Multiple coronally advanced flap with a selective use of connective tissue graft: A 3-year prospective clinical and histological study

BACKGROUND

The purpose of the present study was to prospectively evaluate the 3-year changes in the gingival dimensions following multiple coronally advanced flap (MCAF) with selective use of connective tissue graft (CTG). In addition, the secondary aim was to histologically identify the factors related to phenotype changes.

METHODS

Twenty patients treated with MCAF and site-specific application of a CTG were available for the 3-year follow-up. Outcome measures included complete root coverage (CRC), recession reduction, keratinized tissue width (KTW), marginal tissue thickness changes, and primary flap position. Biopsies were harvested at one of the sites treated with the adjunct of CTG. All sections were stained with hematoxylin and eosin, Masson trichrome, Verhoeff-van Gieson, tenascin, and alcian blue stain for semiquantitative evaluation.

RESULTS

At 3 years, CRC was detected in 86% of sites treated with MCAF alone and 81% of sites treated with MCAF + CTG. The 47% of sites treated with MCAF + CTG presented an apical shift of primary flap from its original position. Linear regression showed a significant association between KTW change and the initial KTW in MCAF-treated sites, while both initial KTW and position of primary flap were statistically significantly associated factors with KTW changes in the MCAF + CTG group. In all the biopsies examined, there is always a marked and clear separation between the connective tissue of the gingival flap and the palatal connective tissue of the graft.

CONCLUSIONS

The selective use of CTG is an effective treatment for multiple gingival recessions. Only a limited increase in KTW can be expected in a bilaminar technique if, during the healing phases, the connective tissue is maintained completely covered.

The effect of connective tissue graft or a collagen matrix on epithelial differentiation around teeth and implants: a preclinical study in minipigs

OBJECTIVES

This study aimed to histologically evaluate the healing at 8 weeks after coronally advanced flap (CAF) with either a superficial (SCTG) or deep palatal connective tissue graft (DCTG), or a collagen matrix (CM) to cover recession defects at teeth and implants.

MATERIAL AND METHODS

One mandibular side of 6 miniature pigs received each 3 titanium implants 12 weeks after extraction. Eight weeks later, recession defects were created around implants and contralateral premolars and 4 weeks later randomly subjected to CAF + SCTG, CAF + DCTG, or CAF + CM. After 8 weeks, block biopsies were histologically analyzed.

RESULTS

For the primary outcome, i.e., keratinization of the epithelium, all teeth and implants exhibited a keratinized epithelium with no histological differences among them also not in terms of statistically significant differences in length (SCTG 0.86 ± 0.92 mm, DCTG 1.13 ± 0.62 mm, and Cm, 1.44 ± 0.76 mm). Pocket formation was histologically seen at all teeth, around most implants with SCTG and DCTG, however not in the CM implant group. The connective tissue grafts showed hardly signs of degradation, whereas the CM was partly degraded and integrated in connective tissue. The mean gain in gingival height was similar in all experimental groups (SCTG 3.89 ± 0.80 mm, DCTG 4.01 ± 1.40 mm, CM 4.21 ± 0.64 mm). Statistically significant differences were found in the height of the junctional epithelium between the control teeth and the connective tissue groups (p = 0.009 and 0.044).

CONCLUSIONS

In this animal model, the use of either a superficial or deep connective tissue graft or a collagen membrane did not seem to have any impact on the epithelial keratinization around both teeth and implants. All procedures (CAF + SCTG/DCTG/CM) resulted in a long JE that was even longer at implants.

CLINICAL RELEVANCE

Deep/superficial palatal connective tissue graft yielded similar keratinization around teeth/implants. Given the absence of pocket formation and inflammatory processes at implants when using a CM, CAF + CM might bear potential clinical benefits.

Treatment of multiple adjacent gingival recessions with coronally advanced flap versus modified coronally advanced tunnel with a volumetrically stable collagen matrix: a 12-months randomized controlled clinical trial

OBJECTIVE

The introduction of a new collagen substitute, that potentially will reduce the invasiveness of the two techniques, by avoiding the need for a second surgical site, i.e., the donor site, need to be evaluated in relation with the surgical procedure that could benefit the most by the utilization of such a matrix. The aim of this study was to compare the clinical outcomes following treatment of RT 1 multiple adjacent gingival recessions (MAGRs) using the modified coronally advanced tunnel technique (MCAT) or the multiple coronally advanced flap (MCAF) in conjunction with a new volume stable xenogeneic collagen matrix (VXCM). Secondarily, the study evaluated whether patients report a preference in terms of discomfort between the two surgical techniques.

METHODS

Twenty patients requiring treatment of MAGRs were randomly assigned to one of the two treatment groups (group A: MCAF+VCMX; group B: MCAT+VCMX). The following measurements were recorded at baseline (i.e. prior to surgery), at 6 and 12 months: gingival recession depth (REC), probing pocket depth (PPD), keratinized tissue width (KTW) and gingival thickness (GT). Post-operative pain and discomfort were recorded using a visual analogue scale (VAS) at 1 week. The primary outcome variable was mean root coverage (mRC), secondary outcomes were complete root coverage (CRC), change in KTW and GT, patient discomfort and satisfaction, and duration of surgery.

RESULTS

Healing was uneventful in both groups. At 12 months, both treatments resulted in statistically significant improvements of REC and GT compared with baseline (p < 0.05). The mRC measured 79.95 ± 29.92% at MCAF group, whereas 64.74 ± 40.5% MCAT group (p = 0.124). CRC was found at 65.6% of MCAF-treated sites and at 52% of MCAT-treated sites (p=0.181).

CONCLUSIONS

Similar clinical results should be expected when MAGRs are treated with MCAF or MCAT, with the adjunct of VCMX.

Treatment of multiple adjacent RT 1 gingival recessions with the modified coronally advanced tunnel (MCAT) technique and a collagen matrix or palatal connective tissue graft: 9-year results of a split-mouth randomized clinical trial

OBJECTIVES

To evaluate t he long-term outcomes following treatment of RT 1 multiple adjacent gingival recessions (MAGR) using the modified coronally advanced tunnel (MCAT) with either a collagen matrix CM or a connective tissue graft (CTG).

MATERIAL AND METHODS

Sixteen of the original 22 subjects included in a randomized, controlled split-mouth clinical trial were available for the 9-year follow-up (114 sites). Recessions were randomly treated by means of MCAT + CM (test) or MCAT + CTG (control). Complete root coverage (CRC), mean root coverage (MRC), gingival recession depth (GRD), probing pocket depth (PD), keratinized tissue width (KTW), and thickness (KGT) were compared with baseline values and with the 12-month results.

RESULTS

After 9 years, CRC was observed in 2 patients, one in each group. At 9 years, MRC was 23.0 ± 44.5% in the test and 39.7 ± 35.1% in the control group (p = 0.179). The MRC reduction compared to 12 months was - 50.1 ± 47.0% and - 48.3 ± 37.7%, respectively. The upper jaw obtained 31.92 ± 43.0% of MRC for the test and 51.1 ± 27.8% for the control group (p = 0.111) compared to the lower jaw with 8.3 ± 46.9% and 20.7 ± 40.3%. KTW and KGT increased for both CM and CTG together from 2.0 ± 0.7 to 3.1 ± 1.0 mm (< 0.0001). There were no statistically significant changes in PD.

CONCLUSION

The present results indicate that (a) treatment of MAGR using MCAT in conjunction with either CM or CTG is likely to show a relapse over a period of 9 years, and (b) the outcomes obtained in maxillary areas seem to be more stable compared to the mandibular ones.

CLINICAL RELEVANCE

The mean root coverage at 12 months could not be fully maintained over 9 years. On a long-term basis, the results seem to be less stable in the mandible as compared to maxillary areas.

Soft and hard tissue changes after immediate implant placement with or without a sub-epithelial connective tissue graft: results from a 6-months pilot randomized controlled clinical trial

AIM

The present pilot RCT aimed to investigate the influence of a connective tissue graft (CTG) in combination with the immediate implant placement (IIP) on hard and soft tissues healing, without a bone replacement graft in the gap between the implant and the socket walls.

MATERIAL AND METHODS

Thirty patients requiring extraction of one anterior tooth (from premolar to premolar) were randomly assigned to one of the two treatment groups (test: IIP+CTG; control: IIP). Cone-beam computed tomography (CBCT) and optically scans were performed before tooth extraction and at 6-months follow-up. Then, DICOM files were superimposed in order to allow the evaluation of osseous ridge and buccal bone changes, while the superimposition of DICOM and STL (Standard Tessellation Language) files allowed for evaluating of soft tissue contour. For testing the differences between the two groups, the non-parametric test as Wilcoxon rank-sum test, was used.

RESULTS

Twenty-six out of the thirty enrolled patients, attended the 6-month follow-up visit. The 4 patients of control group that were lost to follow-up, were analyzed under the intention-to-treat principle. No statistically significant differences between the groups were observed for the vertical buccal bone resorption (p=0.90), as well as for the horizontal buccal bone resorption at all measured levels. Significant differences were found between test and control groups in the horizontal dimensional changes of osseous ridge at the most coronal aspect (p=0.0003 and p=0.02). Changes of tissue contour ranged between -0.32 and -0.04 mm in the test group, and between -1.94 and -1.08 mm in the control group, while changes of soft tissue thickness varied between 1.33 and 2.42 mm in the test group, and between -0.16 and 0.88 mm in the control group, with statistically significant differences for both variables at all measured levels. At 6 months, the mean volume increase was 6.76±8.94 mm³ and 0.16±0.42 mm³ in the test and control groups, respectively, with statistically significant difference.

CONCLUSIONS

The findings of the present study indicate that the adjunct of a connective tissue graft at the time of immediate implant placement, without bone grafting, does not influence vertical bone resorption. Within the limits of the present study, it can be suggested that the adjunct of a connective tissue graft at the time of immediate implant placement, without bone grafting, reduces the horizontal changes of the alveolar ridge. Moreover, it allows maintenance of the tissue contour due to an increase in soft tissue thickness.

“Wire Syndrome” Following Bonded Orthodontic Retainers: A Systematic Review of the Literature

(1) Background and objective: Tooth movements described as unexplained, aberrant, unexpected, unwanted, or undesirable can occur in the presence of an intact orthodontic retention wire, without detachment or fracture. This iatrogenic phenomenon, known little or not by many practitioners, responsible for significant dental and periodontal complications, both functional and aesthetic, is called “Wire Syndrome” (WS). It is therefore considered an undesirable event of bonded orthodontic retainers, which must be differentiated from an orthodontic relapse. The objective was to perform, for the first time, a systematic review of the literature in order to define the prevalence of WS and to study its associated clinical characteristics. (2) Methods: A systematic review of the literature was performed following the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and recommendations using an electronic search strategy on four databases complemented by a manual search. All the prospective and retrospective clinical studies, including case reports and series, written in English or French, clearly mentioning the description, detection, or management of WS were included. Three independent blinding review authors were involved in study selection, data extraction, and bias assessment using the Mixed Methods Appraisal Tool (MMAT). (3) Results: Of 1891 results, 20 articles published between 2007 and 2021 fulfilled the inclusion criteria, with a globally high risk of bias since 16 articles were case report/series. The analysis of each article allowed the highlighting of WS through 13 categories, as follows: prevalence, apparition delay, patient characteristics, arch and tooth involved, families of movements, dental and periodontal consequences, type of wire, risk factors, etiologies, treatment, and preventive approach. (4) Conclusion: This systematic review of the literature elaborated a synthesis on WS, allowing general practitioners, periodontists, and orthodontists to understand this adverse event, to facilitate the diagnostic approach, and to underline preventive measures against WS. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; number CRD42021269297).

Modified Coronally Advanced Tunnel Technique with Site-Specific Application of Connective Tissue Graft for the Treatment of Multiple Adjacent Maxillary Gingival Recessions: A Case Series

The aim of the present case series was to evaluate the outcomes of the modified coronally advanced tunnel technique (MCAT) using the width of keratinized tissue (KTW) as an indicator to apply the connective tissue graft (CTG) specifically. Seven patients requiring treatment for the presence of multiple gingival RT1 recession defects in the maxilla were enrolled in the study. A total of 36 recessions were treated with MCAT, and the CTG was applied in 16 sites presenting < 2 mm of KTW at baseline. The mean root coverage from baseline to 1 year postsurgery was 90% for the sites treated with MCAT alone and 93.7% for those treated with MCAT+CTG. The increase of KTW was higher in the sites treated with CTG than in the sites treated without it. Within the limitations of the present case series, it can be concluded that the proposed surgical technique is extremely effective in gaining root coverage and reducing the amount of connective tissue harvested from the donor site.

Use of platelet-rich fibrin for the treatment of gingival recessions: a systematic review and meta-analysis

OBJECTIVES

The aim of this systematic review and meta-analysis was to compare the use of platelet-rich fibrin (PRF) with other commonly utilized treatment modalities for root coverage procedures.

MATERIALS AND METHODS

The eligibility criteria comprised randomized controlled trials (RCTs) comparing the performance of PRF with that of other modalities in the treatment of Miller class I or II (Cairo RT I) gingival recessions. Studies were classified into 5 categories as follows: (1) coronally advanced flap (CAF) alone vs CAF/PRF, (2) CAF/connective tissue graft (CAF/CTG) vs CAF/PRF, (3) CAF/enamel matrix derivative (CAF/EMD) vs CAF/PRF, (4) CAF/amnion membrane (CAF/AM) vs CAF/PRF, and (5) CAF/CTG vs CAF/CTG/PRF. Studies were evaluated for percentage of relative root coverage (rRC; primary outcome), clinical attachment level (CAL), keratinized mucosa width (KMW), and probing depth (PD) (secondary outcomes).

RESULTS

From 976 articles identified, 17 RCTs were included. The use of PRF statistically significantly increased rRC and CAL compared with CAF alone. No change in KMW or reduction in PD was reported. Compared with PRF, CTG resulted in statistically significantly better KMW and RC. No statistically significant differences were reported between the CAF/PRF and CAF/EMD groups or between the CAF/PRF and CAF/AM groups for any of the investigated parameters.

CONCLUSIONS

The use of CAF/PRF improved rRC and CAL compared with the use of CAF alone. While similar outcomes were observed between CAF/PRF and CAF/CTG for CAL and PD change, the latter group led to statistically significantly better outcomes in terms of rRC and KTW. In summary, the use of PRF in conjunction with CAF may represent a valid treatment modality for gingival recessions exhibiting adequate baseline KMW.

CLINICAL RELEVANCE

The data indicate that the use of PRF in conjunction with CAF statistically significantly improves rRC when compared with CAF alone but did not improve KMW. Therefore, in cases with limited baseline KMW, the use of CTG may be preferred over PRF.

Treatment of class III multiple gingival recessions: Prognostic factors for achieving a complete root coverage

BACKGROUND

This report is intended to present a supplemental analysis of data from a prior report (Aroca et al., ) to investigate factors associated with a complete root coverage at 1 year. The purpose of the prior report was to investigate at 1 year the adjunction effect of EMD for the treatment of Miller's class III recession defects using a coronally advanced modified tunnel/CTG technique with (test group) or without (control group). The purpose of this report was to investigate additional factors associated with root coverage in the same data set.

MATERIALS AND METHODS

On the 138 observations collected from 20 patients, a regression model was used to highlight the relationship between the percentages of root coverage (RC) and three following covariates: the distance from the tip of the papilla and the contact point (DCP) at baseline, the group membership (control vs. test) and tooth position in the mouth (maxillary vs. mandibular).

RESULTS

The statistical analysis showed that there was a significant effect of the DCP at baseline (p = 0.01) and of the tooth type (p < .001) on the percentage of RC at 1 year, whereas no significant difference between the two techniques (group membership effect) was shown (p = 0.69).

CONCLUSION

The probability to obtain a complete root coverage decreases when the DCP at baseline increases. Moreover, maxillary teeth are more likely to give better RC than mandibular teeth. However, in this analysis similar to the last, there was no group effect.

Surgical and prosthetic correction of malposed maxillary implants: a case report

This case report presents a patient who underwent a major correction of malpositioned implants. Two implants were previously placed in a 30-year-old woman to replace the maxillary right central and lateral incisors without any attempt to reconstruct the alveolar and soft tissue defects. This resulted in a significant esthetic problem. The position of the implants was successfully corrected via the mobilization of a bone block in which the implants were maintained. The bone block was then fixed in a predetermined optimal position. After fixing the bone block, gaps were filled with Bio-Oss and covered with a membrane. Nine months after bone healing, a periodontal technique was used to improve soft tissue esthetics. The final result was achieved with the combination of bone surgery, soft tissue management, and progressive adaptation of implant-supported crown restorations.

Treatment of multiple adjacent Miller Class I and II gingival recessions with collagen matrix and the modified coronally advanced tunnel technique

OBJECTIVE

To clinically evaluate the treatment of Miller Class I and II multiple adjacent gingival recessions using the modified coronally advanced tunnel technique combined with a newly developed bioresorbable collagen matrix of porcine origin.

METHOD AND MATERIALS

Eight healthy patients exhibiting at least three multiple Miller Class I and II multiple adjacent gingival recessions (a total of 42 recessions) were consecutively treated by means of the modified coronally advanced tunnel technique and collagen matrix. The following clinical parameters were assessed at baseline and 12 months postoperatively: full mouth plaque score (FMPS), full mouth bleeding score (FMBS), probing depth (PD), recession depth (RD), recession width (RW), keratinized tissue thickness (KTT), and keratinized tissue width (KTW). The primary outcome variable was complete root coverage.

RESULTS

Neither allergic reactions nor soft tissue irritations or matrix exfoliations occurred. Postoperative pain and discomfort were reported to be low, and patient acceptance was generally high. At 12 months, complete root coverage was obtained in 2 out of the 8 patients and 30 of the 42 recessions (71%).

CONCLUSION

Within their limits, the present results indicate that treatment of Miller Class I and II multiple adjacent gingival recessions by means of the modified coronally advanced tunnel technique and collagen matrix may result in statistically and clinically significant complete root coverage. Further studies are warranted to evaluate the performance of collagen matrix compared with connective tissue grafts and other soft tissue grafts.

Predictability of surgical techniques used for coverage of multiple adjacent gingival recessions--A systematic review

OBJECTIVE

Predictable coverage of multiple adjacent gingival recessions (MAGRs) is a major challenge for clinicians. Although several surgical techniques have been proposed to treat MAGR, it is still unclear as to what extent the proposed approaches may lead to predictable root coverage. The aim of this article is to identify the predictability of the available surgical techniques used to achieve complete root coverage (CRC) of Miller Class I, II, and III MAGRs.

METHOD AND MATERIALS

A search of the PubMed database was performed. Additional hand searching and a search for gray literature were also conducted. Due to the heterogeneity of the data, no meta-analysis could be performed.

RESULTS

The search resulted in the selection of 16 publications analyzed in this review. In Miller Class I and II MAGRs, the coronalIy advanced flap (CAF) and the modified coronally advanced flap (MCAF) yielded a CRC ranging from 74.6% to 89.3% and a mean root coverage (MRC) ranging from 91.5% to 97.27% at 6 to 12 months following surgery. In Miller Class I and II recessions, the results obtained with MCAF were maintained for up to 5 years (CRC ranging from 35% to 85.1%), as indicated by two studies. One study has indicated that MCAF + connective tissue grafting (CTG) may improve the long-term stability of CRC compared with MCAF (35% CRC without CTG vs 52% CRC with CTG). In Miller Class I and II MAGRs, the use of CTG in conjunction with CAF, MCAF, coronally positioned pedicle (CPP), double pedicle graft (DPG), or the supraperiosteal tunnel technique yielded higher CRC or MRC than with bioabsorbable membranes, acellular dermal matrix (ADM), or platelet-rich fibrin (PRF). In Miller Class III MAGRs, the modified coronally advanced tunnel (MCAT) and CTG with and without an enamel matrix derivative resulted in 38% CRC and in 82% to 83% MRC, respectively.

CONCLUSION

The present findings indicate that in Miller Class I and II MAGRs, CAF or MCAF with or without CTG may lead to predictable CRC; the CRC obtained with MCAF were maintained over a period of 5 years; the use of CTG appears to improve the long-term stability of the MCAF; and the use of CTG in conjunction with CAF, MCAF, CPP, DPG, or the supraperiosteal tunnel technique appear to yield higher CRC or MRC than the use of bioabsorbable membranes, ADM, or PRF. Also, MCAT plus CTG appears to represent a valuable technique for the treatment of Miller Class III MAGRs.

Treatment of class III multiple gingival recessions: a randomized-clinical trial

BACKGROUND

The aim of this controlled randomized split-mouth study was to evaluate whether a modified tunnel/connective tissue graft (CTG) technique - enamel matrix derivative (EMD) combination will improve the treatment of multiple class III recession when compared with the same technique alone.

MATERIALS AND METHODS

Twenty healthy subjects with a mean age of 31.7 years, were enrolled for the trial in a university periodontal clinic. Patients with at least three adjacent gingival recessions on both sides of the mouth were treated with a modified tunnel/CTG technique. On the test side, an EMD was used in addition. Clinical parameters were measured at baseline, 28 days, 3, 6 and 12 months after the surgery. Results are presented at the subject level.

RESULTS

The mean root coverage from baseline to 1 year post-surgery was 82% for the test group and 83% for the control group. Complete root coverage was achieved at 1 year in eight (38%) of the 20 surgeries (experimental and control group).

CONCLUSIONS

One-year results indicate that the modified tunnel/CTG technique is predictable for the treatment of multiple class III recession-type defects. The addition of EMD does not enhance the mean clinical outcomes.

Clinical evaluation of a modified coronally advanced flap alone or in combination with a platelet-rich fibrin membrane for the treatment of adjacent multiple gingival recessions: a 6-month study

BACKGROUND

The aim of this study was to determine whether the addition of an autologous platelet-rich fibrin clot (PRF) to a modified coronally advanced flap (MCAF) (test group) would improve the clinical outcome compared to an MCAF alone (control group) for the treatment of multiple gingival recessions.

METHODS

Twenty subjects, presenting three adjacent Miller Class I or II multiple gingival recessions of similar extent on both sides of the mouth, were enrolled in the study. The mean recession value at baseline was 2.9 +/- 1.1 mm for test sites and 2.5 +/- 0.9 mm for control sites. Each patient was treated on both sides by an MCAF technique; the combination treatment (with a PRF membrane) was applied on the test side. Probing depth (PD), recession width, clinical attachment level (CAL), keratinized gingival width, and gingival/mucosal thickness (GTH) were measured at baseline and at 6 months post-surgery. Gingival recession was measured at baseline and at 1, 3, and 6 months post-surgery.

RESULTS

Mean root coverage after 1, 3, and 6 months was 81.0% +/- 16.6%, 76.1% +/- 17.7%, and 80.7% +/- 14.7%, respectively, at the test sites and 86.7% +/- 16.6%, 88.2% +/- 16.9%, and 91.5% +/- 11.4%, respectively, at the control sites. Differences between the two groups were statistically significant at 3 and 6 months. At 6 months, complete root coverage was obtained at 74.6% of the sites treated with the control procedure but at only 52.2% of the experimental sites. At 6 months, the increase in GTH was statistically significant when comparing the test sites (from 1.1 +/- 0.3 mm at baseline to 1.4 +/- 0.5 mm at 6 months) to the control sites (from 1.1 +/- 0.3 mm at baseline to 1.1 +/- 0.3 mm at 6 months). In the case of PD, there was no significant difference between the two groups at 6 months, but a significant CAL gain in favor of the control group was observed at that time.

CONCLUSIONS

MCAF is a predictable treatment for multiple adjacent Miller Class I or II recession-type defects. The addition of a PRF membrane positioned under the MCAF provided inferior root coverage but an additional gain in GTH at 6 months compared to conventional therapy.