Michele Nieri

Treatment of gingival recession with coronally advanced flap procedures: a systematic review

BACKGROUND The treatment of buccal gingival recessions is a common requirement due to aesthetic concern or root sensitivity. The aim of this manuscript was to systematically review the literature on coronally advanced flap (CAF) alone or in combination with tissue grafts, barrier membranes (BM), enamel matrix derivative (EMD) or other material for treating gingival recession. MATERIAL AND METHODS Randomized clinical trials on treatment of Miller Class I and II gingival recessions with at least 6 months of follow-up were identified. Data sources included electronic databases and hand-searched journals. The primary outcome variable was complete root coverage (CRC). The secondary outcome variables were recession reduction, clinical attachment gain, keratinized tissue gain, aesthetic satisfaction, root sensitivity, post-operative patient pain and complications. RESULTS A total of 794 Miller Class I and II gingival recessions in 530 patients from 25 RCTs were evaluated in this systematic review. CAF was associated with mean recession reduction and CRC. The addition of connective tissue graft (CTG) or EMD enhanced the clinical outcomes of CAF in terms of CRC, while BM did not. The results with respect to the adjunctive use of acellular dermal matrix were controversial. CONCLUSIONS CTG or EMD in conjunction with CAF enhances the probability of obtaining CRC in Miller Class I and II single gingival recessions.

Does placement of a connective tissue graft improve the outcomes of coronally advanced flap for coverage of single gingival recessions in upper anterior teeth? A multi‐centre, randomized, double‐blind, clinical trial

AIMS This parallel-group, multi-centre, double-blind, randomized-controlled clinical trial was undertaken to compare the clinical outcomes and patient morbidity of coronally advanced flap (CAF) alone or in combination with a connective tissue graft (CAF+CTG) in single Miller Class I and II gingival recessions. MATERIAL AND METHODS Three centres enrolled 85 patients with one recession each. Surgery was performed elevating a pedicle flap; 42 sites randomly received a graft under the flap. Measurements were taken by blind and calibrated examiners. Outcome measures included recession reduction, complete root coverage (CRC), intra-operative and post-operative morbidity, dentine sensitivity, and side effects. RESULTS No differences were noted in the intra-operative and post-operative patient-related variables between the two groups. Surgical time was significantly shorter in the CAF group. Recession reduction was not statistically different between the two groups, even though a model showed a tendency towards improved outcomes in sites treated with CAF+CTG (adjusted difference 0.33 mm, 95% CI=-0.06 to 0.72, p=0.1002). Significantly greater probability of CRC was observed after CAF+CTG (adjusted OR=5.09, 95% CI=1.69-17.57, p=0.0033). Dentine hypersensitivity improved in both the groups. CONCLUSIONS Both treatments were effective in providing a significant reduction of the baseline recession and dentine hypersensitivity, with only limited intra-operative and post-operative morbidity and side effects. Adjunctive application of a CTG under a CAF increased the probability of achieving CRC in maxillary Miller Class I and II defects.

Efficacy of periodontal plastic surgery procedures in the treatment of localized facial gingival recessions. A systematic review

BACKGROUND The aim of this Systematic Review (SR) was to assess the clinical efficacy of periodontal plastic surgery procedures in the treatment of localized gingival recessions (Rec) with or without inter-dental clinical attachment loss (iCAL). MATERIAL AND METHODS Electronic and hand searches were performed to identify randomized clinical trials (RCTs) on treatment of single gingival recessions with at least 6 months of follow-up. Primary outcome variable was complete root coverage (CRC). Secondary outcome variables were recession reduction (RecRed) and keratinized tissue (KT) gain. To evaluate treatment effect, Odds Ratios were combined for dichotomous data and mean differences in continuous data using a random-effect model. RESULTS Fifty-one RCTs (53 articles) with a total of 1574 treated patients (1744 recessions) were included in this SR. Finally, 30 groups of comparisons were identified and a total of 80 meta-analyses were performed. Coronally Advanced Flap (CAF) was associated with higher probability of CRC and higher amount of RecRed than Semilunar Coronal Positioned Flap (SCPF). The combination CAF plus Connective Tissue Graft (CAF+CTG) or CAF plus Enamel Matrix Derivative (CAF+EMD) was more effective than CAF alone in terms of CRC and RecRed. The combination CAF plus Collagen Matrix (CAF+CM) achieved higher RecRed than CAF alone. In addition, CAF+CTG achieved CRC more frequently than CAF+EMD, SCPF, Free Gingival Graft (FGG) and Laterally Positioned Flap (LPS). CAF+CTG was also associated with higher RecRed than Barrier Membranes (CAF+GTR), CAF+EMD and CAF+CM. GTR was not able to improve the clinical efficacy of CAF. Studies adding Acellular Dermal Matrix (ADM) under CAF showed a large heterogeneity and not significant benefits compared with CAF alone. Multiple combinations, using more than a single graft/biomaterial under the flap, usually provide similar or less benefits than simpler, control procedures in term of root coverage outcomes. CONCLUSIONS CAF procedures alone or with CTG, EMD are supported by large evidence in modern periodontal plastic surgery. CAF+CTG achieved the best clinical outcomes in single gingival recessions with or without iCAL.

Coronally advanced flap versus connective tissue graft in the treatment of multiple gingival recessions: a split‐mouth study with a 5‐year follow‐up

AIM The aim of this long-term study was to compare the clinical outcomes of coronally advanced flap (CAF) alone versus coronally advanced flap plus connective tissue graft (CAF+CTG) in the treatment of multiple gingival recessions using a split-mouth design over 5 years of follow-up. MATERIALS AND METHODS A total of 13 patients (mean age 31.4 years) showing multiple bilateral gingival recessions were treated. On one side, CAF+CTG was used, while in the contra-lateral side, a CAF alone was applied. Clinical outcomes were evaluated at the 6-month, 1-year and 5-year follow-ups. RESULTS A total of 93 Miller class I, II and III gingival recessions were treated. In the CAF+CTG-treated sites, the baseline gingival recession was 3.6 +/- 1.3 mm, while in the CAF-treated sites, it was 2.9 +/- 1.3 mm (p=0.0034). No difference in terms of the number of sites with complete root coverage (CRC) was reported (OR=0.49, p=0.1772) at the 6-month follow-up. At the 5-year follow-up, CAF+CTG-treated sites showed a higher percentage of sites with CRC (52%) than CAF-treated sites (35%) (OR=3.94; p=0.0239). An apical relapse of the gingival margin in CAF-treated sites was observed while a coronal improvement of the margin was noted in CAF+CTG-treated sites between the 6-month and the 5-year follow-ups. CONCLUSIONS CAF+CTG provided better CRC than CAF alone in the treatment of multiple gingival recessions at the 5-year follow-up.

Soft tissue management at implant sites

BACKGROUND Dental implants are widely used to replace lost teeth. It was suggested that surgical manipulation/augmentation of peri-implant soft tissue may be beneficial to increase the width/thickness of keratinized tissue (KT) and to enhance aesthetic outcomes of implant therapy. The aim of this paper was to provide a narrative review of the literature concerning soft tissue management at implant sites. MATERIAL AND METHODS Clinical studies were identified with both medline and hand searches. Three topics were considered in this review: (i) the significance of KT at implant sites, (ii) the surgical techniques to increase KT and (iii) soft tissue stability around implants. RESULTS Several papers concerning soft tissue management at implant sites were identified, mainly expert opinions, case reports and case series. In addition, a systematic review was selected. Generally, the level of evidence was weak. So far, literature analysis showed that (i) the width of KT did not influence the survival rate of dental implants; (ii) there is no evidence to recommend a specific technique to preserve/augment KT; and (iii) factors including bone level, KT and implant features have not been shown to be associated with future mucosal recession around dental implants. CONCLUSION Although scientific evidence in most part is lacking, soft tissue augmentation at implant sites may need to be considered in some clinical situations.

Severe periodontitis in young adults is associated with sub‐clinical atherosclerosis

AIM The aim of this study was to evaluate the association between severe periodontitis and sub-clinical atherosclerosis in young (< or =40 years) systemically healthy individuals. MATERIAL AND METHODS Ninety systemically healthy subjects, 45 affected by severe periodontitis (mean age 36.35+/-3.65 years) and 45 controls without a history of periodontal disease (mean age 33.78+/-3.28 years), were enrolled in this study. Patients and controls were paired for age, gender, body mass index and smoking habits. Carotid intima-media thickness (IMT) was bilaterally assessed by ultrasonography at the level of common carotid artery. Traditional cardiovascular risk factors for atherosclerosis were also evaluated. RESULTS The overall mean carotid IMT was 0.82+/-0.13 mm in the test group and 0.72+/-0.07 mm in the control group ( p<0.0001). Stepwise regression analysis showed that periodontitis ( p<0.0001) and regular physical activity ( p=0.0009) were predictor variables of overall mean carotid IMT. When considering an IMT> or =0.82 mm as the critical index of increased cardiovascular risk, periodontal patients overcame this threshold compared with healthy patients by an odds ratio=8.55 [confidence interval 95%: 2.38; 39.81]. No investigated haemostatic variable was associated with increased carotid IMT. CONCLUSION Severe periodontitis is associated with sub-clinical atherosclerosis in young systemically healthy patients.

Retrospective Evaluation of the Influence the Interleukin-1 Genotype on Radiographic Bone Levels in Treated Periodontal Patients Over 10 Years

BACKGROUND A difference in genetic susceptibility to plaque accumulation has been advocated to explain different responses to periodontal therapy. The purpose of this study is to assess the role of the interleukin-1(IL-1) polymorphism on the rate of bone and tooth loss in non-smoking periodontally treated patients during maintenance. METHODS Sixty consecutive non-smoking patients (mean age 46.8 ± 5.0) with moderate to severe periodontitis, treated and maintained for over 10 years were selected. At baseline (T0), radiographic evaluation (cementoenamel junction [CEJ]-root apex, CEJ-bottom of defect mesial and distal, CEJ-bone crest mesial and distal, crown-root ratio) was performed. All patients received scaling and root planing; 36 patients then underwent surgical therapy. Subsequently, all patients were enrolled in a periodontal maintenance program with recall visits every 3.4 ± 1.0 months for at least 10 years. At the latest recall visit (T2) the same radiographic measurements evaluated at baseline were taken and a DNA sample for IL-1 genetic susceptibility testing was collected and sent for analysis. RESULTS Twenty-three of the 60 patients (38.3%) were IL-1 genotype positive. A total of 52 teeth (3.3%) out of 1,566 were lost due to periodontitis between T0 and T2; 28 of 957 (2.9%) in the IL-1 genotype negative group and 24 of 609 (3.9%) in IL-1 genotype positive group. The mean variation in bone defect level (ΔBD) averaged -0.04 mm in IL-1 genotype negative patients and 0.01 mm in IL-1 genotype positive patients. The mean variation in bone crest level (ΔBC) averaged -0.24 mm in IL-1 genotype negative patients and -0.28 mm in IL-1 genotype positive patients. However, a few patients showed significant differences in response to therapy based on initial bone levels and genotype. IL-1 negative patients who showed minimal initial bone loss responded to the therapy better than the IL-1 positive patients. IL-1 positive patients with severe initial bone loss showed a better response to the therapy than IL-1 negative patients. CONCLUSIONS On average, there were no significant differences related to IL-1 genotype in tooth loss after 10 years in a non-smoking, well-maintained periodontal population. On an individual patient basis, the IL-1 genotype, in combination with the initial bone level, seems useful at the beginning of therapy for predicting bone level variation. J Periodontol 2001;72:767-773.

Lack of adjunctive benefit of Er:YAG laser in non-surgical periodontal treatment: a randomized split-mouth clinical trial

AIM This split-mouth, randomized, clinical trial aimed to evaluate the efficacy of erbium-doped:yttrium-aluminium-garnet (Er:YAG) laser application in non-surgical periodontal treatment. MATERIALS AND METHODS A total of 27 patients underwent four modalities of non-surgical therapy: supragingival debridement; scaling and root planing (SRP)+Er:YAG laser; Er:YAG laser; and SRP. Each strategy was randomly assigned and performed in one of the four quadrants. Clinical outcomes were evaluated at 3 and 6 months. Subjective benefits of patients have been evaluated by means of questionnaires. RESULTS Six months after therapy, Er:YAG laser showed no statistical difference in clinical attachment gain with respect to supragingival scaling [0.15 mm (95% CI -0.16; 0.46)], while SRP showed a greater attachment gain than the supragingival scaling [0.37 mm (95% CI 0.05; 0.68)]. No difference resulted between Er:YAG laser+SRP and SRP alone [0.05 mm (95% CI -0.25; 0.36)]. CONCLUSIONS The adjunctive use of Er:YAG laser to conventional SRP did not reveal a more effective result than SRP alone. Furthermore, the sites treated with Er:YAG laser showed similar results of the sites treated with supragingival scaling.

Quality of reporting of randomized clinical trials in implant dentistry. A systematic review on critical aspects in design, outcome assessment and clinical relevance

BACKGROUND The aim of this systematic review (SR) was to assess the quality of reporting randomized clinical trials (RCTs) in the field of implant dentistry, its evolution over time and the possible relations between quality items and reported outcomes. MATERIAL AND METHODS RCTs in implant dentistry were retrieved through electronic and hand searches. Risk of bias in individual studies was assessed focusing on study design, outcome assessment and clinical relevance. Associations between quality items and year of publication of RCTs or reporting of statistically significant outcomes were tested. RESULTS Among the 495 originally screened manuscripts published from 1989 to April 2011, 276 RCTs were assessed in this SR; 59% of them were published between 2006 and 2011. RCTs were mainly parallel (65%), with a single centre (83%) and a superiority design (88%). Trials in implant dentistry showed several methodological flaws: only 37% showed a random sequence generation at low risk of bias, 75% did not provide information on allocation concealment, only 12% performed a correct sample size calculation, the examiner was blind solely in 42% of studies where blinding was feasible. In addition, only 21% of RCTs declared operator experience and 31% reported patient-related outcomes. Many quality items improved over time. Allocation concealment at high risk of bias (p = 0.0125), no information on drop-out (p = 0.0318) and lack of CONSORT adherence (p = 0.0333) were associated with statistically significant reported outcomes. CONCLUSIONS The overall quality of reporting of RCTs in implant dentistry is poor and only partially improved in the last years. Caution is suggested when interpreting these RCTs since risk of bias was associated with higher chance of reporting of statistically significant results.

Coronally advanced flap with and without connective tissue graft for the treatment of single maxillary gingival recession with loss of inter-dental attachment. A randomized controlled clinical trial

BACKGROUND The aim of this randomized clinical trial (RCT) was to evaluate the adjunctive benefit of Connective Tissue Graft (CTG) to Coronally Advanced Flap (CAF) for the treatment of gingival recession associated with inter-dental clinical attachment loss equal or smaller to the buccal attachment loss (RT2). MATERIAL AND METHODS A total of 29 patients with one recession were enrolled; 15 patients were randomly assigned to CAF+CTG while 14 to CAF alone. Measurements were performed by a blind and calibrated examiner. Outcome measures included complete root coverage (CRC), recession reduction (RecRed), Root coverage Esthetic Score (RES), intra-operative and post-operative morbidity, and root sensitivity. RESULTS After 6 months, CAF+CTG resulted in better outcomes in terms of CRC (adjusted OR = 15.51, p = 0.0325) than CAF alone. CRC was observed in >80% of the cases treated with CAF+CTG when the baseline amount of inter-dental CAL was ≤ 3 mm. No difference was detected in term of RecRed. CAF+CTG was associated with longer surgical-time (p < 0.0001), higher number of days with post-operative morbidity (p = 0.0222) and the need for a greater number of analgesics (p = 0.0178) than CAF alone. No difference for final RES score was detected (p = 0.1612). CONCLUSION Both treatments can provide CRC in single gingival recession with inter-dental CAL loss. The application of CTG under CAF resulted in predictable CRC when inter-dental CAL was ≤ 3 mm.