Clinical evaluation of free gingival grafts in periodontal surgery

A New Approach for Root Surface Biomodification Using Injectable Platelet-Rich Fibrin (I-PRF)

Background

This study investigated the potential effects of Injectable Platelet-Rich Fibrin (I-PRF) on root coverage of free gingival graft surgery.

Material/Method

A total of 40 patients with Miller class I or II gingival recession were included. The patients who participated in this study were randomly divided into 2 groups, including the control and experiment groups. The patients in the control group were treated only with free gingival graft (FGG). The patients in the experiment group were treated with free gingival graft and injected with I-PRF as a root surface biomodification agent (FGG+I-PRF). The patients were called back after 3 months, and the amount of exposed root surface was determined and compared to the preoperative findings.

Results

The mean initial exposed root surface was 4.7±1.49 mm for the FGG+I-PRF group, 4.1±1.07 mm for the FGG group, and 4.4±1.31 mm for all subjects. Three months after the operation, the mean root surface coverage values of the 2 groups were 3.5±1.05 and 3.9±0.78 mm in the control and experiment groups, respectively.

Conclusions

The findings showed that the injection of Injectable Platelet-Rich Fibrin (I-PRF) had a positive effect on root coverage in free gingival graft surgery.

Post-Surgical Clinical Monitoring of Soft Tissue Wound Healing in Periodontal and Implant Surgery

Clinical features of surgical soft tissue wound healing in dentistry have been rarely discussed in the international literature. The aim of the present paper is to highlight both the main clinical findings of surgical wound healing, especially in periodontal and implant dentistry, and the wound healing monitoring procedures which should be followed. Wound inspection after careful food and plaque debridement is the essential part of wound healing monitoring. Periodontal and peri-implant probing should be performed only after tissue healing has been completed and not on a weekly basis in peri-implant tissue monitoring. Telephone follow-up and patient self-assessment scales can also be used the days following surgery to monitor the most common surgical complications such as pain, swelling, bleeding, and bruising. Wound healing monitoring is an important concern in all surgical procedures since it allows to identify signs or/and symptoms possibly related to surgical complications.

Mucogingival surgery: where we stand today

Mucogingival problems are developmental and acquired aberrations in the morphology, position, and/or the amount of gingiva surrounding teeth. According to an academic report by American Academy of Periodontology, mucogingival therapy should be advocated for gingival augmentation and to create adequate vestibular depth in areas with insufficient attached gingiva. This paper provides an overview on mucogingival surgical procedures from its inception to the current time.

Free gingival grafts to increase keratinized tissue: a retrospective long-term evaluation (10 to 25 years) of outcomes

BACKGROUND

Gingival augmentation procedures are indicated primarily to increase an insufficient amount of gingiva and sometimes to halt the progression of gingival recession. The aim of this retrospective long-term study was to evaluate changes in the amount of keratinized tissue (KT) and in the position of the gingival margin after free gingival graft procedures over a period of 10 to 25 years.

METHODS

One hundred three subjects presenting with 224 sites completely lacking attached gingiva associated with gingival recessions were treated in a private practice. The experimental sites were treated with gingival augmentation procedures (free gingival grafts). The grafts were positioned at the presurgical level of the gingival margin or in a submarginal position. Clinical variables, including recession depth, amount of KT, and probing depth (PD), were measured at baseline (T(0)), 1 year after surgery (T(1)), and at the end of the follow-up period (10 to 25 years) (T(2)) and analyzed using descriptive statistics and multilevel models.

RESULTS

From T(0) to T(1), the gingival margin shifted coronally 0.8 mm, and KT increased 4.2 mm. From T(1) to T(2), the gingival margin shifted coronally 0.6 mm, and the overall KT decreased 0.7 mm. PD remained stable.

CONCLUSION

Gingival augmentation procedures performed in sites with an absence of attached gingiva associated with recessions provide an increased amount of KT associated with recession reduction over a long period of time.

The double lateral bridging flap for coverage of denuded root surface: longitudinal study and clinical evaluation after 5 to 8 years

Longitudinal results of a 5 to 8 year follow-up study of the double lateral bridging flap for coverage of gingival recessions (GR) are presented. On a total of 75 GR in 18 patients (31 surgical procedures) the majority of the teeth (58%) showed a root denudation reduction of 75% or more. Total coverage was observed on 18 teeth (24%). Examinations did not show a high correlation between the extent of recession and bone dehiscence after surgery, between the degree of root coverage and the initial width of keratinized gingiva, or between the GR before and after surgery. We conclude that neither the quantity of gingival recession nor the quality of the supporting tissues were a prerequisite for the success of this surgical technique.

Effects of citric acid treatment on autogenous free graft coverage of localized recession

Citric acid root conditioning prior to free gingival autograft (FGA) coverage of denuded roots may increase the likelihood of reattachment, but controlled studies to determine the value of the procedure have not been done on human subjects. This investigation was done to compare the effects of FGA root coverage with and without citric acid pretreatment. Nineteen patients with 30 affected teeth participated in the study. Fifteen teeth received FGAs without citric acid pretreatment and 15 teeth received FGAs with citric acid pretreatment. Measurements of gingival recession and sulcus depth were made preoperatively and 30, 60 and 90 days following the surgical procedure. Free gingival autografts with and without citric acid pretreatment each significantly reduced the amount of exposed root, but no differences between groups were found. Except for the 90-day single tooth control group, mean sulcus depths were significantly decreased at 30, 60 and 90 days, but there were no differences noted between single tooth citric acid and control groups or multiple tooth citric acid and control groups. Citric acid treatment of affected roots prior to FGA coverage does not appear to be justifiable.

Free gingival grafts for the treatment of gingival recession. A review of some techniques

Free gingival grafts can be utilized, alone or in combination with a coronally positioned flap, for the prevention and the treatment of gingival recession. The graft can be placed directly on the denuded root, as first described by Sullivan & Atkins (1968). This technique will provide adequate results, especially in cases with relatively little recession. After placing a free gingival graft in such an area, one can often observe bridging and/or creeping attachment. In the case of bridging, some of the grafted tissue will remain vital over the avascular zone, i.e. the root. Creeping attachment is the result of coronal migration of the grafted gingiva and will take place during the years following surgery. Bridging and creeping are most likely to occur in cases of narrow recession where the grafts had been placed directly over the denuded zone. In a second type of surgical procedure, an enlargement of the attached gingiva is first obtained through the graft. The area of recession is later covered by a coronally positioned flop. Several cases are presented which illustrate the results obtained with this procedure. In children, when there is insufficient attached gingiva, it is often desirable to place grafts before orthodonic therapy. In the prevention or treatment of gingival recessions, four possibilities may be considered: 1) no treatment, 2) placement of a graft to prevent recession, 3) stabilizing an existing recession, 4) attempt to cover the denuded root.

Placement of free gingival grafts on denuded alveolar bone. Part I: clinical evaluations

Fourteen patients were examined and determined to lack an adequate zone of attached gingiva in the mandibular incisor region. Each patient was treated on the left side of the mandible by placement of a free gingival graft on denuded bone and 12 of the 14 patients received a free gingival graft on retained periosteum in the right mandibular anterior region. Two patients were treated on the right side by either bone denudation or periosteal bed preparation without graft placement to permit histological evaluation of wound healing under these circumstances. Grafts were retained for time intervals from 1 week to 24 weeks. All patients were evaluated clinically for graft "take", graft healing, graft shrinkage, and graft mobility.

Comparative clinical evaluation of freeze-dried skin allografts and autogenous gingival grafts in humans

Freeze-dried skin (FDS) allografts and fresh autogenous free gingival grafts (FGG) were placed in five paired sites in four patients. Both types of grafts healed uneventfully. Evaluation over a 1-year period demonstrated no statistically or clinically significant differences between the FDS and FGG when: a) increase in the width of keratinized gingiva, b) decrease in recession, c) decrease in sulcus depth, k) gain in attachment level, or e) percent shrinkage of the graft were compared. It was concluded that FDS performs essentially similar to FGG in the correction of mucogingival problems, and has the advantages of decreased patient morbidity (no donor site) and availability of abundant amounts of graft material when needed.

Clinical evaluation of free autogenous gengival grafts placed on alveolar bone. Part I. Clinical predictability

1. Thirty free autogenous gingival grafts were placed on bone and 30 were placed on a periosteal bed. The distribution into the groups was random. All 60 grafts survived, showing that both procedures were predictable. 2. Over one-half (17 of 30) of those on periosteum demonstrated mobility by 6 months postoperatively. No mobility was observed in the group placed directly on bone. 3. Osseous placed grafts demonstrated less swelling and better hemostasis than did the periosteally placed grafts. 4. A healing lag was observed in the grafts placed on bone which lasted only for the first two postoperative visits, approximately 2 weeks. 5. No infections or sequestrations were noted in any case.

Fluorescein angiography of free gingival autografts

The capillary blood circulation of free gingival autografts during healing was studied by means of 45 fluorescein angiographs taken over a postoperative period of 14 days in 10 female patients, 21 to 36 years old. The surgical technique commonly used for transplanting gingiva was slightly modified in that no surgical dressings and, in 3 cases, not even sutures were employed to immobilize the grafts. During the first 3 postoperative days, fluorescent plasmatic diffusion of increasing intensity was observed. In one case, fluorescing capillary circulation was detected as early as 24 hours after surgery, fluorescent capillaries became evident in all graft sites and increased steadily in number. Between 9 and 14 days after surgery, an even capillary loop pattern was established.

Total coverage of multiple and adjacent denuded root surfaces with a free gingival autograft. A case report

A case report is presented dealing with the utilization of a free gingival autograft for the correction of gingival recession, inadequate attached gingiva, and shallow vestibular depth associated with six lower anterior teeth. A technique is described which the author believes is responsible for the successful "take" of the graft to the six vascular root surfaces.

The use of a free connective tissue graft to increase the width of attached gingiva

Various techniques have been employed for increasing the width of keratinized gingiva. In recent years free gingival grafting has been shown to produce more predictable results than previous methods. Wound-healing studies, however, have shown that the surface epithelium of free gingival grafts degenerates and re-epithelizes by cells proliferating from adjacent tissues. In addition, the donor site is left to heal by secondary intention and requires a dressing for 10 to 14 days. Most studies on epithelial-mesenchymal interactions support the concept that epithelium differentiates under the influence of stimuli from the underlying connective tissue. If this is so, then grafting of gingival connective tissue alone should induce keratinization in the proliferating epithelium. A case is presented which illustrates this principle. The graft effectively increased the width of keratinized gingiva. The donor site healed by primary intention, and no dressing was needed.

Complications of free grafts of masticatory mucosa

A discussion has been presented and examples provided to illustrate some of the complications that may be encountered in conjunction with free grafts of masticatory mucosa. The clinical problems presented are seen infrequently, but the clinician must be aware of the possibility of their occurrence when counseling patients on the possible sequelae of such surgical procedures. A knowledge of complications that may occur in free soft tissue grafting procedures, and of the underlying mechanisms causing these problems, may aid the clinician in anticipating and avoiding similar experiences.

Coronally repositioned periodontal flap. Clinical evaluation after one year

After increasing the width of the attached gingiva by free palatal mucosa transplants, 20 procedures with coronal flap repositioning were performed on 41 teeth with gingival recessions in 13 young adults. The amount of gingival recession and the clinical gingival sulcus depth were measured pre-operatively and 1, 6 and 12 months after surgery; the amount of osseous dehiscence was measured during surgery. No significant differences were found among reduction values of gingival recession by reattachment 1, 6 and 12 months post-operatively. Although a significant correlation was found between the degree of gingival recession preoperatively and 1 month post-operatively, non was found between the amount of alveolar bone dehiscence and gingival recession 1 month post-operatively.