Mandibular Anterior Lingual Recession: Keratinized Tissue Grafting and Minimally Invasive Harvesting.

INTRODUCTION: The mandibular anterior lingual (MAL) keratinized tissue (KT) band is often insufficient in dimension: <2 mm height of which <1 mm is attached gingiva (AG). Its gingival phenotype is commonly characterized as thin (<1 mm) gingival thickness (GT) and having inadequate (<1 mm) AG width. When surgical treatment is indicated, prevention of significant apical displacement of the gingival margin and improvement of long-term gingival stability are enhanced by KT increase and phenotype modification in order to establish thick GT and adequate AG. The aim of this case report is to describe a bilaminar surgical approach, the modified coronally advanced flap (mCAF) and connective tissue graft with retained KT band (mCAF + CTGkt). It is an outcomes-driven surgical approach for KT increase and phenotype modification in order to predictably establish thick GT and adequate AG. The mCAF + CTGkt procedure is minimally invasive, predictable, well-tolerated and addresses both the unique features of MAL anatomy and normal oral functioning movement during the postoperative healing phase. CASE PRESENTATION: A 48-year-old female presented with chief complaint of MAL progressive gingival recession (GR). Attachment loss of 3-4 mm and lack of both KT and AG were documented. Primary treatment outcomes objectives were GR cessation, establish KT, increase GT and AG. A secondary outcome was decreasing GR. CONCLUSION: The mCAF + CTGkt procedure resulted in KT increase, phenotype modification to establish thick GT and adequate AG, and decreased GR. It addressed unique features of MAL anatomy. Postoperative healing outcomes were not negatively impacted by normal oral functioning.

Management and prevention of gingival recession.

Gingival recession is highly prevalent worldwide. It increases the risk for root caries and can interfere with patient comfort, function and esthetics. Progressive gingival recession also increases the risk of tooth loss secondary to clinical attachment loss. Although mitigating the causes of gingival recession decreases its incidence and severity, implementing practical management and prevention strategies in the clinical setting can be challenging. Identification of susceptible patients and evaluating them for the presence of modifiable risk exposures are essential first steps in developing action plans for appropriate interventions. This article reviews these steps and introduces chairside tools that can help in the selection of interventions designed to reduce the risk of future gingival recession and may also facilitate patient communication. Practical decision-making criteria are proposed for when and how to monitor gingival recession, for deciding when a patient is a candidate for surgical evaluation or referral to a periodontist, and, if surgery is the treatment of choice, what should be considered as key surgical outcome objectives.

Clinical decision support chairside tools for evidence-based dental practice.

Evidence-based clinical decision support (EB-CDS) tools designed for chairside use, help support the implementation of Evidence-Based Dentistry. EB-CDS tools organize available evidence and risk factors in order to facilitate clinical decision-making as well as to enhance rapid and effective transfer of knowledge to the patient at the point of care. Gingival recession, root exposure, caries, dental sealants, decay prevention and topical fluoride guides are presented and discussed. The Assess-Advise-Decide Approach, described in this article, better enables patients to determine which course of action is in line with their preferences and values.

The Evidence-Based Study Club: a practical means to facilitate EBD awareness and implementation.

The study club model can be a highly effective method to advance the awareness, implementation, and dissemination of the evidence-based dental (EBD) practice approach. Three concepts for developing and facilitating a successful evidence-based study club are described. Simple approaches for study club development and management are introduced. The importance of implementing the EBD approach in practice before teaching EBD is reviewed. The value in starting or joining an evidence-based study club soon after initiating EBD implementation is illustrated.

The practicing clinician's perspective: using the EBD approach and CDS tools in private practice.

Using the evidence-based dentistry (EBD) approach in private practice offers many advantages yet remains challenging. A practical approach to help increase EBD adoption and implementation at the point of care is needed. Three concepts are described that help facilitate the process. EBD implementation efforts should not be delayed for the arrival of more strong scientific evidence demonstrating best EBD implementation strategies. Introducing clinicians, patients, and dental staff to the advantages of evidence-based dental practice by way of a benefits-driven approach enhances EBD adoption and implementation. Simple, easy-to-use chairside tools, online EB knowledge resources, and clinical decision support tools facilitate EBD adoption and implementation.

The evidence-based clinical decision support guide: mucogingival/esthetics making clinical decisions in the absence of strong evidence.

Although evidence-based decision-making in dentistry is quickly evolving, large gaps remain in our clinical knowledge base regarding every day decisions and procedures. Especially in the absence of strong evidence, as is the case with mucogingival conditions, risk assessment and identification are important components of the clinical decision-making process. Utilization of clinical decision support (CDS) guides, frameworks and systems enhances chairside decision-making and improves delivery of patient care. This article introduces an Evidence-Based Clinical Decision Support Guide for mucogingival/esthetic situations. This CDS guide delineates treatment strategies based upon evidence-based risk assessment and when possible, risk management. It provides the clinician with a framework that will support decision-making at the point of care. Recommendations for consultation, treatment and referral are reviewed.

Implementing evidence-based decision making in the private practice setting: the 4-step process.

An important goal of EBDM is to improve outcomes where it matters the most: at the point of care. All dental clinicians need practical tools that facilitate access to the clinical information needed to enable our patients to make better-informed choices. This article provides a 4-step guide for practical implementation of EBDM in the private practice setting. Step 1 is defining your practice purpose. Step 2 describes the use of Ethical Practice Parameters to guide clinical decision-making. Step 3 illustrates how to implement Ethical Practice Parameters. Step 4 describes a simple process for searching for scientific evidence. Online resources are provided and the benefits of the 4-step process are elucidated.

The translational clinical practice system: a way to implement the evidence-based approach in the dental office.

Evidence-based decision-making in dental practice is challenging and rewarding. But for many clinicians, the evidence-based approach is an abstract and even theoretical idea that sounds good, but is not very practical. The Translational Clinical Practice System provides an overriding domain and a system within which the evidence-based approach may be more effectively utilized in clinical practice. Most would agree that using good evidence, information, and data as the basis for decisions are the starting points toward reaching the best results for the patient. However, there are clearly insufficiencies in the currently available best scientific evidence for many of the procedures patients need. The good news is that the evidence environment is improving and better quality information is becoming available in the office where it is needed. This article describes a logical and straightforward approach for clinicians to use in order to put together complex and often interwoven factors involved with patient care. Specific clinical examples are provided.