Augmentation of keratinized tissue using autogenous soft-tissue grafts and collagen-based soft-tissue substitutes at teeth and dental implants: Histological findings in a pilot pre-clinical study.

AIM: To histomorphometrically assess three treatment modalities for gaining keratinized tissue (KT) at teeth and at dental implants. MATERIALS AND METHODS: In five dogs, the distal roots of the mandibular second, third and fourth premolars were extracted. Dental implants were placed at the distal root areas 2 months later. After another 2 months, KT augmentation was performed at both distal (implants) and at mesial root (teeth) areas in the presence (wKT groups) or absence (w/oKT groups) of a KT band at the mucosal/gingival level. Three treatment modalities were applied randomly: apically positioned flap only (APF), free gingival grafts (FGGs) and xenogeneic collagen matrices (XCMs). A combination of the above produced six groups. Two months later, tissue sections were harvested and analysed histomorphometrically. RESULTS: The median KT height and length were greatest at implants with FGG in both wKT (3.7 and 5.1 mm, respectively) and w/oKT groups (3.7 and 4.6 mm), and at teeth with FGG in wKT groups (3.7 and 6.1 mm) and with APF in the w/oKT groups (3.9 and 4.4 mm). The XCM and APF produced more favourable results at teeth than at implants. CONCLUSIONS: FGG was advantageous in gaining KT, especially at implants.

[Timing and surgery option of keratinized mucosa augmentation around implant site].

In recent years, clinicians have paid more attention to the biological and esthetic effects of the 2 mm keratinized mucosa width (KMW) around dental implant. How to increase the keratinized mucosa is the focus of clinicians. While the free gingival graft (FGG) is still the gold standard of keratinized mucosa augmentation, alveolar ridge preservation (ARP), connective tissue graft (CTG) and apically positioned flap (APF) can also be used to obtain more than 2 mm keratinized mucosa width when they are used before implantation, with implantation, within the implant-healing phase, with second stage of implantation or after rehabilitation according to different indications. This article comprehensively summarizes the influencing factors of timing and surgical procedures for keratinized mucosa augmentation, providing guidance for clinicians to treat peri-implant keratinized mucosa deficiencies.

Coronally Advanced Entire Papilla Preservation (CA-EPP) Flap in the Treatment of an Isolated Intrabony Defect to Promote Buccal and Interproximal Soft Tissue Stability: Case Reports.

Surgical treatment of infrabony defects may result in gingival recession of the neighboring teeth. The aim of this clinical report is to describe a surgical technique to promote gingival margin stability in the treatment of infrabony defects at sites with a thin or medium gingival phenotype. A coronally advanced entire papilla preservation (CA-EPP) flap with a connective tissue graft (CTG) was executed in two different clinical cases. This technique substantially improved interproximal clinical attachment level and pocket closure, with no gingival recession. A CA-EPP flap using a CTG may promote gingival margin stability and can be recommended in regenerative periodontal procedures.

Augmentation of Peri-implant Keratinized Mucosa Using a Combination of Free Gingival Graft Strip with Xenogeneic Collagen Matrix or Free Gingival Graft Alone: A Randomized Controlled Study.

Purpose: To evaluate the gain in peri-implant keratinized mucosa (KM) using a combination of a free gingival graft (FGG) strip with a xenogeneic collagen matrix (XCM) and compare it to that of an FGG alone. Materials and Methods: This randomized controlled clinical study included a total of 30 patients with a minimal amount of peri-implant KM (≤ 1 mm) in the maxillary and mandibular anterior regions (including the premolars). The study population was divided into two groups using a randomization protocol; group A (n = 15) received a combination of FGG strip and XCM, and group B (n = 15) received FGG only to augment the KM. Clinical parameters included width of KM (WKM) measured at baseline, 1 month, and 6 months; a customized pink esthetic score (PES) measured at baseline and 6 months; and patient morbidity using visual analog scale (VAS) at days 1, 7, and 14 postoperatively. Results: After 1 month, both groups showed statistically significant gain in KM that reduced slightly by the 6-month follow-up but remained statistically significant when compared to baseline. When the gain was compared between the two groups, the difference was not statistically significant. Better esthetic outcomes and lower morbidity were reported in group A compared to group B, and this difference was statistically significant. Conclusions: Within the limitations of the study, it can be concluded that the combination of FGG strip with XCM is a viable alternative to the use of FGG in augmenting peri-implant KM.

Three-dimensional changes of a porcine collagen matrix and free gingival grafts for soft tissue augmentation to increase the width of keratinized tissue around dental implants: a randomized controlled clinical study.

BACKGROUND: Emerging clinical data points to the relevance of the presence of keratinized tissue (KT). Although apically positioned flap/vestibuloplasty along with free gingival graft (FGG) is considered as a standard intervention for augmenting KT, substitute materials appear to be a viable treatment alternative. So far, there is a lack of data investigating the dimensional changes at implant sites treated with soft-tissue substitutes or FGG. AIM: The present study aimed at comparing three-dimensional changes of a porcine derived collagen matrix (CM) and FGG for increasing KT at dental implants over a 6-month follow-up period. MATERIALS AND METHODS: The study enrolled 32 patients exhibiting deficient KT width (i.e., < 2 mm) at the vestibular aspect who underwent soft tissue augmentation using either CM (15 patients/23 implants) or FGG (17 patients/31 implants). The primary outcome was defined as tissue thickness change (mm) at treated implant sites between 1- (S0), 3- (S1), and 6-months (S2). Secondary outcomes considered changes of KT width over a 6-month follow-up period, surgical treatment time, and patient-reported outcomes. RESULTS: Dimensional analyses from S0 to S1 and from S0 to S2 revealed a mean decrease in tissue thickness of - 0.14 ± 0.27 mm and - 0.04 ± 0.40 mm in the CM group, and - 0.08 ± 0.29 mm and - 0.13 ± 0.23 mm in the FGG group, with no significant differences noted between the groups (3 months: p = 0.542, 6 months: p = 0.659). Likewise, a comparable tissue thickness decrease was observed from S1 to S2 in both groups (CM: - 0.03 ± 0.22 mm, FGG: - 0.06 ± 0.14 mm; p = 0.467). The FGG group exhibited a significantly greater KT gain after 1, 3 and 6 months compared to the CM group (1 month: CM: 3.66 ± 1.67 mm, FGG: 5.90 ± 1.58 mm; p = 0.002; 3 months: CM: 2.22 ± 1.44; FGG: 4.91 ± 1.55; p = 0.0457; 6 months: CM: 1.45 ± 1.13 mm, FGG: 4.52 ± 1.40 mm; p < 0.1). Surgery time (CM: 23.33 ± 7.04 min.; FGG: 39.25 ± 10.64 min.; p = 0.001) and postoperative intake of analgesics were significantly lower in the CM group (CM: 1.2 ± 1.08 tablets; FGG: 5.64 ± 6.39 tablets; p = 0.001). CONCLUSIONS: CM and FGG were associated with comparable three-dimensional thickness changes between 1 and 6 months. While a wider KT band could be established with FGG, the use of CM significantly reduced surgical time and patients´ intake of analgesics.

Xenogeneic collagen matrix versus free gingival graft for augmenting keratinized mucosa around posterior mandibular implants: a randomized clinical trial.

OBJECTIVES: To assess the clinical efficacy of xenogeneic collagen matrix (XCM) plus apically positioned flap (APF) in augmenting the keratinized mucosa (KM) width (KMW) and thickness (KMT) around posterior mandibular implants and compare it with free gingival graft (FGG) plus APF. MATERIAL AND METHODS: Thirty patients with KMW ≤ 2 mm in the posterior mandibular implant site were randomly allocated to the FGG group (FGG plus APF) or the XCM group (XCM plus APF). Clinical assessments, including KMW and KMT, shrinkage rate of established KM, and peri-implant soft tissue health, were evaluated during a 6-month follow-up. Additionally, the esthetic outcomes and patient-reported postoperative morbidity were investigated. RESULTS: At 6 months, the KMW measured 3.60 ± 0.79 mm in the FGG group and 3.28 ± 0.96 mm in the XCM group (p = 0.186). Both groups showed a tendency for graft contraction (FGG, 42.11%; XCM, 53.22%). The KMT measured 1.24 ± 0.34 mm in the FGG group and 0.95 ± 0.29 mm in the XCM group, with statistical difference (p = 0.002). No difference in the peri-implant soft tissue health was observed between the two groups (p > 0.05), but the esthetic outcomes were better in the XCM group (p < 0.05). CONCLUSIONS: XCM plus APF rendered a similar clinical efficacy in augmenting KMW as that with FGG plus APF, but with higher shrinkage. XCM plus APF was inferior with respect to FGG plus APF in augmenting KMT. The esthetic outcomes were better with XCM plus APF than FGG plus APF. Clinical relevance XCM plus APF graft was inferior with respect to FGG plus APF in augmenting KMT. TRIAL REGISTRATION: Trial registration number: ChiCTR2200058027 and date: 03/27/2022.

Gingival pedicle with split-thickness tunnel technique: A retrospective case series for single mandibular anterior recessions.

INTRODUCTION: Gingival recessions in the mandibular anterior sextant are a common clinical finding, but mucogingival treatment in this location is particularly challenging, due to several anatomical and surgical difficulties. In the present case series, a novel technique, called gingival pedicle with split-thickness tunnel (GPST), was retrospectively evaluated. CASE SERIES: Fifteen patients presenting with a single buccal RT1 or RT2 gingival recession of a depth of ≥3 mm in the mandibular anterior sextant were treated by means of the GPST technique. Clinical periodontal parameters at baseline and at the last follow-up evaluation visit (6-84 months) were compared. Early healing was uneventful in all cases, and no complications such as flap dehiscence or loss of connective tissue graft were observed. Mean root coverage (mRC) was 98.1% ± 7.38%, corresponding to a statistically significant recession reduction (ΔRD) of 4.53 ± 1.19 mm. Complete root coverage was achieved in 14 of 15 cases. The gain in keratinized tissue width amounted to 3.13 ± 0.99 mm and was statistically significant, whereas no significant change in periodontal probing depth was observed after treatment. CONCLUSION: In conclusion, treatment with GPST technique seems to achieve a favorable and predictable clinical improvement in gingival recessions on mandibular anterior teeth. Why are these cases new information? Limited information is available about the management of isolated deep labial recessions in the mandibular anterior teeth. A novel surgical approach, called GPST technique, is described in a case series to specifically address this type of defect. What are the keys to successful management of these cases? Horizontal incision ≥ RECwidth Cut-back preparation helps to mobilize the flap without tension. CTG width ≥ 3 times RECwidth CTG height ≥ RECdepth Proper graft and flap stabilization need to be achieved. What are the primary limitations to success in these cases? Limited mesio-distal dimensions, which do not allow to obtain a pedicle with adequate horizontal width Very thin biotype may not be suitable because of the risk of inadequate flap vascularization.

Gingival fenestration defect treated with gingivectomy and gingivoplasty: A case report with an 8-year follow-up.

INTRODUCTION: Gingival fenestration (GF) is scarcely reported in the literature. We present a unique case of GF defect combined with gingivitis and altered passive eruption (APE). CASE PRESENTATION: An 18-year-old female patient with gingivitis, APE, and GF in the mandibular left central incisor presented for periodontal treatment. The gingival lesion was successfully treated with basic periodontal therapy gingivectomy, and gingivoplasty and resulted in an excellent aesthetic long-term outcome. This case report shows its 8-year clinical follow-up. CONCLUSION: There are no earlier reports dealing with the use of gingivoplasty for the treatment of GF, as it is not the usual therapeutic intervention for these defects. Gingivoplasty proved to be effective in treating GF. Why is this case new information? Available literature on gingival fenestration defects does not describe gingivectomy and gingivoplasty as a treatment of choice. Gingivectomy and gingivoplasty proved to be effective in treating gingival fenestration defects. What are the keys to successful management of this case? Proper diagnosis. What are the primary limitations to success in this case? Gingival fenestration has been defined when the overlying gingiva is denuded, exposing the root to the oral cavity. However, in this case report, only the crown was exposed because the patient had altered passive eruption.

Modified gingivoplasty for hereditary gingival fibromatosis: two case reports.

BACKGROUND: Hereditary gingival fibromatosis (HGF) is characterized by sub-epithelial fibromatosis of keratinized gingiva resulting in a fibrotic enlargement of keratinized gingiva. The treatment choice is gingivectomy, which can be performed with an internal or external bevel incision conventionally. However, both techniques can hardly resume the natural status of gingiva, and have a certain recurrence rate, especially in the cases which have limited width of attached gingiva. CASE DESCRIPTION: Two cases of HGF with the chief complaint of difficulty in mastication, pronunciation, and poor esthetics were presented. After the initial periodontal therapy, a novel gingivoplasty modified with a crevicular incision was applied. A full thickness flap above the mucogingival junction and a split flap below the junction were raised. Then, fibrotic connective tissue was completely eliminated and keratinized gingival epithelium was preserved. The fibrotic alveolar bone was shaped by handpiece and bur. Finally, the flap was apically repositioned and sutured. Twelve months after surgery, the gingiva recovered with normal color, contour and consistency. CONCLUSIONS: Compared to traditional gingivectomy, modified gingivoplasty which focuses on eliminating pathological fibrotic connective tissue can completely resume the natural appearance of gingiva and demonstrate no tendency of recurrence.

Clinical applications of mucogingival therapies utilizing adjunctive autologous blood products.

BACKGROUND: Mucogingival deformities are prevalent oral conditions and can result in esthetic compromise, dentinal hypersensitivity, and an increase in radicular caries rates. Mucogingival treatments address thin periodontal phenotype and/or gingival recession defects. Although many of these grafting procedures are predictable in improving soft-tissue quality and quantity around teeth and dental implants, patients often complain of discomfort at both the donor and recipient sites. Free gingival grafts and coronally advanced flaps alone or in combination with subepithelial connective tissue graft and/or acellular dermal matrix are among the most common surgical procedures employed to achieve root coverage and enhance periodontal phenotype. Autologous blood products (ABPs) contain platelets, growth factors, leukocytes, and stem cells that contribute to cell mitosis, collagen production, and angiogenesis, leading to the healing and regeneration of hard and soft tissue. Evaluation of the adjunctive role of ABPs in mucogingival surgery and their impacts on clinical and patient-centered data is critical to achieve optimal patient-reported outcome measures based upon the current scientific evidence. METHODS: We present exemplar cases in which adjunctive ABPs were utilized in mucogingival treatment to enhance treatment outcomes. RESULTS: No adverse events were noted. Satisfactory treatment outcomes were achieved in patients with local and/or systemic compromise when mucogingival therapies were used in combination with ABPs. CONCLUSIONS: Adjunctive use of ABPs may enhance outcomes of mucogingival therapy. Utilization of adjunctive ABPs may be particularly advantageous in situations where the predictability of clinical and esthetic outcomes is limited due to anatomical and/or patient factors.

Connective tissue graft versus xenogeneic collagen matrix for soft tissue augmentation at implant sites: a randomized-controlled clinical trial.

OBJECTIVES: The purpose of this randomized clinical trial (RCT) is to compare xenogeneic collagen matrix (XCM) versus subepithelial connective tissue graft (SCTG) to increase soft tissue thickness at implant site. MATERIALS AND METHODS: The study was a randomized, parallel-group controlled investigation. Thirty patients underwent buccal soft tissue thickness augmentation at the stage of implant placement by two different methods: SCTG (control group) and XCM (test group). Primary outcome was the amount of buccal soft tissue thickness gain, 3 months after the intervention. Secondary outcomes were the operation time, the amount of keratinized mucosa (KM), pain syndrome (PS), and patients' quality of life (QL). Histologic evaluation was also performed. RESULTS: The amount of soft tissue thickness gain was 1.55±0.11 mm in SCTG group, and 1.18±0.11mm in XCM group. The difference between the SCTG and XCM was -0.366 (-0.66 to -0.07; p=0.016). Operation time with XCM was 8.4 (3.737 to 13.06) min shorter than that with the SCTG (p=0.001). KT, PS, and QL for both groups were not statistically significantly different at any time point (p>0.05). At histological examination, the general picture in both groups was similar. No significant differences between the studied groups in most indices, except for the average and maximum formation thickness, cellularity of the basal, mitotic activity and also maximum length of rete ridges. CONCLUSION: Within limitations, this study demonstrates that the use of SCTG provides a statistically significant superior soft tissue thickness gain than XCM for soft tissue augmentation procedures around implants. CLINICAL RELEVANCE: XCM can be used as the method of choice for increasing the thickness of soft tissues.

A Minimally Invasive Approach for the Treatment of Multiple Adjacent Gingival Recessions with a Volume-Stable Collagen Matrix: A Case Series.

Several soft tissue graft materials have been utilized over the years as alternatives to the autogenous connective tissue graft for reducing patient morbidity. In particular, a novel volume-stable xenogeneic collagen matrix (VXCM) has recently been introduced for soft tissue augmentation at implant sites. The VXCM is porous in nature, and its mechanical properties suggest utilizing a specific flap approach when treating multiple adjacent gingival recessions (MAGRs). Herewith, a minimally invasive surgical technique is described in combination with VXCM for treatment of MAGRs. Five patients with 16 MAGRs were treated with this approach. All sites healed uneventfully, and patients reported minimal discomfort. At 6 months, the technique resulted in a mean root coverage of 94.73%, and complete root coverage was achieved in 13 sites (81.25%). The proposed minimally invasive approach may have potential to enhance flap blood supply and graft vascularization, promoting rapid healing with minimal postoperative discomfort. In addition, this approach can result in satisfactory clinical, esthetic, and patient-reported outcomes. Future adequately powered clinical trials are needed to validate the findings of this preliminary report.

Augmentation of Interdental Papilla at Implant/Tooth Sites with the Tunneling Technique and a Pedicle Graft: Technique and Case Report.

Maintaining or creating adequate papillary form is a challenge when placing implants in the esthetic zone. Often, outcomes of procedures designed to maintain or enhance papillae at implant sites yield unsatisfactory results and require secondary microsurgical interventions. This article describes a surgical technique to augment interdental papillae between implants and teeth. The technique uses pedicle flaps from the palate combined with tunneling and is capable of creating a substantial papilla augmentation utilizing vascularized grafts. The surgical technique and requirements for success are presented with a case report.

A customized subepithelial connective tissue graft for interdental papilla reconstruction and soft tissue augmentation.

OBJECTIVE: Due to the minimal blood supply and other reasons, stable reconstruction of interdental papilla is difficult. This article presented three cases, which describe a customized subepithelial connective tissue graft aiming to overcome the clinical challenge, with the combination of tunneling technique. CLINICAL CONSIDERATIONS: An original customized subepithelial connective tissue graft combined with tunnel technique aimed to reconstruct interdental papilla (IP). The subepithelial connective tissue graft was partially spilt to create a bowtie-like shape, with four lateral wings and a main body. The four wings were tightly wrapped around the adjacent abutments, and the body part was used to reconstruct the IP. CONCLUSIONS: With the customized subepithelial connective tissue graft, a favorable outcome has been preliminarily confirmed in these cases. Facing patients with a lack of gingival papilla and soft tissue fullness, the customized subepithelial connective tissue graft may be a good choice. CLINICAL SIGNIFICANCE: This study provides a new method to reconstruct IP. The customized subepithelial connective tissue graft may be a good choice when a lack of gingival papilla and soft tissue fullness occurs, which will be of great benefit to meet the aesthetic needs of patients.

Esthetic Mucogingival Treatment After Biopsy of Inflammatory Fibroepithelial Hyperplasia.

INTRODUCTION: This case reports a biopsy of a large soft tissue defect with gingival grafting. The therapeutic approach presented here combines a partly de-epithelialized free gingival graft (PDFGG) with an envelope technique, which may be useful for cases needing a large reactive lesion biopsy. CASE PRESENTATION: A patient with an esthetic and functional complaint due to a fibroepithelial hyperplastic lesion was treated by excisional biopsy leaving a 10 mm cervical defect on tooth 23. A palatal PDFGG was harvested and sutured into the defect, using an "envelope technique" to improve the blood supply to the graft. The procedure is aimed at both recession coverage and reduction in root hypersensitivity. Stability of the outcome is demonstrated 9 months post-operative. CONCLUSIONS: Gingival margin biopsies pose a significant challenge due to the need to combine significant tissue removal while providing a predictable esthetic and functional outcome. The case is the first description of a successful grafting of a large residual gingival biopsy defect, resulting from using combined mucogingival surgical approach. This technique may be helpful for similar cases.

Gingivosupraperiosteoplasty following Presurgical Maxillary Orthopedics Is Associated with Normal Midface Growth in Complete Unilateral and Bilateral Cleft Patients at Mixed Dentition.

BACKGROUND: Passive orthodontic appliances and gingivosupraperiosteoplasty are adjuncts that can be used by surgeons at the time of primary cleft lip repair. These treatments, along with the surgical technique of cleft lip and palate repair, may impact midface growth. The objective of this study was to describe the authors' protocol for unilateral and bilateral cleft lip repair and to evaluate midfacial growth in a cohort of patients at mixed dentition who had undergone presurgical passive orthodontic appliance therapy and gingivosupraperiosteoplasty at the time of unilateral and bilateral cleft lip repair. METHODS: Fifteen complete unilateral and 15 complete bilateral cleft lip and palate patients underwent passive orthodontic appliance treatment and primary lip repair with gingivosupraperiosteoplasty. Lateral cephalograms were analyzed by three blinded reviewers. Mean cephalometric measurements at mixed dentition were compared to cephalometric values for noncleft patients, unilateral cleft lip and palate patients who did not undergo gingivoperiosteoplasty or presurgical treatment, and unilateral cleft lip and palate patients who underwent gingivoperiosteoplasty/nasoalveolar molding with independent samples t tests. RESULTS: Mean cephalometric values were within age-specific normal values for sella-nasion-A point, sella-nasion-B point, A point-nasion-B point, and facial axis. Eighty-seven (13/15) percent of unilateral cleft lip and palate patients and 93 percent (14/15) of bilateral cleft lip and palate patients did not exhibit skeletal class III malocclusion. There was no significant difference between cephalometric values for our patients and patients who did not receive gingivosupraperiosteoplasty or presurgical treatment or who underwent the gingivoperiosteoplasty/nasoalveolar molding protocol. CONCLUSIONS: Presurgical passive orthodontic appliances, combined with gingivosupraperiosteoplasty at the time of lip repair, leads to normal maxillary development in most patients at mixed dentition. Assessment of midface growth at skeletal maturity is required. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Tratamiento de recesiones gingivales unitarias y múltiples en la zona anterior mandibular mediante técnica de Edlan-Mejchar modificado. Descripción de la técnica quirúrgica y resultados / Treatment of isolated and multiple gingival recessions in the anterior mandibular area using a modified Edlan-Mejchar technique. Description of the surgical technique and results

El tratamiento de recesiones gingivales utilizando procedimientos de cirugía plástica periodontal es habitualmente requerido en la odontología moderna. El objetivo final de estos procedimientos es la cobertura completa de la raíz y los resultados estéticos agradables. La literatura muestra que el colgajo de avance coronal + injerto de tejido conectivo podría ser considerado como el "gold standard" para el tratamiento de recesiones gingivales unitarias. Sin embargo, en la arcada inferior podemos encontrarnos con limitaciones anatómicas que nos impidan realizar las técnicas convencionales de cirugía mucogingival. En este trabajo se presenta y describe el tratamiento de recesiones gingivales unitarias y múltiples que afectan a la zona anteroinferior, las cuales se trataron mediante la técnica de Edlan-Mejchar modificada. La utilización de la técnica de Edlan-Mejchar modificada muestra resultados positivos para tratar recesiones gingivales en el sector anteroinferior

Treatment of gingival recessions using periodontal plastic surgery procedures is routinely required in modern dentistry. The ultimate goal of these procedures is complete root coverage and pleasing aesthetic results. The literature shows that the coronal advancement flap + connective tissue graft could be considered as the "gold standard" for the treatment of single gingival recessions. However, in the lower arch we can find anatomical limitations that prevent us from performing conventional mucogingival surgery techniques. In this work we present and describe the treatment of single and multiple gingival recessions that affect the lower anterior zone, which were treated using the modified Edlan-Mejchar technique. The use of the modified Edlan-Mejchar technique shows positive results to treat gingival recessions in the mandibular anterior area