Massimo de Sanctis

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.

Early healing of implants placed into fresh extraction sockets: an experimental study in the beagle dog. De novo bone formation

OBJECTIVES Describe the early phases of tissue integration in implants placed into fresh extraction sockets and test whether a new implant surface nano-topography (DCD nano-particles, Nanotite) promotes early osseointegration when compared with minimally rough surface implants (DAE, Osseotite). MATERIAL AND METHODS Sixteen beagle dogs received 64 test and control implants randomly installed into the distal socket of (3)P(3) and (4)P(4). Histomorphometric analysis of bone to implant contact (BIC) and bone area was performed at 4 h, 1, 2, 4 and 8 weeks. RESULTS Wound healing initiated with a coagulum that was substituted by a provisional matrix at 1 week. Bone formation started concomitant to a marked bone resorption. At 2 weeks, woven bone formation was evident and gradually remodelled into lamellar bone at 4 and 8 weeks. BIC increased similarly throughout the study in both groups with a tendency to higher percentages for the test devices at 2 and 4 weeks. The influence of the DCD nano-particles was more evident at the fourth premolar site. CONCLUSION Osseointegration occurred similarly at both implant groups, although the socket dimension appeared to influence bone healing. It is suggested that the enhanced nano-topography has a limited effect in the immediate implant surgical protocol.

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.

Early healing of implants placed into fresh extraction sockets: an experimental study in the beagle dog. III: soft tissue findings

AIM To describe histologically the early phases of soft tissue healing to implants placed into fresh extraction sockets. MATERIALS AND METHODS In 16 beagle dogs, 64 3.25-mm-wide cylindrical screw implants were inserted into the distal sockets of the third and fourth lower premolars using a one-stage trans-mucosal healing protocol. Biopsies were then taken at 1, 2, 4 and 8 weeks and prepared for histological examination. RESULTS One-week specimens showed a junctional epithelium and an underlying loose connective tissue rich in inflammatory cells. At 2 weeks, signs of epithelial proliferation and a more organized connective tissue were observed. At 4 and 8 weeks, inflammation was absent; the epithelium appeared mature and in close contact with the surface of the healing abutment or the implant. The connective tissue was dense in an area close to the implant surface and the fibres were aligned parallel to the implant surface. The soft tissue dimensions at 8 weeks were approximately 5 mm, including about 3-3.5 mm of epithelium and 1-1.5 mm of connective tissue. CONCLUSION Soft tissue healing to implants placed in fresh extraction sockets may result in a longer epithelial interface than implants placed in a healed ridge.

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.

Alveolar ridge preservation techniques: a systematic review and meta-analysis of histological and histomorphometrical data

AIM The aim of this article was to systematically review histological and histomorphometrical data from literature that provide information regarding the effect of alveolar ridge preservation procedures on healing after tooth extraction in humans. MATERIALS AND METHODS The MEDLINE-PubMed and the Cochrane CENTRAL databases were searched up to September 2012; 38 papers were selected from 646 founded. A meta-analysis was performed regarding the variations in the mean percentage of Bone, Connective Tissue and Residual Graft Material between three different types of Procedures. RESULTS The highest value regarding bone percentages is produced at 3 months by Procedures with Allografts (54.4%), while the lowest is obtained, at 5 months, by those using Xenografts (23.6%). Referring to connective tissue, the highest and lowest values are shown at 7 months, with Allografts (67%) and Alloplasts (27.1%), respectively. Regarding residual graft material, the lowest rates are displayed by Procedures with Allografts (12.4-21.11%), while those using Xenografts and Alloplasts showed the best results at 7 months (37.14 and 37.23%). No statistical difference was found. CONCLUSIONS With the limitations due to the features of the selected papers, no major histological and histomorphometrical differences arose among different procedures or when compared to spontaneous healing. Thus, it might be argued that in preserved sites it is unnecessary to wait over 3 to 4 months prior to implant insertion.

Flap approaches in plastic periodontal and implant surgery: critical elements in design and execution.

AIM To identify critical elements in design and execution of coronally advanced flap, lateral positioned flap and their variations for the treatment of facial gingival recessions or peri-implant soft tissue dehiscences. MATERIALS AND METHODS Clinical studies were identified with both electronic and hand searches, and examined for the following aspects: flap design and incision techniques, flap elevation, root conditioning, flap mobility, flap stability and suturing. Moreover, prognostic factors for complete recession coverage were identified. RESULTS Some critical elements are evident in flap design and execution: the dimension and the thickness of tissue positioned over the denuded roots; the use on root surface of enamel matrix derivate; the stability and suturing of the flap in a position coronal to the cemento-enamel junction. The pre-determination of the clinical cemento-enamel junction, smoking status, operator surgical skills and the compliance to a supportive care programme have a role in obtaining and maintaining a complete root coverage. CONCLUSIONS Different flap approaches are available when performing periodontal plastic surgery, resulting in a great variability in clinical outcomes. The possibility of using pedicle flaps alone to achieve complete soft tissue coverage of facial implant dehiscence has not yet been investigated.

Immediate implants at fresh extraction sockets: an experimental study in the beagle dog comparing four different implant systems. Soft tissue findings

OBJECTIVES To evaluate whether different implants placed immediately upon tooth extraction may affect the dimension and composition of the peri-implant soft tissues. MATERIAL AND METHODS Eight beagle dogs received implants randomly installed into the distal socket of 3P3 and 4P4. Four commercially available implant systems were evaluated: 3i Osseotite Certain straight; Astra MicroThread-OsseoSpeed; Thommen SPI Element; and Straumann ITI standard. Each animal provided four test implant sites. All animals were sacrificed 6 weeks after implant placement, providing specimens for the evaluation of the soft tissue dimensions by histometric analysis. RESULTS The biological width at 6 weeks after implant placement consisted of a junctional epithelium measuring between 2 and 2.7 mm and a connective tissue component between 1 and 1.8 mm with no statistical differences among the four implant systems. CONCLUSION This study failed to demonstrate differences in the soft tissue healing outcome when placing four different implant systems into fresh extraction sockets. Nevertheless, the length of the epithelium achieved with the four implant systems is longer than what has been reported when placing implants in healed-ridge experimental models.