chronic periodontitis showing persistent periodontal pockets at posterior natural teeth after cause-related therapy were enroled. Periodontal pockets were associated with infrabony defect ≤3 mm; 15 patients were randomly assigned to FibReORS (test group) and 15 to ORS (control group). Measurements were performed by a blind and calibrated examiner. Soft-tissue rebound after flap suture was monitored by changes in gingival recession at 1-, 3-, 6-, and 12- month follow-up. Multilevel analysis considering patient, site, and time levels was performed. RESULTS: Greater osseous resection during surgery and higher post surgical gingival recession was observed in the ORS group. The mean amount of soft-tissue rebound following surgery was 2.5 mm for ORS-treated sites and 2.2 mm for FibReORS-treated sites. Approximately 90% of the coronal re-growth was detectable after 6 months for both procedures. The interaction between ORS and time of observation showed a higher soft-tissue rebound after 12 months (p = 0.0233) for ORS-treated sites. CONCLUSIONS: Both procedures showed a similar coronal soft-tissue re-growth with a significant higher recession reduction for ORS-treated sites. Significant clinical stability of the gingival margin is obtained 6 months after surgery for both procedures.

Stability of root coverage outcomes at single maxillary gingival recession with loss of interdental attachment: 3-year extension results from a randomized, controlled, clinical trial.

BACKGROUND: The aim of this study was to assess the stability of root coverage outcomes 3 years after Connective Tissue Graft (CTG) plus Coronally Advanced Flap (CAF) or CAF alone at single maxillary gingival recession with minimal inter-dental clinical attachment loss. MATERIAL AND METHODS: Twenty-four of the original 29 patients, 13 treated with CAF + CTG and 11 with CAF, were available for the 3-year follow-up. Measurements were performed by a blind and calibrated examiner. Outcome measures included complete root coverage (CRC), recession reduction (RecRed), Root coverage Esthetic Score (RES) and Keratinized Tissue (KT) Gain. Visual Analogue Scale (VAS) was used to evaluate patient satisfaction. RESULTS: After 3 years, CAF + CTG resulted in better outcomes in terms of CRC (p = 0.0054) than CAF alone. No difference was detected in terms of RecRed, RES score and VAS values. Furthermore, CAF + CTG was associated with higher KT gain than CAF at the last follow-up (p < 0.0001). CONCLUSION: Root coverage outcomes in single gingival recession with inter-dental CAL loss are stable after 3 years. The application of CTG under CAF was associated with increased probability to obtain CRC than CAF alone at the final follow-up.

In Vitro Alteration by Dentine and Protein of the Antimicrobial Activity of Two Endodontic Irrigants: HybenX® and Sodium Hypochlorite.

Irrigant solutions commonly used for the treatment of endodontic infections can be inhibited by both organic and inorganic substances. The aim of this study was to evaluate the in vitro antimicrobial activity of the novel irrigant HybenX® and 2.5% and 5% sodium hypochlorite against Enterococcus faecalis, in presence of dentine powder (DP) or bovine serum albumin 20% (BSA) as inhibitory agents. An E. faecalis American Type Culture Collection (ATCC) 29212 suspension was added to the irrigants (Hybenx® or NaOCl) and one or two different inhibitors (BSA and DP) either after one-hour pre-incubation at 35 ± 1 °C or not. The antimicrobial activity of HybenX® against E. faecalis was already proved at 15 min and was neither affected by BSA nor by DP or combinations thereof. NaOCl 2.5% showed an effective antimicrobial activity starting from 15 min and this activity was partially inhibited by BSA and BSA plus DP combination within one hour when pre-incubation occurred. NaOCl 5% showed antimicrobial activity within 15 min, which was inhibited within one hour only in the presence of both BSA and DP regardless of the pre-incubation period. HybenX® could represent a good alternative to common irrigants for the treatment of E. faecalis endodontic infections, showing a rapid antimicrobial activity not inhibited by organic and inorganic inhibitors.

Influences of 432 Hz Music on the Perception of Anxiety during Endodontic Treatment: A Randomized Controlled Clinical Trial.

INTRODUCTION: Patients undergoing endodontic therapy often have severe perioperative and intraoperative anxiety, which may lead to increased perceptions of pain and vital sign instability throughout treatment. The purpose of this study was to test the influences of music, as a nonpharmacologic adjuvant, in terms of significant changes for systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) before, during, and after endodontic treatment in a population with different levels of anxiety assessed with the Corah Dental Anxiety Scale. METHODS: A total of 100 patients were recruited in the present study; before starting the endodontic treatment, the interviewer administered the Corah Dental Anxiety Scale to the participants to assess the baseline level of anxiety. Patients were randomly divided into 2 groups: the first one listened to the music and the second one did not. Before, during, and after the endodontic procedures, the vital signs (diastolic and systolic blood pressure and heart rate) were recorded. Results were collected and statistically analyzed. RESULTS: Direct contrasts between patients listening or not listening to music showed that all the measured vital signs decreased considering the overall period (during and after the canal therapy) in the group of patients listening to music (P < .05). CONCLUSIONS: This study shows the effects of music therapy on vital values and on subjective perception of anxiety during endodontic therapy. Music and medicine always work together; the soothing effects of sounds and musical frequencies make this union an extraordinary tool of synergistic care. Music therapy is a valid nonpharmacologic adjuvant to anxiety perception in endodontic therapies.

Shaping ability of waveone primary reciprocating files and ProTaper system used in continuous and reciprocating motion.

INTRODUCTION: The purpose of this study was to compare the shaping effects of Wave One (Dentsply Maillefer, Ballaigues, Switzerland) and full-sequence ProTaper nickel-titanium (NiTi) files (Dentsply Maillefer) used in reciprocating and conventional movements in a simulated canal. METHODS: Seventy-five S-shaped canals in resin blocks were randomly allocated to 3 groups (n = 25): WaveOne (group 1), full sequence of ProTaper Universal files in conventional movements (group 2), and full sequence of ProTaper Universal files in reciprocating movements (group 3). Preoperative and postoperative photographs of the simulated canals were taken under standardized conditions, after which they were accurately superimposed. Two methods were adopted to evaluate the shaping ability of the 3 approaches: measuring the differences in apical and coronal curvature modifications and measuring the amount of resin removed for both curvatures on the right and left sides of the simulated canals. Differences in canal curvature modifications and in the amount of resin removed were analyzed using 1-way analysis of variance (P < .0001) followed by a Tukey-Kramer multiple comparison post hoc test and mixed-effects linear model (P < .05), respectively. METHODS: Group 3 maintained better coronal and apical canal curvature and less straightening of the simulated canals with respect to groups 1 and 2. CONCLUSIONS: When preparing S-shaped canals, full-sequence ProTaper Universal NiTi files used in a reciprocating motion exhibited better shaping effects than full-sequence ProTaper Universal NiTi files used in a conventional motion and WaveOne.

Mineral trioxide aggregate as apical plug in teeth with necrotic pulp and immature apices: a 10-year case series.

INTRODUCTION: This 10-year study evaluated the clinical and radiologic outcomes of teeth with necrotic pulp, immature apices, and periapical lesions treated with the mineral trioxide aggregate (MTA) apical plug technique. METHODS: Seventeen single-rooted immature teeth with necrotic pulp and periapical lesion from 17 patients treated between January 2001 and December 2001 were included in this study. Apical obturation on all teeth included in the study was completed in 2 visits: first using calcium hydroxide as an interappointment intracanal medication and a second visit for the creation of the artificial apical barrier with MTA. The outcome, based on clinical and radiographic criteria, was assessed by 2 calibrated investigators using the periapical index (PAI). The Friedman test was used to verify the differences between baseline and the 1-, 5-, and 10-year PAI scores. RESULTS: Of the 17 patients treated, 1 patient dropped out at 5 years. At the 10-year follow-up, 15 teeth were healed (PAI ≤2), and 1 tooth had been extracted because of the presence of a longitudinal root fracture. The PAI score exhibited a significant decrease between baseline and 1 year and between 1 and 5 years. The difference between 5 and 10 years was not significant. CONCLUSIONS: The apical plug with MTA was a successful and effective technique for long-term management of this group of teeth with necrotic pulps with immature root development and periapical lesions.

Endodontic management in oculo-facio-cardio-dental syndrome: a case report.

INTRODUCTION: Oculo-facio-cardio-dental (OFCD) syndrome is an X-linked dominant trait. OFCD syndrome is characterized by congenital cataract with secondary glaucoma ocular defects; ventricular and atrial septal defects or mitral valve prolapses; facial traits such as a long narrow face, a high nasal bridge, a bifid nasal tip; and dental anomalies that include radiculomegaly, oligodontia, root dilacerations, malocclusion and delayed eruption. This clinical report describes the endodontic treatment for a 16-year-old girl who suffers from OFCD syndrome. METHODS: The treatment plan included orthograde re-treatment of #9, #10 with apical plug technique and orthograde retreatment and root canal obturation with modified Thermafil (Dentsply Maillefer, Ballaigues, Switzerland) technique of #21, #22 RESULTS: The modified Thermafil technique makes it possible to reach the working length even in teeth with radiculomegaly. CONCLUSIONS: Prompt treatment of dental caries make it possible to maintain tooth function and prevent difficult root canal procedures with poor prognoses for success.

Effects of pH on surface hardness and microstructure of mineral trioxide aggregate and Aureoseal: an in vitro study.

INTRODUCTION: The aim of the study was to evaluate the surface hardness and the morphologic microstructure of white mineral trioxide aggregate (WMTA) and Aureoseal in acid environment. METHODS: WMTA and Aureoseal were mixed and packed into 64 cylindrical stainless steel molds. Thirty-two of each group were exposed to pH values of 4.4 and 7.4, respectively, for 7 days. Four specimens, 2 exposed to acid pH and 2 exposed to pH of 7.4, were prepared for evaluation under scanning electron microscope by using scattered electron (SE) and backscattered electron (BSE) detectors. Vickers surface hardnesses were measured in the remaining 60 samples. RESULTS: The mean surface hardness values ± standard deviation were 37.54 ± 1.52 and 30.24 ± 1.47 for WMTA and 40.63 ± 1.35 and 28.67 ± 1.07 for Aureoseal after exposure to pH values of 7.4 and 4.4, respectively. WMTA showed higher hardness values in acid environment than Aureoseal, which showed the highest microhardness at pH values of 7.4. The SE detector revealed crystal formation on the WMTA surface at pH values of 7.4 and 4.4. In the WMTA specimens the BSE detector showed more unhydrated structures at pH values of 4.4 than at 7.4. The SE detector did not reveal crystal formation on the Aureoseal specimens at pH 7.4 and 4.4. BSE detection showed amorphous microstructures in the Aureoseal specimens treated in the pH 4.4 acid environment. CONCLUSIONS: There was significant interaction between the cements and the environments where the cements hardened.

Mineral trioxide aggregate as repair material for furcal perforation: case series.

The purpose of treating furcal perforation is to seal the artificial communication between the endodontic space and the periradicular tissue to prevent alveolar bone resorption and damage to the periodontal ligament. These complications are not infrequent in cases of furcal and/or old perforations, which show a worse prognosis than fresh, small, coronal, and apical perforations. Mineral trioxide aggregate (MTA) is widely used to seal perforations because of its biocompatibility and sealability. Ten cases of furcal perforation were selected at the department of Endodontics, University of Florence. All the perforations were cleaned with NaOCl, EDTA, and ultrasonic tips and sealed with MTA without internal matrix. Finally, the teeth were endodontically treated and coronally restored. Clinical and radiographic follow-ups were done at 6 months, 1 year, 2 years, and 5 years. After 5 years, the absence of periradicular radiolucent lesions, pain. and swelling along with functional tooth stability indicated a successful outcome of sealing perforations in 9 out of 10 teeth. One patient dropped out of the study after the 1-year follow-up and could not be contacted for further recalls. The results confirm that MTA without matrix provides an effective seal of root perforations and clinical healing of the surrounding periodontal tissue.

Efficacy of ProTaper universal retreatment files in removing filling materials during root canal retreatment.

The aim of this study was to evaluate the efficacy of the ProTaper Universal System rotary retreatment system and of Profile 0.06 and hand instruments (K-file) in the removal of root filling materials. Forty-two extracted single-rooted anterior teeth were selected. The root canals were enlarged with nickel-titanium (NiTi) rotary files, filled with gutta-percha and sealer, and randomly divided into 3 experimental groups. The filling materials were removed with solvent in conjunction with one of the following devices and techniques: the ProTaper Universal System for retreatment, ProFile 0.06, and hand instruments (K-file). The roots were longitudinally sectioned, and the image of the root surface was photographed. The images were captured in JPEG format; the areas of the remaining filling materials and the time required for removing the gutta-percha and sealer were calculated by using the nonparametric one-way Kruskal-Wallis test and Tukey-Kramer tests, respectively. The group that showed better results for removing filling materials was the ProTaper Universal System for retreatment files, whereas the group of ProFile rotary instruments yielded better root canal cleanliness than the hand instruments, even though there was no statistically significant difference. The ProTaper Universal System for retreatment and ProFile rotary instruments worked significantly faster than the K-file. The ProTaper Universal System for retreatment files left cleaner root canal walls than the K-file hand instruments and the ProFile Rotary instruments, although none of the devices used guaranteed complete removal of the filling materials. The rotary NiTi system proved to be faster than hand instruments in removing root filling materials.

The use of MTA in teeth with necrotic pulps and open apices.

Three clinical cases have been treated with the use of an apical plug of MTA for apexification. All three cases were central incisors that had suffered premature interruption of root development as a consequence of trauma. According to the treatment protocol, the root canals were rinsed with 5% NaOCl; then, calcium hydroxide paste was placed in the canals for 1 week. Consequently, the apical portion of the canal (4 mm) was filled with MTA. The remaining portion of the root canals was then closed with thermoplastic gutta-percha. At 6-month and 1-year follow-up period the clinical and radiographic appearance of the teeth showed resolution of the periapical lesions. MTA appears to be a valid option for apexification with its main advantage being the speed at which the treatment can be completed.