Enamel Renal Gingival Syndrome in an Adolescent.

Enamel renal gingival syndrome is a rare clinical condition characterized by the presence of amelogenesis imperfecta hypoplastic type, gingival fibromatosis and delayed tooth eruption, in addition to nephrocalcinosis with normal blood calcium levels. It is inherited as an autosomal recessive trait caused by mutations in the FAM20A gene located on chromosome 17q24.2. The purpose of this report is to describe a case of enamel renal gingival syndrome and discuss its distinct features and management.

VISTA Approach in Conjunction with Enamel Matrix Derivative, Corticocancellous Bone, and Connective Tissue Graft for Periodontal Defect Surgery: A Case Series.

The biggest challenge during periodontal regeneration in the anterior region is the prevention of soft tissue recession. Minimally invasive surgeries, particularly papilla preservation techniques and soft tissue augmentation, may significantly reduce such postoperative soft tissue recession. This article presents the vestibular incision subperiosteal tunnel access (VISTA) approach for periodontal regeneration in the anterior region. A subperiosteal tunnel prepared from a single vertical vestibular incision adjacent to the defect is used for debridement, application of enamel matrix derivative, defect grafting with corticocancellous tuberosity bone, and insertion of the connective tissue graft. Evaluation of six cases with up to 6 years of follow-up showed improvements in all clinical parameters. The probing pocket depth improved from 8.2 ± 0.75 mm initially to 2.7 ± 0.52 mm at follow-up, clinical attachment level improved from 8.5 ± 0.83 mm initially to 2.7 ± 0.52 mm at follow-up, and midfacial gingival recession of 1 mm at two sites was corrected. The papillae were stable at all sites, with an average distance of 4.8 mm from the incisal edge to the papilla tip. This technique seems to be a promising approach for achieving both esthetic and functional goals of periodontal regenerative surgery. However, experience in performing microsurgeries and harvesting tuberosity tissues may be a limitation.

Association between defect morphology and healing of intrabony defects treated with minimally invasive non-surgical therapy: A pilot exploratory analysis of two cohorts.

OBJECTIVE: The aim of this study was to explore the associations between defect morphology (defined by clinical and radiographic parameters) and the healing of periodontal intrabony defects treated with minimally invasive non-surgical therapy (MINST). BACKGROUND DATA: MINST has shown to result in favorable clinical and radiographic improvements in intrabony defects. However, it is not clear which types of intrabony defects are most suitable for this treatment. METHODS: Clinical and radiographic analyses were carried out in a total of 71 intrabony defects treated with MINST belonging to two previously published studies. Baseline defect characteristics were analyzed and related to clinical and radiographic outcomes at 12 months post-MINST with or without adjunctive enamel matrix derivative. RESULTS: No associations were detected between defect depth, angle and predicted number of walls and clinical and radiographic healing 12 months post-MINST. CONCLUSIONS: No evidence emerged for associations between defect characteristics and healing following MINST. These data seem to suggest that factors other than defect morphology may influence treatment response to MINST.

Use of enamel matrix- derived proteins combined with bone graft for the treatment of intrabony defects: overview of reviews (FRISBEE review) / Uso de proteínas derivadas de la matriz del esmalte combinado con injerto óseo para el tratamiento de defectos intraóseos: resumen estructurado de revisiones sistemáticas (revisión FRISBEE)

Introduction: The use of enamel matrix-derived proteins (EMD) has increased in recent years due to their tissue-inducing properties that support periodontal regeneration. This study is an overview of systematic reviews with FRISBEE methodology on the use of EMD alone or combined with autologous bone graft materials (BGM) in the treatment of intrabony defects. Materials and Methods: A systematic search in the Epistemonikos database was performed. RevMan 5.3 and GRADEpro were used for data analysis and presentation Results: Four systematic reviews and two clinical trials were identified. All studies analysed change in probing depth, clinical attachment level, gingival margin level and bone defect depth (all changes in favour of EMD+BGM groups: mean difference (MD): 0.37 mm more, MD: 0.7 mm more, MD: 0.3 mm less, MD: 0.75 more, respectively). Conclusions: Adding autologous bone graft to EMD to treat intrabony defects showed better results, but not a relevant clinical difference compared to the use of EMD alone.

Introducción: El uso de proteínas derivadas de la matriz del esmalte (EMD) ha aumentado en los últimos años debido a sus propiedades inductoras de tejidos que apoyan la regeneración periodontal. Este estudio es una revisión sistemática de revisiones sistemáticas utilizando metodología FRISBEE sobre el uso de EMD solo o combinado con materiales injerto óseo autólogo (BGM) en el tratamiento de defectos intraóseos. Materiales y Métodos: Se realizó una búsqueda sistemática en la base de datos Epistemonikos. Se utilizaron RevMan 5.3 y GRADEpro para el análisis y la presentación de los datos. Resultados: Se identificaron cuatro revisiones sistemáticas y dos ensayos clínicos. Todos los estudios analizaron el cambio en la profundidad de sondaje, el nivel de inserción clínica, el nivel del margen gingival y la profundidad del defecto óseo (todos los cambios a favor de los grupos EMD+BGM: MD: 0,37 mm más, media de diferencia (MD): 0,7 mm más, MD: 0,3 mm menos, MD: 0,75 más, respectivamente). Conclusión: La adición de injerto óseo autólogo a la EMD para tratar defectos intraóseos mostró mejores resultados, pero no una diferencia clínica relevante en comparación con el uso de la EMD sola.

Regenerative Surgery of Mandibular Class II Furcation Defects: A Comparison of Two Techniques in a Randomized Clinical Trial with 3D CBCT Measurements at 24 Months.

The aim of the present study was to evaluate, clinically and via CBCT, the long-term efficacy of a bioresorbable polylactic acid membrane combined with deproteinized bovine bone graft (DBBM) and compare it to enamel matrix derivative (EMD) combined with DBBM graft in the treatment of class II furcation defects. Sites were randomly assigned to the test group (Guidor Matrix Barrier + Bio-Oss) or the control group (Emdogain + Bio-Oss). Probing pocket depth (PPD), clinical attachment level (CAL), gingival recession (REC), and keratinized tissue (KT) width were assessed at 12 and 24 months, and radiographic bone gain was investigated at 24 months via CBCT. Both groups showed a significant radiographic bone fill and clinical gain. The combination of Emdogain + Bio-Oss showed better clinical outcomes and less complications, though this difference was not statistically significant.

Five-year results following regenerative periodontal surgery with an enamel matrix derivative in patients with different smoking status.

OBJECTIVE: To evaluate the five-year results following regenerative periodontal surgery of intrabony defects using an enamel matrix derivative (EMD) in patients with different smoking status. METHOD AND MATERIALS: The dental records of patients treated with regenerative periodontal surgery with EMD between 2001 and 2011 were screened. The clinical parameters at baseline (T0) and 6 months (T1) and 5 years (T2) after surgery were collected and analyzed in relation to patient's smoking status (smokers, former smokers, and nonsmokers). RESULTS: A total of 71 sites were initially assessed in 38 patients. In total, 56 sites could be evaluated at T1, and 34 after 5 years (T2). At 6 months after surgery, a statistically significant mean probing pocket depth (PPD) reduction of 2.91 ± 1.60 mm and a mean clinical attachment level (CAL) gain of 1.89 ± 1.90 mm were measured. Nonsmokers revealed a greater, statistically not significant CAL gain compared to smokers (2.38 ± 2.12 mm vs 1.50 ± 1.71 mm). Although at 5 years the site-specific PPD values remained stable in nonsmokers, smokers showed an increase of 1.60 ± 2.41 mm. CONCLUSIONS: The present study provides evidence that regenerative periodontal surgery with EMD may lead to clinically relevant improvements even in smoking patients. However, the positive effect of EMD seems to be limited in time and can only partially compensate for the negative influence of smoking.

Use of Enamel Matrix Derivative in Minimally Invasive/Flapless Approaches: A Systematic Review with Meta-Analysis.

PURPOSE: The aim of the present systematic review with meta-analysis was to investigate the clinical effectiveness of EMD (enamel matrix derivative) using a minimally invasive surgical technique (MIST) or flapless approach for the treatment of severe periodontal probing depths. MATERIALS AND METHODS: A systematic review of the literature including searches in PubMed/Medline, Cochrane Library, Google Scholar, and Grey Literature databases as well as manual searches was performed on September 1st, 2021. Studies utilising EMD in a non-surgical or minimally invasive approach were included. The eligibility criteria comprised randomised controlled trials (RCTs) comparing minimally-invasive/flapless approaches with/without EMD for the treatment of probing depths >5 mm. RESULTS: From 1525 initial articles, 7 RCTs were included and 12 case series discussed. Three studies investigated a MIST approach, whereas 3 studies utilised a flapless approach. One study compared EMD with either a MIST or a flapless approach. The RCTs included ranged from 19-49 patients with at least 6 months of follow-up. While 5 of the studies included smokers, patients smoking >20 cigarettes/day were excluded from the study. The meta-analysis revealed that EMD with MIST improved recession coverage (REC) and bone fill (BF) when compared to MIST without EMD. However, no difference in CAL or PD was observed between MIST + EMD vs MIST without EMD. No statistically significant advantage was found for employing the EMD via the flapless approach. CONCLUSIONS: Implementing EMD in MIST procedures displayed statistically significant improvement in REC and BF when compared to MIST alone. These findings suggest that MIST in combination with EMD led to improved clinical outcomes while EMD employed in nonsurgical flapless therapy yielded no clinical benefits when compared to nonsurgical therapy alone without EMD. More research is needed to substantiate these findings.

Enamel Matrix Derivative Decreases Pyroptosis-Related Genes in Macrophages.

Background: Pyroptosis is a caspase-dependent catabolic process relevant to periodontal disorders for which inflammation is central to the pathophysiology of the disease. Although enamel matrix derivative (EMD) has been applied to support periodontal regeneration, its capacity to modulate the expression of pyroptosis-related genes remains unknown. Considering EMD has anti-inflammatory properties and pyroptosis is linked to the activation of the inflammasome in chronic periodontitis, the question arises whether EMD could reduce pyroptosis signalling. Methods: To answer this question, primary macrophages obtained from murine bone marrow and RAW 264.7 macrophages were primed with EMD before being challenged by lipopolysaccharide (LPS). Cells were then analysed for pyroptosis-signalling components by gene expression analyses, interleukin-1ß (IL-1ß) immunoassay, and the detection of caspase-1 (CAS1). The release of mitochondrial reactive oxygen species (ROS) was also detected. Results: We report here that EMD, like the inflammasome (NLRP3) and CAS1 specific inhibitors-MCC950 and Ac-YVAD-cmk, respectively-lowered the LPS-induced expression of NLRP3 in primary macrophages (EMD: p = 0.0232; MCC950: p = 0.0426; Ac-YVAD-cmk: p = 0.0317). EMD further reduced the LPS-induced expression of NLRP3 in RAW 264.7 cells (p = 0.0043). There was also a reduction in CAS1 and IL-1ß in RAW 264.7 macrophages on the transcriptional level (p = 0.0598; p = 0.0283; respectively), in IL-1ß protein release (p = 0.0313), and CAS1 activity. Consistently, EMD, like MCC950 and Ac-YVAD-cmk, diminished the ROS release in activated RAW 264.7 cells. In ST2 murine mesenchymal cells, EMD could not be tested because LPS, saliva, and IL-1ß + TNF-α failed to provoke pyroptosis signalling. Conclusion: These findings suggest that EMD is capable of dampening the expression of pyroptosis-related genes in macrophages.

Treatment of Chronic Periodontitis with Periodontal Surgery Including Regenerative Therapy Using Recombinant Human Fibroblast Growth Factor-2 and Papilla Preservation Technique: A Case Report with a Two-year Follow-up.

This report describes a case of generalized chronic periodontitis requiring periodontal therapy including periodontal regeneration. The patient was a 59-year-old man who visited the Tokyo Dental College Suidobashi Hospital with the chief complaint of mobility in tooth #47. Periodontal examination at the first visit revealed that 32.1% of sites had a probing depth of ≥4 mm and 32.7% of sites bleeding on probing. Radiographic examination revealed vertical bone resorption in #26 and horizontal resorption in #12, 13, 42, and 43. Based on a clinical diagnosis of severe chronic periodontitis, initial periodontal therapy consisting of plaque control, scaling and root planing, occlusal adjustment, caries treatment, and placement of an occlusal splint was performed. Tooth #47 was extracted due to bone resorption extending as far as the root apex. After reevaluation, surgical periodontal treatment was performed at the selected site. Periodontal regenerative therapy using recombinant human fibroblast growth factor (rhFGF)-2 and papilla preservation technique was performed for #26. To reduce periodontal pockets, open flap debridement was implemented for #12, 13, 42, and 43. After reevaluation, the patient was placed on supportive periodontal therapy (SPT). Periodontal regenerative therapy with rhFGF-2 and modified papilla preservation technique yielded an improvement in angular bone resorption which has been properly maintained for two years. Periodontal therapy with open flap debridement resulted in an improvement in horizontal bone resorption. Continued SPT is needed to maintain a stable periodontal condition.

Modified minimally invasive surgical technique in human intrabony defects with or without regenerative materials-10-year follow-up of a randomized clinical trial: Tooth retention, periodontitis recurrence, and costs.

AIM: The modified minimally invasive surgical technique (M-MIST) optimizes wound stability in the treatment of intrabony defects. Short-term observations show similar results as with flap alone or adjunctive regenerative materials. This study aims to compare the stability of the long-term outcomes, complication-free survival, and costs of the three treatment options. MATERIALS AND METHODS: Forty-five intrabony defects in 45 patients were randomized to M-MIST alone (N = 15), combined with enamel matrix derivative (M-MIST + EMD, N = 15), or EMD plus bone-mineral-derived xenograph (M-MIST + EMD + BMDX, N = 15). Supportive periodontal care (SPC) and necessary re-treatment were provided for 10 years. RESULTS: Three subjects were lost to follow-up. Clinical attachment level differences between 1 and 10 years were -0.1 ± 0.7 mm for M-MIST, -0.1 ± 0.8 mm for M-MIST + EMD, and -0.3 ± 0.6 mm for M-MIST + EMD + BMDX (p > .05 for within- and between-group differences). Four episodes of recurrence occurred in the M-MIST group, four in the M-MIST + EMD group, and five in the M-MIST + EMD + BMDX group. No significant differences in complication-free survival were observed between the three groups (p = .47). Complication-free survival was 7.46 years (95% confidence interval: 7.05-7.87) for the whole population. The M-MIST + EMD + BMDX group lost one treated tooth. Data indicated no significant inter-group difference of the total cost of recurrence over 10 years. When the baseline cost of treatment was considered, the total cost was lower for M-MIST alone. CONCLUSIONS: Teeth with deep pockets associated with intrabony defects can be successfully maintained over the long term with either M-MIST alone or by adding a regenerative material in the context of a careful SPC programme. M-MIST alone provided similar short- and long-term benefits as regeneration, at a lower cost. These findings need to be confirmed in larger, independent studies.

Treatment of Chronic Periodontitis with Smoking Cessation Care and Periodontal Surgery in an Elderly Patient: A Case Report Including a 4-year Follow-up.

This report describes a case of chronic periodontitis requiring treatment including smoking cessation care and periodontal surgery in an elderly patient with a long-term smoking habit. The patient, a 79-year-old man, presented with the chief complaint of halitosis. He had a 56-year history of smoking cigarettes. An initial examination revealed that 34.5% of sites had a probing depth (PD) of ≥4 mm, with 24.1% of sites showing bleeding on probing (BOP). Open bite and loss of appropriate anterior and lateral guidance were also found. Radiographic examination revealed extensive horizontal bone resorption in the maxillary and mandibular molars. Based on a clinical diagnosis of severe generalized chronic periodontitis, initial periodontal therapy consisting of plaque control, smoking cessation care, scaling and root planing, and caries treatment of #47 was performed. Prosthetic treatment with a removable partial denture was planned for #26, which was missing. The patient quit smoking at the end of initial periodontal therapy. Subsequently, surgical periodontal therapy including open flap debridement was performed on #16, #17, #18, and #27. Following reevaluation, a full metal crown (#47) and removal partial denture (#26) were placed. The patient was then placed on supportive periodontal therapy (SPT). Periodontal treatment including surgical therapy resulted in an improvement in PD and a reduction in the number of sites with BOP. The patient has not started smoking again since initial treatment. Improvement has been adequately maintained over a 4-year period. The present results suggest that even when a patient has been exposed to a risk factor for a long time, periodontal treatment and control of that risk factor can contribute to stabilization of periodontal conditions. Some problems with occlusion have persisted, however. Additional care is necessary to retain stable periodontal conditions during SPT.

Long-term clinical outcomes of periodontal regeneration with enamel matrix derivative: A retrospective cohort study with a mean follow-up of 10 years.

BACKGROUND: Despite the large body of evidence on the efficacy of enamel matrix derivative (EMD) in the treatment of periodontal intrabony defects, few studies reported long-term data (≥10-year). METHODS: Periodontal patients treated with regenerative surgery with EMD between 1999 and 2012 were invited to participate in a clinical examination. The following clinical parameters were recorded and compared at baseline (T0), 6 months after surgery (T1) and after at least 8 years of follow-up (T2): probing depth (PD), gingival recession (GR), clinical attachment level (CAL), plaque and bleeding scores. The primary outcome variable was CAL change. RESULTS: Forty-one patients with 75 treated teeth were available for analysis. Out of these, 68 (tooth survival rate: 90.7%) reached the latest follow-up with a mean observation period of 10.3 years (range: 8.0 to 21.3). The most frequent reason for tooth loss was recurrence of periodontal disease. Tooth survival curves showed a statistically significant difference between smokers and non-smokers (P = 0.028). Mean CAL changed from 8.43 ± 1.86 (T0) to 6.47 ± 1.70 (T1) (P < 0.001) and to 5.91 ± 1.83 (T2) (P < 0.001). At T1, a CAL gain of ≥3 mm was measured in 35% of the defects whereas at T2 it was detected in 51% of cases. CONCLUSIONS: Within their limitations, the present results have shown that in intrabony defects, the clinical improvements obtained following regenerative surgery with EMD can be maintained on a mean period of 10 years. Smoking status and maxillary molars were correlated with an increased risk for tooth and CAL loss, respectively.

Apical approach in periodontal reconstructive surgery with enamel matrix derivate and enamel matrix derivate plus bone substitutes: a randomized, controlled clinical trial.

OBJECTIVES: This parallel, randomized controlled clinical trial evaluated the influence of bone substitutes (BS) on the efficacy of the non-incised papillae surgical approach (NIPSA) with enamel matrix derivate (EMD) in resolving deep, isolated, combined non-contained intrabony and supra-alveolar periodontal defects, preserving the soft tissue. MATERIAL AND METHODS: Twenty-four patients were randomized to treatment with NIPSA and EMD or NIPSA plus EMD and BS. Bleeding on probing (BoP), interproximal clinical attachment level (CAL), interproximal probing depth (PD), recession (REC), location of the tip of the papilla (TP), and width of the keratinized tissue (KT) were evaluated before surgery and at 1 year post-surgery (primary outcomes). Wound closure was assessed at 1 week post-surgery, and supra-alveolar attachment gain (SUPRA-AG) was recorded at 1 year post-surgery. RESULTS: At 1 week, 87.5% of cases registered complete wound closure and there were no cases of necrosis, without differences between groups (p > .05). At 1 year, all cases showed negative BoP. A significant PD reduction (NIPSA + EMD 8.25 ± 2.70 mm vs. NIPSA + EMD + BS 6.83 ± 0.81 mm) and CAL gain (NIPSA + EMD 8.33 ± 2.74 mm vs. NIPSA + EMD + BS 7.08 ± 2.68 mm) were observed (p < .001) in both groups, without significant between-group differences (p > .05). The residual PD was < 5 mm in all defects (NIPSA + EMD 2.50 ± 0.67 mm vs. NIPSA + EMD + BS 2.67 ± 0.78 mm). Soft tissues were preserved without significant between-group differences (REC: NIPSA + EMD 0.25 ± 0.45 mm vs. NIPSA + EMD + BS 0.17 ± 0.58 mm, p > .05; KT: 0.00 ± 0.43 mm vs. 0.08 ± 0.67 mm, p > .05). There were improvements in the papilla in both groups (TP: NIPSA + EMD 0.33 ± 0.49 mm vs. NIPSA + EMD + BS 0.45 ± 0.52 mm, p > .05), which was only significant in the NIPSA EMD + BS group (0.45 ± 0.52 mm; p < .05). In both groups, CAL gain was recorded in the supra-alveolar component, showing full resolution of the intrabony component of the defect in all cases (SUPRA-AG: NIPSA + EMD 1.83 ± 1.11 mm vs. NIPSA + EMD + BS 2.00 ± 1.76 mm, p > .05). CONCLUSIONS: NIPSA and EMD with or without BS seem to be a valid surgical approach in the treatment of isolated, deep non-contained periodontal defects. In our study, both treatments resulted in significant PD reduction and CAL gain, that extended in the supra-alveolar component, without differences with the use of BS. Both treatments resulted in soft tissue preservation. However, the addition of BS may improve interdental papillary tissue. CLINICAL RELEVANCE: NIPSA, with or without bone substitutes, resulted in significant periodontal improvement, with soft tissue preservation in isolated, deep non-contained periodontal defects. The application of bone substitutes may provide interproximal soft tissue gain. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov: NCT04712630.

Treatment of intrabony periodontal defects in controlled diabetic patients with an enamel matrix derivative: a split-mouth randomized clinical trial.

OBJECTIVE: This split-mouth randomized controlled trial aimed to evaluate the effect of enamel matrix derivative (EMD) associated with a simplified papilla preservation flap (SPPF) compared to SPPF alone in the surgical treatment of intrabony defects (ID) in type 2 diabetic mellitus (T2DM) patients. MATERIAL AND METHODS: Thirteen patients with controlled T2DM presenting with ID in at least two quadrants were included. In each patient, the test site (TS) was treated with SPPF plus EMD, whereas the control site (CS) was treated only with SPPF. Prior to surgery and at 6 months after intervention, the following parameters were evaluated: clinical attachment level (CAL), probing pocket depth (PPD), and gingival recession (GR). RESULTS: The TS and CS demonstrated a mean CAL gain of 3.31 ± 0.96 mm and 1.61 ± 1.12 mm, and a PPD reduction from 8.15 ± 0.98 to 3.00 ± 0.57 mm and 7.53 ± 0.96 to 4.69 ± 0.63 mm after 6 months, respectively. In both sites, the mean CAL gain and PPD reduction improved significantly after 6 months compared to baseline; however, the improvement was higher in the TS (p < 0.001). CONCLUSIONS: Both surgical procedures presented with clinical improvements in controlled T2DM patients. However, the additional use of EMD showed enhanced clinical results after 6 months with regard to CAL gain and PPD reduction. CLINICAL RELEVANCE: This study showed a better PPD reduction and CAL gain when an EMD was applied in addition to SPPF. Therefore, EMD may be used to enhance clinical outcomes in periodontal ID of controlled T2DM patients.

Enamel matrix derivative as an adjunct to minimally invasive non-surgical treatment of intrabony defects: A randomized clinical trial.

AIM: To compare the efficacy of minimally invasive non-surgical technique (MINST) with or without enamel matrix derivative (EMD) in the treatment of intrabony defects ≤7 mm. MATERIALS AND METHODS: Thirty-six patients were randomly assigned to the two groups. The control group received MINST, while the experimental MINST+EMD. Clinical measurements were recorded at baseline and at 6 and 12 months, and radiographic measurements were made at baseline and 12 months. RESULTS: All subjects completed the study, 18 in each group. Significant improvements were observed in both groups at 12 months (p < .001) with no differences in mean PD reduction (4.0 ± 1.4 vs. 4.2 ± 1.7 mm), CAL gain (3.5 ± 1.4 vs. 3.4 ± 1.6 mm), and defect resolution (1.9 ± 1.1 vs. 1.8 ± 0.9 mm) for the MINST and the MINST+EMD groups, respectively (p > .05). A trend for greater pocket closure (PD ≤4 mm and no BoP) was achieved with the application of EMD (77.8% vs. 55.6% sites), particularly for sites with baseline PD ≤8 mm (92.3% vs. 69.2% sites), accompanied by an increased number of successful composite outcome results (61.1% vs. 44.4% sites). CONCLUSIONS: MINST demonstrates significant improvements 12 months after treatment of intrabony defects ≤7 mm. The additional application of EMD does not further improve the mean clinical or radiographic outcomes. This study is registered in ClinicalTrials.gov (NCT03622255).

Efficacy of a new-generation platelet-rich fibrin in the treatment of periodontal intrabony defects: a randomized clinical trial.

BACKGROUND: The aim of the study was to clinically evaluate the healing of intrabony defects after treatment with a new generation of platelet-rich fibrin (A-PRF+) respect to enamel matrix derivative (EMD). METHODS: Thirty (30) intrabony defects of 18 patients (9 males, 9 females) were randomly treated with A-PRF+ (test, n = 15) or EMD (control, n = 15). The following clinical parameters were recorded at baseline and 6 months after surgery: pocket depth (PD), gingival recession (GR) and clinical attachment level (CAL). After debridement the intrabony defects were filled with A-PRF+ in the test group, respectively with EMD in the control group, and fixed with sutures to ensure wound closure and stability. RESULTS: Both treatment methods resulted in statistically significant PD reductions, respectively CAL gains six months post-operatively. No statistically significant differences were found between the two groups as the mean CAL gain was 2.33 ± 1.58 mm in the A-PRF+ group, respectively 2.60 ± 1.18 mm in the EMD group (p < 0.001). CONCLUSION: Within the limits of this study the new-generation platelet-rich fibrin seems to be as clinically effective as EMD during surgical treatment of intrabony defects. Treatment with A-PRF+ or EMD resulted in reliable clinical outcomes. The use of A-PRF+ as a human autologous product can give a positive impact on periodontal healing. Clinical Relevance A-PRF+ may be suitable for the treatment of intrabony periodontal defects. Trial registration number (TRN) NCT04404374 (ClinicalTrials.gov ID).

Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivate for root coverage: 5-year results of an RCT using 3D digital measurement technology for volumetric comparison of soft tissue changes.

AIM: Comparison of the clinical efficacy (digitally volumetric, aesthetic, patient-centred outcomes) of tunnel technique (TUN) with subepithelial connective tissue graft (CTG) versus coronally advanced flap (CAF) with enamel matrix derivate (EMD) 5 years after gingival recession therapy. MATERIALS AND METHODS: In 18 patients contributing 36 RT1 recessions, study models were collected at baseline and follow-ups. Optical scans assessed recessions computer-assisted [recession depth, recession reduction (RECred), complete root coverage (CRC), percentage of root coverage (RC), pointwise (pTHK) and mean areal (aTHK) marginal soft tissue thickness]. Root coverage aesthetic Score (RES) was used for aesthetic evaluation and visual analogue scales for patient-centred data collection applied. RESULTS: Sixty months after surgery, 50.0% (TUN+CTG) and 0.0% (CAF+EMD) of sites showed CRC (p = 0.0118), 82.2% (TUN+CTG) and 32.0% (CAF+EMD) achieved RC, respectively (p = 0.0023). CTG achieved significantly better RECred (TUN+CTG: 1.75±0.74 mm; CAF+EMD: 0.50 ± 0.39 mm; p = 0.0009) and aTHK (TUN+CTG: 0.95 ± 0.41 mm; CAF+EMD: 0.26 ± 0.28 mm; p = 0.0013). RES showed superior outcomes (p = 0.0533) for TUN+CTG (6.86 ± 2.31) compared to CAF+EMD (4.63 ± 1.99). The study failed to find significant differences related to patient-centred outcomes (TUN+CTG: 8.30 ± 2.21; CAF+EMD: 7.50 ± 1.51; p = 0.1136). CONCLUSIONS: Five years after treatment, CTG resulted in better clinical and aesthetic outcomes than CAF+EMD. Increased THK was associated with improved outcomes for RECred and RC.

Long-term Clinical Performance of Regeneration versus Conservative Surgery in the Treatment of Infra-bony Defects:A systematic review.

AIMS: To determine the differences in the long-term clinical outcomes between Regeneration (REG) and Conservative Surgery (CS) in infra-bony defects. MATERIALS AND METHODS: Three databases were searched [PubMed, Medline and Embase] up to April 2019. Following screening, 17 studies were included. Randomized Controlled Clinical Trials, Controlled Clinical Trials and retrospective studies with long-term clinical observations (≥ 24-months) were selected. After subgrouping the studies regarding the grafting material and the used flap, meta-analysis was performed for different outcomes [clinical attachment level gain (CALGain), probing pocket depth reduction (PPDRed), recession increase (RECInc) and bone fill (BF)] at different follow-ups (24-, 36-, 48- to 60- and 120- to 240-months). RESULTS: The time-related meta-analysis favoured REG at every interval for every outcome. In subgroup analysis, enamel matrix derivative (EMD) performed significantly better for both CALGain [24- (p less than 0.0001), 36- (p=0.02) and 60-months (p less than 0.00001)] and PPDRed [24- (p=0.0004), 36- (p=0.003) and 60-months (p less than 0.00001)]. For Ceramic Grafts (CGs), CALGain at 48-months (p less than 0.00001) and PPDRed at 24- (p=0.0006), 36- (p less than 0.00001) and 48-months (p less than 0.00001) follow-up showed better results. CONCLUSION: The better outcomes from REG using EMD or CGs can be maintained for a longer duration, suggesting a potential longevity of the occurred healing.

Medium- and long-term clinical benefits of periodontal regenerative/reconstructive procedures in intrabony defects: Systematic review and network meta-analysis of randomized controlled clinical studies.

BACKGROUND: Systematic reviews have established the short-term improvements of periodontal regenerative/reconstructive procedures compared to conventional surgical treatment in intrabony defects. However, a hierarchy of periodontal regenerative/reconstructive procedures regarding the medium- to long-term results of treatment does not exist. AIM: To systematically assess the literature to answer the focused question "In periodontitis patients with intrabony defects, what are the medium- and long-term benefits of periodontal regenerative/reconstructive procedures compared with open flap debridement (OFD), in terms of clinical and/or radiographic outcome parameters and tooth retention?". MATERIAL & METHODS: Randomized controlled clinical trials (RCTs), reporting on clinical and/or radiographic outcome parameters of periodontal regenerative/reconstructive procedures ≥3 years post-operatively, were systematically assessed. Clinical [residual probing pocket depth (PD) and clinical attachment level (CAL) gain, tooth loss] and radiographic [residual defect depth (RDD), bone gain (RBL)] outcome parameters were assessed. Descriptive statistics were calculated, and Bayesian random-effects network meta-analyses (NMA) were performed where possible. RESULTS: Thirty RCTs, presenting data 3 to 20 years after treatment with grafting, GTR, EMD, as monotherapies, combinations thereof, and/or adjunctive use of blood-derived growth factor constructs or with OFD only, were included. NMA based on 21 RCTs showed that OFD was clearly the least efficacious treatment; regenerative/reconstructive treatments resulted in significantly shallower residual PD in 4 out 8 comparisons [range of mean differences (MD): -2.37 to -0.60 mm] and larger CAL gain in 6 out 8 comparisons (range of MD: 1.26 to 2.66 mm), and combination approaches appeared as the most efficacious. Tooth loss after regenerative/reconstructive treatment was less frequent (0.4%) compared to OFD (2.8%), but the evidence was sparse. There were only sparse radiographic data not allowing any relevant comparisons. CONCLUSION: Periodontal regenerative/reconstructive therapy in intrabony defects results, in general, in shallower residual PD and larger CAL gain compared with OFD, translating in high rates of tooth survival, on a medium (3-5 years) to long-term basis (5-20 years). Combination approaches appear, in general, more efficacious compared to monotherapy in terms of shallower residual PD and larger CAL gain. A clear hierarchy could, however, not be established due to limited evidence.

Periodontal regenerative therapy in patients with type 2 diabetes using minimally invasive surgical technique with enamel matrix derivative under 3-year observation: A prospective cohort study.

BACKGROUND: Information regarding periodontal regenerative therapy in patients with diabetes mellitus (DM) is limited. This pilot study compared the regenerative outcomes of minimally invasive periodontal surgery using enamel matrix derivative (EMD) between DM and non-DM patients. METHODS: This prospective study included deep intrabony defects in patients with or without type 2 DM. Minimally invasive surgical technique (MIST) or modified MIST (M-MIST) using EMD, without bone graft materials, was performed. Periodontal examination and intraoral radiography were performed at baseline, 6 months, and 1 and 3 years after surgery. RESULTS: Ten sites of 10 subjects in the DM group, and 20 sites of 18 subjects in non-DM group were evaluated (mean age; 67.5 ± 7.6 and 63.1 ± 9.7, respectively). Probing depth significantly decreased from 7.1 ± 1.6 and 7.0 ± 1.3 mm to 2.2 ± 0.9 and 2.3 ± 1.1 mm at the 1-year examination in the DM and non-DM groups, respectively. Clinical attachment level (CAL) gain and radiographical defect fill at the 3-year examination were 3.8 ± 1.1 mm and 58.3% ± 10.4%, respectively, in the DM group, and 4.1 ± 1.1 mm and 65.5% ± 18.8%, respectively, in the non-DM group, showing no significant differences between the groups. Multiple regression analysis showed no significant association of CAL gain with DM or age after adjustments for relevant confounders. CONCLUSIONS: This is the first documented study of successful periodontal tissue regeneration in patients with DM. Minimally invasive surgery combined with EMD yielded significant clinical attachment gain and bone fill in the DM and non-DM groups at comparable levels.