Evaluation of the effects of photobiomodulation therapy and ozone applications after gingivectomy and gingivoplasty on postoperative pain and patients' oral health-related quality of life.

The aim of this study was to evaluate the effects of photobiomodulation therapy (PBM) and ozone applications on patients' quality of life after gingivectomy and gingivoplasty. In this study, 36 patients with chronic inflammatory gingival enlargement underwent gingivectomy and gingivoplasty. The groups were randomly divided into control (n = 12), PBM (n = 12) and ozone (n = 12) groups. GaAlAs diode laser 810 nm wavelength at a non-contact and continuous mode with a power of 0.3 W and a density of 4 J/cm2 used for PBM for 1 min. Ozone was applied for 1 min for every 5 mm2 in contact mode at power level 9 using probe number 3. PBM and ozone applications were performed immediately after the operation, on the 3rd and 7th days. Pain assessment was performed at 3rd, 7th, 14th and 28th days after gingivectomy and gingivoplasty by using visual analogue scale (VAS). Oral Health Impact Profile (OHIP-14) records were obtained from the patients before gingivectomy and gingivoplasty and postoperative 7th and 14th days. OHIP-14 questions were also evaluated individually. VAS pain levels of the control group measured on the 3rd day were higher than the PBM group and on the 7th day were found to be significantly higher than both groups (p < 0.05). The total OHIP-14 score of the control group on the 7th postoperative day was found to be higher than the PBM group (p < 0.05). The mean score obtained from the third question of OHIP-14 at 7th and 14th day of the PBM group was found to be lower than the control and ozone groups (p < 0.05). The PBM and ozone applications after gingivectomy and gingivoplasty reduce the pain levels of patients and have a positive effect on patients' quality of life.

Outcome of gingivoperiosteoplasty for the treatment of alveolar clefts in patients with unilateral cleft lip and palate.

Gingivoperiosteoplasty (GPP) has produced inconsistent outcomes. The purpose of this prospective study was to investigate the effects of GPP on the production of bone and maxillary growth. We analysed postoperative cone-beam computed tomographic (CT) scans and intraoral dental photographs of 25 children with complete unilateral cleft lip and palate (UCLP) who were treated with GPP at the same time as their primary repair of the lip. Residual cleft defects and unsupported root ratios of central incisors adjacent to clefts were measured from scans. Dental arch relations were assessed from photographs using the Goslon (Great Ormond Street London and Oslo) yardstick. Eighteen children did not require secondary alveolar bone grafts. Residual cleft defects varied by site (20.4mm(3), 38.6mm(3), 88.2mm(3), and 135.2mm(3) for buccal coronal, palatal coronal, buccal apical, and palatal apical defects, respectively; p<0.001). Unsupported root ratios did not differ significantly between coronal and apical central incisors adjacent to clefts. The mean (SD) Goslon score was 4.52 (0.51). Most participants (n=18) who had a GPP did not need secondary alveolar bone grafting. GPP resulted in least bone on the palatal apical portion of the previous alveolar cleft and relatively good periodontal bony support of central incisors adjacent to the cleft. We no longer use GPP because of our concerns about maxillary growth.

Orthodontic characteristics of maxillary arch deficiency in 5-year-old patients undergoing unilateral cleft lip and palate repair with and without early gingivoplasty.

The purpose of this study was to compare the maxillary arch morphology in 5-year-old children treated for unilateral cleft lip and palate (UCLP) with early gingivoplasty (EGP) and without this procedure (non-EGP). Three-dimensional (3-D) imaging was used to verify which measurements and to what degree specific orthodontic parameters differ in both groups. The study included 120 non-syndromic 4.5-5.5-year-old children treated surgically at the age of 6-18 months. Fifty-six children underwent EGP utilising a Skoog-type of technique. The (non-EGP) group consisted of 64 patients. Patients in both groups were treated without nasoalveolar moulding prior to cleft lip repair. The maxillary arch models were obtained and subjected to the 3-D computer-aided imaging procedure and metric analysis. Ten selected orthodontic measurements were calculated based on imaging landmarks. The computed data derived from models in both (EGP and non-EGP) groups were compared. The differences between groups were statistically analysed using Student's test. Five orthodontic measurements: the angle of the lesser segment inclination, dental arch radius of this segment, anterior palatal depth, palatal surface and length of dental arch demonstrate more severe maxillary underdevelopment in patients with previous EGP. The results reaffirm the negative impact of EGP with wide undermining of periosteal flaps on maxillary development and suggest that these five parameters may be the most sensitive early indicators of growth alteration.

Patient outcomes following subepithelial connective tissue graft and free gingival graft procedures.

BACKGROUND: Subepithelial connective tissue grafts (CTGs) and free gingival grafts (FGGs) are common periodontal procedures with similar indications; however, they may differ regarding patient outcomes. Reports on postoperative periodontal patient outcomes are limited. The aim of this observational trial was to compare patient-based outcomes for CTGs and FGGs. METHODS: Patients who received CTG or FGG completed postoperative questionnaires at 3 days and 3 weeks to assess pain, number of analgesic pills taken, and number of days pills were taken. Postoperative pain was assessed using a visual analog scale (VAS). RESULTS: Twenty-three subjects (12 CTGs and 11 FGGs) completed the study. Differences between CTG and FGG groups in VAS pain scores at 3 days did not reach statistical significance. The proportion of subjects reporting pain in the palate at 3 days was significantly greater for FGG (P <0.05). There were no significant intergroup differences at 3 weeks. For the FGG group, 3-week VAS pain scores were less than the 3-day ones (P <0.01). For the entire study population, the number of days analgesic pills were taken, total number of analgesic pills taken, and number of pills taken from day 3 to the end of the study correlated with the 3-week pain scores. CONCLUSIONS: FGG is associated with a greater incidence of donor site pain compared to CTG at the early postoperative period. Longer-term pain after soft tissue grafting is associated with greater analgesic usage. There is an opportunity to improve the postoperative protocols of soft tissue grafting, particularly for FGG.

Incision techniques and flap designs for apical surgery in the anterior maxilla.

Apical surgery is often a last resort, and is used to surgically preserve a tooth with a recurrent lesion of endodontic origin when conventional re-treatment is neither indicated nor clinically or financially feasible. Incision type and flap design are important factors to consider when outlining the surgical area: the first must ensure optimal access to the root end and the second must allow visibility. A variety of factors must be considered when choosing a specific incision technique, particularly in the anterior maxilla. These include status of the marginal periodontium, location and extent of the periapical lesion, presence of a restoration margin, and the patient's esthetic demands. The outcome with respect to soft tissue healing following apical surgery will further depend on anatomical and surgical aspects, such as the biotype of the gingiva, maintenance of vascular supply, marginal bone structure, technique of flap elevation and retraction, duration of surgery, and wound closure. It is important to address soft tissue healing with the patient during planning of apical surgery because, in solving the endodontic problem, a gingival recession may have been created.

Epithelial inclusion cyst after free gingival graft: a case report.

There have been few case reports of cystic lesions occurring after gingival grafting. There are three reports of this type of sequela after connective tissue grafting, but this is the first known case of a cystlike lesion developing secondarily to a free gingival graft procedure. The bulky tissue, which had developed under the previously grafted area, was properly excised under local anesthesia. The small specimen removed was sent for histologic analysis. A new gingival graft was performed immediately after the lesion enucleation, as the cystic lesion had dislocated the earlier graft. The surgical wound healed uneventfully, and no recurrence was seen 18 months later The microscopic sections showed a cystic cavity lined with an orthokeratinized, hyperplastic, stratified squamous epithelium covered with fibrous connective tissue. The development of a cystlike lesion following a free gingival graft is, to date, an unpublished event. The fact that most cystic lesions appear in the mandibular lateral incisor-canine-first premolar area deserves further consideration.

Postoperative complications following gingival augmentation procedures.

BACKGROUND: Postoperative pain, swelling, and bleeding are the most common complications following soft tissue grafting procedures; however, detailed documentation is sparse in the literature. The aims of this prospective study were as follows: 1) to compare the frequency of complication occurrence after free soft tissue grafting (FSTG) or subepithelial connective tissue grafting (SCTG) procedures; 2) to evaluate the use of an acellular dermal matrix (ADM) as the donor tissue alternative to an FSTG or SCTG; and 3) to identify possible predictors for these complications. METHODS: Seventy-five FSTG and 256 SCTG procedures were performed in 228 patients by a single operator. In five free soft tissue and 84 bilaminar graft procedures, an ADM was used instead of autogenous tissue. Variables such as the duration and location of procedures, smoking history, gender, and age were recorded. Patients were asked to fill out a questionnaire 1 week after the surgeries regarding postoperative pain, swelling, and bleeding. Data were analyzed using the chi2 test and logistic regression analysis. Odds ratios were calculated for moderate and severe adverse outcomes grouped together. RESULTS: The duration of surgical procedures was highly correlated with pain or swelling post-surgically (P = 0.001). Current smokers were three times more likely to experience post-surgical swelling (P = 0.01). Patients who underwent FSTG procedures were three times more likely to develop post-surgical pain (P = 0.002) or bleeding (P = 0.03) compared to those who received SCTG procedures. When an ADM was applied instead of autogenous tissue, the probability of swelling or bleeding was significantly reduced (odds ratio [OR] = 0.46, P = 0.02 and OR = 0.3, P = 0.001, respectively). CONCLUSIONS: Long surgical procedures and smoking may increase the severity and frequency of certain post-surgical complications after gingival augmentation procedures. FSTG procedures incur a higher likelihood for postoperative pain or bleeding than SCTG procedures, whereas the application of an ADM may significantly reduce the probability of swelling and bleeding.

Complications with surgical procedures utilizing connective tissue grafts: a follow-up of 500 consecutively treated cases.

The goal of this study was to evaluate the incidence and severity of the complications that occur after connective tissue grafts are used. Five hundred consecutively treated patients, for whom connective tissue grafts were used for root coverage or gingival augmentation, were included in this study. Complications did occur, but the rates and intensities seemed clinically acceptable. There was no pain reported in 81.4% of the patients, no bleeding in 97.0% of the patients, no infection in 99.2% of the patients, and no swelling in 94.6% of the patients. None of the factors evaluated in this study were associated with a statistically significant increase in the rate or intensity of complications. These factors included: age, sex of patient, smoking status, purpose of the graft (ie, for root coverage or for gingival augmentation), size of the recipient area, and the location of the defect being treated. Based on the results of this study, the incidence and severity of complications seemed to be clinically acceptable.

Bony exostoses developed subsequent to free gingival grafts: case series.

Bony exostosis (BE) is described as a benign localised overgrowth of bone of unknown aetiology. Buccal bony exostosis (BBE) development secondary to soft tissue graft procedures has been reported in a small number of cases. The dental literature describes BBE development also at sites where free gingival grafts (FGG) have been used to increase the amount of gingiva. The following case series describes BBE development at nine sites (five cases) at which FGG was performed to increase the width of the attached gingiva. The presence of exostoses has been recognised during postoperative visits. Histological examination revealed osseous enlargements compatible with the diagnosis of exostoses at two re-entry procedures. In conclusion, based on previous reports, periosteal trauma, eg fenestration, seems to be the main aetiologic agent associated with the development of BBE in areas where FGG were placed.

Comparison of long-term papilla healing following sulcular full thickness flap and papilla base flap in endodontic surgery.

AIM: To compare long-term loss of papilla height when using either the papilla base incision (PBI) or the standard papilla mobilization incision in marginal full thickness flap procedures in cases with no evidence of marginal periodontitis. METHODOLOGY: Twelve healthy patients, free of periodontal disease, who had intact interdental papillae were referred for surgical treatment of persisting apical periodontitis and included in the study. The flap design consisted of two releasing incisions connected by a horizontal incision. The marginal incision involved the complete mobilization of the entire papilla in one interproximal space but in the other interproximal space the PBI was performed. Further apically a full thickness flap was raised. Following flap retraction, standard apical root-end resection and root-end filling was performed. Flap closure was achieved with microsurgical sutures. The PBI was sutured with two to three interrupted sutures (size 7/0), the elevated papilla was reapproximated with vertical mattress sutures (size 7/0), which were removed 3-5 days after the surgery. The height of the interdental papilla was evaluated preoperatively and postoperatively after 1-, 3- and 12-month recall using plaster replicas. The loss of papilla height was measured using a laser scanner. Papilla paired sites were evaluated and statistically analysed. RESULTS: Most papilla recession took place within the first month after the surgery in the complete elevation of the papilla. Further small increase in loss of papilla height resulted at 3 months. After 1 year the loss of height diminished to 0.98 +/- 0.75 mm, but there was no statistical difference between the various recall intervals. In contrast, after PBI only minor changes could be detected at all times. There was a highly significant difference between the two incision techniques for all recall appointments (P < 0.001). CONCLUSIONS: In the short as well as long-term the PBI allows predictable recession-free healing of the interdental papilla. In contrast, complete mobilization of the papilla displayed a marked loss of the papilla height in the initial healing phase although this was less evident 1 year postoperatively. In aesthetically relevant areas the use of the PBI is recommended, to avoid opening of the interproximal space, when periradicular surgical treatment is necessary.

A gingival cul-de-sac following a root coverage procedure with a subepithelial connective tissue submerged graft.

BACKGROUND: The subepithelial connective tissue graft (SCTG) used as a submerged graft in combination with a partial thickness advanced flap or rotated flap is a predictable technique for achieving coverage of the denuded root surface and/or for increasing the width of attached gingiva in Miller's class I and II marginal tissue recessions. However, even with a successful result, complications may occasionally occur. METHODS: A 4-mm marginal tissue recession with an insufficient zone of attached gingiva on the facial aspect of a mandibular left lateral incisor (#23) was covered with a submerged SCTG and an envelope partial thickness flap. The mucogingival defect was successfully corrected. Nevertheless, the facial gingiva, specifically between teeth #22 (mandibular left canine) and #23, remained bulky and was reshaped 6 months postoperatively. A 5-mm long gingival cul-de-sac with an intermittent thick white discharge was detected 3 months following the gingivoplasty procedure. RESULTS: With a periodontal probe kept in the tract, the lining of the cul-de-sac was exposed to the oral cavity by making an incision on the facial gingiva, along the axis of the probe, through to the lumen. The gingival tissue was then removed with a rotary bur until only a thin layer of periosteum remained. The mucosal defect was subsequently repaired by grafting with a non-submerged SCTG. The gingival contour was significantly improved and no sign of recurrence was noted up to 4 years later. CONCLUSIONS: The existence of a cyst cannot be verified without a histological evaluation. However, the development of a gingival cyst should be suspected with persistent tissue bulkiness and/or emergence of a thick white discharge from a site where a submerged SCTG procedure was performed. In addition, the ill-circumscribed border around the lesion makes complete elimination of the pathosis relatively hard to achieve by a "superficial" gingivoplasty procedure.

Evaluation of human recession defects treated with coronally advanced flaps and either enamel matrix derivative or connective tissue. Part 2: Histological evaluation.

BACKGROUND: A number of surgical procedures are effective in covering denuded root surfaces. The first paper in this series evaluated the subepithelial connective tissue graft and the coronally advanced flap with enamel matrix derivative (EMD). That paper revealed no significant difference in the percent of root coverage between the two treatments (P = 0.82). There is limited human histological evidence of the type of attachment achieved with these types of procedures. This paper presents a human case report detailing the histological nature of the attachment of these two treatments to the root surfaces previously exposed by recession. METHODS: One patient presented with two hopeless teeth that were randomized to receive either a subepithelial connective tissue graft or a coronally advanced flap plus EMD. The surgery was accomplished in accordance to the protocol previously described. The teeth and a small collar of tissue were removed at 6 months and underwent histological analysis. RESULTS: Histological evaluation of the subepithelial connective tissue graft revealed a connective tissue attachment between the tooth and graft, and no histological evidence of cementum, bone, or periodontal ligament (PDL) and, therefore, regeneration. In addition, there appeared to be some resorption of the dentin adjacent to the graft. Histological evaluation of the coronally advanced flap with EMD revealed new cementum, organizing PDL fibers and islands of condensing bone at a constant distance from the root surface. CONCLUSIONS: The subepithelial connective tissue graft in this study was found to have adhered to the root surface primarily by a connective tissue attachment with some evidence of root resorption. The coronally advanced flap with EMD was found histologically to have all the tissues necessary for regeneration: new cementum, organizing PDL fibers, and islands of condensing bone. These histologic sections strongly suggest that enamel matrix derivative works in a biomimetic fashion by mimicking the natural process of tooth development.

Bilaminar techniques for the treatment of recession-type defects. A comparative clinical study.

OBJECTIVES: Complete root coverage is the primary objective to be accomplished when treating gingival recessions in patients with aesthetic demands. Furthermore, in order to satisfy patient demands fully, root coverage should be accomplished by soft tissue, the thickness and colour of which should not be distinguishable from those of adjacent soft tissue. The aim of the present split-mouth study was to compare the treatment outcome of two surgical approaches of the bilaminar procedure in terms of (i) root coverage and (ii) aesthetic appearance of the surgically treated sites. MATERIAL AND METHODS: Fifteen young systemically and periodontally healthy subjects with two recession-type defects of similar depth affecting contralateral teeth in the aesthetic zone of the maxilla were enrolled in the study. All recessions fall into Miller class I or II. Randomization for test and control treatment was performed by coin toss immediately prior to surgery. All defects were treated with a bilaminar surgical technique: differences between test and control sites resided in the size, thickness and positioning of the connective tissue graft. The clinical re-evaluation was made 1 year after surgery. RESULTS: The two bilaminar techniques resulted in a high percentage of root coverage (97.3% in the test and 94.7% in the control group) and complete root coverage (gingival margin at the cemento-enamel junction (CEJ)) (86.7% in the test and 80% in the control teeth), with no statistically significant difference between them. Conversely, better aesthetic outcome and post-operative course were indicated by the patients for test compared to control sites. CONCLUSIONS: The proposed modification of the bilaminar technique improved the aesthetic outcome. The reduced size and minimal thickness of connective tissue graft, together with its positioning apical to the CEJ, facilitated graft coverage by means of the coronally advanced flap.

Post-surgical hemorrhage: formation of a "liver clot" secondary to periodontal plastic surgery.

Bleeding is a common sequela of periodontal and oral surgery. Generally, bleeding is self-limiting. Special circumstances require additional procedures to reduce or eliminate active hemorrhage. Occasionally hemorrhage can be under control when a patient is dismissed from their surgical appointment and, subsequently, the patient will experience either slow seepage of blood or extravascular clot formation. This case report describes the unique formation of a "liver clot" or "currant jelly clot" following periodontal plastic surgery. The clotting cascade and common laboratory tests to evaluate bleeding disorders are also presented.

Osseous resective surgery.

Osseous resective surgery necessitates following certain guidelines for proper recontouring of the alveolar bone and proper management and positioning of the gingival tissues. The results from osseous resective surgery are technique sensitive. It has limited use in treating cases with very deep intrabony or hemiseptal defects, which should be treated with a different surgical approach. If osseous resective surgery is used in advanced lesions, a compromise in the amount of probing depth reduction should be expected. Yet, osseous resective surgery provides the surest method of reducing pockets with an intrabony or hemiseptal osseous component of 3 mm or less, albeit at the expense of some attachment in the neighboring less involved sites. Osseous resective surgery has been and remains one of the principal periodontal treatment modalities because of its proven success (Fig. 17).

Root coverage with a connective tissue with partial thickness double pedicle graft and an acellular dermal matrix graft: a clinical and histological evaluation of a case report.

Root coverage can be achieved by many techniques. In this case report a patient was treated with a connective tissue with partial thickness double pedicle graft, which resulted in complete root coverage. However, 6 days postsurgery the patient developed a bleeding problem from the palatal donor area. For this reason, a unique approach was used to treat the next area needing root coverage. The procedure combined an acellular dermal matrix and a coronally positioned pedicle. The procedure was used to treat 3 defects. Complete root coverage was obtained on 2 of the 3 defects. The third was covered to within 1 mm of the cemento-enamel junction (CEJ). Histology showed similar results with a connective tissue graft and an acellular dermal matrix. Verhoeff's staining demonstrated that the acellular dermal matrix was incorporated into the gingival tissue. This case report demonstrated that acceptable results can be obtained with the connective tissue with partial thickness double pedicle graft and the acellular dermal matrix combined with a coronally positioned pedicle, both clinically and histologically.

[Conditions of the successful outcome of mucogingival surgery during orthodontic treatment]. / Conditions de la réussite des interventions de chirurgie muco-gingivale au cours du traitement orthodontique.

For the last twenty years the mucogingival surgical technics, particularly displaced flaps, have brought gingival tissue when it is missing improving the periodontic outcome of orthodontic treatment. The displaced flaps are indicated where is a deficient attached gingiva or for uncovering retained cuspids. This state of the art is done both for the surgical and orthodontic care that are necessary as well as for the possible problems and complications after surgery.

Wound healing after mucoperiosteal surgery in the cat.

The purpose of this study was to examine possible tissue-dependent differences in rate of healing after mucogingival flap surgery. After intrasulcular incision and a vertical-releasing incision distal to the maxillary and mandibular cuspids, buccal, full-thickness mucogingival flaps were raised in four quadrants of 10 adult cats. The triangular flaps were left open for 30 min and then repositioned and sutured. Tissue reactions were studied histologically after 1, 3, 7, 14, and 28 days of healing. Although new collagen occasionally was observed in the wound space in the free gingiva at 3 days, collagenous union between the cut dentogingival fibers and the flap seemed well established at 7 days. Flap reattachment to the denuded cortical bone was seen at 14 days in the region of the attached gingiva. In the region of the alveolar mucosa, however, residual coagulum and inflammatory reaction was present as late as at 28 days in several specimens. These observations indicate a marked difference in rate of healing among the different interfaces involved. These variations seem to be related to variations in size of the resulting wound space when a full-thickness mucoperiosteal flap is readapted over cervical root surfaces, alveolar bone crest, and denuded cortical bone, respectively.

Exostosis associated with autogenous gingival grafts: a report of 9 cases.

This report describes 9 cases presenting exostosis at mandibular and maxillary sites where autogenous gingival grafts have been used to increase the amount of attached gingiva. The exostoses were recognized during routine dental examinations and identified by palpation, horizontal sounding, occlusal radiographs, and in one case by histologic examination. Only in three cases was there a surgical removal of exostosis and recurrence was not observed during a follow-up evaluation. The remainder of the cases were not treated and the exostoses appeared to have limited growth. Apparently, a correlation between the presence of tori and the development of exostosis could not be established in these series of case reports, but a possible explanation with respect to the mechanism of bone formation is discussed along with the clinical implications of this interesting clinical finding.