Patient-reported outcome measures after periodontal surgery.

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

Do soft tissue augmentation techniques provide stable and favorable peri-implant conditions in the medium and long term? A systematic review.

OBJECTIVES: To review the available literature on the medium- and long-term effects of soft tissue augmentation (STA) at implant sites and to explore the effects of the different approaches on clinical-, patient-reported, and health-related parameters. MATERIALS AND METHODS: A comprehensive electronic and manual search was performed to identify prospective clinical studies that assessed the medium- and long-term (≥36 months) outcomes following STA, including number of sites maintaining peri-implant health and number of sites developing peri-implant disease, incidence of complications, stability of the clinical, volumetric, and radiographic parameters, and patient-reported outcome measures (PROMs). RESULTS: Fifteen studies were included in the qualitative analysis. STA was performed with either a bilaminar- or an apically positioned flap (APF) approach, in combination with autogenous grafts (free gingival graft [FGG] and connective tissue graft [CTG]) or substitutes (acellular dermal matrix [ADM] and xenogeneic cross-linked collagen matrix [CCM]). An overall high survival rate was observed. Most of the augmented implant sites maintained peri-implant health in the medium and long term, with the incidence of peri-implant mucositis and peri-implantitis ranging from 0% to 50% and from 0% to 7.14%, respectively. The position of the soft tissue margin following APF + FGG and bilaminar approaches involving CTG or CCM was found to be stable over time. No substantial changes were reported for plaque score/index, bleeding on probing/bleeding index, and probing depth between early time points and following visits. CTG-based STA procedures resulted in a stable or increased dimension of keratinized mucosa width (KMW) and mucosal thickness (MT)/volumetric outcomes over time, when compared with early follow-ups. Most of the included studies described stable marginal bone levels at the grafted implant sites over time. No substantial changes for patient-reported outcomes and professionally assessed esthetic results were reported at different time points. CONCLUSIONS: Implants that received STA showed overall high survival rate and relatively low incidence of peri-implantitis in the medium and long term. Augmented sites seem to maintain the level of soft tissue margin and marginal bone over time, while non-augmented implants may exhibit apical shift of the soft tissue margin. The overall favorable early outcomes obtained with STA are maintained in the medium and long term, with an increase in KMW and MT that may be expected over time at CTG-augmented sites.

Surgical management of gingival recessions in patients with refractory gingival pemphigus vulgaris: A multidisciplinary challenge.

BACKGROUND: Mucogingival surgery for root coverage of gingival recessions (GRs) is usually performed in patients with unremarkable periodontal and systemic health. However, the predictable results of surgical procedures and increasingly high aesthetic expectations of patients necessitate optimal management of GR also in patients with systemic conditions that affect the oral cavity. In patients with pemphigus vulgaris (PV), mucosal fragility and complicated surgical management of inflamed soft tissues are major challenges. METHODS AND RESULTS: A 36-year-old female patient with PV and deep GR on the mandibular incisors is presented. After initial unresponsiveness to steroids and immunosuppressants, complete clinical remission was achieved through repeated rituximab infusions and topical platelet-rich plasma. After > 1 year of stable clinical remission off therapy the patient successfully underwent surgical procedures for vertically coronally advanced flap with connective tissue graft. CONCLUSIONS: To the best of our knowledge, no studies have described the surgical management of GR in PV patients. Although controlled studies are required to confirm present results, complete and stable clinical remission is necessary to avoid complications. Collaboration among dermatologists, oral medicine specialists, and periodontologists is essential to determine whether mucogingival surgery for root surface exposure is indicated for PV patients. KEY POINTS: Why are these cases new information? This is the first report of root coverage in a patient with oral PV What are the keys to the successful management of these cases? The achievement of complete and stable clinical remission from oral PV Multidisciplinary collaboration among dermatologists, oral medicine specialists, and periodontologists What are the primary limitations to success in these cases? The refractoriness of gingival lesions induced by PV Poor mucogingival conditions of inflamed gingival tissues exacerbated by PV.

Complications and treatment errors in peri-implant soft tissue management.

Inadequate quality, quantity, or aesthetics of the peri-implant soft tissues can result from a combination of factors related to the outcome of treatments performed before, during, or after implant placement. In this paper, we describe in detail the treatment errors that can pave the way for the onset of mucositis or give rise to soft tissue complications such as peri-implant soft tissue discoloration or dehiscence, graft exposure, or scar formation. By tracing the error back to the planning or surgical stage, clinical insights on surgical soft tissue management are provided to avoid or treat complications that affect the status of the peri-implant soft tissues. Mastering the learning curve and knowing the limitations of each technique are fundamental for preventing added treatment failures that can result in increased patient morbidity and overall discontent.

Wound healing dynamics, morbidity, and complications of palatal soft-tissue harvesting.

Palatal-tissue harvesting is a routinely performed procedure in periodontal and peri-implant plastic surgery. Over the years, several surgical approaches have been attempted with the aim of obtaining autogenous soft-tissue grafts while minimizing patient morbidity, which is considered the most common drawback of palatal harvesting. At the same time, treatment errors during the procedure may increase not only postoperative discomfort or pain but also the risk of developing other complications, such as injury to the greater palatine artery, prolonged bleeding, wound/flap sloughing, necrosis, infection, and inadequate graft size or quality. This chapter described treatment errors and complications of palatal harvesting techniques, together with approaches for reducing patient morbidity and accelerating donor site wound healing. The role of biologic agents, photobiomodulation therapy, local and systemic factors, and genes implicated in palatal wound healing are also discussed.

Shared epigenetic alterations between oral cancer and periodontitis: A preliminary study.

INTRODUCTION: We recently developed a non-invasive sampling procedure for oral squamous cell carcinoma (OSCC) detection based on DNA methylation analysis of a panel of 13 genes. Oral cancer, as well as acute and chronic inflammatory diseases, may influence the methylation level of several genes in the oral cavity. In the present study, we evaluated the presence of periodontal disease (PD) and the methylation status using our 13-gene panel. METHODS: Oral brushing specimens were collected from three different patient groups: 23 gingival OSCC patients, 15 patients affected by PD, and 15 healthy volunteers lacking evidence of PD. DNA methylation analysis was performed and each sample was determined to be positive or negative based on a predefined cut-off value. RESULTS: Positive results were found for 23/23 OSCC patients, 3/15 PD patients, and 0/15 samples from healthy volunteers. The GP1BB and MIR193 genes in the PD group exhibited mean methylation levels similar to OSCC patients. ZAP70 showed different methylation levels among three groups. CONCLUSION: Preliminary data identified shared epigenetic alterations between PD and OSCC patients in two inflammatory genes (GP1BB and MIR193). This study may help to identify potential links between the two diseases and serve as a starting point for the future research focused on pathogenesis.

Three-Dimensional Volumetric Analysis of the Palatal Donor Site Following Soft Tissue Harvesting.

Autogenous soft tissue grafting is a commonly performed procedure in periodontal and implant surgery. Reharvesting a connective tissue graft (CTG) from the same palatal donor site is often required, but little is known about the volumetric changes that occur after harvesting a free gingival graft and how long the palatal mucosa takes to regain its original form and thickness. This study evaluated the volumetric changes that occur at the palatal donor site after harvesting a soft tissue graft with a noninvasive digital technology. Nineteen patients needing a CTG for a single site were enrolled. Intraoral digital scans of the palatal donor sites were obtained at baseline and at 1, 3, 6, and 12 months. The digital scans were imported and analyzed with an imaging software to evaluate volumetric changes. Average volume losses of 5.82 ± 2.63 mm3 and 11.03 ± 5.47 mm3 were observed after 1 and 3 months, respectively. Only minor changes were observed at 6 and 12 months. Linear dimensional changes at 5 and 7 mm from the gingival margin were substantially higher than the changes at 3 mm for the 1- and 3-month interval comparisons compared to baseline. Graft dimension was associated with volume loss at 1 and 3 months (P < .01). After palatal harvesting, the donor site undergoes volumetric changes, mostly during the first 3 months, and is attenuated thereafter.

Repeatability of dental shade by digital spectrophotometry in current, former, and never smokers.

Cigarette smoking contributes to poor oral health and dental discoloration. Therefore, stopping smoking may translate into measurable amelioration of dental shade indices. We compared dental shade parameters by digital spectrophotometry among current, former, and never smokers and verified their repeatability at 7 and 30 days. Dental shade parameters (CIE L*a*b* and corresponding whiteness index for dentistry-WID) were measured in current, former, and never smokers with a digital spectrophotometer (Vita Easyshade V) on three separate study visits: at baseline (day 0), at day 7, and day 30. Dental shade parameters were analyzed in 18 current, 18 former, and 20 never smokers. The repeatability of shade parameters was consistent in current, former, and never smokers. L*, a*, b*, and WID show significant short and long-term repeatability (p < 0.0001, by regression analyses). The mean (± SD) WID score of 13.42 (± 4.9) in current smokers was significantly lower compared to the WID score of 20.38 (± 5.3) in never smokers (p = 0.001). No significant differences were observed between current and former smokers and between former smokers and former smokers. Dental shade measurements by digital spectrophotometry were highly reproducible and showed that teeth whiteness of current smokers is substantially inferior compared to never smokers. Objective discrimination of dental shade can be a valuable regulatory science endpoint for investigating oral hygiene and dental aesthetics of consumer care products, smoking cessation medications, and tar-free tobacco products (e-cigarettes, heated tobacco products, oral nicotine products) for cigarette substitution.Clinical trial registration: the study was not registered in ClinicalTrials.gov considering that it is a pilot study, parts of a larger project with ID: NCT04649645.

Patient-reported outcome measures following soft-tissue grafting at implant sites: A systematic review.

OBJECTIVES: To review the available literature on patient-reported outcome measures (PROMs) following soft tissue augmentation at implant sites. MATERIALS AND METHODS: A comprehensive electronic and manual search was performed to identify clinical studies that involved soft tissue augmentation around dental implants and reported PROMs, including post-operative morbidity, painkillers intake, quality of life, aesthetics and satisfactions. RESULTS: Nineteen articles were included in the qualitative analysis. Autogenous grafts (free gingival graft and connective tissue graft), acellular dermal matrix and xenogeneic collagen matrix were utilized, either with a bilaminar- or an apically positioned flap approach. PROMs reported in the literature included perceived hardship of the procedure and pain during the surgery, post-operative morbidity, painkillers intake, number of days with discomfort, satisfaction, aesthetic evaluation, quality of life and willingness to undergo the treatment again. Most of the included studies showed similar PROMs between autogenous grafts and substitutes, in terms of post-operative morbidity, painkillers intake, quality of life, aesthetic assessment and satisfaction. Nevertheless, a trend towards lower post-operative discomfort was observed for graft substitutes. High scores for patient satisfaction and aesthetic evaluation were observed in all the interventions compared to non-grafted sites. CONCLUSIONS: PROMs represent a crucial endpoint of clinical studies evaluating the outcomes of soft tissue grafts at implant sites. Most of the studies did not find significant differences in terms of patient morbidity and painkillers between autogenous grafts and substitutes. Soft tissue grafting can enhance patient satisfaction and aesthetic evaluation compared to non-grafted sites.

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

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

Patient experience of autogenous soft tissue grafting has an implication for future treatment: A 10- to 15-year cross-sectional study.

BACKGROUND: Patient-reported outcomes have received a great deal of interest in periodontal plastic procedures. However, their evaluation has mainly been short-term. Thus, the aim of this study was to evaluate the impact of soft tissue grafting procedures conducted over a decade ago on the willingness of a patients to undergo the surgery again. METHODS: Subjects that received an autogenous soft tissue graft over 10 years ago were screened and invited for a survey. Their response was only analyzed if they were able to correctly identify the sites of the surgical procedures. Dichotomous questions and visual analogue scales (VASs) were used to assess self-reported pain, willingness to retreat and satisfaction. RESULTS: Fifty-two patients were included in the analyses. Higher pain was reported for mandibular sites, and treated areas including ≥ 3 teeth (P < 0.01). Willingness to retreatment was 84.6% and it was negatively associated with self-reported pain measures, the arch location (mandible), and number of treated sites (≥3 teeth) (P < 0.01). Mean satisfaction rate was 86.9 ± 13.65 (VAS) and showed a positive correlation with willingness to retreat (P < 0.01). Having a complete root coverage at the recall visit was also significantly associated with higher patient satisfaction scores (P < 0.01). CONCLUSIONS: Patient experience of previous autogenous soft tissue grafting has an influence on their decision to undergo future treatment. Willingness to retreat was negatively affected by mandibular sites, larger treated areas and the perceived pain, while presenting with complete root coverage was significantly associated with patient satisfaction.

Interproximal attachment gain: The challenge of periodontal regeneration.

The new classification of periodontal diseases recognizes the key role of the interdental clinical attachment for defining the periodontal status and the extent of disease severity. Regenerating interdental clinical attachment not only improves the prognosis of the tooth, but it also lessens the severity of the disease condition. This manuscript provides a state-of-the-art review on surgical reconstructive approaches for treating papillary deficiency associated with soft and hard tissue interproximal defects. Combination therapy of papilla preservation, connective tissue grafting, and coronally advanced flaps may result in regeneration of the intrabony defect coupled with root coverage. Future research highlighted here may have the potential, especially in combination approaches, to repair challenging interproximal soft and hard tissue deficiencies.

Peri-implant Papillae Reconstruction at an Esthetically Failing Implant.

This case report aimed to describe a soft tissue approach to restore a buccal soft tissue dehiscence (BSTD) combined with the loss of peri-implant papillae and loss of periodontal attachment on the adjacent teeth. The first step of the proposed approach was the removal of the crown and abutment to leave the interproximal soft tissue to fill the space previously occupied by the crown. After 3 months, during which time the patient was wearing a provisional restoration (a temporary Maryland bridge), the implant site was treated as an edentulous area with a soft tissue augmentation procedure: the most substantial modification with respect to the original connective tissue platform technique was the use of the wide mesial and distal papillae of the implant, once de-epithelialized on the occlusal surface, as a "partial" connective platform to suture the connective grafts and submerge the implant. At the 4-month reevaluation visit, a minor soft tissue defect remained in both apico-coronal and buccolingual dimensions, and thus a second surgery was performed to obtain further soft tissue augmentation. A flapless punch procedure was used to expose the implant head, and after conditioning the augmented peri-implant soft tissue with a new provisional crown, the definitive restoration was delivered. Complete coverage of the BSTD was achieved, and both papillae entirely filled the interproximal spaces. The results were well maintained up to the 5-year follow-up visit.

Decision making in root-coverage procedures for the esthetic outcome.

The primary indication for treatment of gingival recessions is esthetics. In the last decades, patients have become increasingly more demanding in the esthetic outcome expected. In order to obtain a successful final result, periodontal plastic surgery should provide not only complete root coverage but also perfect blending in terms of color and texture. In the literature, many techniques have been demonstrated to be effective in obtaining complete root coverage, and the selection of one surgical technique over another depends on several factors related to the anatomic characteristics of the defect. The purpose of this paper was to suggest a decision-making process which starts from the clinical observation of the defects and is structured in progressive nodes that will guide the clinician through the most suitable surgical technique to achieve the ideal esthetic outcome.

Soft-tissue augmentation procedures in edentulous esthetic areas.

Loss of dentition leads to functional and esthetic challenges that are determined by the anatomic features of the edentulous area. These features can complicate the prosthetic rehabilitation of such patients, especially in situations where optimal esthetic outcomes are desired. For these reasons, reconstructive plastic surgery procedures, aimed at restoring the alveolar ridge to its former dimensions, have become of great clinical interest. These reconstructive plastic surgery procedures frequently involve soft-tissue augmentation, performed to improve the quality and quantity of mucogingival tissue with the aim to achieve an ideal esthetic result. This review will focus on the description and expected outcomes of different surgical techniques for soft-tissue augmentation in edentulous areas, as described in the literature. Although more information from a larger number of studies and randomized controlled clinical trials is needed, it is possible to draw some conclusions, namely: pouch procedures are the first choice for soft-tissue augmentation, especially in high-demand esthetic areas; roll techniques are possible in shallow buccolingual soft-tissue augmentations; and onlay, inlay and combination grafts are less suitable for soft-tissue augmentation because of their poor esthetic results.

A Minimally Invasive Approach Using a 4-mm Implant Without Extraction of Impacted Maxillary Canine: Four-Year Postloading Results.

The aim of this case report was to suggest an alternative minimally invasive surgical approach to an impacted maxillary canine using a 4-mm-long implant for a fixed prosthetic rehabilitation, avoiding tooth extraction or surgically forced extrusion and exploiting the 6 mm of coronal bone availability. At 4 years postloading, the implant was healthy and well integrated with stable marginal bone levels. The 4-mm length of the implant reduced operative times, postsurgical morbidity, possible complications, and costs. Short implants might be an alternative to traditional, more invasive surgical procedures used in the rehabilitative treatment of impacted maxillary canines.

Connective Tissue Graft Wall Technique and Enamel Matrix Derivative for the Treatment of Infrabony Defects: Case Reports.

The present case report describes a modification of the connective tissue graft wall technique with enamel matrix derivative applied to treat deep vertical bony defects. The technique presented uses a palatal incision to gain access to the bony defect. Deep infrabony defects affecting two maxillary central incisors associated with interdental and buccal gingival recession were treated. At 1 year after surgery, 9 and 6 mm of interdental clinical attachment level gain were seen in cases 1 and 2, respectively. The position of the interdental papilla was improved, and complete root coverage was achieved. Radiographs demonstrated bone fill of the infrabony components of the defects. This report encourages the possibility to improve, in one surgical session, regenerative and esthetic parameters in the treatment of deep infrabony defects.

Full-mouth treatment of gingival recessions and noncarious cervical lesions with coronally advanced flap and xenogeneic collagen matrix: a 2-year case report.

BACKGROUND: In clinical practice it is common to observe adjacent multiple gingival recessions (MGRs) associated with noncarious cervical lesions (NCCLs). The aim of this 2-year case report was to describe the full-mouth treatment of a patient affected by MGRs and NCCLs, with a combined restorative-surgical approach using a coronally advanced flap (CAF) and a xenogeneic collagen matrix (CM). METHOD: Before surgery, a composite restoration filled the deepest portion of the NCCL defects and was finished at the level of the maximum root coverage (MRC). The surgical technique adopted for the root coverage procedures was CAF for MGRs without vertical releasing incisions in the maxilla, and with one vertical releasing incision in the mandible. The CM was positioned at the level of the cementoenamel junction (CEJ), and sutured at the base of the anatomic de-epithelialized papillae. The flap was shifted coronally, providing complete coverage of the CM, and sutured coronal to the CEJ with a variable number of sling sutures. RESULTS: At 2 years, complete root coverage was achieved in all treated sites, and the patient reported complete resolution of dental hypersensitivity. In the questionnaire, the patient-reported outcome showed a high level of esthetic satisfaction (mean score: 9.6; range: 9 to 10), and the objective esthetic evaluation with the root coverage esthetic score (RES) system showed a very high result (mean: 9.4). CONCLUSIONS: The suggested combined restorative-surgical approach provided successful root coverage and a favorable esthetic outcome in the treatment of MGR associated with NCCLs.

Transmucosal Implant Placement with Submarginal Connective Tissue Graft in Area of Shallow Buccal Bone Dehiscence: A Three-Year Follow-Up Case Series.

The aim of the present case series study was to evaluate the short- and long-term (3 years) soft tissue stability of a surgical technique combining transmucosal implant placement with submarginal connective tissue graft (CTG) in an area of shallow buccal bone dehiscence. A sample of 20 patients were treated by positioning a transmucosal implant in an intercalated edentulous area. A CTG sutured to the inner aspect of the buccal flap was used to cover the shallow buccal bone dehiscence. Clinical evaluations were made at 6 months (T1) and 1 (T2) and 3 (T3) years after the surgery. Statistically significant increases in buccal soft tissue thickness and improvement of vertical soft tissue level were achieved at the T1, T2, and T3 follow-ups. A significant increase in keratinized tissue height was also found at T3. No significant marginal bone loss was recorded. The submarginal CTG technique was able to provide simultaneous vertical and horizontal soft tissue increases around single implants with shallow buccal bone dehiscence and no buccal mucosal recession or clinical signs of mucositis or peri-implantitis at 1 and 3 years.

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

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