Complications and treatment errors in root coverage procedures.

Root coverage procedures have become very common in clinical dental practice. Even though these techniques are considered safe, the clinician may face several issues during the therapy due to their surgical nature. Some of these issues can be defined strictly as complications inherent to the procedure, whereas others are medical errors or treatment errors. This review will focus on describing treatment errors and complications that may arise during different phases of the root coverage therapeutic process and on how to prevent and manage them.

Difficulty score for the treatment of isolated gingival recessions with the coronally advanced flap: a preliminary reliability study.

OBJECTIVES: The treatment of gingival recessions (GRs) is operator-sensitive and dependent upon several local anatomical factors. The aim of this study was to introduce a difficulty score for the treatment of localized GRs with the coronally advanced flap (CAF) and to test its consistency among different operators. MATERIALS AND METHODS: A rubric (difficulty score) consisting of the assessment and grading of 8 anatomical parameters (anatomical papilla, apical and lateral keratinized tissue width, apical and lateral frenum, vestibulum depth, scar tissue, and mucosal invagination) is described based on the available evidence and the authors' experience. Inter-examiner agreement, with the score, was tested on 32 localized GRs among four different experienced practitioners. RESULTS: Minor discrepancies were observed in the total scores between the reviewers (intraclass correlation coefficient [ICC] 0.95). A good reproducibility, with ICCs ranging from 0.56 to 0.98, was found for the individual parameters. All models showed high absolute variance contribution conveying true differences among the cases, and small examiner variance, demonstrating minor systematic variability among the four reviewers and reproducible evaluations. CONCLUSIONS: The proposed difficulty score for the treatment of GRs with CAF was reproducible among different operators. Clinical interventional studies are the next step to validate the clinical magnitude of the present score. CLINICAL RELEVANCE: A novel tool for evaluating the difficulty of the treatment of isolated gingival recession using CAF was described. Clinicians can benefit from this score when assessing the expected level of complexity of the surgical case.

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.

Esthetic evaluation and patient-centered outcomes in single-tooth implant rehabilitation in the esthetic area.

Criteria for successful implants, in the rehabilitation of a single missing tooth in the esthetic area, should be determined by composite outcomes, including functional and esthetic aspects of soft tissues and the reconstruction, as well as patient-reported outcomes. This paper focuses on current methods in esthetic assessment and patient-centered/reported outcomes in single-tooth implant rehabilitation in the esthetic area. The relationship between subjective, patient-based esthetic evaluations and objective, professional-based esthetic evaluations is reviewed. In spite of increasing interest in the assessment of 'success' in implant dentistry, it is not yet possible to provide evidence-based conclusions because of the lack of consensus on a universal implant-supported crown esthetic index. There is also a need to standardize reporting of patient-centered outcomes in partially edentulous patients treated with implants.

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.

Soft-tissue dehiscence coverage at peri-implant sites.

Soft-tissue dehiscence at the facial aspect of an osteointegrated implant is a common complication which impacts on the final esthetic result. The etiology and ways of diagnosing this condition are still controversial. Many factors seem to influence the position of the peri-implant soft-tissue margin, and some of these have been studied more carefully than others. Various surgical and combination surgical-prosthetic approaches have been described to treat soft-tissue dehiscence, with the latter appearing to be more predictable. This paper focuses on the factors affecting peri-implant soft-tissue margins and describes the different treatment approaches, reported in the literature, to treat buccal soft-tissue dehiscence, with more focus on the prosthetic-surgical-prosthetic approach.

Esthetic treatment of altered passive eruption.

Altered passive eruption is described as a condition in which the relationship between teeth, alveolar bone and soft tissues creates an excessive display of gingiva, commonly known as a 'gummy smile'. While there are authors who consider altered passive eruption to be a risk to periodontal health, its impact is greatest in terms of oral esthetics. The aim of periodontal management in such cases is not only to improve patient esthetics but also to restore periodontal health by re-establishing the normal relationship between the gingival margin, alveolar bone crest and cemento-enamel junction. The aim of this article is to present a narrative review of the etiology, classification and management of altered passive eruption.

Esthetic evaluation and patient-centered outcomes in root-coverage procedures.

Treatment of buccal gingival recession is performed for esthetic concerns, root sensitivity, root caries and cervical abrasion resulting from incorrect toothbrushing. Over the years, clinicians and researchers have improved surgical techniques to achieve surrogate end points, such as complete root coverage, gingival recession reduction or keratinized tissue increase, ignoring the input from the patient regarding the true indications for treatment. In the past few years there has been an emphasis to include patient-centered outcomes in the evaluation of root-coverage procedures. The aim of this narrative review is to describe the professional objective assessment of the esthetic results after root-coverage procedures and the patient perception of outcome in terms of esthetics, postoperative morbidity and dentinal hypersensitivity resolution after the treatment of gingival recessions. The need to align professional (surrogate) end points with patient-centered outcomes (true end points) in the future is emphasized.

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.

Does the dimension of the graft influence patient morbidity and root coverage outcomes? A randomized controlled clinical trial.

AIM: Primary aim of this study was to evaluate if patient morbidity was improved by diminishing graft thickness and height; secondary objective was to evaluate if such graft modifications influence root coverage and aesthetic outcomes. METHODS: 60 Miller class I and II gingival recessions (GR) (≥ 3 mm in depth) were treated with the coronally advanced flap plus extraoral de-epithelialized free gingival graft (FGG). In 30 randomly selected control GRs ("big graft group"), the FGG thickness was ≥ 2 mm and the height was equal to bone dehiscence (BD); in the other 30 test defects ("small graft group"), the thickness of the FGG was <2 mm and the height was 4 mm. The post-operative patient morbidity was assessed 1 week after the surgery. The clinical and aesthetic evaluations were performed 1 year after the surgery. RESULTS: Lower analgesic assumption, better post-operative course evaluations, better patient colour match scores and better periodontist aesthetic assessments were reported in the "small graft" group. No statistically significant differences were demonstrated between the two groups in terms of recession reduction, CRC and increase in KTH. Greater GT increase was obtained in the control-treated sites. CONCLUSIONS: Coronally advanced flap plus CTG of reduced thickness and height was associated with less patient morbidity, better aesthetic evaluations with no difference in RC outcomes.

Coronally advanced flap with and without connective tissue graft for the treatment of multiple gingival recessions: a comparative short- and long-term controlled randomized clinical trial.

AIM: The aim of this study was to compare short- and long-term root coverage and aesthetic outcomes of the coronally advanced flap (CAF) alone or in combination with a connective tissue graft (CTG) for the treatment of multiple gingival recessions. METHODS: Fifty patients with multiple (≥2) adjacent gingival recessions (≥2 mm) in the upper jaw were enrolled. Twenty-five patients were randomly assigned to the control group (CAF), and the other 25 patients to the test group (CAF + CTG). Clinical outcomes were evaluated at 6 months, 1 and 5 years. The aesthetic evaluations were made 1 and 5 years after the surgery. RESULTS: No statistically significant difference was demonstrated between the two groups in terms of Rec Red and complete root coverage (CRC) at 6 months and 1 year. At 5 years, statistically greater recession reduction and probability of CRC, greater increase in buccal KTH and better contour evaluation made by an independent periodontist were observed in the CAF + CTG group. Better post-operative course and better colour match were demonstrated in CAF-treated patients both at 1 and 5 years. CONCLUSIONS: CAF + CTG provided better CRC at 5 years; keloid formation due to graft exposure was responsible for the worse colour match evaluation.

A novel surgical-prosthetic approach for soft tissue dehiscence coverage around single implant.

OBJECTIVES: The aim of the study was to evaluate soft-tissue coverage and patient aesthetic satisfaction of a novel surgical-prosthetic approach to soft tissue dehiscence (STD) around single endosseous implant. MATERIAL AND METHODS: Twenty patients with buccal soft tissues dehiscence around single implants in the aesthetic area were consecutively enrolled. Treatment consisted in: removal of the implant supported crown, reduction in the implant abutment, coronally advanced flap in combination with connective tissue graft (CTG) and final restoration. The unrestored contralateral tooth normally positioned without recession defect was used as a reference. The soft tissue coverage and patient satisfaction were evaluated 1 year after the final restoration. RESULTS: One-year mean STD coverage was 96.3%, and complete coverage was achieved in 75% of the treated sites. The increase (1.54 ± 0.21 mm) in buccal soft tissue thickness (STT) at 1 year was significantly correlated with CTG thickness at time of the surgery. The mean difference between graft thickness and STT increase was 0.09 ± 0.14 mm, corresponding to the 5.8% of the original graft thickness. The aesthetic analysis showed a significant improvement between the baseline (median, 3.8; 95% CI, 2-4) and the 1-year (median, 8.0; 95% CI, 8-10) visual analogue scale (VAS) scores. CONCLUSION: The results from the present study demonstrated that the proposed bilaminar technique was effective in the coverage of buccal STD around single dental implant and the suggested prosthetic-surgical approach was aesthetically successful.

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 morbidity and root coverage outcome after subepithelial connective tissue and de-epithelialized grafts: a comparative randomized-controlled clinical trial.

AIMS: The aim of this randomized-controlled clinical trial was to compare the patient morbidity and root coverage outcomes of a coronally advanced flap (CAF) with connective tissue (CTG) or de-epithelialized gingival (DGG) grafts. METHODS: Fifty patients with one recession each were treated. In the control group, the CTG was harvested using the trap-door approach while in the test group the CTG resulted from the de-epithelialization of a free gingival graft. RESULTS: No statistically significant differences were demonstrated between groups in patients's pain killer consumption, post-operative discomfort and bleeding. Lower stress and better ability to chew were demonstrated in the CTG group. Analgesic consumption increased with increasing height of the graft and in the case of dehiscence/necrosis of the primary flap. Pain was negatively correlated with the residual thickness of soft tissue covering the palatal bone. A statistically greater increase in buccal soft tissue thickness was observed in the DGG group. CONCLUSIONS: No differences were demonstrated in the post-operative pain and root coverage outcome in patients subjected to CAF with CTG or DGG.

Classification of facial peri-implant soft tissue dehiscence/deficiencies at single implant sites in the esthetic zone.

BACKGROUND: The incidence of a peri-implant soft tissue dehiscence/deficiency (PSTD) is not a rare finding. Despite multiple previous attempts aimed at correcting the PSTDs, a classification of these conditions has not yet been proposed. This lack in the literature may also lead to discrepancies in the reported treatment outcomes and thus misinform the clinician or the readers. The aim of the present article was therefore to present a classification of peri-implant PSTD at a single implant site. METHODS: Four classes of PSTDs were discussed based on the position of the gingival margin of the implant-supported crown in relation to the homologous natural tooth. In addition, the bucco-lingual position of the implant head was also taken into consideration. Each class was further subdivided based on the height of the anatomical papillae. RESULTS: Subsequently, for each respective category a surgical approach (including bilaminar techniques, the combined prosthetic-surgical approach or soft tissue augmentation with a submerged healing) was also suggested. CONCLUSION: This paper provides a new classification system for describing PSTDs at single implant sites, with the appropriate recommended treatment protocol.

5-year outcomes after coverage of soft tissue dehiscence around single implants: A prospective cohort study.

PURPOSE: To report the 5-year clinical and aesthetic outcomes of a novel surgical-prosthetic approach for the treatment of buccal soft tissue dehiscence around single dental implants. MATERIALS AND METHODS: Twenty patients with buccal soft tissues dehiscence around single implants in the aesthetic area were treated by removing the implant-supported crown, reducing the implant abutment, coronally advanced flap in combination with connective tissue graft and final restoration. After the first year, patients were recalled three times a year until the final clinical re-evaluation performed 5 years after the final prosthetic crown. Complications, bleeding on probing (BoP), peri-implant probing depth (PPD), clinical attachment level (CAL), keratinized tissue height (KTH), soft tissue coverage and thickness (STT), patient satisfaction (VAS) and aesthetic assessment (PES/WES) were evaluated 5 years after the final restoration. RESULTS: Of the 20 patients enrolled in the study, 19 completed the study at 5 years. A total of 99.2% mean soft tissue dehiscence coverage, with 79% of complete dehiscence coverage, was achieved at 5 years. A statistically significant increase in buccal soft tissue thickness (0.3 mm 0.1-0.4 P < 0.001) and keratinized tissue height (0.5 mm 0.0-1.0; P < 0.001) at 5 years with respect to 1 year was demonstrated. The patient aesthetic evaluation showed high VAS scores with no statistical difference between 1 year and 5 years (8.75 ± 1.02 and 8.95 ± 0.91 respectively). A statistical significant PES/WES score improvement was observed between baseline and 5 years (9.48 ± 2.68; P < 0.001), but not between 1 and 5 years. CONCLUSIONS: Successful aesthetic and soft tissue dehiscence coverage outcomes were well maintained at 5 years. The strict regimen of post-surgical control visits and the emphasis placed on the control of the toothbrushing technique could be critical for the successful long-term maintenance of soft tissue dehiscence coverage results.

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.

Coronally Advanced Flap with Different Designs in the Treatment of Gingival Recession: A Comparative Controlled Randomized Clinical Trial.

The aim of this parallel double-blind randomized controlled clinical trial was to describe a modified approach using the coronally advanced flap (CAF) with triangular design and to compare its efficacy, in terms of root coverage and esthetics, with a trapezoidal type of CAF. A sample of 50 isolated Miller Class I and II gingival recessions with at least 1 mm of keratinized tissue apical to the defects were treated with CAF. Of these recessions, 25 were randomly treated with trapezoidal CAF (control group) while the other 25 (test group) were treated with a modified triangular CAF. The clinical and esthetic evaluations, made by the patient and an independent periodontist, were performed 3 months, 6 months, and 1 year after the surgery. No statistically significant difference was demonstrated between the two CAF groups in terms of recession reduction, complete root coverage, or 6-month and 1-year patient esthetic scores. Better 3-month patient esthetic evaluations and better periodontist root coverage, color match, and contiguity assessments were reported after triangular CAF. Trapezoidal CAF was associated with greater incidence of keloid formation. Single-type gingival recessions can be successfully covered with both types of CAF. The triangular CAF should be preferred for esthetically demanding patients.

The connective tissue graft wall technique to improve root coverage and clinical attachment levels in lingual gingival defects.

The present case report describes the application of the connective tissue graft wall (CTGW) technique for the treatment of deep lingual gingival recessions associated with probing pockets and bone loss. Two deep lingual gingival recessions affecting the mandibular central incisors associated with severe lingual attachment and bone loss were treated. The surgical technique comprised a connective tissue graft (CTG) placed below a trapezoidal-type coronally advanced flap (CAF) acting as a lingual soft tissue wall of the infrabony defect. One year after the surgery, clinically significant root coverage, an increase in lingual keratinized tissue (KT) height and thickness, and clinical attachment level gain were achieved in both treated teeth. This case report encourages the application of the CTGW technique to improve both root coverage and regenerative parameters in lingual gingival recessions associated with severe attachment and bone loss.

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.