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The aim of this study was to investigate the inter- and intra-examiner agreement among international experts on the diagnosis of gingival recession defects using the 2018 Classification of Gingival Recession Defects and Gingival Phenotype as proposed in the 2017 World Workshop.Standardized intraoral photographs from 28 gingival recession defects were evaluated twice by 16 expert periodontists. Recession type (RT), recession depth (RD), keratinized tissue width (KTW), gingival thickness (GT), detectability of the cemento-enamel junction (CEJ), and presence of root steps (RS) were recorded and used for the analysis. Intra- and inter-examiner agreements were calculated for individual variables and for the overall classification. Intraclass correlation coefficient with 95% CI was used for RD and KTW; Kappa with 95% CI was used for GT, CEJ, and RS; quadratic weighted Kappa with 95% CI was used for RT.Overall intra- and inter-examiner agreements were highest for KTW (0.95 and 0.90), lowest for GT (0.75 and 0.41), with the other variables in between (RD: 0.93 and 0.68, RS: 0.87 and 0.65, RT: 0.79 and 0.64, CEJ: 0.75 and 0.57). Overall intra- and inter-examiner agreements for the matrix were 62% and 28%, respectively. Significant effects existed between one variable's measurement and other variables' agreements.The 2018 Classification of Gingival Recession Defects and Gingival Phenotype is clinically reproduceable within the examiners, and when the variables forming the matrix are analyzed individually. The between-examiner agreement for the complete matrix showed lower reproducibility. The agreement was highest for KTW and RD, and least for GT.

Maintaining or creating adequate papillary form is a challenge when placing implants in the esthetic zone. Often, outcomes of procedures designed to maintain or enhance papillae at implant sites yield unsatisfactory results and require secondary microsurgical interventions. This article describes a surgical technique to augment interdental papillae between implants and teeth. The technique uses pedicle flaps from the palate combined with tunneling and is capable of creating a substantial papilla augmentation utilizing vascularized grafts. The surgical technique and requirements for success are presented with a case report.

To describe the step-by-step procedure of a novel surgical technique consisting of a combination of the laterally closed tunnel (LCT) and the modified coronally advanced tunnel (MCAT) (ie, LCT/MCAT), designed to treat multiple mandibular adjacent gingival recessions (MAGR) and to present the clinical outcomes obtained in 11 consecutively treated patients.Eleven systemically and periodontally healthy patients (7 females, mean ± SD 33.62 ± 14.6 years, min. 19 years max. 67 years) with a total of 40 adjacent mandibular RT1 (ie, Miller Class 1 and 2) gingival recessions with a minim um depth ≥ 3 mm, were consecutively treated with LCT/MCAT, in conjunction with an enamel matrix derivative (EMD) and subepithelial palatal connective tissue graft (SCTG). Treatment outcomes were assessed at baseline and at 12 months postoperatively. Prior to surgery and at 12 months postoperatively, recession depth (RD) and recession width (RW) were evaluated. The primary outcome variable was complete root coverage (CRC, ie 100% root coverage), the secondary outcome was mean root coverage (MRC).Postoperative pain and discomfort were low and the healing was uneventful in all cases without any complications. At 12 months, statistically significant (P.05) root coverage (RC) was obtained in all patients. CRC was obtained in five patients with a total of 21 recessions, while MRC measured 92.9% (ie, 3.75 mm). In seven patients (ie, 63.6%), RC amounted to93% while the minim um RC per patient measured 83.76%.The results of the present case series suggest that the LCT/MCAT is a valuable technique for the treatment of mandibular RT1 MAGR.

OBJECTIVE To address the myths and realities of soft tissue grafting with the tunnel technique in the mandibular anterior region. MATERIALS AND METHODS Myths associated with use of the tunnel technique for soft tissue grafting in the mandibular anterior region are identified and examined. Explanations for the misunderstandings are presented and documented with case examples and evidence from scientific studies. RESULTS Six myths are described and the realities are presented. CONCLUSIONS This report demonstrates that the tunnel technique can be successfully used in the mandibular anterior region in the presence of anatomic features thought to favor the use of more invasive surgical methods. CLINICAL SIGNIFICANCE Soft tissue grafting in the mandibular anterior region has complicating anatomical features including a strong frenal attachment, shallow vestibule and thin tissue. These features may be successfully managed with a free gingival graft, but that procedure results in an uncomfortable experience for the patient. The tunnel technique, especially when combined with an acellular dermal matrix, dramatically improves the patient experience and esthetic outcome without compromising the clinical outcome.

It is often difficult to perform the tunnel technique for root coverage and soft tissue augmentation in the mandibular anterior region where there is shallow recession and thin soft tissue, particularly when accompanied by prominent roots and alveolar undercuts. The aim of this report is to present a papilla access technique that facilitates tunnel site preparation and graft placement in such sites. This surgical access method may also be applied to sites where there is moderate to severe recession of the mandibular central incisors, and extension of the tunnel to include both the lateral incisors and canines is desired for augmentation. The papillary access provides improved surgical access for both site preparation and graft placement with reduced risk of perforation or injury to thin tissue.

Predictable coverage of deep isolated mandibular gingival recessions is one of the most challenging endeavors in plastic-esthetic periodontal surgery, and limited data is available in the literature. The aim of this paper is to present the rationale, the step-by-step procedure, and the results obtained in a series of 24 patients treated by means of a novel surgical technique (the laterally closed tunnel [LCT]) specifically designed for deep isolated mandibular recessions. A total of 24 healthy patients (21 women and 3 men, mean age 25.75 ± 7.12 years) exhibiting one single deep mandibular Miller Class I (n = 4), II (n = 10), or III (n = 10) gingival recession ≥ 4 mm were consecutively treated with LCT in conjunction with an enamel matrix derivative (EMD) and palatal subepithelial connective tissue graft (SCTG). The following clinical parameters were assessed at baseline and 12 months postoperatively: probing depth (PD), clinical attachment level (CAL), complete root coverage (CRC), mean root coverage (MRC), recession depth (RD), and keratinized tissue width (KTW). The primary outcome variable was CRC. The postoperative morbidity was low, and no complications, such as bleeding, infections/abscesses, or loss of SCTG, occurred. At 12 months, CRC was obtained in 17 of the 24 defects (70.83%), while in the remaining 7 defects RC amounted to 80% to 90% (in 6 cases) and 79% (in 1 case). Of the 17 defects exhibiting CRC, 12 were central incisors and 5 were canines. With respect to defect type, CRC was found in 3 of the 4 Miller Class I, 8 of the 10 Class II, and in 6 of the 10 Class III defects. Mean RD changed from 5.14 ± 1.26 mm at baseline to 0.2 ± 0.37 mm at 12 months, while MRC amounted to 4.94 ± 1.19 mm, representing 96.11% (P < .0001). Mean KTW increased from 1.41 ± 1.00 mm at baseline to 4.14 ± 1.67 mm (P < .0001) at 12 months, yielding a KTW gain of 2.75 ± 1.52 (P < .0001). No statistically significant changes in mean PD occurred following root coverage surgery (1.8 ± 0.2 mm at baseline and 2.1 ± 0.3 mm at 12 months). The present results suggest that the LCT is a valuable approach for the treatment of deep isolated mandibular Miller Class I, II, and III gingival recessions.

Objective: This clinical study aimed to evaluate effectiveness of a commercially available toothpaste containing potassium nitrate, sodium monoflurophosphate, and nano-hydroxyapatite as well as antioxidants phloretin, ferulic acid and silymarin in reducing dental hypersensitivity in adults. Methods: The clinical trial enrolled patients with a history of dentin hypersensitivity. A test toothpaste was introduced into the daily routine, which included initial instruction on usage. Patients completed a five-question visual analog scale (VAS) at the inception/baseline, after two days and after two weeks of using the toothpaste to determine their level of tooth sensitivity at baseline with the use of the toothpaste over time. Results: Patients that had significant sensitivity at baseline had a range of 52% to 76 % improvement after 48 hours and a range of 70% to 84% improvement after two weeks. Conclusion: A toothpaste containing potassium nitrate, sodium monoflurophosphate, and nano-hydroxyapatite plus antioxidants phloretin, ferulic acid and silymarin applied daily significantly decreased tooth pain of dentin hypersensitivity within a two-day and two-week time period. Clinical Significance: Based on the clinical study results, a daily application of a toothpaste containing potassium nitrate, sodium monofluorophosphate, and nano-hydroxyapatite plus antioxidants phloretin, ferulic acid and silymarin can significantly and quickly reduce tooth pain of dentin hypersensitivity.

Focused Clinical Question: How should gingival recession (GR) defects be managed based on current evidence? Summary: The purpose of this practical application is to illustrate the management of GR defects with a primary outcome goal of complete root coverage. The consensus in dental literature and among expert clinicians is that root coverage may be attained through the application of different procedures and that outcomes are generally measured by reduced defect depth, gain in clinical attachment, and an increase in keratinized tissue (KT). These procedures may include the use of: 1) subepithelial connective tissue graft (SCTG); 2) coronally advanced flap; 3) free gingival graft; and 4) soft tissue graft substitutes (acellular dermal matrix and xenogeneic collagen matrix materials) and biologics (recombinant human platelet-derived growth factor and enamel matrix derivative). The variability in these techniques revolves around the inclusion or avoidance of a palatal donor graft. The decision as to how to approach a specific clinical GR-type defect should be a combination of considerations relative to the clinician's surgical goals and the patient's understanding of the anticipated outcome. The associated systematic review (Chambrone and Tatakis, J Periodontol 2015;86(Suppl.):S8-S51) provides clear evidence that SCTG-based procedures provide the best outcome for mean and complete root coverage, as well as an increase in KT. Patient-reported outcomes, a topic that needs additional research, should be considered in the decision-making process. Conclusion: Based on the available evidence and the illustrated cases included in this practical application, root coverage can be predictably achieved and a successful clinical outcome can be maintained long term.

Background: Desquamative gingivitis (DG) is a clinical manifestation common to several diseases. It is known that most cases of DG are caused by mucous membrane pemphigoid (MMP), oral lichen planus (OLP), or pemphigus vulgaris (PV). Early recognition and treatment of these diseases can improve the prognosis, but diagnostic delays are common in patients with DG because obtaining a diagnostic biopsy is technically challenging. A biopsy technique designed to maintain the gingival epithelium for patients with DG was developed. The usefulness of this technique is discussed.Methods: This study is based on a retrospective review of 27 DG cases. A stab-and-roll technique was used to obtain gingival tissue. This technique is designed to reduce lateral forces on the epithelium during the procedure and to thereby prevent the inadvertent removal of the epithelium from the biopsy specimen. A total of 52 biopsies comprising 27 for hematoxylin and eosin (H&E)–stained samples and 25 for direct immunofluorescence (DIF) te...

Objective In dentistry, the use of metals in fillings, braces, implants, bridges and other prosthodontic restorations is a common practice. Previous studies revealed that zinc (Zn) and copper (Cu) released from gold alloys, and nickel (Ni) released from nickel–chromium alloys, have a highly cytotoxic effect on fibroblast cell cultures. Our working hypothesis is that oral fibroblasts are susceptible to damage from metals because they elevate reaction oxygen species (ROS). In this study, we investigated specific antioxidant (AO) combinations to determine if they counteract the effects of Cu, Ni and Zn on cultured oral fibroblast proliferation and oxidative damage. Methods Oral fibroblasts were pretreated with Cu, Ni and Zn for 60 min. Thereafter, cells were treated with 10 -5 M combinations of bioactive AO resveratrol (R), ferulic acid (F), phloretin (P) and tetrahydrocurcuminoids (T) (RFT, PFR, PFT) for 24 h. Cell viability and DNA synthesis were monitored by 3-[4,5-dimethylthiazol-2-yl]-5-[3-carboxymethoxyphenyl]-2-[4-sulfophenyl]-2H-tetrazolium (MTS) and 5-bromo-2-deoxyuridine (BrDU) assays. ROS was measured using the fluorescence response of dichlorodihydrofluorescein diacetate (DCF). Results AO compounds increased recovery of cells exposed to Cu and Zn. Moreover, AO treatment induced DNA synthesis in the presence of the metal stressors. Cu and Ni stimulated production of ROS. PFR treatment decreased ROS in the presence of Cu, Ni and Zn. Significance These data indicate that pure AOs counteracted the detrimental effects of Cu, Ni, Zn on oral fibroblasts in vitro by increasing cell viability, and DNA synthesis and decreasing ROS activity.

Background Oxidative damage to soft oral tissues may result from exposure to the chemicals or biochemicals found in teeth-whitening products, dental restorations, tobacco, and alcohol. Our working hypothesis is that oral tissues are susceptible to the toxic effects of stressors such as hydrogen peroxide (H 2 O 2 ), ethanol (EtOH) and nicotine (Nic), which decrease cell viability/DNA synthesis and elevate reactive oxygen species (ROS). In this study, we investigated specific polyphenols and turmeric derivative antioxidants (AO) in combinations that counteracted the effects of these stressors on cultured oral fibroblast proliferation and ROS production. Methods Oral fibroblasts were exposed to stressors for 30 min and then treated with 10 −5 M of bioactive AO mixtures [resveratrol, ferulic acid and tetrahydrocurcuminoid (RFT), phloretin, ferulic acid and resveratrol (PFR), phloretin, ferulic acid and tetrahydrocurcuminoid (PFT)] for 24 h. Cell viability and DNA synthesis were monitored using incorporated 3-[4,5-dimethylthiazol-2-yl]-5-[3-carboxymethoxyphenyl]-2-[4-sulphophenyl]-2H-tetrazolium (MTS) and 5-bromo-2-deoxyuridine (BrdU) assays, respectively. Total ROS was measured with dichlorodihydrofluorescein diacetate (H 2 DCFDA). Results Incubation of oral fibroblasts in the stressors for 30 min resulted in a dose-dependent decrease of DNA synthesis and number of viable cells, and an increased total ROS activity. AO treatment counteracted the insults by restoring DNA synthesis levels and cell viability, and decreasing the total ROS activity. Conclusion The AO combinations of RFT, PFR and PFT protected the oral fibroblasts from the detrimental effects of H 2 O 2 , EtOH and Nic by decreasing total ROS and increasing cell viability and DNA synthesis.

Introduction:Currentmethodsforgingival depigmentation, includingmechanical surgery,cryosurgery,lasertreatments, and radiosurgery, create significant patient discomfort and risk of complications, thereby reducing attractiveness of the depigmentation procedure for many patients. To our knowledge, this case report presents a first-time application of a new technology, laser-patterned microcoagulation (LPM) based on the concept of fractional laser photothermolysis that was successfully applied in dermatology and ophthalmology. Case Presentation: One patient was treated for local hyperpigmentation of the labial attached gingiva in the maxillary anterior area. A diode laser with wavelength 980 nm and power 20 W was used to create microcoagulation columns with a 30% area filling factor. Two treatments were performed, 2 weeks apart, without anesthesia. The patient was followed for 5 months. The discomfort during the procedure was tolerable without anesthesia. Healing was uneventful and visually completed with significant reduction of pigmentation at 2 weeks after treatment. Complete visual depigmentation was observed at both 2 weeks and 2 months after the second treatment. Conclusions: To our knowledge, this is the first clinical case of hyperpigmentation treatment using LPM, demonstrating feasibility of a new, minimally invasive and effective method of localized gingival hyperpigmentation removal. The patient discomfort is significantly less than that reported for other methods for depigmentation. Clin Adv Periodontics 2011;1:210-214.

Objective Antioxidants (AOs) are the first line of defence against free radical damage and are critical for maintaining optimum health and well being. The need for AOs becomes even more critical with increased exposure to free radicals generated by pollution, cigarette smoke, drugs, illness, stress and exercise. Antioxidant supplementation is an excellent way of improving free radical protection. The aim of this study was to provide cytotoxicity, proliferation and migration data on the in vitro effects of bioactive AO mixtures on human oral fibroblasts. Methods Human oral fibroblasts were obtained from human gingival (HGF) and periodontal (HPDL) tissues. Each of these oral fibroblasts was cultured separately in three concentrations of the bioactive pure polyphenol and turmeric derivative mixtures; resveratrol (R), ferulic acid (F), phloretin (P) and tetrahydrocurcuminoids (T); [(RFT), (PFR), and (PFT)]. Cell viability, proliferation, morphology and migratory behaviour were analysed in vitro using high throughput in vitro 96 well plate wound assay. Results RFT decreased (10−3 M) and increased (10−5 M) cell number in HGF cells. Three concentrations (10−3, 10−4, and 10−5 M) of PFR and PFT increased DNA synthesis in HGF cells. PFT promoted cell migration but PFR and RFT had no significant change in HGF wound healing rates in a 96 well plate assay monolayer wound. In the HPDL cells, the 10−4 M concentration of both RFT and PFT increased cell number at 72 h and 96 h whereas the lower concentration 10−5 M of RFT significantly stimulated cell number at 96 h. PFR (10−3 M and 10−5 M) and PFT (10−3 M) increased DNA synthesis after 48 h treatment in HPDL cells. Conclusions High and low concentrations (10−3–10−5 M) of these AOs (RFT, PFR) may have beneficial effects on functional mechanisms regulating fibroblast migration and proliferation during gingival healing or periodontal repair.

Smoking is associated with an increased risk of oral health and dental problems. The aim of this study is to address the hypothesis that nicotine impairs wound healing by increasing reactive oxygen species and inhibiting cell migration, and antioxidants (AOs) may counteract nicotine effects.Primary human gingival fibroblasts (HGFs) and human periodontal ligament (HPDL) fibroblasts were grown to confluence, pretreated with 6 mM nicotine for 2 hours, and treated with AOs in the presence of nicotine. The pure AO compounds ferulic acid (F), phloretin (P), tetrahydrocurcuminoid Cockroft Gault (T), and resveratrol (R) were tested in single, double, or triple combinations (10(-5) M). The migratory behavior at a scratch-wound edge was recorded every 15 minutes for 10 hours by using live-cell imaging. The active form of the Rho-associated protein (Rac) and guanosine triphosphate (GTP) (RacGTP) was immunolabeled and analyzed using confocal microscopy.Combinations of double and triple AOs had a greater effect than single AOs on migration rates and Rac activation. The triple combinations PFR and RFT clearly and unambiguously counteracted the effects of nicotine and significantly increased migration rates in HGF and HPDL fibroblast.Treatment with AO combinations clearly counteracted the effects of nicotine by restoring and increasing cell-migration rates. We found the combination of PFR was the most effective in HGFs, whereas, RFT was the most effective combination in HPDL fibroblast. These results clearly demonstrate that PF, RFT, and PFR counteract the negative effects of nicotine on cultured oral fibroblasts via the RacGTP signal-transduction pathway.

Hiroyasu Endo, Shinichiro Aoki, Takanori Ito, Terry D. Rees, Edward P. Allen, Kayo Kuyama and Hirotsugu Yamamoto

Management of gingival recession defects, a common periodontal condition, using root coverage procedures is an important aspect of periodontal regenerative therapy. The goal of the periodontal soft tissue root coverage procedures group was to develop a consensus report based on the accompanying systematic review of root coverage procedures, including priorities for future research and identification of the best evidence available to manage different clinical scenarios. The group reviewed and discussed the accompanying systematic review, which covered treatment of single-tooth recession defects, multiple-tooth recession defects, and additional focused questions on relevant clinical topics. The consensus group members submitted additional material for consideration by the group in advance and at the time of the meeting. The group also identified priorities for future research. All reviewed root coverage procedures provide significant reduction in recession depth, especially for Miller Class I and II recession defects. Subepithelial connective tissue graft (SCTG) procedures provide the best root coverage outcomes. Acellular dermal matrix graft (ADMG) or enamel matrix derivative (EMD) in conjunction with a coronally advanced flap (CAF) can serve as alternatives to autogenous donor tissue. Additional research is needed to do the following: 1) assess the treatment outcomes for multiple-tooth recession defects, oral sites other than maxillary canine and premolar teeth, and Miller Class III and IV defects; 2) assess the role of patient- and site-specific factors on procedure outcomes; and 3) obtain evidence on patient-reported outcomes. Predictable root coverage is possible for single-tooth and multiple-tooth recession defects, with SCTG procedures providing the best root coverage outcomes. Alternatives to SCTG are supported by evidence of varying strength. Additional research is needed on treatment outcomes for specific oral sites. Clinical Recommendation: For Miller Class I and II single-tooth recession defects, SCTG procedures provide the best outcomes, whereas ADMG or EMD in conjunction with CAF may be used as an alternative.

Focused Clinical Question: How should gingival recession (GR) defects be managed based on current evidence? Summary: The purpose of this practical application is to illustrate the management of GR defects with a primary outcome goal of complete root coverage. The consensus in dental literature and among expert clinicians is that root coverage may be attained through the application of different procedures and that outcomes are generally measured by reduced defect depth, gain in clinical attachment, and an increase in keratinized tissue (KT). These procedures may include the use of: 1) subepithelial connective tissue graft (SCTG); 2) coronally advanced flap; 3) free gingival graft; and 4) soft tissue graft substitutes (acellular dermal matrix and xenogeneic collagen matrix materials) and biologics (recombinant human platelet-derived growth factor and enamel matrix derivative). The variability in these techniques revolves around the inclusion or avoidance of a palatal donor graft. The decision as to how to approach a specific clinical GR-type defect should be a combination of considerations relative to the clinician's surgical goals and the patient's understanding of the anticipated outcome. The associated systematic review (Chambrone and Tatakis, J Periodontol 2015;86(Suppl.):S8-S51) provides clear evidence that SCTG-based procedures provide the best outcome for mean and complete root coverage, as well as an increase in KT. Patient-reported outcomes, a topic that needs additional research, should be considered in the decision-making process. Conclusion: Based on the available evidence and the illustrated cases included in this practical application, root coverage can be predictably achieved and a successful clinical outcome can be maintained long term.

The aim of the present investigation was to clinically determine the thickness of masticatory mucosa in the hard palate and tuberosity as potential donor sites for ridge augmentation procedures. In 31 periodontally healthy, fully dentate subjects the masticatory mucosa thickness was assessed by bone sounding with a periodontal probe. Eighteen standard measurement points were defined in the hard palate, located on 3 lines which ran at different distances parallel to the gingival margin. Six positions were designated on each of these 3 lines between the level of the canine and the second molar. In the tuberosity, 6 standard measurement points were defined, located on 2 lines running parallel to the gingival margin at 2 different distances from the distal aspect of the second molar. Three positions were designated on each line. The hard palate and tuberosity were anesthetized by a spray followed by carticain injection with an epinephrine vasoconstrictor of 1:100,000. Data were analyzed to determine differences in gender, between different positions, and between lines, using an analysis of variance and Wilcoxon test. The mucosa of the tuberosity was significantly thicker than in the hard palate region. Gender did not influence the thickness of masticatory mucosa, either in the hard palate or the tuberosity with the exception of the most distant line in the palate. The mucosa was thickest at the mid-distal position of the tuberosity. In the hard palate, mucosa thickness increased with greater distances from the marginal gingiva. The mucosa over the palatal root of the maxillary first molar was significantly thinner than at all other positions in the hard palate. This represents an anatomical barrier in graft harvesting. It was concluded that two different regions may be defined for soft tissue graft harvesting from an anatomic point of view: 1) In the canine-premolar region rather wide and shallow grafts may be harvested. This region extends distally to the first palatal molar root with a significantly thinner mucosa. 2) The tuberosity revealed a significantly more soft tissue thickness in comparison to the hard palate. This region allows the harvesting of deeper grafts, but graft size is limited by the width of keratinized tissue.

There is increasing attention to the potential benefit from the use of antioxidants in the field of dental medicine. In general, antioxidants may be available through oral ingestion, diet or vitamin supplements, and in nutraceuticals. In addition, treatment of oral and dental health problems may include drug-free, natural antioxidant remedies that are available in topical oral applications such as mouth rinse, gel, paste, gum, or lozenge compositions. These topical antioxidant remedies help reduce free-radical or reactive-oxygen species, which are causative inflammatory factors in the progression of gingival and periodontal maladies. This review focuses on relationships between antioxidants and free-radical/reactive-oxygen species in the oral environment.

Through dental procedures and environment, periodontal tissues are exposed to many types of reactive oxygen species (ROS). Recently, various forms of antioxidants have been introduced as an approach to fight dental diseases and improve general gingival health. This article focuses on the classification of antioxidants and the link between oxidative stress and periodontal disease. The protective mechanisms of antioxidants and how routine dental procedures may increase ROS is discussed. The final section reviews the effect of tobacco products on gingival health and disease.

Soft tissue grafting is an integral part of treatment of cervical lesions due to the common lack of adequate attached gingiva and root exposure associated with these lesions. Complete root coverage is a predictable outcome for Miller Class I and II recession defects, and partial root coverage can be achieved in Miller Class III defects. In the esthetic zone, it is desirable to cover as much of the root as possible, and all sites require an adequate zone of attached gingiva, especially adjacent to a restoration. Restorations are required for cervical lesions with excessive depth and significant involvement of the enamel, but they should be avoided where the lesion is shallow and the enamel involvement is minimal. Of course, some sites will require both soft-tissue grafting and placement of a restoration. An interdisciplinary approach to treating cervical lesions will create the most biologically appropriate, stable, and esthetic outcome. Establishing the appropriate tooth form first in treatment planning and sequencing will determine the gingival level and extent of periodontal procedures necessary to achieve the desired outcome.

Covering exposed roots becomes more and more difficult as the gingiva becomes thinner and the vestibule becomes more shallow. Also, the outcome becomes less predictable. In addition, where there is high frenal attachment or muscle pull, such as the mentalis muscle in the mandibular anterior region, secondary retraction of a coronally advanced flap will likely occur. Therefore, a transplanted connective tissue graft may not completely cover the recession. This case series presents a technique where the roots are covered with a combination epithelialized-subepithelial connective tissue graft. The epithelialized portions of the graft are positioned directly over the exposed roots to aid in resistance to the environment of the mouth, and there is no displacement of the mucogingival junction or flattening of the vestibule.

The annual review of selected dental literature this year cites 384 published papers and reports. This year's review contains more editorial comment than reviews of years passed. New data on the biological responses to materials is emphasized in several sections. Observations on new compounds able to prevent plaque formation are presented. Clinically relevant advances in knowledge concerning the etching of different tooth structures are reported along with the effect of etching procedures on the dental pulp. Evaluation of periodontal diseases in all age groups is a topic. Limitations of current diagnostic techniques in periodontal disease, temporomandibular disorders, and implant therapy are included. There are new views on the use of dental amalgam. The future use of dental mercury is predicted. Interest in new ceramic systems is indicated as the demand for esthetics continues. Clinical information is emphasized over scientific information throughout this year's review.

This paper describes a new suturing method, the subpapillary continuous sling suture, for use with soft tissue grafts in tunnel procedures to treat gingival recession. This method combines the graft suture and the sutures used to advance the pouch margins over the graft into a single continuous sling suture. It is indicated particularly for sites with shallow recessions and those treated for augmentation rather than root coverage because of a lack of graft access for standard suture placement. The single-suture method may also be used for sites with moderate to severe recession. The advantages of this method include elimination of the need to place additional sutures for coronal advancement of the pouch, resulting in reduced suturing time and reduced opportunity to inadvertently cut the continuous suture with the needle when suturing the pouch.

The clinical success of root coverage with autogenous connective tissue (CT) or acellular dermal matrix (ADM) has been well documented. However, limited histological results of CT grafts have been reported, and a case report of a human block section has been published documenting an ADM graft. The purpose of this study is to document the histological results of CT grafts, ADM grafts, and coronally advanced flaps to cover denuded roots in humans.This study included four patients previously treatment planned for extractions of three or more anterior teeth. Three teeth in each patient were selected and randomly designated to receive either a CT or ADM graft beneath a coronally advanced flap (tests) or coronally advanced flap alone (control). Six months postoperatively block section extractions were performed and the teeth processed for histologic evaluation with hematoxylin-eosin and Verhoeff's stains.Histologically, both the CT and ADM were well incorporated within the recipient tissues. New fibroblasts, vascular elements, and collagen were present throughout the ADM, while retention of the transplanted elastic fibers was apparent. No effect on the keratinization or connective tissue organization of the overlying alveolar mucosa was evident with either graft. For both materials, areas of cemental deposition were present within the root notches, the alveolar bone was essentially unaffected, and the attachments to the root surfaces were similar.Although CT and ADM have a slightly different histological appearance, both can successfully be used to cover denuded roots with similar attachments and no adverse healing.

Periodontal plastic surgical procedures aimed at coverage of exposed root surfaces have evolved into routine treatment modalities. The present study was designed to assess the effectiveness and the predictability of a bioabsorbable barrier in the treatment of human recession defects utilizing a single-step surgical procedure.One hundred consecutive single and multiple adjacent Miller Class I, II, and III buccal recession defects in 41 patients were treated with a combination of a bioabsorbable barrier and coronally advanced flap technique. Clinical parameters were recorded immediately prior to surgery, at 3 months, and after a minimum of 6 months.A highly significant reduction in recession depth from a mean value of 3.2 +/- 0.9 mm preoperatively to 0.3 +/- 0.5 mm postoperatively, corresponding to a mean root coverage of 92. 7% +/- 14.1%, was obtained. Complete (100%) root coverage was obtained in 75% of the sites. Factors adversely affecting root coverage were membrane exposure postoperatively and preoperative recession depthor =4 mm. In addition, inferior results were achieved at mandibular incisor and maxillary molar sites. Factors having no effect on root coverage included maxillary versus mandibular sites and single versus multiple adjacent sites.The use of guided tissue regeneration in periodontal plastic surgery is highly predictable, and highly esthetic root coverage can be gained without requiring a second surgical procedure or a second surgical site and is, therefore, an attractive alternative to conventional grafting techniques.