Periodontal plastic surgery

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.

Double vertical interrupted suture for optimal adaptation and stabilization of free gingival graft around dental implants: a case report

BACKGROUND

Free gingival graft is commonly used to augment the keratinized mucosa and vestibular depth around dental implants. The proper suturing technique is fundamental to achieve a successful result following free gingival graft. However, there are limited studies that focus on the details of the suturing methods to optimize graft adaptation. The purpose of this technical note is to describe a new suturing technique for optimal approximation and stabilization of free gingival graft around dental implants.

CASE PRESENTATION

Here, we present a 53-year-old Persian female with peri-implantitis and lack of keratinized mucosa around mandibular implants who was a candidate for free gingival graft. A new suturing technique, double vertical interrupted suture, was conducted in the interimplant areas. In addition, the suspensory cross-mattress sutures were added to ensure the adaptation of the graft over the implants. The proposed suturing technique is useful for soft tissue augmentation around multiple implants with concave or uneven recipient bed.

CONCLUSION

The present article describes a novel suturing technique for good adaptation and fixation of free gingival graft around dental implants.

The mucosal released-coronally advanced flap: A novel surgical approach-A case report

BACKGROUND

The coronally advanced flap (CAF) can be a predictable surgical technique for the treatment of gingival recessions. However, the characteristics of the defect (e.g., limited amount of keratinized gingiva or flap tension, etc.) may limit the use of the CAF with a possible requirement of additional surgical interventions (i.e., the use of a tissue graft to be harvested from donor sites or connective tissue substitutes).

METHODS

A 28-year-old woman patient, with no history of periodontal disease, came for referral presenting receding gums as a chief complaint, poor esthetics, and dentinal hypersensitivity at the buccal surface of teeth 11, 12, and 13. Clinically, she presented a thick phenotype with gingival recession type, RT1, with detectable cemento-enamel junction (A‒) in the second quadrant. To reduce the need of harvesting soft tissue grafts, the amount of cutting of muscles and vessels from the inner portion of the flap and mitigate the postoperative discomfort associated with the CAF, a novel surgical approach is described here using an advanced flap that incorporates an external incision along the mucogingival junction.

RESULTS

The average root coverage achieved with the novel procedure presented in this case report was 95%, along with an increased amount of keratinized gingiva and minimal postoperative patient's discomfort.

CONCLUSIONS

The mucosal released CAF is a promising technique in which the CAF technique alone may not be an indication.

KEY POINTS

This technique has the following advantages: Reduce the need of harvesting soft tissue grafts. Reduce the amount of cutting of muscles and vessels from the inner portion of the flap. Minimal postoperative discomfort for the patient.

Levels of smoking and outcome measures of root coverage procedures: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis was performed to investigate if there was a significant association between the number of cigarettes smoked per day and the results of root coverage procedures.

METHODS

Electronic search was performed through PubMed, Web of Science, Embase, and Scopus until January 2023. Studies were included if evaluated the outcomes of periodontal plastic surgery procedures for the treatment of gingival recession in smokers. Statistical evaluation was conducted using random-effects method to analyze the odds ratio (OR) and mean difference (MD) with 95% confidence intervals (CI).

RESULTS

From a total of 4494 references, 15 studies were considered relevant to be included in this study. The results showed that 44.39% sites had complete root coverage (CRC) at 6 months (non-smokers: 54.06%, < 10 cigarettes/day: 48%, 10-20 cigarettes/day: 19.56%, ≥ 20 cigarettes/day: 50%). Mean root coverage at 6 months were as follows: non-smokers: 74.94% ± 16.71%, < 10 cigarettes/day: 84.20% ± 2.24%, 10-20 cigarettes/day: 75.30% ± 14.69%, ≥ 20 cigarettes/day: 68.75% ± 26.51%. A significant difference was revealed between non-smokers and individuals who smoked 10-20 cigarettes/day in terms of CRC at 6 months: OR = 0.15 (95% CI = 0.03 to 0.71; P = .017). However, no significant difference was detected comparing 10-20 and ≥ 20 cigarettes/day.

CONCLUSION

As there was not enough data available, any definitive conclusions about the connection between an increase in the amount of cigarettes consumed per day and the results of root coverage procedures could not be reached. Further research is required with comparative studies involving individuals who smoke varying numbers of cigarettes.

Tunnel technique and subepithelial connective tissue graft, with or without cross-linked hyaluronic acid, in the treatment of multiple gingival recessions: 12-month outcomes of a randomized clinical trial

BACKGROUND

This study evaluated the influence of the adjunctive application of a cross-linked hyaluronic acid (HA) in the treatment of multiple gingival recessions, using a modified coronally advanced tunnel (MCAT) technique and subepithelial connective tissue graft (SCTG) (MCAT+SCTG±HA).

METHODS

A randomized, split-mouth, double-masked comparison of the effects of MCAT+HA+SCTG (test) versus MCAT+SCTG (control) in the treatment of multiple, contralateral gingival recessions with clinical, esthetic, and histological evaluations was carried out. All samples were stained with hematoxylin and eosin, Masson's trichrome, Verhoeff-Van Gieson, and Alcian blue stain for semiquantitative evaluation. The primary outcome variable was 12-month mean root coverage (MRC).

RESULTS

Twenty-four patients with 266 gingival recessions received both control and test treatments (133 recessions per group). 12-month MRC of the MCAT+HA+SCTG group was not significantly different from the MCAT+SCTG group with 84.32%±  34.46% and 85.71%±  36.43%, respectively (p = 0.991). Both treatment modes produced favorable esthetic outcomes (root coverage esthetic score [RES] 9.51±  1.01 tests vs. 9.26±  1.10 controls, p = 0.7292). However, the application of HA improved soft tissue texture (p = 0.0091). The remaining end point measures did not differ significantly between groups. Histological evaluation showed a significantly greater number of elastic fibers and a moderate increase in collagen fiber density in biopsy samples taken from the test sides when compared to the control sides (p = 0.0419 and p = 0.300, respectively).

CONCLUSIONS

MCAT+SCTG is an effective procedure in the treatment of multiple recession Type 1 (RT1) and RT2 recessions. There were no statistically significant differences in evaluated clinical treatment outcomes in the MCAT+HA+SCTG group compared to the MCAT+SCTG group within a period of 12 months. The application of HA increased collagen and elastic fiber density.

Risk indicators for gingival recession in the esthetic zone: A cross-sectional clinical, tomographic, and ultrasonographic study

BACKGROUND

To evaluate the risk indicators associated with midfacial gingival recessions (GR) in the natural dentition esthetic regions.

METHODS

Cone-beam computed tomography (CBCT) results of thirty-seven subjects presenting with 268 eligible teeth were included in the cross-sectional study. Clinical measurements included presence/absence of midfacial GR; the depth of the midfacial, mesial, and distal gingival recession; the recession type (RT); keratinized tissue width (KT); and attached gingiva width (AG). Questionnaires were utilized to capture patient-reported esthetics and dental hypersensitivity for each study tooth. Buccal bone dehiscence (cBBD) and buccal bone thickness (cBBT) were measured on the CBCT scans. High-frequency ultrasonography was performed to assess gingival thickness (GT) and buccal bone dehiscence (uBBD). Intraoral optical scanning was obtained to quantify the buccolingual position of each study site (3D profile analysis). Multilevel logistic regression analyses with generalized estimation equations were performed to assess the factors associated with the conditions of interest.

RESULTS

The presence of midfacial GR was significantly associated with the history of periodontal treatment for pocket reduction (OR 7.99, p = 0.006), KT (OR 0.62, p < 0.001), cBBD (OR 2.30, p = 0.015), GT 1.5 mm from the gingival margin (OR 0.18, p = 0.04) and 3D profile 1 mm from the gingival margin (OR 1.04, p = 0.001). The depth of midfacial GR was significantly correlated to previous history of periodontal treatment (OR 0.96, p = 0.001), KT (OR -0.18, p < 0.001), presence of bone fenestration (OR 0.24, p = 0.044), and cBBD (OR 0.43, p < 0.001). The depth of midfacial GR was also the only factor associated with patient-reported esthetics (OR -3.38, p = 0.022), while KT (OR 0.77, p = 0.018) and AG (OR 0.82, p = 0.047) were significantly correlated with patient-reported dental hypersensitivity.

CONCLUSIONS

Several risk indicators of midfacial and interproximal GR in the esthetic region were identified. The use of imaging technologies allowed for detection of parameters associated with the conditions of interest, and, therefore, their incorporation in future clinical studies is advocated. Ultrasonography could be preferred over CBCT for a noninvasive assessment of periodontal phenotype.

Successful management of gingival recession with creeping attachment: A case report

Key Clinical Message

A successful management of a mandibular recession with creeping attachment using free gingival graft. This case highlights the "wait-and-see" approach in the treatment plan, emphasizing the root coverage.

Abstract

This clinical report describes the case of a 23-year-old female patient with gingival recession of the mandibular left central incisor. The patient's symptoms included hypersensitivity and cosmetic improvements. After thorough examination, the patient was diagnosed with plaque-induced gingivitis on a reduced periodontium with acquired mucogingival deformities. Gingival recession was classified as Miller class II or Cairo Recession Type 1. The treatment plan consisted of a nonsurgical phase, followed by a surgical phase using a free gingival graft. The surgical procedure involved harvesting the graft from the palatal mucosa and placing it in the recipient site. Post-operative care and instructions were provided and a comprehensive follow-up schedule was established. At the 12-month evaluation, the patient exhibited healthy periodontal conditions with creeping attachment and complete root coverage. The success of the treatment approach demonstrates its effectiveness in addressing hypersensitivity and cosmetic concerns, while improving periodontal health. Factors influencing the achievement of creeping attachment are discussed, including recession width, graft position, bone support, tooth position, patient hygiene, graft thickness, and root surface treatment.

Allogenic Acellular Dermal Matrix and Xenogeneic Dermal Matrix as Connective Tissue Graft Substitutes for Long-Term Stability Gingival Recession Therapy: A Systematic Review and Meta-Analysis

Connective tissue graft (CTG) serves as a gold standard for gingival recession therapy. Yet the availability of CTG is limited, and it increases patient morbidity. Allogenic acellular dermal matrix (AADM) and xenogeneic dermal matrix (XDM) have been proven to be effective substitutes of CTG although the long-term stability is unclear. The aim of this study was to analyze the long-term stability outcome of gingival recession therapy using AADM and XDM compared to CTG. This study follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted independently from several online databases (PubMed, Scopus, and Embase). Five of 233 publications were included for final qualitative analysis and meta-analysis focusing on the mean difference of clinical parameters such as recession depth (RD), recession width (RW), probing depth (PD), clinical attachment loss (CAL), tissue thickness (TT), keratinized tissue width (KTW), and mean root coverage (MRC). Meta-analyses of RD, RW, CAL, TT, KTW, and MRC display an overall mean of 0.2 mm (95% confidence interval [CI]: -0.45 to -0.05), 0.29 mm (95% CI: -0.65 to 0.08), 0.2 mm (95% CI: -0.69 to 0.29), 0.25 mm (95% CI: -0.53 to 0.03), 0.26 mm (95% CI: -0.5 to 0.02), and 9.19% (95% CI: -13.95 to -4.43]), respectively, favoring the CTG. PD was the only parameter that favored the AADM or XDM with an overall mean of 0.03 mm (95% CI: -0.05 to 0.11). In all, if the long-term stability is the goal, the CTG is considered superior for gingival recession therapy. However, if it is contraindicated, the AADM and XDM might be considered as alternatives.

Treatment of Gingival Recession and Root Coverage Outcomes Using Fascia Lata Allograft: A Case Report with Two Years of Follow-Up

Mucogingival surgery is a procedure for the treatment of gingival recession, which is a shift of marginal gingival tissue to the cementoenamel junction (CEJ), exposing the surface of the root teeth. One treatment for gingival recession is the Langer and Langer bilaminar technique, which involves the use of the fascia lata (FL) membrane. This membrane is harvested from the aponeurosis of the external muscles. The purpose of this case report was to present the clinical results of a 2-year follow-up using the Langer and Langer bilaminar technique modified with FL in a patient with gingival recession. Recessions are a shift of marginal gingival tissue to the CEJ, which exposes the surface of the root teeth. At the 2-year follow-up, the patient presented with a gingival recession in tooth 41, which resulted in complete root coverage, reaching 83.3%; the amount of keratinized tissue increased to 3 mm in each tooth, changing the gingival biotype from thin to thick and scalloped. This case report supports the use of FL as a successful alternative treatment.

Ibero-Panamerican Federation of Periodontology Delphi study on the trends of periodontology and periodontics by the year 2030. A Latin American consensus

BACKGROUND AND OBJECTIVE

As elsewhere in the world, the prevalence of periodontitis in stages I-II is high in the Latin American population, this scenario emphasizes the need for identification of urgent needs for allocating adequate resources to provide diagnosis, prevention, and treatment of these diseases. The aim of this Delphi study was to predict the trends in periodontology/periodontics in the Latin American region by the year 2030.

METHODS

A steering committee and an advisory group of experts in periodontology/periodontics were selected from 16 countries. An open questionnaire of 60 questions was validated and used following the Delphi methodology.

RESULTS

Two hundred and twenty-five experts from Latin America answered the two rounds of the questionnaire. Moderate to strong consensus was reached on 45 questions (75%). The prediction was that the prevalence of gingivitis and periodontitis in stages I and II will be maintained, the importance of the link with systemic diseases will increase, and the impact of prevention and periodontal treatment will also increase, mainly in the private sector. There was a strong consensus that plastic and regenerative surgical procedures will increase, as well as the demand for training in the specialty of periodontology.

CONCLUSIONS

The present study has provided relevant and useful information on predictions in periodontology/periodontics in Latin America, with important level of consensus among experts. It has been predicted that periodontitis will still be a highly prevalent disease, and its links with other medical conditions should demand more attention by health authorities to develop adequate prevention and management policies and strategies.

Treatment of Multiple RT1 Gingival Recessions Using a Coronally Advanced Flap Associated with L-PRF or Subgingival Connective Tissue Graft from Maxillary Tuberosity: A Randomized, Controlled Clinical Trial

The goal of plastic periodontal surgery is to obtain complete root coverage, increasing gingival thickness (GT), a positive prognostic factor for gingival margin stability over time. The aim of this study was to compare the effectiveness of the Coronally Advanced Flap (CAF) in RT1 (GR; gingival recession with no loss of interproximal attachment) when associated with a connective tissue graft from the maxillary tuberosity (tCTG) or with leukocyte and platelet-rich fibrin (L-PRF) membranes in obtaining root coverage and increasing the thickness and width of the keratinized tissue, along with aesthetic improvement, taking into account a number of patient-related outcomes. Thirty patients with two adjacent RT1 GRs (GRs with no loss of interproximal attachment) were each treated using CAF associated with tCTG (15 patients) or L-PRF. The main outcome was a GT increase; secondary outcomes were keratinized tissue width (KT), gingival recession (GR), probing depth (PD), clinical attachment level (CAL), root coverage percentage (RC%), complete root coverage (CRC), and root coverage esthetic score (RES). Patient-reported outcomes were discomfort (D), dentine hypersensitivity (DH), patient-related esthetic score (PRES), and overall treatment satisfaction (OTS). After 12 months, clinical and patient-reported parameters did not show significant differences between groups, with the only exception being a GT gain, which was significantly greater in the CAF + tCTG group. Our results showed that both techniques were effective in treating RT1 GRs, with comparable patient-related outcomes. However, the use of tCTG produces significantly thicker tissue, covering the exposed root surface.

Enhancing root coverage and esthetic outcomes in isolated gingival recession using orthodontic intervention and lateral closed tunnel technique: An interdisciplinary prospective case series

BACKGROUND

Gingival recession (GR) in malposed tooth in association with bone dehiscence and/or fenestration poses a challenge for successful root coverage treatment. Lateral closed tunnel (LCT) technique is particularly useful in isolated GR in mandibular anterior region, where the shallow vestibular depth prevents tension-free coronal mobilization of tissues.

METHODS

Twenty patients with GR associated with tooth malposition were treated using a combined orthodontic-periodontic approach with a torquing auxiliary spring followed by LCT technique.

RESULTS

The two techniques resulted in a combined recession depth reduction from 3.75 ± 1.14 mm to 0.40 ± 0.50 mm at the end of 6-month study period. The orthodontic intervention led to an increase in labial marginal bone levels, as assessed through cone beam computed tomography (CBCT), while the LCT achieved closure of residual recession defect. Also, an increase of keratinized tissue width from 0.81 ± 0.88 mm at baseline to 3.30 ± 0.67 mm at 6 months was achieved. Mean root coverage percentage (MRC%) of 91.40% + 10.25% was seen, with 11 out of 20 sites (55%) showing complete root coverage (CRC).

CONCLUSIONS

Single tooth orthodontic repositioning followed by LCT technique proved effective in successfully managing isolated recession defects in the mandibular anterior gingival region, which often presents challenging mucogingival conditions. The precise single tooth repositioning resulted in labial marginal bone augmentation, while the LCT surgical approach allowed residual defect closure.

KEY FINDINGS

Why are these cases new information? Correction of single tooth malposition is achieved before recession coverage treatment to achieve a favorable environment for graft uptake. The reduction in denuded root surface along with the bone remodeling results in increasing the ratio of vascular to avascular region, thus improving the overall prognosis of the treatment. What are the keys to successful management of these cases? The lateral closed tunnel technique involves creating a mucoperiosteal tunnel to close the recession site. Precision is crucial to avoid damage to surrounding tissues. The recipient site should be wider than the width of recession to improve graft vascularity. What are the primary limitations to success in these cases? Limitations may arise when dealing with complex cases, such as multiple teeth involvement or teeth with significant vertical or horizontal bone loss.

Modified coronally advanced flap technique in the treatment of fibrous epulis: A case report with 1-year follow-up

BACKGROUND

Currently, the treatment of epulis is primarily surgical excision, which would greatly affect the aesthetics of patients if happened in the anterior region. It's challenging for clinicians to balance the aesthetic after surgery and less surgical trauma. To overcome this disadvantage, the authors propose the modified coronally advanced flap technique which applies the principles of minimally invasive surgery to provide satisfactory therapeutic results in fibrous epulis.

METHODS

We report a case of an 18-year-old female with the chief complaint of a gingival swelling in the right upper anterior region. After the initial periodontal therapy, the modified surgical approach was applied to this patient. Unlike conventional coronally advanced flap technique, an additional incision was made, and the free portion was rotated into the adjacent space to completely cover the trauma, which avoided the use of the second operative zone.

RESULTS

The gingiva recovered with normal color, contour, and consistency after surgery, the papilla filled up the proximal space well and was in good harmony with the adjacent papillae. The surgical results remained stable during the follow-up period.

CONCLUSIONS

The use of modified coronally advanced flap technique allows the clinician to successfully resume the natural appearance of gingiva in the treatment of fibrous epulis, as well as simplify the surgical approach, shorten the operative time, and demonstrate no tendency of recurrence.

KEY POINTS

Why is this case new information? This novel technique not only removes the epulis, but also takes into account the postoperative aesthetics of the surgery at the same time. This minimally invasive surgical technique reduces operative time and increases patient comfort. Keys to successful management of this case are as follows: (i) Adequate preoperative assessment of the location of the additional incision; (ii) tension-free coronal flap advancement. What are the primary limitations to success in this case? Clinical studies with long-term outcomes of this approach are needed. This procedure may be limited to larger gingival tumors.

Novel biomaterial advanced platelet-rich fibrin plus block for multiple gingival recession

BACKGROUND

The study was aimed to assess and compare hard and soft tissue augmentation clinicoradiographically with and without advanced platelet-rich fibrin + (A-PRF+) block for the treatment of multiple gingival recession using vestibular incision subperiosteal tunnel access (VISTA).

METHODS

A total of 24 patients, exhibiting multiple Miller's Class I or II recessions in the maxillary esthetic zone were included. Participants were divided into two groups, Group 1 was treated with VISTA & A-PRF+ block whereas Group 2 was with VISTA technique alone. Clinical parameters probing depth, width of keratinized gingiva, gingival biotype, recession depth, and clinical attachment level were recorded at baseline and the end of 6 months. The radiographic cone beam computed tomography measurements of labial plate thickness were taken at baseline and 6 months postoperatively.

RESULTS

From baseline to 6 months both the groups showed a clinical and statistical improvement in the parameters. However, a statistically significant difference between the treatment modalities was not observed. In the inter-group comparison radiographically, labial plate thickness was statistically significant at the end of 6 months when compared to the baseline.

CONCLUSION

A-PRF+ block along with the VISTA technique can be an alternative effective root coverage procedure for the management of multiple gingival recessions in the maxillary esthetic zone.

KEY POINTS

Why is this study new information? To the best of our knowledge, this is the first study using advanced platelet-rich fibrin plus block for the treatment of multiple gingival recession with a thin labial plate. What are the keys to the successful management of these types of cases? Minimally invasive vestibular incision subperiosteal tunnel access technique, and avoidance of second surgical site morbidity are important factors for treatment and for patient compliance. What are the primary limitations of this study? Short study duration, small sample size, and no histological correlation can be considered as limitations of the study.

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.

Esthetic Management of Multiple Gingival Recession - A Case Report and Review of Literature

The importance of esthetics is increasing for the patients as well as for the dentist. With a high incidence that rises with age and a complicated soft-tissue pathology caused by a wide variety of factors, gingival recessions are a common but troublesome dental problem. They are characterized by the exposure of the root surface of the teeth due to the apical migration of the gingival border beyond the cemento-enamel junction, and they cause both functional and cosmetic disruptions. Many different surgical approaches have been offered over the years to address gingival recession, all with the goal of providing enough root coverage and achieving aesthetically pleasing results. No matter the amount of defects, Zucchelli's method is beneficial in terms of root coverage and keratinized tissue gain when treating many neighboring recessions. In this case study, Zucchelli's coronally advanced flap is used to treat numerous neighboring gingival recessions.

The effect of smoking on clinical and biochemical early healing outcomes of coronally advanced flap with connective tissue graft: Prospective cohort study

BACKGROUND

This study aimed to determine the effects of smoking on early (≤3 months) clinical outcomes and relevant molecular biomarkers following root coverage surgery.

METHODS

Eighteen smokers and 18 nonsmokers, status biochemically verified, with RT1 gingival recession defects were recruited and completed study procedures. All patients received coronally advanced flap plus connective tissue graft. Baseline and 3 month recession depth (RD), recession width (RW), keratinized tissue width (KTW), clinical attachment level (CAL), and gingival phenotype (GP) were recorded. Root coverage (RC) percentage and complete root coverage (CRC) were calculated. Recipient (gingival crevicular fluid) and donor (wound fluid) site VEGF-A, HIF-1α, 8-OHdG, and ANG levels were determined.

RESULTS

There were no significant intergroup differences for any baseline or postoperative clinical parameters (P > 0.05), except for whole mouth gingival index (increased in nonsmokers at 3 months; P < 0.05). Compared to baseline, RD, RW, CAL, KTW, and GP significantly improved postoperatively, without significant intergroup differences. There were no significant intergroup differences for RC (smokers = 83%, nonsmokers = 91%, P = 0.069), CRC (smokers = 50%, nonsmokers = 72%, P = 0.177), and CAL gain (P = 0.193). The four biomarker levels significantly increased postoperatively (day 7; P ≤ 0.042) in both groups and returned to baseline (day 28) without significant intergroup differences (P > 0.05). Similarly, donor site parameters were not different between groups. Strong correlations, consistent over time, were found between biomarkers implicated in angiogenesis (VEGF-A, HIF-1α, and ANG).

CONCLUSIONS

The early (3 month) clinical and molecular changes after root coverage surgery utilizing a coronally advanced flap plus connective tissue graft are similar between smokers and nonsmokers.

In Vitro Investigation of Gelatin/Polycaprolactone Nanofibers in Modulating Human Gingival Mesenchymal Stromal Cells

The aesthetic constancy and functional stability of periodontium largely depend on the presence of healthy mucogingival tissue. Soft tissue management is crucial to the success of periodontal surgery. Recently, synthetic substitute materials have been proposed to be used for soft tissue augmentation, but the tissue compatibility of these materials needs to be further investigated. This study aims to assess the in vitro responses of human gingival mesenchymal stromal cells (hG-MSCs) cultured on a Gelatin/Polycaprolactone prototype (GPP) and volume-stable collagen matrix (VSCM). hG-MSCs were cultured onto the GPP, VSCM, or plastic for 3, 7, and 14 days. The proliferation and/or viability were measured by cell counting kit-8 assay and resazurin-based toxicity assay. Cell morphology and adhesion were evaluated by microscopy. The gene expression of collagen type I, alpha1 (COL1A1), α-smooth muscle actin (α-SMA), fibroblast growth factor (FGF-2), vascular endothelial growth factor A (VEGF-A), transforming growth factor beta-1 (TGF-β1), focal adhesion kinase (FAK), integrin beta-1 (ITG-β1), and interleukin 8 (IL-8) was investigated by RT-qPCR. The levels of VEGF-A, TGF-β1, and IL-8 proteins in conditioned media were tested by ELISA. GPP improved both cell proliferation and viability compared to VSCM. The cells grown on GPP exhibited a distinct morphology and attachment performance. COL1A1, α-SMA, VEGF-A, FGF-2, and FAK were positively modulated in hG-MSCs on GPP at different investigation times. GPP increased the gene expression of TGF-β1 but had no effect on protein production. The level of ITG-β1 had no significant changes in cells seeded on GPP at 7 days. At 3 days, notable differences in VEGF-A, TGF-β1, and α-SMA expression levels were observed between cells seeded on GPP and those on VSCM. Meanwhile, GPP showed higher COL1A1 expression compared to VSCM after 14 days, whereas VSCM demonstrated a more significant upregulation in the production of IL-8. Taken together, our data suggest that GPP electrospun nanofibers have great potential as substitutes for soft tissue regeneration in successful periodontal surgery.

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.

Long-term evaluation of combined prosthetic-surgical approach and soft tissue augmentation in the esthetic zone

Background

There is no standard protocol for immediate implant placement and subsequent loading in the smile zone. We aimed to evaluate the long-term outcomes of simultaneous implant placement, soft tissue grafting, and immediate prosthetic loading in the esthetic zone.

Methods

Thirty-five implants were placed in the maxillary aesthetic zone. Twenty-two patients were evaluated using the Pink Esthetic Score (PES) and White Esthetic Score (WES). Also, the degree of peri-implant bone resorption and patient survey were applied for the esthetic and functional outcomes.

Results

The esthetic and harmonizing outcomes were achieved according to the mean total PES/WES value (17.9±2.0). The mean overall PES was 8.5±1.66. The papilla level had the highest mean score (1.8±0.36). Furthermore, the combination of root convexity/color and soft tissue color and texture was one of the key values in evaluating the effectiveness of this method (the mean value was 1.5±0.5). The mesial and distal papillae were 1.6±0.5 and 1.8±0.4, respectively. None of the 35 implants reached below 6 points (which is considered an esthetically unsatisfactory result). The mean WES score was 9.5±0.57. The average degree of total peri-implant bone resorption was 1.05±0.3 mm after 12 months. According to the questionnaire, all the patients smiled without hesitation and were satisfied with the treatment (100%).

Conclusion

This study showed that restoring one or more teeth in the smile zone using the concept of one-stage implant placement, soft tissue flap augmentation, and loading with provisional crowns was an esthetically successful and predictable method.

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.

Two Cases Demonstrating the Role of Creeping Attachment in the Treatment of Keratinized Gingival Deficiency With Free Gingival Graft: A 12-Month Follow-Up

After free gingival graft procedure, partial or complete coverage of exposed root surfaces due to coronal migration of the gingival margin is called "creeping attachment." This case report aimed to evaluate the results of the free gingival graft procedure performed on two patients with keratinized gingival deficiency in the mandibular anterior region and to present the creeping attachment formation process with a 12-month follow-up in light of current literature. Free gingival graft treatment was applied after the initial periodontal treatments were completed for two patients who visited the periodontology clinic complaining of gingival recession. Although the postoperative recovery was completed without any problems, it was observed that there were still root exposures in the relevant areas. Patient motivation was provided by giving oral hygiene training to the patients. After the 12-month follow-up, it was reported that denuded root surfaces were completely covered with creeping attachment formation. Complete coverage of denuded root surfaces is possible through the formation of creeping attachment, with the help of oral care and follow-up procedures, without requiring repeated surgical procedures. So, after relevant procedures, dentists must provide patients with sufficient information and awareness on this issue.

Post-extraction volumetric analysis of alveolar ridge contour using subepithelial connective tissue graft in esthetic zone: a randomized controlled clinical trial

OBJECTIVES

The aim of this randomized clinical trial was to assess the alveolar ridge contour after soft tissue augmentation using subepithelial connective tissue graft (SCTG) buccal to fresh extraction sockets in patients with thin buccal bone, versus minimally-traumatic extraction followed by spontaneous healing solely.

MATERIALS AND METHODS

Forty non-restorable maxillary teeth in the esthetic zone were randomly assigned into two groups: minimally-traumatic extraction with SCTG (test) and minimally-traumatic extraction followed by spontaneous healing (control). The outcomes assessed included linear volumetric change of buccal soft tissue contour, vertical tissue loss, gingival thickness (GT), and interdental papilla (IDP) height after 6 months.

RESULTS

The SCTG group showed a significant improvement (P < 0.001) in all outcomes after 6 months. The SCTG group showed a statistically significant (P < 0.001) gain in the buccal soft tissue volumetric change compared to the control group. The SCTG group showed a statistically significant increase in GT (P < 0.001) and IDP height (P < 0.05) after 6 months compared to the control group.

CONCLUSIONS

The use of SCTG buccal to extraction sockets in the anterior maxilla might be considered as a predictable approach for preserving the alveolar ridge contour.

CLINICAL RELEVANCE

SCTG buccal to extraction sockets might counteract post-extraction hard and soft tissue alterations in the esthetic zone.

Three-dimensional mapping of the greater palatine artery location and physiology

OBJECTIVE

To develop a novel technique for localizing and reconstructing the greater palatine artery (GPA) using three-dimensional (3D) technology.

METHODS

A miniaturized intraoral ultrasound transducer was used to imaging landmarks including the GPA, gingival margin (GM), and palatal masticatory mucosa (PMM). A 5-mm-thick solid hydrogel couplant was integrated to replace traditional ultrasound gel and avoid bubbles when moving the transducer.

RESULTS

A panorama image provided the relative localization of landmarks including the GPA, PMM, and hard palate. Short- and long-axis imaging of GPA was performed in five subjects including 3D mapping of GPA branches and surrounding tissues in a volume of 10 mm × 8 mm × 10 mm. Full-mouth Doppler imaging was also demonstrated on both the dorsal and ventral tongue as well as buccal mucosa and sublingual region on two subjects.

CONCLUSIONS

This study can measure the vertical distance from the GM to the GPA and depth from PMM to GPA and visualize the GPA localization in a 3D manner, which is critical to evaluate the available volume of palatal donor tissues and avoid sectioning of GPA during surgical harvesting of the tissues. Finally, the transducer's small size facilitates full-mouth Doppler imaging with the potential to improve the assessment, diagnosis, and management of oral mucosa.

Treatment of Advanced Gingival Recession Secondary to Surgical Failure with Large Size Deepithelized Gingival Graft Associated with a Modified Tunnel Flap

Objective

To describe the use of a large size deepithelized gingival graft (DGG) associated with full-split tunnel technique in a clinical case of advanced gingival recession secondary to surgical failure (GRSF). Clinical Considerations. The presented case report helped to achieve satisfactory root coverage, ideal keratinized tissue gain, improvement in soft tissue quality and esthetics, scar deformity correction, and vestibular depth deepening with a one-step procedure of large size DGG associated with full-split tunnel technique for a condition of deep gingival recessions of 7-11 mm caused by a failed bone implantation surgery.

Conclusions

The large size DGG associated with full-split tunnel technique provided a versatile one-step procedure to obtain ideal results for advanced GRSF. Clinical Significance. GRSF that is generally associated with inadequate keratinized tissue and scar formation could be rather difficult to deal with. The large size DGG associated with full-split tunnel technique, as a one-step procedure, provided a predictable and practical treatment modality.

A double lateral pedicle graft technique for palatal recession coverage on dental implants

Rough surfaces of dental implants, when exposed to the oral environment, are conducive to biofilm colonization and can predispose the affected implant to periimplantitis. Recession coverage using soft-tissue grafts is one of the treatment modalities used for the treatment of exposed implant threads. Recession coverage on the palatal aspect of maxillary implants is difficult due to the firm nature of the palatal mucosa and, consequently has not been widely documented in the literature. This case report documents a novel double-pedicle technique for palatal recession coverage on a dental implant. Two pedicle grafts were obtained from either side of the implant with the mucosal recession: a full-thickness lateral-pedicle graft from the distal aspect and a subepithelial connective tissue pedicle from the mesial aspect. The connective tissue pedicle was stabilized first on the area of mucosal recession and was then covered with the distal full-thickness lateral pedicle. Complete recession coverage was obtained, and the result was observed to be clinically stable after 18 months of follow-up. The technique demonstrated in this report can be a useful tool for the treatment of localized palatal recessions on dental implants.

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.

Complications and treatment errors in root coverage procedures

Root coverage procedures have become very common in clinical dental practice. Even though these techniques are considered safe, the clinician may face several issues during the therapy due to their surgical nature. Some of these issues can be defined strictly as complications inherent to the procedure, whereas others are medical errors or treatment errors. This review will focus on describing treatment errors and complications that may arise during different phases of the root coverage therapeutic process and on how to prevent and manage them.

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.

Estimation of vestibular depth: An observational cross-sectional study

Background

The vestibular depth (VD) varies to a great extent among individuals and at different points of reference. The normal range of depth of the vestibule at different areas in the mouth remains to be established.

Aim

The primary objective of this study is to assess the average VD around different teeth in the maxilla and the mandible. Furthermore, an attempt has been made to identify the various ranges of VD and understand what could be suggestive of a normal VD.

Materials and Methods

The participants included were divided into four age groups, i.e., 6-14 years (Group 1), 15-30 years (Group 2), 31-50 years (Group 3), and >50 years (Group 4). Further, the subjects were grouped into subgroup A, periodontally healthy and subgroup B, gingival recession (GR). Group 1, 2, and 3 included 30 subjects each in subgroup A, while Group 4 subgroup B had 18 subjects. In case of subgroup B, Group 2 included 9 subjects, Group 3-31 subjects, and Group 4-30 subjects. Measurements included the depth of vestibule from 2 reference point, i.e., gingival margin (GM) and incisal edge (IE).

Results

In subgroup A, the average VD from GM was found to be the least in the Group 1 i.e., 6-14 years (9.2 mm ± 4.26 in maxilla and 7.01 mm ± 3.14 in the mandible) and the highest in the Group 4 i.e., >50 years (12.06 mm ± 2.73 in maxilla and 10.08 mm ± 2.58 in the mandible). In the case of subgroup B, the least depth from GM was found in the Group 3 i.e., >30-50 years (9.44 mm ± 2.73 in the maxilla and 8.32 mm ± 1.7 in the mandible) and the maximum depth in the Group 4 (>50 years) (11.28 ± 2.31 in maxilla and 9.42 ± 2.87 in the mandible).

Conclusion

The study provides a range of VD s in different areas of the mouth in periodontally healthy and individuals with GR, which will contribute to constitute a normal range of VD.

Aesthetic evaluation of free gingival graft applied by partial de-epithelialization and free gingival graft applied by conventional method: a randomized controlled clinical study

OBJECTIVE

The aim of this clinical study was to compare the partially de-epithelialized free gingival grafts (d-FGGs) with the conventional free gingival grafts (FGGs) aesthetically using photographic analysis and Visual Analogue Scale (VAS).

MATERIALS AND METHODS

A total of 30 defects were treated in 15 patients with attached gingiva insufficiency. In the split-mouth study, d-FGGs were applied on one side (test group), while FGGs were applied on the contralateral side (control group). Results of clinical periodontal parameters were evaluated in 6-month follow-up, and aesthetic evaluation results were evaluated in 1-, 3-, and 6-month follow-ups.

RESULTS

Among the periodontal clinical parameters examined, only the keratinized tissue (KT) width was found to be statistically significantly higher in the test group compared to the control group. In the photo analysis evaluation, the ΔE value at the 3rd month was statistically significantly higher in the test group. In VAS evaluation, there was no significant difference between the two groups in the time periods examined.

CONCLUSION

Photo analysis is an objective, sensitive, reproducible, and safe method that can be used in dentistry and medicine by detecting the slightest changes and giving more detailed and superior results than visual evaluation. The d-FGG application could provide acceptable aesthetic results by providing an appearance compatible with the gingival contour and gingiva in the adjacent region in creating keratinized gingiva.

CLINICAL RELEVANCE

While the free gingival graft has color differences with the recipient area, the deep-thelialized gingival graft has a compatible appearance with the recipient area. Partially, de-epithelialized free gingival graft is a method with acceptable aesthetic results.

TRIAL REGISTRATION

U.S. National Institutes of Health Clinical Trials: NCT04970524.

Histological and histomorphometric study of human palatal mucosa: Implications for connective tissue graft harvesting

AIMS

To analyse the histological structure and histomorphometric characteristics of human hard palatal mucosa in order to determine the donor site of choice for connective tissue grafts from a histological point of view.

MATERIALS AND METHODS

Palatal mucosa samples from six cadaver heads were harvested at four sites: incisal, premolar, molar and tuberosity. Histological and immunohistochemical techniques were performed, as was histomorphometric analysis.

RESULTS

In the current study, we found that the density and size of cells were higher in the superficial papillary layer, whereas the thickness of the collagen bundles increased in the reticular layer. Excluding the epithelium, the mean percentage of lamina propria (LP) and submucosa (SM) was 37% and 63%, respectively (p < .001). LP thickness showed similar values in the incisal, premolar and molar regions, and a significantly greater thickness in tuberosity (p < .001). The thickness of SM increased from incisal to premolar and molar, disappearing in the tuberosity (p < .001).

CONCLUSIONS

As dense connective tissue of LP is the tissue of choice for connective tissue grafts, the best donor site from a histological point of view is tuberosity because it is composed only of a thick LP without the presence of a loose submucosal layer.

Comparison of chorion allograft and subepithelial connective tissue autograft in the treatment of gingival recession- A randomized controlled clinical trial

Background

To compare the clinical outcomes of subepithelial connective tissue graft and chorion membrane along with coronally advanced flap in the treatment of gingival recession.

Methods

A total of 12 patients with 24 sites showing isolated bilateral Miller's class I and II gingival recessions were randomly allocated into two treatment sites. One site, connective tissue graft, (n = 12 sites) while on the contra-lateral site, chorion membrane (n = 12 sites) was used with coronally advanced flap. Clinical parameters: probing depth, recession depth, recession width, width of keratinized gingiva, relative attachment level, thickness of keratinized gingiva were recorded at the baseline, 3 months, and 6 months. The amount of root coverage was evaluated after 6 months.

Results

Statistically significant differences were observed between test and control sites in terms of recession depth, recession width, width of keratinized gingiva and thickness of keratinized gingiva at 6 months. The test sites presented 66.17 ± 18.85% and the control site showed 87.17 ± 18.33% of root coverage at 6 months.

Conclusion

Very limited amount of recession coverage with chorion membrane and did not serve as an alternative to connective tissue graft.

Trial registration

CTRI/2017/12/010964.

Vertical soft tissue augmentation to treat implant esthetic complications: A prospective clinical and volumetric case series

INTRODUCTION

Challenging implant esthetic complications are often characterized by implant malpositioning and interproximal attachment loss of the adjacent teeth. However, limited evidence is available on the treatment of these conditions. The aim of this study was to evaluate the clinical, volumetric, and patient-reported outcome following treatment of peri-implant soft tissue dehiscences (PSTDs) exhibiting interproximal attachment loss on adjacent teeth, performed through vertical soft tissue augmentation with implant submersion.

METHODS

Ten subjects with isolated PSTD in the anterior maxilla characterized by adjacent dentition exhibiting interproximal attachment loss were consecutively enrolled and treated with horizontal and vertical soft tissue augmentation, involving crown and abutment removal, two connective tissue grafts, and submerge healing. Clinical outcomes of interest included mean PSTD coverage, mean PSTD reduction, clinical attachment level (CAL) gain at the implant and adjacent sites and soft tissue phenotype modifications at 1 year. Optical scanning was used for assessing volumetric changes. Professional assessment of esthetic outcomes was performed using the Implant Dehiscence coverage Esthetic Score (IDES), while patient-reported esthetic assessment involved a 0-10 visual analogue scale.

RESULTS

The mean PSTD depth reduction and mean PSTD coverage at 1 year were 2.25 mm, and 85.14%, respectively. A mean keratinized tissue width (KTW) gain of 1.15 mm was observed, while the mean gain in mucosal thickness (MT) was 1.58 mm. A mean CAL gain of 1.45 mm was obtained at the interproximal aspect of the adjacent dentition at 1 year. Greater linear dimensional (LD) changes were observed at the midfacial aspect of the implant compared to the interproximal sites. The mean final IDES was 6.90 points, while patient-reported esthetic evaluation was 8.83 points.

CONCLUSIONS

The present study demonstrated that vertical soft tissue augmentation with a submerged healing is an effective treatment approach for the treatment of challenging PSTDs with adjacent dentition exhibiting interproximal attachment loss. This technique can be effective in resolution of esthetic complications in most cases, providing a substantial gain in interproximal attachment levels at the adjacent dentition.

Tunnel technique with cross-linked hyaluronic acid in addition to subepithelial connective tissue graft, compared with connective tissue graft alone, for the treatment of multiple gingival recessions: 6-month outcomes of a randomized clinical trial

OBJECTIVES

The aim of this study was to investigate differences in clinical and esthetic outcomes in the treatment of multiple gingival recession types 1 and 2, using the modified coronally advanced tunnel technique (MCAT) combined with subepithelial connective tissue graft (SCTG), with or without cross-linked hyaluronic acid (HA).

MATERIALS AND METHODS

A total of 24 patients with 266 multiple gingival recessions (GR) were enrolled in the study (133 recessions per group). MCAT was combined with SCTG and HA on the test side, while MCAT with SCTG was used on the control side. Clinical parameters were measured at baseline and 6 months post-operatively. Visual analogue scales (VAS) and questionnaires were used to assess patient-rated outcomes, and the root coverage esthetic score (RES) was used for professional esthetic evaluation.

RESULTS

No significant improvement in root coverage was observed as a result of adding HA. After 6 months, mean root coverage (MRC) was 85% for SCTG + HA group and 83% for SCTG group (p = 0.9819). Complete root coverage (CRC) was observed in 91% (test) and 93% (control) of the cases (p = 0.9001). Professional assessment of soft tissue texture (STT) using RES showed a significant difference (0.94 versus 0.69, p = 0.0219) in favor of the experimental group.

CONCLUSIONS

Both treatments were similarly effective in treating multiple GRs and led to comparable improvements in clinical parameters. However, application of HA improved the appearance of soft tissue texture.

CLINICAL RELEVANCE

Adjunctive application of HA in the MCAT + SCTG procedure may improve STT results.

Difficulty score for the treatment of isolated gingival recessions with the coronally advanced flap: a preliminary reliability study

OBJECTIVES

The treatment of gingival recessions (GRs) is operator-sensitive and dependent upon several local anatomical factors. The aim of this study was to introduce a difficulty score for the treatment of localized GRs with the coronally advanced flap (CAF) and to test its consistency among different operators.

MATERIALS AND METHODS

A rubric (difficulty score) consisting of the assessment and grading of 8 anatomical parameters (anatomical papilla, apical and lateral keratinized tissue width, apical and lateral frenum, vestibulum depth, scar tissue, and mucosal invagination) is described based on the available evidence and the authors' experience. Inter-examiner agreement, with the score, was tested on 32 localized GRs among four different experienced practitioners.

RESULTS

Minor discrepancies were observed in the total scores between the reviewers (intraclass correlation coefficient [ICC] 0.95). A good reproducibility, with ICCs ranging from 0.56 to 0.98, was found for the individual parameters. All models showed high absolute variance contribution conveying true differences among the cases, and small examiner variance, demonstrating minor systematic variability among the four reviewers and reproducible evaluations.

CONCLUSIONS

The proposed difficulty score for the treatment of GRs with CAF was reproducible among different operators. Clinical interventional studies are the next step to validate the clinical magnitude of the present score.

CLINICAL RELEVANCE

A novel tool for evaluating the difficulty of the treatment of isolated gingival recession using CAF was described. Clinicians can benefit from this score when assessing the expected level of complexity of the surgical case.

Comparison of the clinical efficacy of concentrated growth factor and advanced platelet-rich fibrin in the treatment of type I multiple gingival recessions: a controlled randomized clinical trial

OBJECTIVES

The purpose of this randomized controlled clinical trial was to compare and evaluate the clinical effects of concentrated growth factor (CGF) and advanced platelet-rich fibrin (A-PRF) applied together with coronally advanced flap (CAF) technique using a microsurgical approach in the treatment of type I multiple gingival recessions (GR).

MATERIALS AND METHODS

Sixteen patients with multiple recession defects (Cairo type I) were included in this randomized and controlled study. Forty-five gingival recession defects were randomly equally divided into three groups (n = 15): CAF + CGF (test site); CAF + A-PRF (test site), and CAF alone (control site). Clinical attachment level (CAL), vertical gingival recession (VGR), horizontal gingival recession (HGR), gingival thickness (GT), width of keratinized gingiva (KGW), percentages of the mean (MRC), and complete root coverage (CRC), patient esthetic score (PES), and hypersensitivity score (HS) were recorded at baseline and 6 months after surgery. Patient comfort score (PCS) was evaluated at the day of surgery.

RESULTS

Significant improvements were determined in CAL, VGR, HGR, KGW, and GT at 6 months when compared to baseline levels in intra-group comparisons for all groups, and also GT was increased in CAF + A-PRF and CAF + CGF compared to CAF alone at 6 months in intergroup comparisons (p < 0.05). At 6 months, MRC was detected 85.66 ± 22.68% in the CAF + CGF, 90.88 ± 20.87% in the CAF + A-PRF, and 75.10 ± 32,37% in the CAF alone, and a significant increase was detected in the CAF + A-PRF group compared to CAF alone (p < 0.05). CRC in CAF + CGF was 66.66%, in CAF + A-PRF 80% and in CAF alone was 53.33% (p > 0.05). PES and HS values showed significant improvement from baseline to 6 months for all groups and also in CAF + CGF and CAF + A-PRF compared to CAF alone at 6 months in intergroup comparisons (p < 0.05).

CONCLUSIONS

The present study showed that the use of A-PRF and CGF membranes in GR therapy may have an additional benefit in GT increase and also A-PRF may increase the percentages of MRC. The use of A-PRF and CGF membranes may be beneficial in terms of improving patient-related parameters.

CLINICAL RELEVANCE

A-PRF and CGF may be superior to CAF alone in terms of patient-related parameters and GT increase in multiple recession defects.

TRIAL REGISTRATION NUMBER

17578e02-00a9-4a41-8c8d-42a637143531.

Building Confident Smiles Using Aesthetic Crown Lengthening Procedures with Gingivectomy: A Report of Two Cases

We live in a society that appreciates beauty. More than just restoring the teeth, naturally attractive, confident smiles mean restoring and increasing overall quality of life. Making efforts to improve one's physical appearance is now regarded as an investment in one's health and well-being. Superior periodontal health is the cornerstone for an individual's aesthetic regeneration. As an outcome, perio-aesthetics is a comprehensive strategy that improves the appearance of the smile while maintaining long-term dental health. Hence, getting the ideal aesthetic effect is both difficult and gratifying. Crown lengthening is a feasible option for improving aesthetic appearance or aiding restorative therapy. Yet, before planning a crown lengthening operation, the patient's overall periodontal status and cleanliness habits should be assessed. Furthermore, for enhanced, conservative, and predictable results in aesthetic areas, a precise diagnostic and interdisciplinary strategy is essential. This article attempts to discuss guidelines for treating individuals with excessive gingival display, as well as treatment options, using two case reports as examples.

Effect of partial restorative treatment on stress distributions in non-carious cervical lesions: a three-dimensional finite element analysis

BACKGROUND

Partial restoration combined with periodontal root coverage surgery can be applied to the treatment of non-carious cervical lesions (NCCLs) accompanied with gingival recessions in clinical practice. However, the feasibility of NCCL partial restorative treatment from a biomechanical perspective remains unclear. This study aimed to investigate the effect of partial restorations on stress distributions in the NCCLs of mandibular first premolars via three-dimensional finite element analysis.

METHODS

Three-dimensional finite element models of buccal wedge-shaped NCCLs in various locations of a defected zenith (0 mm, 1 mm, and 2 mm) were constructed and divided into three groups (A, B, and C). Three partially restored NCCL models with different locations of the lower restoration border (1 mm, 1.5 mm, and 2 mm), and one completely restored NCCL model were further constructed for each group. The following restorative materials were used in all restoration models: composite resin (CR), glass-ionomer cement (GIC), and mineral trioxide aggregate (MTA). The first principal stress distributions under buccal oblique loads of 100 N were analyzed. Restoration bond failures were also evaluated based on stress distributions at dentin-restoration interfaces.

RESULTS

When the partial restoration fully covered the defected zenith, the first principal stress around the zenith decreased and the maximum tensile stress was concentrated at the lower restoration border. When the partial restoration did not cover the defected zenith, the first principal stress distribution patterns were similar to those in unrestored models, with the maximum tensile stress remaining concentrated at the zenith. As the elastic modulus of the restorative material was altered, the stress distributions at the interface were not obviously changed. Restoration bond failures were not observed in CR, but occurred in GIC and MTA in most models.

CONCLUSIONS

Partial restorations that fully covered defected zeniths improved the stress distributions in NCCLs, while the stress distributions were unchanged or worsened under other circumstances. CR was the optimal material for partial restorations compared to GIC and MTA.

Use of Connective Tissue Graft and Coronally Advanced Flap in Areas of Buccal Contour Concavities for Nonsubmerged Implant Placement

There is a lack of scientific evidence concerning the best timing of soft tissue management around implants, as well as a divergence of topics concerning optimal procedures. The objective of this study is to evaluate the gain in buccal contour and soft tissue stability after a surgical technique combining nonsubmerged implant placement with submarginal connective tissue graft (CTG) and coronally advanced flap (CAF). Seven patients (4 males and 3 females) underwent surgery for transmucosal implant placement in partially edentulous areas showing mild to moderate buccal contour concavities using a technique combining CTG and CAF. The following parameters were evaluated: keratinized tissue height (KTH), soft tissue thickness (STT), and vertical soft tissue level (VSTL) at T0 (before surgery), T1 (6 months after surgery), T2 (12 months after surgery) and T3 (2 years after surgery). After two years, we observed an increase of 78.5% in buccal KTH, 64% in STT, and 24% in VSTL. No implant presented any sign of mucositis or bone loss. Non-submerged implant placement using an "envelope flap design" in addition to CTG and CAF is beneficial.

Simple versus cross-mattress sutures for nondisplaced flaps of the maxillary molar region: a randomized controlled trial

Background

The type of suture used in periodontal surgery can affect post-surgical complications. This study aimed to compare simple with cross-mattress sutures for nondisplaced flaps of the maxillary molar region.

Methods

This randomized controlled trial included 32 candidates of nondisplaced flap surgery of the maxillary molar region referred to the private office of a periodontist in Bandar Abbas, Iran from January 21 to May 4, 2020. First, the patients’ age, sex, and plaque index were recorded. Then, they were randomized into two equal groups. In the first group, the interdental suturing was done using simple sutures with 4–0 vicryl threads, and in the second group, interdental suturing was performed using cross-mattress sutures with the same threads. The primary outcome was suture time, including the duration of the first suture and the total duration of all sutures. The secondary outcomes were bleeding on probing and the requirement of supplementary sutures immediately after the surgery, as well as the gingival index (at suture removal and one month after surgery).

Results

The two groups were comparable regarding age, sex, and plaque index. The first suture duration was significantly longer in the simple group compared to the cross-mattress group (P < 0.001); however, the total suture time did not differ between groups. Moreover, a significantly higher number of patients in the simple group required supplementary sutures (50% vs. 6.3%, P = 0.006). There was no significant difference between groups regarding bleeding on probing and gingival index (at suture removal and one month after surgery).

Conclusions

Cross-mattress sutures were superior to simple sutures in terms of supplementary suture requirement for nondisplaced flaps of the maxillary molar region, while the two suturing techniques were alike regarding total suture time, gingival index, and probing on bleeding.

Trial registration

Iranian Registry of Clinical Trials (IRCT), IRCT20191224045882N1. Registered 08/02/2020. Registered while recruiting, https://www.irct.ir/trial/44754.

Hyaluronic Acid as an Adjunct to Coronally Advanced Flap Procedures for Gingival Recessions: A Systematic Review and Meta—Analysis of Randomized Clinical Trials

Previous systematic reviews have reported that coronally advanced flap (CAF) + connective tissue graft (CTG) are the gold standard in root coverage procedures (RCP). Nevertheless, adjunctive treatment with hyaluronic acid (HA) has been proposed to aim at improving clinical outcomes and reducing patient morbidity. The aim of this systematic review and meta-analysis is to compare the use of HA as an adjunctive treatment to CAF procedures in Miller class I and II (recession type 1; RT1) gingival recession (GR) defects treatment with no adjunctive/other treatments. MEDLINE, The Cochrane Central Register of Controlled Trials, Web of Science, Scopus databases and gray literature were searched up to April 2022. The primary outcome variables were mean recession coverage (MRC) and reduction of the recession depth (RecRed). Weighted mean differences and 95% confidence intervals between treatments were estimated using a random-effect mode. From 264 titles identified, 3 RCTs reporting 90 GR defects in 60 patients were included. Overall analysis of MRC and RecRed were 0.27% (p = 0.01) and 0.40 mm (p = 0.45) in favor of CAF + HA compared to CAF alone/CAF + subepithelial connective tissue graft (SCTG), respectively, with a statistically significant difference only for MRC values. Nevertheless, due to the limited number and heterogeneity of the included studies, well-performed RCTs are needed to clarify a potential advantage of HA in RCPs in the future.

Kuronale Kaydırılan Flep ve Bağ Doku Grefti ile Tedavi Edilen Dişeti Çekilmelerinin Retrospektif Analizi

Aim: The aim of this retrospective study was to evaluate the effectiveness of coronally advanced flap and connective tissue graft (CAF+CTG) in the treatment of gingival recessions (GR).Method: Periodontal records of 32 single and multiple GR in 11 patients treated with CAF+CTG were selected for the study. According to Cairo’s classification, recession type 1 defects were included. Recession depth (RD), probing depth (PD) and clinical attachment level (CAL) were assessed at baseline and follow-ups. Mean root coverage (MRC) and complete root coverage (CRC) were evaluated. Compliance with supportive periodontal therapy (SPT) was also determined.Results: Mean age of 11 patients was 29.6±4.4 years. The mean observation time of 32 recessions was 37.6±24.2 months. All clinical parameters showed an improvement between baseline and the latest follow-up. After treatment with CAF+CTG, MRC was 92.6±13.1% and CRC was achieved in 75% of the recessions. Compliance to SPT was calculated at 83.3%.Conclusion: The use of CAF+CTG yielded positive outcomes in terms of all clinical parameters and complete root coverage in Cairo recession type 1 defects with a mean observation period of &gt;3 years. The results of the present study confirm the use of CAF+CTG as a gold standard for the treatment of gingival recessions.

Treatment of multiple adjacent RT 1 gingival recessions with the modified coronally advanced tunnel (MCAT) technique and a collagen matrix or palatal connective tissue graft: 9-year results of a split-mouth randomized clinical trial

OBJECTIVES

To evaluate t he long-term outcomes following treatment of RT 1 multiple adjacent gingival recessions (MAGR) using the modified coronally advanced tunnel (MCAT) with either a collagen matrix CM or a connective tissue graft (CTG).

MATERIAL AND METHODS

Sixteen of the original 22 subjects included in a randomized, controlled split-mouth clinical trial were available for the 9-year follow-up (114 sites). Recessions were randomly treated by means of MCAT + CM (test) or MCAT + CTG (control). Complete root coverage (CRC), mean root coverage (MRC), gingival recession depth (GRD), probing pocket depth (PD), keratinized tissue width (KTW), and thickness (KGT) were compared with baseline values and with the 12-month results.

RESULTS

After 9 years, CRC was observed in 2 patients, one in each group. At 9 years, MRC was 23.0 ± 44.5% in the test and 39.7 ± 35.1% in the control group (p = 0.179). The MRC reduction compared to 12 months was - 50.1 ± 47.0% and - 48.3 ± 37.7%, respectively. The upper jaw obtained 31.92 ± 43.0% of MRC for the test and 51.1 ± 27.8% for the control group (p = 0.111) compared to the lower jaw with 8.3 ± 46.9% and 20.7 ± 40.3%. KTW and KGT increased for both CM and CTG together from 2.0 ± 0.7 to 3.1 ± 1.0 mm (< 0.0001). There were no statistically significant changes in PD.

CONCLUSION

The present results indicate that (a) treatment of MAGR using MCAT in conjunction with either CM or CTG is likely to show a relapse over a period of 9 years, and (b) the outcomes obtained in maxillary areas seem to be more stable compared to the mandibular ones.

CLINICAL RELEVANCE

The mean root coverage at 12 months could not be fully maintained over 9 years. On a long-term basis, the results seem to be less stable in the mandible as compared to maxillary areas.

Patient and professional use of the root coverage esthetic score (RES) and how it relates to patient satisfaction following periodontal plastic surgery

Background

Following periodontal plastic surgery in the treatment of recession defects, previous studies have reported that patients rate the esthetic outcomes more favorable than dental professionals. The root coverage esthetic score has been developed and suggested to serve as a comprehensive assessment instrument as it addresses several esthetic outcomes following root coverage procedures. However, no study has yet reported on patient use of this instrument. In the present study clinical, esthetic and patient-reported outcomes following periodontal plastic surgery were assessed. The primary objective was to compare the esthetic/clinical outcome as judged by the patient and by one dentist by using the root coverage esthetic score. The secondary objective was to evaluate the correlation between patient-reported outcomes, root coverage esthetic score and clinical parameters following treatment of recession defects.

Materials and methods

Subjects that had undergone periodontal plastic surgery were invited to score the treatment outcome according to the root coverage esthetic score, which subsequently also was professionally scored by a dentist. Thereafter, the subjects answered a questionnaire on patient satisfaction. All types of surgical root coverage procedures in canine or incisor teeth were included.

Results

A total of 34 subjects were included, presenting 46 treated recessions. No statistically significant different score was found comparing the root coverage esthetic score by the patient and the professional. The majority of subjects was satisfied with the treatment outcome, and most would have undergone the treatment again.

Conclusion

The root coverage esthetic score assessment can be conducted by patients and was not statistically significant different to that of the professional. Patient satisfaction is not always dependent on complete root coverage or the other clinical parameters included in the root coverage esthetic score.

Unusual complications at the recipient site following periodontal plastic surgery procedures: a systematic review

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.

Soft tissue phenotype modification predicts gingival margin long-term (10-year) stability: Longitudinal analysis of six randomized clinical trials

Aim

To assess the prognostic value of soft tissue phenotype modification following root coverage procedures for predicting the long‐term (10‐year) behaviour of the gingival margin.

Materials and Methods

Participants from six randomized clinical trials on root coverage procedures at the University of Michigan were re‐invited for a longitudinal evaluation. Clinical measurements were obtained by two calibrated examiners. A data‐driven approach to model selection with Akaike information criterion (AIC) was carried out via multilevel regression analyses and partial regression plotting for changes in the level of the gingival margin over time and interactions with the early (6‐month) results of soft tissue phenotypic modification.

Results

One‐hundred and fifty‐seven treated sites in 83 patients were re‐assessed at the long‐term recall. AIC‐driven model selection and regression analyses demonstrated that 6‐month keratinized tissue width (KTW) and gingival thickness (GT) influenced the trajectory of the gingival margin similarly in a concave manner; however, GT was the driving determinant that predicted significantly less relapse in the treatments, with stability of the treated gingival margin obtained beyond values of 1.46 mm.

Conclusions

Among a compliant patient cohort, irrespective of the rendered therapy, the presence of at least 1.5 mm KTW and 1.46 mm GT was correlated with the long‐term stability of the gingival margin.

A 3D Digital Analysis of the Hard Palate Wound Healing after Free Gingival Graft Harvest: A Pilot Study in the Short Term

Purpose: Within this context, this pilot study aimed to evaluate the healing dynamics process of the hard palate after free gingival graft harvesting in the short term (3 months), utilizing digital imaging technology and tridimensional analysis software. Furthermore, assessing the results found to verify the existence of a relationship between gender or age with tissue loss. Materials and Methods: For connective-tissue harvesting, fifteen patients with gingival recessions type (RT) 1 and RT2 were selected. On the surgery day (before the procedure) and after three months, palatal impressions were taken in all patients, and cast models were done for posterior model scanning. The following variables were analyzed: mean thickness alterations (x¯ TA), maximum thickness loss (MTL), mean maximum thickness loss (x¯ MTL), and volume alterations (VA). A descriptive and bivariate analysis of the data was done. The data were submitted for statistical evaluation and were significant if p < 0.05. Results: Fifteen patients were analyzed, 11 females (73.3%) and four males (26.7%). The patients’ average age was 28 ± 8.52 years (ranging between 16 and 48 years old). The palatal wound region’s mean thickness and volume changes were −0.26 mm (±0.31) and 46.99 mm3 (±47.47 mm3) at three months. There was no statistically significant result correlating age/gender with any variable evaluated. Conclusions: Connective tissue graft harvesting promoted changes with a standard volume and thickness loss of palatal soft tissue. A 3D digital evaluation was a non-invasive method with a reproducible technique for measuring thickness or volume after connective tissue is collected. There was no relationship between age/gender and any variables analyzed.

Recession width evaluation after the use of Advanced PRF (A-PRF) verus subepithilial conncective tissue graft (SCTG) in combination with coronally advanced flap in treatment of gingival recession

Objective: To evaluate the amount of recession width following the use CAF and advanced platelet rich fibrin (A-PRF) compared to CAF with SCTG in the treatment of single gingival recession. Materials and Methods: Twenty gingival recession defects were randomly assigned to receive either CAF+SCTG (n=10) or CAF+A-PRF (n=10). Recession width in mm was assessed at 3, 6 and 9 months post-operatively. Results: Patients in test group (CAF+A-PRF) reported 2.13 ± 0.35 recession width at 3 months, 2.00 ± 0 after 6 months. While, finally decreased to 1.25±1.04 after 9 months. In the control group (CAF+SCTG), the amount of recession width recorded 1.00 ± 1.07 at 3 months, while, after 6 and 9 months decreased to 0.5 ± 0.93. Conclusion and recommendation: There was no statistically significant difference between the two studied groups after 9 months. While, A significant difference reported at 3 and 6 months. Further studies with larger sample size and longer follow-up is needed.