Effect of Root Surface Biomodification on Multiple Recession Coverage with Modified Coronally Advanced Tunnel Technique and Subepithelial Connective Tissue Graft: A Retrospective Analysis

To improve treatment efficacy of gingival recessions (GR), chemical preparation of the exposed root surface was advocated. The aim of this study was to compare the additional influence of root biomodifications with 24% ethylenediaminetetraacetic acid (EDTA) alone or with enamel matrix derivative (EMD) on the 12 month outcomes of modified coronally advanced tunnel (MCAT) with subepithelial connective tissue graft in the treatment of multiple GR. Average root coverage (ARC), complete root coverage (CRC), reduction in GR, reduction in recession width (RW), gain in clinical attachment level (CAL), increase in gingival thickness (GT), increase in keratinized tissue width (KTW) and changes in root coverage esthetic score (RES) were evaluated. A total of 60 patients with 215 GR were enrolled. In 70, GR root surfaces were treated with EDTA + EMD, in other 72, with EDTA, while in the remaining 73 saline solution was applied. ARC was 94%, 89%, and 91% in the EDTA + EMD, the EDTA and the saline groups, respectively (p = 0.8871). Gains in clinical attachment level (CAL; 2.1 ± 1.1 mm) and RES values (9.6 ± 0.9) were significantly higher in the EDTA + EMD group, when compared with two other groups. The differences between other preoperative and postoperative parameters showed statistical significance only within but not between groups. MCAT outcomes may benefit from adjunctive use of EDTA + EMD regarding 12 month CAL gain and professionally assessed esthetics using RES following treatment of GR.

EXPERIENCE OF USING ENAMEL MATRIX PROTEIN IN COMBINATION WITH A CORONARY ADVANCED FLAP AND A CONNECTIVE TISSUE GRAFT TO ELIMINATE GUM RECESSION

The article presents the experience of complex managing a patient with gum recession in the area of the maxillary premolars. Periodontal treatment of gum recession consisted of initial therapy, including supra- and subgingival scaling, root planing, pharmacotherapeutic support (broad-spectrum antiseptics, drugs that stimulate regeneration), surgical combined method based on the use of enamel matrix protein to stimulate regenerative processes. The clinical material Emdogaine is a combination of an enamel matrix derivative and propylene glycol alginate, which performs the function of a carrier. Biora company has been producing it for more than 20 years (Emdogain, BIORA): now the rights to this material belong to Straumann). This preparation was developed to stimulate regeneration of periodontal tissues. Amelogenin is a specific enamel protein capable of stimulating regeneration of lost periodontal tissues by influencing cell differentiation. Dental cement is an osteoid connective tissue that covers the roots of teeth and serves to attach periodontal fibers. Application of an enamel matrix derivative to the sanitized root surface leads to regeneration of non-cellular cement and to the formation of periodontal tissues, which was observed in our study. Transplantation of free connective tissue grafts to eliminate gum recessions makes it possible to effectively eliminate gum recession in most clinical cases (complete root coverage, an increase in the level of clinical attachment from the keratinized attached gum area). In our clinical case, free grafts were obtained in the donor area of the maxillary tuberosity. Transplantation of free connective tissue grafts provides an aesthetic result and is currently considered a standard technique for eliminating gum recession. According to the clinical study, a combined use of connective tissue grafts and the enamel matrix derivative, an additional use of enamel matrix derivative enabled to obtain a satisfactory result and to improve the appearance of the dentition. Such combined surgeries are indicated in an aesthetically significant area. The described materials, methods and stages of patient's follow up can serve as the basis for the protocol of managing patients with gum recession.

Effects of Obesity on Bone Healing in Rats

Although the association between periodontitis and obesity is well explored, it is unclear whether obesity is associated with a worse therapeutic outcome after periodontal treatment. The aim of this study was to investigate the effects of obesity on bone healing with and without the application of regeneration-promoting molecules. A standardized bone fenestration-type defect was created over the root of the mandibular first molar in 15 Wistar rats. Ten animals received a high-fat, high-sucrose diet (HFSD), while the remaining five animals were fed a standard diet. During surgery, the fenestration defects from half of the HFSD-fed, i.e., obese animals, were treated with regeneration-promoting molecules (enamel matrix derivative; EMD). After four weeks, bone healing was evaluated by histomorphometry, TRAP staining and immunohistochemistry for RUNX2 and osteopontin. The analyses revealed that the spontaneous healing of the periodontal defects was compromised by obesity. Application of EMD partially compensated for the negative effect of obesity. Nevertheless, EMD-stimulated bone healing in obese animals was not better than the spontaneous healing in the obesity-free control group, indicating that obesity may also inhibit the stimulatory effects of regeneration-promoting molecules. Our results show that obesity can negatively influence bone healing and suggest that bone healing may be compromised in humans.

Aesthetic root coverage with acellular dermal matrix allograft: a shield for gingival recession

Awareness about root coverage is increasing in day-to-day clinical practice. Patients are more motivated and concerned about aesthetics nowadays along with the issues of sensitivity of teeth. The conventional flap designs and techniques including lateral sliding flaps, coronally advanced flap, subepithelial connective tissue grafts and free gingival grafts are being adopted for root coverage. The newer material including resorbable and non-resorbable guided tissue regenerative membranes, amniotic membrane, platelet-rich fibrin membrane, enamel matrix derivative protein, xenogenic collagen matrix graft along with the soft tissue substitute like acellular dermal matrix allograft are also being used for recession coverage. The present case report describes a case of 22-year-old female patient with the chief complaint of denudation of gums exposing the root surface over the mandibular left central incisor. The soft tissue substitute acellular dermal matrix allograft was used for root coverage as the patient was not willing to procure an autogenous palatal graft. The results were satisfactory with complete root coverage.

Low Frequency Electromagnetic Fields Might Increase the Effect of Enamel Matrix Derivative on Periodontal Tissues

Periodontal regeneration is a complex goal, which is commonly pursued with a combination of surgical techniques, biomaterials, and bioactive compounds. One such compound is enamel matrix derivative (EMD), a medical substance that is extracted from porcine tooth germs and which contains several protein fractions with BMP- and TGF-β-like action. Activation of TGF-β signaling is required for EMD activity on cells and tissues, and a growing body of evidence indicates that EMD largely relies on this pathway. As low frequency electromagnetic fields (EMFs) have long been investigated as a tool to promote bone formation and osteoblast activity, and because recent studies have reported that the effects of EMFs on cells require primary cilia, by modulating the presence of membrane-bound receptors (e.g., for BMP) or signal mediators, it can be hypothesized that the application of EMFs may increase cell sensitivity to EMD: as TGFBR receptors have also been identified on primary cilia, EMFs could make cells more responsive to EMD by inducing the display of a higher number of receptors on the cellular membrane.

Efficacy of a new-generation platelet-rich fibrin in the treatment of periodontal intrabony defects: a randomized clinical trial

Background The aim of the study was to clinically evaluate the healing of intrabony defects after treatment with a new generation of platelet-rich fibrin (A-PRF+) respect to enamel matrix derivative (EMD). Methods Thirty (30) intrabony defects of 18 patients (9 males, 9 females) were randomly treated with A-PRF+ (test, n = 15) or EMD (control, n = 15). The following clinical parameters were recorded at baseline and 6 months after surgery: pocket depth (PD), gingival recession (GR) and clinical attachment level (CAL). After debridement the intrabony defects were filled with A-PRF+ in the test group, respectively with EMD in the control group, and fixed with sutures to ensure wound closure and stability. Results Both treatment methods resulted in statistically significant PD reductions, respectively CAL gains six months post-operatively. No statistically significant differences were found between the two groups as the mean CAL gain was 2.33 ± 1.58 mm in the A-PRF+ group, respectively 2.60 ± 1.18 mm in the EMD group (p < 0.001). Conclusion Within the limits of this study the new-generation platelet-rich fibrin seems to be as clinically effective as EMD during surgical treatment of intrabony defects. Treatment with A-PRF+ or EMD resulted in reliable clinical outcomes. The use of A-PRF+ as a human autologous product can give a positive impact on periodontal healing. Clinical Relevance A-PRF+ may be suitable for the treatment of intrabony periodontal defects. Trial registration number (TRN) NCT04404374 (ClinicalTrials.gov ID).