Increasing the apico-coronal dimension of attached gingiva using the modified apically repositioned flap technique: a case series with a 6-month follow-up.

BACKGROUND: This case series reports on the effectiveness of the modified apically repositioned flap (MARF) in increasing the apico-coronal dimension of attached gingiva over multiple adjacent teeth. METHODS: The MARF surgical technique consists of a single horizontal incision within keratinized tissue, elevation of a split-thickness flap, and suturing of the flap to the periosteum in an apical position. The periosteum is left exposed so that the full perimeter of the wound is surrounded by keratinized tissue. The nature of this wound healing leads to the formation of new keratinized and attached tissue in the area where periosteum is left exposed. A total of 37 areas in 33 systemically healthy patients were analyzed after treatment with the MARF technique. The treatment areas consisted of a minimum of two and a maximum of five adjacent teeth with a minimum of 0.5 mm and a maximum of 2.0 mm of attached gingiva on each tooth. RESULTS: Treatment with MARF resulted in a significant increase in the apico-coronal dimension of the keratinized tissue and attached gingiva (P <0.05). The increase in keratinized tissue ranged from 2.20 to 4.28 mm, and the increase in attached gingiva ranged from 1.0 to 3.14 mm. Gingival recession decreased significantly in the treated areas, but the difference was of little clinical significance. Probing depths in the treated areas did not change significantly compared to baseline values. CONCLUSIONS: MARF is an effective technique in increasing the apico-coronal dimension of the keratinized tissue and attached gingiva. MARF offers considerable advantages over other mucogingival surgery techniques: simplicity, limited chair time for the patient and the operator, low morbidity because of the absence of palatal donor tissue, and a predictable tissue color match.

Culture of human gingival fibroblasts on a biodegradable scaffold and evaluation of its effect on attached gingiva: a randomized, controlled pilot study.

BACKGROUND: An adequate width of attached gingiva is necessary to maintain healthy periodontium, especially in orthodontics or restorative treatments in periodontics. The purpose of this study was to evaluate the width of attached gingiva after clinical application of a cultured gingival graft compared to a periosteal fenestration technique. METHODS: This study was conducted on nine patients (18 sites) with insufficient attached gingiva adjacent to at least two teeth in contralateral quadrants of the same jaw. A small portion (approximately 3 x 2 x 1 mm) of attached gingiva (epithelial + connective tissue) was removed with a surgical blade. After culture of gingival fibroblasts, 2 x 10(5) cells in 250 microl nutritional medium were added to 250 microl collagen gel. One tooth in each patient was randomized to receive a periosteal fenestration technique for gingival augmentation (control) or a tissue-engineered mucosal graft (test). Clinical parameters measured at baseline and 3 months included width of keratinized tissue, probing depth, and width of attached gingiva. RESULTS: An increased amount of keratinized tissue was seen at all treated sites after 3 months. The mean increased amount of attached gingiva was 2.8 mm at test sites and 2 mm at control sites; this difference was significant (P < 0.05). CONCLUSION: Based on the results of this investigation, the tissue-engineered mucosal graft is safe and capable of generating keratinized tissue.

Treatment of gingival recession: comparison of two techniques of subepithelial connective tissue graft.

BACKGROUND: The increasing interest in esthetics and the subsequent need to solve related problems such as hypersensitivity and root caries have favored the development of many surgical procedures that permit the coverage of exposed roots. This clinical study was conducted to examine the coverage of gingival recession defects, where two different subepithelial connective tissue graft (SCTG) techniques (Langer and Langer and modified tunnel) were used. METHODS: Thirty one patients (21 females and 10 males), each contributing Miller Class I and II gingival recessions, were selected. Recession defects were randomly treated by using the Langer and Langer technique (17 patients) or the modified tunnel technique (14 patients). Vertical recession, probing depth (PD), and attachment level were assessed at baseline and 6 months postoperatively. RESULTS: Six months after the surgery, a significant reduction in recession depth was noticed in both groups. There was also a decrease of PD and attachment level for both groups, but not statistically significant. In comparison, at 6 months, statically significant differences were found between the tunnel and Langer and Langer techniques for root coverage and attachment gain. The percentage of root coverage was 96.4% and 75.5% in the tunnel and Langer and Langer groups, respectively. CONCLUSIONS: The present study suggests that the use of SCTG in combination with a tunnel procedure may result in an increased amount of root coverage and clinical attachment gain compared to the Langer and Langer technique. Further comparative studies are necessary to understand the periodontal healing generated by the tunnel procedure and Langer and Langer technique.

Effect of retention of gingival sulcular epithelium on attachment and pocket depth after periodontal surgery.

Both the modified Widman flap and the intrasulcular incision technique produced significant and similar reductions in pocket depth and increases in attachment. Loss of attachment occurred where the initial pocket depth was less than 3 mm. Both techniques resulted in significant and similar increases in gingival recession. Neither technique affected tooth mobility or plaque scores to a clinically important degree. Historically, the necessity for removal of the sulcular epithelium in the course of periodontal therapy is a widely accepted tenet. This study fails to clinically validate this concept.

A clinical and histologic study of healing following the excisional new attachment procedure in rhesus monkeys.

Experimental suprabony periodontal pockets were established around the incisors of Rhesus monkeys and subsequently were treated by the Excisional New Attachment Procedure. Healing was evaluated clinically and histologically for up to 6 months. Clinical examinations demonstrated an overall mean pocket depth reduction from 5.02 mm to 2.82 mm, of which 0.57 mm was recession and 1.59 mm (73.6%) was clinical new attachment. Histologic evaluation of experimental sites consistently revealed a long, thin junctional epithelium with a minimal amount of inflammatory infiltrate in the subjacent, densely fibered, lamina propria. Control areas demonstrated the classic histologic picture of periodontal disease and tended to be progressive in nature clinically.

A clinical study of healing in humans following the excisional new attachment procedure.

The excisional new attachment procedure was used to treat 75 suprabony pockets on 32 teeth in 9 patients. One-year postoperative measurements demonstrated an overall mean pocket reduction from 4.7 mm to 2.0 mm, of which 2.1 mm (77%) was new attachment and 0.6 mm was recession. Average amount of new attachment and percentage of new attachment were greatest on the midlingual surfaces of the teeth treated in this study. The results of this study showed the excisional new attachment procedure to be a simple, effective, and predictable procedure for achieving pocket elimination by means of a clinical new attachment of the gingival tissues in suprabony pockets.

Effects of electrosurgery on the gingival attachment in rhesus monkeys.

A biometric and histometric study of electrosurgical gingival "troughing" with a fully rectified current was accomplished in four Rhesus monkeys. The operation resulted in a statistically significant recession of the free gingival margin and loss of connective tissue attachment associated with apical migration of the junctional epithelium. Burn marks from contacts with the electrodes were observed on the cemental surfaces and in the dentin under the enamel close to the cemento-enamel junction. The cemental burn marks usually were covered by epithelium, which may explain the apical migration of the junctional epithelium observed in the experiemtal teeth. A slight loss of crestal alveolar bone occurred in the experimental areas and a bone sequestrum formed in one instance. Secondary dentin was found in response to electrosurgical contact of the cemental surface.

Periodontal restorative interrelationships: the isolated restoration.

Only by controlling plaque early and consistently, before periodontal and restorative problems require intervention in the form of a full prosthetic and periodontal reconstruction, the continued maintenance of a full dentition is assured. Plaque control is not merely continued prophylaxes, but a striving for a healthy biologic situation with the placement of every restoration. This is attainable only through ensuring a normal attachment apparatus and establishing that all restorative margins be accessible to plaque control measures. Deep, subgingival restorations are not only difficult to place and finish correctly, but, by providing an environment conducive to microbial plaque retention and proliferation, also lead to inflammatory periodontal destruction and recurrent carious lesions. Early detection, although difficult, is essential to avoid excessive destruction of the tooth and its supporting structures. A deterrent to early detection may be the response of the patient's tissue. Paradoxically, if the patient's periodontal tissues respond in a fibrotic manner to early gingival inflammation, rather than in a dramatic, edematous manner, the situation may appear clinically healthy. Waerhaug discussed "submarginal gingivitis," a situation in which the tissue will appear pink and firm, elicit to exudate or bleeding on probing, and mimic healthy to the casual examiner. When this is coupled with the difficulty inherent in detecting early recurrent carious lesions, resulting from the radiographic superimposition of the existing restoration or the deep subgingival extent of the restoration, the situation becomes all the more demanding of the practitioner's efforts.

Laser de-epithelialization for enhanced guided tissue regeneration. A paradigm shift?

The rationale for laser de-epithelialization stems from the attempts to block the down-growth of epithelium into the healing periodontal wound after surgery and prevent formation of a long junctional epithelial attachment. This concept has seen numerous techniques for accomplishing the blockage of epithelium. The advent of GTR was an offshoot of this concept and led Gottlow et al [table: see text] to examine the effects of selectively blocking certain cell types from contacting the root surface during periodontal wound healing. The use of a CO2 laser to de-epithelialize the gingival flaps is an attempt to exclude this cell type from the healing wound and has been used with and without the benefit of GTR membranes. In a study on beagle dogs, the histologic results of using membranes and the laser procedure enhanced the wound healing and regeneration of new bone, cementum, and connective tissue attachment when compared with paired defects using the membranes alone. The results from the human studies and case reports combined with the animal studies indicate a positive benefit in wound healing because of the laser de-epithelialization technique. The use of an osseous graft in treatment of periodontal defects has been shown to stimulate new bone growth effectively and to regenerate new attachment. It has been speculated that the additional benefit of an osseous graft in GTR procedures is the organization of the blood clot at initial healing, which may tend to maintain the space needed for regeneration and to provide a matrix for the fibrin clot to retard epithelial down-growth. Studies comparing the results of osseous grafting with flap debridement always have shown that the amount of new bone formation and clinical new attachment favor the grafted sites versus paired nongrafted sites. The effects of removal of the pocket epithelium at the time of periodontal surgery have been studied by several authors, and these studies generally shown an incomplete removal of the sulcular epithelium by the inverse bevel incision. Epithelial excision was studied by Centty et al, who compared the removal of sulcular epithelium by the CO2 laser technique with conventional methods. Their results confirm that (1) a more complete removal of sulcular epithelium was obtained by laser than by knives, and (2) the technique effectively removes the oral and sulcular epithelium from a gingival flap without damaging the viability of the flap during wound healing. The technique as described in this article was used by Israel et al to verify further the ability to maintain a viable gingival flap during multiple laser deepithelialization procedures in humans during the first 30 days of healing. [table: see text] The concept of laser de-epithelialization as an adjunct to regenerative periodontal procedures currently is being studied in a multicenter university setting using a parallel study in controlled clinical trials. The first of these reports was mentioned previously (Araujo et al, unpublished data) and shows the enhanced wound healing of periodontal defects through use of the laser de-epithelialization technique. The authors believe that this technique has shown significantly better results than those obtained through conventional osseous grafting alone and appears to be comparable to the results reported for GTR procedures with barrier membranes. This concept provides a paradigm shift from the conventional use of GTR therapy by acknowledging the difficulty in controlling epithelium during the early wound healing. It also allows a more comprehensive therapy for treating periodontal disease that addresses the generalized nature of the disease, with multiple lesions being treated concurrently in an economical manner. The patient presenting with generalized advanced periodontal disease could have several defects definitively treated in one quadrant using the laser deepithelialization technique without the need for multiple membrane therapy. (ABSTRACT TRUNCATE

Root reshaping: an integral component of periodontal surgery.

It is the aim of this article to present a surgical option to the traditional method of returning lost biologic width where invasion of the junctional and/or connective tissue attachment associated with a tooth has occurred. The alternative to conventional osseous resection involves reshaping the existing tooth surface in combination with conservative removal of the supporting alveolar bone to create the width needed for the restoration to be biologically acceptable. This procedure accomplishes several goals: (1) minimum supporting bone is removed; (2) deleterious root surface anatomy, such as grooves, concavities, and cementoenamel projections, is diminished; (3) a smooth root surface that is more biologically acceptable to soft tissue is created; (4) Class I and II furcation lesions may be decreased or eliminated; and (5) improved gingival contours and space for restorative materials can be created in situations in which close root proximity is present. This article will present a step-by-step approach to using root reshaping as an alternative to traditional crown lengthening.

Connective tissue grafting employing the tunnel technique: a case report of complete root coverage in the anterior maxilla.

Techniques for surgical root coverage have been continuously revised over the past few decades. With increased knowledge on the etiopathogenesis of gingival recessions and on the repair/regeneration mechanisms of deep and superficial periodontal tissues, procedure simplification has been possible, and more predictable and stable results have been obtained. The maintenance of maximal blood supply has brought major changes in flap design. The coverage of contiguous recessions on the maxillary central incisors using a conservative technique for the incision of the recipient site is presented, along with the 11-month follow-up from surgery. A supraperiosteal tunnel was performed for the insertion and stabilization of a connective tissue autograft.

Soft tissue management techniques for implant dentistry: a clinical guide.

Establishing nontension primary closure over implant and bone-grafted sites begins with proper soft tissue management. This paper will demonstrate the various soft tissue flap designs required to optimize postsurgical wound healing. Simple and advanced flap management techniques are described in a step-by-step manner utilizing drawings to show each step-by-step surgical procedure. Management of postoperative soft tissue complications will also be addressed.

Crown lengthening to facilitate restorative treatment in the presence of incomplete passive eruption.

Crown-lengthening surgery can be utilized to expose subgingival caries. In this clinical case, a patient presented with incomplete passive eruption in the maxillary anterior sextant. This case illustrates that when incomplete passive eruption is present and restorative treatment is necessary in the maxillary anterior sextant, crown-lengthening surgery not only provides exposure of subgingival caries but can also result in a more esthetic therapeutic outcome.

Modification of col shape and interproximal area after periodontal surgery associated with the restorative alveolar interface (RAI) technique. Histological study in dogs.

The modification of the col shape and position by the restorative alveolar interface technique (RAI) was studied in the interproximal areas between the mandibular first molars and fourth premolars of 10 dogs. Full thickness flaps were raised to expose the interproximal root surface and alveolar bone crest. The RAI procedure was performed only on the experimental sides and the control areas were the opposite side of the same animal. The animals were sacrificed at zero hour, 7, 14, 21 and 28 days for histological analyses. Approximately 6.0-micron-thick sections were made in buccolingual and mesiodistal directions and stained with hematoxylin-eosin and Mallory for light microscopy analysis. A satisfactory healing process was observed up to the 14th and 21st days which showed a modified col shape. At this time, an inflammatory reaction developed affecting the evolution of the healing. The surgery had probably created conditions for the installation of an inflammatory process resulting from the modified anatomy of the interdental area.

Human clinical and histologic evaluation of laser-assisted new attachment procedure.

This investigation was designed to evaluate the healing response to the laser-assisted new attachment procedure (LANAP). Eight patients presenting with 12 teeth predetermined to be surgically extracted were enrolled and consented to treatment with full-mouth LANAP therapy. LANAP surgical therapy consisted of a first pass with a 360-Μm fiber diameter, laser settings with verified output of 4.0 W and energy density of 1,965 mJ/mm2, 100-Μs pulse duration, and 20 Hz applied from the gingival margin to the base of the pocket parallel to the root surface and moved laterally and apically to remove the diseased pocket epithelium. The teeth were aggressively scaled and root planed with piezo ultrasonic instrumentation. A second pass was performed with a 360-Μm fiber diameter, laser settings with verified output of 4.0 W and energy density of 1,965 mJ/mm2, 650-Μs pulse duration, and 20 Hz applied from the apical extent of the bone defect to the gingival margin. After 9 months of healing, en bloc biopsy extractions were provided. Ten teeth were analyzed histologically to assess the periodontal wound healing. Five teeth evidenced a degree of periodontal regeneration with new cementum, periodontal ligament, and alveolar bone. One tooth had new attachment with new cementum and inserting collagen fibers, and four teeth healed via a long junctional epithelium. LANAP therapy should be further investigated with long-term clinical trials to compare the stability of clinical results to conventional therapy. This report provides evidence that LANAP therapy can induce periodontal regeneration.

The regeneration of gingiva: its potential value for the recession of healthy gingiva.

The partial withdrawal of healthy gingiva not only affects the appearance but also can bring about some complaints when the healthy gingiva is stimulated for some reasons. The junctional epithelium of gingiva moves to the root with aging, and compared with the tooth crown, the tooth root which has lower mineral content is prone to decay. Thus, gingival recession could lead to the root surface decay and make the tooth sensitive. Gingival recession is not reversible. Once the healthy gingiva shrinked, the teeth could feel uncomfortable, food impaction appeared and the original restorations have to be dismantled with new restorations on account of the exposure of coronal edges. Then the regeneration of gingiva is important. In this article, a hypothesis is proposed that free gingiva could get back to the former non-recessive location through guiding the healthy junctional epithelium to propagate along the crowns. Then the gingiva not only restores the beautiful outlook but also returns the natural barrier function.