Challenges and success in periodontal plastic surgery.

To truly understand a field of study, one must delve into its past and examine the challenges and successes that have shaped its current practices. In the case of periodontal plastic surgery, recognizing how challenges induced changes over the last 70 years-from the 1950s to today-is essential to fully comprehend its evolution. This editorial provides a perspective on the field, highlighting the interrelationships between influential surgical techniques and advancements in research methodology. With each event building upon the last, the evolution of periodontal plastic surgery is a story of scientific progress and ongoing research, fostering a sense of community and shared knowledge.

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.

Short-term comparison of two non-surgical treatment modalities of peri-implantitis: Clinical and microbiological outcomes in a two-factorial randomized controlled trial.

AIM: To compare the efficacy of two different therapies (amino acid glycine abrasive powder and a desiccant material) and their combination in the non-surgical treatment of peri-implantitis. MATERIALS AND METHODS: This was an examiner-blind randomized clinical trial, with 2-factorial design with a follow-up of 6 months. The combination of the two factors resulted in four interventions: (a) non-surgical debridement alone (C); (b) non-surgical debridement and a desiccant material (H); (c) non-surgical debridement and glycine powder (G); and (d) non-surgical debridement, desiccant material and glycine powder (HG). RESULTS: Sixty-four patients with peri-implantitis were randomized, 16 for each intervention. After six months, two implants failed in the G intervention. Mean pocket depth reduction was higher in patients treated with the desiccant material (estimated difference: 0.5 mm; 95% CI from 0.1 to 0.9 mm, p = .0229) while there was no difference in the patients treated with glycine powder (estimated difference: 0.1 mm; 95% CI from -0.3 to 0.5 mm, p = .7333). VAS for pain during intervention and VAS for pain after one week were higher for patients treated with glycine powder (p = .0056 and p = .0339, respectively). The success criteria and other variables did not reveal differences between interventions. CONCLUSIONS: In this 6-month follow-up study, pocket reduction was more pronounced in patients using the desiccant material. Pain was higher in patients using glycine. All the interventions resulted in low success rate.

Periodontal regeneration compared with access flap surgery in human intra-bony defects 20-year follow-up of a randomized clinical trial: tooth retention, periodontitis recurrence and costs.

AIM: Compare the long-term outcomes and costs of three treatment modalities in intra-bony defects. MATERIALS AND METHODS: Forty-five intra-bony defects in 45 patients had been randomly allocated to receive: modified papilla preservation technique with titanium-reinforced expanded-polytetrafluoroethylene (ePTFE) membranes (MPPT Tit, N = 15); access flap with expanded-PTFE membranes (Flap-ePTFE, N = 15) and access flap alone (Flap, N = 15). Supportive periodontal care (SPC) was provided monthly for 1 year, then every 3 months for 20 years. Periodontal therapy was delivered to sites showing recurrences. RESULTS: Forty-one patients complied with SPC. Four subjects were lost to follow-up. Clinical attachment-level differences between 1 and 20 years were -0.1 ± 0.3 mm (p = 0.58) in the MPPT Tit; -0.5 ± 0.1 mm (p = 0.003) in the Flap-ePTFE and -1.7 ± 0.4 mm (p < 0.001) in the Flap. At 20 years, sites treated with Flap showed greater attachment loss compared to MPPT Tit (1.4 ± 0.4 mm; p = 0.008) and to Flap-ePTFE (1.1 ± 0.4 mm; p = 0.03). Flap group lost two treated teeth. Five episodes of recurrences occurred in the MPPT Tit, six in the Flap-ePTFE and fifteen in the Flap group. Residual pocket depth at 1-year was significantly correlated with the number of recurrences (p = 0.002). Sites treated with flap had greater OR for recurrences and higher costs of re-intervention than regenerated sites over a 20-year follow-up period with SPC. CONCLUSIONS: Regeneration provided better long-term benefits than Flap: no tooth loss, less periodontitis progression and less expense from re-intervention over a 20-year period. These benefits need to be interpreted in the context of higher immediate costs associated with regenerative treatment. These initial observations need to be extended to larger groups and broader clinical settings.

Thirty-year stability after regeneration of a deep intrabony defect: a case report.

AIMS: Report clinical improvements and 30-year stability of clinical outcomes of an intrabony defect treated with non-resorbable barriers and mucogingival surgery. METHODS: A 18-year-old male presenting with a very severe intrabony defect at the upper right central incisor was treated with periodontal regeneration with non-resorbable barriers and a fibrin-fibronectin glue. The barriers were removed after 3 months. At 6 months, a free gingival graft (FGG) was positioned to improve mucogingival conditions. The patient was enrolled into a 6-month supportive periodontal care programme (SPC) for 30 years. RESULTS: Clinical attachment level (CAL) of 16 mm was associated with a 12 mm osseous defect and a pocket (PD) 14 mm deep. At 1 year, a CAL of 5 mm was associated with a PD of 2 mm. The 5 mm gingival recession measured at 6 months and treated with FGG was reduced to 3 mm. Measurements taken at 10, 20 and 30 years showed a consistent creeping of the gingival margin. At 30-year examination, CAL gain was 12 mm associated with a 2 mm PD and a minimal gingival recession. CONCLUSIONS: This case demonstrates that it is possible to treat a very severe infrabony pocket applying regeneration and mucogingival surgery and to maintain the clinical outcomes for 30 years.

Influence of inter-dental tissues and root surface condition on complete root coverage following treatment of gingival recessions: a 1-year retrospective study.

AIM: To explore the influence of inter-dental tissues and root surface condition on complete root coverage following surgical treatment of gingival recessions. METHODS: Three hundred and eighty-six single recessions treated over 28 years were assessed. Patient-level and periodontal variables, presence/loss of inter-dental tissues, and presence/absence of non-carious cervical lesions (NCCLs) were recorded. Root coverage was assessed 1-year post-surgery. Multilevel analysis was performed to identify predictors of CRC. RESULTS: Based on type of root coverage procedure four patient groups were created: free gingival graft (FGG) (n = 116), coronally advanced flap (CAF) (n = 107), CAF+connective tissue graft (CTG) (n = 131), and guided tissue regeneration (GTR) (n = 32). Percentages of complete root coverage (CRC) were 18.1% for FGG, 35.5% for CAF, 35.1% for CAF+CTG, and 18.8% for GTR. There was an OR = 0.26 (p < 0.0001) of achieving CRC in cases with loss of inter-dental tissue compared with cases with no inter-dental tissue loss. Similarly, cases with presence of NCCL showed an OR = 0.28 (p < 0.0001) of achieving CRC compared with cases without a NCCL. FGG achieved less CRC then CAF+CTG (p = 0.0012; OR = 0.32). CONCLUSIONS: NCCLs, just like inter-dental tissue loss, are significant negative prognostic factors in achieving CRC following root coverage procedures.

A clinical dilemma: Performing or avoiding root instrumentation in the treatment of the acute phase of endodontic-periodontal lesions? A case report.

BACKGROUND: This study presents the diagnois, management, and tissue response to an acute periodontal lesion with deep pocketing affecting a maxillary central incisor in a young patient devoid of caries or a history of periodontitis. METHODS: Clinical and radiographic examinations facilitated the diagnosis of the pathology as an endoperiodontal lesion (EPL) with root damage, exhibiting supracrestal invasive root resorption. Orthograde endodontic therapy was employed to decontaminate and seal the endodontic space. The resorptive site was treated through the endodontic access, debrided, and sealed. No periodontal therapy (surgical or nonsurgical) was performed. No mechanical instrumentation was performed within the pocketed root surface. RESULTS: At 6-month and 1-year follow-ups after endodontic therapy the periodontium displayed a physiologically healthy condition without pus or inflammation, exhibiting a circumferential probing depth of 2 mm, and absence of tooth mobility. These favorable outcomes persisted throughout a 4-year follow-up period. CONCLUSIONS: The spontaneous healing of pocketing and abscess occurred without mechanical root instrumentation following endodontic therapy and treatment of external invasive root resorption in an EPL. KEY POINTS: Accurate diagnosis and identification of relevant etiologic factors are pivotal for effectively managing endodontic-periodontal lesions. Once a diagnosis is established, the therapy focuses on eliminating the primary cause, followed by a subsequent diagnostic phase after healing. The definitive understanding of the diagnosis and etiology of endodontic-periodontal lesions often becomes clear in retrospect, based on the outcomes of the therapy. When probing acute periodontal lesions, deep probing depths may occur without permanent loss of periodontal attachment. If the acute lesion was not induced by a periodontal cause and if no periodontal etiology arises secondarily, resolving the primary cause of the endoperiodontal lesion can lead to the spontaneous resolution of the pocketing. This results in spontaneous healing of periodontium without the need for intentional periodontal therapy. A clinical dilemma arises when considering periodontal treatment during the acute inflammatory phase of endo-periodontal pathology. It is advisable to refrain from mechanical root instrumentation particularly if a clear periodontal cause is not apparent, to prevent from iatrogenic damage to periodontal fibers and the potential risk of gingival recessions. However, this does not imply avoiding periodontal therapy entirely for every case. Rather, it is recommended to delay the decision on root instrumentation until a new diagnostic phase is conducted following the healing of the endodontic etiology.

Translational approach to tooth autotransplantation: A 27-year case study.

BACKGROUND: The aim of this case report was to present a translational approach to tooth autotransplantation using jiggling forces to enlarge the periodontal ligament (PDL) space before autotransplantation, with the goal of improving treatment success and long-term survival. METHODS: A 23-year-old patient, undergoing orthodontic therapy and with an unrestorable maxillary first molar, was proposed to have a healthy and fully-erupted maxillary third molar transplanted in the socket of the first molar. Jiggling forces were applied to the third molar to enlarge the PDL space and facilitate the preservation of PDL fibers on the root surfaces during the extraction. RESULTS: Jiggling forces induced hypermobility and widened PDL space of the third molar. The autotransplantation was successful and the patient was followed regularly over a 27-year period. At the 27-year visit, the patient showed optimal chewing function, oral plaque control, and absence of gingivitis. The transplanted molar exhibited periodontal health and absence of mobility. Probing depth of 5 mm and radiographic external root resorption was noted on a localized area of the transplanted tooth which had experienced traumatic and unintentional removal of PDL fibers during the extraction. CONCLUSIONS: A translational approach was proposed by integrating knowledge from the fields of orthodontics, trauma from occlusion, and replantation. It validated the crucial importance of maintaining healthy PDL fibers on the root surface and demonstrated clinically the successful autotransplantation of a fully formed third molar into the socket of a first molar with a retention of 27 years. KEY POINTS: Why is this case new information? This case provided evidence of successful autotransplantation of a molar with complete root formation. It reported the longest-term follow-up (27 years) present in the literature. Most importantly, it used a translational medicine approach to apply concepts from the fields of orthodontics and traumatic occlusion to improve the success of the autotransplantation procedure. What are the keys to the successful management of this case? Jiggling forces induced tooth hypermobility and increased the PDL space of the tooth planned for autotransplantation. In turn, they facilitated the atraumatic extraction and preservation of the PDL fibers on the transplanted tooth, improving the success of the reattachment of periodontal fibers. What are the primary limitations to success in this case? Traumatic extraction resulting in the unintended removal of PDL fibers from the tooth planned for autotransplantation, or intentional removal of PDL fibers with root planing are expected to decrease the success rate of the autotransplantation procedure. This is due to the lack of viable PDL cells necessary for reattachment.

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

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

Coronally advanced flap and combination therapy for root coverage. Clinical strategies based on scientific evidence and clinical experience.

During the past three decades, several surgical techniques have been proposed to treat single and multiple gingival recessions. Evidence indicates that coronally advanced flap-based approaches result in the best clinical results. Among all the different techniques, the use of a graft under a coronally advanced flap results in the best short- and long-term outcomes in terms of root coverage and gain in keratinized tissue. The use of a coronally advanced flap + connective tissue graft would appear to be the best choice for root coverage. However, harvesting a graft from the palate adds morbidity, surgical chair-time and requires increased surgical skills. A potential alternative could be the use of enamel matrix derivatives under a coronally advanced flap, and this achieves similar clinical outcomes and is less invasive, but adds economic costs to the treatment. Evidence shows that a coronally advanced flap alone in many instances results in complete root coverage and is stable over time. A coronally advanced flap is less invasive for the patient, requires less chair-time and probably less surgical skill. It would therefore be desirable to use a coronally advanced flap approach when indicated. It has been hypothesized that a coronally advanced flap approach alone could be successfully applied when the residual gingiva is thick and wide, although existing evidence does not support this hypothesis in full. Accordingly, the adjunctive use of a graft or enamel matrix derivatives could be restricted to sites at which there is thin and narrow residual gingiva.

Coronally advanced flap with and without connective tissue graft for the treatment of single maxillary gingival recession with loss of inter-dental attachment. A randomized controlled clinical trial.

BACKGROUND: The aim of this randomized clinical trial (RCT) was to evaluate the adjunctive benefit of Connective Tissue Graft (CTG) to Coronally Advanced Flap (CAF) for the treatment of gingival recession associated with inter-dental clinical attachment loss equal or smaller to the buccal attachment loss (RT2). MATERIAL AND METHODS: A total of 29 patients with one recession were enrolled; 15 patients were randomly assigned to CAF+CTG while 14 to CAF alone. Measurements were performed by a blind and calibrated examiner. Outcome measures included complete root coverage (CRC), recession reduction (RecRed), Root coverage Esthetic Score (RES), intra-operative and post-operative morbidity, and root sensitivity. RESULTS: After 6 months, CAF+CTG resulted in better outcomes in terms of CRC (adjusted OR = 15.51, p = 0.0325) than CAF alone. CRC was observed in >80% of the cases treated with CAF+CTG when the baseline amount of inter-dental CAL was ≤ 3 mm. No difference was detected in term of RecRed. CAF+CTG was associated with longer surgical-time (p < 0.0001), higher number of days with post-operative morbidity (p = 0.0222) and the need for a greater number of analgesics (p = 0.0178) than CAF alone. No difference for final RES score was detected (p = 0.1612). CONCLUSION: Both treatments can provide CRC in single gingival recession with inter-dental CAL loss. The application of CTG under CAF resulted in predictable CRC when inter-dental CAL was ≤ 3 mm.

Fourteen-year outcomes of coronally advanced flap for root coverage: follow-up from a randomized trial.

TRIAL DESIGN: This long-term 14-year-randomized split-mouth study aimed at evaluating (1) the outcomes of two different methods of root surface modifications (root surface polishing versus root planing) used in combination with a coronally advanced flap (CAF) and (2) the long-term results of CAF performed for the treatment of single gingival recessions. METHODS: Ten patients with similar bilateral recessions ≥2 mm were selected for a split-mouth randomized design study. Exposed root surfaces were assigned to receive polishing (test sites) or root planing (control sites). A multilevel model was used to analyse data at 3 months, 1, 5 and 14 years. RESULTS: One patient dropped out after 1 year. At 14 years, recession depth (Rec) was 0.9 (1.2) mm for the test sites and 0.9 (0.9) mm for the control sites. The interaction between treatment and keratinized tissue was significant (p=0.0035). Rec increased slightly over time (p=0.0006) in both the groups. CONCLUSIONS: This study shows that during a long-term follow-up, gingival recession recurred in 39% of the treated sites following the CAF procedure.

Short- and Long-Term Outcomes of Treatment of Multiple Lingual Recessions Using the Bilaminar Subperiosteal Tunnel Technique.

Treatment of gingival recession defects on the lingual surface of mandibular anterior teeth is a challenge for the periodontist because of the region's unique anatomical features. Although there are no esthetic issues, lingual recessions should be considered seriously, especially on mandibular incisors, because they are frequently associated with periodontitis and dental hypersensitivity. The treatments and the long-term outcomes (5 years) of three clinical cases of multiple lingual recessions are presented. The tunnel technique associated with subepithelial connective tissue graft was chosen. The postoperative period was almost uneventful in all treated cases, and the 1-year outcomes were successful. Great recession reduction, up to complete root coverage, was seen, as were significant increases of both the apicocoronal amount and thickness of keratinized tissue. At the 5-year follow-up, the tissues were stable; only a slight apical shift of the gingival margin was noted in one case. The modification of the periodontal phenotype following the tunnel technique with the subepithelial connective tissue graft allowed the patients to maintain good plaque control.

On the value of the 2017 classification of phenotype and gingival recessions.

The 2017 World Workshop completely restructured knowledge in periodontology with a series of official consensus statements jointly agreed upon by the American Academy of Periodontology and the European Federation of Periodontology. Among them, the 2017 classification of phenotype and gingival recession successfully incorporated the most relevant previous classifications into a treatment-oriented diagnostic matrix. Despite the significant advantages related with the implementation of this new classification of gingival recessions, recent articles still report data based on previous outdated systems. Therefore, the present commentary aimed to dive into the key advantages of the 2017 classification of phenotype and gingival recession, and to stress why it should be fully integrated into research and practice settings.

Lack of adjunctive benefit of Er:YAG laser in non-surgical periodontal treatment: a randomized split-mouth clinical trial.

AIM: This split-mouth, randomized, clinical trial aimed to evaluate the efficacy of erbium-doped:yttrium-aluminium-garnet (Er:YAG) laser application in non-surgical periodontal treatment. MATERIALS AND METHODS: A total of 27 patients underwent four modalities of non-surgical therapy: supragingival debridement; scaling and root planing (SRP)+Er:YAG laser; Er:YAG laser; and SRP. Each strategy was randomly assigned and performed in one of the four quadrants. Clinical outcomes were evaluated at 3 and 6 months. Subjective benefits of patients have been evaluated by means of questionnaires. RESULTS: Six months after therapy, Er:YAG laser showed no statistical difference in clinical attachment gain with respect to supragingival scaling [0.15 mm (95% CI -0.16; 0.46)], while SRP showed a greater attachment gain than the supragingival scaling [0.37 mm (95% CI 0.05; 0.68)]. No difference resulted between Er:YAG laser+SRP and SRP alone [0.05 mm (95% CI -0.25; 0.36)]. CONCLUSIONS: The adjunctive use of Er:YAG laser to conventional SRP did not reveal a more effective result than SRP alone. Furthermore, the sites treated with Er:YAG laser showed similar results of the sites treated with supragingival scaling.

Periodontal Pocket: An Ecologic Niche Promoting the Germination of a Plant Seed.

During a scaling and root planing procedure, a large, actively germinating seed was removed from a deep periodontal pocket. The histologic examination confirmed that it was a germinating tomato seed (Solanum lycopersicum). Since all seeds inside their fruits are in a quiescent stage, this seed was quiescent when the patient ate the tomato. Therefore, the germination occurred inside the periodontal pocket. This case led to a very interesting biologic finding: A periodontal pocket is not only a favorable environment for the development of periodontal microbiota, it is also an ecologic niche that can promote the germination and development of a plant seed.

Brain abscess and periodontal pathogens (Fusobacterium Nucleatum). Report of a case.

Patients who develop brain abscesses must be evaluated through a complete set of diagnostic tests including a microbiological and clinical periodontal assessment. A genetic comparison of the pathogens from intracranial/extracranial sites is necessary.

Factors affecting the outcome of the coronally advanced flap procedure: a Bayesian network analysis.

BACKGROUND: The aim of this study was to explore possible causal relationships among several variables in the coronally advanced flap for root coverage procedure using structural learning of Bayesian networks. METHODS: Sixty consecutive patients with maxillary buccal recessions (>or=2 mm) were enrolled. All defects were treated with the coronally advanced flap procedure. Age, gender, smoking habits, recession depth, width of keratinized tissue, probing depth, distance between the incisal margin and the cemento-enamel junction, root sensitivity, and distance between the gingival margin and the cemento-enamel junction were recorded and calculated for all patients at baseline, immediately after surgery, and at 6 months after surgery. A structural learning algorithm of Bayesian networks was used. RESULTS: The distance between the gingival margin and the cemento-enamel junction immediately after surgery was affected by the baseline recession depth; deeper recessions were associated with a more apical location of the gingival margin after surgery. Moreover, complete root coverage also seemed to be affected by the location of the gingival margin after surgery; a more coronal location of the gingival margin after surgery was associated with a greater probability of complete root coverage. CONCLUSIONS: The use of structural learning of Bayesian networks seemed to facilitate the understanding of the possible relationships among the variables considered. The main result revealed that complete root coverage seemed to be influenced by the post-surgical position of the gingival margin and indirectly by the baseline recession depth.

Minimally invasive surgical technique and enamel matrix derivative in intrabony defects: 2. Factors associated with healing outcomes.

This case cohort study was designed to evaluate the healing response of a minimally invasive surgical technique (MIST) in combination with enamel matrix derivative (EMD) in isolated deep intrabony defects. Forty deep intrabony defects were surgically accessed with the MIST This technique was designed to limit the flap extent and reflection to reduce surgical trauma and increase flap stability. EMD was applied on the dried root surfaces. Surgery was performed with the aid of an operating microscope and microsurgical instruments. The 1-year clinical attachment level gain was 4.9 +/- 1.7 mm. Seventy percent of defects gained > or = 4 mm. Clinical attachment level gain was significantly associated with the depth of the three-wall component of the defect, with the intraoperative bleeding tendency of the defect, and with its interaction with the baseline amount of bone loss. Defect morphology and bleeding tendency seem to influence clinical outcomes from the use of MIST in combination with EMD.

Clinical guidelines of the Italian Society of Periodontology for the reconstructive surgical treatment of angular bony defects in periodontal patients.

BACKGROUND: The purpose of these clinical guidelines, commissioned by the Italian Society of Periodontology and compiled with the tools and instructions of the Appraisal of Guidelines for Research and Evaluation (AGREE) collaboration, was to determine, in terms of efficacy, complications, and patient opinions, the most appropriate surgical techniques for periodontal patients with infrabony defects > or = 3 mm. METHODS: Results published in the literature concerning open flap debridement (OFD), guided tissue regeneration (GTR) using a bioabsorbable or non-resorbable membrane, regeneration of periodontal tissues using enamel matrix derivative (EMD), and bone or bone substitute grafts were searched (electronically and manually) and compared. The following variables were analyzed: number of teeth lost, variation in clinical attachment level (CAL gain), variation in probing depth (PD reduction), variation in gingival recession, variation in bony defect depth (bone gain), complications, and the functional and esthetic satisfaction of the patients. Literature searches were performed selecting randomized clinical trials (RCTs) and systematic reviews (SRs) of RCTs published through December 31, 2006 with > or = 1 year of follow-up. The full text of the selected SRs and RCTs were analyzed using checklists for qualitative evaluation according to the Scottish Intercollegiate Guidelines Network (SIGN) method. RESULTS: For the drafting of these guidelines, it was decided to accept the results of two SRs that compared OFD versus GTR, OFD versus EMD, and GTR versus EMD. With regard to efficacy, GTR and EMD can yield better results than OFD in terms of CAL gain (1.22 mm [P value <0.0001] and 1.20 mm [P value <0.0001], respectively), reduction of PD (1.21 mm [P = 0.0004] and 0.77 mm [P = 0.0001], respectively), and bone gain (1.39 and 1.08 mm, respectively) after > or = 1 year of follow-up. The available data are insufficient for an evaluation of bone or bone substitute grafts. The data in the literature are also insufficient for answering questions about complications and patient opinions. CONCLUSIONS: The evidence reported in the literature indicates that it is advisable to treat infrabony defects > or = 3 mm by OFD, GTR, and EMD. Further studies on these topics should be encouraged. There is a need for well-conducted RCTs that report data on complications and patient opinions.