Efficacy of biologics in root coverage and gingival augmentation therapy: An American Academy of Periodontology best evidence systematic review and network meta‐analysis

Abstract

Background: The aim of this systematic review was to assess the efficacy of three biologics, namely autologous blood-derived products (ABPs), enamel matrix derivatives (EMD) and recombinant human platelet-derived growth factor BB (rhPDGF-BB), in root coverage and gingival augmentation therapy. Methods: The protocol of this PRISMA 2020-compliant systematic review was registered in PROSPERO (CRD42021285917). After study selection, data of interest were extracted. A network meta-analysis (NMA) was conducted to assess the effect of different surgical interventions on the main clinical outcomes of interest (i.e., mean root coverage [MRC%], complete root coverage [CRC%], keratinized tissue width [KTW], gingival thickness [GT] change, and recession depth [RD] reduction).Results: A total of 48 trials reported in 55 articles were selected. All studies reported on the treatment of gingival recession defects for root coverage purposes. Forty-six treatment arms from 24 trials were included in the NMA. These arms consisted of treatment with coronally advanced flap (CAF) alone, EMD + CAF, platelet-rich fibrin (PRF) + CAF, and subepithelial connective tissue graft (SCTG) + CAF. Regarding MRC%, SCTG+CAF was associated with a significant higher estimate (13.41%, 95% CI [8.06-18.75], P < 0.01), while EMD+CAF (6.68%, 95% CI [−0.03 to 13.4], P = 0.061) and PRF+CAF (1.03%, 95% CI [−5.65 to 7.72], P = 0.71) failed to show statistically significant differences compared with CAF alone (control group) or with each other. Similarly, only SCTG+CAF led to a significantly higher CRC% (14.41%, 95% CI [4.21 to 24.61], P < 0.01), while treatment arms EMD + CAF (13.48%, 95% CI [−3.34 to 30.32], P = 0.11) and PRF+CAF (-0.91%, 95% CI [−15.38, 13.57], p = 0.81) did not show significant differences compared with CAF alone or with each other. Differences in the CI of PRF+CAF (symmetrical around a zero adjunctive effect) and EMD+CAF (nonsymmetrical) suggest that EMD could have some additional value compared with PRF. Treatment with SCTG+CAF led to a statistically significant higher RD reduction (-0.39 mm, 95% CI [−0.55 to 0.22], P < 0.01), however EMD+CAF

The treatment of multiple gingival recession defects with connective tissue grafting and enamel matrix derivative in a private practice setting: Two case reports

“…This new systematic review will show that root coverage is an extremely predictable procedure to offer our patients. Expert opinion confirms that use of biologics can provide us many benefits for our patients healing processes, especially if the main goal is true periodontal regeneration 2 . Ideal coverage of recession defects should include the restoration of the protective functional morphology of the mucogingival complex, recreation of the esthetic balance between marginal tissues and the adjacent tooth root and crown, and the regeneration of the lost attachment apparatus, including the formation of new cementum with inserting connective tissue fibers and supporting alveolar bone 3 .…”

“…Expert opinion confirms that use of biologics can provide us many benefits for our patients healing processes, especially if the main goal is true periodontal regeneration. 2 Ideal coverage of recession defects should include the restoration of the protective functional morphology of the mucogingival complex, recreation of the esthetic balance between marginal tissues and the adjacent tooth root and crown, and the regeneration of the lost attachment apparatus, including the formation of new cementum with inserting connective tissue fibers and supporting alveolar bone. 3 Unpredictability in root coverage procedures will often occur in recession defects due to underlying conditions, such as root dehiscences, bone loss, a thin gingival phenotype, loss of interproximal clinical attachment, frenal pull, or other anatomic factors such as the presence of non-carious cervical lesions.…”

Periodontal phenotype modification of complexes periodontal‐orthodontic case scenarios: A clinical review on the applications of allogenous dermal matrix as an alternative to subepithelial connective tissue graft

“…Of the available autogenous grafts and soft tissue substitutes used to achieve concomitant root coverage and PPM, the subepithelial connective tissue graft (SCTG) and the allogeneic dermal matrix (ADM) are considered the primary and secondary treatment options, respectively 7–9,14,15 . Although the use of SCTG‐based procedures is recognized as the “gold standard” therapy in root coverage, the amount of grafting material required to treat the defects may be a limiting factor for patients displaying multiple sites of GRD (i.e., those patients requiring greats demands of donor tissue) 7–9,14,15 .…”

“…Different soft tissue grafts and substitutes have been used to increase the width and thickness of the KT band in root coverage and non‐root coverage sites, 2,3,7–9,14,15 based on a concept known as “periodontal phenotype modification” (PPM) 7,16 . Originally described as “biotype modification”, 7 this term is grounded on a two‐fold property required by any soft tissue grafting material: the capability of stimulating both clinical and histological changes to the pre‐established, original genetic conditions of the recipient site.…”

“…11 Moreover, other systematic reviews commissioned by the American Academy of Periodontology (AAP) clearly indicate that teeth presenting thin and narrow gingiva are at an increased risk of developing GRD compared to teeth surrounded by thick and wide gingiva. 12,13 Different soft tissue grafts and substitutes have been used to increase the width and thickness of the KT band in root coverage and non-root coverage sites, 2,3,[7][8][9]14,15 based on a concept known as "periodontal phenotype modification" (PPM). 7,16 Originally described as "biotype modification", 7 this term is grounded on a two-fold property required by any soft tissue grafting material: the capability of stimulating both clinical and histological changes to the pre-established, original genetic conditions of the recipient site.…”