Comparison of two soft tissue substitutes for the treatment of gingival recession defects: an animal histological study

Abstract Objectives: This study aimed to compare two different soft tissue replacement grafts in their ability to treat gingival recession defects and successfully integrate with the surrounding tissues. Methodology: Nine beagle dogs were included and followed up to 10 weeks. Sites for intervention were allocated to one of the grafting materials investigated. Treatment consisted of coronally advanced flap combined with one of the two soft tissue substitutes on a previous surgically created defect. Materials employed were porcine-derived acellular dermal matrix (ADM) [Novomatrix™ (Test)] and collagen-based matrix (CBM) [Mucograft® (Control)]. Animals were sacrificed at 2, 6, and 10 weeks postoperatively and compared using descriptive histology and histomorphometric outcomes. Results: Macroscopic findings were similar between test and control groups at all intervals. After 10 weeks, both groups demonstrated successful incorporation of the grafting materials without signs of rejection and with comparable tissue integration. The histomorphometric data were similar between groups at 2 weeks; however, the test group provided greater root coverage and increase in tissue thickness than the control at 6- and 10-weeks post surgically. Conclusions: Both porcine-derived ADM and CBM revealed similar histological outcomes with successful integration and absence of adverse events. Test group provided superior outcomes regarding root coverage and increase in tissue thickness.

Treatment of peri-implant soft tissue defects: a narrative review

Abstract Soft tissue defects around dental implants, such as papilla or volume loss, peri-implant recession and alterations of the ridge color and/or texture, lead to esthetic and functional complaints. Treatments of these defects in implants are more demanding than in teeth because peri-implant tissue exhibits different anatomical and histological characteristics. This narrative review discusses the proposed treatments for soft tissue defects around implants in the current literature. Several clinical and pre-clinical studies addressed methods to augment the quantity of the peri-implant keratinized mucosa. Autogenous grafts performed better than soft tissue substitutes in the treatment of soft tissue defects, but there is no clinical consensus on the more appropriate donor area for connective tissue grafts. Treatment for facial volume loss, alterations on the mucosa color or texture and shallow peri-implant recessions are more predictable than deep recessions and sites that present loss of papilla. Correction of peri-implant soft tissue defects may be challenging, especially in areas that exhibit larger defects and interproximal loss. Therefore, the regeneration of soft and hard tissues during implant treatment is important to prevent the occurrence of these alterations.

Comparação do enxerto de tecido conjuntivo e de uma matriz de colágeno xenógena no recobrimento radicular de recessões gengivais unitárias em fenótipo gengival fino / Comparison of connective tissue graft and a xenogeneic collagen matrix in root coverage of single gingival recessions in thin gingival phenotype

As recessões gengivais podem causar hipersensibilidade dentinária, desconforto estético e aumentar a prevalência de cáries ou lesões cervicais não-cariosas. Cirurgias para recobrimento radicular associadas a enxertos têm sido consideradas padrão ouro no tratamento das recessões gengivais. OBJETIVO: Comparar o enxerto de tecido conjuntivo e uma matriz de colágeno xenógena no recobrimento radicular de recessões gengivais unitárias em fenótipo gengival fino, em 6 meses de acompanhamento. METODOLOGIA: Este ensaio clínico, controlado, randomizado, duplo cego, de boca dividida, avaliou 28 pacientes com recessões gengivais bilaterais submetidos à cirurgia para recobrimento radicular, através do retalho estendido associado ao enxerto de tecido conjuntivo subepitelial (grupo controle) e matriz de colágeno (grupo teste). Os parâmetros avaliados foram profundidade de sondagem, recessão gengival, nível clínico de inserção, mucosa ceratinizada e sangramento à sondagem tanto dos dentes que receberam os enxertos, como dos dentes distais e mesiais a esse. Além de espessura gengival e alteração do fenótipo gengival dos dentes que receberam os enxertos, dor pós-operatória e qualidade de vida, através do Oral Health-Related Quality of Life, no baseline, três e seis meses após a cirurgia. Os dados foram analisados estatisticamente através dos testes de Friedman, Wilcoxon, Mann-Whitney, Qui-quadrado, McNemar, ANOVA e teste t, sendo pré-estabelecido um nível de significância de 5%. RESULTADOS: 14 homens e 14 mulheres foram incluídos, com uma média de idade de 30,3 (± 6,2) anos. Foram observadas reduções estatisticamente significativas para a recessão gengival e ganho significativo do nível clínico de inserção tanto dos dentes que receberam os enxertos (p<0,001), como dos dentes distais (p=0,001) e mesiais (p<0,001), na análise intragrupo, em ambos os grupos de tratamento, nos períodos avaliados. Além disso, houve aumento significativo da mucosa ceratinizada (p<0,001) e espessura gengival (p<0,001) para os grupos teste e controle, respectivamente, com diferença significativa entre os grupos de tratamento. O protocolo de tratamento proposto também foi capaz melhorar a qualidade de vida (p<0,001). CONCLUSÃO: Ambos os tratamentos resultaram em melhoria dos parâmetros clínicos avaliados em seis meses de acompanhamento. A matriz de colágeno representa uma excelente alternativa ao enxerto de tecido conjuntivo subepitelial no tratamento de recessões gengivais unitárias em fenótipo gengival fino (AU).

Gingival recession may cause dental hypersensitivity, esthetical discomfort and increase the prevalence of carious or non-carious cervical lesion. Root coverage procedures using grafts placement has been the gold standard on this treatment. AIM: To compare the root coverage performed connective tissue graft and collagen matrix using the extended flap technique in single gingival recessions in thin gingival phenotype, at 6 months of follow- up. METHOD: This controlled, randomized, double-blind, split-mouth, clinical trial evaluated 28 patients with bilateral gingival recession subjected to root coverage procedure through extended flap technique with subepithelial connective tissue graft (control) and xenogenic collagen matrix (test). The parameters evaluated were deep on probing, gingival recession, clinical attachment level, keratinized mucosa and bleeding on probing for teeth that received the graft and the distal and mesial teeth. In addition, gingival thickness and gingival phenotype change of the teeth that received the grafts, postoperative pain and quality of life through Oral Health-Related Quality of Life, at baseline, three and six months after surgery. The data were statistically analyzed through the tests of Friedman, Wilcoxon, Mann-Whitney, Qui-quadrado, McNemar, ANOVA and t Test. The significance level of 5% was pre-estlablished. RESULTS: 14 men and 14 women were included, with an average of 30.3 years (± 6.2). Statistically significant reductions were observed for gingival recession and clinical attachment level significant increase of both teeth of the grafts (p <0.001), distal (p=0.001) and mesial (p<0.001) teeth, within each group and in both treatment groups, during the follow-up. In addition, there was keratinized mucosa significant increase (p <0.001) and gingival thickness (p<0.001) for test and control group, respectively, with statistical difference between groups. The treatment protocol was able to improve the quality of lite (p<0.001). CONCLUSION: Both treatments resulted in improved clinical parameters at six months of follow-up. The collagen matrix represents an excellent alternative to the subepithelial connective tissue graft in the treatment of single gingival recessions in thin gingival phenotype (AU)

Relación entre frenillos labiales y periodonto en una población peruana / Relationship between labial frenulum and periodontium in a Peruvian population

RESUMEN: Los frenillos aberrantes están incluidos dentro de las deformidades mucogingivales, y estas pueden alterar la función y la estética del periodonto de protección. Este estudio tuvo como objetivo evaluar la inserción de los frenillos labiales y establecer una relación con la pérdida papilar y recesión gingival a nivel de los dientes anterosuperiores y anteroinferiores. Materiales y métodos Estudio transversal que evaluó a 97 pacientes sistémicamente sanos en los cuales se evaluó el tipo de frenillo (TF), la altura del frenillo (AF), el tipo de recesión gingival y la pérdida papilar al nivel de los sectores anteriores maxilar y mandibular. Resultados El TF más prevalente fue el mucoso, con un 54,6% y 93,8% de prevalencia a nivel maxilar y de la mandíbula respectivamente; la AF promedio fue de 8,37mm ± 2,671mm para el frenillo labial maxilar y 8,33mm ± 1,657mm para el frenillo labial mandibular. No se encontraron relaciones entre el TF, la AF con la presencia y severidad de pérdida papilar y recesión gingival al nivel de los incisivos centrales (p>0,05). Conclusión El frenillo más común de la población estudiada fue el frenillo mucoso, no existiendo una relación directa entre su clasificación e inserción con la presencia de una recesión gingival o pérdida papilar.

ABSTRACT: Aberrant frenums are included within the mucogingival deformities, which can alter the function and aesthetic periodontal protection. This study aimed to evaluate the adherence of labial frenulum and establish a relationship with papillary loss and gingival recession of the anterior teeth in maxilla and in the jaw. Materials and methods A cross-sectional study was conducted on 97 systemically healthy patients in whom the type of frenulum (TF), the height of the frenulum (AF), the type of gingival recession, and papillary loss was evaluated in the upper maxillary and mandibular sectors. Results The most prevalent frenum was the mucosal. The prevalence of TF was 54.6% and 93.8% of maxilla and mandible, respectively. The mean AF was 8.37mm ± 2.671mm for the labial frenulum in maxillary, and 8.33mm ± 1.657mm for frenulum. No relationship was found between the TF, AF with the presence and severity of papillary loss and gingival recession (P>.05). Conclusion The most common frenulum of the study population was the mucosal frenulum. There was no direct relationship between the classification and adherence of the frenulum with the presence of gingival recession or papillary loss.

The influence of primary occlusal trauma on the development of gingival recession / La influencia del trauma oclusal primario en el desarrollo de la recesión gingival

This study aimed to histometrically evaluate the presence of gingival recession in the mesial surface of the teeth of rats experimentally subjected to primary occlusal trauma. This evaluation verified the distance from the cement-enamel junction (CEJ) to the free marginal gingiva (FMG) and to the height of the alveolar bone crest (CEJ-crest bone distance). There were 10 animals, randomly divided into 2 groups: occlusal trauma (OT) (n = 5) - creation of an occlusal interference by fixing an orthodontic wire segment on the mandibular first molar occlusal face, which was randomly chosen, and a Control Group (CG) (n = 5) - five animals with no exposure to the OT variable were euthanised after 14 days to obtain the initial parameters. The inter-group evaluation showed there was no significant difference between OT × CG when the CEJ-FGM distance (P = 0.192) was evaluated after 14 days, but there was a significant difference between the two groups as regards the CEJ-alveolar crest bone distance (P = 0.0142). Thus, it can be concluded that the OT induction model, after 14 days of experiment, promoted bone resorption. This was observed by the increase in the CEJ-alveolar crest bone distance. It also did not promote gingival recession, which was evaluated by the CEJ-FGM distance.

El objetivo de este estudio fue evaluar histométricamente en ratas la presencia de recesión gingival en la superficie mesial de los dientes sometidos experimentalmente a trauma oclusal primario a partir de la evaluación de la distancia desde la unión esmalte cemento (CEJ) a la encía marginal libre y la altura de la cresta ósea restante (distancia de la CEJ-cresta ósea) Con este fin, 10 animales fueron divididos al azar en 2 grupos: trauma oclusal (TO) (n = 5) - creación de una interferencia oclusal mediante la fijación de un segmento de alambre de ortodoncia en la superficie oclusal del primer molar elegido al azar; y un grupo control (CO) (n = 5) -5 animales sin la introducción de la variable TO fueron sometidos a eutanasia después de 14 días para obtener los parámetros iniciales. La evaluación intergrupo no mostró diferencias significativas entre los grupos TO × CO al evaluar después de 14 días la distancia de la CEJ-encía marginal libre (p = 0,192) pero mostró una diferencia significativa entre los grupos TO × CO en cuanto a distancia de la CEJ-cresta ósea alveolar (p = 0,0142). Por lo tanto, se concluye que el modelo de inducción del TO después de 14 días del experimento promueve reabsorción ósea siendo observado por el aumento en la distancia de la CEJ-cresta ósea alveolar y no promueve la recesión gingival evaluada a partir de la distancia de la CEJ-encía marginal.

Reconstrucción de la papila gingival alrededor del implante mediante técnica novedosa / Papilla reconstruction around the implant using novel technique

La reconstrucción de la estética gingival (rosada) es un tema importante en la odontología implanto-soportada moderna, y cualquier resultado estético comprometido se considera un fracaso. En la literatura se proponen variados enfoques quirúrgicos y no quirúrgicos para reconstruir la papila interdental perdida. En esta técnica modificada, el extremo distal del injerto pediculado fue dividido en dos partes creando una estructura bífida, que luego se colocó alrededor del pilar y suturó por vestibular. Esta técnica dio como resultado un aumento significativo de volumen de la papila en las direcciones coronaria y vestibular. El injerto de tejido conectivo pediculado subepitelial asociado con un colgajo coronalmente desplazado parece ser un abordaje viable para el tratamiento de la papila ausente, asociado con restauraciones implanto-soportadas.

Rebuilding the pink esthetic is an important issue in modern esthetic implant dentistry, and any compromised esthetic results following implant-supported restorations are considered failures. Several surgical and nonsurgical approaches are proposed in the literature to reconstruct the lost interdental papilla. In this modified technique the distal end of the pedicle graft was divided into two parts creating a bifid, which were then placed around the abutment and sutured on the facial aspect. This technique resulted in a significant gain of papillary volume in both coronal and facial directions. The subepithelial connective pedicle graft associated with a coronally advanced flap seems to be a viable approach for the treatment of missing papilla associated with implant-supported restorations.

Morphological patterns of gingival recession in adult chilean population / Patrones morfológicos de recesiones gingivales en población chilena adulta

The aim of this study was to determine the prevalence of morphological patterns of gingival recession, attachment loss, and type of interdental papilla in adult subjects of different age in a Chilean population. A total of 105 patients with ages ranging from 18 to 64 years of both sexes participated in our study. The prevalence of gingival recession was 92.38 percent, affecting 530 teeth. The morphological pattern of gingival recession most common was class II (34.94 percent), followed by types III, I and IV. According to ANOVA test, differences were significant in relation to the mean number of affected teeth. Of those who had recessions, females had a slightly higher prevalence. The range 18-34 years showed a prevalence of 82.22 percent and from 35 years increased to 100 percent. The vertical extent between 0-3mm and horizontal between 4-7mm were the most prevalent affected 88.68 percent and 59.05 percent of teeth, respectively. Attachment loss was 3-4mm in 316 teeth (59.62 percent), and the most prevalent interdental papillae on the different patterns was type I (40.18 percent) followed by type III (21.88 percent). Differences were statistically significant (p=0.001) in relation to age of individuals who presented diferent morphological patterns of gingival recession. For the others parameters (depth and width of the recession, attachment loss) we found no statistically significant differences with a confidence interval of 95 percent. These findings represent a contribution for the evaluation of gingival recession in our population, particularly in the anterior aesthetic zone.

El objetivo fue determinar los patrones morfológicos de recesión gingival más prevalentes junto al grado de pérdida de inserción clínica y tipo de papila interdentaria en una muestra de población chilena. Se evaluaron 105 pacientes de ambos sexos, con edades entre 18 y 64 años. La prevalencia de recesión gingival fue del 92,38 por ciento, afectando 530 dientes. El patrón morfológico de recesión más frecuente fue el clase II (34,94 por ciento), seguido por los tipos III, I y IV. Según la Prueba de ANOVA, fueron encontradas diferencias significativas en relación a las medias de dientes afectados entre los individuos que presentaban recesión. El sexo femenino presentó una prevalencia ligeramente mayor. En el rango de 18-34 años se observó una prevalencia de 82,22 por ciento y desde los 35 años aumentó al 100 por ciento. La extensión vertical entre 0-3mm y horizontal entre 4-7mm fueron las más prevalentes y afectaron al 88,68 por ciento y 59,05 por ciento de los dientes, respectivamente. La perdida de inserción más habitual fue del rango 3-4mm en 316 dientes (59,62 por ciento ). El tipo de papila interdentaria en las recesiones gingivales fue del tipo I (40.18 por ciento) seguido por el tipo III (21.88 por ciento). Se encontraron diferencias estadísticamente significativas (p=0.001) en relación a la edad de los individuos que presentaron estos patrones morfológicos de recesión gingival y quiénes no. Estos resultados representan una contribución para la evaluación de la recesión gingival en nuestra población, particularmente en la zona estética anterior.

Recobrimento radicular pela técnica de Zucchelli e De Sanctis / Root covering by the technical Zucchelli and De Sanctis

A recessão gengival é encontrada com certa frequência na periodontia. Clinicamente, apresenta-se pela exposição radicular causada por um deslocamento apical da posição da gengiva em relação à junção cemento/esmalte. A recessão pode ser localizada, afetando apenas um dente ou grupo de dentes ou generalizada, ocorrendo em toda a boca. Sua etiologia está relacionada a vários fatores, incluindo placa bacteriana, posição dos dentes na arcada, escovação errônea, oclusão traumática, inserção alta de freios ou inserções musculares, área de gengiva estreita e pressão labial, entre outros. Uma meta do tratamento periodontal é regenerar a perda do aparelho de inserção dos dentes. Portanto, tornou--se evidente, durante a última década, que diversos procedimentos regenerativos têm potencial para corrigir não só a recessão gengival, pelo aumento da largura e altura da gengiva inserida ou queratinizada, como também obter recobrimento radicular parcial ou completo. Portanto, o objetivo deste trabalho é apresentar um relato de caso de recobrimento radicular de múltiplas recessões em áreas estéticas pela técnica de Zucchelli e De Sanctis.

Gingival recession is a common finding in periodontics. Clinically, it consists of root exposure caused by apical displacement of the gingival margin in the cement-enamel junction. Recession may be localized, affecting only a tooth or group of teeth, or widespread, affecting the entire mouth. Its etiology is related to several factors, such as bacterial plaque, position of the teeth in the arch, incorrect brushing, traumatic occlusion, high frenum insertion or muscle insertions, narrow gingival area and lip pressure, among others. The goal of periodontal treatment is to regenerate the periodontium. Therefore, it became evident during the last decade that several procedures have the potential to regenerate not only gingival recession by increasing the width and height of the inserted or keratinized gums, but also to achieve partial or full root coverage. In this context, the objective of this work is to present a case report of the coverage of multiple recessions in aesthetic areas by the Zucchelli and De Sanctis technique.

Treatment of gingival recession with collagen membrane and DFDBA: a histometric study in dogs

In a previous study, we evaluated the findings related to the use of resorbable collagen membranes in humans along with DFDBA (demineralized freeze-dried bone allograft). The aim of this subsequent study was to histometrically evaluate in dogs, the healing response of gingival recessions treated with collagen membrane + DFDBA (Guided Tissue Regeneration, GTR) compared to a coronally positioned flap (CPF). Two types of treatment were randomly carried out in a split-mouth study. Group 1 was considered as test (GTR: collagen membrane + DFDBA), whereas Group 2 stood for the control (only CPF). The dogs were given chemical bacterial plaque control with 0.2 percent chlorhexidine digluconate during a 90-day repair period. Afterwards, the animals were killed to obtain biopsies and histometric evaluation of the process of cementum and bone formation, epithelial migration and gingival level. A statistically significant difference was found between groups with a larger extension of neoformed cementum (GTR = 32.72 percent; CPF = 18.82 percent; p = 0.0004), new bone (GTR = 23.20 percent; CPF = 09.90 percent; p = 0.0401) and with a smaller area of residual gingival recession in the test group (GTR = 50.69 percent; CPF = 59.73 percent; p = 0.0055) compared to the control group. The only item assessed that showed no statistical difference was epithelial proliferation on the root surface, with means of 15.14 percent for the GTR group and 20.34 percent for the CPF group (p = 0.0890). Within the limits of this study we concluded that the treatment of gingival recession defects with GTR, associating collagen membrane with DFDBA, showed better outcomes in terms of a larger extension of neoformed cementum and bone, as well as in terms of a smaller proportion of residual recessions.