Background: Gingival augmentation procedures around natural teeth and dental implants are performed to facilitate plaque control, to improve patient comfort, to prevent future recession, and in conjunction with restorative, orthodontic, or prosthetic dentistry. The aim of this study is to answer the most common questions related to this treatment modality based on the most relevant and current knowledge in the field.Methods: Two reviewers worked to answer the five most common and clinically relevant questions with supporting literature to understand the role of gingiva around teeth. 1) What circumstances require an increased zone of keratinized tissue (KT), or is KT important? 2) What is the ideal thickness of an autogenous gingival graft? Is a thick autogenous gingival graft more effective than a thin autogenous gingival graft? 3) What are the alternatives to autogenous gingival grafting to increase the zone of attached gingiva? 4) Does orthodontic intervention affect soft tissue health and dimensions? 5) What is the patient‐reported patient outcome for minimal KT compared with that for an enhanced zone of KT? An extensive literature search was performed using PubMed, the Cochrane Oral Health Group Specialized Trials Registry (the Cochrane Library), and the most respected journals in the field.Results: Although gingival augmentation procedures were first introduced in 1960s, there have not been in‐depth comparative studies examining the five questions that have been proposed by the authors. Lack of relevant systematic reviews and randomized clinical trials (RCTs) on this topic do not allow authors to answer those questions with a strong level of evidence. However, the following can be recommended after reviewing case reports and case series on these topics. 1) There is enough clinical evidence to support maintaining an adequate band of gingiva for intracrevicular margin restoration. 2) Thick grafts do not appear to result in better clinical outcomes than thin grafts. Thick grafts are likely to result in more primary contraction, whereas thin grafts tend to be prone to secondary contraction. 3) Viable alternative treatment modalities are currently available that are capable of providing KT augmentation without the need for palatal donor tissue. 4) Appropriately applied orthodontic forces do not cause permanent damage to a healthy periodontium. The probability of recession during tooth movement in thin biotype is high to justify gingival augmentation when the dimension of gingiva is inadequate. In addition, cases in which there will be a facial tooth movement outside of the alveolar process need to be considered for a gingival augmentation procedure. 5) Although the articles that have been published on this topic did not consider patient‐reported outcomes and esthetics as part of the overall treatment success assessment, patients who have received alternative treatment modalities that did not depend on palatal tissue harvesting appear to have reported more satisfaction and less discomfort after treatment.Conclusions: Autogenous gingival grafts are still considered to be the “gold standard” procedure with unmatched success rates and clinical success when gingival augmentation procedures are required. However, tissue‐engineered materials may offer viable options to palatal tissue harvesting for gingival augmentation. KT augmentation may prevent the development and progression of gingival recession, especially when restorative margins may interact with the periodontium and/or orthodontic treatment is indicated. Patient‐reported outcomes should be considered for future studies on this topic. Additional RCTs and systematic reviews are needed to support these conclusions.

Background: Clinical and radiographic examinations are essential in establishing correct periodontal diagnoses as well as providing appropriate treatment options. Current radiographic examinations, however, do not provide adequate information regarding the severity of periodontal disease, presenting a need to investigate alternative methods. The aim of this best evidence consensus is to determine when cone‐beam computed tomography (CBCT) imaging is appropriate for diagnostic inquiry in the management of inflammatory periodontitis.Methods: Literature was systematically reviewed to answer three clinically relevant focused questions regarding the role of CBCT in the management of inflammatory periodontitis. 1) Clinical situation: In patients with periodontitis, what (if any) clinical situations/conditions exist where CBCT imaging improves diagnostic acumen and subsequent treatment recommendations compared with two‐dimensional radiographic interpretation? 2) Intervention: Does CBCT imaging improve the accuracy of a diagnostic assessment and establishment of a prognosis in the analysis of furcation and/or intrabony defects? Is the execution of therapy improved and facilitated, or is it therapeutically challenged? 3) Outcomes: Does the use of CBCT imaging provide superior short‐term or long‐term clinical outcomes, more favorable patient‐reported outcomes, or more consistent clinical treatment decisions affecting tooth prognosis (as measured by defect fill, improvements in bone anatomy, mobility patterns, and ultimate tooth survival)? An extensive literature search was performed using the MEDLINE database and the most respected journals in the field.Results: An electronic database search identified 885 citations, and a manual search yielded an additional five citations. After screening of article titles and abstracts, studies were excluded if irrelevant to the topic of this systematic review. Of the remaining full‐text articles, 74 were obtained and reviewed. Sixty‐two articles not meeting inclusion criteria were further excluded. Twelve total references met the inclusion criteria to determine the role of CBCT in diagnosis and treatment of both intrabony and furcation defects. Intrabony and furcation defects were the two most commonly discussed bony defects when comparing efficacy of CBCT versus intraoral radiographs (IRs). After a review of the literature, while diagnostic aspects of intrabony and furcation defects can be improved via the use of CBCT, limited evidence supported the use of CBCT imaging improving the execution of therapy for both types of defects. There was also a lack of literature to support the use of CBCT imaging for superior short‐term or long‐term clinical outcomes. None of the literature reported patient‐reported outcomes when CBCT imaging was used.Conclusions: Currently, limited evidence supports the utilization of CBCT for diagnosis of intrabony and furcation defects. Despite the fact that there is rapidly accruing literature on CBCT, there are still no current evidence‐based guidelines on its necessity and use for periodontal treatment planning. In selective cases, however, limited field of view CBCT may be useful for periodontal disease diagnoses due to less radiation dosage to the patient, higher spatial resolution, and shorter volumes to be interpreted.

David M. Kim, DDS, DMSc/Nicola De Angelis, DDS/Marcelo Camelo, DDS/Marc L. Nevins, DMD, MMSc/Peter Schupbach, PhD/Myron Nevins, DDS: The purpose of this study was to determine the clinical and histologic efficacy of the combination of alloplastic biphasic calcium phosphate composed of 30% hydroxyapatite and 70% β?tricalcium phosphate (Osteon II) and a cross-linked collagen membrane used to reconstruct an extraction socket with new bone formation. Twelve patients from two private dental practices requiring extraction of maxillary and mandibular nonmolar teeth (n = 30) received both Osteon II (0.5- to 1.0-mm particle size) and the collagen membrane. The primary healing intention group (group A, n = 12) received primary flap closure over the membrane, while in the secondary healing intention group (group B, n = 18), the membrane was left exposed. Early wound healing seemed to be slower in group B when compared to group A, but the difference was not noticeable after 4 weeks. Clinical reentry revealed that the dimensions of the ridge appeared to be maintained in both groups, and internal socket bone fill was evident. The grafted area appeared to be well vascularized, but clinically visible graft particles were noted in some cases. Light microscopic analysis revealed the formation of new bone directly apposing the surfaces of graft particles and bridging the space between them, indicating that the graft material behaved as an osteoconductive scaffold. The mean amount of vital bone in group A was 40.3% ? 7.8%, while the remaining graft was 6.0% ? 4.0%. The mean amount of vital bone in group B was 47.3% ? 11.3%, while the remaining graft was 18.0% ? 20.0%. The absence of primary flap closure did not affect the percentage of vital bone formation or residual graft. (Int J Periodontics Restorative Dent 2013;33:71?78. doi: 10.11607/prd.1463)

Many patients and clinicians would prefer a synthetic particulate bone replacement graft, but most available alloplastic biomaterials have limited osteogenic potential. An alloplast with increased regenerative capacity would be advantageous for the treatment of localized alveolar ridge defects. This prospective, randomized controlled preclinical trial utilized 6 female foxhounds to analyze the osteogenic impact of different formulations of biphasic calcium phosphate (BCP) in combination with an hydroxyapatite-collagen membrane and their ability to reconstruct deficient alveolar ridges for future implant placement. The grafted sites were allowed to heal 3 months, and then trephine biopsies were obtained to perform light microscopic and histomorphometric analyses. All treated sites healed well with no early membrane exposure or adverse soft tissue responses during the healing period. The grafted sites exhibited greater radiopacity than the surrounding native bone with BCP particles seen as radiopaque granules. The graft particles appeared to be well-integrated and no areas of loose particles were observed. Histologic evaluation demonstrated BCP particles embedded in woven bone with dense connective tissue/marrow space. New bone growth was observed around the graft particles as well as within the structure of the graft particulate. There was intimate contact between the graft particles and newly formed bone, and graft particles were bridged by the newly formed bone in all biopsies from the tested groups. The present study results support the potential of these BCP graft particulates to stimulate new bone formation. Clinical studies are recommended to confirm these preclinical findings.