Giovanni Zucchelli

Enamel Matrix Proteins and Guided Tissue Regeneration With Titanium-Reinforced Expanded PolytetrafluoroethyleneMembranes in the Treatment of Infrabony Defects: A Comparative Controlled Clinical Trial

BACKGROUND Several studies have documented the clinical efficacy of guided tissue regeneration (GTR) with non-resorbable expanded polytetrafluoroethylene (ePTFE) membranes and enamel matrix proteins (EMP) in the treatment of infrabony defects. The objective of this controlled clinical study was to compare the clinical outcomes of 3 surgical modalities in the treatment of deep interproximal infrabony defects. METHODS Ninety (90) defects in 90 healthy subjects affected by chronic periodontitis were assigned to 1 of 3 treatment groups by blocking to prognostic variables. The test group was treated with the application of EMP and the simplified papilla preservation (SPP) technique; the second group was treated with titanium-reinforced ePFTE membranes and the SPP technique; and the third group was treated with the SPP technique used as access flap control procedure. No differences were observed in terms of baseline oral hygiene and defect characteristics among the 3 groups, indicating that the blocking approach was effective. A stringent infection control program was adopted for 1 year. RESULTS The 1-year results indicated that: 1) all treatment modalities resulted in clinically significant improvements in clinical attachment levels (CAL) and reduction in probing depth (PD); 2) a statistically significant treatment effect was demonstrated comparing the EMP test, the membrane control, and the flap control groups in terms of CAL gains; 3) both the EMP test and the membrane control groups showed significant CAL gains compared to the flap control group; 4) a statistically significantly greater amount of CAL gain was demonstrated in GTR-treated compared to EMP-treated patients; 5) deeper residual probing depths but smaller increases in gingival recession were demonstrated following EMP therapy; and 6) smoking habits reduced the clinical outcomes of both regenerative procedures. CONCLUSIONS The use of a regenerative procedure is indicated in the treatment of deep vertical bony defects since both the regenerative techniques (GTR and EMD) in the present study resulted in clinically and statistically significant improvements in clinical parameters compared to the access flap procedure. The use of EMP can be helpful in esthetically-sensitive sites and in reducing patient morbidity. J Periodontol 2002;73:3-12.

Coronally Advanced Flap With and Without Vertical Releasing Incisions for the Treatment of Multiple Gingival Recessions: A Comparative Controlled Randomized Clinical Trial

BACKGROUND Vertical releasing incisions might damage the blood supply to the flap and result in unesthetic visible white scars. The aim of the present study was to compare root coverage and esthetic outcomes of the coronally advanced flap (CAF) with and without vertical releasing incisions in the treatment of multiple gingival recessions. METHODS Thirty-two systemically and periodontally healthy subjects with esthetic complaints due to the exposure of Miller Class I and II multiple (at least two) gingival recession defects (> or =1 mm) affecting adjacent teeth of the same quadrant of the upper jaw were enrolled in the study. Sixteen patients (with 45 gingival recessions) were randomly assigned to the control group, and the other 16 patients (with 47 recession defects) were assigned to the test group. All recessions were treated with a CAF; vertical releasing incisions were performed in the control group, whereas an envelope-type flap was used in the test group. The patients postoperative morbidity was assessed 1 week after the surgery, whereas the esthetic evaluation, made by the patient and independent periodontist, and the clinical evaluation were made 1 year later. RESULTS Surgical time was significantly shorter in the envelope-type CAF group. No statistically significant difference was demonstrated between the two groups in terms of recession reduction and clinical attachment level gain. A statistically greater probability of complete root coverage (adjusted odds ratio, 3.76; 95% confidence interval: 0.92 to 15.33; P <0.05) and a greater increase in buccal keratinized tissue height were observed with the envelope type of CAF. Patient satisfaction with esthetics was very high in both treatment groups, with no statistically significant differences between them. A better postoperative course and better results in the esthetic evaluation made by an independent periodontist were demonstrated in patients treated with the envelope type of CAF. CONCLUSIONS Both CAF techniques were effective in reducing recession depth. The envelope type of CAF was associated with an increased probability of achieving complete root coverage and with a better postoperative course. Keloid formation along the vertical releasing incisions was responsible for the worst esthetic evaluation made by an independent expert periodontist.

Treatment of gingival recession defects with a coronally advanced flap and a xenogeneic collagen matrix: a multicenter randomized clinical trial

AIM To evaluate the clinical outcomes of the use of a xenogeneic collagen matrix (CM) in combination with the coronally advanced flap (CAF) in the treatment of localized recession defects. MATERIAL & METHODS In a multicentre single-blinded, randomized, controlled, split-mouth trial, 90 recessions (Miller I, II) in 45 patients received either CAF + CM or CAF alone. RESULTS At 6 months, root coverage (primary outcome) was 75.29% for test and 72.66% for control defects (p = 0.169), with 36% of test and 31% of control defects exhibiting complete coverage. The increase in mean width of keratinized tissue (KT) was higher in test (from 1.97 to 2.90 mm) than in control defects (from 2.00 to 2.57 mm) (p = 0.036). Likewise, test sites had more gain in gingival thickness (GT) (0.59 mm) than control sites (0.34 mm) (p = 0.003). Larger (≥3 mm) recessions (n = 35 patients) treated with CM showed higher root coverage (72.03% versus 66.16%, p = 0.043), as well as more gain in KT and GT. CONCLUSIONS CAF + CM was not superior with regard to root coverage, but enhanced gingival thickness and width of keratinized tissue when compared with CAF alone. For the coverage of larger defects, CAF + CM was more effective.

Patient morbidity and root coverage outcome after subepithelial connective tissue and de‐epithelialized grafts: a comparative randomized‐controlled clinical trial

AIMS The aim of this randomized-controlled clinical trial was to compare the patient morbidity and root coverage outcomes of a coronally advanced flap (CAF) with connective tissue (CTG) or de-epithelialized gingival (DGG) grafts. METHODS Fifty patients with one recession each were treated. In the control group, the CTG was harvested using the trap-door approach while in the test group the CTG resulted from the de-epithelialization of a free gingival graft. RESULTS No statistically significant differences were demonstrated between groups in patientss pain killer consumption, post-operative discomfort and bleeding. Lower stress and better ability to chew were demonstrated in the CTG group. Analgesic consumption increased with increasing height of the graft and in the case of dehiscence/necrosis of the primary flap. Pain was negatively correlated with the residual thickness of soft tissue covering the palatal bone. A statistically greater increase in buccal soft tissue thickness was observed in the DGG group. CONCLUSIONS No differences were demonstrated in the post-operative pain and root coverage outcome in patients subjected to CAF with CTG or DGG.

Enhanced superoxide production with no change of the antioxidant activity in gingival fluid of patients with chronic adult periodontitis

In the gingival crevicular fluid (GCF) of control and chronic adult periodontitis (CAP) patients there is a spontaneous release of O2- radicals from polymorphonuclear leukocytes (PMN). The addition of the exogenous stimuli phorbol myristate acetate (PMA) decreased the O2-. formation in control GCF, while in CAP patients produced a marked enhancement of O2-. generation. The circulating PMN of control subjects did not show a spontaneous O2-. formation, differently from CAP patients. On the contrary, a similar O2-. production was measured when the circulating PMN were stimulated with PMA. Moreover, the antioxidant activity measured in 10 microliters of cell free gingival supernatant (GS) of control and CAP patients had the same values by inhibiting 12.6% and 18.9% respectively of the O2- formation supported by a xanthine/xanthine oxidase system. Probably, the protective or destructive effect of PMN in GCF of CAP patients depends on the variations of the rate of O2- formation in respect to the intrinsic antioxidant property of GS.

Immediate implants at fresh extraction sockets: bone healing in four different implant systems.

OBJECTIVES To describe the differences in bone healing, when placing four different implant systems in fresh extraction sockets. MATERIAL AND METHODS Eight beagle dogs received implants randomly installed into the distal socket of three P3 and four P4. Four-implant systems were evaluated. Each animal provided four test implant sites. All animals were sacrificed at 6 weeks after implant placement, providing specimens for histo-morphometric analysis of bone to implant contact (BIC), bone area, new bone formation, as well as histometric measurements of the ridge alterations. RESULTS No statistically significant difference was observed among the four-implant systems. The mean BIC % ranged between 58.5% and 72.1%. Bone modelling of the buccal plate was marked and amounted approximately to 2.5 mm, independently of the system used. CONCLUSION This study failed to demonstrate differences in the healing pattern after 6 weeks when placing four different implant systems in fresh extraction sockets. In spite of achieving predictable osteointegration with the four implants studied, the occurrence of buccal bone resorption may limit the use of this surgical approach.

Periodontal plastic surgery

The aim of the present article is to summarize current knowledge in terms of the etiology, diagnosis, prognosis and surgical treatment of gingival recession. Whilst the main etiological factors (i.e. toothbrushing trauma and bacterial plaque) are well established, challenges still remain to be solved in the diagnostic, prognostic and classification processes of gingival recession, especially when the main reference parameter - the cemento-enamel junction - is no longer detectable on the affected tooth or when there is a slight loss of periodontal interdental attachment. Root coverage in single type gingival recession defects is a very predictable outcome following the use of various surgical techniques. The coronally advanced flap, with or without connective tissue grafting, is the technique of choice. The adjunctive use of connective tissue grafts improves the probability of achieving complete root coverage. Surgical coverage of multiple gingival recessions is also predictable with the coronally advanced flap and the coronally advanced flap plus the connective tissue graft, but no data are available indicating which, and how many, gingival recessions should be treated adjunctively with connective tissue grafting in order to limit patient morbidity and improve the esthetic outcome. None of the allograft materials currently available can be considered as a full substitute for the connective tissue graft, even if some recent results are encouraging. The need for future studies with patient-based outcomes (i.e. esthetics and morbidity) as primary objectives is emphasized in this review.

Non-carious cervical lesions associated with gingival recessions: a decision-making process.

BACKGROUND A method to predetermine the maximum root coverage level (MRC) was recently demonstrated to be reliable in predicting the position of the soft tissue margin after root coverage surgery. The aim of the present study is to suggest a decision-making process for treating non-carious cervical lesions (NCCLs) associated with gingival recessions based upon the topographic relationship between the MRC and NCCL and to assess patient and independent-periodontist esthetic evaluations. METHODS Five treatments were performed in 94 patients with NCCLs associated with a single gingival recession: 1) coronally advanced flap (CAF); 2) bilaminar procedure; 3) coronal odontoplasty plus restoration plus root odontoplasty plus CAF; 4) restoration plus CAF; and 5) restorative therapy. Clinical and esthetic evaluations made by the patient and an independent periodontist were done 1 year after treatments. RESULTS The satisfaction of the patient and periodontist with esthetics was very high in all NCCL treatments and Miller Class gingival recessions. The patient satisfaction and evaluation of root coverage and the periodontist evaluation of root coverage were statistically correlated with color-match evaluations and not with the amount of root coverage clinically achieved in each patient. CONCLUSION The proposed approaches provided good esthetic appearance and correct emergence profile for the great majority of NCCLs associated with gingival recessions.

Root Coverage Esthetic Score After Treatment of Gingival Recession: An Interrater Agreement Multicenter Study

BACKGROUND The root coverage esthetic score (RES) system was proposed for evaluating esthetic outcomes of root coverage procedures. The aim of this multicenter study is to assess the interrater agreement of the RES among expert periodontists. METHODS Eleven periodontists were selected in different clinical centers. Each operator had ≥15 years of experience in mucogingival surgery. Each periodontist was trained to use RES before the beginning of the study. Subsequently, baseline and post-treatment (6 months) photographs of 41 Class I and II gingival recessions in 41 patients were separately given to each operator who evaluated the outcomes according to the RES method. A two-way random interclass correlation coefficient and 95% confidence interval (CI) were used to assess the global interrater agreement for RESs. RESULTS The total interrater agreement for RESs was 0.92 (95% CI: 0.88 to 0.95), which indicated that an almost perfect agreement was achieved. CONCLUSION Tested individually by a group of periodontists, the RES seems to be a reliable method for assessing the esthetic outcomes of root coverage procedures.

Coronally advanced flap with and without connective tissue graft for the treatment of multiple gingival recessions: a comparative short- and long-term controlled randomized clinical trial.

AIM The aim of this study was to compare short- and long-term root coverage and aesthetic outcomes of the coronally advanced flap (CAF) alone or in combination with a connective tissue graft (CTG) for the treatment of multiple gingival recessions. METHODS Fifty patients with multiple (≥2) adjacent gingival recessions (≥2 mm) in the upper jaw were enrolled. Twenty-five patients were randomly assigned to the control group (CAF), and the other 25 patients to the test group (CAF + CTG). Clinical outcomes were evaluated at 6 months, 1 and 5 years. The aesthetic evaluations were made 1 and 5 years after the surgery. RESULTS No statistically significant difference was demonstrated between the two groups in terms of Rec Red and complete root coverage (CRC) at 6 months and 1 year. At 5 years, statistically greater recession reduction and probability of CRC, greater increase in buccal KTH and better contour evaluation made by an independent periodontist were observed in the CAF + CTG group. Better post-operative course and better colour match were demonstrated in CAF-treated patients both at 1 and 5 years. CONCLUSIONS CAF + CTG provided better CRC at 5 years; keloid formation due to graft exposure was responsible for the worse colour match evaluation.