Papilla reconstruction: Interdisciplinary consideration for clinical success.

One of the most difficult achievements in the periodontal therapy is the reconstruction of interdental papilla that has been lost by periodontal disease. The poor esthetic appearance caused by the "black triangle," especially in the maxillary anterior region has been a concern for both patients and professionals. However, when the papilla destruction is followed by loss of contact point, the use of different specialties is usually necessary to restore the interproximal embrasure. This clinical case report describes an interdisciplinary (periodontic-orthodontic-restorative) approach for the treatment of a patient with severe case of papilla destruction in an esthetic zone. The patient's esthetic expectations for the anterior maxilla were met through phase I treatment, including the surgical reconstruction of the papillary complex and the orthodontic movement to restore the contact point. However, after the initial treatment was successfully concluded, the long-term stability of the result was compromised as the intercommunication among the specialists was not coordinated. CLINICAL SIGNIFICANCE: The treatment plan that involves interdisciplinary teamwork should be followed by an understanding about the principles of the specialties as well the intercommunication among specialists.

Clinical long-term evaluation of acellular dermal matrix in the treatment of root recession: case report.

Several clinical studies have documented success when using an acellular dermal matrix (ADM) to treat mucogingival defects; however, information concerning its long-term stability is limited. This article presents a case involving a patient with root recession treated with an ADM. Probing depth, marginal tissue recession, and the amount of keratinized and attached tissues were evaluated for 10 years post-treatment; the results showed long-term stability during the observation period.

Combining Techniques to Treat Isolated Deep Recession-Type Defects: A Case Report with Long-Term Stability.

INTRODUCTION: The purpose of this case report was to show the clinical long-term stability of a successful two-step root coverage procedure. A combination of two single techniques was used to treat an isolated deep-wide defect. Case Presentation. A 28-year-old female patient was referred in order to treat a single recession defect at #22. Due to her fear of dental procedures and a poor economic situation, the team developed an alternative solution. They used a modified apically repositioned flap (MARF) to increase the donor area and then a laterally positioned flap (LPF) to treat the root defect. Clinical evaluation at the three-year follow-up revealed complete resolution of the defect, a gain in clinical attachment, excellent esthetic results, and minor morbidity to the patient. CONCLUSION: The combination of the MARF and the LPF procedures was able to successfully treat a single deep recession defect with some advantages over traditional techniques such as simplicity, ideal color match of tissues, and the absence of palatal donor tissue.

The Modified Apically Repositioned Flap Technique and Its Potential to Create Attached Gingiva in Areas with No Keratinized Tissue: A Long-Term (1 to 11 Years) Retrospective Case Series Study.

The modified apically repositioned flap (MARF) technique has been previously published as a successful method to increase the zone of attached gingiva with numerous advantages, such as simplicity, predictability, and long-term stability. However, this technique has only been used in areas with at least 0.5 mm of attached gingiva, presurgically. In the current study, the MARF technique was utilized in 21 sites (teeth) with no attached gingiva and only mucosa comprising the marginal tissue. The long-term follow-up results over the course of 1 to 11 years (average follow-up: 3.2 years) show a statistically significant increase of 3.6 ± 0.8 mm for keratinized tissue and of 2.21 ± 0.83 mm for attached gingiva, and no increases in probing depths or marginal tissue recession. These results indicate that the MARF procedure has generated keratinized tissue and attached gingiva in areas with a presurgical absence of these tissues.

Rieger Syndrome: Rehabilitation With Dental Implants.

INTRODUCTION: Axenfeld-Rieger syndrome (ARS), also known as Rieger syndrome, is a rare autosomal dominant condition defined by craniofacial, ocular, dental, periumbilical, and systemic anomalies. CASE PRESENTATION: This case report describes in detail a multidisciplinary approach to successfully restore the oral function and esthetics of a 22-year-old patient diagnosed with ARS. The patient's clinical evaluation revealed that the area corresponding with teeth #13, #12, #11, #21, #22, and #23 was occupied by four malformed and/or deciduous teeth. The four anterior teeth were extracted, and socket preservation was performed using bovine-derived porous bone mineral. Six months after extractions, two implants were placed in the location of the lateral incisors and additional bone graft was performed. Two months after the initial healing, a temporary fixed partial was delivered and 9 months after implant placement the implants were restored with a porcelain-fused-to-metal fixed partial denture. CONCLUSIONS: The use of implant-supported fixed partial dentures to restore missing teeth in patients with ARS provides biological and mechanical advantages over conventional, fixed, or removable prosthodontics. Further evaluation is needed to determine the longevity and long-term prognosis of dental implants in patients with ARS.

Absence of histologic signs of chronic inflammation following closed subgingival scaling and root planing using the dental endoscope: human biopsies - a pilot study.

BACKGROUND: The primary goal of periodontal therapy is the reduction or elimination of inflammation. Traditionally, this is accomplished through removal of subgingival tooth-borne accretions using non-surgical and/or surgical treatment modalities. Numerous studies indicated the difficulty in removing these accretions to the point that histologic manifestations of chronic inflammation are eliminated. A companion to the current study demonstrated that subgingival inflammation was associated most often with calculus covered with biofilm, not biofilm alone. This pilot study evaluated the histologic response in humans to removal of calculus and biofilm with the aid of the dental endoscope. METHODS: Twelve teeth in six patients were identified as test teeth, and all subgingival deposits visible with the endoscope were removed in a single treatment by an operator experienced in root planing and the use of the dental endoscope. The 12 teeth and the coronal portion of their periodontal attachment apparatus were removed 6 months after a single episode of closed subgingival scaling and root planing. Biopsies were processed for histologic evaluation. RESULTS: There were no histologic signs of chronic inflammation. Deposits of calculus and biofilm were seen on one section of one tooth but apparently were deposited after initial therapy. Bone repair and the growth of a long junctional epithelium were observed on previously diseased root surfaces. CONCLUSION: Histologic signs of chronic inflammation were absent 6 months after a single course of closed subgingival scaling and root planing using the dental endoscope.

The Modified Apically Repositioned Flap Technique: A Long-Term (4 to 16 Years) Retrospective Study.

Attached gingiva is desirable for the maintenance of gingival health. Although many methods are used to increase the zone of attached gingiva, the modified apically repositioned flap (MARF) technique has the advantages of simplicity and predictability. The short-term follow-up of the MARF technique demonstrated an increase in keratinized tissue and attached gingiva. This study evaluated long-term results of the MARF technique as used to increase the apicocoronal dimensions of keratinized tissue and attached gingiva in 28 sites (25 patients; average follow-up of 9 years). There was a statistically significant increase in keratinized tissue and attached gingiva with no increase in probing depths or gingival recession. These results suggest that the MARF procedure predictably generates keratinized tissue and attached gingiva with long-term stability.

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.

Use of the Modified Apically Repositioned Flap Technique to Create Attached Gingiva in Areas of No Keratinized Tissue: A Clinical and Histologic Evaluation.

The complete absence of keratinized attached gingiva on the buccal surface of a tooth can make the area more susceptible to gingival recession. The modified apically repositioned flap (MARF) technique is an effective procedure to increase the dimensions of attached gingiva in areas that present with some existing keratinized tissue. The objective of this case report is to present long-term clinical and histologic evidence that the MARF technique can be used to create attached gingiva in areas that lack keratinized tissue.

The modified apically repositioned flap to increase the dimensions of attached gingiva: the single incision technique for multiple adjacent teeth.

This article describes a surgical technique directed at increasing the dimensions of attached gingiva over multiple adjacent teeth. The described technique is a variation of the modified apically repositioned flap (MARF) technique previously proposed. The MARF technique uses one single horizontal incision within keratinized tissue, elevation of a split-thickness flap, and suturing of the flap to the periosteum in an apical position. Periosteum is left exposed in the area between the initial horizontal incision and the coronal margin of the flap. The full perimeter of the exposed periosteal area is completely surrounded by keratinized tissue. Therefore, keratinized epithelial cells migrate over the periosteum during wound healing, resulting in the formation of keratinized attached tissue in the area of the previously exposed periosteum. The advantages associated with this surgical technique include its simplicity: It employs one single horizontal incision, generates minimal morbidity since it does not involve any palatal donor tissue, and provides predictable gingival color match.

Replacement of a fractured upper central incisor with an implant-supported crown: a step-by-step approach to achieve acceptable esthetics.

Implant-supported restorations in the upper anterior segment need to meet biological, functional, and esthetic requirements to be successful. Bone availability and soft-tissue characteristics in the area of implant placement are crucial for achieving maximum success. This article describes the steps involved in replacing a fractured upper central incisor with an implant-supported crown. Using surgical techniques involving extraction socket preservation/augmentation and connective tissue grafting, ideal positioning of the implant was possible and gingival contours were idealized. With this multiple step treatment, the final restoration met biological and functional requirements and its esthetic results were maximized.

A technique for augmenting the palatal connective tissue donor site: clinical case report and histologic evaluation.

This case report describes a simple method for augmenting tissue at prospective palatal connective tissue donor sites. The patient was referred for treatment of facial marginal tissue recession on the maxillary left canine. Clinical examination indicated that the palatal mucosa was thin and did not provide an adequate volume of soft tissue for donor harvesting, precluding the use of a palatal connective tissue graft for treatment of the recession defect. Sterile lyophilized bovine collagen sponge was therefore surgically inserted between a full-thickness palatal flap and bone at the prospective donor site. Eight weeks postoperative, the augmented palatal donor area showed a significant clinical increase in thickness and volume and served as a connective tissue donor source in the treatment of the facial marginal tissue recession. Histologic analysis of the donor tissue demonstrated normal structure, fibrous connective tissue, and abundant collagen. Clinical examination 6 months following surgery showed complete root coverage, with tissue texture, volume, and color similar to those of the adjacent soft tissue. Healing of the donor site was uneventful. This case report demonstrates that sterile lyophilized collagen sponge material may be used to augment palatal donor connective tissue and can subsequently be used as a donor source for soft tissue grafting.

Palatal Augmentation Technique: A Predictable Method to Increase the Palatal Connective Tissue at Donor Sites- A Consecutive Case Series.

The palatal masticatory mucosa between the canine and first molar is the main source of connective tissue graft (CTG) for use in periodontal plastic surgery. The purpose of this study was to evaluate the palatal augmentation technique (PAT) to increase the palatal connective tissue donor area using a collagen sponge inserted between the palatal flap and bone. The 26 patients enrolled in this study were referred for root coverage and ridge augmentation procedures. All patients lacked adequate donor palatal tissue thickness. The PAT uses a full-thickness flap and insertion of a sterile lyophilized bovine collagen sponge between the flap and bone. The palatal thickness was clinically assessed before and after collagen sponge insertion. A manual probe was inserted in the mucosal surface perpendicular to the long axis of each tooth approximately 6 mm from the gingival margin. Probing depth (PD) and recession (REC) were also recorded. Treatment with PAT resulted in a statistically significant increase in the palatal thickness. The overall mean increase was from 2.03 mm before surgery to 3.57 mm after surgery, with no major alterations in PD and REC. Healing proceeded uneventfully and occurred by primary intention. PAT appeared to be a predictable procedure to create connective tissue donor graft in deficient areas and had uneventful postoperative healing.

Surgical Techniques to Increase the Apicocoronal Dimension of the Attached Gingiva: A 1-Year Comparison Between the Free Gingival Graft and the Modified Apically Repositioned Flap.

The attached gingiva is a desirable anatomical element for the maintenance of gingival health. The free gingival graft (FGG) and the modified apically repositioned flap (MARF) are predictable surgical techniques often employed to increase the zone of attached gingiva. This randomized study compared the FGG and the MARF in increasing the zone of attached gingiva in contralateral sides of 15 patients 1 year posttreatment. There was an increase in keratinized tissue and attached gingiva in both groups. Gingival recession did not significantly change between pre- and posttreatment levels in either group. The MARF surgical time was approximately half as long as that of the FGG. The authors conclude that both techniques are viable; however, the main advantages of the MARF were decreased surgical time and less postoperative discomfort.

Nonsurgical periodontal therapy to treat a case of severe periodontitis: A 12-year follow-up.

BACKGROUND AND OVERVIEW: This case report describes the successful treatment of a severe chronic periodontitis case by nonsurgical therapy and a strict maintenance program over a 12-year period. CASE DESCRIPTION: A 38-year-old man concerned about the protrusion of his maxillary incisors was referred for periodontal treatment. The teeth in the maxillary arch had generalized severe chronic periodontitis. Several treatment options were presented to the patient including the most aggressive, extraction of all maxillary teeth, and the most conservative, scaling and root planing. The patient opted to having the most conservative approach, even though the prognoses for the maxillary teeth were unfavorable. Therefore, he received nonsurgical therapy via scaling and root planing combined with systemic antibiotics before referral to an orthodontist to address the esthetic concerns. The maxillary dentition was treated with orthodontic therapy to retract and align the maxillary anterior segment. Periodontal maintenance (1-hour session), including subgingival instrumentation, was performed 4 times per year until the end of the 12-year follow-up period. The patient only missed 2 appointments in 12 years. Twelve years later, the results revealed that all but 1 maxillary tooth were maintained in a state of acceptable health, function, and esthetics. CONCLUSIONS AND PRACTICAL IMPLICATIONS: Although most would agree with the initial poor prognosis of this patient's case, nonsurgical periodontal therapy was utilized with a 3-month periodontal maintenance program and demonstrated long-term success. The outcome presented in this case report may only have been possible because of patient compliance, professional experience, skill, and supervision throughout the course of treatment.

Immediate implants covered with connective tissue membranes: human biopsies.

BACKGROUND: Osseointegration has been shown to occur around implants placed immediately after tooth extraction in humans. To date, such osseointegration has been achieved only with titanium plasma-sprayed (TPS) implants placed in extraction sockets with a bone-to-implant distance of less than 2 mm. In a previous report, when this horizontal defect dimension (HDD) exceeded 2 mm, the resulting percentage of bone-to-implant contact was reduced, indicating that the immediate technique would be limited in most cases to non-molar teeth. In an attempt to improve the bone-to-implant contact and the initial bone-to-implant contact in a vertical dimension, the implant surface, the type of membrane, and the method of membrane placement used in a previous study by our group were modified. METHODS: Ten large-grit sandblasted, acid-attacked (SLA) titanium implants were placed into immediate extraction sites in 5 patients. HDDs of 0.0 to 1.5 mm (controls), 1.5 to 4.0 mm, and >4.0 mm were used. Following insertion, implants were completely covered with a connective tissue membrane. This was in contrast to the use of an expanded polytetrafluoroethylene (ePTFE) membrane penetrated by the neck of the implant in our previous report. Primary closure of soft tissue flaps was achieved in each case. Six months after placement, 7 of the implants were histologically examined. RESULTS: Osseointegration occurred across all HDDs, with the percentage of bone-to-implant contact in the 0.0 to 1.5 mm HDDs similar to that seen in the >4.0 mm HDDs. The first bone-to-implant contact measured vertically was similar in both the smaller and larger HDDs. CONCLUSIONS: Osseointegration was successful in immediate implant placement sites with horizontal defect dimensions wider than 4 mm in humans when SLA titanium implants were completely covered with connective tissue membranes. It remains undetermined whether the different type of membrane, placement of the membrane, type of implant surface, or a combination of these 3 factors were responsible for the improved osseointegration in HDDs >4 mm. Further study is needed.

Histological evaluation of 4 cases of root coverage following a connective tissue graft combined with an enamel matrix derivative preparation.

BACKGROUND: The purpose of this report was to evaluate the histological characteristics of 4 clinically successful root coverage procedures performed with a combination of a connective tissue (CT) graft and an enamel matrix derivative (EMD) preparation. METHODS: Four maxillary teeth (3 canines and 1) first premolar) that presented with mucogingival problems and Miller's Class II and III gingival recession were evaluated in the study. Surgical therapy for root coverage consisted of autogenous CT grafts combined with the topical application of EMD. Following healing, treated teeth were extracted with a portion of their buccal attachment apparatus. Two teeth were extracted at 6 months and 2 teeth at 1 year postoperatively. Specimens were prepared for histology and analyzed by light microscopy. RESULTS: All treated teeth presented with clinical signs of successful root coverage. Histological observations of the 4 specimens revealed similar findings. The junctional epithelium was < or = 2 mm long. Apical to the junctional epithelium, dense CT fibers were found in close proximity to the root surface, but in general, no insertion of these fibers into the root was observed. In one 6-month specimen, formation of new cementum and new bone was observed in the most apical end of the grafted area. CONCLUSIONS: The results of this study suggest that a combination of CT grafts and EMD results mainly in an adhesion between the CT and root surface. Some periodontal regeneration may occur in some regions. The development of a long junctional epithelium was not observed with this combined therapy for the treatment of gingival recession.

Surgical reconstruction of interdental papilla using an interposed subepithelial connective tissue graft: a case report.

The unpredictability of current surgical procedures for papilla reconstruction has been a matter of concern for both periodontists and patients. This case report presents a complete papilla reconstruction in a 20-year-old woman using an interposed subepithelial connective tissue graft. The results show that this technique can be successfully used in treating the loss of papillae and achieving long-term stability. The objective of this report is to describe the surgical technique and comment on the factors that may have influenced the final result.

Root resorption associated with a subepithelial connective tissue graft for root coverage: clinical and histologic report of a case.

This article reports on a case of root resorption following a clinically successful root coverage procedure with a subepithelial connective tissue graft on a maxillary lateral incisor. Two years after the graft procedure was performed, the tooth was extracted in conjunction with the buccal attachment apparatus. Histologic examination of the specimen revealed signs of active resorption of the dentinal surface and bone formation in the deepest portion of the resorption cavity. Possible causative factors of the root resorption process are discussed.

Alveolar bone preservation following tooth extraction: a perspective of clinical trials utilizing osseous grafting and guided bone regeneration.

Based on data from the authors' three clinical trials that focused on the role exerted by various regenerative materials and techniques in preserving alveolar ridge dimensions following tooth extraction, there is evidence to support the use of nonresorbable and resorbable membranes in combination with a closed-socket approach. There also is evidence to support a higher predictability of the results with resorbable membranes compared with nonresorbable membranes because the latter can become exposed to the oral environment during healing. A combination of bioactive glass and calcium sulfate using an open-socket approach is of marginal benefit in preserving alveolar ridge dimensions following tooth extraction. More research is necessary on combining osseous graft/guided bone regeneration using a closed-socket approach, on assessing the quality of bone present in the previous extraction socket following various preservation techniques, and on how effectively preserved/regenerated bone supports dental implants.