Efficacy of platelet-rich fibrin and connective tissue graft in papilla reconstruction.

PURPOSE: To evaluate efficacy of platelet-rich fibrin (PRF) or connective tissue graft (CTG) in papilla reconstruction (PR) with the semilunar incision (SI) technique. MATERIALS AND METHODS: The analysis consisted of 55 sites (27 CTG and 28 PRF) from 20 patients who underwent PR with either PRF or CTG placed in the maxillary anterior region with SI technique. Baseline (BL) and follow-up (T1 , first month, T3 , third month, T6 , sixth month) clinical data including periodontal evaluations (gingival index (GI), plaque index (PI), pocket depth (PD), keratinized tissue width (KTW), gingival recession), papilla-associated recordings (alveolar crest-interdental contact point [AC-IC], alveolar crest-papilla tip [AC-PT], papilla tip-interdental contact point [PT-IC], papilla height loss [PHL], interdental tissue stroke [ITS] and papilla presence index [PPI]) and patient satisfaction were analyzed. RESULTS: CTG provided better PR outcomes. GI, PI, and PD showed a slight increase at T1 and then, turned to their BL levels. The other periodontal parameters showed significant improvement after both treatment modalities. No inter-group difference was found except for KTW, which was in favor of CTG. CONCLUSION: Based on the results, CTG is recommended over PRF in PR treatment due to its superior outcomes with less recurrence risk. CLINICAL SIGNIFICANCE: Connective tissue graft provides superior results than platelet-rich fibrin in papilla reconstruction with the semilunar incision technique.

Evaluation of the Effects of Er:YAG Laser for the De-Epithelialization of the Palatal Graft in the Treatment of Multiple Gingival Recessions: A Randomized Clinical Trial.

Objective: The purposes of this split-mouth pilot study were to investigate the efficacy of the Er:YAG laser use for the de-epithelialization of the palatal graft in the treatment of the multiple gingival recessions using the bilaminar procedure and also to evaluate the patient-reported esthetic outcomes after 6 months. Materials and methods: Five systemically healthy participants with total 28 bilateral-multiple adjacent maxillary Miller I recessions were included. The treatment was performed with the bilaminar technique [coronally advanced flap (CAF)+de-epithelialized free gingival graft]. De-epithelialization procedure was done with scalpel (control site) or Er:YAG laser (Versawave, Hoya ConBio, San Francisco, CA; 40 hz, 50 mJ/pulse), under water irrigation, noncontact mode (∼1 mm away from the target tissue) in sweeping motion with chisel-type laser (test site). Root coverage and patient-reported outcomes were evaluated at 6 months after the operations. Results: Clinical outcomes of the both treatment sites did not show any statistically significant differences except for the gingival thickness parameter. However, patient-reported outcomes regarding the esthetic appearance of the gingiva was detected in favor of the Er:YAG laser applied sites. Conclusions: Within the limits of the study, it can be concluded that both de-epithelialization techniques were highly effective at 6 months. However, Er:YAG laser-applied grafted sites revealed more uniform and esthetic gingival appearance compared with scalpel-used grafted sites.

Una Nueva Alternativa para la Creación de Papilas en Implantes de Carga inmediata: Reporte de Caso / A New Alternative for the Creation of Papillae in Immediate Loading Implants: Case Report

RESUMEN: El objetivo de este artículo es evaluar el éxito clínico de una nueva alternativa para crear papilas en implantes de carga inmediata, que se realizó en una paciente de sexo femenino de 26 años de edad. Se inició el tratamiento con la confección de una guía quirúrgica, previo a la manipulación de los tejidos para crear las papilas peri-implantarias. En la cirugía se realizan 2 incisiones semilunares, unidas por una incisión perpendicular, las que al suturarlas sobre ellas mismas permitió crear las papilas; se instala un implante con buena estabilidad primaria y se toma la impresión para la rehabilitación. A las 24 horas se instala una corona atornillada, mostrando la presencia de las papilas de forma inmediata. Se realiza controles hasta los 20 meses de función, evidenciando buena estabilidad de las papilas mesial y distal sin presentar ningún tipo de complicación.

ABSTRACT: The aim of this paper is to evaluate the clinical success of a new alternative to create papillae in immediate load implants, which was performed in a 26-yearold female patient. The treatment was started with the preparation of a surgical guide, prior to the manipulation of tissues to create the peri-implant papillae. In the surgery, two semilunar incisions are made, joined by a perpendicular incision, which when sutured on them allowed to create the papillae. An implant with good primary stability is installed and the impression is taken for rehabilitation. At 24 h a screwed crown is installed, showing the presence of the papillae immediately. Controls are performed up to 20 months of function, demonstrating good stability of the mesial and distal papillae without presenting any type of complication.

Interproximal Tunneling with a Customized Connective Tissue Graft: A Microsurgical Technique for Interdental Papilla Reconstruction.

Interdental papilla reconstruction is one of the most challenging clinical procedures in periodontal plastic surgery. Several surgical approaches have been proposed but have varying degrees of success. It has long been acknowledged that the narrowness of the interdental papilla and the limited blood supply are major impediments to achieving predictable outcomes. Advances in microsurgery could offer an opportunity to overcome these anatomic and biologic barriers. The authors propose an original microsurgical technique based on interproximal tunneling combined with utilization of a customized tissue graft for interdental papilla reconstruction.

Nonincised Papillae Surgical Approach (NIPSA) in Periodontal Regeneration: Preliminary Results of a Case Series.

A new surgical approach has been developed to optimize the preservation of the gingival margin and papillae when treating periodontal defects. The flap is raised by one mucosal incision far away from the marginal tissues. This case series reports on the effectiveness of a nonincised surgical approach (NIPSA) in conjunction with a hydroxyapatite-based graft biomaterial and enamel matrix derivative in treating intrabony defects. Ten defects in 10 patients were treated. The follow-up period ranged from 6 to 18 months (mean: 10.8 ± 4.7 months). Probing pocket depth was 9.6 ± 2.3 mm before surgery and 2.3 ± 0.5 mm postsurgery. Clinical attachment level (CAL) decreased from 10.4 ± 2.7 mm to 3.1 ± 0.87 mm postsurgery. The gingival papilla height, keratinized tissue width, and buccal gingival margin remained stable over time. No wound dehiscence was recorded. Mean Early Healing Index was 1.5 ± 0.7. Results show a substantial CAL gain, limited postsurgical shrinkage, minimal morbidity, and early healing.

Surgical reconstruction of the interdental papilla: 2 case reports.

The loss of interdental papillae may create esthetic and phonetic problems and facilitates food impaction. Nonsurgical and surgical approaches can be developed to restore these areas, depending on the amount of tissue lost. Periodontal surgical techniques are difficult to perform in the interdental space because of the limited amount of tissue and poor blood supply. The aim of this article is to describe a periodontal plastic surgical technique in which subepithelial connective tissue grafts associated with composite restorations are used to reconstruct interdental papillae. This approach was followed in 2 patients whose grafts were obtained from different donor sites: the palate and the retromolar tuberosity. The 12-month recall examinations of both patients revealed satisfactory results, including stable gingival margins and complete, harmonious fill of the interdental papillary areas.

Dimensions of hard and soft tissue around adjacent, compared with single-tooth, zirconia implants.

Preservation or regeneration of the papilla has always been a challenge around consecutive implants or with implants next to teeth, and many studies have evaluated the papilla's behaviour and patterns based on surgical technique and prosthetic design, though evidence about its behaviour around zirconia implants is scarce. The aim of this study was to evaluate papilla behaviour between implants and teeth (tooth-implant group) and between consecutive implants (implant-implant group). Ninety patients with 122 zirconia implants (Straumann® PURE Ceramic Implant) were examined at the one-year follow up. We measured the effect of the distance: first from the base of the contact point of the crowns to the contact with bone at the implant site (D1); secondly, to the contact with the bone at the neighbouring tooth or implant site (D2); and thirdly on the papillary deficit (D3). In both the tooth-implant group and the implant-implant group, D1 and D2 correlated significantly with the papillary deficit (D3), whereas D2 was the major determinant factor (Spearman's rho=0.60). In both groups, when D1 and D2 were <6mm, the papilla was present every time. The papillary deficit was significantly greater in the tooth-implant group than in the implant-implant group (p=0.048). We conclude that the ideal distance from the base of the contact point to the bone contact at the implant and to the bone contact at the adjacent tooth in both groups is <6mm. The height of the bone on the teeth adjacent to implants has a significant impact on that of the papilla.

Connective Tissue Graft Wall Technique and Enamel Matrix Derivative for the Treatment of Infrabony Defects: Case Reports.

The present case report describes a modification of the connective tissue graft wall technique with enamel matrix derivative applied to treat deep vertical bony defects. The technique presented uses a palatal incision to gain access to the bony defect. Deep infrabony defects affecting two maxillary central incisors associated with interdental and buccal gingival recession were treated. At 1 year after surgery, 9 and 6 mm of interdental clinical attachment level gain were seen in cases 1 and 2, respectively. The position of the interdental papilla was improved, and complete root coverage was achieved. Radiographs demonstrated bone fill of the infrabony components of the defects. This report encourages the possibility to improve, in one surgical session, regenerative and esthetic parameters in the treatment of deep infrabony defects.

Does the Papilla Preservation Flap Technique Induce Soft Tissue Modifications over Time in Endodontic Surgery Procedures?

INTRODUCTION: The aim of the present controlled clinical trial was to compare 2 incision techniques, papilla base incision (PBI) and sulcular incision (IS), evaluating changes in papilla and recession height over a 12-month period. METHODS: A total of 24 subjects requiring endodontic surgery on a single tooth were enrolled. PBI was used in 1 group and IS in the other group. The primary outcomes were changes in gingival recession of the tooth affected by periapical lesions and the mesial and distal teeth and the mesial and distal papilla height using the treated tooth as the reference. Outcome variables were assessed at baseline and 12 months after the surgical intervention. Statistical analysis was performed by a blinded operator through appropriate tests, with significance set at a P value equal to .05. RESULTS: In the PBI group, the papilla height at the 12-month follow-up in the mesial and distal aspect decreased 0.10 ± 0.32 mm and 0.10 ± 0.32 mm, respectively, and 0.23 ± 0.68 mm and 0.25 ± 0.40 mm, respectively, in the IS group without any significant differences. There were no differences found for recession change values between groups. CONCLUSIONS: The PBI and IS approaches in endodontic surgery showed similar results in terms of papilla height preservation and recession changes.

Tratamiento de recesión única de clase III con injerto libre subepitelial mediante técnica de colgajo de doble papila reposicionado: informe de un caso clínico / Treatment of a single Class III recession combining free subepithelial connective tissue graft and a double papilla repositioned flap: report of a clinical case

Objetivo: mostrar y evaluar los resultados clínicos de un procedimiento de cirugía plástica periodontal, efectuada para cubrir una recesión radicular de clase III de Miller, con una técnica bilaminar. Además, analizar el aumento de la banda de encía y el cambio de biotipo gingival de la pieza dentaria. Caso clínico: paciente femenino de 30 años de edad, con una recesión gingival de Clase III de Miller por vestibular de la pieza 43 que no sobrepasa la línea mucogingival, con pérdida interproximal de tejidos duros y blandos. El tratamiento consiste en un colgajo de doble papila a espesor parcial, con injerto libre subepitelial tomado del paladar, con seguimiento a 1 año. Conclusiones: la técnica bilaminar es una solución viable en casos de recubrimiento radicular poco predecibles, como la recesión de clase III de Miller. El biotipo gingival se vio engrosado y la encía queratinizada no sufrió variaciones.

Six Month Clinical Evaluation of Interdental Papilla Reconstruction with Injectable Hyaluronic Acid Gel Using an Image Analysis System.

PURPOSE: Obtaining predictable and aesthetically pleasing interdental papilla is challenging in dental reconstruction. Hyaluronic acid gel has been successfully used to reduce facial creases and similar abnormalities. The purpose of this study was to clinically assess the efficiency of interdental papilla reconstruction with injectable hyaluronic acid gel. MATERIALS AND METHODS: Ten patients with 43 treated sites in the maxillary anterior region were studied. Photographic standardization devices were designed for image analysis before treatment. This treatment was repeated up to five times during 3-week intervals. Patients were followed 6 months after initial gel application. RESULTS: Twenty-nine sites had complete papilla reconstruction and 14 sites improved from 39 to 96% of interdental papilla reconstruction rate. Complete interdental papilla reconstruction was performed when black triangle at initial examination had area of ≤0.25 mm(2) , height of ≤1mm, or width of ≤0.5mm. CONCLUSION: Injectable hyaluronic acid gel may be a promising treatment for enhancing papillary esthetics. CLINICAL SIGNIFICANCE: Interdental papilla reconstruction with injectable hyaluronic acid gel can be suggested as a minimally invasive treatment option for interdental papilla deficiencies in small areas. However, long-term results of this treatment beyond 6 months are not yet known. (J Esthet Restor Dent 28:221-230, 2016).

New Surgical Protocol to Create Interimplant Papilla: The Preliminary Results of a Case Series.

The aim of this study was to introduce a new surgical technique to regenerate the papilla adjacent to multiple or single implants using a novel instrument and a new incision design. A total of 10 consecutively treated patients with maxillary anterior implant-supported provisional restorations and missing interproximal papillae received a subepithelial connective tissue graft. The recipient site was prepared with a buccal incision apical to the mucogingival junction and to the defective papilla, and a palatal incision, followed by buccolingual tunneling performed with a translingual curette (EBINA). A total of 10 sites were treated and evaluated pre- and postoperatively with the papilla score based on the Jemt classification. The final prosthesis was delivered 3 months after the papilla regeneration surgical procedure. An average improvement in papilla index score from 0.8 to 2.4 was found after an average follow-up period of 16.3 months. This case series demonstrated that interimplant papilla regeneration can be successful over a period of 11 to 30 months postloading. Long-term prospective studies on tissue stability and esthetic outcomes are needed to corroborate the findings in this study.

A multicenter randomized comparative trial of implants with different abutment interfaces to replace anterior maxillary single teeth.

PURPOSE: The implant-abutment interface may affect peri-implant mucosal architecture, and influence health and esthetics. The goal of this 1-year follow-up report of a 5-year clinical investigation was to examine the peri-implant mucosal tissue responses to different implant-abutment interface designs. MATERIALS AND METHODS: Subjects requiring an anterior maxillary implant were recruited. Tooth extractions, with or without preservation or ridge augmentation procedures, were performed as required. After 5 months of healing, one of three different implant-abutment combinations (conical interface [CI] n = 48); flat-to-flat interface [FI] n = 49); or platform switch interface [PS] n = 44) was placed and provisionalized. Twelve weeks later, permanent crowns were placed and data gathered throughout the first year. Peri-implant mucosal architecture and bone levels were evaluated clinically, photographically, and radiographically. RESULTS: At 1 year, seven FI and six PS implants failed and two FI and two PS implant participants were lost to follow-up, resulting in survival rates of 100% (CI), 85.7% (FI), and 86.4% (PS) (90.8% overall). Marginal bone level changes were -0.22 mm (CI, P < .05), -1.2 mm (FI, P < .05), and -1.32 mm (PS, P < .05) after 1 year. Marginal bone level stability (≤ 0.5-mm bone loss or gain) was recorded for 87% (CI), 8% (FI), and 27% (PS) of implants. Measurement of midbuccal mucosal zenith and papilla positions revealed no change in the mucosal positions and 0.2 to 0.3 mm of gain in papilla dimensions in all groups. CONCLUSION: Significant differences in marginal bone loss were observed among the three implant-abutment interfaces. At 1 year follow-up, changes in the buccal mucosal zenith position or papilla dimensions were not discernable. A continued longitudinal evaluation of peri-implant bone and mucosal changes around these different interfaces is ongoing.

Minimizing shrinkage of interdental papilla height when treating multiple Miller Class III gingival recession defects.

Miller Class III and IV gingival recession defects have interdental bone and soft-tissue loss that limit root coverage. Given the importance of the interdental papilla, protecting the integrity of this structure would seem prudent. Tunnel techniques have been successfully used to protect the interdental papilla. This article discusses the results of two cases in which multiple Miller Class III gingival recession defects were treated using tunnel-grafting techniques and an acellular dermal matrix. In both cases, root coverage was achieved while protecting the interdental papilla height.

Using papillae-sparing incisions in the esthetic zone to restore form and function.

The objective of this study was to determine interleukin (IL)-1alpha and IL-8 levels in the gingival crevicular fluid (GCF) of patients with different levels of crown margin placements. Samples of GCF were obtained from 12 study participants with definitive full-coverage restorations with supragingival or equigingival crown margin placements. The periodontal status of the volunteers ranged from healthy to generalized severe periodontitis. Pocket depth and bleeding on probing were assessed at the clinical examination, and interleukin concentrations were determined by enzyme-linked immunosorbent assay (ELISA). Analysis of variance (ANOVA) was used to statistically compare interleukin concentrations between the control, supragingival, and equigingival GCF samples. Compared to controls (60.4 plus/minus 8.9 pg/mL), the average IL-1alpha concentration in the GCF samples surrounding the supragingival margins was 53.8 plus/minus 9.7 pg/mL and was 110.5 plus/minus 23.3 pg/mL in the equigingival margins. Compared to controls (59.0 plus/minus 14.1 pg/mL), the average IL-8 concentration in the supragingival margins was 46.9 plus/minus 9.7 pg/mL and was 131.4 plus/minus 27.5 pg/mL in the equigingival margins. The trend of higher levels of interleukins in GCF corresponding to equigingival margins was consistent, as was the trend of lower concentrations in supragingival margins compared to the controls; however, statistical significance was not achieved because of the wide biological variation within and between patients. In conclusion, differences in GCF IL-1alpha and IL-8 concentrations were observed when comparing fixed crown restorations with equigingival and supragingival margins. Gingival inflammation may be dependent on the periodontal condition in addition to restoration or margin placement.

Tissue response following papilla-sparing and sulcular incisions in oral surgery--an experimental study.

OBJECTIVES: The objective of this study is to compare tissue reduction following papilla-sparing and sulcular incisions in oral surgical indications. MATERIAL AND METHODS: Five beagle dogs were used. Three months after tooth extraction of P2-M1, notches were prepared at the height of the interproximal gingiva into M2 and P1. Papilla-sparing and sulcular incisions were randomly performed, full-thickness flaps elevated and flaps repositioned. Three months postoperatively, tissue reduction was assessed using a digital calliper, mean values were calculated per group and analysed using a Wilcoxon matched-pair rank test. RESULTS: Papilla-sparing incisions revealed significantly less (p < 0.05) tissue reduction than sulcular incision techniques. CONCLUSION: Papilla-sparing incisions seem to induce less tissue response following flap surgery compared to sulcular incisions in oral surgical indications. Nevertheless, tissue reduction was seen in both groups. CLINICAL RELEVANCE: For surgical approaches without the necessity of direct access to the root surface (i.e., implantology, oral surgery), papilla-sparing incisions may be superior compared to sulcular incisions.

Predictors of inter-proximal and midfacial recession following single implant treatment in the anterior maxilla: a multivariate analysis.

PURPOSE: A number of factors have been associated with soft tissue recession following single implant treatment. However, given the cross-sectional design of most of these studies and crude associations based on univariate analyses, such factors may only be considered risk indicators. The objective of the present retrospective cohort study using multivariate analyses was to identify predictors of recession. MATERIAL AND METHODS: Patients who had been treated by two periodontists and two prosthodontists in 2006 and 2007 for a single implant in the anterior maxilla were re-examined in 2009 and their records were scrutinized. Subjects treated via flap surgery with and without ridge re-contouring were considered. Outcome variables were inter-proximal and midfacial recession. Explanatory variables included demographic data, the surgical approach and a number of local factors that were evaluated on radiographs taken pre-operatively or at permanent crown installation (baseline). RESULTS: Data pertaining to 97/115 (60 females, 37 males; mean age 51, SD 13, range 23-80) patients were available for evaluation. Significant bone loss was observed between baseline and re-examination at the implant surface (0.2-0.3 mm, p < 0.001) and tooth surface (0.3-0.5 mm, p < 0.001). Surgery with ridge re-contouring demonstrated 0.2 mm additional bone loss at the distal tooth surface when compared to surgery without ridge re-contouring (p = 0.034). This could be explained by a disparity in possible papilla-opening procedures (three versus one or two). As a result, regression analyses identified surgery with ridge re-contouring as a predictor of inter-proximal recession (OR ≥ 3.4). Pre-operative bone level at the tooth surface was another predictor of inter-proximal recession (OR ≥ 2.1). Recession of the distal papilla was also affected by a missing contact point (OR = 221.9), the implant-to-tooth distance (OR = 0.3) and the distance of the bone peak to the contact point (OR = 2.9). Midfacial recession was only associated with a buccal shoulder position (OR = 17.2). CONCLUSIONS: To optimize soft tissue levels around single implants, clinicians should limit papilla-opening procedures and pay utmost attention to a correct implant and contact point positioning.

Double-blind randomized controlled trial study on post-extraction immediately restored implants using the switching platform concept: soft tissue response. Preliminary report.

AIM: To evaluate the soft tissue response to immediately placed implants using the platform switching concept. MATERIAL AND METHODS: In 22 patients, 22 implants of 5.5 mm platform diameter were placed immediately into fresh extraction sockets in maxillae without compromised bone tissue. Eventual post-extraction bone defects were filled using bovine bone matrix mixed with collagen. Immediately after insertion, implants were randomly divided: 11 implants were connected with a 3.8 mm diameter abutment (test group) and 11 with a 5.5 mm diameter abutment (control group). A provisional crown was adapted and adjusted for non-functional immediate positioning. Two months later, definitive prosthetic rehabilitation was performed. Periodontal parameter, buccal peri-implant mucosal changes (REC), mesial and distal papilla height (PH) and vertical height of jumping distance (VHG) were measured at the time of implant placement, of definitive prosthesis insertion and every 6 months thereafter. RESULTS: The mean follow-up was 25 months. All implants were clinically osseointegrated. The test group showed a +0.18 mm REC gain. PH gain was +0.045 mm on average. The mean values were statistically significant (P< or =0.005) compared with the control group (PH=-0.88 mm; REC=-0.45 mm). No difference between the two groups in periodontal parameters was found. The mean value of bone filling was 7.51 mm in the test group (97.4% of VHG) and 8.57 mm in the control group (95.2% of VHG). No statistically significant difference was found between the two groups. CONCLUSIONS: This study suggests that, in a limited time period of 2 years, immediately placed implants with subsequent platform switching can provide peri-implant tissue stability.

Interdental papilla reconstruction combining periodontal and orthodontic therapy in adult periodontal patients: a case report.

Migration of maxillary anterior teeth because of the loss of periodontal support can alter the appearance of the esthetic zone. The loss of contacts between adjacent teeth results in the recession of interdental papillae. To restore sustainable periodontal health and the normal, esthetic appearance of a healthy 37-year-old woman with generalized advanced chronic periodontitis in the maxillary arch, a combined periodontal and orthodontic technique was used. This approach resulted in stable periodontium and an esthetically pleasing appearance of the maxillary anterior area.