Treatment of Multiple Areas of Gingival Recession Using a Simple Harvesting Technique for Autogenous Connective Tissue Graft

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.

Propylene mesh versus acrylic resin stent for palatal wound protection following free gingival graft harvesting: a short-term pilot randomized clinical trial

BACKGROUND

Protection of the palatal wound is an essential step following harvesting a palatal soft tissue graft. The aim of the current pilot randomized clinical study was to assess the efficacy of using propylene mesh as protective sheet when compared to conventional custom made acrylic stent after harvesting a palatal graft. The primary outcome of this study was bleeding postoperatively and secondary outcomes were pain, healing profile of the donor site as well as patient satisfaction.

METHODS

Between 2018 and 2019 we conducted a prospective randomized controlled trial of 24 patients with palatal defects. Two groups of 12 patients with 24 sites were included in this study and were treated with soft tissue grafting technique using free grafts harvested from the hard palate. The palatal wounds were protected with propylene mesh (test group) or custom-made acrylic palatal stent (control group). Participants were assessed for the amount and duration of bleeding, pain duration, and the risk of infection 2, 4, 6, 8, 14 days post-operatively. The trial had been registered in clinical trials.gov (NCT04348279).

RESULTS

Four sites were excluded from the study as dropouts. The polypropylene mesh was more effective at reducing bleeding by (2.4 ± 1.075) and pain by (1.600 ± 0.516), while the custom-made acrylic stent reduced the bleeding (5.8 ± 1.22) and pain (7.100 ± 0.316). The decline in amount of bleeding amount (P value = 0.021) and its duration (P value = 0.001) achieved by the propylene mesh was statistically significant. There was no statistical significant difference in patient satisfaction and the duration of healing process between the 2 groups. However, the healing profile of the test group was statistically significant when compared with the control group (P value = 0.002).

CONCLUSIONS

Propylene mesh is a promising material for protection of the palatal wound due to its light weight, limited bacterial wicking, tissue compatibility. Further studies are required to adequally assess the benefits of this material in periodontal plastic surgeries.

De-epithelialized gingival graft versus subepithelial connective tissue graft in the treatment of multiple adjacent gingival recessions using the tunnel technique: 1-year results of a randomized clinical trial

AIM

To compare the clinical efficacy and postoperative morbidity of de-epithelialized gingival graft (DGG) with subepithelial connective tissue graft (SCTG) on treatment of multiple adjacent gingival recessions (MAGRs) with tunnel technique (TUN) and to evaluate histological characteristics of the palatal grafts.

MATERIALS AND METHODS

Twenty-seven patients with MAGRs affecting at least 2 adjacent teeth were treated with either DGG + TUN or SCTG + TUN. Recession depth(RD) and width(RW), probing depth(PD), clinical attachment level(CAL), keratinized tissue height(KTH), gingival thickness(GT), and complete and mean root coverage(CRC, MRC) were evaluated at 6 and 12 months postoperatively. Multilevel analysis was performed to identify patient- and tooth/site-related predictors for the 12-month MRC outcomes. Postoperative patient morbidity and histological characteristics of palatal graft samples obtained during harvesting were investigated.

RESULTS

At the 12-month follow-up, MRC was 91.72% ± 16.59% and 84.72% ± 19.72% in DGG + TUN and SCTG + TUN groups (p = .001). Multilevel regression analysis identified RD, KTH and GT as variables associated with MRC. No significant difference between the groups was observed regarding postoperative patient morbidity parameters. Cellularity was found significantly higher in the SCTG samples compared to the DGG samples (p < .05).

CONCLUSIONS

Although DGG + TUN presented higher MRC and CRC compared to SCTG + TUN in the treatment of MAGRs, treatment method was not a significant predictive factor for the amount of MRC outcomes while RD, KTH and GT were significant predictive factors.

Technical Note on Root Coverage of Lower Anterior Teeth Using a Partially Deepithelialized Connective Tissue Graft (PE-CTG) Aided by a High-Speed Handpiece

Root coverage in the mandibular anterior region is challenging because of a thin gingival biotype, shallow vestibule, and high frenum attachment. Several methods have been introduced to predict the root coverage in this area. Stimmelmayr proposed a method of performing root coverage using a combination epithelialized-subepithelial connective tissue graft (CTG). However, it is difficult to precisely acquire connective tissue according to this method. Therefore, in this case report, we would like to introduce a technique to harvest a partially deepithelialized CTG (PE-CTG) aided by a high-speed handpiece, which helps in procuring the graft easily and quickly. This method could lower the patient's morbidity at donor sites and enhance the healing process. Additionally, it could increase the amount of keratinized gingiva in the mandibular anterior region without reducing the vestibular depth. Therefore, PE-CTG using a high-speed handpiece can be a promising treatment option for the root coverage of the mandibular anterior teeth.

44-year journey of palatal connective tissue graft harvest: A narrative review

Connective tissue graft (CTG) is considered the gold standard for soft-tissue correction and augmentation surgeries, but involves a secondary donor area and its associated complications. The techniques to harvest CTG have undergone a large number of modifications over a period of 44 years since the time it was introduced by Edel in 1974 to increase the width of keratinized gingiva. This review compiles all the techniques of graft harvest from the palate and their modifications which have been introduced in the last 44 years till date. This review is based on systematic reviews, comparative human studies, and case reports describing any new technique of graft harvest. Publications till April 2018 were selected and further reviewed. In addition, specific related journals and books were searched upon. In order to minimize the pain, bleeding, and morbidity associated with donor site, several researchers proposed harvesting of the connective tissue by means of different techniques, each precisely different from others in terms of design, incisions, and procedure of harvest. Although the latest techniques are minimally invasive with reduced incision lines, less compromised blood supply, accelerated healing, and no sloughing of the overlying flap, they are technique sensitive which requires higher expertise to execute.

Augmentation of the hard palate thin masticatory mucosa in the potential connective tissue donor sites using two collagen materials-Clinical and histological comparison

BACKGROUND

Due to the similarity of keratinized gingival and palatal mucosa the latter can pose as a potential donor site for gingival recession coverage. However, its availability is restricted and a thin transplant bears the risk of being rejected. The aim of the present study was to compare the clinical and histological results of thin palatal mucosa augmentation, using lyophilized Biokol^® xenogenous collagen sponge and a suspension of xenogenous Gel 0^® pure collagen with non-augmented tissue from the same patients.

MATERIALS AND METHODS

Ten patients simultaneously underwent bilateral augmentation procedures using Biokol^® and Gel 0^® collagen material. The donor sites were augmented 8 weeks prior to the harvesting of the connective tissue graft (CTG) for the gingival recession coverage procedures. Prior to the implantation of the collagen material and during the course of harvesting the augmented CTG, tissue specimens were taken for histological examination. Prior to the commencement of the study and after it, the parameters of palatal gingival thickness at 4mm (PGT1), and at 8mm apical to the gingival margin (PGT2) around the teeth neighboring the operating fields were determined.

RESULTS

In both groups the palatal mucosa had thickened significantly in both measuring sites. An intergroup comparison revealed greater thickening of the masticatory mucosa in the Biokol^® group at both measuring points. The histological image of the grafts, obtained from sites augmented using both test methods, revealed a typical pattern of mature fibrous connective tissue. No epithelial cells were found.

CONCLUSION

Augmentation of thin masticatory mucosa using Biokol^® or Gel 0^® collagen materials resulted in a significant thickening of the mucosa, which could be demonstrated to be greater in the first group.

Effects of Ozone Therapy on the Early Healing Period of Deepithelialized Gingival Grafts: A Randomized Placebo-Controlled Clinical Trial

BACKGROUND

This study evaluates the effects of ozone therapy (OT) on the early healing period of deepithelialized gingival grafts (DGG) placed for non-root coverage gingival augmentation by laser Doppler flowmetry (LDF).

METHODS

Thirty-three patients were assigned to study groups: 1) test: DGG + OT; or 2) control group: DGG alone. Thirty patients completed the study. Ozone was applied on DGGs placed in the recipient bed and donor site immediately after surgery and at days 1 and 3 post-surgery. Blood perfusion in the recipient site was measured by LDF on the day of surgery and at 1, 2, 3, 6, 8, 10, and 13 days after surgery. Quality of life (assessed by the Oral Health Impact Profile-14) and pain at donor/recipient sites (assessed by visual analog scale) were also investigated.

RESULTS

Increase in blood perfusion units in the test group was significantly higher than control group at 1, 2, 3, 6, and 8 days post-surgery (P <0.001). Significant differences occurred between test and control groups in terms of visual analog scale values during the first week post-surgery for both donor and recipient sites (P <0.05). The ozone-treated group showed significantly higher quality of life than control group on postoperative day 6 (P = 0.002).

CONCLUSIONS

OT enhanced blood perfusion units in the first postoperative week. This outcome is also consistent with improvement in wound healing, accompanied by an increase in quality of life and decrease in postoperative pain in the test group.

AB, Grisi MFDM, Maia LP, Souza SLSD. Palatal Harvesting Technique Modification for Better Control of the Connective Tissue Graft Dimensions

Subepithelial connective tissue graft (SCTG) has been extensively used for a variety of clinical applications. However, the surgical procedure may not allow control of graft thickness. The purpose of this case series is to illustrate a modification to the single incision palatal harvesting technique in order to control the SCTG thickness without increasing patient discomfort. Fifty cases from thirty systemically and periodontally healthy patients with at least one multiple gingival recession were treated with coronally advanced flaps combined with a SCTG. The palatal area served as the donor site, from where a single perpendicular incision was made to obtain a full thickness flap. Next, 1-2 mm of the flap was elevated and dissected to obtain a partial thickness flap. The graft remained attached to the full-partial thickness flap. After determining the desired SCTG thickness, the graft was harvested from the palatal flap. The patients healed uneventfully at 7 days postoperatively and primary closure was obtained for all palatal donor sites. The SCTG length and width varied depending on the needs of each case, but the SCTG thickness was well controlled with only 0.24 mm standard deviation. The suggested modification granted control of the SCTG dimensions and achieved complete wound closure within a week.