Comparação de duas técnicas cirúrgicas para recobrimento radicular de recessões unitárias: ensaio clínico paralelo, randomizado e duplo cego / Comparison of two surgical techniques for root coverage of single-unit recessions: parallel, randomized, double-blind clinical trial

As crescentes demandas dos pacientes pelo tratamento das recessões gengivais trazem à tona questões terapêuticas clinicamente significativas, exigindo dos profissionais constante aperfeiçoamento em técnicas cirúrgicas cada vez menos invasivas e mais previsíveis. OBJETIVO: Comparar duas técnicas para recobrimento radicular em recessões gengivais unitárias, unilaterais, do tipo 1. METODOLOGIA: Este estudo clínico, paralelo, randomizado e duplo cego avaliou indivíduos com recessões gengivais unitárias, unilaterais, do tipo 1 (RT1), submetidos à cirurgia para recobrimento radicular, através da associação do enxerto de tecido conjuntivo subepitelial ao retalho posicionado coronalmente (grupo controle) e técnica de túnel (grupo teste). Os principais parâmetros avaliados foram profundidade de sondagem (PS), sangramento à sondagem (SS), nível clínico de inserção (NCI), recessão gengival (RG), faixa e espessura da mucosa ceratinizada (MC e EG), percentual de recobrimento radicular (RR) e fenótipo gengival (FG), além de fatores centrados no paciente (FCP), como dor pós-operatória, hipersensibilidade dentinária cervical (HSDC), estética, grau de satisfação e a qualidade de vida, intra e intergrupo, ao longo de 06 meses de acompanhamento. Os dados foram analisados estatisticamente através dos testes t emparelhado de Student, teste t para amostras independentes, Qui-quadrado, McNemar, Análise de Variância Split-Plot com pós-teste t de Student (α = 5%). RESULTADOS: 46 indivíduos finalizaram este estudo (controle: 23; teste: 23). O tempo de cirurgia foi maior para o grupo teste (controle: 40min ± 5,6; teste: 51min ± 5,9; p = 0,041). Foram observadas reduções estatisticamente significativas para a RG e ganho significativo do NCI, de MC e de EG na análise intragrupo, em ambos os grupos de tratamento, porém, sem diferenças entre as técnicas. O RR aumentou significativamente nos períodos avaliados, mas não foram observadas diferenças intergrupo (controle: 89,2%; teste: 86,5%; p = 0,069). A análise intragrupo revelou mudança de FG (controle: 95,65%; teste: 91,3%; p < 0,001). Ambos os protocolos de tratamento reduziram dor pós-operatória e HSDC, e proporcionaram melhora na estética, satisfação e na qualidade de vida (p < 0,001), sem diferenças entre as técnicas ao longo do tempo. CONCLUSÃO: Ambos os tratamentos apresentaram eficácia clínica semelhante em termos de recobrimento radicular e melhora dos FCP (AU).

The increasing demands of patients for the treatment of gingival recessions bring up clinically significant therapeutic issues, requiring professionals to constantly improve in less invasive and more predictable surgical techniques. AIM: To compare two root coverage techniques to treat single, unilateral, type 1 gingival recessions. METHOD: This parallel, randomized, doubleblind clinical trial evaluated individuals with single, unilateral, type 1 gingival recessions 1 (RT1), who underwent root coverage procedure with subepithelial connective tissue graft associated to a coronally advanced flap (control group) or a tunnel technique (test group). The main parameters evaluated were probing depth (PD), bleeding on probing (BoP), clinical attachment level (CAL), gingival recession (GR), heigth of keratinized tissue (KTH), gingival thickness (GT), percentage of root coverage (RC) and gingival phenotype (GP), in addition to patient-reported outcome measures (PROMs), such as postoperative pain, cervical dentin hypersensitivity (CDH), esthetics, degree of satisfaction and quality of life, intra and intergroup, throughout 06 months follow-up. Data were statistically analyzed using paired Student t-test, t-test for independent samples, Chi-square, McNemar, Split-Plot Analysis of Variance with post hoc t-test (α = 5%). RESULTS: 46 subjects completed this study (control: 23; test: 23). Surgery time was longer for the test group (control: 40min ± 5.6; test: 51min ± 5.9; p = 0.041). Statistically significant reductions for GR and significant gain for CAL, KTH and GT were observed in the intragroup analysis, in both treatment groups, however, without differences between techniques. The CR increased significantly, but no intergroup differences were observed (control: 89.2%; test: 86.5%; p = 0.069). Intragroup analysis revealed a change in GP (control: 95.65%; test: 91.3%; p < 0.001). Both treatment protocols reduced postoperative pain and CDH and improved esthetics, satisfaction and quality of life (p < 0.001), with no differences between the techniques over time. CONCLUSION: Both treatments showed similar clinical efficacy in terms of root coverage and improvement in PROMs (AU).

Partly deepithelialised palatal graft for the treatment of deep-wide palatal recession defect: simplified protocol with 18-month follow-up.

Advances in periodontal plastic surgical procedures have led to achieve predictable root coverage outcomes for the recession defects. However, little has been reported and emphasised over management of palatal recession defects. The root coverage surgical procedures used for coverage of palatal recession defect are technically challenging in terms of accessibility and graft coverage. The purpose of this report is to describe a surgical technique used to manage deep-wide palatal recession defect. The technique uses partly deepithelialised palatal graft that is designed to approximately fit the defect site. This is employed for prolonged protection of the underlying healing process. This case report is unique in terms of treatment of deep (9.0 mm), wide (6.0 mm) palatal recession defect and its long-term follow-up for 18 months.

Avaliação do desempenho de duas resinas compostas e dois sistemas adesivos em um novo protocolo cirúrgico-restaurador para tratamento de lesões cervicais não-cariosas associadas à recessão gengival: estudo clínico controlado randomizado / Evaluation of two resin composites and two adhesives for a novel surgical-restorative protocol for the treatment of non-carious cervical lesions associated with gingival recession: a randomized controlled clinical trial

A recessão gengival está frequentemente associada à lesão cervical não-cariosa. Quando as duas lesões estão associadas, dão origem a uma lesão combinada (LC) que tem um prognóstico de tratamento diferente de quando as duas lesões se apresentam sozinhas. A literatura apresenta alguns estudos que avaliaram uma abordagem multidisciplinar para otimizar o tratamento dessa LC. No entanto, as abordagens propostas possuem limitações de técnicas e materiais, sem um protocolo clínico ideal estabelecido. Dessa forma, o objetivo do presente estudo foi avaliar um novo protocolo multidisciplinar, com duas resinas compostas e dois sistemas adesivos distintos através de estudo clínico randomizado. Foram selecionadas 80 lesões combinadas, alocadas aleatoriamente em um dos seguintes grupos: AC+NP (n=20) - restauração parcial da lesão cervical com resina nanoparticulada e sistema adesivo de condicionamento total em 2 passos e cirurgia para recobrimento radicular, AU+NP (n=20) - restauração parcial da lesão cervical com resina nanoparticulada e sistema adesivo autocondicionante e cirurgia para recobrimento radicular, AC+MH (n=20) - restauração parcial da lesão cervical com resina microhíbrida e sistema adesivo de condicionamento total em 2 passos e cirurgia para recobrimento radicular, AU+MH (n=20) - restauração parcial da lesão cervical com resina microhíbrida e sistema adesivo autocondicionante e cirurgia para recobrimento radicular. Foram realizadas avaliações das restaurações pelo método USPHS após 1 semana, 6 meses e 12 meses. A análise de sobrevivência das restaurações foi realizada através do teste de Kaplan-Meier. Os protocolos restauradores foram comparados para cada parâmetro pelo teste exato de Fisher, considerando tipo de adesivo e tipo de resina empregados. Teste de Qui-Quadrado foi utilizado para comparação das taxas após 6 e 12 meses entre os grupos testados. A avaliação da normalidade foi realizada pelo teste de Shapiro-Wilks. As medidas clínicas de RGR, PS, NIC, ETQ, ATQ, Hipersensibilidade Dentinária e Estética (VAS) foram comparadas tanto intra como intergrupo por teste de variância de medidas repetidas ANOVA de dois fatores e Tukey com teste post-hoc. IP, IS foram avaliados pelo teste de Qui-Quadrado. Os parâmetros de DC, Porcentagem de recobrimento e RecRed foram analisados pelo ANOVA 1 fator. Pôde-se observar uma taxa de sucesso geral cumulativo do tratamento de 98,7% aos 6 primeiros meses e 92,4% aos 12 meses de acompanhamento, sem diferença estatisticamente significativa entre os tempos e grupos avaliados. Todos os grupos apresentaram melhora estética e redução de hipersensibilidade significativa em relação ao baseline (p<0,001) após 6 meses. Houve redução significativa da recessão gengival relativa (p<0,05) após 12 meses de acompanhamento. Dentro dos limites do presente estudo, pode-se concluir que os materiais utilizados apresentaram desempenho clínico similares, sendo que as diferentes combinações de materiais restauradores adesivos estudados associados às técnicas cirúrgicas utilizadas podem ser empregadas no tratamento das lesões cervicais não-cariosas associadas a recessão gengival(AU)

Non-carious cervical lesion is frequently associated with gingival recession, resulting in a combined lesion (CL) that has a different treatment prognosis when the two lesions appear alone. The literature presents few studies that evaluate a multidisciplinary approach to optimize the treatment of this CL. The previously proposed approaches and materials have limitations and an optimal clinical protocol has not been established yet. Thus, the aim of this study was to evaluate a novel multidisciplinary protocol with two resin composites and two different adhesive systems by a randomized clinical. Eighty combined lesions were randomly assigned to one of the following groups: NP + TE (n = 20) - partial restoration of cervical lesions with nanofilled composite and total-etch adhesive system and periodontal surgery for root coverage, NP + UA (n =20) - partial restoration of cervical lesions with nanofilled composite and self-etching adhesive system and periodontal surgery for root coverage, MH + TE (n = 20) - partial restoration of cervical lesions with microhybrid composite and total-etch adhesive system and periodontal surgery for root coverage, MH + UA (n = 20) - partial restoration of cervical lesions with microhybrid composite and selfetching adhesive system and periodontal surgery for root coverage. Restorations were assessed using the USPHS criteria after one week, six months and twelve months. Survival rate was assessed by Kaplan-Meier test. Restorative protocols were compared for each parameter by Fisher's exact test, considering type of adhesive and type of composite used. Chi-square test was used to compare the rates at 6 and 12 months between the groups tested. Normality evaluation was assessed by Shapiro-Wilks test. Clinical measures of RGR, PS, NIC, KTW, KTH, Hipersensitivity and Esthetics (VAS) were compared both intra and inter-group by analysis of variance of repeated measures Two-Way ANOVA and Tukey posthoc test. IP, IS were evaluated by Chi-square test. CD parameter, Coverage percentage and RecRed were evaluated by One-Way ANOVA. It was observed a successful cumulative rate of 98.7 % at 6 months and 92.4 % at 12 months with no significant difference between groups. When compared to baseline, all groups presented significant improvement in esthetics and reduction of hipersensitivity at 6 months (p<0.001). Significant reduction of gingival recession was recorded after 12 months (p<0.05). It can be concluded that there is no difference between the tested materials, and different combinations of adhesive restorative materials associated with periodontal surgical techniques can be used to treat non-carious cervical lesions associated with gingival recession(AU)

The influence of professional competence on the inter- and intra-individual esthetic evaluation of implant-supported crowns in the anterior maxilla.

OBJECTIVES: Evaluation of the influence of professional competence on esthetic predictability of implant-supported crowns in the anterior maxilla and identification of objective factors allowing predictable planning for esthetic results. MATERIALS AND METHODS: Sixty patients with 82 implants in the esthetic zone were included in this study. Width of keratinized mucosa, biotype, recessions, and papilla index according to Jemt as well as radiological bone loss were assessed. Study casts and photographs were obtained. Each patient as well as people with different level of expertise (laypersons, students and dentists) rated the esthetic satisfaction after final restoration on a scale (1-10). Correlations between esthetic assessments and previously documented clinical parameters were tested. RESULTS: The study failed to show a significant relationship between the raters' level of dental expertise and their subjective esthetic evaluation. However, patients rated themselves much more favorable than the three evaluator groups did. A comparison of the clinical parameters with the esthetic evaluation revealed significantly more favorable ratings by the lay group in the presence of a wide attached gingiva (P = 0.021) than by the other groups and by the laypersons (P = 0.002), the dentists (P = 0.003), and students (P = 0.009) in the absence of recessions. The ratio of the implant crown length to the length of the contralateral crown had a negative effect on ratings for all three groups ([laypersons P < 0.001], [students P < 0.001] and [dentists P = 0.001]). The papilla index of the mesial papilla correlated significantly with laypersons' ratings (P = 0.036). CONCLUSION: Earlier investigations are confirmed. Width of keratinized mucosa is a risk factor for esthetic predictability of implant-supported crowns in the anterior maxilla in laypersons' ratings. Furthermore, there is an association between the discrepancy of lengths of implant-supported single crowns to their contralateral natural teeth and esthetic satisfaction for all expertise levels.

[Root coverage: Prognostic factors and surgical techniques]. / Le recouvrement radiculaire : facteurs pronostiques et techniques chirurgicales.

Gingival recession is an oral exposure of the root surface due to an apical displacement of the gingival margin below the cemento-enamel junction. The root coverage is indicated for esthetic reasons, to reduce root hypersensitivity and to create or to augment keratinized tissue. Several surgical techniques have been described, the decision depending on anatomical and technical parameters. The main therapeutic goal is to achieve complete root coverage (CRC) and a satisfactory esthetic result. The purpose of this work was to make an update on the different factors that determine the success of root coverage and to evaluate the efficacy of different surgical techniques reported in literature.

Gingival recession: its causes and types, and the importance of orthodontic treatment.

Gingival recession has direct causes and predisposing factors. Orthodontic treatment is able to prevent recession and even contribute to its treatment, with or without periodontal approach, depending on the type and severity of gingival tissue damage. There is no evidence on the fact that orthodontic treatment alone might induce gingival recession, although it might lead the affected teeth (usually mandibular incisors or maxillary canines) to be involved in situations that act as predisposing factors, allowing direct causes to act and, therefore, trigger recession, especially when the buccal bone plate is very thin or presents with dehiscence. Several aspects regarding the relationship between orthodontic treatment and gingival recession have been addressed, and so has the importance of the periosteum to the mechanism of gingival recession formation. Clinical as well as experimental trials on the subject would help to clarify this matter, of which understanding is not very deep in the related literature.

Recessões gengivais múltiplas na zona estética ­ relato de caso com a técnica Vista / Multiple gingival recessions in the esthetic zone ­ a case report using the Vista technique

O objetivo deste trabalho foi demonstrar a resolução de recessões gengivais múltiplas na zona estética. Uma paciente de 32 anos e idade apresentou-se com recessões classe I de Miller, restaurações cervicais classe V, e sensibilidade radicular localizada. O exame clínico não mostrou perda óssea proximal ou invasão da linha mucogengival. Após a anestesia, as restaurações classe V foram removidas, com raspagem e alisamento radicular, ácido cítrico e EDTA. O tecido mole foi manejado usando a técnica Vista, sem alteração da margem coronal da papila interdentária. As suturas foram ancoradas nas faces vestibulares dos caninos e incisivos usando-se resina composta. O creeping attachment foi observado 15 dias depois. Nos dois meses seguintes, a sensibilidade radicular foi controlada com uso de fluoretos. Após cinco meses, a estabilidade do ganho tecidual adquirido foi constatada. Os resultados observados compensaram a complexidade desta técnica.

The aim of this paper was to demonstrate a solution for multiple gingival recessions in the esthetic zone. A 32-years old female patient presented with Miller's class I recessions, type V cervical restorations, and localized root sensitivity. Upon clinical exam, no proximal bone loss and invasion of the mucogingival line were identified. After anesthetic infiltration, the class V restorations were removed, followed by root debridement and polishing, citric acid, and EDTA application. Soft tissue management was performed with the Vista technique, with no changes on the coronal margins of interproximal papillae. Sutures were anchored at the buccal tooth surfaces with a flow composite resin. Fifteen days later, the creeping attachment was observed. On the next two months, root sensitivity was controlled by the use of local fl uoride solution. After 5 months, soft tissue gain and stability were confi rmed. The observed outcomes can counterbalance the complexity of this technique highlighting its importance in the daily practice.

Gingival recession: its causes and types, and the importance of orthodontic treatment

abstract Gingival recession has direct causes and predisposing factors. Orthodontic treatment is able to prevent recession and even contribute to its treatment, with or without periodontal approach, depending on the type and severity of gingival tissue damage. There is no evidence on the fact that orthodontic treatment alone might induce gingival recession, although it might lead the affected teeth (usually mandibular incisors or maxillary canines) to be involved in situations that act as predisposing factors, allowing direct causes to act and, therefore, trigger recession, especially when the buccal bone plate is very thin or presents with dehiscence. Several aspects regarding the relationship between orthodontic treatment and gingival recession have been addressed, and so has the importance of the periosteum to the mechanism of gingival recession formation. Clinical as well as experimental trials on the subject would help to clarify this matter, of which understanding is not very deep in the related literature.

Resumo As recessões gengivais têm causas diretas e fatores predisponentes. O tratamento ortodôntico pode prevenir as recessões e, até, contribuir para o seu tratamento, com ou sem uma abordagem por parte do periodontista, dependendo do tipo e da severidade do comprometimento dos tecidos gengivais. Não há evidências de que o tratamento ortodôntico possa induzir, de forma primária, as recessões gengivais, muito embora possa levar os dentes envolvidos (comumente, os incisivos inferiores e os caninos superiores) a situações que ajam como fatores predisponentes para que as causas diretas possam atuar e produzir recessões - em especial, quando deixa-se uma tábua óssea vestibular muito fina ou, até, com deiscência. Vários aspectos da relação entre o tratamento ortodôntico e as recessões gengivais já foram abordados, assim como a importância do periósteo no mecanismo de formação delas. Trabalhos clínicos e experimentais sobre o assunto ajudariam a esclarecer o assunto, que ainda se apresenta muito pouco aprofundado na literatura pertinente.

[Clinical and periodontal predictive factors of severity in gingival recession (GR)]. / Parámetros clínicos y periodontales predictores de la severidad de la recesión gingival (RG).

INTRODUCTION: Gingival recession is an unsightly condition due to root exposure. It can lead to dental hypersensitivity, root caries, and tooth loss. OBJECTIVE: To determine the influence of different clinical and periodontal parameters on the severity of gingival recession evaluated at four periods: initial, 6, 12, and 18 months of follow-up. MATERIAL AND METHODS: Forty patients with gingival recession were included in the study. Sociodemographic data, systemic diseases, harmful habits, dental hygiene habits, parafunctional habits, and orthodontic treatment were collected. Periodontal status (plaque index, gingival bleeding index, attached gingiva loss, pocket probing depth, and attachment loss) was also measured. RESULTS: None of the clinical parameters studied influenced the number of teeth with gingival recession. Smokers showed a higher number of teeth with attached gingiva loss (p=0.03). A direct relationship between the severity of gingival recession and plaque index (p=0.02) or 4-6 mm attachment loss (p=0.04) was observed. At six months of follow-up, gingival index was the only parameter that influenced the severity of gingival recession (p=0.01).

Clinical attachment loss: estimation by direct and indirect methods.

OBJECTIVE: This observational study aimed to compare the estimation of clinical attachment loss (CAL) as measured by direct (CALD ) and indirect (CALI ) methods. METHODS: Periodontitis patients (n = 75; mean age: 50.9 ± 8.02 years; 72.2% women; 50.6% smokers) received a periodontal examination (six sites/tooth) to determine the presence of visible plaque and calculus, the gingival bleeding index (GBI), periodontal probing depth (PPD), bleeding on probing (BOP), CALD and gingival recession (GR). CALI values resulted from the sum of PPD and GR values. Statistical analysis considered only data from sites with visible GR (e.g. the gingival margin apical to the cemento-enamel junction; n = 4,757 sites) and determined the mean difference between CALI and CALD measurements. Based on the mean difference, univariate and multivariate analyses were also performed. RESULTS: Mean CALD and CALI values were 3.96 ± 2.07 mm and 4.47 ± 2.03 mm, respectively. The indirect method overestimated CAL compared with the direct method (mean difference: 0.51 ± 1.23 mm; P < 0.001). On uni- and multivariate analyses, absence of GBI and BOP, PPD and proximal site location had significant influences on the overestimation of CAL by the indirect method (all P ≤ 0.01). The indirect method increased the CAL value by 0.38 mm for each additional 1 mm in PPD. CONCLUSIONS: To decrease the number of probing errors in daily practice it is suggested that direct examination is more appropriate than the indirect method for estimating CAL.

Dental disorders in brown howler monkeys (Alouatta guariba clamitans) maintained in captivity.

BACKGROUND: The aim of this study was to investigate dental disorders of brown howler monkeys maintained in captivity. The hypothesis is that the identification and diagnosis of the lesions may contribute to control and prevention. METHODS: Sixteen intact brown howler monkeys (Alouatta guariba clamitans), eight females and eight males, weighing from 3.9 to 6.8 kg, were studied. Under general anesthesia, the teeth were evaluated by visual inspection, probing, palpation, and intra-oral radiographic exam. The findings were registered on a dental chart specific for primates. RESULT: Of the 16 monkeys evaluated in the present study, 94% (n = 15) had some type of dental disorder. The lesions observed were dental calculus (88%), dental wear (81%), missing teeth (38%), gingivitis (19%), gingival recession (6%), dental fracture (19%), pulp exposure (19%), and dental staining (25%). CONCLUSIONS: Alouatta guariba clamitans maintained in captivity have a high rate of dental problems.

Influência da aplicação de laser de baixa intensidade no recobrimento radicular associado à técnica de enxerto de tecido conjuntivo: estudo clínico controlado randomizado com acompanhamento de dois anos / 2-year results of connective tissue graft associated with low level laser therapy in the treatment of recession defects: a randomized clinical trial

A terapia com laser de baixa intensidade (LBI) tem sido utilizada com sucesso para fotobioestimular e acelerar a cicatrização de feridas em seres humanos. Porém, a literatura carece de estudos controlados que avaliem o uso desta terapia no campo da cirurgia plástica periodontal. O presente estudo tem como objetivo avaliar os resultados de longo prazo (≥ 24 meses) da técnica de enxerto de tecido conjuntivo associado à aplicação do LBI no tratamento da recessão gengival. Além disso, o presente estudo também tem como objetivo avaliar a influência de fatores anatômicos no recobrimento radicular através de medidas clínicas, digitais e tomográficas. Foram incluídos quarenta pacientes com recessão gengival Classe I e II de Miller previamente tratados com: enxerto de tecido conjuntivo (grupo controle; n = 20) ou enxerto de tecido conjuntivo + LBI (grupo de teste; n = 20). Um laser de diodo (GaAlAs, 660 nm) foi aplicado no grupo teste imediatamente após a cirurgia e a cada dois dias durante 14 dias (8 aplicações). Após 2 anos de acompanhamento, avaliações clínicas, estéticas, digitais e tomográficas foram realizadas em trinta e seis pacientes. A porcentagem média de recobrimento radicular foi de 93,43% no grupo de teste e 92,32% no grupo controle (p = 0,55). O recobrimento radicular completo foi de 79% (n = 15) no grupo de teste e 76% (n = 13) no grupo controle (n = 13) (p = 0,8). Os dois grupos apresentaram manutenção da estética após 2 anos de acompanhamento. A análise de regressão linear múltipla demonstrou uma associação significativa e um forte coeficiente de correlação (R2 = 0,73) entre o recobrimento radicular e a recessão gengival, a largura papila, a espessura do tecido queratinizado e a altura da crista óssea. Dentro das limitações do presente estudo, nossos resultados indicam que a aplicação de LBI não mostrou benefícios adicionais, em longo prazo, quando associado com enxerto de tecido conjuntivo no tratamento de recessões gengivais Classe I e II de Miller(AU)

Low-level laser therapy (LLLT) has been successfully used to photobiostimulate and to accelerate wound healing in humans. However, there is a lack of controlled studies evaluating the use of this therapy in the field of periodontal plastic surgery. The present study shows a 2-year result of connective tissue graft associated with LLLT in the treatment of gingival recession defects. Furthermore, this study also aims to evaluate the influence of anatomical factors in root coverage through clinical, digital and tomographic measurements. Forty patients presenting Miller Class I and II gingival recessions were previously treated by: Connective tissue graft (Control group; n = 20) or Connective tissue graft + LLLT (Test group; n = 20). A diode laser (GaAlAs, 660 nm) was applied to the test sites immediately after surgery and every other day for 14 days (8 applications). After a follow-up of 2 years, clinical and aesthetic evaluations were performed in thirtysix patients. The mean percentage of root coverage was 93.43% for the test group and 92.32% for control group (p = 0.55). Complete root coverage was 79% (n = 15) for test group and 76% (n = 13) for control group (n = 13) (p = 0.8). The two groups showed aesthetics maintenance after 2 years. The multiple linear regression analysis demonstrated that there was a significant association and a strong correlation coefficient (R2 = 0.73) between root coverage and gingival recession, papilla width, keratinized tissue thickness and alveolar crest height. Within the limitations of this study, the previous results indicated that LLLT showed no additional benefit in the long term when associated with connective tissue graft in the treatment of Miller Class I and II gingival recessions(AU)

Recobrimento radicular e peri-implantar em área anterior usando a técnica de tunelização / Root and peri-implant coverage in anterior area using the tunnel technique

A estética de reabilitações dentarias e implantossuportadas se vê afetada pela exposição radicular ou da cinta metálica de pilares protéticos em situações de recessões gengivais e peri-implantares, sendo motivo de consulta dos pacientes pelo desconforto com o resultado estético, ainda mais quando este problema se apresenta na área anterior de incisivos centrais. Para resolver estas situações existem várias técnicas cirúrgicas de enxertos e manipulação de tecidos moles para otimizar esses resultados estéticos. O objetivo deste trabalho é apresentar a técnica de enxerto de tecido conjuntivo subepitelial sem desinserir as papilas, conhecida como técnica de túnel, realizada nos incisivos centrais superiores para recobrimento radicular e da cinta metálica da prótese sobre implante. Pode se concluir que a técnica de enxerto de tecido conjuntivo subepitelial tem sido utilizada com alto índice de sucesso e, para obter estética e função em Implantodontia e Periodontia, especificamente neste caso clínico, melhorou-se a situação inicial antiestética e ofereceu a vantagem de manter as papilas inseridas sem serem afetadas no procedimento cirúrgico...

In cases of gingival recession, the dental prostheses are aesthetically compromised by the exposure of dental roots or of metal strap abutments. Therefore this condition is commonly brings to the dental office patients unsatisfied with the aesthetic result, especially when it occurs on the anterior area. There are several grafting surgical techniques and tissue management to improve this situation and optimize aesthetic results. The objective of this paper is to present the sub epithelial connective tissue graft technique without detachment of the papillae (tunnel technique) performed on maxillary central incisors for root and metal strap coverage. It could be concluded that this technique has been used with high success rate for both aesthetics and function in Implantology and Periodontics. In the reported case it enabled significant, improve of the initial aesthetic condition, with the advantage of preserving the papillae unaffected in the surgical procedure...

Enxerto de tecido conjuntivo subepitelial como alternativa ao tratamento de recessões gengivais múltiplas û relato de caso / Subepithelial connective tissue graft as an alternative to treat multiple gingival recession û case report

A recessão gengival é definida como o deslocamento da margem gengival apicalmente à junção cemento-esmalte, a qual pode resultar em estética desfavorável, aumento da susceptibilidade de cárie radicular e hipersensibilidade dentinária. O objetivo deste estudo foi apresentar um caso clínico de tratamento periodontal cirúrgico de uma paciente com múltiplas recessões gengivais nas faces vestibulares dos dentes 13 e 14, 23, 24, 25 e 26, classificadas como Classe I e II de Miller. Como método foi utilizada a técnica de enxerto de tecido conjuntivo e deslocamento coronal do retalho para o recobrimento radicular nos dentes descritos acima. Após 12 e 36 meses da cirurgia foi observado um percentual de recobrimento radicular nos dentes 13 e 14 de 80 a 86%, e nos dentes 23, 24, 25 e 26 observou-se um ganho de volume tecidual (tecido queratinizado) e recobrimento radicular de 60 a 89%. Concluiu-se que houve um resultado satisfatório em relação ao recobrimento radicular e aumento de gengiva inserida, resultando em melhor estética e função para a paciente.

Gingival recession can be defined as the displacement of the gingival margin apical to the cemento-enamel junction, resulting in root surface exposure, which can lead to unfavorable aesthetics, increased susceptibility to root caries and dentin hypersensitivity. The objective of this study was to present a clinical treatment of a patient with multiple gingival recessions in teeth 13-14, 23, 24, 25 and 26 (Miller Class I and II). A palatal connective tissue graft was used to cover the root surface. After 12 months, teeth 13 and 14 presented 80-86% of root coverage. An increase of keratinized tissue width and 60-89% of root coverage were observed on teeth 23, 24, 25 and 26. It can be concluded that proper root coverage and tissue augmentation were obtained, resulting on improved aesthetics and function.

Development and validation of a self-reported periodontal disease measure among Jordanians.

BACKGROUND: The development of self-reported measures of periodontal disease would be of great benefit to facilitate epidemiological studies of periodontal disease on a larger scale, and to allow for surveillance of the periodontal condition of populations over time. OBJECTIVES: To develop a culturally adapted self-reported measure of periodontal disease, test its predictive and discriminative validity and establish a cut-off value for this measure to diagnose periodontal disease. METHODS: A total of 288 Jordanian adults completed the questionnaire assessing self-reported periodontal health (18 questions) and underwent periodontal examination. Of the 18 questions, six were significantly associated with at least one clinical definition of periodontitis and were used to constitute the self-reported periodontal disease measure. Receiver-operating characteristics (ROC) curve analyses were used to examine the overall discriminatory power, sensitivity and specificity, and corresponding cut-off points of the self-reported periodontal disease measure. RESULTS: ROC analysis showed that the self-reported periodontal disease measure had an excellent performance to discriminate between those with and without periodontal disease, regardless of the clinical definition used. A score of 2, on a scale of 0 to 6, had the highest sensitivity and specificity to detect periodontal disease when defined by all study criteria. Significant associations were observed between self-reported periodontal disease measures and all clinical definitions in the regression analysis (the odds ratio ranged from 8.31 to 18.96), according to the clinical definition to be predicted. CONCLUSION: Self-reported periodontal disease measures have excellent predictive and discriminative validity when tested against clinical definitions, and severity and extent of periodontal disease.

The effect of changes in lower incisor inclination on gingival recession.

AIM: Orthodontic treatment may promote development of recessions. The mechanism by which orthodontic treatment influences occurrence of recessions remains unclear. The aim of this study was to test the hypothesis that a change of mandibular incisor inclination promotes development of labial gingival recessions. MATERIALS AND METHODS: The study sample comprised dental casts and lateral cephalograms obtained from 109 subjects before orthodontic treatment (Tb) and after orthodontic treatment (Ta). Depending on the change of lower incisor inclination during treatment, the subjects were divided into three groups: Retroclination (R), Stable Position (S), and Proclination (P). The presence of gingival recessions of mandibular incisors and clinical crown heights were assessed on plaster models. RESULTS AND CONCLUSIONS: From Tb to Ta, Inc_Incl showed a statistically significant change in the R, P, and S groups (p < 0.05). Increase of clinical crown heights of the lower incisors (42, 4, and 31) was not statistically significant in any group. The only statistically significant intergroup difference was the greater increase of the clinical crown height of tooth number 32 in the P group in comparison with the R group (p = 0.049). The change of lower incisor inclination during treatment did not lead to development of labial gingival recessions in the study sample.

Periodontal plastic surgery.

The aim of the present article is to summarize current knowledge in terms of the etiology, diagnosis, prognosis and surgical treatment of gingival recession. Whilst the main etiological factors (i.e. toothbrushing trauma and bacterial plaque) are well established, challenges still remain to be solved in the diagnostic, prognostic and classification processes of gingival recession, especially when the main reference parameter - the cemento-enamel junction - is no longer detectable on the affected tooth or when there is a slight loss of periodontal interdental attachment. Root coverage in single type gingival recession defects is a very predictable outcome following the use of various surgical techniques. The coronally advanced flap, with or without connective tissue grafting, is the technique of choice. The adjunctive use of connective tissue grafts improves the probability of achieving complete root coverage. Surgical coverage of multiple gingival recessions is also predictable with the coronally advanced flap and the coronally advanced flap plus the connective tissue graft, but no data are available indicating which, and how many, gingival recessions should be treated adjunctively with connective tissue grafting in order to limit patient morbidity and improve the esthetic outcome. None of the allograft materials currently available can be considered as a full substitute for the connective tissue graft, even if some recent results are encouraging. The need for future studies with patient-based outcomes (i.e. esthetics and morbidity) as primary objectives is emphasized in this review.

Soft tissues stability of cad-cam and stock abutments in anterior regions: 2-year prospective multicentric cohort study.

AIM: Aim of this study was to verify if the type of implant abutment manufacturing, stock or cad-cam, could influence the maintenance of stable gingival margins around single restorations in anterior areas. METHODS: After 16 weeks of healing, implants (Osseospeed, Astra Tech Dental Implant) were positioned. Depending on the different fixture inclination and the thickness of buccal peri-implant soft tissue, abutment selection resulted in four groups: Group 1 (patients with zirconia ZirDesign(®) stock abutments), Group 2 (titanium stock TiDesign(®) abutments), Group 3 (zirconia cad-cam abutments), and Group 4 (titanium cad-cam abutments). The following parameters were assessed: buccal gingival margin modification (BGM). The modification of the implant gingival margin was followed at 1 and 2 years of follow-up. A computerized analysis was performed for measurements. Differences between soft tissue margin at baseline and after 2 years measured the gingival margin recession. A general linear model was used to evaluate each group in relation to gingival recession after two years. Tukey's post hoc test was used to compare the mean REC indexes of each group of abutments. RESULTS: Seventy-two healthy patients (39 males and 33 females; mean age of 46 years) scheduled for single gap rehabilitation in anterior areas were enrolled. A 100% of implant survival rate was observed after 24 months of function. One failure occurred due to fracture of a Zirconia cad-cam abutment. Moreover, two abutment screw unscrewing were observed. Both for zirconia and titanium stock abutments (Group 1 and 2), the mean recession of implant buccal soft tissue was of 0.3 mm (SD of 0.3 and 0.4 mm, respectively). Soft tissue mean recession of zirconia and titanium cad-cam abutments (Group 3 and 4) was of 0.1 and -0.3 mm, respectively (SD of 0.3 and 0.4 mm, respectively). REC values of cad-cam titanium abutments (Group 4) were significantly lower than that of Group 1 (-0.57 mm), Group 2 (-0.61 mm), and Group 3 (-0.40 mm), respectively (Table 4). CONCLUSION: In the anterior area, the use of cad-cam abutments is related to a better soft tissue stability. Such a relationship is significant if cad-cam titanium abutments are compared to both titanium and zirconia stock abutments.

[Clinical observation of glycine powder air-polishing during periodontal maintenance phase].

OBJECTIVE: To evaluate the clinical effect of the 65 µm glycine powder air-polishing (GPAP) and ultrasonic scaling during periodontal maintenance phase. METHODS: Twenty-three patients at the age of 28-72 (8 males and 15 females) who were systematically healthy were involved in this study. According to splitting-mouth design, one side of a mouth was randomly assigned to the experiment group with 65 µm GPAP therapy, while the other side was the control group with ultrasonic scaling therapy. The clinical parameters including probing depth (PD), bleeding index (BI), gingival recession (Rec), plaque index (PLI), staining index (SI) were recorded. The patients' perception of treatment was assessed by visual analogue scale (VAS). The treatment time was recorded and compared between the two groups. RESULTS: Both of the two methods had good clinical effects. PD, BI and PLI of the two groups 12 weeks after treatment were better than those at baseline (P < 0.01). There was no significant deference between the two methods at baseline and at the 12 weeks after treatment. The VAS value of experiment group was better than that of control group (1.7 ± 1.3 vs. 3.3 ± 1.8, P < 0.01). The treatment time of experiment group was also shorter than that of control group [(192.7 ± 82.7) s vs. (345.4 ± 116.9) s, P < 0.01]. CONCLUSIONS: The results indicate that 65 µm GPAP may be as effective as the ultrasonic scaling during periodontal maintenance phase. 65 µm GPAP had the advantage of more comfort and less time consuming.

Inter-rater agreement in the diagnosis of mucositis and peri-implantitis.

AIM: The objective was to assess the inter-rater agreement in the diagnosis of mucositis and peri-implantitis. MATERIAL AND METHODS: Adult patients with ≥ 1 dental implant were eligible. Three operators examined the patients. One examiner allocated the patients to three groups of nine as follows: nine implants with peri-implantitis, nine implants with mucositis, and 9 implants with healthy mucosa. Each examiner recorded on all 27 patients (one implant per patient) recessions, probing depth, bleeding on probing, suppuration, keratinized tissue depth and bone loss, leading to a final diagnosis of mucositis, peri-implantitis or healthy mucosa. Examiners were independent and blinded to each other. RESULTS: Fleiss k-statistic with quadratic weight in the diagnosis of peri-implantitis and mucositis was 0.66 [CI95%: 0.45-0.87]. A complete agreement was obtained only in 14 cases (52%). Fleiss k-statistics in bleeding on probing and bone loss were respectively 0.31 [CI95%: 0.20-0.41] and 0.70 [CI95%: 0.45-0.94]. Intra-class correlation coefficients for recession, probing depth and keratinized tissue depth were respectively 0.69 [CI95%: 0.62-0.75], 0.54 [CI95%: 0.44-0.63] and 0.56 [CI95%: 0.27-0.77]. CONCLUSIONS: The inter-rater agreement in the diagnosis of peri-implant disease was qualified as merely good. This could also be due in part to the unclear definition of peri-implantitis and mucositis.