Pain perception following epithelialized gingival graft harvesting: a randomized clinical trial

Harvest of epithelialized gingival grafts without application of hemostatic sutures: A randomized clinical trial using laser speckle contrast imaging

BACKGROUND

This randomized controlled trial with two parallel arms and a 1:1 allocation ratio aimed to compare early microvascular healing (primary outcome), surgical times, and patient-reported outcomes (PROM) after harvesting palatal epithelialized gingival grafts (EGG), where hemostasis was achieved with sutures and hemostatic sponges (control) or with a sutureless approach (test).

METHODS

From a total of 33 patients, 34 EGG were harvested. Thirty-two were randomized to the test/control group (n = 16) and two were excluded. Early palatal microvascular healing was assessed at 7, 14, and 30 days with laser speckle contrast imaging (LSCI). Postoperative bleeding, pain, discomfort, and analgesic consumption were assessed over 2 weeks with a dedicated questionnaire.

RESULTS

A faster onset and resolution of postharvest hyperemia was observed in the test group where peak blood flow was reached at 7 days. No significant blood flow differences were observed between the groups at any of the evaluated timepoints. The mean surgical time was 13 min shorter in the test (p = 0.00). No significant differences were observed for postoperative bleeding and analgesic consumption at any timepoint.

CONCLUSIONS

The tested approach represents a viable alternative to the standard one, providing no relevant differences in microvascular, clinical, and patient-related results, but with significantly shorter surgical times.

Soft tissue elasticity at teeth and implant sites. A novel outcome measure of the soft tissue phenotype

AIM

To assess ultrasonographic tissue elasticity at teeth and implant sites and its variation after peri-implant soft tissue augmentation with a connective tissue graft (CTG).

METHODS

Twenty-eight patients, each contributing with one clinically healthy dental implant exhibiting a soft tissue dehiscence (PSTD), were included. Implant sites were augmented with CTG and monitored over 12 months. Ultrasonographic strain elastography, expressed as strain ratios (SR1, SR2, and SR3, respectively) was assessed at baseline, 6-, and 12-month, and compared with the corresponding contralateral homologous natural tooth. SR1 assessed the strain/elasticity of the midfacial coronal portion of the soft tissue in comparison to the natural tooth crown/implant-supported crown, SR2 evaluated the strain of the midfacial coronal soft tissue in relation to the one of the alveolar mucosa, while SR3 depicted the strain of the midfacial soft tissue in relation to the interproximal soft tissue on the transverse ultrasound scan.

RESULTS

SR1 in natural dentition and at implant sites was 0.20 ± 0.08 and 0.30 ± 0.14, respectively (p = .002), indicating that the coronal portion of the soft tissue around teeth is generally more elastic than its counterpart around dental implants. Soft tissue augmentation with CTG promoted an increased stiffness of the midfacial coronal portion of the soft tissue over 12 months (p < .001 for SR1, SR2, and SR3). Strain ratios at the 12-month time points were significantly higher than the values observed at 6 months (p < .001). Regression analysis demonstrated that strain elastography ratios in natural dentition were significantly associated with keratinized gingiva width, and gingival thickness. At implant sites, SR1 was significantly associated with keratinized mucosa width and mucosal thickness (p < .001 for both correlations), SR2 was significantly associated with keratinized mucosa width (p = .013), and SR3 was significantly associated with the surgical technique performed in combination with CTG (p = .022).

CONCLUSION

Ultrasound strain elastography captures and quantifies tissue elasticity and its changes after soft tissue augmentation. A different baseline tissue elasticity was observed between teeth and dental implants in the most coronal aspect of the soft tissue. The main factors affecting tissue elasticity-related outcomes were the keratinized tissue width, and mucosal thickness.

Performance of multiple therapeutic approaches for palatal wound healing after soft tissue graft removal - an overview of systematic reviews

OBJECTIVE

To overview the literature to answer the following question: "What is the performance of different therapies on wound healing and postoperative discomfort after palatal ASTG removal?"

METHODS

SRs that evaluated the wound healing (WH), postoperative pain, bleeding, and analgesic consumption of patients submitted to de-epithelialized/free gingival grafts (FGG) or subepithelial connective tissue grafts (SCTG) removed from the palate were included. The searches were conducted on six white and two gray databases up to December 2023. Methodological quality was evaluated through AMSTAR 2. The synthesis of results was described as a narrative analysis.

RESULTS

Ten SRs (involving 25 randomized clinical trials) related to low-level laser therapy (LLLT) (3), platelet-rich fibrin (PRF) (4), cyanoacrylate tissue adhesives (CTA) (2), and ozone therapy (OT) (1) were included in this overview. All techniques demonstrated improvements in WH. LLT, PRF, and CTA reduced pain and analgesic consumption. PRF and CTA reduced bleeding. Regarding methodological quality, the SRs were classified as critically low (2), low (5), moderate (2), or high quality (1).

CONCLUSIONS

In SRs related to LLLT, PRF, CTA, and OT, the use of different therapies after palatal ASTG removal improved WH and postoperative discomfort. Due to the studies' low methodological quality and high heterogeneity, data should be interpreted with caution.

CLINICAL RELEVANCE

The present overview compiles the evidence of SRs related to different therapies for WH and patients' postoperative experience and reveals that different treatments can significantly improve the clinical outcomes of patients who require ASTG removal for periodontal or peri-implant surgeries.

REGISTRATION

PROSPERO registration number: CRD42022301257.

A combination technique of strip free gingival grafts and xenogeneic collagen matrix in augmenting keratinized mucosa around dental implants: a single-arm clinical trial

BACKGROUND

The aim of this study was to assess the outcomes of the combination technique of strip free gingival grafts (SFGG) and xenogeneic collagen matrix (XCM) in augmenting the width of keratinized mucosa (KMW) around dental implants, and compare its efficacy with the historical control group (FGG).

METHODS

Thirteen patients with at least one site with KMW ≤ 2 mm after implant surgery were included and received SFGG in combination with XCM. Another thirteen patients with the same inclusion and exclusion criteria from the previous trial received FGG alone. The same outcomes as the previous trial were evaluated. KMW, thickness of keratinized mucosa (KMT), gingival index (GI) and probing depth (PD) were measured at baseline, 2 and 6 months. Postoperative pain, patient satisfaction and aesthetic outcomes were also assessed.

RESULTS

At 6 months after surgery, the combination technique could attain 3.3 ± 1.6 mm of KMW. No significant change could be detected in GI or PD at 6 months compared to those at 2 months (p > 0.05). The postoperative pain and patient satisfaction in VAS were 2.6 ± 1.2 and 9.5 ± 1.2. The total score of aesthetic outcomes was 3.8 ± 1.2. In the historical FGG group, 4.6 ± 1.6 mm of KMW was reported at 6 months, and the total score of aesthetic outcomes was higher than the combination technique (4.8 ± 0.7 vs. 3.8 ± 1.2, p < 0.05).

CONCLUSIONS

The combination technique of SFGG and XCM could increase KMW and maintain peri-implant health. However, this combination technique was associated with inferior augmentation and aesthetic outcomes compared with FGG alone.

TRIAL REGISTRATION

This clinical trial was registered in the Chinese Clinical Trial Registry with registration number ChiCTR2200057670 on 15/03/2022.

Periodontal phenotype modification in orthodontic patients

OBJECTIVE

The purpose of this study was to assess the feasibility of phenotype modification in orthodontic patients using combined bone and soft tissue grafting substitutes.

CLINICAL CONSIDERATION

The surgical procedure was conducted on 18 patients (3 males, 15 females). Periodontal phenotype modification was conducted using demineralized freeze-dried bone allograft and a xenogeneic collagen matrix. The following parameters were recorded for each tooth at baseline and 12-month follow-up: O'Leary plaque index (PI), probing depth (PD), bleeding on probing (BOP), gingival thickness (GT), keratinized tissue width (KTW), gingival recession (GR), and vestibular depth (VD). The results showed a statistically significant increase in GT (2.02 ± 0.39 mm), KTW (1.11 ± 0.82 mm), and VD (0.18 ± 1.16 mm) (p < 0.05). GR was also significantly decreased (1.02 ± 0.99 mm) (p < 0.05).

CONCLUSION

Within the limitation of this study, the proposed approach enhanced the periodontal condition in orthodontic patients. However, further studies with a larger sample size are needed to ensure long-term stability.

CLINICAL SIGNIFICANCE

Hard and soft tissue conditions have paramount importance for long-term periodontal stability. Phenotype modification in orthodontic patients can diminish the probability of adverse consequences and result in optimal esthetic outcomes. The proposed technique using combined bone and soft tissue substitutes indicated promising results and could be recommended in orthodontic patients with thin periodontal phenotypes.

Clinical effectiveness of orange peel polymethoxy-flavonoids rich fraction as a palatal dressing material compared to Alveogyl: randomized clinical trial

This study assessed the clinical effectiveness of orange peel polymethoxy-flavonoids rich fraction (OPMF) solid dispersion as a palatal dressing material, compared with Alveogyl, in a randomized clinical trial. After harvesting free gingival grafts for 18 patients in three groups, the donor site in group I received OPMF; group II received Alveogyl; and group III received placebo dough material. The visual analog scale (VAS) pain score in group I showed the lowest value in week one without a significant difference. In week 2, there was a substantial decrease in pain in group I compared to group III. Week 4 showed reduced pain scores in all groups without significant differences. The results of the number of analgesic pills revealed, after 1 week, the lowest number of pills consumed in group I, with a considerable difference compared to group III. Healing process results showed that group I had the highest healing values in each interval, with a significant difference between group I and group III at 1 and 2 weeks. Color matching parameter showed slight differences between the groups' readings in favor of group I in all intervals without a statistically significant difference. The results suggest OPMF as a palatal dressing material that facilitates hemostasis, pain relief, and palatal wound healing.

Postoperative local interventions for the palate as a gingival graft donor area: a scoping review

OBJECTIVE

This scoping review aimed to systematically identify evidence-based interventions to stimulate healing or protect the harvested palate of patients undergoing gingival grafting.

MATERIAL AND METHODS

The study followed guidelines from the Joanna Briggs Institute and PRISMA-ScR (protocol available at osf.io/zhafn). PubMed, Embase, and seven other databases were searched on November 2022, with additional monitoring until April 2023. The inclusion criteria focused on studies evaluating outcomes related to the donor area (palate) and interventions for healing or protecting it, regardless of publication year and language. Data from the included publications was extracted and presented through narrative text, tables, and figures.

RESULTS

Eighty-one studies (including 64 clinical trials, four case series, five theses, and eight systematic reviews) and 37 clinical trial records were included. The number of studies on this topic has significantly increased, reflecting a growing interest in the field. Thirty-six interventions with published results and 12 interventions with unpublished results from clinical trial registers were identified. Some promising interventions that showed potential for improving patient-reported outcomes include cyanoacrylate adhesive, platelet-rich fibrin (PRF), and the combination of palatal stents and healing agents.

CONCLUSIONS

Thirty-six interventions with published results were identified for postoperative use on the harvested palate, showing varying levels of evidence and conflicting effectiveness for specific outcomes.

CLINICAL RELEVANCE

Postoperative discomfort and pain in the palate are commonly experienced by patients undergoing grafting procedures using this region as the donor area. Awareness of the available options and their levels of evidence is crucial for informed decision-making.

Is there an effective way to control pain perception after free gingival graft removal? A systematic review and meta-analysis

The literature describes multiple ways to stimulate wound healing to reduce the patient's perception of pain. This systematic review aimed to evaluate if methods that enhance wound healing can reduce the patient's perception of pain after free gingival graft removal from the palate region compared to natural healing. A systematic review protocol was written following the PRISMA checklist. Electronic searches of five databases were performed to identify randomized clinical trials (RCTs) that assessed the patient's perception of pain after the removal of a free gingival graft from the palate. The primary outcome was the visual analog scale (VAS) score assessing the patient's perception of pain 7 days after the free gingival graft removal from the palate region. Of the 1,622 potentially relevant articles retrieved from the electronic databases, 16 RCTs were selected for qualitative analysis, and of these, 6 RCTs were included in the meta-analysis. RCTs showed a significant VAS reduction associated with the use of methods to enhance wound healing. The pooled estimates revealed a significant overall VAS reduction of 2.20 (95% CI 2.32, 2.07) 7 days after surgery. The methods that presented the greatest reduction in the perception of pain were platelet-rich fibrin, hyaluronic acid, and autologous fibrin glue. Methods that enhance wound healing, including platelet-rich fibrin, hyaluronic acid, and autologous fibrin glue, can reduce pain perception after free gingival graft removal in the palate region. However, only 1 RCT investigated each approach, which hinders the conclusion regarding the best procedure to reduce the perception of pain.

Modified Free Gingival Autograft: A Case Report

The purpose of this case study was to introduce an innovative method utilizing a modified free gingival graft technique, with the goal of accomplishing vertical and horizontal augmentation of soft tissue in the mandibular anterior region. A 35-year-old female patient underwent the modified free gingival graft technique in the anterior mandibular area. Remarkably, after a span of nine months, an increase was noted in both horizontal and vertical dimensions of the gingival tissue. This transformation was met with satisfaction from the patient. Following the successful graft procedure, a vertical gain of 3 mm was observed in the keratinized gingiva.

Coronally advanced flap versus tunnel technique for the treatment of peri-implant soft tissue dehiscences with the connective tissue graft: A randomized, controlled clinical trial

AIM

To evaluate the efficacy of coronally advanced flap (CAF) versus tunnel technique (TUN) in covering isolated mid-facial peri-implant soft tissue dehiscences (PSTDs).

MATERIALS AND METHODS

Twenty-eight participants presenting with isolated non-molar implants exhibiting PSTDs were enrolled and randomized to receive either CAF or TUN, both with a connective tissue graft (CTG). The primary outcome of the study was the percentage of mean PSTD coverage at 12 months. Secondary endpoints included the frequency of complete PSTD coverage, changes in keratinized mucosa width (KMW) and horizontal mucosal thickness (MT), as assessed with transgingival probing, 3D optical scanning and ultrasonography, professional aesthetic evaluation and patient-reported outcome measures (PROMs).

RESULTS

At 12 months, the mean PSTD coverage of the CAF and TUN groups was 90.23% and 59.76%, respectively (p = .03). CAF-treated sites showed a substantially higher frequency of complete PSTD coverage (p = .07), together with significantly greater gain of KMW (p = .01), increase in MT (p = .02), volumetric gain (p < .01) and professional aesthetic outcomes (p = .01). Both interventions showed an improvement in patient-reported aesthetics and a reduction of the anxiety related to the appearance of the implant compared to baseline, with the CAF group obtaining significantly higher scores (p = .03 for both PROMs).

CONCLUSIONS

CAF + CTG resulted in superior PSTD coverage outcomes, greater gain in KMW and MT, and better PROMs than TUN + CTG for the treatment of isolated PSTDs (ClinicalTrials.gov NCT03498911).

Wound healing dynamics, morbidity, and complications of palatal soft-tissue harvesting

Palatal-tissue harvesting is a routinely performed procedure in periodontal and peri-implant plastic surgery. Over the years, several surgical approaches have been attempted with the aim of obtaining autogenous soft-tissue grafts while minimizing patient morbidity, which is considered the most common drawback of palatal harvesting. At the same time, treatment errors during the procedure may increase not only postoperative discomfort or pain but also the risk of developing other complications, such as injury to the greater palatine artery, prolonged bleeding, wound/flap sloughing, necrosis, infection, and inadequate graft size or quality. This chapter described treatment errors and complications of palatal harvesting techniques, together with approaches for reducing patient morbidity and accelerating donor site wound healing. The role of biologic agents, photobiomodulation therapy, local and systemic factors, and genes implicated in palatal wound healing are also discussed.

Effect of collagen sponge and flowable resin composite on pain management after free gingival graft harvesting: A randomized controlled clinical trial

The aim of this study was to compare the effect of the application of a flowable resin composite coating, over a collagen sponge stabilized with suture, on postoperative pain after free gingival graft harvesting. Thirty-two free gingival grafts were harvested from the palate in 32 patients, who were subsequently randomized to have only a collagen sponge stabilized with sutures applied to the palatal wound (control), or to have the collagen sponge coated with a flowable resin composite (test). Patients were observed for 14 days, and the pain level was evaluated by using a numerical rating scale. The consumption of analgesics during the postoperative period and the characteristic of the graft were also analyzed. The patients in the test group reported having experienced significantly less pain statistically than the patients in the control group throughout the study. The consumption of analgesics was lower in the test group. The dimensions of harvested grafts in the control and test groups showed no significant differences in height, width, and thickness. In conclusion, the addition of flowable resin composite coating to the hemostatic collagen sponge on the palatal wound following free gingival graft harvesting helped to minimize postoperative pain.

Influence of graft thickness on tunnel technique procedures for root coverage: a pilot split-mouth randomized controlled trial

OBJECTIVE

To compare the clinical outcomes of the tunnel technique (TUN) combined with either thin connective tissue graft (CTG) (TUN + thin CTG) (1 mm) or thick CTG (TUN + thick CTG) (2 mm) for the treatment of localized gingival recession (GR).

MATERIAL AND METHODS

Twelve patients, with 24 maxillary localized type RT1 GR were randomly assigned into two groups. Clinical, esthetic, and patient-reported outcomes were evaluated at baseline and at 6-month follow-up.

RESULTS

The TUN + thin CTG group showed a higher mean GR reduction (1.53 ± 0.66) (primary outcome variable) than the TUN + thick CTG group (1.44 ± 0.89), but no statistically significant difference was detected at the 6-month follow-up (p = 0.77). No statistically significant differences were found between TUN + thin CTG and TUN + thick CTG concerning complete root coverage (CRC) (58.3% versus 41.7%, respectively), gingival ticknness (GT) or Root-coverage Esthetic Score (RES) at 6 months. Regarding patient-reported outcomes, both groups reported having experienced similar pain at 7 days (p > 0.05). No statistically significant differences were found between the groups in the analysis of the aesthetic score.

CONCLUSION

Both treatments showed a similar reduction in GR. In addition, similar CRC, GT, RES, pain and self-reported esthetics were achieved in both groups.

CLINICAL RELEVANCE

Application of thin CTG provided a similar result than thick CTG for the treatment of RT1 localized GR.

Clinical and patient-reported outcomes of tissue engineering strategies for periodontal and peri-implant reconstruction

Scientific advancements in biomaterials, cellular therapies, and growth factors have brought new therapeutic options for periodontal and peri-implant reconstructive procedures. These tissue engineering strategies involve the enrichment of scaffolds with living cells or signaling molecules and aim at mimicking the cascades of wound healing events and the clinical outcomes of conventional autogenous grafts, without the need for donor tissue. Several tissue engineering strategies have been explored over the years for a variety of clinical scenarios, including periodontal regeneration, treatment of gingival recessions/mucogingival conditions, alveolar ridge preservation, bone augmentation procedures, sinus floor elevation, and peri-implant bone regeneration therapies. The goal of this article was to review the tissue engineering strategies that have been performed for periodontal and peri-implant reconstruction and implant site development, and to evaluate their safety, invasiveness, efficacy, and patient-reported outcomes. A detailed systematic search was conducted to identify eligible randomized controlled trials reporting the outcomes of tissue engineering strategies utilized for the aforementioned indications. A total of 128 trials were ultimately included in this review for a detailed qualitative analysis. Commonly performed tissue engineering strategies involved scaffolds enriched with mesenchymal or somatic cells (cell-based tissue engineering strategies), or more often scaffolds loaded with signaling molecules/growth factors (signaling molecule-based tissue engineering strategies). These approaches were found to be safe when utilized for periodontal and peri-implant reconstruction therapies and implant site development. Tissue engineering strategies demonstrated either similar or superior clinical outcomes than conventional approaches for the treatment of infrabony and furcation defects, alveolar ridge preservation, and sinus floor augmentation. Tissue engineering strategies can promote higher root coverage, keratinized tissue width, and gingival thickness gain than scaffolds alone can, and they can often obtain similar mean root coverage compared with autogenous grafts. There is some evidence suggesting that tissue engineering strategies can have a positive effect on patient morbidity, their preference, esthetics, and quality of life when utilized for the treatment of mucogingival deformities. Similarly, tissue engineering strategies can reduce the invasiveness and complications of autogenous graft-based staged bone augmentation. More studies incorporating patient-reported outcomes are needed to understand the cost-benefits of tissue engineering strategies compared with traditional treatments.

Modified-free gingival graft technique for treatment of gingival recession defects at mandibular incisors: A randomized clinical trial

BACKGROUND

The aim of this study was to evaluate clinical and patient-reported outcomes following surgical root coverage at RT1 gingival recession defects at mandibular incisors, using either a conventional free gingival graft (FGG) or a modified FGG (ModFGG).

METHODS

Total of 30 patients with RT1 gingival recessions at mandibular incisors were enrolled and randomly allocated to either a control (FGG) or test group (ModFGG). Evaluations of clinical changes (recession depth, height of keratinized tissue) and patient satisfaction were performed over a follow-up period of 12 months. Post-surgical changes of keratinized tissue height (shrinkage) were assessed from 1 month and onward.

RESULTS

ModFGG resulted in more pronounced root coverage at 1 year compared to FGG (91.8% vs. 60.7%, p < 0.001). Height of keratinized tissue was improved by 4.2 and 2.2 mm (p < 0.001), respectively, with significantly less shrinkage in ModFGG. Post-surgical morbidity was significantly lower for ModFGG at 2 weeks and patient satisfaction was significantly higher 12 months after treatment (9.1 vs. 5.4; p < 0.001).

CONCLUSIONS

ModFGG represents a valid approach for the management of RT1 recession defects at mandibular incisors. The technique is superior to traditional FGG in terms of root coverage, the gain of keratinized tissue height, and patient satisfaction.

Patient-reported outcomes of palatal donor site healing using four different wound dressing modalities following free epithelialized mucosal grafts: A four-arm randomized controlled clinical trial

BACKGROUND

The aim of this study was to compare the effects of four different commonly used wound dressings in improving patient reported outcomes (PROMS) after free epithelialized mucosal grafts (FEGs) harvesting.

METHODS

Following 72 FEGs harvesting from 72 patients, patients were assigned into four groups.

CONTROL

collagen plug + sutures (CPS); test: collagen plug with cyano-acrylate (CPC), platelet rich fibrin (PRF) + sutures, or palatal stent only (PS). Patients were observed for 14 days, with evaluation of pain level utilizing the visual analog scale, number of analgesics consumed, need for additional analgesics, amount of swelling, amount of bleeding, activity tolerance, and willingness for retreatment.

RESULTS

Compared to the control group all test groups indicated significant lower pain perception (P < 0.0001), lower analgesic consumption (P < 0.0001), and higher willingness for retreatment (P < 0.0001), while no statistically significant differences among test groups were observed. There were no statistically significant differences in amount of day-by-day swelling, bleeding, and activity tolerance among four groups. Compared to other groups, the PS had the lowest overall pain scores (over the 14-day period). Palatal thickness, graft length, graft width, and graft thickness did not appear to affect patient morbidity (P > 0.05).

CONCLUSIONS

All interventions significantly decreased pain perception compared to a hemostatic collagen sponge alone over the palatal donor site after FEG surgery. In the first few days after surgery, the use of a palatal stent seemed to be associated with less overall pain, pain pills consumed, and higher willingness of doing the same procedure again.

Assessment of early wound healing, pain intensity, quality of life and related influencing factors during periodontal surgery: a cross-sectional study

BACKGROUND

This cross-sectional study assessed early wound healing, pain intensity, quality of life, surgical satisfaction, and related factors during periodontal surgery.

METHODS

A total of 369 patients completed the questionnaire before undergoing periodontal surgery (baseline), immediately after the operation (phase I), on the day of suture removal (phase II), and one month later (phase III). The Early Wound Healing Score (EHS) was assessed, and the short-form McGill Pain Questionnaire (SF-MPQ), tooth hypersensitivity visual analog scale (VAS), oral health-related quality of life measure (OHQoL-UK), and surgical satisfaction VAS were administered and analysed.

RESULTS

The EHS was 8.41 ± 2.74 and was influenced by disease severity and surgical factors. Scores on the SF-MPQ, pain intensity scores, and OHQoL-UK scores were significantly increased in phase I and decreased later. Tooth sensitivity decreased significantly one month after periodontal surgery. Psychological factors were positively related to SF-MPQ, pain intensity, OHQoL-UK and tooth sensitivity VAS scores in all phases, while disease severity and surgical factors were only related to these scores at baseline or in phases I/II/III. Surgical acceptance and reoperation willingness continuously decreased after surgery, and all these scores were related to surgical satisfaction.

CONCLUSIONS

EHS, pain intensity and quality of life were closely related to disease severity, psychological factors and surgical factors in phase I (i.e., immediately after surgery). The findings suggest that surgical details should be enhanced and that behavioural and psychological interventions measures should be implemented to improve outcomes during periodontal operation and during the early postoperative period as well as to improve patient-oriented periodontal surgery experiences. Trial registration This cross-sectional study did not include interventions with human participants, and all the experimental procedures involving humans in this study were approved by the Ethics Committee of West China College of Stomatology, Sichuan University (WCHSIRB-D-2020-284).

Dimensional Influence of Epithelialized Tissue Graft Harvested From Palate on Postoperative Pain: a Systematic Review

Objectives

The aim of the present systematic review was to evaluate the dimensional influence of the epithelialized tissue graft harvested from the palate in the postoperative pain.

Material and Methods

Research was conducted in electronic databases Cochrane Library, Embase, LILACS, PubMed, Scopus, and Web of Science upwards May 15, 2022. Studies that reported the influence of graft dimensions of palatal epithelized harvesting on postoperative pain were eligible. The evaluation was made using the methodological quality assessment by Joanna Briggs Institute Critical Appraisal Checklist for randomized clinical trials and non-randomized studies and the level of evidence according to GRADE.

Results

Four studies were included. The clinical and methodological heterogeneity among studies led to an analysed narrative. The postoperative pain was assessed during the period of 1 to 28 postoperative days. It was determined by using visual analog scale in three studies, while the evaluation was performed indirectly based on analgesics intake in one study. According to three studies, bigger graft sizes were associated with higher postoperative pain. The methodological quality assessment categorized two study as high (one randomized control trial and one non-randomized), and two as moderate (one randomized control trial and one non-randomized). The data was considered moderate.

Conclusions

Based on the moderate certainty level, bigger graft sizes of palatal epithelized harvesting appear to promote more postoperative pain. Understanding the postoperative pain as a response to a graft extension may assist some clinical decisions regarding the surgical periodontal and peri-implant planning.

Clinical outcomes of keratinized mucosa augmentation in jaws reconstructed with fibula or iliac bone flaps

This prospective study was undertaken to evaluate the treatment outcomes of keratinized mucosa augmentation (KMA) on the buccal and palatal/lingual sides of implants in jaws reconstructed after oncological surgery. Forty-two implants in 12 patients whose jaws had been reconstructed with a fibula or iliac bone flap were included. KMA was performed at 3 months after implant placement; this included an apically displaced partial-thickness flap and a free gingival graft (FGG) around the implants to increase the keratinized mucosa width (KMW). Patients were followed up for at least 6 months post-surgery. KMW, shrinkage, and patient pain and discomfort measured on a visual analogue scale were analysed. A histological analysis was performed of tissue epithelium from two patients. The results showed that KMW was >2 mm on both the buccal and palatal/lingual sides during follow-up. Before surgery, histological analysis showed epithelium with no epithelial spikes; normal keratinized epithelial spikes were observed at 8 weeks after KMA. Greater KMW was observed around implants in reconstructed maxillae than around those in reconstructed mandibles (P < 0.001). Patients felt more pain at the donor site than at the recipient site during the first 3 days post-surgery. KMA with FGG was predictable in reconstructed jaws and may help maintain the long-term stability of implants.

Stability of biomaterials used in adjunct to coronally advanced flap: A systematic review and network meta-analysis

AIM

The objective of this network meta-analysis was to rank different biomaterials used in adjunct to coronally advanced flap (CAF), based on their performance in root-coverage for Miller's Class I and II gingival recessions.

MATERIALS AND METHODS

An electronic database search was carried out in PUBMED, CENTRAL, SCOPUS, and EMBASE to identify the eligible articles and compiled into the citation manager to remove the duplicates. The primary outcome was keratinized gingival tissue width (KGW) and percentage of root coverage (%RC). The treatment effect of different biomaterials was estimated using predictive interval plots and ranked based on biomaterials performance, using multidimensional scale ranking.

RESULTS

CAF + connective tissue graft (CTG), CAF + platelet concentrate matrix (PCM) and acellular dermal matrix (ADM) ranked at the top positions in performance in improving KGW. The highest ranked materials in improving percentage of root coverage in gingival recession were CAF + collagen matrix (CM) + gingival fibroblasts (GF), CAF + ADM + platelet rich plasma (PRP) and CAF + ADM, as compared to CAF alone.

CONCLUSION

CTG, ADM, platelet concentrates, and CM + GFs, when used in adjunct to CAF, showed improved stability over ≥12 months of follow-up, better percentage of root coverage, and improved keratinized gingival width.

Comparison between Tissue Adhesive Cyanoacrylate and Suture for Palatal Fibromucosa Healing: A Randomized Controlled Study

Cyanoacrylate tissue adhesive is proposed to promote soft tissue healing in oral surgery and minimize complications (pain, inflammation, and bleeding) associated with wound healing by secondary intention. The objective was to compare cyanoacrylate tissue adhesive (test group) with suture (control group) in terms of postoperative complications, operative time, and wound healing in the palatal donor area after harvesting a de-epithelialized gingival graft. A randomized controlled clinical trial was performed in 24 patients randomly assigned to one of two study groups. Data were gathered on wound bleeding, operative time, postoperative pain, inflammation, hyperesthesia, necrosis, and donor area healing time. Operative time was almost 50% shorter in the tissue adhesive cyanoacrylate group, a significant between-group difference (p = 0.003). Spontaneous bleeding in the donor area during the first 24 h was observed in 11.1% of the tissue adhesive cyanoacrylate group versus 88.9% of the suture group—a significant difference. No significant between-group difference was observed in postoperative pain, inflammation, or degree of healing over time. There were no cases of hyperesthesia or wound necrosis. Utilization of tissue adhesive cyanoacrylate rather than suture in palatal de-epithelialized gingival graft harvesting reduces postoperative bleeding during the first 24 h, as well as the operative time.

Patient-reported outcome measures following soft-tissue grafting at implant sites: A systematic review

OBJECTIVES

To review the available literature on patient-reported outcome measures (PROMs) following soft tissue augmentation at implant sites.

MATERIALS AND METHODS

A comprehensive electronic and manual search was performed to identify clinical studies that involved soft tissue augmentation around dental implants and reported PROMs, including post-operative morbidity, painkillers intake, quality of life, aesthetics and satisfactions.

RESULTS

Nineteen articles were included in the qualitative analysis. Autogenous grafts (free gingival graft and connective tissue graft), acellular dermal matrix and xenogeneic collagen matrix were utilized, either with a bilaminar- or an apically positioned flap approach. PROMs reported in the literature included perceived hardship of the procedure and pain during the surgery, post-operative morbidity, painkillers intake, number of days with discomfort, satisfaction, aesthetic evaluation, quality of life and willingness to undergo the treatment again. Most of the included studies showed similar PROMs between autogenous grafts and substitutes, in terms of post-operative morbidity, painkillers intake, quality of life, aesthetic assessment and satisfaction. Nevertheless, a trend towards lower post-operative discomfort was observed for graft substitutes. High scores for patient satisfaction and aesthetic evaluation were observed in all the interventions compared to non-grafted sites.

CONCLUSIONS

PROMs represent a crucial endpoint of clinical studies evaluating the outcomes of soft tissue grafts at implant sites. Most of the studies did not find significant differences in terms of patient morbidity and painkillers between autogenous grafts and substitutes. Soft tissue grafting can enhance patient satisfaction and aesthetic evaluation compared to non-grafted sites.

Enamel matrix derivative effects on palatal mucosa wound healing: Randomized clinical trial

BACKGROUND

This study was conducted to evaluate the clinical, immunologic, and patient-centered outcomes of enamel matrix protein derivative (EMD) on excisional wounds in palatal mucosa.

MATERIALS

Forty-four patients in need of ridge preservation were randomly allocated into two groups: control group (n = 22): open palatal wound after free gingival graft (FGG) harvest and EMD group (n = 22): open palatal wound after FGG harvest that received 0.3 ml of EMD. Clinical and patient-centered parameters were analyzed for 3 months post-treatment. Wound fluid levels of inflammatory markers were assessed 3 and 7 days postoperatively.

RESULTS

No significant inter-group difference was observed in remaining wound area and re-epithelialization. EMD and control groups achieved wound closure and re-epithelialization 30 days postoperatively (p < .001), without inter-group differences. Similarly, number of analgesics and Oral Health Impact Profile scores did not present significant inter-group differences (p > .05). EMD appeared to selectively modulate wound fluid levels of monocyte chemoattractant protein-1, macrophage inflammatory protein-1α, matrix metallopeptidase 9, and tissue inhibitor of metalloproteinases-2.

CONCLUSION

Within the limits of the present study, it can be concluded that EMD application to excisional palatal wounds using the investigated protocol does not provide clinical healing benefits, despite an apparent modulation of selected inflammatory markers.

Comparative analysis of the hemostatic, analgesic and healing effects of cyanoacrylate on free gingival graft surgical wounds in donor and recipient areas: a systematic review

To analyze the hemostatic, Dsurgical wounds in donor and recipient areas of free gingival grafts (FGG). Five databases (PubMed, Scopus, Science Direct, Cochrane and Web of Science) were searched up to March 2021 (PROSPERO CRD42019134497). The focus of the study (cyanoacrylate) was combined with the condition (periodontal surgery OR free gingival graft OR free soft tissue graft OR autografts), and outcome (healing OR epithelialization OR pain OR analgesia OR bleeding OR hemostasis OR hemostatic). Studies reporting cyanoacrylate isolated or associated with another substance in FGG stabilization and closure were investigated and assessed for the quality and risk of bias through the Cochrane Manual. Six studies with 323 participants were included. Evaluation of the quality and risk of bias highlighted a low risk for four articles, intermediate for one and unclear for another. The use of cyanoacrylate associated or not with the hemostatic sponge or the platelet-rich fibrin was more effective in healing (three studies), analgesia (four studies), and hemostasis in one study (p < 0.05). However, groups with the association in cyanoacrylate showed superior healing, and analgesic action to the isolated cyanoacrylate group. In addition, two studies demonstrated that cyanoacrylate use reduces surgery duration, one study showed that it reduces postoperative sensibility, and another present hemostatic effect (p < 0.05). There is scarce literature for the use of cyanoacrylate in FGG wounds indicates that it can promote a minor inflammatory response, reduce operation time, does not interfere with healing, relieves postoperative discomfort, and suggests the possibility immediate hemostasis. Its use presents an alternative to suturing in FGG surgeries. But, the limited number of cases and the relative heterogeneity of the included studies suggest caution in generalizing the indication.

CLINICAL RELEVANCE

Cyanoacrylate seems to present analgesic effects and less pain when applied to wound closure and covering donor and recipient areas reducing the need for postoperative analgesic medication; and has a healing effect in the closure of the donor area on the palate. In addition, it can reduce bleeding time after surgery, and prevents late bleeding during the first postsurgical week. Scientific justification: To evaluate the hemostatic, analgesic and healing actions of cyanoacrylate compared to the suture thread and other agents when used to close surgical wounds from periodontal free gingival graft surgical wounds in both the donor and recipient areas of the graft.

MAIN FINDINGS

The use of cyanoacrylate individually or in association with wound dressing agents presents analgesic effects because the patient reports less pain experienced when cyanoacrylate is applied to the wound closure and covering, thereby reducing the need for postoperative analgesic medication. In addition, a healing effect is observed in the closure of the donor area on the palate; as well as it seems to present hemostatic effects, reducing the bleeding time after surgery, and preventing late bleeding during the first postsurgical week.

PRACTICAL IMPLICATIONS

Dentists may cautiously apply cyanoacrylate after periodontal surgeries for free gingival graft in both the donor and recipient areas of the graft. However, they must consider the limitations of the surgery, tension-free positioning, the patient's dyscrasia and postoperative care, constituting a set of predictors for adequate clinical decision-making. Widespread use of such material for all patients and surgical configurations may not be recommended.

Patient-reported outcome measures and clinical outcomes following peri-implant vestibuloplasty with a free gingival graft versus xenogeneic collagen matrix: a comparative prospective clinical study

BACKGROUND

The objective of this study was to compare patient-reported outcome measures (PROMs) and clinical outcomes after augmentation with xenogeneic collagen matrix (XCM) or free gingival graft (FGG) during different postoperative phases.

METHODS

Forty-two patients (21 per group) with keratinized mucosa width (KMW) of < 2 mm at buccal implant sites in the posterior mandible were enrolled. All underwent vestibuloplasty and were allocated to either FGG (control) or XCM (test) group. Intraoperative morbidity of pain, stress, nausea, tolerance to time, and acceptance of surgery were evaluated immediately after surgery. The severity and duration of subjective pain, swelling, and bleeding were compared within a 2-week postoperative period. The willingness to retreat and satisfaction were assessed at 6 months. All PROMs were obtained using questionnaires and visual analog scales. The buccal KMW and other peri-implant parameters were also evaluated.

RESULTS

No significant between-group differences were observed in PROMs immediately after surgery, except acceptance of surgery (0, 0-30.0 vs. 30, 0-50.0, p = 0.025). At 2 weeks, pain severity (46.7 ± 25.9 vs 61.9 ± 20.2, p = 0.040) and duration (5.52 ± 3.57 vs 8.48 ± 2.80, p = 0.005) were significantly lower in the test group, and pain perception during speaking and chewing was significantly higher for FGG, with no significant between-group differences in swelling and bleeding. At 6 months, the test group showed a higher willingness to retreat (76% vs 43%, p = 0.021); however, satisfaction with treatment outcomes was similar in both groups. At 6 months, the gain of KMW was significantly higher in FGG than in XCM (XCM: 1.57 ± 1.69 mm, FGG: 2.68 ± 1.80 mm, p = 0.003). Other peri-implant parameters did not show significant differences.

CONCLUSIONS

Within the limitation of the present nonrandomized study, XCM demonstrated more positive PROMs than FGG during different postoperative phases, mainly for less pain perception during the early healing stage, but was inferior to FGG in terms of gain of KMW. For KMW augmentation in the posterior mandible, XCM may be indicated when patients can bear little pain.

CLINICAL TRIAL REGISTRATION

ChiCTR1900022575 , date of registration: 17/4/2019, retrospectively registered.

Is the postoperative discomfort after connective tissue harvesting from the palate influenced by the use of a bipolar coagulator? A randomized controlled trial

Objectives

This study aimed to determine the effect of the use of a bipolar coagulator on postoperative pain and complications when used during connective tissue harvesting from the palate.

Material and methods

A randomized controlled clinical trial was conducted with 57 sequential patients requiring a connective tissue graft for periodontal or implant surgery. All samples were harvested superficially and de‐epithelized outside the mouth. The patients were randomly allocated to two groups: in one group, the bipolar coagulator was used before suturing to control bleeding, and in the other group, the coagulator was not used. The surgeon was unaware of the randomization until the end of the harvesting phase. Self‐reported maximum pain, number of painkillers used, bleeding events, emergency visits at the clinic were recorded 7 days after surgery.

Results

Fifty patients were randomized and treated (seven were excluded for different reasons). The mean harvested area was 75.24 mm² (SD, 33.96), and the mean thickness of the samples was 2.47 mm (SD, 0.75). The mean self‐reported pain value on the visual analog scale was 3.37 (SD, 2.30), and the mean number of pain medications used was 7.1 (SD, 6.60). Seven patients made an emergency visit each, and 17 delayed bleeding events were reported by 15 patients. No statistically significant differences were reported in postoperative pain, postoperative bleeding, and emergency visit to the clinic between the groups that did and did not use the bipolar coagulator. When smoking habits were taken into consideration, the number of pain medications was higher among male smokers and older smokers than among male non‐smokers and younger smokers. This study was not able to find a relationship between harvested sample dimension or thickness and postoperative discomfort.

Conclusions

The bipolar coagulator can be used during connective tissue harvesting from the palate to control bleeding without influencing postoperative pain.

Outcome measurements following palatal soft tissue graft harvesting: A review

Background

Free gingival graft (FGG) and connective tissue graft (CTG) are two of the most commonly techniques performed in periodontal and peri-implant plastic surgery. Although several outcome measurements have been proposed for evaluation of palatal wound healing and patient morbidity, a comprehensive review about these variables is lacking. The objective of this review is to present comprehensive information about outcome measurements related to postoperative palatal wound healing and postoperative patient-reported morbidity after FGG or CTG procedures.

Material and Methods

An electronic search of English language dental literature in the Medline database via PubMed access was conducted from May 1994 to May 2020 following the PRISMA guidelines. Electronic search strategy complemented by hand search of impacting related dental journals, and the reference list of all included studies were used to complete data collection considering only clinical trials. Finally, inclusion criteria were applied to identify articles after full-text evaluation.

Results

A total of 111 articles were identified. After the exclusion of 34 articles based on title and abstract evaluation, 77 articles were full text screened. Following, 46 articles were excluded since they evaluated other surgical areas. Finally, 31 studies were selected and included for final evaluation. Outcome measurements were classified in variables collected by indexes and systems assessed professionally and patient-centered measurements. Visually-assessed measurements include indexes, photographs, bleeding and use of laboratory-aided measurements. Patients-centered outcomes comprise pain, discomfort and quality-of life, among others.

Conclusions

The most commonly used outcome measurements related to postoperative palatal wound healing are hydrogen peroxide test, tissue color match, visual inspection, and bleeding evaluation. Pain perception, analgesic consumption, discomfort sensation, burning sensation, and changes in feeling habits are the most commonly used outcome measurements related to postoperative patient-reported morbidity. Key words:Morbidity, patient comfort, periodontics, tissue harvesting, wound healing.

Is the use of platelet-rich fibrin effective in the healing, control of pain, and postoperative bleeding in the palatal area after free gingival graft harvesting? A systematic review of randomized clinical studies

OBJECTIVE

A systematic review (SR) was conducted to answer the following focused question based on PICO strategy: In patients who were submitted to harvesting palatal free gingival graft, could platelet-rich fibrin (PRF) application in comparison with another method improve the healing, pain, and control of postoperative bleeding in the palatal area in randomized clinical trials?

METHODS

A SR was conducted according to the PRISMA guidelines. The MEDLINE (PubMed), Scopus, Embase, and Web of Science databases were searched, and hand searches were made, covering the period up to August 2020, for randomized clinical trials (RCTs) reporting the effect of PRF membrane in postoperative palatal healing management compared with any other methods. The risk of bias (RoB) of the studies included was assessed by using the RoB 2 tool.

RESULTS

The electronic search strategy identified 150 articles. After title screening and abstract reading, 141 studies were excluded, and 9 full-text publications were comprehensively evaluated. Finally, 8 articles were included in the systematic review. Six studies showed that the PRF membrane was effective in improving wound healing during the first 2 weeks. As regards patient-centered outcomes, five studies showed that PRF promoted less postoperative pain. Finally, five studies that evaluated bleeding showed that the PRF membrane improved control of postoperative bleeding. RoB was classified as low in 4 studies, 3 with some concerns, and only one study did not describe the outcome data, and as this was missing, it was not possible to verify the protocol of data analysis for this study; therefore, it was classified as having high RoB.

CONCLUSION

Within the limitations of this study, the collective evidence emerging from this SR may support the use of PRF membrane in the palatal area after free gingival graft harvesting. The results of this review must be interpreted with caution, due to the low number of RCTs included and high degree of heterogeneity among the PRF protocols. Further well-designed RCTs with accurate protocol and standard PRF parameters are required in order to gain clear understanding of the influence of PRF on wound healing and patient-centered outcomes.

CLINICAL RELEVANCE

The use of PRF membrane for the protection of the palatal donor site following free gingival graft harvesting procedures improves wound healing and patients' quality of life.

Platelet-Rich Fibrin in Single and Multiple Coronally Advanced Flap for Type 1 Recession: An Updated Systematic Review and Meta-Analysis

Background and Objectives: The aim of the present systematic review and meta-analysis was to investigate the efficacy of leukocyte–platelet-rich fibrin (L-PRF) in addition to coronally advanced flap (CAF) for the treatment of both single and multiple gingival recessions (GRs) compared to the CAF alone and to the adjunct of connective tissue graft (CTG). Root coverage outcomes using platelet concentrates have gained increased interest. In particular, it has been suggested that adding L-PRF to CAF may provide further benefits in the treatment of GRs. Materials and Methods: An electronic and manual literature search was conducted to identify randomized controlled trials (RTCs) investigating root coverage outcomes with CAF + L-PRF. The outcomes of interest included mean root coverage (mRC), recession reduction, keratinized tissue width (KTW) gain, gingival thickness (GT) gain, and patient-reported outcome measures (PROms) such as pain perception and discomfort. Results: A total of 275 patients and 611 surgical sites were analyzed. L-PRF in adjunct to single CAF seems to show statistically significant results regarding clinical attachment level (CAL) with a weighted means (WM) 0.43 95% CI (−0.04, 0.91), p < 0.0001, GT (WM 0.17 95% CI (−0.02, 0.36), p < 0.0001, and mRC (WM 13.95 95% CI (−1.99, 29.88) p < 0.0001, compared to single CAF alone. Interesting results were obtained from the adjunct of PRF to multiple CAF with respect to multiple CAF alone with an increase in the mRC WM 0.07 95% CI (−30.22, 30.35), p = 0.0001, and PPD change WM 0.26 95% CI (−0.06, 0.58), p < 00001. On the other hand, no statistically significant data were obtained when L-PRF was added to single or multiple CAF combined with CTG according to the included outcomes such as mRC (p = 0.03 overall). Conclusions: L-PRF is a valid alternative to CAF alone. L-PRF compared to CTG in single and multiple CAF showed statistically significant results regarding pain perception and discomfort PROms (p < 0.0001). However, CTG remains the gold standard for treating gingival recession.

Ultrasonographic tissue perfusion analysis at implant and palatal donor sites following soft tissue augmentation: A clinical pilot study

AIM

To describe the application of power Doppler Ultrasonography (US) for evaluating blood flow at implant and palatal donor sites following soft tissue augmentation with the connective tissue graft (CTG).

MATERIALS AND METHODS

Five patients exhibiting a peri-implant soft tissue dehiscence received treatment with a coronally advanced flap and corresponding CTG. Power Doppler US was used for assessing blood volume at baseline, 1 week, 1 month, 6 months and 12 months post-surgery for assessing blood-flow dynamics at the implant and palatal donor sites. The speed-weighted and power-weighted colour pixel density (CPPD) were computed from colour velocity (CV) and colour power (CP), respectively.

RESULTS

A mean increase in CV of 199.25% was observed at the midfacial region of the implant sites after 1 week compared to baseline. CV and CP were increased in all sites at 1 week and 1 month. At 6 and 12 months, the mean CV appeared lower than baseline at the implant sites. CCPD was increased at the palatal donor sites and at the great palatine foramen areas at the 1-week and 1-month post-operative evaluations.

CONCLUSIONS

Power Doppler US is a non-invasive and valuable tool for estimating tissue perfusion and CPPD variation during different phases of intra-oral soft tissue graft healing.

Effect of cyanoacrylate tissue adhesive in postoperative palatal pain management: a systematic review

OBJECTIVE

To critically appraise available literature concerning the effect of cyanoacrylate tissue adhesive (CTA) in postoperative palatal pain management.

MATERIALS AND METHODS

Electronic databases (Cochrane, PubMed, LILACS, Scopus, and Web of Science) were searched, complemented with grey literature databases up to June 2020. Studies reporting the effect of cyanoacrylate tissue adhesive compared to any other methods in postoperative palatal pain management were considered eligible. The risk of bias among and across included studies was assessed.

RESULTS

Finally, four studies were considered eligible. Regarding free gingival graft (FGG), cyanoacrylate tissue adhesive with hemostatic sponge promoted less postoperative pain (PP) and analgesic consumption (AC). Also, cyanoacrylate tissue adhesive with platelet-rich fibrin produced less PP and more wound healing at the palatal area than cyanoacrylate tissue adhesive and wet gauze. Additionally, cyanoacrylate tissue adhesive promoted less PP and AC than wet gauze and suture. Concerning connective tissue graft (CTG), cyanoacrylate tissue adhesive, and suture produced similar PP, AC, and willingness for retreatment.

CONCLUSIONS

Based on the low certainty level, cyanoacrylate tissue adhesive appears to promote less PP and AC than wet gauze and suture regarding FGG. Additionally, cyanoacrylate tissue adhesive appears to increase the effect of hemostatic sponge, contributing to the reduction of PP and AC. Regarding CTG, cyanoacrylate tissue adhesive appears to promote similar PP, AC, and willingness for retreatment than the suture. Therefore, cyanoacrylate tissue adhesive has shown promising usefulness for PP management in FGG, but not a clear benefit for CTG.

CLINICAL RELEVANCE

The adoption of different agents for the protection of the palatal donor site following gingival harvesting procedures may provide better comfort to the patient.

Patient experience of autogenous soft tissue grafting has an implication for future treatment: A 10- to 15-year cross-sectional study

BACKGROUND

Patient-reported outcomes have received a great deal of interest in periodontal plastic procedures. However, their evaluation has mainly been short-term. Thus, the aim of this study was to evaluate the impact of soft tissue grafting procedures conducted over a decade ago on the willingness of a patients to undergo the surgery again.

METHODS

Subjects that received an autogenous soft tissue graft over 10 years ago were screened and invited for a survey. Their response was only analyzed if they were able to correctly identify the sites of the surgical procedures. Dichotomous questions and visual analogue scales (VASs) were used to assess self-reported pain, willingness to retreat and satisfaction.

RESULTS

Fifty-two patients were included in the analyses. Higher pain was reported for mandibular sites, and treated areas including ≥ 3 teeth (P < 0.01). Willingness to retreatment was 84.6% and it was negatively associated with self-reported pain measures, the arch location (mandible), and number of treated sites (≥3 teeth) (P < 0.01). Mean satisfaction rate was 86.9 ± 13.65 (VAS) and showed a positive correlation with willingness to retreat (P < 0.01). Having a complete root coverage at the recall visit was also significantly associated with higher patient satisfaction scores (P < 0.01).

CONCLUSIONS

Patient experience of previous autogenous soft tissue grafting has an influence on their decision to undergo future treatment. Willingness to retreat was negatively affected by mandibular sites, larger treated areas and the perceived pain, while presenting with complete root coverage was significantly associated with patient satisfaction.

Coronally advanced flap achieved higher esthetic outcomes without a connective tissue graft for the treatment of single gingival recessions: a 4-year randomized clinical trial

OBJECTIVES

Limited long-term data are available when comparing the esthetic outcomes of coronally advanced flap (CAF) with or without a connective tissue graft (CTG). The aim of this study was to compare the 4-year esthetic outcomes of CAF vs CAF + CTG for the treatment of isolated maxillary gingival recessions.

MATERIAL AND METHODS

Forty-eight patients were randomly assigned for treatment either with CAF (control; N = 24) or to CAF + CTG (test group; N = 24). Patients were followed after the surgery until the final evaluation. A professional esthetic evaluation was performed using the Root coverage Esthetic Score (RES). Recession reduction, mean root coverage, and complete root coverage were also evaluated.

RESULTS

Forty-two patients completed the study at the 4-year recall. A significant recession reduction was evident at 4 years, without significant intergroup differences. The CAF group showed a statistically significant higher final RES compared with the CAF + CTG group (9.14 ± 1.08 vs 7.25 ± 1.29, respectively, p < 0.001). Regarding the individual components of RES, gingival margin and marginal tissue contour were significantly higher in the CAF group compared with that in the CAF + CTG group.

CONCLUSIONS

CAF presented with a significantly higher overall esthetic score than CAF + CTG, and in the individual RES components of marginal tissue contour and gingival margin after 4 years.

CLINICAL RELEVANCE

CAF without the addition of CTG provided higher esthetic outcomes for the treatment of isolated gingival recessions.

Periodontal phenotype: A review of historical and current classifications evaluating different methods and characteristics

OBJECTIVE

To review the historical and current periodontal phenotype classifications evaluating methods and characteristics. Moreover, to identify and classify the methods based on periodontal phenotype components.

OVERVIEW

Several gingival morphology studies have been frequently associated with different terms used causing confusion among the readers. In 2017, the World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions recommended to adopt the term "periodontal phenotype". This term comprises two terms, gingival phenotype (gingival thickness and keratinized tissue width) and bone morphotype (buccal bone plate thickness). Furthermore, gingival morphology has been categorized on "thin-scalloped", "thick-scalloped" and "thick-flat" considering the periodontal biotype. However, by definition, the term phenotype is preferred over biotype. Periodontal phenotype can be evaluated through clinical or radiographic assessments and may be divided into invasive/non-invasive (for gingival thickness), static/functional (for keratinized tissue width), and bi/tridimensional (for buccal bone plate thickness) methods.

CONCLUSIONS

"Thin-scalloped," "thick-scalloped," and "thick-flat" periodontal biotypes were identified. These three periodontal biotypes have been considered in the World Workshop but the term periodontal phenotype is recommended. Periodontal phenotype is the combination of the gingival phenotype and the bone morphotype. There are specific methods for periodontal phenotype evaluation.

CLINICAL SIGNIFICANCE

The term periodontal phenotype is currently recommended for future investigations about gingival phenotype and bone morphotype. "Thin-scalloped," "thick-scalloped," and "thick-flat" periodontal phenotypes can be evaluated through specific methods for gingival thickness, keratinized tissue width, and buccal bone plate thickness evaluation.

Peri-implant soft tissue phenotype modification and its impact on peri-implant health: A systematic review and network meta-analysis

BACKGROUND

The peri-implant soft tissue phenotype (PSP) encompasses the keratinized mucosa width (KMW), mucosal thickness (MT), and supracrestal tissue height (STH). Numerous approaches to augment soft tissue volume around endosseous dental implants have been investigated. To what extent PSP modification is beneficial for peri-implant health has been subject of debate in the field of implant dentistry. The aim of this systematic review was to analyze the evidence regarding the efficacy of soft tissue augmentation procedures aimed at modifying the PSP and their impact on peri-implant health.

METHODS

A comprehensive search was performed to identify clinical studies that involved soft tissue augmentation around dental implants and reported findings on KMW, MT, and/or STH changes. The effect of the intervention on peri-implant health was also assessed. Selected articles were classified based on the general type of surgical approach to increase PSP, either bilaminar or an apically positioned flap (APF) technique. A network meta-analysis including only randomized-controlled trials (RCTs) reporting on PSP outcomes was conducted to assess and compare different techniques.

RESULTS

A total of 52 articles were included in the qualitative analysis, and 23 RCTs were included as part of the network meta-analysis. Sixteen RCTs reported the outcomes of PSP modification therapy with bilaminar techniques, whereas 7 involved the use of APF. The analysis showed that bilaminar techniques in combination with soft tissue grafts (connective tissue graft [CTG], collagen matrix [CM], and acellular dermal matrix [ADM]) resulted in a significant increase in MT compared to non-augmented sites. In particular, CTG and ADM were associated with higher MT gain as compared to CM and non-augmented sites. However, no significant differences in KMW were observed across different bilaminar techniques. PSP modification via a bilaminar approach utilizing either CTG or CM showed beneficial effects on marginal bone level stability. APF-based approaches in combination with free gingival graft (FGG), CTG, CM, or ADM showed a significant KMW gain compared to non-augmented sites. However, compared to APF alone, only FGG exhibited a significantly higher KMW gain. APF with any evaluated soft tissue graft was associated with with reduction of probing depth, soft tissue dehiscence and plaque index compared to non-augmented sites compared to non-augmented sites. The evidence regarding the effect of PSP modification via APF-based approaches on peri-implant marginal bone loss or preservation is inconclusive.

CONCLUSIONS

Bilaminar approach involving CTG or ADM obtained the highest amount of MT gain, whereas APF in combination with FGG was the most effective technique for increasing KMW. KMW augmentation via APF was associated with a significant reduction in probing depth, soft tissue dehiscence and plaque index, regardless of the soft tissue grafting material employed, whereas bilaminar techniques with CTG or CM showed beneficial effects on marginal bone level stability.

Alvogyl and absorbable gelatin sponge as palatal wound dressings following epithelialized free gingival graft harvest: a randomized clinical trial

OBJECTIVES

This randomized controlled trial compares for the first time effects of Alvogyl versus absorbable gelatin sponge as palatal wound dressings on postoperative pain, amount of analgesic consumption, post-surgical bleeding, and wound re-epithelization.

MATERIALS AND METHODS

Following sample size calculation, 36 systemically healthy patients requiring palatal mucosal graft harvesting were randomized to receive Alvogyl (intervention group, 18 patients) or absorbable gelatin sponge (control group, 18 patients) palatal dressings. Patient-reported VAS pain scores over 2 weeks were defined as primary outcome. Post-surgical bleeding, number of analgesics consumed, and complete re-epithelialization of the palatal wound for up to 5 weeks were defined as secondary outcomes.

RESULTS

Although significantly higher VAS pain scores were reported in the control as compared with the intervention group up to 12 days post-surgically (from (median [range]) 8.5 [2-10] to 1 [0-2] and from 6 [0-10] to 0 [0-2] respectively), with higher analgesics consumption (from 2 [1-3] to 1 [0-3] and from 1 [0-3] to 0 [0-2] tablets respectively), a multivariate regression analysis considering age, gender, graft width/length, tissue thickness, analgesics intake, and dressing type demonstrated no statistically significant effect of any factor, including dressing type on VAS pain scores. At 4 weeks, 22.2% of patients in the intervention group versus 11.1% in the control group demonstrated complete re-epithelization of their palatal engraftment site, before complete re-epithelization in both groups at 5 weeks. No post-surgical bleeding was reported with both dressings.

CONCLUSIONS

Within the study's limitations, results suggest Alvogyl as a practical palatal surgical dressing, comparable with absorbable gelatin sponge in cost, pain reduction, hemostasis, and re-epithelization properties.

TRIAL REGISTRATION

www.ClinicalTrials.gov Identifier: NCT03402321 CLINICAL RELEVANCE: Alvogyl could present a novel palatal wound dressing material, comparable with gelatin sponge.

Autogenous soft tissue grafting for periodontal and peri-implant plastic surgical reconstruction

This state-of-the-art review presents the latest evidence and the current status of autogenous soft tissue grafting for soft tissue augmentation and recession coverage at teeth and dental implant sites. The indications and predictability of the free gingival graft and connective tissue graft (CTG) techniques are highlighted, together with their expected clinical and esthetic outcomes. CTGs can be harvested from the maxillary tuberosity or from palate with different approaches that can have an impact on graft quality and patient morbidity. The influence of CTGs on soft tissue thickness and keratinized tissue width are also discussed.

The Effect of Time on Root Coverage Outcomes: A Network Meta-analysis

The stability of root coverage outcomes has gained a great deal of interest. However, insufficient evidence is available, mainly due to limited direct comparisons among different techniques and the small sample size among clinical trials. Therefore, the aim of this study was to propose a mixed-models network meta-analysis (NMA) that includes the novelty of assessing time on root coverage outcomes while simultaneously comparing different surgical approaches. A literature search was performed by 2 individual reviewers to identify randomized clinical trials (RCTs) reporting the outcomes of root coverage procedures of at least 2 time points to estimate the slopes of different treatment approaches. The primary outcomes were the changes in slopes for recession depth (REC), keratinized tissue width (KTW), and clinical attachment level. Sixty RCTs with a total of 2,554 gingival recessions (1,864 patients) were included in the NMA. Connective tissue graft (CTG) and enamel matrix derivative (EMD) approaches provided superior initial REC reduction compared to flap advancement alone. However, only CTG-based procedures were effective in maintaining the stability of the gingival margin over time, while EMD, acellular dermal matrix, collagen matrix, and flap alone showed a similar tendency for gingival recession recurrence. Baseline REC and KTW at the earliest postoperative recall were predictors for the stability of the gingival margin. In addition, a geographic center effect on the treatment slopes was observed for REC and KTW. While limitations of the present linear mixed-modeling approach should be considered as it refers to estimation and comparison of time slopes based on an examined while linear framework, the designed NMA showed to be an effective tool for the simultaneous comparison of multiple treatment approaches while taking into account the critical element of time.

Incidence and severity of postoperative complications following oral, periodontal, and implant surgeries: A retrospective study

BACKGROUND

Incidence and severity of postoperative complications are key elements in determining the risk-benefit relationship of any surgical procedure. The aim of this retrospective study was to assess and categorize the postoperative complications that occur following, and are associated with, oral, periodontal, and implant surgeries.

METHODS

A total of 3,900 patients who underwent surgical procedures including, but not limited to, sinus floor elevation, guided tissue regeneration, crown lengthening, implant placement, soft tissue graft, open flap debridement or surgical removal of impacted teeth were included. Postoperative complications were recorded and graded based on impedance to routine daily activity and favorable surgical outcomes. Regression models were generated to evaluate correlations between complication types, as well as between patient/surgical characteristics and the incidence of complications.

RESULTS

Surgical removal of impacted teeth and lateral sinus floor elevation had the highest incidence and severity of complications. Postoperative dentinal hypersensitivity (5.7%) was the most frequent complication, followed by excessive pain (4.1%), and moderate postoperative bleeding (3.5%). Based on the devised grading system described in this paper, the complications were 11.1% of Grade I, 3.3% of Grade II, 8.3% of Grade III, 0.1% of Grade IV, and no complications recorded under Grades V or VI.

CONCLUSIONS

Surgical removal of impacted teeth and lateral sinus floor elevation are more prone to more severe complications compared with other procedures. Additionally, complications that do not impede favorable surgical outcomes and/or routine daily activity are the most likely to occur. Smoking and diabetes are generally associated with postoperative complications.