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Pohl S, Gluckman H. Management of hyperplastic tissue response following connective tissue grafting. J ESTHET RESTOR DENT 2024; 36:1228-1235. [PMID: 38563127 DOI: 10.1111/jerd.13232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/21/2024] [Accepted: 03/23/2024] [Indexed: 04/04/2024]
Abstract
OBJECTIVE While connective tissue graft shrinkage is a well-documented post-transplantation reaction, there is a literature gap concerning hyperplastic tissue response. Despite its infrequent occurrence, investigation is warranted due to its capacity to compromise esthetics, disrupt lip dynamics, and promote food retention. Moreover, efforts to mitigate hyperplastic tissue response often prove challenging, and there is a potential risk of exacerbating gingival tissue rebound. CLINICAL CONSIDERATIONS This report presents a potential solution to managing tissue overgrowth after connective tissue grafting in five clinical cases. The patients underwent corrective surgery involving internal excision of excessive tissue while preserving the overlying mucosa. The surgical approach was tailored to excise hyperplastic tissue with minimal trauma, aiming to optimize esthetic outcomes. Subsequent follow-up assessments spanning 1-5 years demonstrated stable results, with no indications of relapse or recurrence of tissue overgrowth. CONCLUSIONS Within the limitations of this case series, surgical internal excision holds promise as a viable treatment modality for addressing post-transplantation hyperplastic tissue response. CLINICAL SIGNIFICANCE This case series addresses the challenge of uncontrolled tissue overgrowth following connective tissue grafting, a concern for which previous attempts have proven unsuccessful. Internal in-toto excision emerges as a promising approach for effectively eliminating overgrown tissue, offering potential advancements in the clinical management of this complication.
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Affiliation(s)
- Snjezana Pohl
- Department of Oral Medicine and Periodontology, University of Rijeka, Private Clinic Rident, Rijeka, Croatia
| | - Howard Gluckman
- Department of Periodontics, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA
- Department of Oral Medicine and Periodontics, School of Dentistry, University of Western Cape, Cape Town, South Africa
- Dental School, University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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de Paula J, da Silva LAB, Wayar MAS, Campagnoli EB, Dos Santos FA. Epithelial cyst following subepithelial connective tissue graft: A case report. Clin Adv Periodontics 2024. [PMID: 38430209 DOI: 10.1002/cap.10284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/25/2024] [Accepted: 02/15/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Various surgical approaches have been employed to manage gingival recession, including subepithelial connective tissue grafting, which has yielded favorable outcomes. METHODS AND RESULTS We present the case of a 17-year-old patient who developed gingival recession on tooth #6 following an esthetic crown lengthening procedure. The recession was treated with a subepithelial connective tissue graft; however, this case details the occurrence of two epithelial cysts adjacent to the region subjected to the surgical procedure, 6 months after surgery. The treatment involved periodontal surgical intervention, during which the lesions were completely excised and the associated osseous defect was filled using an inorganic bovine bone matrix along with a collagen membrane. The healing progressed without any complications. Histopathological analysis revealed the presence of cystic lesions, which were characterized by a cystic cavity lined with stratified orthokeratinized epithelium with cuboidal cells in some areas surrounded by fibrous connective tissue. The patient's progress was monitored through tomography performed 6 months, 1 year, and 5 years post-procedure, all of which demonstrated the absence of any signs of lesion recurrence. CONCLUSION This case study emphasizes the effectiveness and predictability of subepithelial connective tissue grafting in the treatment of gingival recession. However, dental professionals should be cautious about the potential risk of gingival recession following esthetic crown lengthening procedures and recognize the potential complications associated with subepithelial connective tissue grafting, such as the observed development of epithelial cysts in this specific case. KEY POINTS Why is this case new information? We present a case of an epithelial cyst following a subepithelial connective tissue graft, which resulted in buccal cortical bone resorption. The treatment involved excisional biopsy and the use of an inorganic bovine bone matrix with a collagen membrane. What are the keys to the successful management of this case? Successful treatment included periodontal surgery, bone defect filling using an inorganic bovine bone matrix and a collagen membrane, and regular monitoring with CT scans at 6 months, 1 year, and 5 years post-surgery; all showed no recurrence. Success factors included careful surgery, appropriate biomaterial usage, and ongoing follow-up. What are the primary limitations to success in this case? The limitations involve potential complications from subepithelial connective tissue grafting such as cyst development. This report stresses the importance of meticulous patient selection and periodontal phenotype evaluation to minimize risks. Continuous follow-up is critical to detect recurrence and other issues.
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Affiliation(s)
- Julien de Paula
- Department of Dentistry, Universidade Estadual de Ponta Grossa, Ponta Grossa, Brazil
| | - Luise A B da Silva
- Department of Dentistry, Universidade Estadual de Ponta Grossa, Ponta Grossa, Brazil
| | - Mariane A S Wayar
- Department of Dentistry, Universidade Estadual de Ponta Grossa, Ponta Grossa, Brazil
| | - Eduardo B Campagnoli
- Department of Dentistry, Universidade Estadual de Ponta Grossa, Ponta Grossa, Brazil
| | - Fábio A Dos Santos
- Department of Dentistry, Universidade Estadual de Ponta Grossa, Ponta Grossa, Brazil
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Stefanini M, Marzadori M, Sangiorgi M, Rendon A, Testori T, Zucchelli G. Complications and treatment errors in peri-implant soft tissue management. Periodontol 2000 2023; 92:263-277. [PMID: 36594486 DOI: 10.1111/prd.12470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 06/24/2022] [Accepted: 07/26/2022] [Indexed: 01/04/2023]
Abstract
Inadequate quality, quantity, or aesthetics of the peri-implant soft tissues can result from a combination of factors related to the outcome of treatments performed before, during, or after implant placement. In this paper, we describe in detail the treatment errors that can pave the way for the onset of mucositis or give rise to soft tissue complications such as peri-implant soft tissue discoloration or dehiscence, graft exposure, or scar formation. By tracing the error back to the planning or surgical stage, clinical insights on surgical soft tissue management are provided to avoid or treat complications that affect the status of the peri-implant soft tissues. Mastering the learning curve and knowing the limitations of each technique are fundamental for preventing added treatment failures that can result in increased patient morbidity and overall discontent.
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Affiliation(s)
- Martina Stefanini
- Department of Biomedical and Neuromotor Sciences, Bologna University, Bologna, Italy
| | - Matteo Marzadori
- Department of Biomedical and Neuromotor Sciences, Bologna University, Bologna, Italy
| | - Matteo Sangiorgi
- Department of Biomedical and Neuromotor Sciences, Bologna University, Bologna, Italy
| | - Alexandra Rendon
- Department of Biomedical and Neuromotor Sciences, Bologna University, Bologna, Italy
| | - Tiziano Testori
- Section of Implant Dentistry and Oral Rehabilitation, IRCCS Orthopedic Institute Galeazzi, Dental Clinic, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Milan, Italy
- Department of Periodontics and Oral Medicine, University of Michigan, School of Dentistry, Ann Arbor, Michigan, USA
| | - Giovanni Zucchelli
- Department of Biomedical and Neuromotor Sciences, Bologna University, Bologna, Italy
- Department of Periodontics and Oral Medicine, University of Michigan, School of Dentistry, Ann Arbor, Michigan, USA
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Couso-Queiruga E, Gonzalez-Martin O, Stuhr S, Gamborena I, Chambrone L, Avila-Ortiz G. Comparative histological evaluation of intra- and extraorally de-epithelialized connective tissue graft samples harvested from the posterior palate region. J Periodontol 2022; 94:652-660. [PMID: 36582071 DOI: 10.1002/jper.22-0493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/20/2022] [Accepted: 12/25/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Autologous connective tissue graft (CTG) is generally considered the gold standard for peri-implant soft tissue phenotype modification and root coverage therapy. The presence of epithelial remnants in CTG has been associated with complications after soft tissue augmentation surgery. However, a specific method for de-epithelization that is patently superior has not been identified yet. This study aimed to evaluate the effectiveness of two different approaches to de-epithelialize CTG samples harvested from the posterior palate. METHODS Patients in need of periodontal or implant-related surgery that required harvesting a CTG from the posterior palate region were recruited. CTG samples harvested with an indirect approach were de-epithelialized using either an intraoral (IO group) or an extraoral (EO group) method. Tissue specimens were subsequently processed for histological analysis. The presence or absence of oral epithelial remnants was determined by two examiners using light microscopy. RESULTS Twenty-four patients, who provided a total of 46 analyzable CTG samples, were enrolled in this study. Histological assessment revealed that 19 out of 22 samples in the IO group were free of epithelial remnants. In the EO group, 20 out of 24 samples did not exhibit epithelial residues. These results translate into 86.4% and 83.3% of epithelium-free samples in the IO and EO groups, respectively. CONCLUSIONS Although the intraoral method may provide several practical advantages compared with the extraoral technique, both approaches for de-epithelialization of CTG samples harvested from the posterior palate region tested in this study were comparably effective. However, none of these methods ensured complete removal of the oral epithelium in a predictable manner, which should be considered in clinical practice.
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Affiliation(s)
- Emilio Couso-Queiruga
- Department of Oral Surgery and Stomatology, University of Bern School of Dental Medicine, Bern, Switzerland.,Formerly, Department of Periodontics, University of Iowa College of Dentistry, Iowa City, Iowa, USA
| | - Oscar Gonzalez-Martin
- Private Practice, Atelier Dental Madrid, Madrid, Spain.,Harvard School of Dental Medicine, Boston, Massachusetts, USA.,Department of Periodontology, Complutense University of Madrid, Madrid, Spain
| | - Sandra Stuhr
- Formerly, Department of Periodontics, University of Iowa College of Dentistry, Iowa City, Iowa, USA.,Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, Ann Arbor, Michigan, USA
| | - Iñaki Gamborena
- Private Practice, San Sebastian, Spain.,Department of Preventive and Restorative Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA.,Department of Restorative Dentistry, University of Washington School of Dentistry, Seattle, Washington, USA
| | - Leandro Chambrone
- Evidence-Based Hub, Interdisciplinary Research Center Egas Moniz (CiiEM), Egas Moniz-Cooperative of Higher Education, CRL, Monte de Caparica, Portugal.,Unit of Basic Oral Investigations (UIBO), School of Dentistry, Universidad El Bosque, Bogotá, Colombia
| | - Gustavo Avila-Ortiz
- Department of Oral Surgery and Stomatology, University of Bern School of Dental Medicine, Bern, Switzerland.,Formerly, Department of Periodontics, University of Iowa College of Dentistry, Iowa City, Iowa, USA.,Private Practice, Atelier Dental Madrid, Madrid, Spain
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Unusual complications at the recipient site following periodontal plastic surgery procedures: a systematic review. Clin Oral Investig 2022; 26:5595-5609. [PMID: 35809115 DOI: 10.1007/s00784-022-04596-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 06/20/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To identify and describe unusual soft tissue complications of periodontal plastic surgery procedures at the recipient site after periodontal grafts. MATERIALS AND METHODS Two independent reviewers performed a comprehensive search in MEDLINE, Cochrane, periodontics journals, reference lists, and grey literature for articles dated up to July 2021. Publications related to surgical interventions only around the teeth with an unusual complication at the recipient site were selected. No restrictions were made in the number of cases, follow-up period, or language. The Cochrane Collaboration's tool for assessing risk of bias, the Newcastle-Ottawa Scale (NOS), and two validated case report/series checklists were used to critically appraise the studies. RESULTS A total of 1434 articles were examined, of which 28 met the inclusion criteria: one RCT, two cohort studies, and twenty-five case reports/series. The periodontal plastic surgery procedures described in these articles were conducted to treat lack of attached gingiva and gingival recessions. The following unusual complications were found: bone exostosis, epithelial inclusion, root resorption, abscess, overgrowth, "liver clot" formation, and oroantral communication. CONCLUSION Bone exostosis and epithelial inclusions were the most prevalent unusual complications following treatment with subepithelial connective tissue graft, free gingival graft, and acellular dermal matrix allograft. Due to the nature of the reports, the clinical recommendations for diagnosis and treatment cannot be homogenized. Clinical studies reporting complications are required to develop management protocols (PROSPERO CRD42021230875). CLINICAL RELEVANCE Clinicians need to know the main complications that can occur in mucogingival surgeries as well as their clinical management to provide a successful and predictable treatment.
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