Burton Langer

The subepithelial connective tissue graft

A technique has been described which can augment concavities and irregularities in edentulous ridges where cosmetics are important. Using the combination of temporary acrylic resin restorations and connective tissue autografts, unattractive con-cavities and ridge irregularities can be corrected.

Periodontal soft tissue root coverage procedures: a consensus report from the AAP Regeneration Workshop.

BACKGROUND Management of gingival recession defects, a common periodontal condition, using root coverage procedures is an important aspect of periodontal regenerative therapy. The goal of the periodontal soft tissue root coverage procedures group was to develop a consensus report based on the accompanying systematic review of root coverage procedures, including priorities for future research and identification of the best evidence available to manage different clinical scenarios. METHODS The group reviewed and discussed the accompanying systematic review, which covered treatment of single-tooth recession defects, multiple-tooth recession defects, and additional focused questions on relevant clinical topics. The consensus group members submitted additional material for consideration by the group in advance and at the time of the meeting. The group also identified priorities for future research. RESULTS All reviewed root coverage procedures provide significant reduction in recession depth, especially for Miller Class I and II recession defects. Subepithelial connective tissue graft (SCTG) procedures provide the best root coverage outcomes. Acellular dermal matrix graft (ADMG) or enamel matrix derivative (EMD) in conjunction with a coronally advanced flap (CAF) can serve as alternatives to autogenous donor tissue. Additional research is needed to do the following: 1) assess the treatment outcomes for multiple-tooth recession defects, oral sites other than maxillary canine and premolar teeth, and Miller Class III and IV defects; 2) assess the role of patient- and site-specific factors on procedure outcomes; and 3) obtain evidence on patient-reported outcomes. CONCLUSIONS Predictable root coverage is possible for single-tooth and multiple-tooth recession defects, with SCTG procedures providing the best root coverage outcomes. Alternatives to SCTG are supported by evidence of varying strength. Additional research is needed on treatment outcomes for specific oral sites. Clinical Recommendation: For Miller Class I and II single-tooth recession defects, SCTG procedures provide the best outcomes, whereas ADMG or EMD in conjunction with CAF may be used as an alternative.

Periodontal Soft Tissue Root Coverage Procedures: Practical Applications From the AAP Regeneration Workshop

Focused Clinical Question: How should gingival recession (GR) defects be managed based on current evidence? Summary: The purpose of this practical application is to illustrate the management of GR defects with a primary outcome goal of complete root coverage. The consensus in dental literature and among expert clinicians is that root coverage may be attained through the application of different procedures and that outcomes are generally measured by reduced defect depth, gain in clinical attachment, and an increase in keratinized tissue (KT). These procedures may include the use of: 1) subepithelial connective tissue graft (SCTG); 2) coronally advanced flap; 3) free gingival graft; and 4) soft tissue graft substitutes (acellular dermal matrix and xenogeneic collagen matrix materials) and biologics (recombinant human platelet-derived growth factor and enamel matrix derivative). The variability in these techniques revolves around the inclusion or avoidance of a palatal donor graft. The decision as to how to approach a specific clinical GR-type defect should be a combination of considerations relative to the clinicians surgical goals and the patients understanding of the anticipated outcome. The associated systematic review (Chambrone and Tatakis, J Periodontol 2015;86(Suppl.):S8-S51) provides clear evidence that SCTG-based procedures provide the best outcome for mean and complete root coverage, as well as an increase in KT. Patient-reported outcomes, a topic that needs additional research, should be considered in the decision-making process. Conclusion: Based on the available evidence and the illustrated cases included in this practical application, root coverage can be predictably achieved and a successful clinical outcome can be maintained long term.

Unintentional root fragment retention in proximity to dental implants: a series of six human case reports.

There has been renewed interest in intentionally placing dental implants in proximity to or in contact with tooth root fragments. In clinical practice, human teeth are usually extracted due to nonrestorable caries, vertical or horizontal root fractures, periodontal disease, or endodontic failure, which is commonly accompanied by inflammation and bacterial contamination. The aim of this case series is to present the adverse effects in humans of clinically undetected root-to-implant contact (CURIC), where implants were unintentionally placed in proximity to undetected retained root fragments. The adverse effects of small (3 to 5 mm) root fragments were detectible 6 to 48 months post implant placement. Three out of seven implants in six patients were removed due to severe coronal bone loss. This differs from retrograde peri-implantitis, where only the apical area of the implant is affected and the coronal portion remains integrated. The detrimental effect of root fragment-to-implant contact is described along with its clinical management. Based on the review of currently relevant data, mixed results have been documented regarding the success of dental implants in proximity to tooth-root fragments. Careful evaluation of long-term, postloading results in humans where hopeless teeth have been extracted due to infection and significant bone loss are required before intentional root fragment retention is considered a safe and reliable clinical option for implant placement.

The immediate palatal plate

The immediate palatal plate is therapeutically beneficial for relief of temporomandibular joint pain, for reduction of occlusal trauma with and without selective grinding, for orthodontic tooth movement as a disarticulating device, and for relief of pericementitis subsequent to periodontal surgery. The immediate palatal plate is durable and well tolerated by patients and has established itself to be more than just an interim appliance.