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Periodontal bony defects are classified into ‘supraosseous’ (‘suprabony’) or ‘infraosseous’ (‘infrabony’) according to the location of the base of the defect compared to the coronal part of the residual alveolar crest. Infraosseous defects are generally considered more challenging to treat and are thought to be associated with a higher risk of periodontal progression. The emergence and advancement of periodontal regenerative procedures have improved the clinician’s ability to manage infraosseous defects. However, limitations still exist. This paper reviews the definitions of periodontal osseous defects and provides a new classification framework for infraosseous defects, relating them to the chances of success of regenerative procedures and therefore to their treatment planning options. Infraosseous defects are hereby divided into intrabony and inter-root defects. Factors affecting treatment response, such as number of walls, depth and extension into buccal and lingual surfaces are added to the classification framework. Keywords: bone loss, infrabony, periodontitis, suprabony

The present study introduces a novel "anatomic recession ratio" (ARR) and evaluates the clinical outcomes of using a tunnel technique (TUN) with a connective tissue graft (CTG) for root coverage (RC). Sixteen systemically healthy patients contributing a total of 33 recession types 1 and 2 were treated with TUN + CTG. The predictive value of a panel of baseline clinical parameters (ARR) on RC was evaluated 12 months postoperatively. At 12 months, mean recession depth decreased from 2.74 ± 0.22 mm to 0.46 ± 0.13 mm (P < .0001); 19 sites (58%) showed complete RC, and the mean RC rate was 88.85% ± 2.73%. The mean ARR value was 0.74 ± 0.3, revealing a positive correlation with RC (r²: 0.73, P < .0001). The 12-month esthetic evaluation resulted in a score of 8.52 ± 1.75 using the root coverage esthetic score. TUN + CTG is effective in reducing recession depth and obtaining good esthetic outcomes. Within the limits of the present study, it may be suggested that ARR has potential as an analytical baseline parameter for RC outcomes with TUN + CTG.

This study involves a group of 168 teeth in 126 patients treated with crown lengthening and tooth reconstruction (experimental group), and a group of 75 teeth from 62 patients that were judged irrational to treat, extracted, and replaced (control group). In the control group, 13 teeth in 12 patients were not replaced; 37 were replaced with an implant-supported crown, 14 with a tooth-supported partial denture, 2 with a Maryland partial denture; and 9 patients requested a removable prosthesis. In the experimental group, 44 teeth in 37 patients received a conservative restoration (24 direct and 20 indirect), while 124 teeth in 94 patients received a full crown. All 168 teeth were surgically treated with minimally invasive crown lengthening. Endodontic treatment and orthodontic extrusion were applied when necessary. Treatment resulted in healthy periodontal and dental/implant conditions at the 1-year follow-up in both groups. Function and esthetics were described from satisfactory to extremely satisfactory by patients of both groups, with the exception of three patients in the control group who received a mobile prosthesis restoration and reported some difficulties in chewing. When comparing treatment cost and duration of the reconstructed teeth (experimental group) to the treatment cost and duration of extracted and replaced teeth (control group), the difference is significantly in favor of the preservation of natural teeth, both monetarily and in terms treatment time. Saving a tooth with a compromised crown is more favorable for the patient than extraction and replacement. This conservative approach is advisable to clinicians whenever the clinical conditions enable treatment.

The present article describes a treatment planning clinical strategy based on a flowchart developed to facilitate the treatment of teeth with severely compromised clinical crowns. The study comprised a group of 978 patients presenting with 2327 teeth needing clinical crown reconstruction. The patients were screened, diagnosed, and treated with a multidisciplinary approach according to a flowchart structure. A subgroup of 75 teeth in 62 patients was considered irrational to treat when a composite risk-evaluation model was applied. Another subgroup of 168 teeth in 126 patients required periodontal surgery and received a minimally invasive crown lengthening (MICL) procedure. Endodontic treatment was necessary for 73 teeth, and retreatment for 51. Most of the teeth (124 in 94 patients) received a full crown, while the remaining 44 teeth received a direct (24 teeth) or an indirect (20 teeth) reconstruction. Six teeth were orthodontically extruded before surgery. The 1-year average probing depth and clinical attachment level at the treated teeth was 2.5 ± 0.5 mm and 2.7 ± 0.6 mm, respectively. Bleeding on probing was detected in 19 sites (11.3%). No side effects or short-term recurrences were detected in 168 treated sites. Patients described function and esthetics as extremely satisfactory, very satisfactory, or satisfactory. In conclusion, an accurate screening based on a flowchart supported the clinical decision to treat 168 teeth with MICL and to replace 75 out of 2327 teeth presented at our clinic for restorations. The use of MICL and the high-quality restorations resulted in a healthy periodontal and dental condition of all the treated teeth as well as patient satisfaction at the 1-year follow-up.

Im vorliegenden Artikel wird eine Flussdiagramm-basierte Strategie zur Behandlungsplanung für Zähne mit stark zerstörter Krone vorgestellt. Die dazugehörige Studie umfasste 978 Patientinnen und Patienten mit 2327 Zähnen, deren Kronen rekonstruiert werden mussten. Die Patienten wurden gescreent, untersucht und nach einem multidisziplinären Ansatz auf Basis eines Flussdiagramms behandelt. Für eine Untergruppe von 75 Zähnen bei 62 Patienten wurde basierend auf einer kombinierten Risikoanalyse die Behandlung als nicht sinnvoll eingeschätzt. In einer weiteren Untergruppe von 168 Zähnen bei 126 Patienten waren parodontalchirurgische Maßnahmen erforderlich und eine minimalinvasive Kronenverlängerung (MIKV) wurde durchgeführt. Von diesen benötigten 73 Zähne eine Wurzelkanalbehandlung und 51 eine endodontische Revision. Die meisten Zähne dieser Gruppe (124 bei 94 Patienten) wurden voll überkront, während die übrigen 44 Zähne eine direkte (24 Zähne) oder indirekte (20 Zähne) Restauration erhielten. Sechs Zähne wurden vor der chirurgischen Maßnahme kieferorthopädisch extrudiert. Nach einem Jahr lag die durchschnittliche Sondierungstiefe bei 2,5 ± 0,5 mm, das klinische Attachmentniveau bei 2,7 ± 0,6 mm. Sondierungsbluten trat an 19 Stellen (11,3 %) auf. An den 168 behandelten Zähnen wurden keine Komplikationen oder kurzfristigen Rezidive beobachtet. Die Patientinnen und Patienten gaben an, mit der Funktion und Ästhetik „vollständig zufrieden“, „sehr zufrieden“ oder „zufrieden“ zu sein. Zusammengefasst führte in der Praxis der Autoren das exakte Flussdiagramm-basierte Screening von insgesamt 2327 Zähnen mit Restaurationsbedarf zu der Behandlung von 168 Zähnen mit einer MIKV und zur Extraktion und dem Ersatz von 75 weiteren Zähnen. Dank minimalinvasiver Kronenverlängerung und hochwertiger Restaurationen waren nach einjähriger Nachbeobachtung alle behandelten Zähne dental und parodontal gesund und die Patientenzufriedenheit hoch.

This study describes a clinical strategy based on a flowchart developed to facilitate the treatment of teeth with a severely compromised clinical crown. A group of 168 teeth in 126 patients required periodontal surgery and received a minimally invasive crown-lengthening procedure with the aim to reach a minimal supracrestal tissue attachment width of 2.5 mm, including a free space between the cervical margin of the restoration and the bottom of the sulcus. Surgery was performed with the aid of an operating microscope and microsurgical instruments, trying to reduce bone surgery and invasiveness as much as possible. An average postsurgical radiographic bone resection of 1 ± 0.6 mm was measured. Endodontic treatment was necessary in 73 teeth, re-treatment in 51. Most of the teeth (124 in 94 patients) received a full crown, while the remaining 44 received a direct (24 teeth) or an indirect (20 teeth) reconstruction. Six teeth were orthodontically extruded before surgery. The 1-year average pocket depth at the treated units was 2.5 ± 0.5 mm, resulting in a reduction of 0.7 ± 0.9 mm compared to the preoperative measurement (P < .0001). Bleeding on probing was detected in 19 sites (11.3%) and was significantly reduced from the preoperative condition (57 sites, 33.9%). The distance between the apical margin of the restoration and the gingival margin was 0.2 ± 0.4 mm (range: 0 to 1 mm); clinical attachment level was 2.7 ± 0.6 mm. A clinical approach based on minimally invasive crown lengthening with minimal or no ostectomy and high-quality restorative dentistry resulted in healthy periodontal and dental condition of all the treated units at the 1-year follow-up.

When it comes to complete root coverage of exposed root surfaces, several limiting factors have been suggested. Although tooth malposition and papillae dimension are capable of influencing root coverage, they have not received sufficient emphasis in the literature. Therefore, the aim of the present commentary is to discuss the impact of tooth malposition and papillae dimension on rootcoverage outcomes. This commentary combines evidence from the literature with the authors' experience. Limited evidence is available in the literature regarding the influence of tooth malposition on root-coverage outcomes. Severe buccal displacement and tooth extrusion and/or rotation may limit the amount of achievable root coverage, and the cementoenamel junction should no longer be considered the landmark for root coverage in these cases. The relationship between papillae dimension and root coverage has been tested in different clinical conditions and by applying different root-coverage approaches, thereby resulting in contradictory outcomes. The clinical experience of the authors suggests that having wider papillae is advantageous for coronally advanced flap and tunnel flap preparations and connective tissue graft stabilization. Although scientific evidence and the authors' clinical experience suggest that papillae dimension can play a major role in determining the surgical management of soft tissues and the amount of achievable root coverage, further studies are necessary to evaluate to which extent papillae dimensions contribute to treatment outcomes.

Primary wound closure and uneventful early wound stability over the biomaterials are the most critical elements of successful periodontal regeneration. Yet the surgical elevation of the interdental papilla to access deep and wide intrabony defects entails an impairment of the papillary blood supply that can result in difficult healing due to a lack of primary closure in the early healing period. This negative event might complicate the healing process, favoring bacterial contamination. A novel modified tunnel surgical technique designed to maintain the integrity of the interdental papilla is presented in this article, with the aim of providing an optimal environment for wound healing in regenerative procedures. Entire papilla preservation is described and applied in three different cases, in association with the use of a combination of bone substitutes and enamel matrix derivative for periodontal regeneration. The entire papilla preservation technique was successfully applied to the three selected cases, resulting in an uneventful postsurgical period and a substantial defect fill over the 8-month follow-up. This tunnel-like technique can be recommended for further research to support the success identified in this case series.

Tiefe Taschen in Verbindung mit ausgedehnten intraossären Defekten verschlechtern die Prognose des betroffenen Zahnes. Erreicht der Defekt den Apex oder erstreckt er sich gar darüber hinaus, dann gilt der Zahn traditionell als nicht erhaltungswürdig und wäre demnach zu extrahieren. Neuere Erkenntnisse zeigen aber, dass die parodontale Regeneration die mittel- bis langfristige Prognose eines solchen Zahnes verbessern kann. Beschrieben wird der klinische Ansatz zur parodontalen Regeneration von Zähnen, die von ausgedehnten Defekten bis zum Apex oder darüber hinaus betroffen sind. Anhand eines detaillierten Fallberichts werden die Fallauswahl, die Parodontalhygiene, die Zahnmobilität und ihre Therapie sowie der Zustand der Pulpa und mögliche Konsequenzen erläutert. In vielen Fällen vereinfacht die parodontale Regeneration bei Patienten mit zunächst nicht erhaltungswürdig erscheinenden Zähnen die Behandlung durch den möglichen Verzicht auf komplexe herkömmliche oder implantatgetragene Restaurationen. Die Anwendung parodontalregenerativer Verfahren erfordert eine umfassende Weiterbildung in der entsprechenden chirurgischen Therapie mit interdisziplinären Ansätzen. Keywords: Parodontale Regeneration, intraossäre Defekte, Paro-Endo-Läsionen, Zahnprognose, Papillenerhaltung, Lappenoperation

Purpose: The purpose of this clinical guidelines project was to determine the most appropriate surgical techniques, in terms of efficacy, complications, and patient opinions, for the treatment of buccal single gingival recessions without loss of interproximal soft and hard tissues. Methods: Literature searches were performed (electronically and manually) for entries up to 28 February, 2013 concerning the surgical approaches for the treatment of gingival recessions. Systematic reviews (SRs) of randomised controlled trials (RCTs) and individual RCTs that reported at least 6 months of follow-up of surgical treatment of single gingival recessions were included. The full texts of the selected SRs and RCTs were analysed using checklists for qualitative evaluation according to the Scottish Intercollegiate Guidelines Network (SIGN) method. The following variables were evaluated: Complete Root Coverage (CRC); Recession Reduction (RecRed); complications; functional and aesthetic satisfaction of the patients; and costs of therapies. Results: Out of 30 systematic reviews, 3 SRs and 16 out of 313 RCTs were judged to have a low risk for bias (SIGN code: 1+). At a short-term evaluation, the coronally advanced flap plus connective tissue graft method (CAF+CTG) resulted in the best treatment in terms of CRC and/or RecRed; in case of cervical abrasion and presence of root sensitivity CAF + CTG + Restoration caused less sensitivity than CAF+CTG. CAF produced less postoperative discomfort for patients. Limited information is available regarding postoperative dental hypersensitivity and aesthetic satisfaction of the patients. Conclusion: In presence of aesthetic demands or tooth hypersensitivity, the best way to surgically treat single gingival recessions without loss of interproximal tissues is achieved using the CAF procedure associated with CTG. Considering postoperative discomfort, the CAF procedure is the less painful surgical approach, while the level of aesthetic satisfaction resulted higher after CAF either alone or with CTG. It is unclear how much tooth hypersensitivity is reduced by surgically covering buccal recessions. It is important to note that the present recommendations are based on short-term data (less than 1 year). Source of funding: The guidelines project was made possible through self-financing by the authors. Keywords: aesthetics, gingival recession, guidelines, mucogingival surgery, systematic review