Multiple gingival recessions associated with non-carious cervical lesions treated by partial restoration and modified coronally advanced flap with either connective tissue graft or xenogeneic acellular dermal matrix: A randomized clinical trial

Tissue Perfusion and Biomarkers Assessment Following Root Coverage Procedures

AIM

To assess tissue perfusion changes and wound healing biomarker levels after root coverage procedures with coronally advanced flap in combination with the cross-linked xenogeneic collagen matrix (CCMX), loaded either with a placebo or recombinant human platelet-derived growth factor-BB (rhPDGF).

METHODS

This study was designed as a secondary analysis from a previously published clinical trial, and it assessed the tissue perfusion changes over 6 months around multiple gingival recession defects, treated with either with CCMX alone (control) or with CCMX + rhPDGF (test). High frequency Doppler ultrasonography (HFUS) scans were obtained at sites of interest at baseline, 2 weeks, 3 months, and 6 months after surgery. Dynamic tissue perfusion measurements (DTPMs) were performed at the midfacial, interproximal, and transverse aspects of the teeth by an operator, blinded to treatment allocation, using a software package. The expression of different wound healing biomarkers from the gingival crevicular fluid was also assessed.

RESULTS

The regression analyses showed similar tissue perfusion changes between the two groups throughout the majority of the 6 months. DTPMs at 2 weeks showed the test group to have significantly higher perfusion relief intensity (pRI, p < 0.001), mean perfused area (pA, p < 0.001), mean blood flow intensity (FImean, p = 0.021), and total blood flow intensity (FItot, p = 0.021) at the graft region of interest (ROI) compared to control sites. The test sites also exhibited significantly greater pA (p = 0.033) and blood flow intensity "blue" (FIblue, meaning flow away from the transducer, p = 0.035) at the level of the flap compared to the control sites. At 2 weeks, FIblue of the graft was directly correlated with the final mean root coverage (p = 0.008) and complete root coverage (p = 0.003). FImean and FItot of the graft exhibited a direct correlation with volume gain at 6 months (p = 0.031 for both parameters). The final GT gain was correlated to the early DTPMs (pA and FIblue) of the graft and the flap. The two groups exhibited different expressions of IL-1β, PDFG-BB, and VEGF over 3 months, with the 1-week levels of PDGF-BB that were associated with time to recovery.

CONCLUSIONS

HFUS allowed exquisite assessment of tissue perfusion occurring at the entire surgical reconstructive regions and also within the flap and the graft. Sites treated with CCMX + rhPDGF exhibited higher DTPMs, primarily within the graft and flap ROIs at the 2-week timepoint compared to sites augmented with CCMX + saline. Early DTPMs at the graft and flap ROIs showed associations with PROMs and the final clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04462237.

Double-vestibular incision subperiosteal tunnel access (double-VISTA) with connective tissue graft for treating multiple gingival recessions: 2-year follow-up

BACKGROUND

Gingival recession has a multifactorial etiology, involving various predisposing and precipitating factors. Non-carious cervical lesions (NCCLs) are often associated with gingival recession and pose challenges due to their complex pathodynamics. There is limited evidence regarding tunnel-based procedures combined with connective tissue grafts (CTGs) for treating recession-associated NCCLs. This case study illustrates a periodontal-restorative approach for addressing multiple adjacent recession-associated NCCLs.

METHODS

A healthy, non-smoking 55-year-old Asian male presented with generalized mucogingival conditions, including gingival recessions and lack of keratinized tissue on the facial aspect of the maxillary right first molar through the left first molar, accompanied by physiological gingival pigmentation. The recessions were classified as Cairo RT I. NCCLs were evident in all six maxillary anterior teeth. After restoring the NCCLs to the maximum root coverage (MRC) level with composite resin, the patient underwent a mucogingival procedure via a double-vestibular incision subperiosteal tunnel access (double-VISTA) approach with autogenous CTG for treating the recession defects. Due to limited CTG availability, the maxillary left side was treated first, followed by the right side 3 months later.

RESULTS

Post-surgical healing was uneventful, except for mild facial swelling for 5 days, which subsided within a week. After 12 months, all treated teeth exhibited complete coverage to the predetermined MRC level, with a thick gingival phenotype. At the 2-year follow-up, all treated teeth maintained a stable root coverage outcome with harmonious gingival margins.

CONCLUSION

This case study demonstrates that the double-VISTA technique for treating recession-associated NCCLs is promising in achieving complete coverage at sites where the MRC level was predetermined.

KEY POINTS

This case study introduces a modified vestibular incision subperiosteal tunnel access (VISTA) technique, termed double-VISTA, which employs two distant vestibular incisions to enhance access for instrumentation and recipient site preparation in the treatment of multiple adjacent recession defects. A periodontal-restorative approach is detailed in this case study, demonstrating a step-by-step process for managing multiple adjacent recession-associated non-carious cervical lesions using the double-VISTA technique with a promising treatment outcome. The advantages and disadvantages of the double-VISTA technique are further discussed in this case study. Limitations of this technique include shallow vestibular depth and close proximity to the mental nerve, necessitating careful attention during recipient site preparation under these conditions.

PLAIN LANGUAGE SUMMARY

Gingival recession, where gums recede and expose tooth roots, can result from various causes. Non-cavity lesions on the tooth necks (NCCLs) are often associated with this condition and are challenging to treat. Limited evidence exists on using tunnel-based procedures with connective tissue grafts (CTGs) for NCCLs. This case study presents a method to treat multiple adjacent NCCLs in a healthy 55-year-old Asian man with gum recession on his upper teeth and pigmented gums. The patient had non-cavity lesions on all six upper front teeth. Initially, the exposed root necks were covered with composite resin, followed by a double-vestibular incision subperiosteal tunnel access (double-VISTA) surgical approach with CTGs to address the recession. Due to limited graft availability, the left side was treated first, then the right side 3 months later. The patient experienced mild facial swelling for 5 days, which resolved within a week. After 12 months, all treated teeth showed complete coverage with thickened gums, and the results remained stable with even gum margins at the 2-year check-up. This case study suggests that the double-VISTA technique for treating NCCLs shows promising results for achieving complete coverage, offering a viable treatment option for these dental conditions.

Microbiome and Inflammatory Biomarkers Associated With Palatal Wound Healing

AIM

The clinical outcomes of a variety of surgical procedures highly depend on tissue repair and show high variability among patients. There is a gap in the literature on how the host inflammatory response, the microbiome, and the interplay between them can influence oral mucosa healing. In this pilot study, we aimed to evaluate the microbiome and biomarkers profiles in patients who had desired versus undesired wound healing in the palatal mucosa.

METHODS

Seventeen patients underwent a free gingival graft (FGG) for socket preservation. Palatal wound closure (WC) and epithelization (EPT) were assessed clinically. Biofilm from the palatal wound was collected before the surgical procedure and 3, 7, 14, and 30 days postoperatively. The inflammatory exudate was sampled on Days 3 and 7. At 14 days posttreatment, patients were classified into two groups based on EPT rates: (1) undesired healing (UH) and (2) desired healing (DH).

RESULTS

No difference was observed in alfa diversity over time or between groups. In beta diversity, both UH and DH showed microbiome changes on Days 3-7 and 7, respectively, compared with the baseline (p = 0.01), returning to its initial condition 30 days later. There was a trend toward a different microbiome profile between groups on Day 7 (p = 0.08). Bacterium composition in DH showed a balance between healthy species and oral pathogens over time, whereas UH composition was characterized by microorganisms correlated with epithelium invasion/cytotoxicity; virulence factor upregulation; and oral diseases, such as periodontitis and aphthous stomatitis, until Day 30. UH showed an increase in IL-6, MCP-1, and MIP-1α over time, and DH showed a decrease in TIMP-1, IL-1β, and MIP-1α. On Days 3 and 7, MIP-1α and MMP-2 showed greater concentrations of DH in the intergroup assessment, and MCP-1 increased on Day 7 in UH.

CONCLUSION

Specific microbiome/inflammatory profiles are associated with DH and UH.

TRIAL REGISTRATION

NCT05171400.

Treatment of single gingival recessions using biofunctionalized collagen matrix: A case series

BACKGROUND

Connective tissue graft substitutes have been used widely to overcome autogenous graft limitations. Nevertheless, they do not provide comparable results in the treatment of periodontal and peri-implant soft tissue defects. Based on the principles of tissue-engineered materials, injectable platelet-rich fibrin (i-PRF) has been combined with collagen matrices (CMs) to enhance their clinical efficacy. To the best of our knowledge, this is the first case series demonstrating the use of i-PRF for the biofunctionalization of a volume-stable collagen matrix (VCMX) as an adjunct to coronally advanced flap (CAF) to treat single gingival recession (GR) defects.

METHODS & RESULTS

The study included 10 patients. Bleeding on probing, probing depth, GR height, clinical attachment level, esthetics, and dentin hypersensitivity were evaluated. After 6 months, a significant GR reduction (RecRed: 2.15 ± 0.7 mm; p = 0.005) and percentage of root coverage (% RC) of 81.13% were observed. Additionally, 40% of the sites showed complete root coverage. Gingival thickness increased 0.64 mm. Patient-centered evaluations demonstrated dentin hypersensitivity and esthetics improvements by the end of follow-up.

CONCLUSION

VCMX biofunctionalized with i-PRF associated with CAF technique showed promising clinical outcomes in the treatment of single RT1 GR defects.

Treatment of Localized Gingival Recession with an Enamel Matrix Protein-Coated Xenogeneic Dermal Matrix: A Randomized Controlled Trial

This study aims to evaluate the influence of the additional use of enamel matrix derivate (EMD) in the treatment of gingival recession defects using a coronally advanced flap (CAF) and a xenogeneic dermal matrix (XDM) by means of digital and clinical assessment methods. In this prospective randomized controlled study, recession height and area, width and thickness of keratinized gingiva, pocket probing depth, and clinical attachment levels were measured at the baseline and followed up for one year. Fifteen patients (n = 15) with 24 gingival recession defects were treated between 2019 and 2021. On average, the digitally assessed root coverage of the control group (CAF + XDM) was not significantly different compared to the test group (CAF + XDM + EMD), with 69 ± 28% and 36 ± 32%, respectively (p = 0.094). One year postoperatively, there were no differences found regarding keratinized tissue width (KTW) between the control group and test group (p = 0.690). However, the control group showed superior results in the thickness of keratinized gingiva (p = 0.044). The present study showed that there were no statistically significant differences in the root coverage results in the CAF + XDM + EMD group compared to the CAF + XDM group. The adjunctive use of EMD to a CAF and XDM in the treatment of gingival recession defects does not appear to have any clinical benefit.

Efficacy of acellular xenogeneic dermal matrix graft in the treatment of multiple gingival recessions: systematic review and meta-analysis

OBJECTIVE

This study aimed to compare the efficacy of acellular xenogeneic dermal matrix graft (AXDM) compared to connective tissue graft (CTG) in treating multiple gingival recessions.

MATERIALS AND METHODS

A systematic search of electronic databases was conducted to identify randomized clinical trials (RCTs) that compared AXDM and CTG. The selected studies were subjected to bias risk assessment, data extraction, and meta-analyses. Parameters such as gingival recession height, width, mean percentage of root coverage, and complete root coverage were analyzed.

RESULTS

Seven RCTs involving 146 patients were included. The meta-analyses indicated that CTG was statistically superior to AXDM in reducing gingival recession height at the final follow-up (mean difference: -0.104 mm, 95% confidence interval [CI]: -0.180-0.028, p = 0.008) and width at the final follow-up (mean difference: -0.285 mm, 95% CI: -0.541-0.030, p = 0.029). CTG also demonstrated a significantly higher mean percentage of root coverage at the 6-month follow-up (difference in means: -2.761 mm, 95% CI: -4.932-0.590, p = 0.013) and a higher percentage of complete root coverage at the 6-month follow-up (odds Ratio [OR]: 0.598, 95% CI: 0.4-0.892, p = 0.012) compared to AXDM. However, there was no significant difference in the number of teeth with complete root coverage between CTG and AXDM (OR: 1.610, 95% CI: 0.983-2.636, p = 0.058) and aesthetic outcomes (mean difference: 0.148, 95% CI: -0.277-0.573, p = 0.494).

CONCLUSIONS

CTG is more effective than AXDM in treating multiple gingival recessions. This is evidenced by significant reductions in gingival recession height and width, a higher mean percentage of root coverage, and a greater percentage of complete root coverage at the 6-month follow-up.

CLINICAL RELEVANCE

In some clinical situations an alternative to CTG is required for the treatment of multiple gingival recessions. AXDM, despite presenting clinical outcomes that are not as satisfactory as CTG, can be used for this purpose.