Patient morbidity and root coverage outcomes after the application of a subepithelial connective tissue graft in combination with a coronally advanced flap or via a tunneling technique: a randomized controlled clinical trial

Evaluation of advanced platelet-rich fibrin compared to subepithelial connective tissue graft in the surgical management of interdental papilla recession: a randomized controlled trial

OBJECTIVES

The current study aims to compare advanced-platelet-rich fibrin membrane (A-PRF) to connective tissue graft (CTG) using Han and Takei's approach.

MATERIALS AND METHODS

The defective papilla was randomly allocated to either the control group (CTG) or to the experimental group (A-PRF). Papilla height (PH) and percent change in the gingival black triangle (GBT) area were recorded at 1, 3, 6, 9, and 12 months.

RESULTS

Thirty-two deficient IDPs with an initial papilla presence index (PPI) of 2 or 3 were included. At 12 months, the papilla-fill significantly increased in both groups (p < 0.001) without a significant difference between the study groups (p = 0.637). A mean gain in IDP height of 2.25 mm (± 0.97) in the CTG group and 1.86 mm (± 0.7) in the A-PRF group were recorded with a nonsignificant difference. Gingival black triangle fill showed a 57.98% fill in the CTG and 54.65% fill in the A-PRF group, with no statistically significant difference between the groups (0.956). Regarding postoperative pain patients, the CTG group consumed significantly more analgesics than the A-PRF group (11.75 ± 3.51 and 8 ± 3.08, respectively, with p = 0.003).

CONCLUSION

Both CTG and A-PRF were found to be equally effective in increasing deficient IDP height with Han and Takei's surgical technique, with no significant difference. Within the current study's limitations, A-PRF seems to be a viable alternative to CTG in the treatment of GBTs.

CLINICAL RELEVANCE

Multilayered A-PRF membrane can be used as a choice in the augmentation of receded papillae, using Han and Takei's technique.

Mixed-Thickness Tunnel Access (MiTT) through a Linear Vertical Mucosal Incision for a Minimally Invasive Approach for Root Coverage Procedures in Anterior and Posterior Sites: Technical Description and Case Series with 1-Year Follow-Up

PURPOSE

The goal of this article was to introduce a new root coverage (RC) technique, the mixed-thickness tunnel access (MiTT) technique, which approaches a full-split design and intends to augment soft tissues coronal to the gingival margin. It was shown step-by-step, and the results were presented in a case series.

METHODS

Healthy individuals (non-diabetics) and non-smokers with gingival recession (GR) type 1 or 2 (RT1 or RT2) were included. After evaluation, prophylaxis was performed 14 days before the surgical procedure. During the surgical appointment, one or two vertical incision(s) on the mucosa (around 1-2 mm apical to the MGJ), lateral to the papilla base, was/were performed after anesthesia. Initially, there was a partial incision to detach the mucosa of the muscles (split design). It was permitted (but not mandatory) to perform intrasulcular incisions. Through the vertical incision, internally, subperiosteal access from the MGJ toward the gingival margin (coronally) was performed to create a full-thickness tunnel. Then, communication from the vertical incision with the gingival sulcus and the papilla base occurred, keeping the papilla tip intact. A connective tissue graft was harvested and inserted through the linear incision or intrasulcularly. There were interrupted sutures. An adjunctive material may be applied (e.g., Endogain). The root coverage was measured using a periodontal probe and considered fully covered when the gingival margin was 1 mm coronal to the cementum-enamel junction (CEJ).

RESULTS

Nine healthy individuals (seven females and two males) aged 19 and 43 were enrolled. They were treated following the MiTT steps. Four cases had a single GR; two patients had two teeth involved; and three others had three or four GR. There were seven cases of RT1 and two RT2. All RT1 cases achieved 100% RC, while the mean RC obtained for RT2 was around 80%.

CONCLUSION

The MiTT technique can be considered a more straightforward approach for minimally invasive surgical techniques, which is a feasible option to treat RC with a high success rate, predictability, and esthetic preservation. Therefore, there is a technical sensitivity to performing the full-split design procedure.

Tunnel vs. coronally advanced flap in combination with a connective tissue graft for the treatment of multiple gingival recessions: a multi-center randomized clinical trial

OBJECTIVE

To evaluate the efficacy of the partial-thickness non-advanced tunnel technique (TUN) versus the coronally advanced flap (CAF), both combined with a connective tissue graft, in the treatment of multiple gingival recessions.

MATERIALS AND METHODS

Twenty-nine patients (83 teeth) affected by multiple gingival recessions were treated in two clinical centers with either the test (TUN) or the control (CAF) intervention combined with a connective tissue graft. Outcomes at 3 and 6 months after surgery included complete root coverage (CRC-primary outcome), mean root coverage (mRC), changes in recession depth (RD), probing pocket depth (PPD), and keratinized tissue height (KT). Root sensitivity and root coverage esthetic score (RES) were also evaluated at 6-month examination. Surgery duration, wound healing index (WHI), and patient-reported outcome measures (PROMs) were additionally considered.

RESULTS

At 6 months, CRC was observed in 80.9% and 79.5% of the teeth treated with TUN and CAF, respectively (odds ratio = 1.2; p = 0.802). No differences between groups were also observed in terms of mRC (TUN = 94.0%; CAF = 91.1%), RD and PPD reductions, root sensitivity, RES, and WHI. KT increase was significantly higher in teeth treated with TUN (Difference in Means - MD =  - 1.0 mm; p = 0.001). Surgery duration was shorter (MD =  - 19.3 min; p = 0.001), and patients reported less intra-surgical pain (MD =  - 16.4; p = 0.028) as well as postoperative morbidity in TUN compared with CAF.

CONCLUSIONS

Both surgical interventions showed a similar efficacy in terms of root coverage, albeit TUN was associated with a higher increase in KT and with a milder patient's surgical experience.

CLINICAL RELEVANCE

Both techniques have shown similar efficacy for the coverage of exposed root surfaces, although clinicians may consider TUN as less invasive.

TRIAL REGISTRATION

Clinicaltrials.gov (NCT05122468).

Clinical Evaluation of Bilateral Multiple Gingival Recession Treatment with Autogenous Connective Tissue Graft Associated with Low-Level Laser Therapy

BACKGROUND

Gingival recession (GR) is described as an apical displacement of the gingival margin in relation to the cementoenamel junction, exposing the root surface to the oral cavity environment. This study aimed to evaluate the clinical results of a bilateral root coverage (RC) of GR associated with an autogenous connective tissue graft (aCTG) alone or combined with low-level laser therapy (aCTG + LLLT).

METHODS

This cross-sectional, split-mouth, double-blind, clinical pilot study featured three individuals who attended a periodontics post-graduate program with the main complaint of GR and dental hypersensitivity (DHS). Of these, only one patient met the inclusion criteria and the parameters evaluated were: DHS, the keratinized tissue's thickness and width clinical attachment level (CAL), probing on depth (PD), and bilateral GR based on Cairo RT I. The patient was evaluated by a first clinical evaluator and the treatment was randomly divided into two groups, G1: aCTG only (control group, n = 3 teeth per side) and G2: aCTG + LLLT (test group, n = 3 teeth per side). LLLT used a diode laser (660 nm) with a dose of 3 J/cm² per point and 4 s per point was applied in four different periods, preoperatively; transoperatively and immediately postoperatively, the application was performed in three points (eight applications) on alternate days for 7 days and a 90-day follow-up was performed for clinical evaluations of the periodontal parameters and the collected data were analyzed by Kruskal-Wallis and Dunn tests.

RESULTS

the RC mean percentage was <95% in both groups after 90 days. Comparing treatment sides, G1 (n = 3/3, 100%) had a higher prevalence of RC than G2 had (n = 3/3, 95%). DHS significantly decreased after 90 days in both groups. Both groups showed an improvement in the other periodontal parameters evaluated during the short-term follow-up; mainly, PD had a statistically significant (p ˂ 0.05) increase after 90 days and a CAL decrease during this period; KTW and KTT also had a significant increase in both groups (p ˂ 0.05).

CONCLUSIONS

the results indicated that aCTG + LLLT might have an additional benefit to GR root coverage within the evaluated time and this section also includes the within-study limitations.

Comparative study of the modified VISTA technique (m-VISTA) versus the coronally advanced flap (CAF) in the treatment of multiple Miller class III/RT2 recessions: a randomized clinical trial

OBJECTIVES

To compare the percentage of mean root coverage (MRC%) obtained in the treatment of multiple Miller class III/RT2 gingival recessions using the modified VISTA (m-VISTA) technique versus the coronally advanced flap (CAF) technique, using a connective tissue graft (CTG) in both cases.

MATERIALS AND METHODS

Twenty-four patients were randomly treated with m-VISTA (test group (TG) = 12) or CAF (control group (CG) = 12). A calibrated, experienced, and blinded examiner collected data related to multiple periodontal clinical variables, especially the recession (REC) in order to calculate the MRC% at 6 and 12 months, which was the primary outcome of the study. Also, the radiological bone level, the characteristics of the CTG, and postsurgical incidences were assessed. Finally, a descriptive and an analytical statistical analysis of the variables and their associations was performed.

RESULTS

The recessions (n = 84) were located mainly in the mandible (n = 65) and in posterior sectors (premolars: n = 35; molars: n = 8). At 6 months, the MRC% was 61% (2 mm) for both study groups, and at 12 months, it increased to 73.26% (2.11 mm) in the TG and decreased to 56.49% (1.78 mm) in the CG.

CONCLUSION

When approaching multiple Miller class III/RT2 recessions, there were no statistically significant differences in the MRC% at 6 and 12 months between the group treated with the m-VISTA technique and the group treated with the CAF.

CLINICAL RELEVANCE

The characteristics of the m-VISTA technique, such as the closed approach, the mobilization of the papilla, and the coronal stabilization of the CTG, could facilitate the maturation of the tissues in the treatment of Miller class III/RT2 recessions. This would favor better root coverage.

TRIAL REGISTRATION

NCT03258996.

Clinical comparison between different surgical techniques used to manage advanced gingival recession (Miller's class III & IV)

Advanced gingival recession is considered a complex soft tissue problem, which is increased in severity with age, and has multiple etiological factors. Therefore, the treatment is very complicated with low predictability. However, in the last decade, many clinical trials have shown highly predictable results when managing advanced recession cases by surgical intervention.

The present review shows different surgical techniques with their clinical outcomes in order to choose the most suitable technique required by the clinical condition. Although there are relatively few studies, modified tunnel technique and coronal advanced flap (CAF) showed the highest percentage of root coverage (%RC) during the first year (up to 86%). These techniques are primarily indicated to manage advanced recession in the esthetic zone. Pedicle buccal fat pad (PBFP) also had a good percentage of root coverage when used in the maxillary posterior area, as it has a high blood supply with minimal risk for infection and necrosis. Free gingival graft (FGG) can be used in the mandibular anterior area, as it creates a band of keratinized tissue that can resist recession with a fair percentage of root coverage. However, color match and graft shrinkage are the main problems of this procedure.

Treating Gingival Recessions Using Coronally Advanced Flap or Tunnel Techniques with Autografts or Polymeric Substitutes: A Systematic Review and Meta-Analysis

Gingival recessions are a prevalent oral mucosa alteration. To solve this pathology, palatal mucosa or polymeric soft tissue substitutes are used when performing coronal advanced flap (CAF) or tunnel (TUN) surgical techniques. To evaluate which is the most successful approach, a literature review and meta-analysis were conducted. For the electronic search the National Library of Medicine, the Cochrane Oral Health Group Trials Register, EMBASE and WOS were used. Pooled data for the percentage of root coverage was collected and weighted means were calculated. Heterogeneity was determined using the Higgins (I²) statistic and a random-effects model was applied. Thirteen studies were included in the systematic review (12 randomized and 1 controlled clinical trials) in which both techniques (394 patients) were compared with a follow-up of 4 to 12 months. Galbraith and Baujat plots were used to control for the presence of potential outliers. After performing the meta-analysis (11 studies), the mean root coverage was similar when using the TUN or CAF techniques (p = 0.49). The only differences between the two were found for single recessions, where CAF offered a higher percentage of root coverage (mean difference = 4.98%; p = 0.006). There were no differences when applying an autograft or a polymeric substitute with either of the two tested surgical techniques (p = 0.445).

De-epithelialized gingival graft versus subepithelial connective tissue graft in the treatment of multiple adjacent gingival recessions using the tunnel technique: 1-year results of a randomized clinical trial

AIM

To compare the clinical efficacy and postoperative morbidity of de-epithelialized gingival graft (DGG) with subepithelial connective tissue graft (SCTG) on treatment of multiple adjacent gingival recessions (MAGRs) with tunnel technique (TUN) and to evaluate histological characteristics of the palatal grafts.

MATERIALS AND METHODS

Twenty-seven patients with MAGRs affecting at least 2 adjacent teeth were treated with either DGG + TUN or SCTG + TUN. Recession depth(RD) and width(RW), probing depth(PD), clinical attachment level(CAL), keratinized tissue height(KTH), gingival thickness(GT), and complete and mean root coverage(CRC, MRC) were evaluated at 6 and 12 months postoperatively. Multilevel analysis was performed to identify patient- and tooth/site-related predictors for the 12-month MRC outcomes. Postoperative patient morbidity and histological characteristics of palatal graft samples obtained during harvesting were investigated.

RESULTS

At the 12-month follow-up, MRC was 91.72% ± 16.59% and 84.72% ± 19.72% in DGG + TUN and SCTG + TUN groups (p = .001). Multilevel regression analysis identified RD, KTH and GT as variables associated with MRC. No significant difference between the groups was observed regarding postoperative patient morbidity parameters. Cellularity was found significantly higher in the SCTG samples compared to the DGG samples (p < .05).

CONCLUSIONS

Although DGG + TUN presented higher MRC and CRC compared to SCTG + TUN in the treatment of MAGRs, treatment method was not a significant predictive factor for the amount of MRC outcomes while RD, KTH and GT were significant predictive factors.

Effect of cyanoacrylate tissue adhesive in postoperative palatal pain management: a systematic review

OBJECTIVE

To critically appraise available literature concerning the effect of cyanoacrylate tissue adhesive (CTA) in postoperative palatal pain management.

MATERIALS AND METHODS

Electronic databases (Cochrane, PubMed, LILACS, Scopus, and Web of Science) were searched, complemented with grey literature databases up to June 2020. Studies reporting the effect of cyanoacrylate tissue adhesive compared to any other methods in postoperative palatal pain management were considered eligible. The risk of bias among and across included studies was assessed.

RESULTS

Finally, four studies were considered eligible. Regarding free gingival graft (FGG), cyanoacrylate tissue adhesive with hemostatic sponge promoted less postoperative pain (PP) and analgesic consumption (AC). Also, cyanoacrylate tissue adhesive with platelet-rich fibrin produced less PP and more wound healing at the palatal area than cyanoacrylate tissue adhesive and wet gauze. Additionally, cyanoacrylate tissue adhesive promoted less PP and AC than wet gauze and suture. Concerning connective tissue graft (CTG), cyanoacrylate tissue adhesive, and suture produced similar PP, AC, and willingness for retreatment.

CONCLUSIONS

Based on the low certainty level, cyanoacrylate tissue adhesive appears to promote less PP and AC than wet gauze and suture regarding FGG. Additionally, cyanoacrylate tissue adhesive appears to increase the effect of hemostatic sponge, contributing to the reduction of PP and AC. Regarding CTG, cyanoacrylate tissue adhesive appears to promote similar PP, AC, and willingness for retreatment than the suture. Therefore, cyanoacrylate tissue adhesive has shown promising usefulness for PP management in FGG, but not a clear benefit for CTG.

CLINICAL RELEVANCE

The adoption of different agents for the protection of the palatal donor site following gingival harvesting procedures may provide better comfort to the patient.

Aesthetic-And patient-related outcomes following root coverage procedures: A systematic review and network meta-analysis

BACKGROUND

Aim of this systematic review (SR) of randomized controlled trials (RCTs) was to evaluate effect of different flap designs and graft materials for root coverage, in terms of aesthetics, patient satisfaction and self-reported morbidity (post-operative pain/discomfort).

MATERIAL AND METHODS

A comprehensive literature search was performed. A mixed-modelling approach to network meta-analysis was utilized to formulate direct and indirect comparisons among treatments for Root Coverage Esthetic Score (RES), with its individual components, and for subjective patient-reported satisfaction and post-operative pain/discomfort (visual analogue scale (VAS) of 100).

RESULTS

Twenty-six RCTs with a total of 867 treated patients (1708 recessions) were included. Coronally Advanced Flap (CAF) + Connective Tissue Graft (CTG) (0.74 (95% CI [0.24, 1.26], p = .005)), Tunnel (TUN) + CTG (0.84 (95% CI [0.15, 1.53]), p = .01) and CAF + Graft substitutes (GS) (0.55 (95% CI [0.006, 1.094], p = .04)) were significantly associated with higher RES than CAF. No significant difference between CAF + CTG and TUN + CTG was detected (0.09 (95% CI [-0.54, 0.72], p = .77)). Addition of CTG resulted in less natural tissue texture (-0.21 (95% CI [-0.34, -0.08]), p = .003) and gingival colour (-0.06 (95% CI [-0.12, -0.03], p = .03)) than CAF. CTG techniques were associated with increased morbidity.

CONCLUSIONS

Connective tissue graft procedures showed highest overall aesthetic performance for root coverage, although graft integration might impair soft tissue colour and appearance. Additionally, CTG-based techniques were also correlated with a greater patient satisfaction and morbidity.

Gingival recession treatment with concentrated growth factor membrane: a comparative clinical trial

Objective

This clinical trial sought to evaluate the clinical effectiveness of concentrated growth factor (CGF) and compare it with connective tissue graft (CTG) with coronally advanced flap (CAF) in the treatment of Miller Class I gingival recessions (GR).

Methodology

This split-mouth study included 74 Miller Class I isolated (24 teeth) or multiple (50 teeth) GRs in 23 jaws of 19 patients. GRs were randomly treated using CGF (test group: 37 teeth; 12 teeth in isolated GRs, 25 teeth in multiple GRs) or CTG with CAF (control group: 37 teeth;12 teeth isolated GRs, 25 teeth in multiple GRs). Clinical variables, plaque index (PI), gingival index (GI), probing depth (PD), recession depth (RD), recession width (RW), clinical attachment level (CAL), keratinized tissue thickness (KTT), keratinized tissue width (KTW), and root coverage (RC) were assessed at the baseline as well as at three and six months post-surgery. Healing index (HI) were obtained in the second and third weeks post-surgery. Postoperative pain was assessed for the first seven days using a horizontal visual analog scale (VAS).

Results

No significant change was observed in PI, GI, or PD values in either the intergroup or the intragroup comparisons. A statistically significant decrease was observed in CAL, RD, and RW, and KTT increased in all groups at three and six months compared with the baseline. The control group had greater increases in KTW, KTT, and RC at three and six months. No significant difference was found in CAL or RD at the third and sixth months between the two groups. Healing was found to be similar for both groups in the second and third weeks post-surgery. The VAS values in the control group were higher than in the test group, especially at the second, fourth, fifth, and seventh days postoperatively.

Conclusions

CTG is superior to CGF with CAF for increasing KTT, KTW, and RC. CGF may be preferable due to decreased postoperative pain.

Amniotic Membrane In Palatal Epithelial-Connective Tissue Reconstruction

Mucogingival surgery has the objective to obtain coverage of the recession, with a favorable long-term prognosis, but also to minimize postoperative problems and surgery-related risks. Human amniotic membrane is increasingly employed for periodontal tissue repair in order to promote epithelialization and to reduce pain and scar tissue formation. A 38-year-old female patient reports dental hypersensitivity resulting from gingival recession affecting tooth 4.1. A mucogingival surgical procedure was proposed and a partial-thickness flap of epithelial-connective tissue was harvested from the palate and grafted on to the receiving site. The amniotic membrane was positioned at the donor site to reduce postoperative morbidity and to encourage rapid palatal healing. One week after the application of HAM (human amniotic membrane), the wound was healed and 1 month after the donor site was completely re-epithelialized. The present case report suggests that in the surgical treatment of gingival recession with palatal epithelial-connective tissue graft, HAM promotes rapid epithelialization of the palatal donor site wound with a reduction in morbidity.

[Vestibular incision subperiosteal tunnel access with connective tissue graft for the treatment of Miller classI and II gingival recession]

OBJECTIVE

To evaluate the clinical outcomes of vestibular incision subperiosteal tunnel access (VISTA) with connective tissue graft (CTG) in the treatment of Miller classes I and II localized gingival recession.

METHODS

Ten patients with 10 Miller classes I and II localized gingival recessions were enrolled in the study. All defects were equal to or above 2 mm in recession depth. All the patients received treatment with VISTA+CTG. Their clinical parameters, including recession depth (Rec), recession width (RW), keratinized tissue width (KT), clinical attachment loss (CAL), probing depth (PD) were recorded and compared before surgery and 6 months later. The mean root coverage (MRC) and complete root coverage (CRC) were calculated at the end of 6 months. A visual analogue scale (VAS) was used to estimate the patients' discomfort during the operation and during the 2 weeks post-operation. Patient-based aesthetic satisfaction 6 months after surgery was evaluated by a VAS.

RESULTS

The mean Rec was (2.65±0.82) mm at baseline, and (0.35±0.58) mm after 6 months. The VISTA+CTG treatment resulted in an improvement of (2.30±0.98) mm in recession depth (P<0.001). MRC was 86.67%±21.94% and CRC reached 70% at the end of 6 months. KT increased (0.90±1.22) mm (P<0.05). Aesthetic satisfaction on the patients' level was 8.30 based on VAS (0=unsatisfied, 10=extremely satisfied). The patients' discomfort during the operation and 2 weeks post operation were 2.40 and 4.30 (0=no pain, 10=extreme pain). Furthermore, clinical outcomes showed no statistically significant difference between the gingival biotypes, and between the teeth positioned in maxillary and in mandibular.

CONCLUSION

VISTA+CTG could be an effective treatment for Miller classes I and II localized gingival recession. Clinical outcomes indicated decrease in recession depth and width, and increase in width of keratinized tissue. Patients suffered little pain during the operation and 2 weeks post-operation of healing and accessed good aesthetic satisfaction. VISTA+CTG could be an option for the treatment of Miller classes I and II localized gingival recession.

Root coverage procedures for treating localised and multiple recession-type defects

BACKGROUND

Gingival recession is defined as the oral exposure of the root surface due to a displacement of the gingival margin apical to the cemento-enamel junction and it is regularly linked to the deterioration of dental aesthetics. Successful treatment of recession-type defects is based on the use of predictable root coverage periodontal plastic surgery (RCPPS) procedures. This review is an update of the original version that was published in 2009.

OBJECTIVES

To evaluate the efficacy of different root coverage procedures in the treatment of single and multiple recession-type defects.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 12) in the Cochrane Library (searched 15 January 2018), MEDLINE Ovid (1946 to 15 January 2018), and Embase Ovid (1980 to 15 January 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 January 2018). No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) only of at least 6 months' duration evaluating recession areas (Miller's Class I or II ≥ 3 mm) and treated by means of RCPPS procedures.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, data extraction and risk of bias assessment were conducted independently and in duplicate. Authors were contacted for any missing information. We expressed results as random-effects models using mean differences (MD) for continuous outcomes and odds ratios (OR) for dichotomous outcomes with 95% confidence intervals (CI). We used GRADE methods to assess the quality of the body of evidence of our main comparisons.

MAIN RESULTS

We included 48 RCTs in the review. Of these, we assessed one as at low risk of bias, 12 as at high risk of bias and 35 as at unclear risk of bias. The results indicated a greater reduction in gingival recession for subepithelial connective tissue grafts (SCTG) + coronally advanced flap (CAF) compared to guided tissue regeneration with resorbable membranes (GTR rm) + CAF (MD -0.37 mm; 95% CI -0.60 to -0.13, P = 0.002; 3 studies; 98 participants; low-quality evidence). There was insufficient evidence of a difference in gingival recession reduction between acellular dermal matrix grafts (ADMG) + CAF and SCTG + CAF or between enamel matrix protein (EMP) + CAF and SCTG + CAF. Regarding clinical attachment level changes, GTR rm + CAF promoted additional gains compared to SCTG + CAF (MD 0.35; 95% CI 0.06 to 0.63, P = 0.02; 3 studies; 98 participants; low-quality evidence) but there was insufficient evidence of a difference between ADMG + CAF and SCTG + CAF or between EMP + CAF and SCTG + CAF. Greater gains in the keratinized tissue were found for SCTG + CAF when compared to EMP + CAF (MD -1.06 mm; 95% CI -1.36 to -0.76, P < 0.00001; 2 studies; 62 participants; low-quality evidence), and SCTG + CAF when compared to GTR rm + CAF (MD -1.77 mm; 95% CI -2.66 to -0.89, P < 0.0001; 3 studies; 98 participants; very low-quality evidence). There was insufficient evidence of a difference in keratinized tissue gain between ADMG + CAF and SCTG + CAF. Few data exist on aesthetic condition change related to patients' opinion and patients' preference for a specific procedure.

AUTHORS' CONCLUSIONS

Subepithelial connective tissue grafts, coronally advanced flap alone or associated with other biomaterial and guided tissue regeneration may be used as root coverage procedures for treating localised or multiple recession-type defects. The available evidence base indicates that in cases where both root coverage and gain in the width of keratinized tissue are expected, the use of subepithelial connective tissue grafts shows a slight improvement in outcome. There is also some weak evidence suggesting that acellular dermal matrix grafts appear as the soft tissue substitute that may provide the most similar outcomes to those achieved by subepithelial connective tissue grafts. RCTs are necessary to identify possible factors associated with the prognosis of each RCPPS procedure. The potential impact of bias on these outcomes is unclear.

Papilla and pontic area regeneration in patient with gingival smile: A clinical case

Purpose

Connective tissue grafts are widely documented as a predictable technique for treating Miller Class I and II recessions, as well as procedures in which soft tissue augmentation is required for aesthetic reasons. This article aims to explore the resolution of a clinical case with this type of problema.

Clinical case

This case describes a technique for reconstructing a pontic area and adjacent papilla by means of two consecutive connective tissue grafts. The first graft served to increase the amount of tissue in the horizontal direction, and the second promoted vertical reconstruction of the defect.

Results and Conclusion

In cases with aesthetic requirements, restorative intervention may be able to mask tissue loss, but it can hardly achieve optimal aesthetic results. Periodontal plastic surgery techniques can be used to achieve that ideal result. The clinician must diagnose conditions in order to select correct treatment regimen for each individual case. Key words:Papilla, gingival smile, pontic, restorative dentistry.

Xenogenous Collagen Matrix and/or Enamel Matrix Derivative for Treatment of Localized Gingival Recessions: A Randomized Clinical Trial. Part I: Clinical Outcomes

BACKGROUND

Considering xenogeneic collagen matrix (CM) and enamel matrix derivative (EMD) characteristics, it is suggested that their combination could promote superior clinical outcomes in root coverage procedures. Thus, the aim of this parallel, double-masked, dual-center, randomized clinical trial is to evaluate clinical outcomes after treatment of localized gingival recession (GR) by a coronally advanced flap (CAF) combined with CM and/or EMD.

METHODS

Sixty-eight patients presenting one Miller Class I or II GRs were randomly assigned to receive either CAF (n = 17); CAF + CM (n = 17); CAF + EMD (n = 17), or CAF + CM + EMD (n = 17). Recession height, probing depth, clinical attachment level, and keratinized tissue width and thickness were measured at baseline and 90 days and 6 months after surgery.

RESULTS

The obtained root coverage was 68.04% ± 24.11% for CAF; 87.20% ± 15.01% for CAF + CM; 88.77% ± 20.66% for CAF + EMD; and 91.59% ± 11.08% for CAF + CM + EMD after 6 months. Groups that received biomaterials showed greater values (P <0.05). Complete root coverage (CRC) for CAF + EMD was 70.59%, significantly superior to CAF alone (23.53%); CAF + CM (52.94%), and CAF + CM + EMD (51.47%) (P <0.05). Keratinized tissue thickness gain was significant only in CM-treated groups (P <0.05).

CONCLUSIONS

The three approaches are superior to CAF alone for root coverage. EMD provides highest levels of CRC; however, the addition of CM increases gingival thickness. The combination approach does not seem justified.