Long-term stability of gingival margin and periodontal soft-tissue phenotype achieved after mucogingival therapy: A systematic review.

BACKGROUND: The aim of this systematic review was two-fold: (i) to evaluate the long-term (≥5 years) stability of the gingival margin position, keratinized tissue width (KTW) and gingival thickness (GT) in sites that underwent root coverage (RC) or gingival augmentation (GA); and (ii) to assess the influence of different local variables on the long-term stability of dental and gingival tissues. MATERIALS AND METHODS: Randomized controlled trials (RCTs) and non-RCTs reporting short-term (i.e., 6-12 months after baseline surgical intervention) and long-term (≥5 years) follow-up data after surgical treatment of adult patients presenting single or multiple mucogingival deformities, defined as sites presenting gingival recession defects (GRDs) and/or (KTW) deficiency (i.e., <2 mm), were considered eligible for inclusion. MEDLINE-PubMed, EMBASE and Cochrane Central Register of Controlled Trials databases were searched for articles published up to 15 May 2023. Mixed-effects multiple linear regression was used to assess the association between KTW, type of surgical procedure and time (i.e., independent variables) on the stability of the gingival margin in sites that received RC or GA therapy. RESULTS: Of the 2569 potentially eligible records, 41 (reporting 40 studies) met the eligibility criteria. Graphical estimates including data from all RC procedures found an upward trend in recession depth (RD) increase over time. Conversely, it was observed that in 63.63% of RC studies and in 59.32% of RC treatment arms KTW increased over time, particularly in sites treated with subepithelial connective tissue grafts (SCTGs). Conversely, sites that underwent GA procedures generally exhibited an overall reduction of KTW over time. However, sites treated with free gingival grafts (FGGs) showed a decrease in RD after 10 years of follow-up. Three main findings derived from the pooled estimates were identified: (i) Gingival margin stability was associated with the amount of KTW present during short-term assessment (i.e. the greater the KTW at 6-12 months after treatment, the more stable the gingival margin). (ii) The use of autogenous soft-tissue grafts was associated with lower RD increase over time. (iii) Treatment approaches that contribute to the three-dimensional enhancement of the gingival phenotype, as clearly demonstrated by FGG, were associated with gingival margin stability. CONCLUSIONS: The extent of apical migration of the gingival margin appears to be directly related to the amount of KTW and GT upon tissue maturation. Interventions involving the use of autogenous grafts, either SCTG or FGG, are associated with greater short-term KTW gain and lower RD increase over time.

Introduction of a modified single stage reconstruction technique of male penopubic epispadias.

OBJECTIVE: To represent the long-term outcomes of our modified single-stage technique for the reconstruction of isolated penopubic epispadias in male patients. PATIENTS AND METHODS: Data from 113 patients were obtained from bladder-exstrophy-epispadias database of our tertiary center. A total of seven boys with isolated penopubic epispadias with no prior history of surgery and any other anomaly underwent our modified surgical approach from February 1997 to September 2019. The mean ± SD age at surgery was 6.5 ± 2.4 years. Volitional voiding status and cosmetic appearance were evaluated at each follow-up interval. Postoperative follow-up was performed at quarterly intervals in the first year and once a year in subsequent years. RESULTS: The mean ± SD of follow-up was 8.5 ± 6 years. All boys who were incontinent achieved urinary control and the ability of normal transurethral micturition following the surgery. Four boys became completely dry, and the other three attained social dryness. Postoperative mean (SD) bladder capacity was significantly increased from 54.5 (11) to 124 (40.0) within 6 months, and to 194 (47.5) at 18 months after surgery. Dorsal curvature has been resolved in all cases, and no postoperative complications were noted except for surgical site infection in one patient treated with antibiotics and bilateral vesicourethral reflux resolved after injection of bulking agents. Four patients had normal erectile function and ejaculation, while the others have not reached puberty yet. Moreover, none of the patients developed urethrocutaneous fistula, stricture, or penile ischemia. CONCLUSION: The present findings suggest the safety and effectiveness of the combination of single-stage urethro-genitoplasty, bladder neck plication, and fat pad pedicled flap in management of boys with isolated penopubic epispadias that can lead to the achievement of urinary control, acceptable sexual function, and cosmetically satisfactory genitalia. Minimal morbidity, low complication rate, and promising outcomes are essential factors, supporting the notion of introducing this technique as a valid option for management of this entity.

Pedicled Serratus Anterior Flap as an Alternative Muscle Target for Targeted Muscle Reinnervation in Transhumeral Amputees.

Upper limb amputation is a universally devastating injury that results in substantial loss of function. Myoelectric prostheses represent a new generation of battery-powered programmable prostheses controlled by EMG signals. The aim of upper limb targeted muscle reinnervation (TMR) is to enhance the control of a myoelectric prosthesis by improving the number and quality of EMG signals that can be used to control prosthetic elbow, wrist, and hand movements. Current TMR techniques rely on preservation of parts of biceps and triceps to be used as reinnervated muscle targets. However, a subset of amputations exists in which the proximity or mechanism of injury results in loss of these local muscle targets, making these techniques less suitable. Alternative muscles beyond the zone of injury must be sought and imported as targets for residual nerves. Through its neurovascular anatomy and physical structure, the serratus anterior offers multiple potential targets in close vicinity to the upper limb, making the creation of additional signals through a single flap achievable in this challenging scenario. We present our technique using a pedicled serratus anterior muscle flap as an alternative muscle target in transhumeral amputees undergoing TMR.

Urethral Complications After Transgender Phalloplasty: Strategies to Treat Them and Minimize Their Occurrence.

Radial forearm free flap phalloplasty (RFFP) is the current standard of care for most FTM gender confirmation surgeries. This procedure is associated with a rate of urethral stricture as high as 51%, which falls only to 23-35% even among the most experienced contemporary surgeons. While some modifications have been proposed to combat this high complication rate, it still remains a major source of lasting morbidity. The method involves literature review of RFFP literature. Lowest stricture rates are found when neourethra is made with a long, meticulously constructed tube of well-vascularized perivaginal/periurethral and labia minora tissue. In cases of urethral stricture, urethroplasty is required in 94-96% of patients. Surgery should be delayed until all acute inflammation has subsided. Urethroplasty is technically challenging and fails in up to 50% of cases. Repeated surgery or salvage urethral exteriorization procedures, which can leave the patient with lifelong perineal urethrostomy, are often required. Patient and physician knowledge regarding the high burden and poor treatment options for urethral stricture after phalloplasty is incomplete, and patient acceptance of this reality is crucial for honest understanding of the potential complications of this increasingly common but extremely complex surgery. Clin. Anat. 31:187-190, 2018. © 2018 Wiley Periodicals, Inc.

Unilateral pectoralis major muscle flap for the treatment of sternal wounds due to Ludwig's angina.

Necrotising descending mediastinitis may rarely originate from Ludwig's angina, which is an infection of the submandibular space. The use of the bilateral pectoralis major muscle flap for the treatment of sternal wound dehiscence is common, but reports of the unilateral application of this flap are scarce. This study aims to report the use of the unilateral pectoralis major muscle flap for the treatment of sternotomy dehiscence in a patient with mediastinitis due to Ludwig's angina. A 21-year-old male patient underwent an exploratory cervicotomy and median sternotomy for drainage of a submandibular infection that extended to the anterior, retropharyngeal and mediastinal cervical spaces. The patient had dehiscence of the sternal wound, and the unilateral pectoralis major muscle flap was used for reconstruction of the defect. This flap was able to completely cover the area of dehiscence of the sternotomy, and the patient presented a good postoperative evolution, without complications. The reconstruction technique using the unilateral pectoralis major muscle flap was considered a good option for the treatment of sternotomy dehiscence. It is an adjuvant method in the treatment of infections such as mediastinitis and osteomyelitis of the sternum secondary to Ludwig's angina, allowing a stable coverage of the sternum.

Connective tissue graft and tunnel or trapezoidal flap for the treatment of single maxillary gingival recessions: a randomized clinical trial.

BACKGROUND: Although ample evidence supports connective tissue graft (CTG) use for root coverage, there is need for research on recipient site preparation approaches. The purpose of this study was to compare the outcomes of trapezoidal coronally advanced flap (CAF) and coronally advanced tunnel flap (TUN) when used in conjunction with CTG. METHODS: Forty-two patients presenting 42 single maxillary, Miller Class I and II, gingival recession defects were randomly assigned to receive either CAF + CTG (N = 21) or TUN + CTG (N = 21). Clinical, patient-centred, and aesthetic outcomes were assessed. RESULTS: Six months postoperatively, both groups resulted in significant reduction in recession depth and increases in keratinized tissue thickness and width. CAF + CTG and TUN + CTG mean root coverage was 87.2 ± 27.1% and 77.4 ± 20.4% respectively (p = 0.02). Complete root coverage was achieved in 71.4% and 28.6% of defects treated with CAF + CTG and TUN + CTG respectively (p = 0.01). At 7 days postoperatively, TUN + CTG patients reported significantly less pain experience (p = 0.04). Both approaches reduced dentine hypersensitivity by approximately 85% (p < 0.05). Patient-based aesthetic evaluation indicated significant improvement for both groups. Although patient- and professional-based aesthetic assessments revealed no differences between groups, tissue texture was significantly better for TUN + CTG (p = 0.02). CONCLUSIONS: For root coverage of single maxillary recession defects, CAF + CTG was more effective than TUN + CTG (ClinicalTrial.org-NCT02814279).

Free lateral tarsal artery perforator flap with functioning extensor digitorum brevis muscle for thenar reconstruction: a case report.

In this case report, we describe reconstructive surgery in one patient using a free lateral tarsal artery perforator flap with a functioning extensor digitorum brevis muscle. A 47-year-old woman sustained a crush-avulsion injury to her dominant right hand while working in a factory. A large thenar skin and muscle defect (5.5 cm × 4.0 cm) occurred as a consequence of surgical debridement. The skin and muscle defect was repaired using a free lateral tarsal artery perforator flap with a functioning extensor digitorum brevis muscle in a single operation. The donor site defect was repaired using a full-thickness skin graft. The patient recovered without postoperative complications. The patient showed satisfactory functional gain without significant donor site morbidity at the 4-year follow-up visit. Thus, we have demonstrated that a functional reconstruction of a thenar skin defect complicated by muscle loss is possible by transferring a free lateral tarsal artery perforator flap with the underlying extensor digitorum brevis muscle.

[Reconstruction with supraclavicular island flaps : An option in oncological treatment of head and neck carcinomas]. / Rekonstruktion mit dem supraklavikulären Insellappen : Eine Alternative in der onkologischen Therapie von Kopf-Hals-Karzinomen.

BACKGROUND: Reconstruction of defects after extirpation of head and neck cancer is a highly challenging and complex surgical undertaking. Commonly used techniques, e.g., the radial forearm flap, the anterior lateral thigh flap, or flaps harvested from the chest-deltopectoral or pectoralis major-share numerous disadvantages, such as donor-site morbidity, poor color matching for cutaneous reconstruction, and excessive tissue bulk. The use of a supraclavicular artery island flap is a long-forgotten but increasingly popular option for reconstruction in the head and neck area. MATERIALS AND METHODS: In the period 03/2013-02/2016, a total of 12 patients were treated with a supraclavicular island flap after surgical resection of carcinoma of the oral cavity, pharynx, parotid, or facial skin. RESULTS: Using examples, reconstruction of the lateral tongue and tongue base following resection of a squamous cell carcinoma, and reconstruction of the parotideal region after total parotidectomy and neck dissection for a skin spinalioma that had infiltrated the parotid are reported. In both patients, the flap healed without problems and led to very good functional and cosmetic outcomes. CONCLUSION: The supraclavicular island flap is a reliable and versatile flap for reconstruction in the head and neck region. Minimal donor-site morbidity, excellent cosmetic properties, and the relative ease of preparation and use compared to other distant flaps render it an excellent reconstructive tool for ENT surgeons.

A Systematic Review of Outcomes and Complications of Primary Fingertip Reconstruction Using Reverse-Flow Homodigital Island Flaps.

BACKGROUND: Fingertip reconstruction using reverse-flow homodigital island flaps has been very popular over the years. However, the outcomes of reconstruction have not been clearly understood. In these circumstances, a systematic review of available literature is warranted. OBJECTIVE: To assess the outcomes and complications of fingertip reconstruction using reverse-flow homodigital island flaps. To justify the usage of reverse-flow homodigital island flaps for fingertip reconstruction. SEARCH METHODS: A PubMed [MEDLINE] electronic database was searched (1985 to 15 April 2015). SELECTION/ELIGIBILITY CRITERIA: Retrospective case series that met the following criteria were included: (1) Study reported primary data; (2) Study included at least five cases of fingertip defects treated using reverse-flow homodigital island flaps; (3) Study reported outcomes and complications of fingertip reconstruction, either primary or delayed, using reverse-flow homodigital island flaps; (4) The study presented at least one of the following functional outcomes: Static two-point discrimination, return-to-work time, range of motion of distal interphalangeal joints; (5) The study presented at least one complication. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed search results, and two other review authors analyzed the data and resolved disagreements. The following endpoints were analyzed: survival rate of the flap, sensibility, and functional outcomes and complications. MAIN RESULT: Eight studies were included in this review. The included studies were published between 1995 and 2014, and a total of 207 patients with 230 fingertip defects were reported. The overall survival rate of the flap was 98 % (including partial survival). The mean static two-point discrimination (2PD) was 7.2 mm. The average range of motion of the DIP joint was 63°. The average return-to-work time was 7 weeks after injury. On average, 2 % of the patient had complete flap necrosis, 5 % had partial flap necrosis, 4 % developed venous congestion, 4 % developed flexion contracture, and 12 % experienced mild-to-moderate cold intolerance. AUTHORS' CONCLUSIONS: Survival of reconstructed fingertips (98 %) is better with reverse-flow homodigital island flaps than fingertip replantation (86 %). The sensibility outcome using sensate flaps (mean s2PD = 7.2 mm) is similar to the sensibility outcome following replantation (mean s2PD = 7 mm). The common complications include cold intolerance, venous congestion, and flexion contracture. Therefore, reverse-flow homodigital island flaps may not be the ideal choice but are a very reliable alternative for fingertip reconstruction. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Facial transplantation surgery introduction.

Severely disfiguring facial injuries can have a devastating impact on the patient's quality of life. During the past decade, vascularized facial allotransplantation has progressed from an experimental possibility to a clinical reality in the fields of disease, trauma, and congenital malformations. This technique may now be considered a viable option for repairing complex craniofacial defects for which the results of autologous reconstruction remain suboptimal. Vascularized facial allotransplantation permits optimal anatomical reconstruction and provides desired functional, esthetic, and psychosocial benefits that are far superior to those achieved with conventional methods. Along with dramatic improvements in their functional statuses, patients regain the ability to make facial expressions such as smiling and to perform various functions such as smelling, eating, drinking, and speaking. The ideas in the 1997 movie "Face/Off" have now been realized in the clinical field. The objective of this article is to introduce this new surgical field, provide a basis for examining the status of the field of face transplantation, and stimulate and enhance facial transplantation studies in Korea.

[Submental artery island flaps for reconstruction in the head and neck region]. / Der submentale Insellappen zur Rekonstruktion im Kopf-Hals-Bereich.

BACKGROUND: Reconstruction of defects after extirpation of head and neck neoplasms is a highly challenging and complex surgical undertaking. Commonly used techniques, such as the radial forearm flap or anterior lateral thigh flap, have numerous disadvantages, e.g., donor-site morbidity, poor color match for cutaneous reconstruction, and excessive tissue bulk for intraoral reconstruction. Use of a submental artery island flap is a relatively new and increasingly performed option for reconstruction in the head and neck region. MATERIALS AND METHODS: From March 2013 to August 2015, 12 patients were treated with a submental island flap after surgical resection of intraoral carcinomas or cutaneous neoplasms of the lower half of the face. CASE DESCRIPTION: This paper reports on two cases. The first case describes reconstruction of the floor of the mouth using a pull-through technique after resection of a squamous cell carcinoma. The submental flap was pedicled on the contralateral side, since neck dissection of regions I-V had been performed on the ipsilateral side. The second case is a reconstruction of the lower midface with parts of the upper lip, after removal of a cutaneous spinalioma. In a N0 neck, no neck dissection was performed. The flap healed without problems in both patients, leading to a very good functional and cosmetic outcome. CONCLUSION: The submental island flap demonstrates reliability and versatility for head and neck reconstructions. Its minimal donor site morbidity, excellent cosmetic match, pliability, and relative ease of dissection and application confer a definite advantage over distant flaps.

[Treatment strategies for fracture-related infections with concurrent soft tissue damage]. / Therapiestrategien bei frakturassoziierten Infektionen mit begleitendem Weichteilschaden.

Fracture-related infections are the predominant complication following surgical fracture treatment. The distal lower leg, e.g., in pilon tibial fractures, is at a high risk of infection due to poor soft tissue coverage, particularly in cases of open fractures in this area. Fracture-related infections with significant soft tissue damage require special attention alongside treatment of the infection itself. In general, the principle is that healing of fracture-related infection is not possible without sufficient soft tissue coverage. Therefore, it is crucial to integrate both soft tissue damage and fracture-related infection into a comprehensive treatment plan from the beginning. An interdiscpilinary treatment approach between trauma and plastic surgery is often necessary and beneficial. In cases, where fracture fixation devices or bone is exposed, mid- or long-term use of vacuum-assisted wound therapy is not advisable due to a higher risk of reinfection. Hence, an interdisciplinary treatment strategy involving trauma and plastic surgery should prioritize early soft tissue closure, referred to as the "orthoplastic approach". If this cannot be done in the own hospital, early patient transfer is indicated to ensure optimal interdisciplinary therapy with early soft tissue closure and simultaneous trauma surgical treatment to control the infection and enable bone healing. Free fasciocutaneous or muscle flap techniques in combination with adequate trauma surgical and antibiotic therapy lead to good reliable results in these situations.

Promising long-term outcome of bladder autoaugmentation in children with neurogenic bladder dysfunction.

PURPOSE: We evaluated the long-term outcome of bladder autoaugmentation in children with neurogenic bladder dysfunction. MATERIALS AND METHODS: Data were compiled from the records of 25 children with a median age of 9.3 years (range 0.9 to 14.2) who underwent detrusor myotomy between 1992 and 2008. All patients were diagnosed with small bladder capacity, low compliance and high end filling pressures, and were unresponsive to clean intermittent catheterization and anticholinergics. RESULTS: Median followup was 6.8 years (range 0.1 to 15.6). Median postoperative bladder capacity was unchanged or decreased to 95 ml (range 25 to 274) during the first 3 months compared to a median preoperative capacity of 103 ml (14 to 250). At 5 months postoperatively median bladder capacity increased significantly to 176 ml (range 70 to 420, p<0.01). This increase remained significant during the rest of followup. Median bladder compliance doubled after 1 year to 10 ml/cm H2O (range 1 to 31, p<0.05) compared to the preoperative level, and further increased to 17 ml/cm H2O (5 to 55) at 5 years (p<0.05). Median maximal detrusor pressure was 43 cm H2O (range 8 to 140) preoperatively. This value decreased significantly postoperatively (p<0.01) and at final followup it was 26 cm H2O (range 6 to 97). Kidney function developed normally in all patients except 1 with persistent uremia. Reflux was alleviated in 7 of 9 cases. Of the patients 18 became continent on clean intermittent catheterization. CONCLUSIONS: Bladder autoaugmentation in children with neurogenic bladder dysfunction offers, after a transient decrease in bladder capacity, a long lasting increase in capacity and compliance, while the end filling pressure decreases.

Distally Based Peroneal Artery Perforator-Plus Fasciocutaneous Flap to Reconstruct Soft Tissue Defect Combined With Chronic Osteomyelitis in the Lateral Malleolus.

Distally based peroneal artery perforator-plus fasciocutaneous (DPAPF) flaps are widely used to reconstruct soft tissue defects of the lower extremity. Treatment for soft tissue defect combined with chronic osteomyelitis in the lateral malleolus has rarely been reported. The aim of this study was to elaborate the superiority of the DPAPF flap and provide referential experience for using the DPAPF flap in this situation. Between June 2010 and December 2017, soft tissue defects in the setting of chronic osteomyelitis in the lateral malleolus were reconstructed with DPAPF flaps in 17 patients. After thorough debridement, the defect was repaired with the DPAPF flap, and patients subsequently followed an antibiotic regimen for 6 weeks. Follow-up periods for all patients were at least 24 months. The reconstruction outcomes and the satisfaction of the 17 patients were evaluated. Of the 17 flaps, 16 survived uneventfully, except one occurrence of partial necrosis. No infection occurred in the follow-up period. In the study, 17 patients except one were satisfied with flap appearance. All the patients were satisfied with the reconstruction outcomes. In a one-stage procedure, the use of DPAPF flaps is ideal for reconstructing soft tissue defects in the setting of chronic osteomyelitis in the lateral malleolus.

Quality of life after endoscopic skull base surgery with a nasoseptal flap: a systematic review.

BACKGROUND: The past two decades have seen a widespread adoption of endoscopic skull base surgery with the use of nasoseptal flaps. Attention has been diverted in recent times to evaluate the quality of life of these patients. OBJECTIVE: This systematic review aimed to evaluate the available literature to compare the quality of life after endoscopic skull base surgery with or without nasoseptal flaps. METHODS: This systemic review was conducted using PubMed, Embase and Cochrane Library databases for literature published after 2009. RESULTS: The majority of studies concluded that there was no statistically significant difference in the quality of life associated with the use of nasoseptal flaps. Post-operatively, more extensive surgery, peri-operative radiotherapy, smoking and younger age were associated with poorer quality of life. CONCLUSION: While the use of nasoseptal flaps can have negative effects on patients' quality of life in terms of sinonasal symptoms, this systematic review found no difference in quality of life associated with the use or non-use of a nasoseptal flap.

Second dorsal metacarpal artery-based index finger dorsal island flap for the management of thumb defects.

Index finger dorsal island flaps were frequently utilized by hand surgeons to reconstruct thumb defects. However, the blood supply of the traditional index finger dorsal island flap comes from the first dorsal metacarpal artery, which has a smaller diameter, more anatomical variation, and can be injured in conjunction with thumb injuries. Therefore, we design an alternative index finger dorsal island flap based on the second dorsal metacarpal artery to treat thumb skin defects. From August 2015 to October 2018, we used the index finger dorsal island flaps with the second dorsal metacarpal artery to treat 11 patients with thumb skin defects. All the flaps and skin grafts survived completely without complications. At the last follow-up, the mean 2PD of the flap was 6.4 mm (45.5% for excellent, 54.5% for good), the mean ROM of the injured thumbs was 115.9° (72.7% for excellent, 27.3% for good), and the mean cosmetics score was 8.6. Our results demonstrate that the index finger dorsal island flap with the second dorsal metacarpal artery is suitable for the reconstruction of thumb skin defects. The flap has an excellent survival rate and good coverage with satisfactory results and represents a promising treatment for the selected patients. Level of Evidence: Therapeutic, level IV.

Acellular dermal matrix for root coverage procedures: 9-year assessment of treated isolated gingival recessions and their adjacent untreated sites.

BACKGROUND: The long-term outcomes of acellular dermal matrix (ADM) for the treatment of isolated gingival recessions has not yet been evaluated. Thus, the aim of this study was to observe the root coverage outcomes of coronally advanced flap with ADM over time, and compare them with their adjacent untreated sites. METHODS: Twelve patients (from 20) were available at the 9-year recall. Clinical parameters (recession depth, mean root coverage [mRC], keratinized tissue width [KTW], and gingival thickness) were evaluated and compared with the 1-year results, and the ADM-adjacent untreated sites (on mesial and distal) via mixed-modeling regression analyses. RESULTS: From 1 to 9 years, the ADM-treated isolated recessions showed a relapse from 77% to 62% mRC (P <0.05). A similar pattern toward apical shift of the gingival margin was noticed for the ADM-adjacent untreated sites without baseline recession. However, ADM-adjacent untreated sites which had presented with recession at baseline but were not treated showed a significantly more apical shift of the gingival margin (almost two-fold). A significant increase in KTW was noted for all sites. Baseline KTW ≥2 mm was a significant predictor for the stability of the gingival margin at the ADM-treated, and the ADM-adjacent sites with baseline recession. CONCLUSIONS: ADM-treated sites displayed recession relapse from 1 to 9 years. The untreated adjacent sites with a recession at baseline, showed a higher apical displacement of the gingival margin compared with the ADM-treated sites, and ADM-adjacent sites without a recession at baseline.

"V-Reverse" Suturing Technique for Tunnel Soft Tissue Graft and Flap Stabilization: Technique Illustration.

INTRODUCTION: In periodontal and peri-implant plastic procedures, proper stabilization of the graft and the flap plays a crucial role in the outcomes. While the coronally advanced flap allows for better access with the possibility of suturing the graft to the periosteum and the de-epithelialized papillae, there is little evidence regarding what is the best approach in stabilizing the graft and the flap when performing the tunnel techniques (TUN). The purpose of this technical note is to describe a new suturing technique "V-reverse" for stabilization of the graft and the flap during a TUN procedure. CASE PRESENTATION: The V-reverse suturing technique was used to enhance the stabilization of the graft and the flap during root coverage procedures, papilla augmentation, and immediate implant placement. Other advantages of this technique include reduced flap and graft micromotion; simple, easy, and fast procedure; and high patient compliance. CONCLUSIONS: The present article describes three main clinical scenarios in which V-reverse suturing technique is used to stabilize TUN + connective tissue graft for root coverage procedures, papilla augmentation, and immediate implant placement.

The Multiple Pedicle Coronally Advanced Flap for Multiple Deep Miller Class II Recessions: A Case Report.

INTRODUCTION: In recent years, several methods have been described for the treatment of deep Miller Class II recessions. Most of these techniques concentrate on single recessions or one deep recession accompanied by just slight neighboring root denudations. A modified technique is presented for treating two or more deep recessions beyond the mucogingival margin combining a subepithelial connective tissue graft (SCTG), enamel matrix derivative, and a multiple pedicle coronally advanced flap. To the best of our knowledge, this is the first report to describe the treatment of multiple deep Miller Class II recessions exceeding beyond the mucogingival junction using a pedicled advanced flap. CASE PRESENTATION: A 29-year-old woman was referred to the periodontal practice of JT for the treatment of progressive deep Miller Class II recessions. The root coverage procedure was performed by a modified multiple pedicle flap combined with a connective tissue graft harvested from the palate and enamel matrix derivative. The case was followed up for 2 years. CONCLUSIONS: This modified technique of a multiple pedicled flap is a feasible and useful method for treating several deep neighboring recessions. Due to the improved incision techniques, scar tissue formation might be reduced not to interfere with the esthetic result.