Martina Stefanini

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.

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.

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.

Root coverage in molar teeth: a comparative controlled randomized clinical trial

AIM To compare the clinical outcomes of laterally moved, coronally advanced flap (LMCAF) versus Bilaminar technique (BT) in the treatment of single gingival recession on molar teeth. MATERIAL AND METHODS Fifty patients showing Miller I and II gingival recessions at first molar teeth were treated: 25 were randomly assigned to the BT group and 25 belonged to the LMCAF group. Patients post-operative morbidity was assessed 1 week after the surgery, while aesthetic evaluation and the clinical evaluation were made 1 year later. RESULTS No statistically significant difference was demonstrated in terms of recession and PPD reduction. Statistically greater probability of complete root coverage (CRC, Odds Ratio 22.1) and greater increase in gingival thickness were observed in the BT group. Greater increase in keratinized tissue was obtained in the LMCAF. Patient satisfaction with aesthetics was very high in both treatment groups. Better post-operative course was observed in the LMCAF, while better post-operative sensitivity and root coverage evaluation were demonstrated in patients treated with BT. CONCLUSIONS Gingival recession at first molar teeth can be successfully treated with LMCAF and BT. Better CRC was achieved with BT, while more comfortable post-operative course was associated with the LMCAF.

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.

Long-Term Stability of Root Coverage by Coronally Advanced Flap Procedures

BACKGROUND This study compared 6-month and 3-year outcomes for root coverage (RC) by coronally advanced flap (CAF) procedures in localized gingival recessions. METHODS Two centers, that had participated in a 6-month multinational multicenter randomized clinical trial (RCT), followed up 18 patients with 36 Miller Class I and II defects that had been treated in a split-mouth design with CAF procedures or CAF + xenogeneic collagen matrix (CMX). Percentage of RC, complete root coverage (CRC), width, and thickness of keratinized tissue were assessed by the same masked examiners as after the 6-month RCT. RESULTS There was a high correlation between 6-month and 3-year RC outcomes for both CAF procedures. Mean RC after CAF + CMX amounted to 89.9% after 6 months and 91.7% after 3 years (Pearsons correlation: 0.91). Corresponding values for CAF were 83.7% versus 82.8% (Pearsons correlation: 0.94). Likewise, CRC was stable with 61%/61% for CAF + CMX and 39%/39% for CAF after 6 months/3 years, respectively. CONCLUSIONS In this 3-year follow-up of a subgroup of patients from a previous 6-month RCT, there was a high correlation between the results for RC after 6 months and 3 years, indicating their stability. These data suggest that 6-month outcomes may be useful to predict long-term outcomes in CAF procedures with or without additional use of CMX.