Simplified Subperiosteal Sling Suture for Connective Tissue Graft Stabilization in Root Coverage and Phenotype Modification.

This technical report describes the simplified subperiosteal sling (SPS) suture for connective tissue graft (CTG) stabilization in root coverage and phenotype modification of single and multiple recession defects via the vestibular incisional subperiosteal tunnel access (VISTA). The simplified SPS suture engages the CTG only and stabilizes it to the tooth in the coronal most position inside the subperiosteal tunnel independent of the overlying gingival tissue. The simplified SPS suture differs from the original SPS suture in that it engages the CTG first, and the needle and tail of the suture are knotted before the suture is introduced into the subperiosteal tunnel. This allows the needle to pass through the subperiosteal tunnel only once from the vestibular access to the intended gingival sulcus. When multiple teeth are treated, only one simplified SPS suture traverses the vestibular access at a time as the CTG is incrementally advanced into the tunnel. This prevents suture entanglement and improves the practical application of the technique.

Modified Dual-Zone Therapeutic Concept of Single Immediate Implants with Bone and Soft Tissue Augmentation: Technical Report with Three Cases.

Although connective tissue grafts (CTGs) have been found to increase gingival thickness and reduce facial gingival recession in immediate implant placement and provisionalization (IIPP), they are associated with significant loss of buccal bone thickness. This loss is thought to be related to the preparation of the facial CTG recipient site. This technical report presents a modified dual-zone therapeutic concept in which the bone zone is grafted with bone graft and the tissue zone is grafted with tuberosity CTG without elevation of a facial partial- or full-thickness envelope.

Enucleation of recurrent central odontogenic fibroma and bone regeneration of the osseous defect with enamel matrix derivative and bone allograft: Case report with 5-year follow-up.

INTRODUCTION: Odontogenic fibroma is a rare benign neoplasm of mature fibrous connective tissue with variable amounts of inactive-looking odontogenic epithelium. Few recurrences of central odontogenic fibroma (COF) have been reported in the literature. This manuscript reports the enucleation of a recurrent COF and bone regeneration of the osseous defect with enamel matrix derivative and bone allograft. CASE PRESENTATION: A 28-year-old Asian female presented in 2015 with a palatal depression between #10 and 11. The patient previously had an odontogenic fibroma between #10 and 11 removed in 2008. Cone beam computed tomographic evaluation revealed a well-defined, multiloculated radiolucency centered between #10 and 11 that extended from #9-12, and from the alveolar crest to the anterior border and floor of the maxillary sinus. The lesion resulted in splaying of the roots of #10 and 11, external root resorption on #10, loss of crestal and palatal bone cortices, and thinning of labial cortex between #10 and 11. The patient was referred to an oral surgeon for biopsy, and the lesion was diagnosed as odontogenic fibroma. The lesion was enucleated. Enamel matrix derivative was applied to the affected teeth and defect, which was subsequently grafted with bone allograft. At the 5-year follow-up, bone was regenerated to the midroot of #10 and coronal third of #11, with reestablishment of crestal and palatal bone cortices. CONCLUSION(S): Enucleation of COF and regeneration of the osseous defect with enamel matrix derivative and bone allograft appear to be a viable treatment approach that allows for preservation of contiguous teeth. Why is this case new information? This appears to be the first publication to report on bone regeneration following enucleation of a recurrent odontogenic fibroma. What are the keys to successful management of this case? Graft material provided space maintenance and a scaffold for bone regeneration. What are the primary limitations to success in this case? Loss of the labial bone resulted in a through-and-through defect between 10 and 11 that limited the amount of vertical bone regeneration.

Perigraftitis and implant therapy: A case report.

BACKGROUND: A previous case study reported periimplantitis and concomitant perigraftitis of a second implant placed at a site that had alveolar ridge preservation three decades earlier. Infection at the site persisted 4 months after implant removal by flapless implant reversal. A flap was subsequently reflected, the grafted bone was removed, and a second alveolar ridge preservation was performed with a freeze-dried bone allograft. The publication reported infection resolved, and the site healed uneventfully. However, it is unknown if placement of another implant at the site would be successful. The purpose of this paper is to report on the findings at surgical reentry and outcome of the third implant. METHODS: Eleven months after the second alveolar ridge preservation, the site was reentered. The bone graft was found to be partially soft tissue encapsulated. All encapsulated graft materials and soft tissue were removed. An implant was placed, and the alveolar defect was grafted with a demineralized bone allograft. Seventeen months after implant placement, a buccal free gingival graft was performed during which the crestal bone adjacent to the implant was found to be hard and corticated. The implant was deemed to be osseointegrated and restored after soft tissue healing. RESULTS: Twenty-five months after implant placement, the third implant remained functional and asymptomatic with the peri-implant bone exhibiting normal trabeculation. CONCLUSIONS: Implant therapy can be successful following treatment and resolution of perigraftitis. KEY POINTS: Perigraftitis may play a contributing role in the biologic complications of implants that have been placed into grafted bone. Perigraftitis may be successfully resolved by completely removing all grafted bone. Once perigraftitis has been eliminated, an implant may be successfully placed.

Multiple Subperiosteal Sling Sutures for Connective Tissue Graft Stabilization in the Treatment of Multiple Recession Defects Utilizing Subperiosteal Tunnels via VISTA and Intrasulcular Access.

This report describes the utilization of multiple subperiosteal sling (SPS) sutures to stabilize connective tissue grafts in the treatment of multiple recession defects using subperiosteal tunnels via vestibular and intrasulcular accesses. The SPS sutures engage only the graft and stabilize it against teeth inside the subperiosteal tunnel without engaging the overlying soft tissue, which is neither sutured nor coronally advanced. At sites with deep recessions, the graft is left exposed over the denuded root surfaces and allowed to epithelialize, which results in root coverage and increased attached keratinized tissue. Further controlled studies are required to investigate the predictability of this treatment approach.

Peri-Implantitis and Concomitant Perigraftitis of an Implant Placed in a Site That Had Alveolar Ridge Preservation Three Decades Earlier: A Case Report With Human Histology.

INTRODUCTION: Although alveolar ridge preservation may minimize alveolar ridge shrinkage following tooth extraction, there is a paucity of data on the effects of alveolar ridge preservation on implant-related outcomes. The purpose of this manuscript is to report on peri-implantitis of an implant placed at a site that had alveolar ridge preservation three decades earlier, and the subsequent dislodgement of an approximately 1-cm3 grafted bone specimen during degranulation 4 months after implant reversal. CASE PRESENTATION: A 58-year-old male had #18 removed and the extraction socket grafted in the 1980s. In 2016, an implant was placed at #18 and restored with a screw-retained restoration. It developed mobility and was removed in 2017; the explantation site was not grafted. In 2018, another implant was placed at #18 and restored in 2019 with a screw-retained restoration. At the 1-year follow-up, the implant had developed peri-implantitis. Consequently, it was reversed without flap elevation. Four months later, infection remained. A buccal mucoperiosteal flap was reflected. Implant threads remained visible in the grafted bone. During degranulation, an approximately 1-cm3 grafted bone specimen dislodged from the mandible. Microscopy of the specimen shows numerous synthetic graft particulates surrounded by vital bone, with a mixed acute and chronic inflammatory infiltrate on its periphery. CONCLUSION(S): Within the limitation of this case report, absence of bone resorption due to impaired/altered bone metabolism of the grafted bone likely allowed bacteria to reach and infect the grafted bone via the implant fixture during development and progression of peri-implantitis.

"Periimplant Mucositis" Secondary to Infection of Residual Bone Allograft Embedded in the Periimplant Sulcus of a Patient With Diabetes: A Case Report.

INTRODUCTION: Currently, inflammation of tissue around implants is diagnosed as either periimplant mucositis or periimplantitis, and the etiology is bacterial biofilm colonization of the implant and its transmucosal component. The purpose of this manuscript is to report a case of "periimplant mucositis" secondary to infection of a residual bone allograft embedded in the periimplant sulcus of a patient with diabetes. CASE PRESENTATION: A #8 implant was placed and provisionalized in a 46-year-old male patient. During implant placement, facial contour augmentation with an allograft (1000-2000 µm), a collagen membrane, and a connective tissue graft was performed. Healing was uneventful. The crown was removed 9 months after implant placement; a graft particulate was observed in the periimplant sulcus and left undisturbed. The subgingival contour of the crown was adjusted, and the crown was reseated. The patient subsequently developed soreness and foul smell at #8. The crown was removed, and the previously observed graft particulate was more exposed and contaminated. It was removed and the crown was reseated. A month later, symptoms persisted. Palpation produced suppuration. A facial flap was reflected, and residual graft particulates embedded in the facial flap were removed. The site was grafted with a connective tissue graft. Subsequently, symptoms resolved, and the implant was restored. CONCLUSION(S): Within the limitation of this case report, it appears residual graft materials can get infected once exposed to the oral cavity and subsequently induce an inflammatory response in the surrounding tissue, especially in a patient with hyperglycemia.

Bone Regeneration of Maxillary Molar Proximal Class 2 Furcation Defects Treated With Microscope-Assisted Papilla Preservation Technique and DFDBA: A Case Series.

INTRODUCTION: Periodontal regeneration of maxillary molar proximal furcation defects are challenging due to limited access. While combination therapy of open flap debridement with barrier membrane, bone graft, and biologics are reported to be more successful than monotherapeutic approaches, combination therapy can be complicated and costly. CASE PRESENTATION: A total of four teeth in three patients are presented to demonstrate radiographic bone regeneration of deep Class 2 maxillary molar proximal furcation defects (MMPFD) treated with microscope-assisted papilla preservation technique (PPT) and demineralized freeze-dried bone allograft (DFDBA). CONCLUSION(S): Radiographic bone regeneration of deep Class 2 MMPFD is possible with microscope-assisted PPT and DFDBA. Furthermore, treatment outcomes appear to be superior to those from previous clinical trials of Class 2 MMPFD treatment.

Connective Tissue Graft Stabilization by Subperiosteal Sling Suture for Periodontal Plastic Surgery Using the VISTA Approach.

This report describes a minimally invasive surgical approach using the vestibular incision subperiosteal tunnel access and a suture called the subperiosteal sling (SPS) to stabilize the connective tissue graft (CTG) for periodontal plastic surgery. The SPS suture engages only the CTG and stabilizes the CTG against the tooth independent of the overlying tissue, which minimizes the risk of graft mobility caused by muscle movement.