Randomized clinical trial evaluating single maxillary gingival recession treatment with connective tissue graft and tunnel or trapezoidal flap: 2-year follow-up.

BACKGROUND: The literature lacks long-term evidence regarding outcomes of the coronally advanced tunnel flap (TUN) combined with connective tissue graft (CTG) when compared to the trapezoidal coronally advanced flap (CAF) and CTG combination. This study presents 2-year results of a randomized clinical trial comparing CTG combined with either CAF or TUN in the treatment of single maxillary gingival recession (GR) defects. METHODS: Thirty-nine patients, each contributing a single Miller Class I or II GR defect, were treated by CAF+CTG (control; n = 19) or TUN+CTG (test; n = 20) and completed the 2-year follow up. Clinical, patient centered, and esthetic evaluations were performed and differences among groups were analyzed. RESULTS: At 2 years, mean root coverage for control and test group was 89.5% ± 14.6% and 87.7% ± 18.4%, respectively (P = 0.5). The corresponding complete root coverage prevalence was 68.4% and 50% (P = 0.4). Dentin hypersensitivity significantly decreased for both groups. The two groups showed improvement in esthetics, as assessed by both professionals and patients, without significant intergroup differences (P > 0.5). TUN+CTG sites were much more likely to present improvement in root coverage between 6 months and 2 years, exhibiting creeping attachment of 0.7 ± 0.6 mm. CONCLUSIONS: At 2 years of follow up, both CAF+CTG and TUN+CTG resulted in significant clinical and esthetic improvements and provided similar results in the treatment of single maxillary GRs.

Efeito de estimulação elétrica no retalho posicionado coronariamente para tratamento de recessões gengivais: estudo clínico controlado randomizado / Electrical stimulation effect on coronally advanced flap for the treatment of gingival recession: randomized controlled clinical trial

A recessão gengival é um problema muito comum na clínica odontológica, podendo afetar até 100% da população. Mesmo as melhores técnicas cirúrgicas para recobrimento radicular apresentam certa variação em seus resultados, e muitas estratégias são usadas para acelerar o processo de cicatrização. Uma delas é a aplicação de uma estimulação elétrica local para ativar o reparo tecidual. O objetivo deste estudo foi avaliar clinicamente e através da quantificação de diversos biomarcadores, os resultados de 6 meses do retalho posicionado coronalmente (CAF), associado ou não à um protocolo de eletroestimulação (E) para o tratamento de recessões gengivais. Para isso, 60 pacientes portadores de recessões gengivais unitárias Classe I e II de Miller, foram divididos em 2 grupos: CAF+E (n=30): retalho avançado coronalmente seguido de estimulação elétrica e grupo CAF (n=30): retalho avançado coronalmente e estimulação SHAM. Os resultados clínicos e centrados no paciente foram avaliados no baseline e 6 meses após os procedimentos. O fluido crevicular dos sítios tratados foi analisado para citocinas, colagenases e seus inibidores. Aos seis meses, ambos os grupos obtiveram porcentagem significativa de recobrimento e redução da recessão, sendo de 79,4 ±27,2% para o CAF e 85,9±17,4% para o CAF+E (p=0,6). O recobrimento radicular completo foi obtido em 53% e 56% dos defeitos tratados com CAF e CAF+E, respectivamente (p=0,9). Aos 7 dias, pacientes do grupo CAF+E relataram menor desconforto pós-operatório (p=0,04). A expressão de IL1ß, IL-6, TNF-α e VEGF foi reduzida significantemente no grupo CAF+E aos 7 e 14 dias (p˂0,05), já a concentração das MMPs e TIMPs não mostrou diferença entre os grupos em nenhum dos períodos avaliados. A estimulação elétrica não apresentou benefícios adicionais quando associada ao CAF em termos de recobrimento radicular para o tratamento de recessões gengivais. Entretanto, o protocolo de eletroterapia utilizado promoveu menor desconforto pós-operatório e modulação favorável dos marcadores inflamatórios durante a primeira semana de reparo(AU)

Gingival recession is a very common problem in dentistry and can affect up to 100% of the population. Even the best surgical techniques for root coverage have some variation in their results, and many strategies are used to accelerate the healing process. The objective of this study was to evaluate clinically and through the quantification of several biomarkers, the 6-month results of the coronally advanced flap (CAF), associated or not to an electrostimulation protocol (E) for the treatment of gingival recessions. For this, 40 patients with Miller Class I and II gingival recessions were divided into 2 groups: CAF+E (n=20): advanced flap coronally followed by electrical stimulation and CAF group (n=20): advanced flap coronally and SHAM stimulation. Clinical and patient-centered outcomes were assessed at baseline and 6 months post- procedure. The crevicular fluid of the treated sites was analyzed for cytokines, collagenases and their inhibitors. At six months, both groups had a significant percentage of root coverage and recession reduction, being 79.4±27.2% for CAF and 85.9 ± 17.4% for CAF+E (p=0.6). Complete root coverage was obtained in 53% and 56% of the defects treated with CAF and CAF+E, respectively (p=0.9). At 7 days, patients in the CAF+E group reported less postoperative discomfort (p=0.04). The expression of IL-1ß, IL-6, TNF-α and VEGF was significantly reduced in the CAF+E group at 7 and 14 days (p˂0.05), whereas the concentration of MMPs and TIMPs showed no difference between groups in any of the evaluated periods. Electrical stimulation did not present additional benefits when associated with CAF in terms of root coverage for the treatment of gingival recessions. However, the electrotherapy protocol used promoted less postoperative discomfort and favorable modulation of inflammatory markers during the first week of healing(AU)

Treatment of single maxillary gingival recession associated with non-carious cervical lesion: Randomized clinical trial comparing connective tissue graft alone to graft plus partial restoration.

BACKGROUND: Gingival recession (GR) is frequently associated with non-carious cervical lesion (NCCL) forming a combined defect (CD). The aim of this study was to evaluate a new multidisciplinary protocol for CDs. METHODS: Forty patients presenting 40 Miller's Class I or II GR defects associated with B+ tooth cervical defect were randomly allocated to one of the following treatments: test group (n = 20), partial restoration (PR) of the NCCL, in which the apical border of the restoration was placed 1 mm beyond the cement-enamel junction estimation, and connective tissue graft (CTG + PR) and Control Group (n = 20), odontoplasty of the NCCL and connective tissue graft (CTG). Clinical, aesthetic and patient-centred outcomes were evaluated. RESULTS: After 12 months, CD coverage rates were 75.3% (2.5 ± 1.0 mm) for CTG + PR and 74.6% (2.4 ± 1.1 mm) for CTG (p > 0.05). The estimated complete root coverage was 60% (n = 12) for CTG + PR and 70% (n = 14) for CTG. CTG + PR resulted in significantly better dentin hypersensitivity (DH) reduction (p = 0.034). Both groups resulted in aesthetic improvements; however, the CTG + PR group showed better gingival contour results. CONCLUSIONS: CTG and CTG + PR were effective to treat CD. Use of PR resulted in better gingival margin contour and DH reduction, without effect on CD coverage by CTG. (NCT02817763).

Nova abordagem no tratamento de recessões gengivais associadas à lesão cervical não cariosa / New approach in the treatment of gingival recessions associated with non-carious cervical lesion ­ case report

A recessão gengival está frequentemente associada à lesão cervical não cariosa (LCNC), originando uma lesão combinada que tem um prognóstico de tratamento diferente de quando as duas lesões se apresentam sozinhas. Tratamentos propostos possuem limitações, e o protocolo clínico ideal para o manejo dessas lesões ainda não foi estabelecido. Assim, o objetivo do presente relato de caso foi apresentar uma nova técnica cirúrgico-restauradora para o tratamento de recessões gengivais associadas à LCNC. Para tal, uma restauração parcial em resina composta foi realizada somente na parte coronal da lesão cervical. Em uma segunda sessão, o procedimento cirúrgico para recobrimento radicular com enxerto de tecido conjuntivo foi realizado. Seis meses após o procedimento, a paciente estava satisfeita com o resultado final alcançado, demonstrando que esse protocolo pode ser uma alternativa de tratamento aos protocolos existentes para o tratamento de recessões gengivais associadas à LCNC.

Gingival recession is often associated with non-carious cervical lesion (NCCL), resulting in a combined lesion which has a different treatment prognosis when the two lesions appear alone. Proposed treatments have limitations and the ideal clinical protocol for the management of these lesions has not been established. Thus, the aim of this case report is to present a new surgical-restorative technique for the treatment of gingival recessions associated with NCCL. For this, a composite resin partial restoration was performed only in the coronal part of the cervical lesion. In a second session, the surgical procedure for root coverage with connective tissue graft was performed. Six months after the procedure, the patient was satisfied with the final result achieved, demonstrating that this protocol may be an alternative to the existing protocols for the treatment of gingival recessions associated with NCCL.

Xenogenous Collagen Matrix and/or Enamel Matrix Derivative for Treatment of Localized Gingival Recessions: A Randomized Clinical Trial. Part II: Patient-Reported Outcomes.

BACKGROUND: Gingival recession (GR) might be associated with patient discomfort due to cervical dentin hypersensitivity (CDH) and esthetic dissatisfaction. The aim is to evaluate the effect of root coverage procedure with a xenogenous collagen matrix (CM) and/or enamel matrix derivative (EMD) in combination with a coronally advanced flap (CAF) on CDH, esthetics, and oral health-related quality of life (OHRQoL) of patients with GR. METHODS: Sixty-eight participants with single Miller Class I/II GRs were treated with CAF (n = 17), CAF + CM (n = 17), CAF + EMD (n = 17), and CAF + CM + EMD (n = 17). CDH was assessed by evaporative stimuli using a visual analog scale (VAS) and a Schiff scale. Esthetics outcome was assessed with VAS and the Questionnaire of Oral Esthetic Satisfaction. Oral Health Impact Profile-14 (OHIP-14) questionnaire was used to assess OHRQoL. All parameters were evaluated at baseline and after 6 months. RESULTS: Intragroup analysis showed statistically significant reduction in CDH and esthetic dissatisfaction with no intergroup significant differences (P >0.05). The impact of oral health on QoL after 6 months was significant for CAF + CM, CAF + EMD, and CAF + CM + EMD (P <0.05). Total OHIP-14 score and psychologic discomfort, psychologic disability, social disability, and handicap dimensions showed negative correlation with esthetics. OHIP-14 physical pain dimension had positive correlation with CDH (P <0.05). OHIP-14 showed no correlation with percentage of root coverage, keratinized tissue width, or keratinized tissue thickness (P >0.05). CONCLUSION: Root coverage procedures improve patient OHRQoL by impacting on a wide range of dimensions, perceived after reduction of CDH and esthetic dissatisfaction of patients with GRs treated with CAF + CM, CAF + EMD, and CAF + CM + EMD.

Xenogenous Collagen Matrix and/or Enamel Matrix Derivative for Treatment of Localized Gingival Recessions: A Randomized Clinical Trial. Part I: Clinical Outcomes.

BACKGROUND: Considering xenogeneic collagen matrix (CM) and enamel matrix derivative (EMD) characteristics, it is suggested that their combination could promote superior clinical outcomes in root coverage procedures. Thus, the aim of this parallel, double-masked, dual-center, randomized clinical trial is to evaluate clinical outcomes after treatment of localized gingival recession (GR) by a coronally advanced flap (CAF) combined with CM and/or EMD. METHODS: Sixty-eight patients presenting one Miller Class I or II GRs were randomly assigned to receive either CAF (n = 17); CAF + CM (n = 17); CAF + EMD (n = 17), or CAF + CM + EMD (n = 17). Recession height, probing depth, clinical attachment level, and keratinized tissue width and thickness were measured at baseline and 90 days and 6 months after surgery. RESULTS: The obtained root coverage was 68.04% ± 24.11% for CAF; 87.20% ± 15.01% for CAF + CM; 88.77% ± 20.66% for CAF + EMD; and 91.59% ± 11.08% for CAF + CM + EMD after 6 months. Groups that received biomaterials showed greater values (P <0.05). Complete root coverage (CRC) for CAF + EMD was 70.59%, significantly superior to CAF alone (23.53%); CAF + CM (52.94%), and CAF + CM + EMD (51.47%) (P <0.05). Keratinized tissue thickness gain was significant only in CM-treated groups (P <0.05). CONCLUSIONS: The three approaches are superior to CAF alone for root coverage. EMD provides highest levels of CRC; however, the addition of CM increases gingival thickness. The combination approach does not seem justified.

Connective tissue graft and tunnel or trapezoidal flap for the treatment of single maxillary gingival recessions: a randomized clinical trial.

BACKGROUND: Although ample evidence supports connective tissue graft (CTG) use for root coverage, there is need for research on recipient site preparation approaches. The purpose of this study was to compare the outcomes of trapezoidal coronally advanced flap (CAF) and coronally advanced tunnel flap (TUN) when used in conjunction with CTG. METHODS: Forty-two patients presenting 42 single maxillary, Miller Class I and II, gingival recession defects were randomly assigned to receive either CAF + CTG (N = 21) or TUN + CTG (N = 21). Clinical, patient-centred, and aesthetic outcomes were assessed. RESULTS: Six months postoperatively, both groups resulted in significant reduction in recession depth and increases in keratinized tissue thickness and width. CAF + CTG and TUN + CTG mean root coverage was 87.2 ± 27.1% and 77.4 ± 20.4% respectively (p = 0.02). Complete root coverage was achieved in 71.4% and 28.6% of defects treated with CAF + CTG and TUN + CTG respectively (p = 0.01). At 7 days postoperatively, TUN + CTG patients reported significantly less pain experience (p = 0.04). Both approaches reduced dentine hypersensitivity by approximately 85% (p < 0.05). Patient-based aesthetic evaluation indicated significant improvement for both groups. Although patient- and professional-based aesthetic assessments revealed no differences between groups, tissue texture was significantly better for TUN + CTG (p = 0.02). CONCLUSIONS: For root coverage of single maxillary recession defects, CAF + CTG was more effective than TUN + CTG (ClinicalTrial.org-NCT02814279).

Tratamento cirúrgico para recobrimento radicular em molar superior / Surgical treatment for root coverage in the upper molar tooth ­ a case report

A recessão gengival é uma condição muito comum atualmente, definida como o deslocamento da margem gengival apicalmente à junção cemento/esmalte, com consequente exposição da superfície radicular ao ambiente bucal. Apesar das recessões gengivais afetarem diversos grupos de dentes, poucos trabalhos tentam elucidar qual é o melhor protocolo de tratamento para as recessões gengivais presentes em molares. Visando um protocolo cirúrgico que proporcione uma satisfatória taxa de recobrimento radicular e um melhor resultado estético, o presente relato de caso teve como objetivo apresentar uma técnica cirúrgica alternativa para o tratamento de recessões gengivais em molares superiores. Para tal, um retalho dividido foi confeccionado por meio de incisões relaxantes e deslocado lateralmente, a partir da área doadora, para o elemento dental com a recessão. Após o deslocamento do retalho, o mesmo foi suturado em posição. Seis meses após o procedimento, o paciente estava satisfeito com o resultado final alcançado, demonstrando que esse protocolo pode ser uma alternativa de tratamento aos protocolos existentes para o tratamento de recessões gengivais.

Gingival recession is a condition defined as the apical positioning of the gingival margin in relation to the cemento-enamel junction, resulting in root exposure in the oral environment. Although gingival recession may affect many groups of teeth, there are few studies that attempt to clarify which is the best treatment protocol for gingival recessions localized in molars. In order to evaluate a surgical approach that lead to a satisfactory root coverage rate and a good esthetic outcome, the aim of this case report is to present an alternative surgical technique for the treatment of gingival recession in upper molar teeth. For this, a split-flap was made through vertical incisions and laterally positioned from the donor area to the affected tooth and sutured in position. Six months after the procedure, the patient was satisfied with the final result achieved, showing that this protocol may be an alternative to the existing treatments for the gingival recession.

Resin composite plus connective tissue graft to treat single maxillary gingival recession associated with non-carious cervical lesion: randomized clinical trial.

AIM: To evaluate clinically, the aesthetics and the patient-centred parameters after the treatment of gingival recession associated with non-carious cervical lesion by connective tissue graft alone or combined with a nanofilled resin composite restoration. METHODS: Thirty-six patients presenting one Miller Class I or II gingival recessions and B+ tooth cervical defect were included. The defects were treated by either connective tissue graft (CTG: control group; n = 18) or connective tissue graft plus resin composite restoration (CTG+RC: test group; n = 18). RESULTS: The mean percentage of defect coverage was 82.16 ± 16.1% for CTG and 73.84 ± 19.2% for CTG+RC after 1 year (p > 0.05). Both groups presented statistically significant improvements in two aesthetics evaluations. The professional evaluation (MRES) was 7.44 ± 2.3 for the CTG group and 7.52 ± 2.27 for CTG+RC after 1 year, with no significant difference between the groups. The two groups presented significant reduction of dentin sensitivity (DS), it decreased from 94.4% of the sites to 44.4% in the CTG group and from 88.8% to 5.5% in the CTG+RC group. CONCLUSIONS: CTG or CTG+RC can successfully treat gingival recession associated with B+ non-carious cervical lesion, but less sensitivity may be expected with the combined approach (NCT02423473).

Comparação de dois tipos de retalho para enxerto de tecido conjuntivo no tratamento de recessões gengivais: estudo clínico controlado randomizado / Evaluation of two different types of flap associated with connective tissue graft in the treatment of gingival recession: randomized clinical trial

A recessão gengival é um problema altamente prevalente, podendo atingir até 100% dos indivíduos com mais de 50 anos de idade. A presença da recessão pode implicar no aparecimento de outros problemas, como hipersensibilidade dentinária, queixas estéticas, acúmulo de biofilme,cáries radiculares, lesões cervicais não-cariosas entre outros. O objetivo do presente estudo foi comparar, do ponto de vista clínico, estético e de parâmetros centrados no paciente, dois tipos diferentes de retalho para o enxerto de tecido conjuntivo no tratamento de recessões gengivais. Foram selecionados 42 pacientes apresentando recessão gengival, divididos nos grupos teste: cirurgia periodontal para recobrimento radicular por meio de retalho em túnel e enxerto de tecido conjuntivo e grupo controle: cirurgia periodontal para recobrimento radicular por meio de retalho trapezoidal e enxerto de tecido conjuntivo. Foram avaliadas a taxa de recobrimento,estética e conforto dos pacientes aos baseline, 3 e 6 meses após o procedimento. Após 6 meses, o grupo controle apresentou uma média de recobrimento de 87,2±27,1 % enquanto o grupo teste alcançou uma média de 77,3±20,4 % com diferença significante entre os grupos. O recobrimento radicular completo foi alcançado em 71.42 % das recessões tratadas com o retalho trapezoidal e em 28,57 % das recessões tratadas com retalho em túnel, com diferença estatisticamente significante entre os grupos. A média da RES foi 8,42±1,5 para o grupo controle e 7,81±1,91 para o grupo teste após o tratamento sem diferença entre os grupos. A análise da escala VAS mostrou uma menor morbidade associada ao retalho em túnel (p= 0,04). Pode-se concluir que o a técnica de retalho trapezoidal foi mais eficaz que a técnica de túnel em alcançar o recobrimento radicular. Entretanto a técnica de túnel foi associada a uma melhor textura gengival e maior conforto do paciente sendo uma valiosa opção de tratamento

Gingival recession is a highly prevalent problem and can reach up to100% of individuals over 50 years of age. The presence of the recessionmay result in the occurrence of other problems such as dentin hypersensitivity, esthetic complaints, biofilm accumulation, root caries,non-carious cervical lesions among others. The aim of this study was to compare clinically, esthetically and patient-centered parameters, two type sof flap designs for connective tissue graft in the treatment of gingival recession. Were selected forty two patients presenting with gingival recession divided in the test group: periodontal surgery for root coverage using the tunnel flap and graft of connective tissue and control group:trapezoidal flap and graft of connective tissue. Clinical, esthetics, and comfort of patients parameters were assessed at 45 days, 2, 3 and 6 months after the procedure. After six months, the control group presented mean root coverage of 87.2±27.1 % while the test group presented a mean of 77.3±20,4 % with significant difference between groups. Thecomplete root coverage was achieved in 71.42 % of recessions treated with trapezoidal flap and 28.57 % of recessions treated with tunnel flap,with a statistically significant difference between groups. The average of RES was 8.42 ± 1.5 for the T + CTG group and 7.81 ± 1.91 for the E +CTG group after treatment with no difference between groups. The VAS scale analysis showed a lower morbidity associated to tunnel technique (p= 0.04). It can be concluded that the trapezoidal flap technique was more effective than the tunnel flap technique in achieve the root coverage.However tunnel technique was associated with better gingival texture and patient comfort being a valuable treatment option

Anatomical study of palato gingival groove on maxillary central incisors / Estudo anatômico do sulco palato-gengival em incisivos centrais superiores

O sulco palato-gengival (SPG) é uma anomalia de desenvolvimento que acomete principalmente os incisivos superiores. Inicia-se no ou perto do cíngulo dental, e sulca a raiz apresentando uma grande variedade de profundidades e comprimentos. Sua incidência, profundidade e comprimento, são de importância clínica, uma vez que em periodontia podem ser o agente causal de periodontites severa se localizadas, e na endodontia provocam a divisão do canal radicular e o aparecimento de foram es acessórios. O objetivo deste trabalho foi realizar um estudo sobre a presença, forma, comprimento e profundidade do sulco palato-gengival em incisivos centrais superiores. Foram utilizados 1.668 dentes incisivos centrais superiores da coleção de dentes da Disciplina de Anatomia do ICT - SJ Campos –UNESP. Cada dente teve a sua porção radicular inspecionada com a finalidade de verificar a presença e a profundidade do SPG. Os sulcos palato-gengivais encontrados foram classificados de acordo com o sistema proposto por Gu (2011), em: Tipo I (curtoe superficial), Tipo II (longo e superficial) e Tipo II (longo e profundo). Concluída esta classificação,todos os dentes que apresentaram o SPG foram radiografados e cinco dentes tiveram sua superfície radicular avaliada através do uso de um Microscópio Eletrônico de Varredura (MEV). Finalmente foram separados quatro dentes representativos de cada tipo de SPG encontrado para a obtenção de cortes histológicos e subsequente análise microscópica.

Palatogingival groove (PGG) is a developmental anomaly affecting mainly the maxillary incisors.PGG incidence, depth, and length are clinically important because it may cause severe and localized periodontitis; and it may divide the root canal resulting in accessory foramina. This study aimed to analyze the presence, shape, length, and depth of the palatogingival groove in maxillary central incisors. 1,668 maxillary central incisors were used. Each tooth had its root portion inspected inorder to verify PGG presence and depth. The found palatogingival grooves were classified according tothe system proposed by Gu [5], as follows: Type I (short and superficial), Type II (long and superficial),and Type III (long and deep). All teeth that showed the grooves were radiographed; five teeth had their root surface analyzed through Scanning Electron Microscopic (SEM); and four teeth corresponding to each PGG type were sent to obtain histological sections and then submitted to microscopic analysis.Of the 1.668 analyzed incisors, 27 (1.61%) showed the palatogingival groove: 8 (29.6%) Type I, 17(63%) type II, and 2 (7.4%) Type III. Microscopic analysis revealed no communication between PGGand root canal. In conclusion, our results showed that PGG can be clinically and radiographically diagnosed on maxillary central incisors, with the type II being the most common. The professionals should be aware of the features of this groove dueto its severe clinical consequences.

Tratamento cirúrgico de recessões gengivais por meio do retalho em túnel e enxerto conjuntivo / Surgical treatment of multiple gingival recessions using the tunnel technique. Case report

A recessão gengival é definida como o posicionamento apical da margem gengival em relação à junção cemento-esmalte. Dentre as diversas técnicas cirúrgicas empregadas para o tratamento das recessões, o retalho posicionado coronalmente associado ao enxerto de tecido conjuntivo é aquele que apresenta os melhores resultados. O tipo de retalho mais frequentemente utilizado para a realização do enxerto de tecido conjuntivo é o retalho trapezoidal, proposto por Langer e Langer. No entanto, essa técnica possui algumas limitações. Assim, o objetivo do presente relato de caso foi apresentar uma técnica cirúrgica alternativa para o tratamento de múltiplas recessões gengivais. Para tal, um túnel submucoso foi confeccionado através de incisões intrasulculares nos dentes acometidos e sem incisões relaxantes para maximizar a estética. Após a acomodação do enxerto conjuntivo, o retalho foi então deslocado coronalmente e suturado. Seis meses após o procedimento, a paciente estava satisfeita com o resultado final alcançado, demonstrando que esse protocolo pode ser uma alternativa de tratamento aos protocolos existentes para o tratamento de recessões gengivais.