Ilham Mounssif

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.

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.

Predetermination of Root Coverage

BACKGROUND A method to predetermine the maximum root coverage level (MRC) achievable with surgery was recently presented. The present study evaluates the predictability of such a method by comparing the predetermined MRC with that effectively achieved by means of root coverage surgical procedures. METHODS A total of 50 patients with single and multiple recession defects were enrolled. MRC was predetermined by an independent periodontist by assessing the ideal height of the interdental papilla. The distance from the apical reference point of a stent (StRP) and the MRC was measured 7 days before root coverage surgery. A total of 135 Miller Class I, II, and III gingival recessions were treated with the coronally advanced flap (CAF) or with the subepithelial connective tissue graft (SCTG). The distance from StRP and the gingival margin (GM) was measured by another independent periodontist 15, 30, and 90 days after surgery. RESULTS In 97 (71.8%) of 135 treated gingival recessions, the StRP-MRC distance coincided exactly with the StRP-GM distance. No statistically significant difference was demonstrated in the cases with exact predetermination between gingival recessions belonging to the maxilla or mandible and between gingival defects treated with CAF or SCTG. The StRP-MRC distance measured before surgery was greater in 24 recession defects (17.7%) and lower in 14 gingival recessions (10.3%) than the StRP-GM distance measured 90 days after surgery. More cases of underestimation and fewer cases with overestimation of the level of root coverage were found in the SCTG group compared to the CAF group. The difference was statistically significant (P <0.01). CONCLUSIONS The adopted method was effective in predetermining the position of the soft tissue margin 90 days after root coverage surgery. The cases with underestimation of the level of root coverage should be considered clinically and esthetically successful.

Hand and Ultrasonic Instrumentation in Combination With Root-Coverage Surgery : A Comparative Controlled Randomized Clinical Trial

BACKGROUND The role of vigorous root planing in the surgical treatment of gingival recession was recently questioned. The aim of the present randomized controlled split-mouth clinical study was to compare the effectiveness, in terms of root coverage, of hand and ultrasonic root instrumentation in combination with a coronally advanced flap for the treatment of isolated-type recession defects. METHODS Eleven systemically and periodontally healthy subjects with bilateral recession defects (> or = 3 mm) of similar (< or = 1 mm) depth affecting contralateral teeth were enrolled in the study. Only Miller Class I gingival recession with no deep cervical abrasion or root caries/demineralization were included in the study. Control root exposures were treated with curets, whereas test roots were instrumented with ultrasonic piezoelectric devices. Randomization for test and control treatment was performed by a coin toss immediately prior to surgery. All recessions were treated with a coronally advanced flap surgical technique. The clinical reevaluation was made 6 months after surgery. RESULTS The two approaches resulted in a high percentage of root coverage (95.4% in the control group and 84.2% in the test group) and complete root coverage (82% in the control group and 55% in the test teeth), with no statistically significant difference between them. Clinical attachment level gains were clinically significant in both groups (3.36 +/- 0.92 mm in the control group and 2.90 +/- 0.70 mm in the test group), with no statistically significant difference between them. The increase in keratinized tissue height was statistically significant in both groups (0.55 +/- 0.52 mm in the control group and 0.36 +/- 0.67 mm in the test group), with no difference between them. CONCLUSIONS The present study failed to demonstrate any superiority, in terms of root-coverage results, for hand instruments over ultrasonic treatment of the root surface in combination with coronally advanced flap mucogingival surgery. Further studies of longer-term duration and larger sample size could help to establish the superiority of one form of root instrumentation in conjunction with root-coverage surgery.

Coronally advanced flap + connective tissue graft techniques for the treatment of deep gingival recession in the lower incisors. A controlled randomized clinical trial

AIM The aim of this study was to compare the clinical and aesthetic outcomes of two different surgical approaches for the treatment of deep gingival recession affecting the mandibular incisors. METHODS Fifty patients with Miller class I and II gingival recessions (≥ 3 mm) in the lower incisors were enrolled. Twenty-five patients were randomly assigned to the control group and the other 25 patients to the test group. All defects were treated with the coronally advanced flap + connective tissue graft (CAF + CTG) and in the test group the labial submucosal tissue (LST) was removed. Post-operative morbidity was evaluated at 1 week. Clinical and aesthetic evaluations were made at 1 year. RESULTS Statistically greater recession reduction, probability of CRC (adjusted OR 7.94 95% CI = 1.88-33.50, p = 0.0024) and greater increase in GT were observed in the test group. Greater graft exposure and increase in KTH were demonstrated in the control group. Better aesthetics outcomes were observed in the test group. No statistically significant between groups differences were demonstrated in patient analgesic assumption and post-operative discomfort and bleeding. CONCLUSIONS LST removal during CAF + CTG surgery is indicated to provide better root coverage and aesthetic outcomes in the treatment of gingival recessions affecting the lower incisors.

Esthetic treatment of peri-implant soft tissue defects: a case report of a modified surgical-prosthetic approach.

A major esthetic concern is soft tissue defects around implant restorations, which often result in an extra long prosthetic crown. This report describes a modified prosthetic-surgical approach to the treatment of peri-implant horizontal and vertical soft tissue defects in an esthetically demanding patient. One month before surgery, the implant crown restoration was removed, the preexisting implant abutment was reduced, and a short provisional crown, at the level of the homologous contralateral incisor, was applied. A bilaminar technique, consisting of an envelope coronally advanced flap covering two connective tissue grafts, was used to treat the soft tissue defects around the implant site. Four months after surgery, a new implant abutment and provisional crown were applied for soft tissue conditioning before the final impression. Nine months after surgery, the peri-implant soft tissue margin was 4 mm more coronal compared with baseline and at the same soft tissue margin level of the right central incisor. A 2.2-mm increase in buccal soft tissue thickness measured 1.5 mm apical to the soft tissue margin was accomplished. The emergence profile of the replaced tooth faithfully reproduced that of the healthy homologous contralateral central incisor. Two years after surgery, the soft tissue margin was stable and the esthetic appearance of the implant site was well maintained. This report demonstrates the possibility of fully correcting severe vertical and horizontal peri-implant soft tissue defects and achieving high patient satisfaction through a combined mucogingival and prosthetic treatment.

Coronally Advanced Flap with Different Designs in the Treatment of Gingival Recession: A Comparative Controlled Randomized Clinical Trial.

The aim of this parallel double-blind randomized controlled clinical trial was to describe a modified approach using the coronally advanced flap (CAF) with triangular design and to compare its efficacy, in terms of root coverage and esthetics, with a trapezoidal type of CAF. A sample of 50 isolated Miller Class I and II gingival recessions with at least 1 mm of keratinized tissue apical to the defects were treated with CAF. Of these recessions, 25 were randomly treated with trapezoidal CAF (control group) while the other 25 (test group) were treated with a modified triangular CAF. The clinical and esthetic evaluations, made by the patient and an independent periodontist, were performed 3 months, 6 months, and 1 year after the surgery. No statistically significant difference was demonstrated between the two CAF groups in terms of recession reduction, complete root coverage, or 6-month and 1-year patient esthetic scores. Better 3-month patient esthetic evaluations and better periodontist root coverage, color match, and contiguity assessments were reported after triangular CAF. Trapezoidal CAF was associated with greater incidence of keloid formation. Single-type gingival recessions can be successfully covered with both types of CAF. The triangular CAF should be preferred for esthetically demanding patients.

Esthetics in periodontics and implantology

Periodontal plastic surgery comprises an increasing part of clinical periodontology. Clinical trials have traditionally used professionals to judge esthetic outcome, and few studies have addressed patient needs and requests (true end points). Development of universally accepted and validated methods for professional esthetic assessment, together with standardized questionnaires for patient-perceived outcome, may help to provide better insights into the true needs and benefits of periodontal and implant-associated plastic surgery. In this volume of Periodontology 2000, experienced researchers and clinicians from different subdisciplines of periodontology evaluate: treatment of gingival recession with or without papilla elevation; clinical crown lengthening in the natural dentition and in prosthodontic preparative treatment; periodontal regeneration around natural teeth; and soft-tissue augmentation in edentulous areas. Similarly, experts in different areas of implant science address esthetic outcomes with single and multiple implant rehabilitation, alveolar ridge preservation, implant positioning and immediate implant placement in the esthetic zone.

Soft-tissue dehiscence coverage at peri-implant sites

Soft-tissue dehiscence at the facial aspect of an osteointegrated implant is a common complication which impacts on the final esthetic result. The etiology and ways of diagnosing this condition are still controversial. Many factors seem to influence the position of the peri-implant soft-tissue margin, and some of these have been studied more carefully than others. Various surgical and combination surgical-prosthetic approaches have been described to treat soft-tissue dehiscence, with the latter appearing to be more predictable. This paper focuses on the factors affecting peri-implant soft-tissue margins and describes the different treatment approaches, reported in the literature, to treat buccal soft-tissue dehiscence, with more focus on the prosthetic-surgical-prosthetic approach.

Esthetic evaluation and patient‐centered outcomes in root‐coverage procedures

Treatment of buccal gingival recession is performed for esthetic concerns, root sensitivity, root caries and cervical abrasion resulting from incorrect toothbrushing. Over the years, clinicians and researchers have improved surgical techniques to achieve surrogate end points, such as complete root coverage, gingival recession reduction or keratinized tissue increase, ignoring the input from the patient regarding the true indications for treatment. In the past few years there has been an emphasis to include patient-centered outcomes in the evaluation of root-coverage procedures. The aim of this narrative review is to describe the professional objective assessment of the esthetic results after root-coverage procedures and the patient perception of outcome in terms of esthetics, postoperative morbidity and dentinal hypersensitivity resolution after the treatment of gingival recessions. The need to align professional (surrogate) end points with patient-centered outcomes (true end points) in the future is emphasized.