10 August 2022

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Evidence-based periodontal plastic surgery: translation of research findings to practice

Edoardo Mancuso

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When talking about recession‐type defects, health, function, and esthetics are very closely interrelated. Such defects may routinely be associated with dentin hypersensitivity, root abrasion, accumulation of dental biofilm, inflammation and ulcerations at the free gingival margin, and root caries. Therefore, it is paramount for dentists to make an adequate diagnosis and to offer evidence‐based treatment options to fulfill patients’ expectations.

On the matter, Professor Leandro Chambrone and his team have written a remarkable review, published in the Periodontology 2000 Journal, with the aim to turn the research findings from several systematic reviews into usable and predictable tools to be applied in dental practice.

In the first part of the review, the authors briefly discuss the gingival recession ‐related factors (from etiology to the main root coverage/periodontal plastic surgery procedures reported in the literature). Conversely, the second part of the paper appraises evidence‐based periodontal plastic surgery through an overview of the different published systematic reviews. The aim of the paper is then to evaluate the results achieved by root‐coverage procedures in the treatment of localized and multiple recession‐type defects.

GINGIVAL RECESSION REVISITED
In the first part of the review, the gingival recession is described as the oral exposure of the root surface as a result of displacement of the gingival margin apical to the cemento‐enamel junction, with or without interdental soft and hard tissue loss.

The article continues assessing that etiologically, the development of recession‐type defects can be related to anatomic, pathologic, professional (iatrogenic), or traumatic factors.
The author lists the different procedures proposed over the years in the scientific literature as periodontal plastic surgery procedures. The firsts techniques enumerated are the laterally positioned and coronally advanced flaps, proposed specifically to cover denuded root surfaces. Since then, modifications to pedicle flaps, as well as the use of free gingival grafts, subepithelial connective tissue  grafts, matrix grafts, guided tissue regeneration, and other procedures associated with several biomaterials have been proposed and evaluated as periodontal plastic surgery procedures.

BASE OF EVIDENCE
In the article’s second section, the author delineates that to reach the excellence of treatment for a patient presenting a gingival recession, the identification of the appropriate evidence-based therapy is necessary. So, professor Chambrone analyzed a set of systematic reviews on root‐coverage procedures published over the last 18 years and extrapolated the key data that could be applied during dental practice. 

These findings may be summarized in the following points:

- Within the surgical procedures assessed, all can lead to a statistically significant reduction of recession depth and gain in clinical attachment level when the characteristics of postsurgical recession defects are compared with those at baseline.

- Between procedures, techniques advocating the use of subepithelial connective tissue grafts and coronally advanced flaps showed better evidence of statistically significant gains in recession depth and clinical attachment level when compared with other root-coverage procedures; however, significant improvements in the width of keratinized tissue were directly associated with the use of subepithelial connective tissue grafts.

- Subepithelial connective tissue grafts also showed better outcomes in terms of complete root coverage.

- The use of root-modification agents did not increase or decrease the rate of root coverage.

- For non-carious cervical lesions, the association of restorative procedures and either subepithelial connective tissue grafts or coronally advanced flaps can also achieve similar statistically significant outcomes, but subepithelial connective tissue grafts showed a trend of better outcomes.

CONCLUSION
The article concludes by indicating that all of the periodontal plastic surgery  procedures used to achieve root coverage can lead to statistically significant improvements in initial clinical parameters regardless of the technique. However, the base of evidence also showed that subepithelial connective tissue graft procedures should be considered as the gold standard when planning a treatment involving the coverage of exposed roots. The latter techniques have shown a better predictability (in terms of achieving complete root coverage), improved stability over time, and concomitant increase in the width of keratinized tissue thickness and width.

To conclude, even if in the scientific literature it is clear that subepithelial connective tissue graft‐based procedures might be selected to treat any kind of recession, it is important to remember that selective and tailored approaches could be preferable to prevent overtreatments. Thus, the selection of the most appropriate procedure for each recession defect will guarantee that patients’ individual needs and complaints will be addressed, leading to the best esthetic and functional outcomes.

For additional information: The concepts of evidence‐based periodontal plastic surgery: Application of the principles of evidence‐based dentistry for the treatment of recession‐type defects