Tunnel vs. coronally advanced flap in combination with a connective tissue graft for the treatment of multiple gingival recessions: a multi-center randomized clinical trial.

OBJECTIVE: To evaluate the efficacy of the partial-thickness non-advanced tunnel technique (TUN) versus the coronally advanced flap (CAF), both combined with a connective tissue graft, in the treatment of multiple gingival recessions. MATERIALS AND METHODS: Twenty-nine patients (83 teeth) affected by multiple gingival recessions were treated in two clinical centers with either the test (TUN) or the control (CAF) intervention combined with a connective tissue graft. Outcomes at 3 and 6 months after surgery included complete root coverage (CRC-primary outcome), mean root coverage (mRC), changes in recession depth (RD), probing pocket depth (PPD), and keratinized tissue height (KT). Root sensitivity and root coverage esthetic score (RES) were also evaluated at 6-month examination. Surgery duration, wound healing index (WHI), and patient-reported outcome measures (PROMs) were additionally considered. RESULTS: At 6 months, CRC was observed in 80.9% and 79.5% of the teeth treated with TUN and CAF, respectively (odds ratio = 1.2; p = 0.802). No differences between groups were also observed in terms of mRC (TUN = 94.0%; CAF = 91.1%), RD and PPD reductions, root sensitivity, RES, and WHI. KT increase was significantly higher in teeth treated with TUN (Difference in Means - MD = - 1.0 mm; p = 0.001). Surgery duration was shorter (MD = - 19.3 min; p = 0.001), and patients reported less intra-surgical pain (MD = - 16.4; p = 0.028) as well as postoperative morbidity in TUN compared with CAF. CONCLUSIONS: Both surgical interventions showed a similar efficacy in terms of root coverage, albeit TUN was associated with a higher increase in KT and with a milder patient's surgical experience. CLINICAL RELEVANCE: Both techniques have shown similar efficacy for the coverage of exposed root surfaces, although clinicians may consider TUN as less invasive. TRIAL REGISTRATION: Clinicaltrials.gov (NCT05122468).

Morphological changes in alveolar bone thickness and height after orthodontic proclination or labial movement combined with autogenous soft tissue grafting: a CBCT evaluation.

BACKGROUND: Autogenous soft tissue grafting is indicated in thin gingival biotypes before orthodontic proclination or labial movements to increase the keratinized gingiva and prevent gingival recession. However, its effect on local alveolar bone remodeling is unclear. The aim of this study was to investigate the effects of autogenous soft tissue grafting on local alveolar bone after orthodontic proclination or labial movements. METHODS: Sixteen patients with a thin scalloped gingival biotype, narrow keratinized gingiva, or thin cortical bone requiring orthodontic proclination or labial movement of teeth were included. Cone-beam computed tomography (CBCT) images were obtained before grafting and at least 6 months after surgery. Sixty mandibular teeth were included, and the vertical bone level and horizontal labial bone thickness were measured. The results were compared using paired t-tests or Wilcoxon signed-rank test. RESULTS: The horizontal labial bone thickness increased, especially at 6 mm below the cementoenamel junction (CEJ) in the mandibular central and lateral incisors (P < 0.05). The total alveolar bone area of the canines, first premolars, and second premolars increased at 3, 6, and 9 mm below the CEJ, respectively, and the differences were statistically significant (P < 0.05). Additionally, vertical bone height increased minimally on the labial side, but the differences were not statistically significant (P > 0.05). CONCLUSIONS: New bone regeneration was observed on the labial (pressure) side after autogenous soft tissue grafting, which may represent a mechanism to effectively prevent gingival recession and maintain periodontal health. IRB APPROVAL: All the experimental procedures involving humans in this study were approved by the Medical Ethics Committee of Xiangya Stomatological Hospital, Central South University ( No. 20190048).

Effectiveness of Plasma-Rich Fibrin and De-Epithelialized Free Gingival Graft in the Treatment of Gingival Recessions.

Introduction/Aim: Soft tissue dehiscences such as gingival recessions are a very common problem that we face in modern periodontics. This clinical study aimed to analyze the effectiveness of surgical procedures using a de-epithelialized gingival graft (DGG) combined with a coronally advanced flap and to evaluate the application of plasma-rich fibrin (PRF). Methods: The study included 40 teeth (20 patients) with Miller class I and II gingival recessions. Twenty recessions (20 patients) were treated utilizing the de-epithelialized gingival graft in combination with the coronally advanced flap, and on the opposite side of the jaw, the same number of recessions were treated utilizing plasma-rich fibrin combined with the coronally advanced flap. To evaluate tissue condition and the clinical parameters before and after the surgical procedure, the following parameters were used: the degree of epithelial attachment (DEA), the width of keratinized gingiva (WKG), and the vertical depth of recession (VDR). Results: based on the achieved results and the analysis of clinical parameters, a statistically significant reduction in the vertical depth of recession was proven in both groups, with very similar mean percentages of root coverage, with the difference being that the stability of the soft tissues of the treated region was more visible in the DGG. Conclusion: using modern surgical procedures allows the regeneration of not only the soft tissues but also deeper periodontal tissues.

Comparison between connective tissue graft and xenogeneic acellular dermal matrix to treat single gingival recession: A data reanalysis of randomized clinical trials.

OBJECTIVES: There are few studies comparing xenogeneic acellular dermal matrixes (XDMs) with connective tissue graft (CTG) to treat single gingival recession (GR). The present study involved a reanalysis of previous studies and comparison of CTG or XDM to treat single RT1/GR. MATERIALS AND METHODS: Fifty patients from three previous randomized clinical trials treated either by CTG (n = 25) or XDM (n = 25) were evaluated after 6-month. Clinical, patient-centered, and esthetic parameters were assessed. Pearson's correlation and regression analyses were also performed. RESULTS: Greater recession reduction (RecRed), percentage of root coverage (%RC), and complete root coverage (CRC) were observed in the CTG group (p ≤ 0.02). Gingival thickness (GT) and keratinized tissue width (KTW) gains were higher in the CTG group. The CTG group showed better esthetic at 6-month. Logistic analyses reported that GT([OR] = 1.6473 ) and papilla height (PH) (OR = 8.20) are predictors of CRC. GT*XDM interaction was a negative predictor of CRC (OR = 7.105-5 ). GT at baseline acted as a predictor of RecRed in both groups (p = 0.03). The XDM graft impacted RecRed and %RC negatively. Baseline PH was a predictor of %RC for both grafts. CONCLUSION: CTG was superior for treating RT1/GR, providing better root coverage outcomes and tissue gains over time. GT, PH, and graft type were classified as predictors of CRC. CLINICAL SIGNIFICANCE: CTG presented better outcomes to treat single RT1 gingival recession when compared to the XDM.

Periodontal Approaches to Esthetic Dentistry: A Review on Current Trends.

AIM: Thepresent review is to discuss the current trends in periodontal approaches for improving the esthetics in dentistry. BACKGROUND: Esthetics is an essential component of today's dental care. A growing awareness of esthetics has fueled an increase in esthetic demand in dentistry in recent years. The ultimate goal in modern dentistry is to attain "white and pink esthetics" in the esthetically important zone Review results: Current evidence-based periodontal approaches for improving esthetic dentistry are discussed. The periodontal management of esthetics is mainly focused on proper assessment of the case scenario including the associated mucogingival deformities and selection of a proper technique for the correction of the same. CLINICAL SIGNIFICANCE: There is drastic increase in esthetic demand for the dental procedures in recent years. With the evolution of innovative techniques, clinicians can fulfill the patient's esthetic demands. Thus it is important to be updated in this field about the current innovative approaches. CONCLUSION: Newer procedures are being developed all the time and are gradually being integrated into periodontal practice. The practitioner should be mindful that novel approaches are sometimes presented without appropriate clinical research. Our ongoing progress toward better therapeutic approaches should be guided by critical analysis of freshly offered methodologies.

Retrospective evaluation of gingival thickness and tissue stability after connective tissue grafting in Asian populations: 1 month to 3.5 years.

BACKGROUND/PURPOSE: The objectives of this retrospective study are to analyze post-surgical gingival thickness after connective tissue grafting in the Asian population and to assess its tissue stability for up to approximately 3.5 years. METHODS: A total of 111 grafted teeth and 57 nearby nongrafted teeth in 28 Asian patients who had undergone connective tissue grafting surgery were selected. Gingival thickness was measured by transgingival probing. The mean gingival thickness of the grafted teeth was compared with adjacent nongrafted teeth in the same individuals. The mean gingival thickness of the grafted teeth in different tooth types and at various time intervals were statistically analyzed. RESULTS: The average gingival thickness following connective tissue grafting is 1.99 ± 0.62 mm compared to 0.96 ± 0.40 mm with nongrafted teeth (P < .0001). The maxillary premolar is the tooth type that underwent connective tissue grafting most frequently in our study. Among different tooth types, mandibular molars showed the thickest gingival tissues whereas mandibular incisors presented the thinnest tissues. No statistically significant difference in the mean tissue thickness at different time intervals was observed. CONCLUSION: Connective tissue grafting is a predictable treatment modality for gingival phenotype conversion, even in Asians, achieving nearly 2 mm of gingival thickness on average, post-operation. Tissue stability after connective tissue grafting has been presented in our study. This quantitative assessment of the gingival thickness in Asians may encourage clinicians to deal with soft tissue architecture ahead of main surgical, restorative and orthodontic treatments in order to achieve pleasing treatment outcomes.

Description of the modified vestibular incision subperiosteal tunnel access (m-VISTA) technique in the treatment of multiple Miller class III gingival recessions: a case series.

BACKGROUND: Gingival recession is a common finding in the adult population. It is considered a challenge for clinicians to obtain a complete root coverage of Miller class III recession. The aim of this case series was to assess the outcomes achieved with the use of modified VISTA technique (m-VISTA) in patients having multiple Miller class III recessions after 6 months. METHODS: Ten patients (six women and four men; mean age: 53 years), who showed multiple Miller class III recessions (depth ≥ 2 mm) and who met the established inclusion and exclusion criteria, were treated by postgraduate students with the use of m-VISTA technique. RESULTS: A total of 38 recessions were performed. The recessions were mainly located in the mandible (80%), which included six molars. The mean baseline recession was 3.12 mm. Post the intervention, a mean root coverage of 58.72% was achieved, with complete root coverage observed in 29% of the recessions. CONCLUSIONS: m-VISTA may offer several advantages in the treatment of Miller class III gingival recession. Nevertheless, more clinical trials with a longer follow-up period are needed to arrive at a concrete conclusion about its advantages. TRIAL REGISTRATION: NCT03258996. Data registration: 08/18/2017.

Epidemiology of mid-buccal gingival recessions in NHANES according to the 2018 World Workshop Classification System.

AIM: There are no nationally representative epidemiological studies available reporting on the different recession types according to the 2018 classification system or focusing on the aesthetic zone. The aims of this cross-sectional study were (a) to provide estimates on the prevalence, severity and extent of mid-buccal GRs according to the 2018 classification and (b) to identify their risk indicators in the adult U.S. population from the NHANES database. MATERIALS AND METHODS: Data from 10,676 subjects, representative of 143.8 millions of adults, were retrieved from the NHANES 2009-2014 database. GR prevalence was defined as the presence of at least one mid-buccal GR ≥1 mm. GRs were categorized following the 2018 World Workshop classification system (RT1, RT2, RT3) and according to different severity cut-offs. An analysis for GR risk indicators was also performed, selecting subjects without periodontitis. RESULTS: The patient-level prevalence of mid-buccal GRs (all types) was 91.6%, while it decreased to 70.7% when considering only the aesthetic zone. When focusing on RT1 GRs, the patient-level prevalence (whole mouth) was 12.4%, while it was 5.8% considering only the aesthetic zone. The majority of RT1 GRs were considered as mild (1-2 mm). The whole-mouth patient-level prevalence of RT2 and RT3 GRs was 88.8% and 55.0%, respectively. Age (35-49 years), gender (female), ethnicity (non-Hispanic Whites), last dental visit (>6 months before), tooth type (incisors) and the arch (mandible) resulted as risk indicators associated with the presence of RT1 GR. CONCLUSIONS: Mid-buccal GRs affect almost the entire US population. Age, gender, ethnicity, dental care exposure, tooth type and arch were identified as risk indicators for RT1 GRs.

Effect of enamel matrix derivative on wound healing following gingival recession coverage using the modified coronally advanced tunnel and subepithelial connective tissue graft: a randomised, controlled, clinical study.

OBJECTIVES: The potential effect of enamel matrix derivative (EMD) on wound healing following recession coverage surgery is still controversially discussed in the literature. The aim of this randomised, controlled, single blinded clinical study was, therefore, to investigate clinically and immunologically the potential effects of EMD on early wound healing and clinical results following treatment of single and multiple gingival recessions by the modified coronally advanced tunnel technique (MCAT) and subepithelial connective tissue graft (sCTG). MATERIALS AND METHODS: A total of 40 systemically healthy patients with Miller class I, II or III single or multiple gingival recessions were treated with MCAT + sCTG with or without EMD. Patients were consecutively enrolled and randomly assigned to test or control treatment. Inflammatory markers (interleukin (IL)-1ß, IL-8, IL-10 and matrix metalloprotease (MMP)-8) were measured at baseline, 2 days and 1 week postoperatively. The following clinical parameters were assessed at baseline and at 6 months postoperatively: Recession Depth (RD), Recession Width (RW), Width of Keratinized Tissue (KT) and Probing Depth (PD). Patient-reported outcomes were analysed by means of a visual analogue scale. RESULTS: No statistically significant differences were detected between the 2 groups in terms of inflammatory markers and patient-reported outcomes during early wound healing. In the test group, RD was reduced from 4.0 ± 1.2 mm at baseline to 0.9 ± 1.3 mm at 6 months (p < 0.001), while the corresponding values in the control group were 4.5 ± 2.0 mm at baseline and 1.0 ± 1.0 mm at 6 months, respectively. At 6 months, mean root coverage measured 78 ± 26% in the test group and 77 ± 18% in the control group, respectively. CONCLUSION: Within their limits, the present data have failed to show an influence of EMD on the clinical and immunological parameters related to wound healing following recession coverage surgery using MCAT and sCTG. CLINICAL RELEVANCE: Early wound healing following recession coverage by means of MCAT and sCTG does not seem to be influenced by the additional application of EMD.

Free gingival graft and acellular dermal matrix for gingival augmentation: a 15-year clinical study.

OBJECTIVES: This study evaluated clinical outcomes of acellular dermal matrix (ADM) allograft compared with autogenous free gingival graft (FGG) for gingival augmentation after 15 years. MATERIAL AND METHODS: Twenty-two patients were originally included and evaluated by de Resende et al. (Clin Oral Investig 23:539-550, 2019), and 12 accepted to participate in this longitudinal evaluation. Clinical parameters evaluated were recession depth (RD), probing depth (PD), clinical attachment level (CAL), keratinized tissue width (KTW), and soft tissue thickness (TT). In addition, esthetic perception was evaluated by patients and by a calibrated periodontist. Data were evaluated by ANOVA complemented by Tukey tests (p < 0.05). RESULTS: After 15 years, both treatments provided a significant increase in KTW and TT but with superior results for the FGG group (p < 0.05). No differences were observed between groups for PD and CAL. In the ADM group, RD significantly increased in long term, as well as the rate of tissue contraction. The percentage of shrinkage for the ADM group was 59.6%. Conversely, the FGG group presented a creeping attachment of 17.6% and RD significantly decreased in long term. The ADM group presented superior results considering professional esthetic perception. CONCLUSIONS: Both treatments longitudinally promoted significant gain of keratinized tissue width and thickness with superior outcomes for the FGG group. The ADM group demonstrated more tissue contraction and gingival recession whereas the FGG group presented creeping attachment. Professional esthetic perception was superior for the ADM group. CLINICAL RELEVANCE: This study added important clinical data with long-term evaluation of ADM compared with FGG.

Root coverage of gingival recessions with non-carious cervical lesions: a controlled clinical trial.

OBJECTIVE: The non-carious cervical lesion (NCCL) is commonly produced by improper toothbrushing techniques, occlusion trauma, anatomic mal-positioned teeth, and acid erosion, thus sharing the same etiology of gingival recession (GR). The association of a graft to the coronally advanced flap had demonstrated the best long-term outcome for root coverage (RC). However, substitutes for the autogenous graft must be studied. This split-mouth clinical trial investigates the RC and the increase in keratinized tissue (KT) when comparing RC of NCCLs associated with GR with intact roots using an extended coronally advanced flap (ECAF) associated with the acellular dermal matrix graft (ADMG), a connective tissue replacement graft. MATERIAL AND METHODS: Seventeen individuals with bilateral GR were included in the study. One side had a NCCL (TG) and the opposite root was intact (CG). All patients were treated with the ECDF associated with ADMG. All clinical parameters were assessed at baseline and 6 months postoperative. RESULTS: Root coverage means (CG, 69.5 ± 19 and TG. 72.2 ± 16.5; p value = 0.849570) were not significantly different between control and test groups. In addition, the KT had an increase in the follow-up period for both groups. CONCLUSION: GR associated with NCCLs can be successfully treated with the ECDF and ADMG. CLINICAL RELEVANCE: Patients frequently search for GR treatment due to cervical wear, root sensitivity, and compromising aesthetics. The NCCL participates with the same issues. The present study contributes to the literature that GR associated with NCCLs can be successfully treated with the ECAF and the ADMG.

Creeping attachment: A literature review.

OBJECTIVE: Mucogingival surgery has been widely applied in clinics. An interesting phenomenon after mucogingival surgery is the coronal migration of gingival margin, which is described as "creeping attachment." The goal of this review is to summarize the characteristics, significance, mechanism, and manifestation of the creeping attachment after mucogingival surgery and to describe the factors associated with its occurrence. OVERVIEW: A total of 82 relevant articles were included in the literature review. The characteristics and significance of the creeping attachment after mucogingival surgery were analyzed. The mechanism of the creeping attachment was explored. Different manifestations of and factors associated with creeping attachment were summarized. CONCLUSIONS: Creeping attachment may occur to obtain additional root coverage after the healing of various mucogingival surgeries. However, this coverage is not always complete nor entirely predictable. CLINICAL SIGNIFICANCE: Creeping attachment plays an important role in the prognosis of mucogingival surgeries. This review will help clinicians get a thorough recognition and understanding of this phenomenon.

Acellular dermal matrix allograft versus free gingival graft: a histological evaluation and split-mouth randomized clinical trial.

OBJECTIVES: This split-mouth controlled randomized clinical trial evaluated clinical and histological results of acellular dermal matrix allograft (ADM) compared to autogenous free gingival graft (FGG) for keratinized tissue augmentation. MATERIAL AND METHODS: Twenty-five patients with the absence or deficiency of keratinized tissue (50 sites) were treated with FGG (control group) and ADM (test group). Clinical parameters included keratinized tissue width (KTW) (primary outcome), soft tissue thickness (TT), recession depth (RD), probing depth (PD), and clinical attachment level (CAL). Esthetic perception was evaluated by patients and by a calibrated periodontist using visual analog scale (VAS). Histological analysis included biopsies of five different patients from both test and control sites for each evaluation period (n = 25). The analysis included percentage of connective tissue components, epithelial luminal to basal surface ratio, tissue maturation, and presence of elastic fibers. Data were evaluated by ANOVA complemented by Tukey's tests (p < 0.05). RESULTS: After 6 months, PD and CAL demonstrated no differences between groups. ADM presented higher RD compared to FGG in all periods. Mean tissue shrinkage for control and test groups was 12.41 versus 55.7%. TT was inferior for ADM group compared to FGG. Esthetics perception by professional evaluation showed superior results for ADM. Histomorphometric analysis demonstrated higher percentage of cellularity, blood vessels, and epithelial luminal to basal surface ratio for FGG group. ADM group presented higher percentage of collagen fibers and inflammatory infiltrate. CONCLUSIONS: Both treatments resulted in improvement of clinical parameters, except for RD. ADM group presented more tissue shrinkage and delayed healing, confirmed histologically, but superior professional esthetic perception. CLINICAL RELEVANCE: This study added important clinical and histological data to contribute in the decision-making process between indication of FGG or ADM.

Treatment of buccal soft tissue dehiscence around single implant: 5-year results from a prospective study.

OBJECTIVES: The aim of this study is to report the 5-year outcomes of a coverage procedure of shallow maxillary soft tissue dehiscences, around single tissue-level implants. MATERIAL AND METHODS: The original population consisted of 16 patients presenting a single maxillary buccal implant soft tissue recession. A connective tissue graft, taken from the maxillary tuberosity, was inserted underneath a split-thickness envelope flap. After treatment, patients received individually tailored supportive periodontal therapy (SPT). RESULTS: Two patients were lost to follow-up, while one implant was removed due to peri-implantitis, before the final examination. At 5 years, complete implant soft tissue coverage was depicted in 8 out of 13 cases (62%). Mean soft tissue dehiscence coverage was 86%. Patients' esthetic evaluation showed the persistency of high VAS scores. CONCLUSIONS: Treatment of buccal soft tissue dehiscence around single implant, followed by regular supportive therapy, resulted in good esthetic and functional results in the majority of patients. CLINICAL RELEVANCE: Within the limits of this study, the positive results suggest that the proposed technique may be a reliable option in selected cases.

Effectiveness of adjunctive hyaluronic acid application in coronally advanced flap in Miller class I single gingival recession sites: a randomized controlled clinical trial.

OBJECTIVES: The aim of this randomized controlled clinical trial was to evaluate the possible advantages of adjunctive hyaluronic acid (HA) application in the coronally advanced flap (CAF) procedure in single Miller class I/recession type 1 (RT1) gingival recession treatment. MATERIAL AND METHODS: Thirty patients with one recession were enrolled; 15 were randomly assigned CAF + HA and 15 to CAF alone. The recession reduction (RecRed), clinical attachment level gain (CAL-gain), changes in probing pocket depth (PPD) and in the width of keratinized tissue (KT), complete root coverage (CRC), and mean root coverage (MRC) were calculated after 18 months. Post-operative morbidity (pain intensity, discomfort, and swelling) was recorded 7 days after treatment using visual analogue scale (VAS). RESULTS: After 18 months, RecRed was statistically significantly higher in the test group (2.7 mm [1.0]) than in the control group (1.9 mm [1.0]; p = 0.007). PPD were found to be slightly but statistically significantly increased in both groups. No statistically significant difference was found for KT gain between treatments. CRC was 80% for test and 33.3% for control sites (p < 0.05). A MRC of 93.8 ± 13.0% for test and 73.1 ± 20.8% for control sites was calculated (p < 0.05). The test group reported lower swelling and discomfort values 7-days post-surgery (p < 0.05). Statistically significant difference was not found for pain intensity. CONCLUSIONS: The adjunctive use of HA was effective in obtaining CRC for single Miller class I/RT1 gingival recession sites. CLINICAL RELEVANCE: Adjunctive application of HA in the coronally advanced flap procedure may improve the reduction of the recessions and increase the probability of CRC in Miller class I recessions.

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.

Effect of EDTA root conditioning on the outcome of coronally advanced flap with connective tissue graft: a systematic review and meta-analysis.

OBJECTIVES: CAF in combination with a connective tissue graft (CTG) is considered the technique of choice for treating gingival recessions (GRs). Among the many recognized factors that can affect the outcomes, the use of chemical agents has been proposed. The effect of EDTA, as a commonly used agent, remains controversial. Therefore, the aim of this review was to assess the efficacy of EDTA root conditioning when combined to CAF + CTG. MATERIAL AND METHODS: A literature search was conducted to identify randomized clinical trials (RCTs) that performed CAF + CTG with and without EDTA for root coverage procedures. The following outcomes were assessed: recession reduction (Rec Red), complete root coverage (CRC), keratinized tissue gain (KT gain), clinical attachment level changes (CAL gain), and changes in pocket depth (PD changes). RESULTS: Fourteen RCTs (575 GRs) were included and analyzed. Six articles were included in the EDTA group, with 8 in the non-EDTA group. Meta-analyses revealed statistically significant differences for the outcomes of Rec Red (3.68 mm versus 3.07 mm), CAL gain (4.15 mm versus 3.07 mm), and PD changes (- 0.44 mm versus 0.27 mm) in favor of the EDTA group, while outcomes of CRC (odds ratio of 1.15) and KT gain (1.98 mm versus 1.62 mm) were not significantly different. CONCLUSIONS: Limited evidence is available when evaluating the effectiveness of EDTA root conditioning with CAF + CTG. However, the adjunct application of EDTA with CAF + CTG appears to be beneficial. CLINICAL RELEVANCE: The adjunct application of EDTA may provide benefits when performing root coverage procedure via CAF + CTG.

Treatment of multiple recession defects with vestibular incision subperiosteal tunnel access (VISTA): A retrospective pilot study utilizing digital analysis.

OBJECTIVE: To examine the correlation between initial site-specific characteristics of patients with multiple gingival recession defects and the outcome of root coverage therapy. MATERIALS AND METHODS: Pretherapy and post-therapy study models of 21 patients (154 teeth) with multiple gingival recession defects, treated with Vestibular Incision Subperiosteal Tunnel Access (VISTA), were optically scanned. Three-dimensional analysis of superimposed preoperative and postoperative images was performed. Linear and surface root coverage were calculated and correlated to various clinical and/or anatomical parameters. A multilevel statistical analysis was conducted, adjusting for the correlation among multiple observations. RESULTS: The mean percentages of linear root coverage were 96.2 ± 13.1% and 84.3 ± 14.4% for Miller Class I/II and Class III recessions, respectively. The mean percentages of root surface area coverage were 92.1 ± 12.0% and 78.6 ± 15.7% for Miller Class I/II and III defects, respectively. Root prominence, initial recession width and posterior tooth type were negatively correlated with linear and root surface area coverage. Initial recession depth was negatively correlated with root surface area coverage. Initial gingival margin thickness was positively associated with both linear and root surface area coverage. CONCLUSION: The results of the present study identified important positive and negative site-specific characteristics that may have utility in predicting the outcome of root coverage. CLINICAL SIGNIFICANCE: This study used sensitive 3-dimensional digital analysis tools to examine the correlation between initial site-specific characteristics of patients with multiple gingival recession defects and the outcome of periodontal root coverage therapy. Results demonstrated that initial root prominence, loss of interdental tissue (Miller Class III), molar tooth type, initial recession depth and width were negatively correlated with the outcome of periodontal root coverage achieved. Conversely, initial gingival margin thickness was associated with increased percentage of root coverage. These site-specific characteristics may serve as important risk indicators to predict the outcome of root coverage procedure.

Coronal advanced flap in combination with a connective tissue graft. Is the thickness of the flap a predictor for root coverage? A prospective clinical study.

AIM: Evaluate if there is any relationship between the flap thickness (FT) and the presence of complete root coverage (CRC) when performing coronally advanced flaps in combination with a connective tissue graft (CTG). MATERIALS AND METHODS: Prospective clinical study, in which multiple Miller class I and II recessions were treated with a coronally advanced flap and a CTG standardized at 1 mm of thickness. Individual stents permitted repeated measurements of conventional periodontal parameters at the same point. The primary outcome variable was CRC. Secondary outcomes were recession reduction, gingival thickness and width of keratinized tissue (KT) achieved at 6 months post-surgery. RESULTS: Forty-five recessions (2.4 ± 0.75 mm) were treated in 20 patients. Mean root coverage was 93.4 ± 10.98%; 65% achieved CRC. The mean FT was 1.01 mm ± 0.64 mm and 1.01 ± 0.61 mm at 2 and 5 mm from the gingival margin, respectively. No relationship could be found between FT and CRC (p > .05). Statistical significant changes (p < .05) were observed for recession depth, clinical attachment level, KT and soft tissue thickness at the end of the study. CONCLUSIONS: Flap thickness seems not to be a predictor for CRC when performing a coronally advanced flap plus a CTG. This technique may be of choice when treating thin biotypes.

Diode laser for harvesting de-epithelialized palatal graft in the treatment of gingival recession defects: a randomized clinical trial.

AIMS: The aim of present randomized controlled clinical study was to evaluate the effects of the use of diode laser for graft harvesting and palatal wound irradiation on post-operative morbidity and root coverage outcomes after a coronally advanced flap (CAF) with de-epithelialized gingival grafts (DGG). METHODS: Fifty-two patients with isolated recessions were treated. The CTG resulted from the de-epithelialization of a free gingival graft (FGG) with blade (control group:DGG-B) or diode laser (DL) (test group:DGG-L). The DL was used to de-epithelialize the outer part of the FGG and photo-biostimulate the palatal wound area. Post-operative morbidity was evaluated by using Oral Health-related Quality of Life (OHQoL) and Visual Analogue Scale-discomfort (VAS). Root coverage outcomes were also evaluated 6 months after operation. RESULTS: Statistically significant differences were found for OHQoL (p = 0.0001) and VAS (p = 0.0001) at the 7th day post-operatively favouring test sites. Root coverage results did not show a statistically significant difference. CONCLUSIONS: While both techniques were effective with regard to root coverage at 6 months, the DGG-L technique decreased post-operative morbidity associated with palatal donor-site surgery.