Umberto Pagliaro

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.

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.

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.

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.

The interproximal clinical attachment level to classify gingival recessions and predict root coverage outcomes: an explorative and reliability study

BACKGROUND The aims of this study were (i) to test the reliability of a new classification system of gingival recessions using the level of interproximal clinical attachment as an identification criterion and (ii) to explore the predictive value of the resulting classification system on the final root coverage outcomes. MATERIAL AND METHODS Patients showing at least one buccal gingival recession were recruited by one operator. Three recession types (RT) were identified. While class RT1 included gingival recession with no loss of interproximal attachment, class RT2 recession was associated with interproximal attachment loss less than or equal to the buccal site and class RT3 showed higher interproximal attachment loss than the buccal site. The classification was tested by two examiners blinded to the data collected by the other examiner. Intra-rater and inter-rater agreement was assessed. Furthermore, the 6-month root coverage outcomes of consecutively treated gingival recessions were retrospectively evaluated in order to explore the predictive value of the proposed classification on the final recession reduction (Rec Red). RESULTS The new classification system of gingival recessions was tested in a total of 116 gingival recessions (mean 3.2±1.2 mm) in 25 patients. The intra-class correlation coefficient (ICC) for inter-rater agreement was 0.86, showing an almost perfect agreement between the examiners. The RT classification was predictive of the final Rec Red (p<0.0001) at the 6-month follow-up in 109 treated gingival recessions. CONCLUSIONS The evaluation of interproximal clinical attachment level may be used to classify gingival recession defects and to predict the final root coverage outcomes.

Long-term outcomes of soft tissue augmentation around dental implants on soft and hard tissue stability: a systematic review.

AIM To investigate whether the height and volume of the soft tissues and peri-implant bone levels around dental implants are stable, when soft tissue augmentation has been performed. MATERIALS AND METHODS Three operators conducted a search on electronic databases (MEDLINE, COCHRANE, EMBASE) and a hand searching on the main journals dealing with periodontology and implantology until 30 October 2014. Only articles that considered peri-implant soft tissue augmentation performed in a group of at least 10 patients and with a follow-up of at least 1 year were selected. The outcome variables were peri-implant attached/keratinized tissue width (KTW) changes, peri-implant marginal soft tissue level (PSL) changes, and peri-implant marginal bone level (PBL) changes. The review was performed according to the PRISMA statements. RESULTS Ten articles were selected for the qualitative synthesis, but only one meta-analysis was accomplished, indicating that 1 year after implant recession coverage procedures, a mean gain of 1.65 ± 0.01 mm (90% CrI [1.44; 1.85]) was observed. CONCLUSIONS There is no long-term evidence whether augmented soft tissues can be maintained over time and able to influence the peri-implant bone levels.

Inter‐rater agreement in the diagnosis of mucositis and peri‐implantitis

AIM The objective was to assess the inter-rater agreement in the diagnosis of mucositis and peri-implantitis. MATERIAL AND METHODS Adult patients with ≥ 1 dental implant were eligible. Three operators examined the patients. One examiner allocated the patients to three groups of nine as follows: nine implants with peri-implantitis, nine implants with mucositis, and 9 implants with healthy mucosa. Each examiner recorded on all 27 patients (one implant per patient) recessions, probing depth, bleeding on probing, suppuration, keratinized tissue depth and bone loss, leading to a final diagnosis of mucositis, peri-implantitis or healthy mucosa. Examiners were independent and blinded to each other. RESULTS Fleiss k-statistic with quadratic weight in the diagnosis of peri-implantitis and mucositis was 0.66 [CI95%: 0.45-0.87]. A complete agreement was obtained only in 14 cases (52%). Fleiss k-statistics in bleeding on probing and bone loss were respectively 0.31 [CI95%: 0.20-0.41] and 0.70 [CI95%: 0.45-0.94]. Intra-class correlation coefficients for recession, probing depth and keratinized tissue depth were respectively 0.69 [CI95%: 0.62-0.75], 0.54 [CI95%: 0.44-0.63] and 0.56 [CI95%: 0.27-0.77]. CONCLUSIONS The inter-rater agreement in the diagnosis of peri-implant disease was qualified as merely good. This could also be due in part to the unclear definition of peri-implantitis and mucositis.

Fence technique: guided bone regeneration for extensive three-dimensional augmentation.

This report describes a novel bone reconstructive technique based on guided bone regeneration for extensive three-dimensional hard tissue augmentation. This two-stage technique utilizes bioresorbable osteosynthesis plates, pins, and collagen membranes that form a physical barrier resembling a fence, which contains the bone graft biomaterials composed of a combination of deproteinized bovine bone matrix and autologous bone grafted from intraoral sites. This technique can result in significant bone regeneration with minimal patient discomfort. Four case reports are presented. Histologic analysis of specimens shows the presence of mature bone. This procedure yields favorable results for bone formation, implant placement, and patient satisfaction.

Regenerative Therapies in the Treatment of Intrabony Defects Show High Clinical Efficacy.

Article Title and Bibliographic Information Periodontal Regeneration – Intrabony Defects: A Systematic Review From the AAP Regeneration Workshop. Kao RT, Nares S, Reynolds MA. J Periodontol 2015;86(Suppl.):S77-S104. Reviewers Francesco Cairo, DDS, Umberto Pagliaro, MD Purpose/Question What is the evidence for periodontal regeneration in intrabony defects related to patient-centered behavioral and systemic considerations, results, tooth mobility, flap design, defect morphology, and surgical complications? What is the evidence for classic regenerative approaches (demineralized freeze-dried bone allograft [DFDBA], GTR, and GTR combined with graft materials), laser-assisted regeneration (LAR), enamel matrix derivatives (EMD) (EMD alone, EMD versus GTR, and EMD combination), and recombinant human platelet-derived growth factor BB (rhPDGF-BB)? What is the optimal timing of regenerative treatment of intrabony defects in relation to orthodontic and endodontic therapy? Source of Funding The authors reported that Dr. Nares has received lecture fees from DENTSPLY (York, Pennsylvania). Dr. Reynolds has received research funding from Millennium Dental Technologies (Cerritos, California) and Zimmer Dental (Carlsbad, California), and is an unpaid consultant for LifeNet Health (Virginia Beach, Virginia); Dr. Kao reported no conflicts of interest related to this review. The 2014 Regeneration Workshop was hosted by the American Academy of Periodontology (AAP) and supported in part by the AAP Foundation, Geistlich Pharma North America, Colgate-Palmolive, and the Osteology Foundation. Type of Study/Design Comprehensive literature review Level of Evidence Level 3: Consensus, disease-oriented evidence Strength of Recommendation Grade Grade C: Consensus, disease-oriented evidence

From initial case report to randomized clinical trial through 20 years of research in periodontal therapy

AIM Case reports (CRs) are often the first publication of a new treatment, but randomized clinical trials (RCTs) are needed to confirm the data. The aim of this study was to evaluate how many therapies published as CRs were followed by RCTs of these therapies over a 20-year period. MATERIAL AND METHODS Two researchers conducted a search through international periodontal journals and found the CRs on periodontal treatments published from 1984 to 1986. Subsequent electronic searches made it possible to verify how many of the treatments published as CRs were also investigated through RCTs over the following 20 years. RESULTS Thirty-one different therapies were selected out of the 33 published CRs; 15 (48%) of these 31 treatments were investigated by RCTs over the next 20 years. CONCLUSIONS As 52% of the CRs were not validated by RCTs, practitioners should view their results with caution.