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Treatment of gingival recession defects on the lingual surface of mandibular anterior teeth is a challenge for the periodontist because of the region's unique anatomical features. Although there are no esthetic issues, lingual recessions should be considered seriously, especially on mandibular incisors, because they are frequently associated with periodontitis and dental hypersensitivity. The treatments and the long-term outcomes (5 years) of three clinical cases of multiple lingual recessions are presented. The tunnel technique associated with subepithelial connective tissue graft was chosen. The postoperative period was almost uneventful in all treated cases, and the 1-year outcomes were successful. Great recession reduction, up to complete root coverage, was seen, as were significant increases of both the apicocoronal amount and thickness of keratinized tissue. At the 5-year follow-up, the tissues were stable; only a slight apical shift of the gingival margin was noted in one case. The modification of the periodontal phenotype following the tunnel technique with the subepithelial connective tissue graft allowed the patients to maintain good plaque control.

Retrograde peri-implantitis (RPI) is a periapical lesion that develops after implant insertion in which the coronal portion of the implant achieves a normal bone-to-implant interface. The most common etiology of RPI is the presence of an adjacent endodontic lesion. In most of the case reports available in the literature, the diagnosis of RPI occurred between 1 week and 4 years after implant placement. This case report illustrates the treatment of RPI that occurred more than 15 years after implant loading, caused by endodontic infection of the adjacent tooth.

BACKGROUND: The aim of this long-term case series was to assess the development/prevalence of non-carious cervical lesions (NCCLs) at sites that have and have not been treated with gingival augmentation following free gingival graft (FGG). METHODS: Fifty-two patients had at least one test and one control site: 1) test site showing absence of attached gingiva (AG) associated with gingival recession (GR) treated with FGG; and 2) contralateral site with or without AG. Patient/tooth/site-associated variables were recorded for each tooth/site at baseline (T0), 12 months after surgery (T1), during the follow-up period (T2) (15 to 20 years), and at the end of the follow-up period (T3) over 25 to 30 years. Mixed-effects logistic regression was used throughout the study. RESULTS: Forty-nine patients/130 sites were available for analysis at T2 whereas 44 patients/120 sites at T3. Twenty-two NCCLs >0.5 mm were restored in the test sites and in 35 in the untreated sites. The development of NCCL over time appeared associated with sites with attached KT

Orthodontic and periodontal treatment of the permanent maxillary teeth, which were retained due to trauma on the deciduous dentition, showed a perfect alignment of the teeth associated with healthy and stable periodontal tissues during an 11‐year follow‐up.

Introduction When gingival recession is combined with cervical abrasion, root coverage outcomes are less predictable due to the challenging adaptation of the connective tissue graft (CTG) to the marked root step. Removing additional tooth structure can improve soft-tissue adaptation with the downside of a possible increase in dental hypersensitivity or pulpitis. Therefore, the aim of this report was to demonstrate a surgical technique using two grafts which does not require any further modification of the root surface, in order to successfully treat recession associated with deep cervical abrasion. Case presentation A case of gingival recession associated with a deep root step and cemento-enamel junction alteration (B+; abrasion depth > 1 mm) was successfully treated via a bilaminar grafting technique using two CTG layers covered by a coronally advanced flap (CAF). The tooth surface was polished and did not receive any grinding, blending, planing, or other alterations. Complete recession coverage, complete abrasion coverage, and resolution of baseline sensitivity were achieved 1 year after surgical intervention and were maintained for 19 years with further coronal displacement of the gingival margin due to creeping attachment. Conclusions The double CTG technique showed optimal clinical results in terms of coverage and resolution of hypersensitivity of a recession associated with a deep cervical abrasion. No additional removal of dental tissue was needed, and the clinical outcomes were stably maintained over a long-term follow-up.

Amalgam tattoos are a serious cosmetic problem for patients. A 35-year-old woman came to a private periodontal practice complaining of black pigmentation (amalgam tattoo) above temporary crowns on the lateral and central maxillary incisors and asked that the cosmetic problem be solved before the new permanent crowns were cemented into place. A full-thickness coronoapical incision was made to raise a thick flap; another incision parallel to the surface of the alveolar mucosa made it possible to remove the pigmented connective tissue, which was sent for histologic examination. Due to the fact that the pigmentation extended into the gingival epithelium, the gingiva of the lateral and central incisors was completely removed, with a horizontal incision in the alveolar mucosa from the ends of the distal releasing incisions. Therefore, partially denuded alveolar bone was used as the recipient site for a free gingival graft (FGG). The histologic analysis revealed the presence of amalgam fragments of different sizes in both connective tissue and epithelium. At 6 months, 3 years, and 24 years postoperatively, the periodontal tissues appeared healthy, and the treated area was pink, without pigmentation or scarring, and was perfectly integrated with the adjacent tissues. The patient was very pleased with her appearance. A one-stage procedure, namely an FGG, should be considered an effective treatment of amalgam tattoo providing positive morphologic and cosmetic outcomes over a 24-year follow-up period.

BACKGROUND Coronally advanced flap (CAF) has been considered as one of the most predictable and versatile root coverage procedures. Thus, the aims of this study are two-fold: 1) to evaluate the long-term outcomes following CAF in the treatment of gingival recession (GR); and 2) to explore the influence of several tooth/patient-related factors on the stability of gingival margin at 5, 10, and 20 years after surgery. METHODS Ninety-four patients with 97 GR (73 Miller`s Class I and 24 Miller's Class III) were treated with CAF in a private practice between 1984 and 1996. Recession depth (RD), probing depth (PD), keratinized tissue (KT) width and patient/tooth-associated variables were recorded for each GR at baseline, 1 year, 5 years, 10 years, 15 years and 20 years after surgery. Parametric, non-parametric, and logistic regression statistics were used throughout the study RESULTS: A total of 72 patients with 72 GR were available for analysis at the 20-year follow-up examination (final patients' dropout rate = 23.4%). Statistically significant improvements were found for RD in all evaluations (P

Background This updated Cochrane systematic review (SR) evaluated the efficacy of different root coverage (RC) procedures in the treatment of single and multiple gingival recessions (GR). Methods We included randomized controlled trials (RCTs) only of at least 6 months' duration evaluating Miller's Class I or II GR (≥3 mm) treated by means of RC procedures. Five databases were searched up to January 16, 2018. Random effects meta-analyses were conducted thoroughly. Results We included 48 RCTs in the SR. The results indicated a greater GR reduction for subepithelial connective tissue grafts (SCTG) + coronally advanced flap (CAF) compared to guided tissue regeneration with resorbable membranes (GTR rm) + CAF (mean difference [MD]: -0.37 mm). There was insufficient evidence of a difference in GR reduction between acellular dermal matrix grafts (ADMG) + CAF and SCTG + CAF or between enamel matrix derivative (EMD) + CAF and SCTG + CAF. Greater gains in the keratinized tissue width (KTW) were found for SCTG + CAF when compared to EMD + CAF (MD: -1.06 mm), and SCTG + CAF when compared to GTR rm + CAF (MD: -1.77 mm). There was insufficient evidence of a difference in KTW gain between ADMG + CAF and SCTG + CAF. Conclusions SCTG, CAF alone or associated with another biomaterial may be used for treating single or multiple GR. There is also some evidence suggesting that ADMG appear as the soft tissue substitute that may provide the most similar outcomes to those achieved by SCTG.

BACKGROUND: Gingival recession is defined as the oral exposure of the root surface due to a displacement of the gingival margin apical to the cemento‐enamel junction and it is regularly linked to the deterioration of dental aesthetics. Successful treatment of recession‐type defects is based on the use of predictable root coverage periodontal plastic surgery (RCPPS) procedures. This review is an update of the original version that was published in 2009. OBJECTIVES: To evaluate the efficacy of different root coverage procedures in the treatment of single and multiple recession‐type defects. SEARCH METHODS: Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 15 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 12) in the Cochrane Library (searched 15 January 2018), MEDLINE Ovid (1946 to 15 January 2018), and Embase Ovid (1980 to 15 January 2018). The US National Institutes of Health Ongoing Trials Register (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials (15 January 2018). No restrictions were placed on the language or date of publication when searching the electronic databases. SELECTION CRITERIA: We included randomised controlled trials (RCTs) only of at least 6 months' duration evaluating recession areas (Miller's Class I or II ≥ 3 mm) and treated by means of RCPPS procedures. DATA COLLECTION AND ANALYSIS: Screening of eligible studies, data extraction and risk of bias assessment were conducted independently and in duplicate. Authors were contacted for any missing information. We expressed results as random‐effects models using mean differences (MD) for continuous outcomes and odds ratios (OR) for dichotomous outcomes with 95% confidence intervals (CI). We used GRADE methods to assess the quality of the body of evidence of our main comparisons. MAIN RESULTS: We included 48 RCTs in the review. Of these, we assessed one as at low risk of bias, 12 as at high risk of bias and 35 as at unclear risk of bias. The results indicated a greater reduction in gingival recession for subepithelial connective tissue grafts (SCTG) + coronally advanced flap (CAF) compared to guided tissue regeneration with resorbable membranes (GTR rm) + CAF (MD ‐0.37 mm; 95% CI ‐0.60 to ‐0.13, P = 0.002; 3 studies; 98 participants; low‐quality evidence). There was insufficient evidence of a difference in gingival recession reduction between acellular dermal matrix grafts (ADMG) + CAF and SCTG + CAF or between enamel matrix protein (EMP) + CAF and SCTG + CAF. Regarding clinical attachment level changes, GTR rm + CAF promoted additional gains compared to SCTG + CAF (MD 0.35; 95% CI 0.06 to 0.63, P = 0.02; 3 studies; 98 participants; low‐quality evidence) but there was insufficient evidence of a difference between ADMG + CAF and SCTG + CAF or between EMP + CAF and SCTG + CAF. Greater gains in the keratinized tissue were found for SCTG + CAF when compared to EMP + CAF (MD ‐1.06 mm; 95% CI ‐1.36 to ‐0.76, P < 0.00001; 2 studies; 62 participants; low‐quality evidence), and SCTG + CAF when compared to GTR rm + CAF (MD ‐1.77 mm; 95% CI ‐2.66 to ‐0.89, P < 0.0001; 3 studies; 98 participants; very low‐quality evidence). There was insufficient evidence of a difference in keratinized tissue gain between ADMG + CAF and SCTG + CAF. Few data exist on aesthetic condition change related to patients' opinion and patients' preference for a specific procedure. AUTHORS' CONCLUSIONS: Subepithelial connective tissue grafts, coronally advanced flap alone or associated with other biomaterial and guided tissue regeneration may be used as root coverage procedures for treating localised or multiple recession‐type defects. The available evidence base indicates that in cases where both root coverage and gain in the width of keratinized tissue are expected, the use of subepithelial connective tissue grafts shows a slight improvement in outcome. There is also some weak evidence suggesting that acellular dermal matrix grafts appear as the soft tissue substitute that may provide the most similar outcomes to those achieved by subepithelial connective tissue grafts. RCTs are necessary to identify possible factors associated with the prognosis of each RCPPS procedure. The potential impact of bias on these outcomes is unclear.

Aim The purpose of this editorial was to discuss a definition of success after periodontal therapy based on the retention of natural dentition. Materials and methods Based on topic and relevance, references were collected and then divided into four categories: (a) the influence of available therapeutic techniques on the definition of hopeless teeth, (b) the long-term rate of tooth loss during supportive periodontal therapy, (c) the duration of time that the treatment outcomes may be considered stable and (d) patients' perception and satisfaction of periodontal therapy. Results Periodontal therapy can change the prognosis of hopeless teeth, making them maintainable in the long term. The rate of tooth loss can be minimized in a way that a period of 10 years or more is needed to evaluate further periodontal breakdown. In addition, patients' perception and satisfaction of the treatment should be considered as the main therapeutic endpoints of the provided periodontal therapy. Conclusions Definition of success is linked to the available therapeutic tools. Due to the recent advancement of treatment modalities, periodontally hopeless teeth can now be treated and maintained for a long period of time with health, function and patient satisfaction.

BACKGROUND Subepithelial connective tissue graft with coronally advanced flap (SCTG + CAF) has been considered the best and most predictable root coverage procedure. Thus, the aims of this study are two-fold: 1) to evaluate the long-term outcomes following SCTG + CAF in the treatment of gingival recessions (GR) and 2) to explore the influence of several tooth/patient-related factors on the stability of gingival margin at 1 year and at 5,10, 15, and 20 years after surgery. METHODS Forty-five patients with 45 maxillary GR (Miller's Class I or III) were treated with SCTG + CAF in a private practice between 1990 and 1997. Recession depth (RD), probing depth (PD), keratinized tissue (KT) width and patient/tooth-associated variables were recorded for each GR at baseline, 1, 5, 10, 15, and 20 years after surgery. Parametric, non-parametric, and logistic regression statistics were used throughout the study. RESULTS A total of 21 Class I (44.67%) and 24 Class III (53.33%) GR were treated. Considering all the 45 GR, statistically significant improvements were found for RD in all evaluations (P

Cell phenotype is influenced by the linear sequence of bases and by epigenetic changes. Despite the huge number of implants placed every year, epigenetic mechanisms controlling peri-implant processes remain unexplored. The purpose of this systematic qualitative review was to investigate the available articles dealing with the relationships between DNA methylations, histone modifications, or micro-RNA (miRNA) production and implant therapy. A large variety of different surfaces were evaluated based on their osteogenic stimulation of osteoblasts. Dental implant treatments like potassium hydroxide (KOH) alkali-etching, electrolytic etching, ionization, functionalization with miRNAs or anti-miRNAs, or osteogenic peptides enhanced osteoblast differentiation and gene activation by regulating miRNA production. Zirconia and anatase coating inhibited the activation of osteogenic genes. Epigenetic changes on peri-implant cells induced by smoking still remain unclear. Due to the heterogeneity of methodologies, a meta-analysis was not possible. Even if it is impossible to define which implant surface was best to genetically stimulate osteogenesis, there is evidence that implant surface features can upregulate or downregulate genes related to osseointegration.

An extremely rare case presenting two bilateral transposed and infraosseus impacted maxillary canines was treated with a combined two-step periodontal and orthodontic technique. The canines were transposed mesially and buccally to the lateral incisors, close to the midline and in a horizontal position. Direct orthodontically guided traction of the teeth toward the center of the alveolar ridge was not possible due to the roots of the lateral incisors. The procedure consisted of two distinct treatment phases for each side preceded by an initial orthodontic treatment to achieve the palatal inclination of the roots of the lateral incisors, creating a parallel buccal inclination of the crowns. This approach provided a submucosal buccal space into which the canines could be moved buccally and distally, avoiding any contact with the roots of the lateral incisors. In the first phase, the transposed canines were guided distally. When the canines, still in a submucosal position, were freed from those obstacles, the second phase was begun. The teeth were exposed, permitting the orthodontically guided traction toward the center of the ridge, simulating a proper physiologic eruption alignment pattern in the arch. The combined two-step periodontal and orthodontic approach used to treat two bilateral transposed and infraosseus impacted maxillary canines was extremely successful, resulting in adequate alignment in the arch associated with a physiologic sulcus depth, adequate keratinized tissue width, and absence of marginal recession at the end of the active treatment and 5 years postsurgery.

AIMS The aims of this study were to verify patients' perception of buccal recessions and their requests for treatment. METHODS The patients filled out a questionnaire dealing with demographic variables and perception of buccal gingival recessions. A calibrated examiner checked for recessions and recorded the clinical variables. Then, the patients were asked to explain what they believed to be the causes of the recessions and whether they were interested in obtaining treatment of their lesions. Descriptive statistics and multilevel logistic models were used. RESULTS Of 120 enrolled patients, 96 presented 783 gingival recessions, of which 565 were unperceived. Of 218 perceived recessions, 160 were asymptomatic, 36 showed dental hypersensitivity, 13 aesthetics, 9 aesthetic + hypersensitivity issues. Only 11 patients requested treatment for their 57 recessions. Younger individuals (p = 0.0077), deeper recessions (p

Background The aim of this randomized clinical trial was to evaluate the efficacy of Apically Positioned Flap with Fibre Retention Osseous Resective Surgery (FibReORS) or Osseous Resective Surgery (ORS) to treat periodontal pockets associated with infrabony defect ≤3 mm at posterior natural teeth. Material and methods Thirty patients with chronic periodontitis showing persistent periodontal pockets after cause-related therapy were enrolled; 15 patients were randomly assigned to FibReORS (test group) and 15 to ORS (control group). Measurements were performed by a blind and calibrated examiner. Outcome measures included intra-operative and post-operative morbidity and root sensitivity, 1-year probing depth (PD), gingival recession (Rec) and radiographic bone changes. Results No differences in clinical and bone defect parameters were observed at baseline. Marginal bone resection was reduced by 0.9–1.6 mm in the FibReORS group. ORS was associated with patient perception of greater surgical hardship (p = 0.0264), higher 1-week pain experience (p = 0.0001) and greater dental hypersensitivity (p = 0.0002). After 1 year, shallow, maintainable PD with no difference between the two procedures (p = 0.3707) was obtained. FibReORS was associated with less final Rec (p

Background: The root coverage esthetic score (RES) system was proposed for evaluating esthetic outcomes of root coverage procedures. The aim of this multicenter study is to assess the interrater agreement of the RES among expert periodontists. Methods: Eleven periodontists were selected in different clinical centers. Each operator had ≥ 15 years of experience in mucogingival surgery. Each periodontist was trained to use RES before the beginning of the study. Subsequently, baseline and post-treatment (6 months) photographs of 41 Class I and II gingival recessions in 41 patientswere separately given to each operatorwho evaluated the outcomes according to the RES method. A two-way random interclass correlation coefficient and 95% confidence interval (CI) were used to assess the global interrater agreement for RESs. Results: The total interrater agreement for RESs was 0.92 (95% CI: 0.88 to 0.95), which indicated that an almost perfect agreement was achieved. Conclusion: Tested individually by a group of periodontists, the RES seems to be a reliable method for assessing the esthetic outcomes of root coverage procedures.

Pini-Prato GP, Cairo F, Nieri M, Franceschi D, Rotundo R, Cortellini P. Coronally advanced flap versus connective tissue graft in the treatment of multiple gingival recessions: a split-mouth study with a 5-year follow-up. J Clin Periodontol 2010; 37: 644–650. doi: 10.1111/j.1600-051X.2010.01559.x Abstract Aim: The aim of this long-term study was to compare the clinical outcomes of coronally advanced flap (CAF) alone versus coronally advanced flap plus connective tissue graft (CAF+CTG) in the treatment of multiple gingival recessions using a split-mouth design over 5 years of follow-up. Materials and Methods: A total of 13 patients (mean age 31.4 years) showing multiple bilateral gingival recessions were treated. On one side, CAF+CTG was used, while in the contra-lateral side, a CAF alone was applied. Clinical outcomes were evaluated at the 6-month, 1-year and 5-year follow-ups. Results: A total of 93 Miller class I, II and III gingival recessions were treated. In the CAF+CTG-treated sites, the baseline gingival recession was 3.6 ± 1.3 mm, while in the CAF-treated sites, it was 2.9 ± 1.3 mm (p=0.0034). No difference in terms of the number of sites with complete root coverage (CRC) was reported (OR=0.49, p=0.1772) at the 6-month follow-up. At the 5-year follow-up, CAF+CTG-treated sites showed a higher percentage of sites with CRC (52%) than CAF-treated sites (35%) (OR=3.94; p=0.0239). An apical relapse of the gingival margin in CAF-treated sites was observed while a coronal improvement of the margin was noted in CAF+CTG-treated sites between the 6-month and the 5-year follow-ups. Conclusions: CAF+CTG provided better CRC than CAF alone in the treatment of multiple gingival recessions at the 5-year follow-up.

Aim: The aim of this study was to evaluate the association between severe periodontitis and sub-clinical atherosclerosis in young (40 years) systemically healthy individuals. Material and Methods: Ninety systemically healthy subjects, 45 affected by severe periodontitis (mean age 36.35±3.65 years) and 45 controls without a history of periodontal disease (mean age 33.78±3.28 years), were enrolled in this study. Patients and controls were paired for age, gender, body mass index and smoking habits. Carotid intima-media thickness (IMT) was bilaterally assessed by ultrasonography at the level of common carotid artery. Traditional cardiovascular risk factors for atherosclerosis were also evaluated. Results: The overall mean carotid IMT was 0.82±0.13 mm in the test group and 0.72±0.07 mm in the control group ( p

Objective: To evaluate the influence of pretreatment radiographic features (α-angle, d-distance, and s-sector) on (1) the duration of active orthodontic traction and (2) the posttreatment periodontal status (pocket depth [PD] and keratinized tissue width [KT]) of impacted maxillary canines treated by a combined surgical (flap approach) and orthodontic (direct traction to the center of the ridge) treatment. Material and Methods: A study population of 168 patients (168 canines) was evaluated. Multiple regression analysis was used. Results: Pretreatment radiographic variables were associated significantly with the duration of orthodontic traction. Age, sex, and site of impaction did not significantly affect the duration of traction. No significant differences in PD and KT were present at the end of surgical-orthodontic treatment with respect to any of the variables considered. The analysis of PD and KT variables after orthodontic treatment revealed a healthy periodontium. Conclusions: α-angle, d-distance, and s-sector are valid indicators for the duration of orthodontic traction. They are not prognostic indicators of final periodontal status of orthodontically-repositioned canines.

AIM: The aims were to evaluate and compare the periodontal status of unilateral impacted maxillary canines treated by a combined surgical-orthodontic technique with that of normally erupted controlateral canines. MATERIAL AND METHODS: One hundred and twenty-five patients, consecutively enrolled, aged between 12.8 and 52.0 years, 31 males and 94 females, presented one impacted maxillary canine (test group) and the controlateral canine normally erupted (control group). All cases were treated by a surgical flap and orthodontic traction directed to the centre of the crest and evaluated periodontally at the end of treatment. Fifty-eight patients were followed up for a mean of 3.4 +/- 0.5 years. Pocket depth (PD), keratinized tissue width (KT) and gingival recession were recorded. Multilevel models were created. RESULTS: At the end of the orthodontic treatment, PD and KT of the 125 impacted canines were slightly, but statistically significantly higher than controls. Only one treated canine showed a recession (1 mm). At follow-up (58 patients), this difference decreased and the two groups were not significantly different. CONCLUSIONS: The combined technique permitted the traction of the impacted canines to the centre of the crest, thus simulating a physiological eruption pattern. Correct alignment and good periodontal status were obtained.

BACKGROUND The aim of this study was to assess the stability of root coverage outcomes 3 years after Connective Tissue Graft (CTG) plus Coronally Advanced Flap (CAF) or CAF alone at single maxillary gingival recession with minimal inter-dental clinical attachment loss. MATERIAL AND METHODS Twenty-four of the original 29 patients, 13 treated with CAF + CTG and 11 with CAF, were available for the 3-year follow-up. Measurements were performed by a blind and calibrated examiner. Outcome measures included complete root coverage (CRC), recession reduction (RecRed), Root coverage Esthetic Score (RES) and Keratinized Tissue (KT) Gain. Visual Analogue Scale (VAS) was used to evaluate patient satisfaction. RESULTS After 3 years, CAF + CTG resulted in better outcomes in terms of CRC (p = 0.0054) than CAF alone. No difference was detected in terms of RecRed, RES score and VAS values. Furthermore, CAF + CTG was associated with higher KT gain than CAF at the last follow-up (p < 0.0001). CONCLUSION Root coverage outcomes in single gingival recession with inter-dental CAL loss are stable after 3 years. The application of CTG under CAF was associated with increased probability to obtain CRC than CAF alone at the final follow-up.

Background: Langerhans' cell histiocytosis (LCH) is a rare disorder in which a neoplastic proliferation of cells similar to the Langerhans' cell of the epidermis is observed. The disease may affect different organs as solitary or multiple lesions with a complete dissemination in different organs such as the bone (jaws), lung, hypothalamus, skin and mucous membranes, lymph nodes, liver, and other tissues. Although LCH is considered a childhood or juvenile disease, the diagnosis is often made in adults, and in many cases, a juvenile form progresses into adult life. Hand- Schuller-Christian disease (HSCD) is an LCH form in which the typical lesions involve the cranial bones, the eyes, and the pituitary gland. Methods: This article describes a case of a patient diagnosed, through periodontal lesions and diabetes insipidus, as having Langerhans' cell histiocytosis. Conclusion: As far as LCH lesions appearing in periodontal tissues, the periodontist should be involved in the detection of oral lesions. J Periodo...

Aims The aim of this work was to conduct a Bayesian network meta-analysis (NM) of randomized controlled trials (RCTs) to establish a ranking in efficacy and the best technique for coronally advanced flap (CAF)-based root coverage procedures. Material and Methods A literature search on PubMed, Cochrane libraries, EMBASE, and hand-searched journals until June 2012 was conducted to identify RCTs on treatments of Miller Class I and II gingival recessions with at least 6 months of follow-up. The treatment outcomes were recession reduction (RecRed), clinical attachment gain (CALgain), keratinized tissue gain (KTgain), and complete root coverage (CRC). Results Twenty-nine studies met the inclusion criteria, 20 of which were classified as at high risk of bias. The CAF+connective tissue graft (CTG) combination ranked highest in effectiveness for RecRed (Probability of being the best = 40%) and CALgain (Pr = 33%); CAF+enamel matrix derivative (EMD) was slightly better for CRC; CAF+Collagen Matrix (CM) appeared effective for KTgain (Pr = 69%). Network inconsistency was low for all outcomes excluding CALgain. Conclusion CAF+CTG might be considered the gold standard in root coverage procedures. The low amount of inconsistency gives support to the reliability of the present findings.

This case report describes the healing of gingival recessions on mandibular incisors resulting from orthodontic treatment of a deep bite malocclusion at a 30-year follow-up observation. The marked improvement in the severe recessions was a consequence of the elimination of the direct trauma, orthodontic intrusion of the affected teeth, and subsequent creeping attachment over time. No periodontal treatment was performed before or after orthodontic treatment.

Altered passive eruption/gummy smile is a common challenge in patients requiring aesthetic treatment. A specific surgical protocol was designed and tested in patients with altered passive eruption. Standardized preoperative X-rays were used to assess crown length at baseline and to place submarginal incisions. Osseous respective therapy was performed to achieve biological width. Clinical outcomes were recorded 6 months after surgery. Eleven patients with a total of 58 teeth were treated with flap surgery and osseous resective therapy at upper anterior natural teeth. At the last followup, a significant and stable improvement of crown length was obtained when compared to the baseline (P<0.0001). All patients rated as satisfactory in the final outcomes (final VAS value = 86.6). In conclusion, this study showed that periodontal plastic surgery including osseous resection leads to predictable outcomes in the treatment of altered passive eruption/gummy smile: A careful preoperative planning avoids unpleasant complications and enhances postsurgical stability of the gingival margin.

Gingival recession is often associated with abrasion in the cervical area with an unidentifiable cementoenamel junction (CEJ). This condition complicates the diagnosis and treatment of gingival recession. The aim of this study was to propose a technique to identify the CEJ level for planning periodontal and restorative treatment of the recession. The CEJ of a contralateral homologous tooth or adjacent teeth was used to replicate the lost CEJ at the treated tooth. Reconstruction of the CEJ using composite resin and a coronally advanced flap, with or without a connective tissue graft, was performed for 25 recessions in 12 patients. After 2 years, 20 defects (80%) showed complete root coverage with a significant recession reduction (2.4 mm, P.0001).

The aim of this long-term study was to compare the clinical outcomes of coronally advanced flap (CAF) alone versus coronally advanced flap plus connective tissue graft (CAF+CTG) in the treatment of multiple gingival recessions using a split-mouth design over 5 years of follow-up.A total of 13 patients (mean age 31.4 years) showing multiple bilateral gingival recessions were treated. On one side, CAF+CTG was used, while in the contra-lateral side, a CAF alone was applied. Clinical outcomes were evaluated at the 6-month, 1-year and 5-year follow-ups.A total of 93 Miller class I, II and III gingival recessions were treated. In the CAF+CTG-treated sites, the baseline gingival recession was 3.6 +/- 1.3 mm, while in the CAF-treated sites, it was 2.9 +/- 1.3 mm (p=0.0034). No difference in terms of the number of sites with complete root coverage (CRC) was reported (OR=0.49, p=0.1772) at the 6-month follow-up. At the 5-year follow-up, CAF+CTG-treated sites showed a higher percentage of sites with CRC (52%) than CAF-treated sites (35%) (OR=3.94; p=0.0239). An apical relapse of the gingival margin in CAF-treated sites was observed while a coronal improvement of the margin was noted in CAF+CTG-treated sites between the 6-month and the 5-year follow-ups.CAF+CTG provided better CRC than CAF alone in the treatment of multiple gingival recessions at the 5-year follow-up.

The aim of the present explorative cross-sectional study was to evaluate the potential role of some periodontal variables in predicting sub-clinical atherosclerosis and systemic inflammation in young adults (or=40 years) with severe periodontitis compared with healthy individuals without periodontitis.A total of 90 systemically healthy subjects, 45 (mean age 36.35+/-3.65 years) affected by severe periodontitis (test group) and 45 individuals (mean age 33.78+/-3.28 years) without a history of periodontal disease (control group) were enrolled in the present study. Test and control groups were paired for age, gender, body mass index (BMI) and smoking habits. Carotid intima-media thickness (carotid IMT) was bilaterally assessed by ultrasonography at the level of the common carotid artery to evaluate sub-clinical atherosclerosis. Blood samples to assess inflammatory markers (leucocytes, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, total serum cholesterol, high sensitivity C-reactive protein, glucose and haemoglobin A1c% were taken.In periodontal patients, mean probing depth (PD) was a predictor of mean carotid IMT (P=0.0005), BMI (P=0.0002), systolic blood pressure (P=0.0300) and diastolic blood pressure (P= 0.0199). Full-mouth bleeding score (FMBS) was a predictor of C-reactive protein levels (P=0.0218). In controls, full-mouth plaque score was a predictor of glucose levels (P=0.0074) and higher FMBS of lower triglycerides levels (P=0.0312).Mean PD and FMBS may predict sub-clinical atherosclerosis and systemic inflammation in young adults with severe periodontitis.

The aim of this article was to present the treatment of an unesthetic smile in a 27-year-old woman showing gingival recession, gingival asymmetry, and an altered passive eruption in the natural dentition. First, an apically positioned flap with osseous resective surgery was applied to correct the gingival asymmetry at the maxillary right incisors. The amount of bone resection was determined by means of bone sounding at the maxillary left incisors. Six weeks later, a coronally advanced flap procedure was performed to cover the gingival recession at the maxillary right canine, along with an enamelplasty and a direct composite resin restoration. The patient was satisfied with the final treatment outcome.

Introduction The aim of this study was to apply Bayesian networks to evaluate the relative role and possible causal relationships among various factors affecting the diagnosis and final treatment outcome of impacted maxillary canines. Methods A total of 168 patients with infraosseous impacted maxillary canines had a combined surgical-orthodontic approach aimed to guide the impacted tooth to the center of the alveolar ridge. Demographic, orthodontic, and periodontal variables were recorded and analyzed by means of Bayesian network analysis. Results All 168 impacted canines were successfully moved and aligned in the dental arches with healthy periodontiums. According to the Bayesian network analysis, bilateral impaction was associated with palatal impaction and longer treatment; the pretreatment α-angle was a determinant for the duration of orthodontic traction, also because of the associations between greater angulation of impacted canines with more severe tooth displacement and with greater distance of the impacted canine from the occlusal plane; the posttreatment periodontal outcome was not related to the pretreatment radiographic variables. Conclusions Bayesian network analysis was useful to identify possible relationships among the variables considered for diagnosis and treatment of impacted canines.

Generally, esthetic outcomes following root-coverage procedures are not assessed. This article proposes a score for evaluating the esthetic outcome following root-coverage surgery.Thirty-one patients with Miller Class I and II recession defects treated with root-coverage procedures were evaluated. Esthetic outcomes were assessed using the root coverage esthetic score (RES) 6 months after surgery. This score evaluates five variables: level of the gingival margin, marginal tissue contour, soft tissue texture, mucogingival junction alignment, and gingival color. Because complete root coverage was the primary treatment goal, and the other variables were considered secondary, the value assigned for root coverage was 60% of the total score, whereas 40% was assigned to the other four variables. With regard to assessment of the final position of the gingival margin, 3 points were given for partial root coverage, and 6 points were given for complete root coverage; 0 points were assigned when the final position of the gingival margin was equal or apical to the previous recession. One point was assigned for each of the other four variables. Thus, 10 points was a perfect score.Of the 31 treated recession defects, 24 (77%) exhibited complete root coverage at 6 months. The mean amount of root coverage was 89.4% (range, 0% to 100%). The mean RES was 7.8. Five of 24 cases of complete root coverage achieved a perfect score (RES = 10). In one case, RES = 0.The RES system may be a useful tool to assess the esthetic outcome following root-coverage procedures.

The enhanced visual perception and illumination of an operative microscope improve surgical techniques in terms of flap incision, quality of root debridement, and suturing. The aim of this study is to describe microsurgical flap access for the treatment of periodontal pockets associated with shallow to moderate bony defects in the esthetic zone of the mouth. This technique combines preservation of the still-attached gingival fibers and maintenance of the body of the interproximal papilla. The results in terms of attachment level gain and residual pocket depth show that the described microsurgical approach helps to minimize marginal tissue recession and improve esthetics in the treatment of shallow to moderate bony defects.

The purpose of this study was to evaluate the periodontal variables of impacted maxillary canines that were treated with a combined surgical and orthodontic approach aimed at reproducing the physiologic eruption pattern of canines. Twenty-five patients who presented with unilateral impacted maxillary canines were consecutively enrolled (age range, 13.2 to 23.2 years). They were treated with a surgical flap and orthodontic traction directed to the center of the crest and were evaluated periodontally at the end of treatment and again at a follow-up visit (2 to 5 years posttreatment). Pocket depth, keratinized tissue width, and gingival recession were recorded. At the end of orthodontic treatment, all 25 treated canines presented with normal pocket depth (2.0 +/- 0.3 mm) and a normal amount of keratinized tissue (5.0 +/- 1.2 mm). No sites showed gingival recession. At the follow-up visit, both pocket depths and keratinized tissues were slightly reduced. The combined technique permits traction of the impacted canines to the center of the crest, simulating the physiologic eruption pattern and resulting in correct alignment and good periodontal status.

The aim of the study was to evaluate the influence of pre-treatment radiographic features (alpha-angle, d-distance and s-sector) on the duration of active orthodontic traction of impacted maxillary canines treated by a combined surgical (flap approach) and orthodontic (direct traction to the center of the ridge) treatment.A study population of 168 patients (168 canines) was evaluated. Multiple regression analysis was used.Pre-treatment radiographic variables were associated significantly with the duration of orthodontic traction. Age, gender and site of impaction did not affect the duration of traction significantly.Alpha-angle, d-distance and s-sector are valid indicators for the duration of orthodontic traction.

The great challenge in clinical periodontology is assigning a prognosis to a periodontally affected patient. Many different factors can affect the long-term maintenance of periodontally compromised teeth. The main questions usually considered by the periodontist are: 1) Will a tooth lose more bone in the future? 2) Will the tooth itself be lost in the future? The purpose of this retrospective study was to evaluate the value of some clinical, genetic, and radiographic variables in predicting tooth loss in periodontal patients (aged 40 to 60 years) treated and maintained for 10 years.Sixty consecutive non-smoking patients (aged 46.77 +/- 4.96 years) with moderate to severe chronic periodontitis (CP) were treated with scaling and root planing (SRP). Some patients also underwent additional surgical treatments. All patients were maintained in the same private practice for 10 years. The frequency of recall appointments was 3.4 +/- 1.0 months. At baseline (T(0)) and 10 years later (T(2)) the following clinical variables were evaluated: the number of teeth, probing depths (PD), tooth mobility (TM), and presence of prosthetic restorations (PR). In addition, radiographic measurements were taken of the mesial and distal distances from the cemento-enamel junction (CEJ) to the bottom of the defect (BD), to the bone crest (BC), and to the root apex (RA). At T(2), a genetic test to determine the IL-1 genotype and genetic susceptibility for severe periodontal disease was performed for all 60 patients, and they were classified as IL-1 genotype positive (G+) or negative (G-) according to the test results. Tooth loss was used as the outcome variable. Different predictor variables were then tested using a two-level statistical model (patient and tooth levels). At the patient level, these were: age, gender, mean bone loss (mean CEJ-BD)(T0), the interleukin-1 (IL-1) genotype, the interaction between mean bone loss, and IL-1 genotype (mean CEJ-BD(T0) x IL-1 genotype). At the tooth level, the variables were: TM(T0), prosthetic restorations (PR)(T0), molar teeth (MT)(T0), the infrabony component of the defect (BC-BD)(T0), PD(T0), bone level (CEJ-BD)(T0), and residual supporting bone (BD-RA)(T0).Among the considered predictor variables, the following were significantly associated with the outcome variable: 1) MT(T0) (P0.0001); 2) BC-BD(T0) (P = 0.0377); and 3) BD-RA(T0) (P0.0001). MT(T0) were found to be more prone to loss and the amount of BD-RA(T0) prognostic for tooth loss: the lower the residual amount of supporting bone, the higher the probability of tooth loss. Conversely, the BC-BD(T0)was associated with a reduced probability of future tooth loss: the greater the infrabony component, the lower the probability of tooth loss. None of the other considered predictors proved predictive for tooth loss.Within the scope of this study, many traditional prognostic factors were ineffective in predicting future tooth loss and, therefore, were of no prognostic value. Conversely, a few specific factors at the tooth level emerged as viable prognostic factors. The use of these factors may be of great value to practitioners as predictors of tooth loss when assigning a prognosis.

An assessment of the factors affecting the clinical outcome of root coverage procedures may be useful in clinical decision making. The aim of this study is to investigate whether the post-surgical location of gingival margin relative to the cemento-enamel junction (CEJ) can influence the recession reduction (RecRed) and complete root coverage (CRC) following coronally advanced flap procedure (CAF).Sixty patients, aged between 22 and 57 years, 15 males and 45 females, each showing maxillary buccal recessions (or =2 mm) identified as Miller's Class I were consecutively enrolled. All the defects were treated by CAF procedure from 2000 to 2003 by a single operator with more than 20 years of clinical experience. Age, gender, smoking habits, and type of tooth of each patient were recorded. In addition, the following clinical data were measured or computed: recession depth, width of keratinized tissue, probing depth, distance between incisal margin (IM) and CEJ, dental hypersensitivity, clinical attachment level, distance between IM and gingival margin (IMGM), distance between IM and mucogingival junction (IMMG), and the location of gingival margin relative to the CEJ following CAF procedure (GM(1)). A multiple linear regression, and a logistic linear regression analyses were performed.The recession depth at baseline (Rec(T0)) and the location of the gingival margin after suturing (GM(1)) are positively correlated to recession reduction. Complete root coverage appeared to be influenced by GM(1): the more coronal the level of the gingival margin after suturing (GM(1)), the greater the probability of CRC.The location of the gingival margin relative to the cemento-enamel junction following CAF procedure seems to affect CRC.

This study was designed to describe a method for measuring root curvature of extracted teeth, compare root curvature of four different dental morphotypes before mechanical instrumentation, and measure root curvature after mechanical instrumentation.Fifty-five maxillary (14 central incisors, 13 lateral incisors, 14 cuspids, 14 premolars) extracted teeth were analyzed. Measurements were recorded on the horizontal plane at the most apical point of the cemento-enamel junction (CEJ). A 4 mm wide root portion on the buccal aspect was selected and recorded on this plane. A digital scanner traced the circle coinciding with the profile of this root portion and calculated its radius, arc, chord, and arrow (i.e., the perpendicular bisector of the chord). Since root curvature is the inverse of the radius (1/r), the radius was related to root curvature; the arc to the mesio-distal dimension of the root portion; and the reduction of the arrow to root flattening after mechanical instrumentation. The measurements were recorded four times: before treatment (baseline), after polishing, after a first root planing, and after a second root planing. The radii of each dental morphotype (upper central incisors, upper lateral incisors, upper canines, upper premolars) recorded in the first measurement were calculated and used for the statistical analyses: one-way analysis of variance (ANOVA) test and the Tukey multiple comparison method were used to study the curvature. The measurements of the radius, the arc, and the arrow at the four times were used for the statistical analyses: the two-way ANOVA test and the Tukey multiple comparison method were applied in the study of the root modifications after mechanical instrumentation. The accuracy and reliability of the method were also evaluated.The mean radii of the four dental morphotypes were: central incisors: 3.613 +/- 0.258 mm; lateral incisors: 2.558 +/- 0.256 mm; canines: 2.822 +/- 0.238 mm; and premolars: 2.321 +/- 0.179 mm. The statistical analyses revealed differences among central incisors, canines, lateral incisors, and premolars. There was no statistically significant difference between lateral incisors and premolars. Regarding the root modifications after mechanical treatment, the radius did not show statistically significant differences in any of the comparisons. The arc and the arrow did not show significant differences between baseline and polishing, while they did show significant differences after the second root planing.This study indicates that: 1) the method of measuring is accurate and reliable; 2) there are statistically significant differences among the root curvatures of different dental morphotypes; and 3) polishing did not modify the root. A vigorous root planing did not modify root curvature, but it did reduce the mesio-distal dimension and flatten the root surface slightly.

Prevention and treatment of alveolar ridge deformities aim at preserving and/or reconstructing soft and hard tissues of the edentulous ridge. Different surgical techniques may be used to prevent ridge collapse before tooth extraction or to reconstruct lost ridge anatomy before tooth replacement. In cases of mild or moderate ridge defects, soft tissue augmentation is generally sufficient to repair the deformity. On the other hand, hard tissue augmentation should be selected primarily when implant therapy is scheduled. In cases of severe ridge defects, a staged or a combined approach may be appropriate. This article reviews the various approaches for the prevention and treatment of ridge deformities.

Several reasons contribute to the loss of interdental papillae and the establishment of "black triangles" between teeth. The most common reason in the adult population is loss of periodontal support because of plaque-associated lesions. However, abnormal tooth shape, improper contours of prosthetic restorations, and traumatic oral hygiene procedures may also negatively influence the outline of the interdental soft tissues. Several surgical and nonsurgical techniques have been proposed to treat soft tissue deformities and manage the interproximal space. The nonsurgical approaches (orthodontic, prosthetic, and restorative procedures) modify the interproximal space, thereby inducing modifications to the soft tissues. The surgical techniques aim to recontour, preserve, or reconstruct the soft tissue between teeth and implants. This review categorizes the various approaches in different clinical situations.— Reprinted with permission of Quintessence Publishing.