title: Root coverage in molar teeth: a comparative controlled randomized clinical trial. Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue: comparison of clinical parameters at 10 years. Coverage of localized gingival recessions: comparison of micro- and macrosurgical techniques. Tunnel technique versus coronally advanced flap with acellular dermal matrix graft in the treatment of multiple gingival recessions. Combination of direct and indirect evidence in mixed treatment comparisons. Root coverage esthetic score after treatment of gingival recession: an interrater agreement multicenter study. Clinical evaluation of acellular allograft dermis for the treatment of human gingival recession. Coronally advanced flap with and without connective tissue graft for the treatment of single maxillary gingival recession with loss of inter-dental attachment. A randomized controlled clinical trial. Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 1: Comparison of clinical parameters. Subepithelial connective tissue graft with or without enamel matrix derivative for the treatment of Miller class I and II gingival recessions: a controlled randomized clinical trial. Treatment of multiple adjacent Miller class I and II gingival recessions with a Modified Coronally Advanced Tunnel (MCAT) technique and a collagen matrix or palatal connective tissue graft: a randomized, controlled clinical trial. A comparison of methods of aesthetic assessment in root coverage procedures. Does placement of a connective tissue graft improve the outcomes of coronally advanced flap for coverage of single gingival recessions in upper anterior teeth? A multi-centre, randomized, double-blind, clinical trial. Clinical application of autologous fibroblast cell culture in gingival recession treatment.
abstract: AIM To compare the clinical outcomes of laterally moved , coronally advanced flap ( LMCAF ) versus Bilaminar technique ( BT ) in the treatment of single gingival recession on molar teeth . MATERIAL AND METHODS Fifty patients showing Miller I and II gingival recessions at first molar teeth were treated : 25 were r and omly assigned to the BT group and 25 belonged to the LMCAF group .  Patient 's post-operative morbidity was assessed 1 week after the surgery , while aesthetic evaluation and the clinical evaluation were made 1 year later . RESULTS No statistically significant difference was demonstrated in terms of recession and PPD reduction . Statistically greater probability of complete root coverage ( CRC , Odds Ratio 22.1 ) and greater increase in gingival thickness were observed in the BT group . Greater increase in keratinized tissue was obtained in the LMCAF .  Patient satisfaction with aesthetics was very high in both treatment groups . Better post-operative course was observed in the LMCAF , while better post-operative sensitivity and root coverage evaluation were demonstrated in patients treated with BT . CONCLUSIONS Gingival recession at first molar teeth can be successfully treated with LMCAF and BT . Better CRC was achieved with BT , while more comfortable post-operative course was associated with the LMCAF BACKGROUND The effective treatment of gingival recession ( GR ) defects is crucial for predictable outcomes . The most common treatment is the subepithelial connective tissue graft ( CTG ) , but good outcomes have also been obtained using enamel matrix derivative ( EMD ) . A split-mouth , r and omized controlled trial was previously performed during a 12-month period to evaluate primary and secondary outcomes in Miller Class I and II GR defects treated with CTG or EMD , both in combination with coronally advanced flap ( CAF ) . The purpose of the current study is to examine the major qualitative and quantitative parameters of this study after a 10-year follow-up . METHODS Nine of 17 original patients were available for follow-up evaluation 10 years after the original surgery . The parameters measured were : ( 1 ) GR depth ; ( 2 ) probing depth ( PD ) ; ( 3 ) clinical attachment level ; ( 4 ) width of keratinized tissue ( wKT ) ; ( 5 ) percentage of root coverage ; ( 6 ) root dentin hypersensitivity ; ( 7 ) color , texture , and contour of treatment sites ; and ( 8) patient satisfaction at 10 years . Results at 1 and 10 years of these nine patients ( nine test and nine control teeth ) were compared to original baseline values . In addition , results within treatment groups between 1 and 10 years and between treatment groups ( i.e. , EMD versus CTG ) at the same time points were examined . RESULTS At 10 years , all quantitative parameters except PD for both treatment protocol s showed statistically significant improvements from baseline values , including wKT in the EMD group , which at 1 year was not significantly improved compared with baseline wKT . In addition , at 10 years , there were no statistically significant differences between EMD + CAF and CTG + CAF for any measured parameter . The only statistically significant finding in this study was the difference in wKT found at 1 year ( EMD , 3.00 mm ; CTG , 3.89 mm ; P = 0.031 ) . Qualitative parameters at 10 years demonstrated similar stability . The only major qualitative difference was the marginal tissue contour , which was similar to adjacent tissues at EMD-treated sites but greater than adjacent tissues at all CTG sites except one . Esthetically , both EMD- and CTG-mediated treatments were similar at 10 years . However , given the choice , six of nine patients would choose EMD over CTG treatment to avoid a secondary harvesting procedure . CONCLUSIONS This paper highlights the importance of long-term data as it relates to procedural effectiveness in selecting optimally effective protocol s to treat gingival recession . Based on the results of this 10-year follow-up investigation , treatment with either EMD + CAF or CTG + CAF for Miller Class I and II GR defects appears stable , clinical ly effective , and similar to each other on all measured parameters BACKGROUND In the presence of a thin and narrow zone of gingival tissue root recessions caused by trauma or inflammatory reactions seem to be a common feature of the buccal tissue morphology . The surgical coverage is mainly indicated for aesthetic reasons and may be accomplished with pedicled flaps in conjunction with or without the use of connective tissue grafts . AIM The purpose of the present study was to evaluate the degree of vascularization of connective tissue grafts by applying a microsurgical approach . In addition , the clinical outcome was followed for 1 year . MATERIAL AND METHODS The study population consisted of 10 patients with bilateral Class I and II recessions at maxillary canines . In split-mouth design , the defects were r and omly selected for recession coverage either by a microsurgical ( test ) or macrosurgical ( control ) approach . Immediately after the surgical procedures , and after 3 and 7 days of healing , fluorescent angiograms were performed to evaluate graft vascularization . In addition , the clinical parameters were assessed before the surgical intervention , and 1 , 3 , 6 and 12 months postoperatively . RESULTS The results of the angiographic evaluation at test sites revealed a vascularization of 8.9+/-1.9 % immediately after the procedure . After 3 days and after 7 days , the vascularization rose to 53.3+/-10.5 % and 84.8+/-13.5 % , respectively . The corresponding vascularization at control sites were 7.95+/-1.8%/44.5+/-5.7 % and 64.0+/-12.3 % , respectively . All the differences between test and control sites were statistically significant . The clinical measurements revealed a mean recession coverage of 99.4+/-1.7 % for the test and 90.8+/-12.1 % for the control sites after the first month of healing . Again , this difference was statistically significant . The percentage of root coverage both test and control sites remained stable during the first year at 98 % and 90 % , respectively . CONCLUSIONS The present controlled clinical study has demonstrated that in root surface coverage , a microsurgical approach substantially improved the vascularization of the grafts and the percentages of root coverage compared with applying a conventional macroscopic approach AIM The aim of this r and omized controlled clinical study was to evaluate the outcomes of acellular dermal matrix ( ADM ) graft in combination with tunnel technique ( TUN ) on root coverage , aesthetics , and patient satisfaction and to compare with coronally advanced flap (CAF)+ADM in the treatment of multiple gingival recessions . MATERIAL AND METHODS A total of 20 patients with 58 Miller Class I multiple recessions ≥3 mm were included and divided into TUN+ADM and CAF+ADM groups . At baseline and 12 months , probing depth ( PD ) , clinical attachment level ( CAL ) , recession height ( RH ) and width ( RW ) , keratinized tissue height ( KT ) , gingival thickness , and complete and mean root coverage ( CRC , MRC ) were evaluated . Patient satisfaction and root coverage aesthetic scores ( RES ) were also assessed . RESULTS Mean root coverage was 75.72 % in TUN+ADM and 93.81 % in CAF+ADM . Intragroup comparisons revealed significant differences at 12 months for all parameters in both groups ( p < 0.05 ) . Intergroup differences were found to be statistically significant for RH and RW reduction , KT increase , CAL gain , MRC , CRC , and RES in favour of CAF+ADM group ( p < 0.05 ) . CONCLUSION Both techniques were effective in root coverage of multiple recessions ; however , better clinical results were achieved with CAF and ADM combination Mixed treatment comparison ( MTC ) meta- analysis is a generalization of st and ard pairwise meta- analysis for A vs B trials , to data structures that include , for example , A vs B , B vs C , and A vs C trials . There are two roles for MTC : one is to strengthen inference concerning the relative efficacy of two treatments , by including both ' direct ' and ' indirect ' comparisons . The other is to facilitate simultaneous inference regarding all treatments , in order for example to select the best treatment . In this paper , we present a range of Bayesian hierarchical models using the Markov chain Monte Carlo software WinBUGS . These are multivariate r and om effects models that allow for variation in true treatment effects across trials . We consider models where the between-trials variance is homogeneous across treatment comparisons as well as heterogeneous variance models . We also compare models with fixed ( unconstrained ) baseline study effects with models with r and om baselines drawn from a common distribution . These models are applied to an illustrative data set and posterior parameter distributions are compared . We discuss model critique and model selection , illustrating the role of Bayesian deviance analysis , and node-based model criticism . The assumptions underlying the MTC models and their parameterization are also discussed 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 patients were separately given to each operator who evaluated the outcomes according to the RES method . A two-way r and om 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 BACKGROUND Periodontal root coverage procedures to treat recession areas are indicated for unesthetic , exposed , and /or painful root surfaces . Many methods , most using autogenous soft tissue grafts , have been utilized , but with associated morbidity at the donor sites . An alternative donor material would reduce the morbidity and provide for sufficient available donor tissue . METHODS An acellular allogeneic dermal connective tissue matrix ( AD ) and autogenous palatal connective tissue ( CT ) were compared as subepithelial grafts for the treatment of gingival recession . Twenty-two patients with similar isolated gingival recession of > or = 2 mm on 2 separate teeth were treated with the  subepithelial graft technique . Exposed roots were h and root planed only and , by r and om allocation , either a fitted AD or fitted CT graft was secured in place and covered by coronally positioned flaps . RESULTS Mann Whitney U test analysis found the following changes at 6 months for AD and CT , respectively , compared to presurgical conditions : root coverage of 1.7 + /- 1.2 ( 65.9 % ) and 2.2 + /- 1.1 mm ( 74.1 % ) ( both P<0.01 ) , increase in keratinized tissue ( KT ) of 1.2 + /- 1.3 and 1.6 + /- 1.9 ( both P<0.01 ) , and an increase in gingival thickness with both ; 83.2 % of expected root coverage was obtained with AD and 88.6 % with CT ( P= 0.43 ) . There were no significant differences between treatments for any parameter . Global assessment s by clinicians and patients suggested a more esthetic clinical result with AD . CONCLUSIONS These results suggest that acellular allogeneic dermal matrix may be a useful substitute for autogenous connective tissue grafts in root coverage procedures BACKGROUND The aim of this r and omized clinical trial ( RCT ) was to evaluate the adjunctive benefit of Connective Tissue Graft ( CTG ) to Coronally Advanced Flap ( CAF ) for the treatment of gingival recession associated with inter-dental clinical attachment loss equal or smaller to the buccal attachment loss ( RT2 ) . MATERIAL AND METHODS A total of 29 patients with one recession were enrolled ; 15 patients were r and omly assigned to CAF+CTG while 14 to CAF alone . Measurements were performed by a blind and calibrated examiner . Outcome measures included complete root coverage ( CRC ) , recession reduction ( RecRed ) , Root coverage Esthetic Score ( RES ) , intra-operative and post-operative morbidity , and root sensitivity . RESULTS After 6 months , CAF+CTG result ed in better outcomes in terms of CRC ( adjusted OR = 15.51 , p = 0.0325 ) than CAF alone . CRC was observed in > 80 % of the cases treated with CAF+CTG when the baseline amount of inter-dental CAL was ≤ 3 mm . No difference was detected in term of RecRed  . CAF+CTG was associated with longer surgical-time ( p < 0.0001 ) , higher number of days with post-operative morbidity ( p = 0.0222 ) and the need for a greater number of analgesics ( p = 0.0178 ) than CAF alone . No difference for final RES score was detected ( p = 0.1612 ) . CONCLUSION Both treatments can provide CRC in single gingival recession with inter-dental CAL loss . The application of CTG under CAF result ed in predictable CRC when inter-dental CAL was ≤ 3 mm BACKGROUND Recession defects around teeth have been treated with a variety of surgical techniques . Most of the literature suggests that the subepithelial connective tissue graft has the highest percentage of mean root coverage with the least variability . Previous studies have demonstrated that enamel matrix derivative ( EMD ) has the ability to improve clinical parameters . The purpose of this study was to compare the clinical efficacy of enamel matrix derivative placed under a coronally advanced flap to subepithelial connective tissue placed under a coronally advanced flap in patients with recession type defects . METHODS Twenty patients with incisors or premolars presenting with a facial recession of > or = 4 mm in contralateral quadrants of the same jaw were treated ; 17 patients completed the study . One tooth in each patient was r and omized to receive either a coronally advanced flap with a subepithelial connective tissue graft ( control ) or a coronally advanced flap with EMD ( test ) . Clinical parameters measured at baseline and at 6 , 9 , and 12 months included amount of recession ; width at the coronal extent of the gingival defect ; width of keratinized tissue ; probing depth ; clinical attachment level ; inflammation score ; plaque score ; plaque index ; alveolar bone level ; tissue texture and color ; and patient perception of pain , bleeding , swelling , and sensitivity . RESULTS Results for both the test and control groups were similar for all measured clinical parameters with the exception of early healing , self-reported discomfort , and the amount of keratinized tissue obtained . The coronally advanced flap with EMD was superior to the subepithelial connective tissue graft with regard to early healing and patient-reported discomfort , whereas the subepithelial connective tissue graft demonstrated greater amount of keratinized tissue during the 12-month evaluation period . However , both the test and control showed a significant increase in the amount of keratinized tissue at 9 and 12 months compared to baseline . No significant difference in the amount of root coverage was found between the test and control groups ( n = 19 ; P = 0.82 ) . On average , a gain of 4.5 mm ( range 4 to 8 mm ) tissue covering the previously exposed root surfaces was achieved with both treatment groups . The average percentages of root coverage for control and test groups were 93.8 % and 95.1 % , respectively . One hundred percent root coverage was obtained 89.5 % of the time with the coronally advanced flap with EMD and 79 % of the time with the subepithelial connective tissue graft . CONCLUSION Based on the results of this investigation , the addition of EMD to the coronally advanced flap result ed in root coverage similar to the subepithelial connective tissue graft but without the morbidity and potential clinical difficulties associated with the donor site surgery BACKGROUND The aim of this study was to evaluate whether the combination of enamel matrix derivative ( EMD ) with subepithelial connective tissue graft ( SCTG ) plus coronally advanced flap ( CAF ) would improve the treatment outcomes of Miller class I and II gingival recessions when compared with the same technique ( SCTG plus CAF ) alone . METHODS The study was design ed as a r and omized , parallel , controlled , double-blinded clinical trial . Forty-two patients were r and omly assigned in the test group ( SCTG plus EMD ) and in the control group ( SCTG ) . Patients had at least one gingival recession ≥ 2 mm .  The clinical parameters were evaluated at baseline and at 14 d , 1 , 3 , 6 and 12 mo follow-up time points . RESULTS Forty-two patients , 21 in the test group ( SCTG plus EMD  ) and 21 in the control group ( SCTG ) , aged 21 - 48 years ( mean age 31 ± 8.56 ) were initially included in the study . Both treatments , STCG plus EMD and SCTG , result ed in a significant final mean root coverage ( 2.91 ± 0.95 mm and 2.91 ± 1.29 mm , respectively ) ( p < 0.001 ) and in a high mean percentage of root coverage ( 82.25 ± 22.20 % and 89.75 ± 17.33 % , respectively ) ( p < 0.001 ) , 1 year after surgery . The differences in mean root coverage recorded for the two techniques after 1 year , were not statistically significant ( p = 0.19 ) . Complete root coverage was achieved in 56.5 % of patients treated with SCTG plus EMD and in 70.6 % of patients treated with SCTG ( p = 0.275 ) , 1 year after treatment . CONCLUSIONS The present study failed to demonstrate any additional clinical benefits when EMD was added to SCTG plus CAF BACKGROUND A newly developed collagen matrix ( CM ) of porcine origin has been shown to represent a potential alternative to palatal connective tissue grafts ( CTG ) for the treatment of single Miller Class I and II gingival recessions when used in conjunction with a coronally advanced flap ( CAF ) . However , at present it remains unknown to what extent CM may represent a valuable alternative to CTG in the treatment of Miller Class I and II multiple adjacent gingival recessions ( MAGR ) . The aim of this study was to compare the clinical outcomes following treatment of Miller Class I and II MAGR using the modified coronally advanced tunnel technique ( MCAT ) in conjunction with either CM or CTG . METHODS Twenty-two patients with a total of 156 Miller Class I and II gingival recessions were included in this study . Recessions were r and omly treated according to a split-mouth design by means of MCAT + CM ( test ) or MCAT + CTG ( control ) . The following measurements were recorded at baseline ( i.e. prior to surgery ) and at 12 months : Gingival Recession Depth ( GRD ) , Probing Pocket Depth ( PD ) , Clinical Attachment Level ( CAL ) , Keratinized Tissue Width ( KTW ) , Gingival Recession Width ( GRW ) and Gingival Thickness ( GT ) . GT was measured 3-mm apical to the gingival margin . Patient acceptance was recorded using a Visual Analogue Scale ( VAS ) . The primary outcome variable was Complete Root Coverage ( CRC ) , secondary outcomes were Mean Root Coverage ( MRC ) , change in KTW , GT , patient acceptance and duration of surgery . RESULTS Healing was uneventful in both groups . No adverse reactions at any of the sites were observed . At 12 months , both treatments result ed in statistically significant improvements of CRC , MRC , KTW and GT compared with baseline ( p < 0.05 ) . CRC was found at 42 % of test sites and at 85 % of control sites respectively ( p < 0.05 ) . MRC measured 71 ± 21 % mm at test sites versus 90 ± 18 % mm at control sites ( p < 0.05 ) . Mean KTW measured 2.4 ± 0.7 mm at test sites versus 2.7 ± 0.8 mm at control sites ( p > 0.05 ) . At test sites , GT values changed from 0.8 ± 0.2 to 1.0 ± 0.3 mm , and at control sites from 0.8 ± 0.3 to 1.3 ± 0.4 mm ( p < 0.05 ) . Duration of surgery and patient morbidity was statistically significantly lower in the test compared with the control group respectively ( p < 0.05 ) . CONCLUSIONS The present findings indicate that the use of CM may represent an alternative to CTG by reducing surgical time and patient morbidity , but yielded lower CRC than CTG in the treatment of Miller Class I and II MAGR when used in conjunction with MCAT AIM To evaluate the reliability of professional qualitative scoring methods used in evaluating aesthetic results after  root coverage therapy and to evaluate the relationship between subjective and objective measurements . MATERIAL AND METHODS A review panel of seven professional and non-professional , trained and untrained observers used photographic records to assess the overall cosmetic results of 162 root coverage surgical procedures in 133 patients ( mean follow-up 17.51+/-17.37 months ) . Two different methods were used . In the before-after panel scoring system , observers evaluated the difference between preoperative and postoperative views , whereas in the r and om panel scoring system , observers rated each photograph independently . RESULTS For both methods , intrarater agreement ranged from substantial to almost perfect for the periodontists . The best interrater agreement was found for trained periodontists using the five-point ordinal scale of the before-after panel scoring system ( kappa=0.68 ) . Neither root coverage percentage nor gingival augmentation was correlated to cosmetic assessment . CONCLUSIONS The before-after scoring system is an acceptable and reliable method for professional cosmetic assessment of root coverage therapy . The overall cosmetic evaluation does not appear to be related to the percentage of root coverage AIMS This parallel-group , multi-centre , double-blind , r and omized-controlled clinical trial was undertaken to compare the clinical outcomes and patient morbidity of coronally advanced flap ( CAF ) alone or in combination with a connective tissue graft ( CAF+CTG ) in single Miller Class I and II gingival recessions . MATERIAL AND METHODS Three centres enrolled 85 patients with one recession each .  Surgery was performed elevating a pedicle flap ;  42 sites r and omly received a graft under the flap . Measurements were taken by blind and calibrated examiners . Outcome measures included recession reduction , complete root coverage ( CRC ) , intra-operative and post-operative morbidity , dentine sensitivity , and side effects . RESULTS No differences were noted in the intra-operative and post-operative patient-related variables between the two groups . Surgical time was significantly shorter in the CAF group . Recession reduction was not statistically different between the two groups , even though a model showed a tendency towards improved outcomes in sites treated with CAF+CTG ( adjusted difference 0.33 mm , 95 % CI=-0.06 to 0.72 , p=0.1002 ) . Significantly greater probability of CRC was observed after CAF+CTG ( adjusted OR=5.09 , 95 % CI=1.69 - 17.57 , p=0.0033 ) . Dentine hypersensitivity improved in both the groups . CONCLUSIONS Both treatments were effective in providing a significant reduction of the baseline recession and dentine hypersensitivity , with only limited intra-operative and post-operative morbidity and side effects . Adjunctive application of a CTG under a CAF increased the probability of achieving CRC in maxillary Miller Class I and II defects BACKGROUND AND OBJECTIVE Gingival recession is defined as soft and hard tissue displacement result ing in root surface exposure . The optimal outcome of gingival recession treatment is complete , predictable and long-lasting root coverage with a significant level of tissue regeneration . Tissue engineering , which applies active regeneration principles , presents the contemporary treatment approach in the restitution and regeneration of lost tissues . The objective of the present study was to evaluate and compare the clinical results of application of an autologous fibroblast cell culture ( AFCC ) on a collagen matrix and a connective tissue graft ( CTG ) placed under a coronally advanced flap ( CAF ) , in the treatment of single and multiple gingival recessions . MATERIAL AND METHODS Eighteen patients from the Department of Periodontology , School of Dentistry , University of Bel grade , were r and omly enrolled in this study . Inclusion criteria were the bilateral presence of Miller Class I or II single or multiple maxillary gingival recessions . A split-mouth design was used in the study . The experimental group was treated with AFCC on a collagen scaffold , which was placed under a CAF . The control group received a combination of CTG and CAF . Clinical parameters such as gingival recession coverage , keratinized tissue width , clinical attachment level and gingival index were recorded at baseline and at 12 mo postoperatively . The oral hygiene level was assessed by plaque index evaluation . Postoperative healing was evaluated through the healing index , recorded 1 , 2 and 3 wk postoperatively . The final esthetic outcome was assessed using the mean root coverage esthetic score ( RES ) . RESULTS Statistically significant improvement of all parameters assessed was found compared with baseline . A statistically significant difference between groups was observed only in keratinized tissue width . Greater keratinized tissue width is still obtained with the use of CTG . Regarding the tissue-healing results , no statistically significant difference was achieved . The RES results were similar for both groups . CONCLUSIONS Within the limitations of the present study , both procedures proved to be efficient in gingival recession treatment . AFCC , as a novel tissue-engineering concept and living cell-based therapy , proved to be a reliable and successful treatment concept
target: Periodontal Plastic Surgery ( PPS ) techniques applying grafts underneath CAF with or without the adding of EMD are associated with improved aesthetics assessed by final patient perception and RES as professional evaluation system
background: BACKGROUND The aim of this study was to perform a systematic review ( SR ) of r and omized controlled trials ( RCTs ) to explore if periodontal plastic surgery procedures for the treatment of single and multiple gingival recessions ( Rec ) may improve aesthetics at patient and professional levels .