Tunnel technique with connective tissue graft versus coronally advanced flap with enamel matrix derivate for root coverage: 2‐year results of an RCT using 3D digital measuring for volumetric comparison of gingival dimensions

Clinical efficacy of tunnel flap combined with de-epithelialized connective tissue graft in treating gingival recession: a case-series study

To evaluate the clinical efficacy and influencing factors of the tunnel flap (TUN) combined with de-epithelialized connective tissue graft (DCTG) in the treatment of gingival recession (GR) from patient- and site-specific perspectives. Patients treated with the TUN + DCTG technique for GR between August 2020 and December 2023 were included. Baseline and follow-up periodontal measurements were recorded, including gingival recession depth (GRD), keratinized gingival width (KGW), and clinical attachment loss (CAL). Paired sample t-test was performed to assess the clinical efficacy. Moreover, primary outcome metrics, such as complete root coverage rate (CRC), mean root coverage rate (MRC), root coverage esthetic score (RES), and patient satisfaction, were calculated. Patient- and site-specific influencing factors were analyzed using a generalized linear mixed model regression (GLMM). A total of 34 patients with 201 affected teeth were included, comprising 78 cases of Cairo RT1, 86 of RT2, and 37 of RT3. Significant clinical improvements were observed over an average follow-up of 11.97 ± 4.11 months, including reductions in GRD (from 2.13 ± 1.14 mm to 0.48 ± 0.73 mm, P < 0.001) and CAL (from 3.22 ± 1.16 mm to 1.64 ± 0.90 mm, P < 0.001) and increases in KGW (from 2.58 ± 1.28 mm to 3.72 ± 1.66 mm, P < 0.001), with a CRC of 59.2% and MRC of 77.26% ± 33.48%. The mean RES was 8.21 ± 1.74, with 83.3% of patients reporting an improved quality of life. GLMM identified recession type, age, and tooth arch as predictable factors for clinical outcomes (P < 0.001). Within its limitations, this study suggests that the TUN + DCTG technique is a promising approach for managing GR, yielding favorable clinical and aesthetic outcomes. Clinical decision-making for GR treatment should consider a range of influencing factors to optimize individualized patient care.Clinical relevance: The TUN + DCTG technique is a reliable and effective option for GR treatment, providing consistent clinical and aesthetic benefits. Understanding predictive factors enables clinicians to tailor treatment strategies, improving success rates and patient satisfaction.

Changes in creeping attachment for soft tissue augmentation surgery

OBJECTIVES

To investigate creeping attachment after soft tissue augmentation surgery in areas with gingival recession.

MATERIALS AND METHODS

This study observed sites of gingival recession who underwent soft tissue augmentation surgery. Changes in gingival recession depth (RD), keratinized tissue height (KTH) and gingival thickness (GT) were measured at 1, 3, 6, and 12 months post-surgery. The changes in creeping attachment (CA) and mean root coverage (MRC) were calculated, and the relationship between the increase in GT and CA was analyzed.

RESULTS

A total of 58 sites in 24 patients were observed. At 1 month postoperatively, RD, KTH and GT improved in all patients with CA of 0.66 ± 0.40 mm and MRC of 22.9 ± 13.9%. All indicators further improved from 3 to 12 months post-surgery. There was a positive correlation between the increase in GT and CA from 1 to 6 months post-surgery.

CONCLUSION

Significant changes in RD, KTH and GT were observed 1 month after soft tissue augmentation surgery, with all indicators stabilizing by 3 months. The increase of GT was positively correlated with CA, and the phenomenon of creeping attachment was still observed 1 year after the surgery.

CLINICAL RELEVANCE

The study identified changes in creeping attachment after soft tissue augmentation surgery to help clinicians understand this phenomenon better.

Methods for 3D evaluation and quantification of gingival recessions and gingival margin changes: Advancements from conventional techniques

In an era of increasing life expectancy and growing patient demands towards lifelong natural tooth retention, accurate assessment of gingival recessions is crucial for diagnosing periodontal diseases, planning preventive or restorative interventions, and evaluating their outcomes. The traditional two-dimensional (2D) methods, while useful, often fall short in capturing the complex topography of gingival tissue margins and their changes over time. By examining relevant published studies, this review highlights the transition from 2D to 3D techniques, analyzing the limitations of widely used 2D approaches, while emphasizing the potential of novel 3D tools and techniques. It discusses their comparative effectiveness, accuracy, and application challenges in clinical and research settings. Advancements in three-dimensional (3D) imaging regarding methodologies for the precise evaluation and quantification of free gingival margin changes and gingival recessions are explored and critically evaluated. The review underscores the potential for these technologies to enhance patient outcomes through more precise diagnosis and data generation. It also identifies gaps in current research and suggests directions for future investigation. Overall, this review provides a comprehensive overview of the state of the art in 3D evaluation methods for gingival recessions and gingival margin changes, offering valuable insights for clinicians and researchers.

Tunnel Technique and Subepithelial Connective Tissue Graft, With or Without Cross-Linked Hyaluronic Acid, in the Treatment of Multiple Gingival Recessions: Prognostic Parameters for Clinical Treatment Outcomes of Randomized Controlled Trial

Objectives: This study aimed to investigate factors that influence the 12-month outcomes after the treatment of multiple gingival recessions (GRs) with a modified coronally advanced tunnel (MCAT) and a subepithelial connective tissue graft (SCTG), with cross-linked hyaluronic acid (HA, tests) or without (controls). Materials and Methods: Twenty-four patients with 266 GRs were treated. A logistic regression model was set to identify the baseline parameters that could predict the 12-month outcomes. The study protocol was registered at ClinicalTrials.gov (ID No. NCT05045586). Results: The evaluated clinical and esthetic parameters showed marked improvement in both groups without any statistically significant differences between the groups, with the exception of the soft tissue texture (STT). The STT was in favor of the HA group (0.96 versus 0.73, p = 0.0091). The likelihood of an MRC > 85%, of achieving CRC, and of gaining an RES = 10 was the highest for the incisors (reference group) and the lowest for the molars (OR = 0.046, p = 0.005). With each 1 mm increase in the baseline clinical attachment level, the odds of failure (MRC < 85%, not achieving CRC) increased, whereas each 1 mm increase in the baseline keratinized tissue width (KTW) improved the chances of an MRC > 85%, of achieving CRC, and of gaining an RES = 10. The application of HA increased the likelihood of a perfect RES more than twofold (OR = 2.683, p = 0.001). Conclusions: The application of HA improved the 12-month esthetic outcomes after the treatment of GRs with the MCAT technique. The baseline CAL, KTW, and tooth type predicted the 12-month MRC, CRC, and RES. An evaluation of the baseline characteristics of the surgical area might help clinicians develop individualized treatment plans.

Digital workflow to assess gingival recession coverage independently of the cemento-enamel Junction: a prospective clinical study using the modified coronally advanced tunnel technique with porcine dermal matrix

OBJECTIVES

The limited number of studies using digital workflows to measure soft tissue changes depend on the cemento-enamel junction (CEJ), which has been reported to be unreliable. Our primary objective was to apply an advanced digital assessment method, measuring independent from the CEJ to evaluate the modified coronally advanced tunnel technique (MCAT) with a porcine dermal matrix (PDM) for gingival recession coverage.

MATERIALS AND METHODS

Patients with type RT1 and RT2 gingival recessions were treated with the MCAT and a PDM. Plaster casts (preoperative and 6 months postoperative) were digitalized. Subsequent stereolithography (STL)-files were imported and superimposed in the open-source software GOM Inspect for computer-based analysis. Recession depth, mean root and complete root coverage (mRC and cRC), mean recession reduction (mRR) and gingival thickness were evaluated. Statistical analysis was performed using mixed linear models.

RESULTS

A total of 82 teeth (19 patients) were included in the study. Healing was uneventful in all patients. The mean preoperative recession depth was 1.34 ± 0.92 mm. mRC was 65.06 ± 48.26%, cRC was 25.61%, mRR was 0.87 ± 0.83 mm, and gingival thickness gain was 0.33 ± 0.30 mm, with comparable results for RT1 and RT2. Neither tooth type nor type of jaw had any effect on the amount of root coverage.

CONCLUSIONS

The digital evaluation workflow employed offers an approach to evaluate gingival recession coverage outcomes independent of the CEJ. The PDM used in combination with the MCAT shows promising results for root coverage.

Root Coverage Techniques: Coronally Advancement Flap vs. Tunnel Technique: A Systematic Review and Meta-Analysis

INTRODUCTION

Gingival recession, characterized by the apical displacement of the gingival margin, presents challenges to oral health. This study compares the effectiveness of the coronally advanced flap (CAF) and the tunnel technique (TT) for treating gingival recessions.

METHODS

Bibliographical searches included PubMed, Embase, Web of Science, Cochrane, Scopus, and the grey literature, with keywords "root coverage" "coronary advanced flap", and "tunnel". A systematic coreview was performed that included 26 studies evaluating root coverage, and 14 articles were included for the meta-analysis. Three groups were analyzed: Group 1 compared TT with connective tissue graft (CTG) versus CAF with CTG; Group 2 examined TT with CTG and/or other biomaterials versus TT with CTG alone; Group 3 compared TT with CAF, regardless of complementary biomaterials. Meta-analysis assessed mean root coverage (MRC), complete root coverage (CRC), and keratinized tissue gain (KTG).

RESULTS

In Group 1, TT with CTG demonstrated superior MRC compared with CAF with CTG (-8.68 CI95% -17.19 to -0.17; p = 0.0457). In Group 2, TT with CTG and/or other biomaterials showed similar MRC (4.17 CI95% -17.91 to 26.26; p = 0.7110) and CRC (0.37 CI95% -1.14 to 1.89; p = 0.6269) to TT with CTG alone, with variations in keratinized tissue gain. Group 3 indicated higher potential MRC for TT compared with CAF (5.73 CI95% -8.90 to 13.55; p = 0.685) but without statistically significant differences.

CONCLUSIONS

This study suggests that TT with CTG might offer better root coverage than CAF with CTG; however, biomaterial selection requires consideration.

Influence of fixed orthodontic steel retainers on gingival health and recessions of mandibular anterior teeth in an intact periodontium - a randomized, clinical controlled trial

OBJECTIVE

Aim of this randomized clinical controlled trial was to evaluate the influence of fixed orthodontic steel retainers on gingival health and recessions of mandibular anterior teeth.

MATERIALS AND METHODS

After end of the orthodontic treatment, patients were randomly assigned into the test (fixed steel retainer) or control group (modified removable vacuum-formed retainer). Periodontal parameters (periodontal probing depth: PPD; recession: REC; bleeding on probing: BOP) as well as plaque and gingival index were assessed on mandibular anterior teeth directly before attaching/handing over the retainer (baseline: BL), 6 and 12 months after orthodontic treatment.

RESULTS

37 patients (test: n = 15, mean age: 16.1±4.2 years; control: n = 17, mean age: 17.1±5.4 years) completed the study. REC and PPD failed to show significant pairwise differences. The number of patients showing gingival health in the area of the mandibular anterior teeth (test: BL n = 10, 6 months n = 9, 12 months n = 11; control: BL n = 10, 6 months n = 16, 12 months n = 15) revealed a significant difference for the intra-group comparison between BL and 6 months in the control group (p = 0.043). The inter-group comparisons failed to show significant differences.

CONCLUSION

Young orthodontically treated patients with fixed steel retainers show in 73.3% healthy gingival conditions after one year which are comparable to the control group (88.2%). Gingival recessions were in a clinically non-relevant range at any time of the examination.

CLINICAL TRIAL NUMBER

DRKS00016710.

A critical look at outcome measures: Comparison between four dental research journals by use of a hierarchical model

AIM

To assess the status quo of outcome measures used in treatment studies in Endodontics, and potentially identify strategies for improvement, by (i) systematically assessing the outcome measures using a conceptual model and (ii) comparing these with measures used in corresponding studies in the adjacent fields.

METHODOLOGY

The International Endodontic Journal, Caries Research, The Journal of Clinical Periodontology and The Journal of Oral & Facial Pain and Headache were selected to cover four adjacent dental disciplines. In each journal, the 50 most recent consecutive publications fulfilling inclusion criteria were included. A hierarchical model for diagnostic imaging studies was modified to assess studies related to treatment. The model comprised six levels, with technical as the lowest level and societal as the highest. Extracted data included study origin, study type, and identified outcome measures. Fisher's Exact Tests with Bonferroni corrections compared studies. p < .05 was considered statistically significant.

RESULTS

Amongst 756 publications, the 200 most recent studies matching the inclusion criteria were identified. Less than half (36.5%) assessed the clinical, patient, or societal aspects of treatment; 10.0% in International Endodontic Journal, 28.0% in Caries Research, 38.0% in Journal of Clinical Periodontology, and 70.0% in Journal of Oral & Facial Pain and Headache (p < .001).

CONCLUSIONS

According to included publications, research on treatment within the endodontic field is mainly focusing on technical and biological outcomes. The benefits of patients and society were less frequently examined than in corresponding journals in adjacent disciplines. When designing studies, including higher-level outcomes should be considered.

The effects of vertically coronally advanced flap and free gingival graft techniques on shallow vestibule: a randomized comparative prospective trial

OBJECTIVES

The present study aimed to compare the influence of vertically coronally advanced flap (V-CAF) and free gingival graft (FGG) techniques on shallow vestibule depth (VD).

MATERIALS AND METHODS

Parallel-arm randomized clinical trial was conducted on 38 sites treated with either FGG or V-CAF. Periodontal variables (VD, recession depth and width, probing depth, clinical attachment level, keratinized tissue height (KTH), and tissue thickness (TT)), clinician- and patient-based subjective variables were assessed.

RESULTS

All periodontal variables showed significant improvements in both groups at all follow-up intervals compared to baseline (p < 0.05). Both groups increased VD compared to baseline. RC and CRC were similar after treatment for both techniques. FGG provided a greater increase in KTH (p < 0.001) and VD (VD1, p = 0.02 and VD2, p < 0.001) while V-CAF exhibited more TT gain (p = 0.002). Except overall tissue appearance that was better in V-CAF (p < 0.001), no inter-group significant difference existed in patient-based variables.

CONCLUSIONS

Both techniques were significantly effective in VD increasing. While both techniques were equally successful in RC, V-CAF provided higher TT gain and better tissue appearance. V-CAF can be chosen instead of FGG in the treatment of recessions with shallow VD.

CLINICAL RELEVANCE

It can be recommended to prefer V-CAF instead of FGG in the treatment of shallow vestibule.

TRIAL REGISTRATION NUMBER

NCT05777811 (clinicaltrials.gov).

Root coverage with platelet-rich fibrin or connective tissue graft: a split-mouth randomized trial

This study aimed to compare the use of connective tissue grafts (CTG) and platelet-rich fibrin (PRF) associated with the tunnel technique (TT) for the treatment of multiple gingival recessions (GR). Fourteen patients with multiple bilateral GR [type 1 recession (RT 1)] in the maxillary incisors, canines, and/or premolars were included. The TT was performed on both sides (split-mouth model); CTG (36 GR) was used on one side, and on the other, PRF (36 GR) was used. Clinical parameters, including recession depth (RD), probing depth, clinical attachment level (CAL), and keratinized gingiva thickness/width (GT/KTW), were obtained at baseline and after 1, 3, 6, and 16 months. Lower RD (0.81 ± 0.68 vs. 1.23 ± 0.71 mm) and CAL (2.54 ± 0.63 vs. 2.73 ± 0.82 mm) were observed for CTG compared to PRF after 16 months. Higher GT was obtained for CTG compared to PRF after 3 (1.81 ± 0.56 vs 1.43 ± 0.47 mm) and 6 months (1.67 ± 0.61 vs. 1.38 ± 0.55 mm, p < 0.05). The recession coverage (RC) was higher for CTG (55.42% ± 37.14) in comparison to PRF (29.53% ± 34.08) after 16 months (p < 0.05). Similarly, CTG presented a more complete coverage of the recession (15; 41.66%) than PRF (9; 24.32%). There were no significant differences between the groups in terms of surgery time, postoperative pain, or healing patterns. Greater esthetic satisfaction was obtained with CTG. It was concluded that CTG combined with TT showed clinical and esthetic results superior to those of PRF in multiple GR treatments.

Oral health-related quality of life and patient-reported outcome measures after 10 years of supportive periodontal care

OBJECTIVE

The aim of this retrospective study was to evaluate the oral health-related quality of life (oHRQoL) and patient-reported outcome measures (PROMs) after 10 years of supportive periodontal care (SPC).

MATERIAL AND METHODS

Patients were re-examined 120±12 months after active periodontal therapy. Dental and periodontal status and oHRQoL by completing Oral Health Impact Profile-G49 (OHIP-G49) and PROMs by marking a visual analogue scale (VAS) for self-perceived esthetics (VASe), chewing function (VASc), and hygiene ability (VASh) were assessed. Patient- and tooth-related factors (age, insurance status, number of SPC, compliance, change of therapist, smoking, tooth loss, need for surgery or antibiotic intake, bleeding on probing (BOP), periodontal inflamed surface area) influencing oHRQoL and PROMs were evaluated.

RESULTS

One hundred eight periodontally compromised patients (59 female, mean age 65.4±10.7 years) lost 135 teeth during 10 years of SPC. At re-examination, 1.8% of all sites showed PPD ≥6mm. The mean OHIP-G49 sum score was 17.6±18.5, and VAS resulted in 76.0±22.5 (VASe), 86.3±16.3 (VASc), and 79.8±15.8 (VASh). Linear regression analyses identified a positive correlation with oHRQoL and/or PROMs for private insurance status (OHIP-G49, p=0.015, R2=0.204; VASc, p=0.005, R2=0.084; VASh, p=0.012, R2=0.222) and compliance to SPC (VASe, p=0.032; R2=0.204), as well as a negative correlation for active smoking (VASc, p=0.012, R2=0.084), increased BOP (VASh, p=0.029, R2=0.222) at the start of SPC, and number of lost molars (VASh, p=0.008, R2=0.222).

CONCLUSION

It is realistic to obtain satisfactory oHRQoL and PROM values in most of the patients after 10 years of SPC. The identified factors may help to predict patient satisfaction in the long-term course of therapy.

CLINICAL RELEVANCE

Systematic therapy of periodontally compromised patients provides values for oHRQoL and PROMs in a favorable range 10 years after therapy. This should encourage dentists to implement SPC in their daily routine.

CLINICAL TRIAL NUMBER

NCT03048045.

Efficacy of Tunnel Technique (TUN) versus Coronally Advanced Flap (CAF) in the Management of Multiple Gingival Recession Defects: A Meta-Analysis

Objective

We systematically assessed the efficacy of tunnel technique (TUN) vs. coronally advanced flap (CAF) in the management of multiple gingival recession defects in adults.

Methods

Five databases were searched until September 2021 for randomized controlled trials (RCTs) assessing TUN vs. CAF; grafts of interest were acellular dermal matrix (ADM) and connective tissue graft (CTG). Primary outcomes were root coverage (RC) and complete root coverage (CRC). Secondary outcomes were clinical attachment level (CAL), keratinized tissue width (KTW), probing depth (PD), and recession coverage (REC). Effect measures were risk ratio (RR) or mean difference (MD) with their confidence intervals (95% CI). Inverse variance methods and random-effects model meta-analyses were used. Subgroup analyses by the type of graft were performed. Quality of evidence was assessed using GRADE methodology.

Results

Five RCTs (n = 173) were included, with a follow-up of 6 months for all outcomes. In comparison to CAF, TUN did not significantly reduce CRC (RR 0.65; 95% CI 0.002-176.7; p = 0.51) and did not increase RC (MD 0.99%; 95% CI -6.7 to 8.6; p = 0.80). In comparison to CAF, TUN showed no significant reduction of secondary outcomes. Subgroup analyses by type of graft showed no differences in comparison to primary analyses for primary and secondary outcomes. Three RCTs had a high risk of bias, and five RCTs had very low quality of evidence for all outcomes.

Conclusions

In adults with gingival recessions, TUN had similar primary and secondary outcomes in comparison with CAF. Subgroup analyses by the type of graft did not affect main conclusions. More RCTs with better design are needed to further characterize the effects of TUN vs. CAF in the treatment of multiple gingival recession defects.

Efficacy of biologics in root coverage and gingival augmentation therapy: An American Academy of Periodontology best evidence systematic review and network meta-analysis

BACKGROUND

The aim of this systematic review was to assess the efficacy of three biologics, namely autologous blood-derived products (ABPs), enamel matrix derivatives (EMD) and recombinant human platelet-derived growth factor BB (rhPDGF-BB), in root coverage and gingival augmentation therapy.

METHODS

The protocol of this PRISMA 2020-compliant systematic review was registered in PROSPERO (CRD42021285917). After study selection, data of interest were extracted. A network meta-analysis (NMA) was conducted to assess the effect of different surgical interventions on the main clinical outcomes of interest (i.e., mean root coverage [MRC%], complete root coverage [CRC%], keratinized tissue width [KTW], gingival thickness [GT] change, and recession depth [RD] reduction).

RESULTS

A total of 48 trials reported in 55 articles were selected. All studies reported on the treatment of gingival recession defects for root coverage purposes. Forty-six treatment arms from 24 trials were included in the NMA. These arms consisted of treatment with coronally advanced flap (CAF) alone, EMD + CAF, platelet-rich fibrin (PRF) + CAF, and subepithelial connective tissue graft (SCTG) + CAF. Regarding MRC%, SCTG+CAF was associated with a significant higher estimate (13.41%, 95% CI [8.06-18.75], P <  0.01), while EMD+CAF (6.68%, 95% CI [-0.03 to 13.4], P = 0.061) and PRF+CAF (1.03%, 95% CI [-5.65 to 7.72], P = 0.71) failed to show statistically significant differences compared with CAF alone (control group) or with each other. Similarly, only SCTG+CAF led to a significantly higher CRC% (14.41%, 95% CI [4.21 to 24.61], P < 0.01), while treatment arms EMD + CAF (13.48%, 95% CI [-3.34 to 30.32], P = 0.11) and PRF+CAF (-0.91%, 95% CI [-15.38, 13.57], p = 0.81) did not show significant differences compared with CAF alone or with each other. Differences in the CI of PRF+CAF (symmetrical around a zero adjunctive effect) and EMD+CAF (non-symmetrical) suggest that EMD could have some additional value compared with PRF. Treatment with SCTG+CAF led to a statistically significant higher RD reduction (-0.39 mm, 95% CI [-0.55 to 0.22], P < 0.01), however EMD+CAF (-0.13 mm, 95% CI [-0.29 to 0.01], P = 0.08) and PRF+CAF (-0.06 mm, 95% CI [-0.23 to 0.09], P = 0.39) failed to show significant differences compared with CAF or with each other. While SCTG+CAF was associated with a statistically significant higher gain of KTW (0.71 mm, 95% CI [0.48 to 0.93], P < 0.01), EMD+CAF (0.24 mm, 95% CI [-0.02 to 0.51], P = 0.08) and PRF+CAF (0.08 mm, 95% CI [-0.23 to 0.41], P = 0.58) did not result into significant changes compared with CAF alone or with each other. Regarding the use of rhPDGF-BB+CAF, although available studies have reported equivalent results compared with SCTG+CAF, evidence is very limited.

CONCLUSIONS

The use of ABPs, EMD, or rhPDGF-BB in conjunction with a CAF for root coverage purposes is safe and generally promotes significant improvements respective to baseline clinical parameters. However, the adjunctive use of ABPs and EMD does not provide substantial additional improvements in terms of clinical outcomes and patient-reported outcome measures to those achieved using CAF alone, when baseline KTW is >2 mm. Both PRF+CAF and EMD+CAF rendered inferior MRC%, CRC%, RD reduction, and KTW gain compared with SCTG+CAF, which should still be considered the gold-standard in root coverage therapy. Although some studies have reported equivalent results for rhPDGF-BB+CAF compared with the gold-standard intervention, limited evidence precludes formal comparisons with CAF or SCTG+CAF that could be extrapolated to guide clinical practice.

Soft tissue phenotype modification predicts gingival margin long-term (10-year) stability: Longitudinal analysis of six randomized clinical trials

Aim

To assess the prognostic value of soft tissue phenotype modification following root coverage procedures for predicting the long‐term (10‐year) behaviour of the gingival margin.

Materials and Methods

Participants from six randomized clinical trials on root coverage procedures at the University of Michigan were re‐invited for a longitudinal evaluation. Clinical measurements were obtained by two calibrated examiners. A data‐driven approach to model selection with Akaike information criterion (AIC) was carried out via multilevel regression analyses and partial regression plotting for changes in the level of the gingival margin over time and interactions with the early (6‐month) results of soft tissue phenotypic modification.

Results

One‐hundred and fifty‐seven treated sites in 83 patients were re‐assessed at the long‐term recall. AIC‐driven model selection and regression analyses demonstrated that 6‐month keratinized tissue width (KTW) and gingival thickness (GT) influenced the trajectory of the gingival margin similarly in a concave manner; however, GT was the driving determinant that predicted significantly less relapse in the treatments, with stability of the treated gingival margin obtained beyond values of 1.46 mm.

Conclusions

Among a compliant patient cohort, irrespective of the rendered therapy, the presence of at least 1.5 mm KTW and 1.46 mm GT was correlated with the long‐term stability of the gingival margin.

Comparison between connective tissue graft and xenogeneic acellular dermal matrix to treat single gingival recession: A data reanalysis of randomized clinical trials

OBJECTIVES

There are few studies comparing xenogeneic acellular dermal matrixes (XDMs) with connective tissue graft (CTG) to treat single gingival recession (GR). The present study involved a reanalysis of previous studies and comparison of CTG or XDM to treat single RT1/GR.

MATERIALS AND METHODS

Fifty patients from three previous randomized clinical trials treated either by CTG (n = 25) or XDM (n = 25) were evaluated after 6-month. Clinical, patient-centered, and esthetic parameters were assessed. Pearson's correlation and regression analyses were also performed.

RESULTS

Greater recession reduction (RecRed), percentage of root coverage (%RC), and complete root coverage (CRC) were observed in the CTG group (p ≤ 0.02). Gingival thickness (GT) and keratinized tissue width (KTW) gains were higher in the CTG group. The CTG group showed better esthetic at 6-month. Logistic analyses reported that GT([OR] = 1.647³ ) and papilla height (PH) (OR = 8.20) are predictors of CRC. GT*XDM interaction was a negative predictor of CRC (OR = 7.105^-5 ). GT at baseline acted as a predictor of RecRed in both groups (p = 0.03). The XDM graft impacted RecRed and %RC negatively. Baseline PH was a predictor of %RC for both grafts.

CONCLUSION

CTG was superior for treating RT1/GR, providing better root coverage outcomes and tissue gains over time. GT, PH, and graft type were classified as predictors of CRC.

CLINICAL SIGNIFICANCE

CTG presented better outcomes to treat single RT1 gingival recession when compared to the XDM.

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).

Connective Tissue Graft with or without Enamel Matrix Derivative for Treating Gingival Recession Defects: A Systematic Review and Meta-Analysis

OBJECTIVES

The aim of this systematic review is to compare the root coverage outcomes of using a connective tissue graft (CTG) with and without the application of enamel matrix derivative (EMD).

METHODOLOGY

An electronic search was performed up to July 2020 in 4 databases, including Ovid MEDLINE, EMBASE, Web of Science and Cochrane Central. Human clinical studies with data on comparing outcomes of root coverage using CTG with and without the application of EMD were included. Meta-analyses for the recorded parameters were performed and the weighted mean difference (WMD) between the 2 groups and 95% confidence interval (CI) were reported.

RESULTS

Nine clinical studies were selected for inclusion in this review. The WMD of clinical attachment level gain was 0.78 mm (95% CI of 0.23-1.34 mm, P = .005) and the WMD of recession depth reduction was 0.28 mm (95% CI of 0.06-0.51 mm, P = .01), favoring the CTG + EMD approach. However, the comparisons for the percentage of complete root coverage and mean root coverage between the 2 approaches were not statistically significant.

CONCLUSION

Although the use of a CTG with and without the application of EMD in root coverage procedures achieved a similar percentage of complete root coverage and mean root coverage, the addition of EMD to CTG may improve the outcome of recession depth reduction and clinical attachment level gain.

A novel computer-aided method for direct measurements and visualization of gingival margin changes

AIM

To introduce and validate a computer-aided method for direct measurements and visualization of gingival margin (GM) changes.

MATERIALS AND METHODS

The method consists of five main steps: digital model acquisition, superimposition, computer-aided GM detection, distance calculation between the GM curves, and visualization. The precision of the method was evaluated with repeatability and reproducibility analysis (n = 78 teeth). The method's repeatability was evaluated by repeating the algorithm on the same digital models by two operators. The reproducibility was evaluated by repeating the algorithm on two consecutive digital models obtained with a scan-rescan process at the same time point on the same patient. For demonstration, the proposed method for direct measurements of GM changes was performed on patients who had undergone root coverage procedures and treatment of periodontal disease.

RESULTS

Excellent repeatability was found for both intra- and inter-operator variability, that is, 0.00 mm, regarding computer-aided GM detection. The reproducibility of computer-aided GM detection evaluated on scan-rescan models was 0.10 mm.

CONCLUSIONS

The presented method enables the evaluation of GM changes in a simple, precise, and comprehensive manner through non-invasive acquisition and superimposition of digital models.

A new digital evaluation protocol applied in a retrospective analysis of periodontal plastic surgery of gingival recessions

This research aimed to develop a new digital evaluation protocol to objectively quantify the volumetric changes of root coverage periodontal plastic surgery when combined with connective tissue graft. Consecutive patients with Cairo recession type 1 (RT1) or Cairo recession type 2 (RT2) were treated. Accurate study models obtained at baseline and follow-ups were optically scanned. Healing dynamics were measured by calculating volume differences between time points. Nineteen patients were treated between December 2014 and January 2019. At 3-month follow-up, root coverage was 95.6% (± 14.5%) with tunnel and connective tissue graft (TUN + CTG) technique, and 88.9% (± 20.5%) with the vestibular incision subperiosteal tunnel access and connective tissue graft (VISTA + CTG) technique. Recession decreased 1.33 (± 0.86) mm and 1.42 (± 0.92) mm, respectively (p = 0.337). At 6-month follow-up, root coverage was 96.5% (± 10.4%) with the TUN + CTG and 93.9% (± 10.3%) with the VISTA + CTG. Recession decreased 1.35 (± 0.85) mm and 1.45 (± 0.82) mm, respectively (p = 0.455). Complete root coverage was achieved in 86.7% (± 0.4%) with TUN + CTG and 70.6% (± 0.5%) with VISTA + CTG. No statistically significant differences were found between techniques. The digital protocol presented proved to be a non-invasive technique for accurate measurements of clinical outcomes. Both techniques reduce gingival recessions, with no statistically significant differences.

The precision of gingival recession measurements is increased by an automated curvature analysis method

Background

The extent of gingival recession represents one of the most important measures determining outcome of periodontal plastic surgery. The accurate measurements are, thus, critical for optimal treatment planning and outcome evaluation. Present study aimed to introduce automated curvature-based digital gingival recession measurements, evaluate the agreement and reliability of manual measurements, and identify sources of manual variability.

Methods

Measurement of gingival recessions was performed manually by three examiners and automatically using curvature analysis on representative cross-sections (n = 60). Cemento-enamel junction (CEJ) and gingival margin (GM) measurement points selection was the only variable. Agreement and reliability of measurements were analysed using intra- and inter-examiner correlations and Bland–Altman plots. Measurement point selection variability was evaluated with manual point distance deviation from an automatic point. The effect of curvature on manual point selection was evaluated with scatter plots.

Results

Bland–Altman plots revealed a high variability of examiner’s recession measurements indicated by high 95% limits of agreement range of approximately 1 mm and several outliers beyond the limits of agreement. CEJ point selection was the main source of examiner’s variability due to smaller curvature values than GM, i.e., median values of − 0.98 mm^− 1 and − 4.39 mm^− 1, respectively, indicating straighter profile for CEJ point. Scatter plots revealed inverse relationship between curvature and examiner deviation for CEJ point, indicating a threshold curvature value around 1 mm^− 1.

Conclusions

Automated curvature-based approach increases the precision of recession measurements by reproducible measurement point selection. Proposed approach allows evaluation of teeth with indistinguishable CEJ that could be not be included in the previous studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01858-9.

Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

The Scientific Investigation Committee of the American Academy of Restorative Dentistry offers this review of the 2020 professional literature in restorative dentistry to inform busy dentists regarding noteworthy scientific and clinical progress over the past year. Each member of the committee brings discipline-specific expertise to this work to cover this broad topic. Specific subject areas addressed include prosthodontics; periodontics, alveolar bone, and peri-implant tissues; implant dentistry; dental materials and therapeutics; occlusion and temporomandibular disorders (TMDs); sleep-related breathing disorders; oral medicine and oral and maxillofacial surgery; and dental caries and cariology. The authors focused their efforts on reporting information likely to influence day-to-day dental treatment decisions with a keen eye on future trends in the profession. With the tremendous volume of dentistry and related literature being published today, this review cannot possibly be comprehensive. The purpose is to update interested readers and provide important resource material for those interested in pursuing greater detail. It remains our intent to assist colleagues in navigating the extensive volume of important information being published annually. It is our hope that readers find this work useful in successfully managing the dental patients they encounter.

Methods and parameters for digital evaluation of gingival recession: a critical review

OBJECTIVES

The aim of the present review was to find, compare, and critically discuss digital methods for quantitative evaluation of gingival recessions dimensions.

DATA

Collection of articles and classification related to digital evaluation of gingival recessions.

SOURCES

A search of PubMed, Web of Science, Scopus, and reference lists of articles was conducted up to April 2021 STUDY SELECTION: Twenty-two articles used digital evaluation of gingival recessions dimensions. The methods in the included articles were extracted, compared, and categorized.

RESULTS

Digital measurements were performed on 2D intraoral photographs, 3D models, or cross-sections obtained from 3D models. Baseline measurement were performed for diagnostic and treatment planning and categorised into distance and area measurements. Follow-up evaluation of treatment was based either on repeating the "baseline" measurements and calculating differences or measuring differences directly on composite images, composed from two superimposed images obtained at two time-points. Direct measurements were categorised into distance, area, and volume measurements.

CONCLUSIONS

Digital evaluation predominantly means just digitalization of the established evaluation methods; therefore, increasing measurements accuracy and maintaining comparability with past studies. At present, a large variability of digital evaluation workflow among the included studies renders the comparison among different studies difficult if not impossible. The potential of digital evaluation seems not to have been fully exploited as only a few novel measurements and parameters introduced, i.e., volumetric evaluation of soft tissue dynamics. For reproducible and comparable studies in the future, the research should be aimed at evaluation, optimization and standardization of all phases of the digital evaluation.

CLINICAL SIGNIFICANCE

Digital evaluation, based on 3D image superimposition is a promising approach as it increases measurements accuracy, maintains compatibility with past studies and simultaneously introduces novel evaluation possibilities.

Modified coronally advanced tunnel technique with enamel matrix derivative in addition to subepithelial connective tissue graft compared with connective tissue graft alone for the treatment of multiple gingival recessions: prognostic parameters for clinical treatment outcomes

Objectives

To investigate factors that influence 12-month outcomes after treatment of multiple gingival recessions (GR) with modified coronally advanced tunnel (MCAT) and subepithelial connective tissue graft (SCTG) with enamel matrix derivative (EMD) (tests) or without (controls).

Materials and methods

Twenty patients with 150 GR were treated. Logistic regression models were used to identify baseline parameters that could predict 12-month average root coverage (ARC), complete root coverage (CRC), root esthetic coverage score (RES), gain in keratinized tissue width (KTW), and gain in gingival thickness (GT).

Results

The likelihood of ARC > 85% increased sevenfold (odds ratio [OR] = 7.33; 95% confidence interval [CI] = 2.43–12.12), of achieving CRC: 21-fold (OR = 21.23; 95% CI = 10.21–45.32), and of gaining RES = 10: tenfold (OR = 10.23; 95% CI = 5.78–32.23) in favor of EMD-treated sites. With each 1-mm² increase in baseline avascular exposed root surface area (AERSA), the odds of failure (ARC ≤ 85%, not achieving CRC and postoperative GT ≤ 2 mm) increased almost fourfold (OR = 3.56; 95% CI = 1.98–10.19), fourfold (OR = 4.23; 95% CI = 1.11–9.02), and nearly sixfold (OR = 5.76; 95% CI = 2.43–12.87), respectively. The greater the baseline GT, the more likely the chance of achieving CRC (OR = 10.23; 95% CI = 8.37–16.23) and RES = 10 (OR = 5.50; 95% CI = 3.34–16.43). All models exhibited fair to excellent discrimination and satisfactory calibration.

Conclusions

Based on logistic regression, EMD application improved postoperative ARC, CRC and RES; baseline AERSA predicted 12-month ARC, CRC, and GT gain, whereas baseline GT was a predictor of achieving CRC and perfect RES.

Clinical relevance

Additional use of EMD, lower baseline AERSA, and greater baseline GT significantly increase the odds of obtaining better outcomes 12 months after MCAT + SCTG technique.

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

AIM

Comparison of the clinical efficacy (digitally volumetric, aesthetic, patient-centred outcomes) of tunnel technique (TUN) with subepithelial connective tissue graft (CTG) versus coronally advanced flap (CAF) with enamel matrix derivate (EMD) 5 years after gingival recession therapy.

MATERIALS AND METHODS

In 18 patients contributing 36 RT1 recessions, study models were collected at baseline and follow-ups. Optical scans assessed recessions computer-assisted [recession depth, recession reduction (RECred), complete root coverage (CRC), percentage of root coverage (RC), pointwise (pTHK) and mean areal (aTHK) marginal soft tissue thickness]. Root coverage aesthetic Score (RES) was used for aesthetic evaluation and visual analogue scales for patient-centred data collection applied.

RESULTS

Sixty months after surgery, 50.0% (TUN+CTG) and 0.0% (CAF+EMD) of sites showed CRC (p = 0.0118), 82.2% (TUN+CTG) and 32.0% (CAF+EMD) achieved RC, respectively (p = 0.0023). CTG achieved significantly better RECred (TUN+CTG: 1.75±0.74 mm; CAF+EMD: 0.50 ± 0.39 mm; p = 0.0009) and aTHK (TUN+CTG: 0.95 ± 0.41 mm; CAF+EMD: 0.26 ± 0.28 mm; p = 0.0013). RES showed superior outcomes (p = 0.0533) for TUN+CTG (6.86 ± 2.31) compared to CAF+EMD (4.63 ± 1.99). The study failed to find significant differences related to patient-centred outcomes (TUN+CTG: 8.30 ± 2.21; CAF+EMD: 7.50 ± 1.51; p = 0.1136).

CONCLUSIONS

Five years after treatment, CTG resulted in better clinical and aesthetic outcomes than CAF+EMD. Increased THK was associated with improved outcomes for RECred and RC.

Assessment of reference areas for superimposition of serial 3D models of patients with advanced periodontitis for volumetric soft tissue evaluation

AIM

This study aimed to determine the optimal reference area for superimposition of serial 3D dental models of patients with advanced periodontitis.

MATERIALS AND METHODS

Ten pre- and post-periodontal treatment 3D models (median time lapse: 13.1 months) of patients with advanced periodontitis were acquired by intraoral scanning. Superimposition was performed with the iterative closest point algorithm using four reference areas: (A) all stable teeth, (B) all teeth, (C) third palatal rugae and (D) the whole model. The superimposition accuracy was evaluated at two stable evaluation regions using the mean absolute distance and evaluated with two-way ANOVA and post-hoc multivariate model. The intra- and inter-operator reproducibility was calculated by intraclass correlation coefficient (ICC).

RESULTS

Superimposition accuracy evaluated at stable tooth evaluation region were 71 ± 29 μm, 73 ± 21 μm, 127 ± 52 μm and 113 ± 53 μm for areas A, B, C and D, respectively. All reference areas showed similarly high ICC values >0.990, except for reference area C showing ICC of 0.821 (intra-operator) and 0.767 (inter-operator) for tooth evaluation area.

CONCLUSIONS

Area A and B provide the highest accuracy for superimposition of serial 3D dental models acquired by intraoral scanning of patients with advanced periodontitis.

Soft tissue grafting with the tunnel technique in the mandibular anterior: Myths and realities

OBJECTIVE

To address the myths and realities of soft tissue grafting with the tunnel technique in the mandibular anterior region.

MATERIALS AND METHODS

Myths associated with use of the tunnel technique for soft tissue grafting in the mandibular anterior region are identified and examined. Explanations for the misunderstandings are presented and documented with case examples and evidence from scientific studies.

RESULTS

Six myths are described and the realities are presented.

CONCLUSIONS

This report demonstrates that the tunnel technique can be successfully used in the mandibular anterior region in the presence of anatomic features thought to favor the use of more invasive surgical methods.

CLINICAL SIGNIFICANCE

Soft tissue grafting in the mandibular anterior region has complicating anatomical features including a strong frenal attachment, shallow vestibule and thin tissue. These features may be successfully managed with a free gingival graft, but that procedure results in an uncomfortable experience for the patient. The tunnel technique, especially when combined with an acellular dermal matrix, dramatically improves the patient experience and esthetic outcome without compromising the clinical outcome.