Periosteal pedicle graft for the treatment of gingival recession defects: a novel technique

Free gingival graft embossed over laterally flipped periosteum for root coverage: A novel case report

Innovations in surgical techniques have improved the esthetic outcome and predictability of root coverage procedures in recent years. A free gingival graft (FGG) augments the attached gingiva, but the compromised blood supply precludes its use in root coverage. In the surgical technique described in this case report, the FGG kept over a laterally placed periosteal flap enhanced the outcome. A laterally flipped periosteal flap was adapted over the root surface using resorbable sutures. The free graft was secured at the recipient site with cyanoacrylate adhesive, and adaptation was ensured with suspensory sutures. Satisfactory root coverage was appreciated and maintained at 6 months with excellent functional outcomes. Adequate width of the attached gingiva and vestibular depth were also noticed at the recipient site. The patient was highly satisfied with the obtained results, which were maintained until the 1-year postoperative period.

Clinical effectiveness of periosteal pedicle graft for the management of gingival recession defects-a systematic review and meta-analysis

OBJECTIVE

The purpose of this systematic review and meta-analysis was to evaluate the effectiveness of periosteal pedicle graft (PPG) in terms of root coverage and patient related outcomes. To the best of our knowledge this is the first systematic review with meta-analysis on PPG.

MATERIAL AND METHODS

A comprehensive search was performed using electronic and hand searches upto January 2023. Primary outcomes were Recession depth Reduction (Rec Red), mean root coverage (mRC) and complete root coverage (CRC). Secondary outcomes were gain in width of keratinized gingiva (WKG) and patient reported outcome measures (PROMs). Meta-analysis was performed when possible. The risk bias assessment was done using RevMan5.4.1 and Joanna Briggs institute scale for the included RCTs and case series respectively.

RESULTS

A total of 8 RCTs and 2 case series (538 recession sites) were included based upon the predefined inclusion and exclusion criteria. The follow up period ranged from 6 months to 18 months. Results demonstrated that mRC of PPG + Coronally advanced flap (CAF) was 87.7% for localized gingival recession defects (GRDs) and 84.83% for multiple GRDs. An overall gain in WKG (Weighted Mean =1.49 ± 0.27 mm) was observed among all the included studies in the PPG + CAF group with mean difference (-0.10 (95% CI [-0.52, 0.33], p = 0.66)). Sub-group meta-analysis comparing PPG + CAF with sub-epithelial connective tissue graft (SCTG) + CAF resulted in similar outcomes in terms of Rec Red (0.10 (95% CI [-0.56 to 0.77], p = 0.76)) and gain in WKG (-0.03 (95% CI [-0.25 to 0.18], p = 0.76)). In terms of PROMs systematic review revealed better patient satisfaction with PPG + CAF than SCTG + CAF.

CONCLUSION

PPG + CAF is a viable treatment modality for management of GRDs. The primary and secondary outcomes achieved utilizing PPG + CAF were found to be comparable to other conventional techniques including the gold standard i.e., SCTG.

Periosteum: Functional Anatomy and Clinical Application

Periosteum is a connective tissue that envelopes the outer surface of bones and is tightly bound to the underlying bone by Sharpey’s fibers. It is composed of two layers, the outer fibrous layer and the inner cambium layer. The periosteum is densely vascularised and contains an osteoprogenitor niche that serves as a repository for bone-forming cells, which makes it an essential bone-regenerating tissue and has immensely contributed to fracture healing. Due to the high vascularity of inner cambium layer of the periosteum, periosteal transplantation has been widely used in the management of bone defects and fracture by orthopedic surgeons. Nevertheless, the use of periosteal graft in the management of bone defect is limited due to its contracted nature after being harvested. This review summarizes the current state of knowledge about the structure of periosteum, and how periosteal transplantation have been used in clinical practices, with special reference on its expansion.

Periosteal pedicle graft with coronally advanced flap and its comparison with modified coronally advanced flap in the treatment of multiple adjacent gingival recessions-a randomized clinical trial

The present study aimed at evaluating clinical utility of periosteal pedicle graft with coronally advanced flap (PPG ​+ ​CAF) vs modified coronally advanced flap (M-CAF) in cases of multiple adjacent gingival recessions involving maxillary and mandibular anteriors labially. Random allocation of 40 patients with 269 gingival recessions was done into two groups. In Test group (20 patients) periosteal pedicle graft followed by coronally advanced flap (PPG ​+ ​CAF) technique was performed and in control group (20 patients) modified coronally advanced flap (M-CAF) was attempted. Primary outcome measures included percentage root coverage (PRC), gingival thickness (GT), probing depth (PD), clinical attachment level (CAL), recession depth (RD) and width of keratinized gingiva (WKG). Secondary outcomes measures were patient centred outcomes, plaque index (PI) and gingival index (GI). Patients were recalled at baseline, 3,6 and 18 months postoperatively.

Results

There was a significant decrease in the mean recession depth from 3.58 ​± ​0.53 ​mm (baseline) to 0.22 ​± ​0.01 ​mm (18 months) in PPG ​+ ​CAF test group and 3.7 ​± ​0.56 ​mm (baseline) to 0.21 ​± ​0.01 mm (18 months) in M-CAF control group. With 85% root coverage in test group and 78% root coverage in control group, the difference was statistically significant at 18 months. The test group showed significant higher clinical attachment level gain and increase in width of keratinized gingiva as compared to control group.

Conclusion

In both the study groups PPG ​+ ​CAF and M-CAF, significant root coverage was achieved. However, in terms of increase in width of keratinized gingiva, gingival thickness and percentage root coverage, PPG ​+ ​CAF group presented significantly better results than M-CAF group at 18 months follow up. Thus, periosteum can be used as a pedicle graft along with coronally advanced flap as an alternative method in achieving better results with minimal cost.

Advanced Platelet-Rich Fibrin in Periosteal Inversion Technique for Root Coverage: A Case Report

INTRODUCTION

The management of gingival recession associated with esthetic concerns and root hypersensitivity is challenging, and its sequelae is based on the assessment of etiological factors and the degree of tissue involvement. Procedures using pedicle flaps, free soft tissue grafts, combination of pedicle flaps with grafts, barrier membranes, and the use of platelet concentrates are all effective for this purpose. The use of the third-generation platelet concentrate, advanced platelet-rich fibrin (A-PRF), has evolved as a promising regenerative material for root coverage procedure wherein it acts as a scaffold and also accelerates wound healing due to its dense fibrin meshwork.

CASE PRESENTATION

This case report, discusses treating an isolated maxillary Miller Class I recession in a 25-year-old male patient by a periosteal inversion method along with the A-PRF membrane. A partial thickness flap was reflected; periosteum was inverted; and an A-PRF membrane was placed over the denuded root surface which aided in enhanced regeneration; 100% root coverage was obtained as seen in follow-up visits.

CONCLUSION

The periosteal inversion technique along with an A-PRF membrane seems to be a novel approach in managing an isolated Miller Class I maxillary gingival recession.

Ascertaining the regenerative potential of the "gold standard" grafts: Achieving 100% root coverage in Miller's Class III recession with periosteal pedicle graft and autogenous bone

Recession of the gingiva is defined as the stripping of a portion of the dental root surface as a result of gingival margin shifting apically. Various techniques have been advocated for root coverage. The practice of utilizing periosteal pedicle graft for covering gingival recession defects is a contemporary development. Utilizing bone grafts for hard tissue regeneration has also been implemented. This case report assesses the effectiveness of the surgical approach utilizing autogenous bone and periosteum for recession coverage. A participant with Miller's Class III gingival recession in #23 and #24 was treated using this technique. The loss of periodontal attachment was recorded to be 8 mm and 5 mm on the mid-buccal surface of the upper left canine and first premolar, respectively. Clinical parameters were recorded at 1, 3, 6, 9, and 12 months postoperatively. Complete root coverage was achieved when evaluated from baseline till 12 months, with clinical attachment level and keratinized tissue gain. The results of esthetics in terms of color match and tissue contours were satisfactory to the patient as well as to the clinicians.

Low-level laser therapy as an adjunct to connective tissue graft procedure in the treatment of gingival recession defects: A systematic review and meta-analysis

OBJECTIVE

The aim of this study was to systematically evaluate the effectiveness of low level laser therapy (LLLT) as an adjunct to connective tissue graft (CTG) procedure for the treatment of gingival recession (GR).

MATERIALS AND METHODS

The addressed PICO question was; "In patients with Miller Class I or II recession defects (Population), what is the effect of LLLT as adjunct to CTG (Intervention) in comparison to CTG alone (Comparison) on gingival recession depth (Outcome)" Electronic databases were searched up to December 2017. Primary outcomes included gingival recession depth (GRD), whereas secondary outcomes were width of keratinized tissue (WKT) and relative clinical attachment level gain (RCAL). The weighted mean differences (WMD) of outcomes and 95% confidence intervals (CI) for each variable were calculated using random effect model.

RESULTS

Four randomized clinical studies were included. Two studies showed significantly greater improvements with LLLT whereas, 2 studies showed comparable outcomes between LLLT and CTG group. Considering the effects of adjunctive LLLT as compared to CTG, a high degree of heterogeneity for GRD (Q value = 9.40, P = .02, I² =68.11%) and WKT ((Q value = 16.04, P = .001, I² =81.31%) was noticed among both the groups. Meta-analysis showed a statistically significant GRD (WMD= -0.61, 95% CI= -1.23 to 0.004, P = .05) for LLLT + CTG treatment versus CTG alone only.

CONCLUSIONS

LLLT improves clinical and patient-centered outcomes of CTG procedures for the treatment of GR remains debatable. However, due to the small number of included studies and high heterogeneity in the laser parameters, precautions must be exercised when interpreting the results of the present systematic review.

CLINICAL SIGNIFICANCE

Gingival recessions in dentistry are of major esthetic concern. Minimal gingival recessions can be treated by flap operations, but the predictability and stability of the outcomes is debatable. In the present review, low level laser therapy (LLLT) adjunct to connective tissue graft (CTG) depicted a significant improvement in the predictability and stability of root coverage outcomes compared with CTG alone.

Innovative use of laterally positioned periosteal pedicle graft for coverage of gingivitis artefacta

There are many etiological factors for nonplaque-induced gingival diseases, out of which physical trauma due to psychiatric reasons leading to self-infliction is less studied upon. This case report presents one such case which has been successfully treated stepwise where psychological counseling was done to restrain from habit followed by using an innovative laterally positioned periosteal pedicle graft for dehiscence coverage.

Periosteal pedicle graft for the treatment of gingival recession defects current status and future prospects: What the evidence suggests?

BACKGROUND

Gingival Recession defects are one of the most common defects for which patients seek periodontal treatment. Many treatment options are available for the management of gingival recession. Most of the treatments offered aim to treat the cause, cover the denuded root surface and produce a long term aesthetic result. The use of periosteal pedicle graft (PPG) is a recent innovation for the treatment of gingival recession defects and has gained much attention in a short span of time. Although studies have been done utilizing PPG successfully for the treatment of gingival recession defects (GRD) but it is still not clear, whether PPG technique should be included in the established list of techniques used to treat GRD? An effort has been made to arrive at a decision on the current utility of PPG in the treatment of GRD based on the scientific evidence available in literature.

MATERIALS AND METHODS

A review of current literature was done to critically evaluate the evidence related to the Periosteal pedicle graft technique.

RESULTS AND CONCLUSION

Periosteal Pedicle Graft has come up as a viable treatment option for the treatment of GRD although it's still too early to predict the long-term results associated with PPG.

The periosteum eversion technique for coverage of denuded root surface

The periosteum is highly cellular connective tissue with rich vascularity and regenerative potential, which make it suitable autogenous graft. The periosteum eversion technique utilized periosteum for coverage of denuded root surface. The purpose of this case report was to evaluate the periosteum eversion technique that involves a single surgical site, in terms of root coverage, gingival height, and probing depth. A patient with Miller class I gingival recession of 3.0 mm, gingival height of 2.0 mm and probing depth of 2.0 mm was treated by the periosteum eversion technique. Root conditioning was done with 24% ethylenediaminetetra-acetic acid. In this technique, marginal periosteum was used as a pedicle graft. At the end of 6 months, 100% root surface was covered successfully with 5.0 mm of gingival height and 1.0 mm of probing depth. The periosteum eversion technique can be used for the treatment of gingival recession defect successfully.

Periosteal pedicle graft for the treatment of gingival recession: A viable alternative to sub-epithelial connective tissue graft

Treating gingival recessions is important to satisfy the functional and aesthetic needs of the patients. Among various available techniques to treat gingival recessions, the subepithelial connective tissue graft technique is still considered to be the best despite its inherent disadvantages. The recent innovation utilising periosteum as a pedicle graft to treat gingival recession defects has drawn considerable attention and may provide a viable alternative to subepithelial connective tissue graft.

Periosteal pedicle graft: A novel root coverage approach

Gingival recession along with reduced width of attached gingiva and inadequate vestibular depth is a very common finding. Many techniques have been adopted in order to treat such defects and obtain predictable root coverage. Several graft procedures are used to obtain the coverage, but they have not been able to deliver predictable and satisfactory results (except connective tissue graft). Some of them also resulted in the secondary surgical site that was very uncomfortable for the patients. There was an intense need for a technique that provides not only good and predictable root coverage, but also reduces the need for secondary surgical site. Hence, this paper describes a single stage technique for increasing the width of attached gingiva and root coverage by using the periosteal pedicle graft.

[Experimental study of the collagen matrix for increase the gums using a 3D-modeling]

In an experimental study on mini-pigs demonstrated that the use of collagen matrix Mucograft open method leads to the formation of mature connective tissue around the implants, more pronounced after 70 days, and the width of attached mucosa already 45th day (from 4.4 ± 0.3 to 7.7 ± 0.5 mm) is comparable to that of free gingival graft. Three-dimensional computer modeling of jaws experimental animals showed the soft tissue augmentation by 0.8 ± 0.1 cm3 after use of collagen matrix Mucograft and 1.1 ± 0.12 cm3 after free gingival graft.

Comparative study of the osseous healing process following three different techniques of bone augmentation in the mandible: an experimental study

The aim of this study was to evaluate the osseointegration of three different bone grafting techniques. Forty-eight mature New Zealand rabbits were divided randomly into three groups of 16 each. Horizontal augmentation was performed on the corpus of the mandible using three different techniques: free bone graft (FBG), free periosteal bone graft (PBG), pedicled bone flap (BF). The animals were sacrificed at postoperative weeks 1, 3, or 8. Specimens were decalcified for histological examination, and histomorphometric measurements were performed. The histological evaluation demonstrated bony fusion between the grafts and the augmented mandibular bone after 8 weeks in all groups. At week 8, the bone volume was significantly greater in the BF group than in the FBG (P<0.001) and PBG (P=0.001) groups, and also the trabecular thickness was significantly greater than in the FBG (P=0.015) and PBG (P=0.015) groups. Trabecular separation was significantly lower in the BF group than in the FBG group at week 8 (P=0.015). BF demonstrated greater osseous healing capacity compared to FBG and PBG. The preserved vascularization in BF improves the bone quality in mandibular bone augmentations.

Post-operative morbidity following the use of the inverted periosteal graft: A case series

Post-operative complications following flap surgeries or mucogingival procedures are important factors influencing patient's perception of periodontal procedures. Hence, it is important to foresee such complications and take adequate measures pre- and post-operatively. We treated five consecutive cases of gingival recession in the maxillary canine-premolar area using the inverted periosteal graft with a coronally positioned flap technique. Following each of these surgeries, the patients complained of post-operative swelling the next day involving the canine space or buccal space area. The swelling persisted for at least 5 days, however, it was painless. This paper highlights the post-operative complications associated with the said procedure and makes a case for detail enquiry in the form of controlled studies.

Vestibular deepening by periosteal fenestration and its use as a periosteal pedicle flap for root coverage

Gingival recession along with reduced width of attached gingiva and inadequate vestibular depth is a very common finding. Multiple techniques have been developed to obtain predictable root coverage and to increase the width of attached gingiva. Usually, the width of gingiva is first increased and then the second surgery is caried out for root coverage. The newer methods of root coverage are needed, not only to reconstruct the lost periodontal tissues but also to increase predictability, reduce the number of surgical sites, reduce the number of surgeries and improve patient comfort. Hence, this paper describes a single stage technique for increasing the width of attached gingiva and root coverage by using the periosteal pedicle flap.

Comparison of periosteal pedicle graft and subepithelial connective tissue graft for the treatment of gingival recession defects

BACKGROUND

The use of periosteum as a pedicle graft in the treatment of gingival recession defects is a recent advancement. The subepithelial connective tissue graft (SCTG) is considered the gold standard for the treatment of gingival recession defects. The present randomized controlled trial was done to compare periosteal pedicle graft (PPG) with SCTG for the treatment of gingival recession defects.

METHODS

10 males and 10 females between the ages of 16 and 40 years (mean age 25.2 years) with Miller's Class I and II recessions ≥3 mm participated in this one-year clinical study. They were assigned randomly to test group (PPG) and control group (SCTG). Results were evaluated based on parameters measuring patient satisfaction and clinical outcomes associated with two treatment procedures. Significance was set at p < 0.05.

RESULTS

At the end of the study, the defect coverage was 3.1 ± 0.13 mm or 92.6% in the test group compared to the control group in which the defect coverage was 2.70 ± 0.11 mm or 88.5%. The difference between the two groups was statistically significant (p < 0.0001). The average residual defect was comparable between the two groups, i.e. 0.3 ± 0.67 and 0.5 ± 0.84 in the PPG and SCTG group respectively. The test group was rated higher in terms of overall patient satisfaction (p < 0.02) and comfort during and after the procedure (p < 0.001).

CONCLUSIONS

PPG and SCTG have comparable clinical effectiveness, but PPG is superior to SCTG in terms of patient-centred outcomes, reflecting improved patient comfort and overall patient satisfaction.

Periosteum: a highly underrated tool in dentistry

The ultimate goal of any dental treatment is the regeneration of lost tissues and alveolar bone. Under the appropriate culture conditions, periosteal cells secrete extracellular matrix and form a membranous structure. The periosteum can be easily harvested from the patient's own oral cavity, where the resulting donor site wound is invisible. Owing to the above reasons, the periosteum offers a rich cell source for bone tissue engineering; hence, the regenerative potential of periosteum is immense. Although the use of periosteum as a regenerative tool has been extensive in general medical field, the regenerative potential of periosteum is highly underestimated in dentistry; therefore, the present paper reviews the current literature related to the regenerative potential of periosteum and gives an insight to the future use of periosteum in dentistry.

Treatment of multiple gingival recession defects using periosteal pedicle graft: a case series

BACKGROUND

The periosteum is a highly vascular connective tissue with immense regenerative potential. These qualities make it a suitable autogenous graft. A technique is described for using an autogenous periosteal pedicle graft (PPG) for the treatment of multiple gingival recession defects.

METHODS

Twenty teeth in six subjects with Miller Class I and II recessions ≥ 2 mm were treated using PPGs. In addition to the depth of the gingival recession defect, the probing depth and widths of keratinized and attached gingiva were recorded. The mean +/- SD was calculated for each of the clinical parameters. The paired t test was used to test the significance of the change.

RESULTS

At the end of 1 year, 90.95% of root coverage was attained with a significant increase in the widths of keratinized and attached gingiva (P = 0.0001); no change was observed in probing depths (P = 0.36).

CONCLUSION

The PPG technique can be successfully used for the treatment of multiple gingival recession defects.