Miller Class Research Articles

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

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

Clinical and Patient-Centered Outcomes Following Treatment of Multiple Gingival Recessions Using Acellular Dermal Matrix Allografts.

The aim of this case series was to evaluate clinical and patient-centered outcomes when treating multiple recessions (Miller Class I, II, and III) affecting five or more teeth in a single procedure using acellular dermal matrix in 18 eligible participants (mean of 7.4 ± 1.7 recessions/patient). Low mean visual analog scale pain scores (0.7 ± 0.8) and analgesic consumption (2.3 ± 2.5 tablets) were reported from days 0 to 6 postoperatively. Mean baseline recession depth was 2.1 ± 1 mm. At 1 year postsurgery, mean percent root coverage was 87.1% ± 18.3%, and complete root coverage was achieved in 61.7% of recessions with statistically significant differences between smokers and nonsmokers.

A novel volumetric analysis using cad/cam scanners in gingival recession treatment

Objective: In this study, randomized clinical trial (RCT), the aim was to compare clinical periodontal data of subepithelial connective tissue graft (SCTG) group and SCGT+enamel matrix derivatives (EMD) group in terms of gained gingiva volume (GGV) and gained gingiva surface area (GGSA) by scanners of computer-aided design/computer-aided manufacturing (CAD/CAM) devices. Material and Methods: In this study, a total of 35 Miller class I-II gingival recession defects were involved (n=17 in SCTG group, n=18 in SCTG+EMD group). In addition to, periodontal clinical parameters, and three dimensional (3D) images were recorded by using CAD/CAM system before the treatment, at the 1st month and the 6th months after the treatment. The images were superimposed by using softwares and GGV, and GGSA were calculated. Results: There was no significant difference in terms of GGV and GGSA values at the 1st month and 6thmonths between SCTG+EMD and SCTG groups. Similarly, there was no significant difference in periodontal clinical parameters between groups. Conclusion: Images obtained from CAD/CAM system can be easily used in calculating GGV and GGSA data after the gingival recession treatment and in determining of the success of administered treatment. It is expected that the evaluation of the success of many therapeutic approaches for periodontal treatment will be carried out by using CAD/CAM system in the future.

Blood flow changes using a 3D xenogeneic collagen matrix or a subepithelial connective tissue graft for root coverage procedures: a pilot study.

The study investigated the early healing process following the treatment of single Miller class I and II recessions with a 3D xenogeneic collagen matrix (CMX) or connective tissue graft (CTG). This pilot investigation was designed as a single-center randomized controlled parallel trial. A total of eight subjects (four per group) were treated with either CMX or CTG in the anterior maxilla. Vascular flow changes were assessed by laser Doppler flowmetry (LDF) before and after surgery and at days 1, 2, 3, 7, 14, and 30 while clinical evaluations took place at baseline and at days 60 and 180. Pain intensity perception was evaluated by the short-form McGill pain questionnaire (SF-MPQ), at days 1 and 14. The vascular flow fluctuated similarly in both groups pre- and post-operatively, but the CTG exhibited a more homogeneous pattern as opposed to CMX that showed a second phase of increased blood flow at 14days. Clinically, the CTG led to greater change in mean root coverage and keratinized tissue gain but CMX was associated with lower early pain intensity scores. Within the limits of the study, the vascular flow alterations during the early healing of both graft types followed a similar pattern. The CMX was associated with a second peak of increased blood flow. The vascular flow changes after the application of CMX for single tooth recession root coverage did not show major differences from those observed after the use of a CTG. A trend for better clinical performance in terms of root coverage and keratinized tissue gain was noted for the CTG, but the initial patient morbidity was less for CMX.

Clinical evaluation of coronally advanced flap with or without platelet-rich fibrin for the treatment of multiple gingival recessions.

The aim of this randomized, controlled study was to assess the clinical effect of platelet-rich fibrin (PRF) in combination with coronally advanced flap (CAF) on root coverage, esthetics, and patient satisfaction when compared to CAF alone for the treatment of multiple Miller class I recessions. A total of 24 patients with 52 Miller class I multiple recessions ≥3mm were included and divided into CAF + PRF and CAF groups. At baseline and 12months after surgery, recession height (RH), keratinized tissue height, gingival thickness (GT), and mean and complete defect coverage were evaluated. Patient satisfaction and root coverage esthetic scores were also assessed. Baseline RH in CAF + PRF and CAF groups was 3.15±0.24 and 3.36±0.34mm, respectively. Intragroup comparisons revealed significant differences at 12months for all parameters (p<0.05). RH reduction was 2.75±0.33 and 2.51±0.33mm (mean root coverage of 88.36 and 74.63%) in the CAF + PRF and CAF groups, respectively. Intergroup differences were found to be significant for GT gain (p<0.05). The additional use of PRF membrane did not provide additional benefits in terms of root coverage outcomes compared with CAF alone. The use of PRF membranes increased tissue thickness significantly.

Effectiveness and predictability of titanium-prepared platelet-rich fibrin for the management of multiple gingival recessions.

Titanium-prepared platelet-rich fibrin (T-PRF) is activated with titanium, which results in a more mature and aggregated form than PRF. In our previous studies, we established that the fibrin carpet formed with titanium had a firmer network structure, and longer resorption time in the tissue than the fibrin carpet formed with glass. The purpose of this randomized controlled clinical trial is to compare the effects of autogenous T-PRF and connective tissue graft (CTG). A total of 114 Miller Class I/II gingival recessions with abrasion defects were treated either T-PRF (63 teeth) or CTG (51 teeth) using a modified tunnel technique. Clinical periodontal indexes, keratinized tissue (KTW), gingival thickness, and recession depth were recorded before surgery and at 6- and 12-month follow-up examinations. The visual analog scale and healing index scores were assessed. The mean root coverages were 93.29 and 93.22% in the T-PRF and CTG groups, respectively, at 12months post-operatively. CTG resulted in greater gingival thickness than T-PRF at 6 and 12months post-surgery compared to baseline. Furthermore, the mean amounts of KTW increased by 1.97 and 0.75mm in the T-PRF and CTG groups, respectively. Within the limits of this study, the results demonstrated that T-PRF is safe and effective for treatment of multiple Miller Class I/II gingival recession defects. T-PRF can serve as a good autogenous alternative to CTG, which is the gold standard for root coverage.

Homological stability and stable moduli of flat manifold bundles

We prove that the group homology of the diffeomorphism group of #gSn×Sn\\int(D2n) as a discrete group is independent of g in a range, provided that n>2. This answers the high dimensional version of a question posed by Morita about surface diffeomorphism groups made discrete. The stable homology is isomorphic to the homology of a certain infinite loop space related to the Haefliger's classifying space of foliations. One geometric consequence of this description of the stable homology is a splitting theorem that implies certain classes called generalized Mumford–Morita–Miller classes lift to a secondary R/Z-invariants for flat (#gSn×Sn)-bundles provided g≫0.

Treatment of multiple maxillary adjacent class I and II gingival recessions with modified coronally advanced tunnel and a new xenogeneic acellular dermal matrix.

To evaluate the treatment of maxillary Miller Class I and II multiple adjacent gingival recessions using the modified coronally advanced tunnel technique (MCAT) combined with a new porcine acellular dermal matrix (PADM). Twelve patients exhibiting at least six adjacent maxillary Miller Class I and II gingival recessions were consecutively treated by means of MCAT and a PADM. Recession depth (RD), recession width (RW), probing pocket depth (PD), keratinized tissue height (KT), clinical attachment level (CAL), mean root coverage (RC), and complete root coverage (CRC) were recorded. At 12 months, CRC was obtained in 43% of the 100 gingival recessions, while the mean RC measured 84.35%. Mean RD reduction was 3.16 ± 0.75 mm (P < 0.001), mean RW reduction was 1.73 ± 0.65 mm (P < 0.001), while the gain of CAL was 3.26 ± 1.33 mm (P < 0.001). All patients were satisfied with the esthetic appearance and would undergo the same surgery again. Within their limits, the present results indicate that treatment of Miller Class I and II multiple gingival recessions using PADM in conjunction with the MCAT could be successfully used as an alternative to connective tissue grafts, with the advantage of avoiding the discomfort and morbidity of connective tissue harvesting. The modified coronally advanced tunnel technique using the new porcine acellular dermal matrix represents a clinically and esthetically satisfactory treatment of multiple Miller Class 1 and 2 recession defects.

Alternatives to connective tissue graft in the treatment of localized gingival recessions: A systematic review.

The aim of this Systematic Review (SR) was to assess the clinical efficacy of alternatives procedures; Acellular Dermal Matrix (ADM), Xenogeneic Collagen Matrix (XCM), Enamel Matrix Derivative (EMD) and Platelet Rich Fibrin (PRF), compared to conventional procedures in the treatment of localized gingival recessions. Electronic searches were performed to identify randomized clinical trials (RCTs) on treatment of single gingival recession with at least 6 months of follow-up. Applying guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analyses statement (PRISMA). The risk of bias was assessed using the Cochrane Collaboration's Risk of Bias tool. Eighteen randomized controlled trials (RCTs) with a total of 390 treated patients (606 recessions) were included. This systematic review showed that: Coronally Advanced Flap (CAF) in conjunction with ADM was significantly better than CAF alone, while the comparison between CAF+ADM and CTG was affected by large uncertainty. The CAF+EMD was significantly better than CAF alone, whereas the comparison between CAF+EMD and CTG was affected by large uncertainty. No significant difference was recorded when comparing CAF+XCM with CAF alone, and the comparison between CAF+XCM and CTG was affected by large uncertainty. The comparison between PRF and others technique was affected by large uncertainty. ADM, XCM and EMD assisted to CAF might be considered alternatives of CTG in the treatment of Miller class I and II gingival recession.

Epithelial Inclusions Following a Bilaminar Root Coverage Procedure with a Subepithelial Connective Tissue Graft: A Histologic and Clinical Study.

The aim of this study was to histologically examine any epithelial cell inclusions in submerged subepithelial connective tissue graft (SCTG) after clinical healing was achieved. A total of 16 patients with Miller Class I or II gingival recessions were consecutively treated with a bilaminar procedure. At 2 months after surgery, a gingival tissue specimen was harvested from all SCTG-treated sites and stained with hematoxylin-eosin. The histologic evaluation revealed connective tissue in active reorganization without epithelial inclusions in 14 of the 16 tissue specimens. In the remaining 2 specimens, epithelial islands were observed deep in the connective tissue. In one case they developed in a solid cystic space, while in the second case they were strictly integrated in the lamina propria. Complete recession coverage was obtained in 14 of the 16 treated defects, with a mean root coverage of 95.1% ± 14.2% at 12 months.

Root Coverage of Multiple Miller Class I and II Recession Defects Using Acellular Dermal Matrix and Tunneling Technique in Maxilla and Mandible: A 1-Year Report.

The objective of the present report was to study the influence of the location (maxilla versus mandible) and class (Miller classification) of gingival recessions on the total root coverage achievement using the tunnel procedure with acellular dermal matrix in adjacent single-root teeth. Twenty-four patients with 93 recessions were treated and evaluated 1 year postsurgery. Results showed 100% of root covered in 67.9% of the maxillary recessions and 52.5% in the mandible (P = .676). In cases of partial root coverage, the initial recession diminished from 4.41 mm (SD: 1.12) to 0.82 mm (SD: 0.24) in the maxilla and from 3.78 mm (SD: 1.08) to 0.78 mm (SD: 0.30) in the mandible. Root coverage of 100% was observed in 74.07% of Miller Class I recessions in comparison with 43.59% of Class II recessions (P = .003).

Coronal advanced flap in combination with a connective tissue graft. Is the thickness of the flap a predictor for root coverage? A prospective clinical study

Evaluate if there is any relationship between the flap thickness (FT) and the presence of complete root coverage (CRC) when performing coronally advanced flaps in combination with a connective tissue graft (CTG). Prospective clinical study, in which multiple Miller class I and II recessions were treated with a coronally advanced flap and a CTG standardized at 1mm of thickness. Individual stents permitted repeated measurements of conventional periodontal parameters at the same point. The primary outcome variable was CRC. Secondary outcomes were recession reduction, gingival thickness and width of keratinized tissue (KT) achieved at 6months post-surgery. Forty-five recessions (2.4±0.75mm) were treated in 20 patients. Mean root coverage was 93.4±10.98%; 65% achieved CRC. The mean FT was 1.01mm±0.64mm and 1.01±0.61mm at 2 and 5mm from the gingival margin, respectively. No relationship could be found between FT and CRC (p>.05). Statistical significant changes (p<.05) were observed for recession depth, clinical attachment level, KT and soft tissue thickness at the end of the study. Flap thickness seems not to be a predictor for CRC when performing a coronally advanced flap plus a CTG. This technique may be of choice when treating thin biotypes.

Vascularization and Innervation of Connective Tissue Grafts in the Treatment of Gingival Recessions: A Histologic and Immunohistochemical Study.

The goal of this study was to histologically evaluate the healing process of subepithelial connective tissue graft in humans. A sample of 16 patients with Miller Class I or II localized gingival recession defects were consecutively treated with a bilaminar technique. At baseline and after 2 months, tissue samples were taken from the donor and recipient sites. The revascularization and reinnervation of the graft were examined by means of hematoxylin-eosin and immunohistochemical techniques. After 2 months of healing, the integration of the grafted tissue was evident with the connective tissue expressing features belonging to both the recipient (cellular component) and the donor site (extracellular matrix) in the inner and superficial layers, respectively. This was accompanied by increased neovascularization and reduction in intraepithelial free nerve endings.

Creation of a Zone of Immobile Connective Tissue with Acellular Dermal Matrix Allografts.

Acellular dermal matrix allografts (ADMs) have been hypothesized to create a zone of immobile connective tissue (ICT) extending apical to the mucogingival junction (MGJ). This 12-month prospective randomized trial investigated the presence of ICT after the use of two commercially available ADMs with coronally advanced flaps in the treatment of Miller Class I and II recession defects. This study demonstrated that the use of either type of ADM resulted in predictable root coverage and a zone of ICT extending apical to the MGJ by 1.88 to 2.69 mm. Hence, minimal keratinized gingival width should not preclude the use of ADMs.

Long-Term Stability of Root Coverage by Coronally Advanced Flap Procedures.

This study compared 6-month and 3-year outcomes for root coverage (RC) by coronally advanced flap (CAF) procedures in localized gingival recessions. Two centers, that had participated in a 6-month multinational multicenter randomized clinical trial (RCT), followed up 18 patients with 36 Miller Class I and II defects that had been treated in a split-mouth design with CAF procedures or CAF + xenogeneic collagen matrix (CMX). Percentage of RC, complete root coverage (CRC), width, and thickness of keratinized tissue were assessed by the same masked examiners as after the 6-month RCT. There was a high correlation between 6-month and 3-year RC outcomes for both CAF procedures. Mean RC after CAF + CMX amounted to 89.9% after 6 months and 91.7% after 3 years (Pearson's correlation: 0.91). Corresponding values for CAF were 83.7% versus 82.8% (Pearson's correlation: 0.94). Likewise, CRC was stable with 61%/61% for CAF + CMX and 39%/39% for CAF after 6 months/3 years, respectively. In this 3-year follow-up of a subgroup of patients from a previous 6-month RCT, there was a high correlation between the results for RC after 6 months and 3 years, indicating their stability. These data suggest that 6-month outcomes may be useful to predict long-term outcomes in CAF procedures with or without additional use of CMX.

Platelet-rich fibrin membrane does not improve clinical outcomes compared with other treatment modalities in the treatment of gingival recession

Systematic review conclusionThe use of platelet-rich fibrin (PRF) membrane did not improve clinical outcomes (root coverage [RC], clinical attachment level [CAL], and keratinized mucosa width [KMW]) compared with other treatment modalities in Miller Class I and II gingival recession.Critical summary assessmentThe results of this well-conducted systematic review show limited evidence on the effects of PRF membrane on the clinical outcomes in the treatment of gingival recession, for which there are no clinical advantages of PRF membranes over other treatment modalities. However, the clinical significance of the added benefits is unclear due to the lack of patient-oriented outcome measures.Evidence quality ratingLimited. The use of platelet-rich fibrin (PRF) membrane did not improve clinical outcomes (root coverage [RC], clinical attachment level [CAL], and keratinized mucosa width [KMW]) compared with other treatment modalities in Miller Class I and II gingival recession.

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

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

2‐Year Assessment of Tissue Biostimulation With Low‐Level Laser on the Outcomes of Connective Tissue Graft in the Treatment of Single Gingival Recession: A Randomized Clinical Trial

Periodontal wound healing has been accelerated by different low-level laser therapy (LLLT) protocols. However, just a few studies have evaluated use of this therapy adjunctive to periodontal plastic surgery procedures. The present study shows 2-year results of a connective tissue graft (CTG) associated with LLLT in the treatment of gingival recession (GR) defects. Forty patients presenting Miller Class I and II GRs were previously treated by CTG (control group; n = 20) or CTG + LLLT (test group; n = 20). A diode laser (aluminum-gallium-arsenide, 660 nm) was applied to test sites immediately after surgery and every other day for 14 days (total of eight applications). After a follow-up of 2 years, clinical and esthetic evaluations were performed in 36 patients. Mean percentage of root coverage was 93.43% for the test group and 92.32% for the control group (P = 0.55). Complete root coverage was 79% (n = 15) for the test group and 76% (n = 13) for the control group (n = 13) (P = 0.80). Both groups showed esthetics maintenance after 2 years. Within the limitations of this study, results indicate that LLLT showed no additional benefit in the long term when associated with a CTG in the treatment of Miller Class I and II GRs.

Coronally Advanced Flap for Root Coverage: A 2-Year Case Series Follow-up.

The coronally advanced flap (CAF) has demonstrated controversial results in the treatment of gingival recession (GRs). The hypothesis of this study was that the CAF can partially reduce GR values over time. Root coverage (RC) in 24 Miller Class I GRs treated with a CAF by one experienced operator is presented with several periodontal parameters and postoperative morbidity. The mean percentage of RC was 80.35% at 3 months and 58.56% at 24 months; these differences were statistically significant. Keratinized gingival width, keratinized papillary gingival height, and gingival thickness were related to RC at 6 months. Postoperative pain was not statistically different over time. The CAF is not a predictable treatment for Miller Class I GRs after a 2-year follow-up period.

Gingival recession and root caries in the ageing population: a critical evaluation of treatments.

To review evidence for the treatments of gingival recession and root caries in older populations. A systematic approach was adopted to identify reviews and articles to allow us to evaluate the treatments for gingival recession and root caries. Searches were performed in PubMed, Medline and Embase, the Cochrane trials register and bibliographies of European and World Workshops. Gingival recession: We identified no articles that focussed specifically on older populations. Conversely, no evidence suggested that Miller class I and II lesions should be managed differently in older patients when compared to younger cohorts. Six systematic reviews included older patients and suggested that connective tissue grafts are the treatment of choice, alone or in combination with enamel matrix derivative. Root caries can be controlled at the population level by daily brushing with fluoride-containing toothpastes, whilst active decay may be inactivated using professional application of fluoride varnishes/solutions or self-applied high-fluoride toothpaste. Active root caries lesions that cannot be cleaned properly by the patient may be restored by minimally invasive techniques. Gingival recession and root caries will become more prevalent as patients retain their teeth for longer. Whilst surgical (gingival recession) and non-operative approaches (root caries) currently appear to be favoured, more evidence is needed to identify the most appropriate strategies for older people.