The Scalloped Surgical Guide as an Alternative to Flat Bone Reduction Guide in Full-Arch Implant Restoration.

The goal of this clinical report was to present an alternative to traditional flat bone reduction guides, using a custom-designed 3-dimensional (3D)-printed guide according to the future gingival margin of the planned dentition. A 61-year-old woman with concerns regarding her smile appearance was presented. The initial examination revealed excessive gingival show accompanied by excessive overjet. The dentition was in a failing situation. The proposed treatment plan, relying on the sufficient amount of bone and keratinized tissue, consisted of recontouring of the alveolar ridge and gingiva and placement of 6 implants and an FP-1 prosthesis after extraction of all remaining maxillary teeth. Digital smile design was completed, and a fully digitally guided surgery was planned. This consisted of using 3 surgical guides, starting with the fixation pin guide, continuing with the scalloped hard- and soft-tissue reduction guide, and finally the implant placement template. Following the surgery, the patient received a temporary restoration, and on the 4-month follow-up, a new polymethyl meta-acrylate temporary prosthesis was delivered. The patient's 7-month follow-up is presented in the article. The report of this triple-template guided surgery indicated that digital 3D planning is a considerably predictable tool to properly establish and evaluate future occlusal plane, smile line, and lip support. Scalloped guides seem to be an excellent alternative to conventional bone reduction guides since they require less bone removal and improve patient comfort during surgery.

Management of interdental papillary defects using subperiosteal hyaluronic acid injection overlay technique: a prospective longitudinal clinical study.

OBJECTIVE: Currently, there is no established treatment protocol to treat interdental papillary loss. This research aimed to evaluate the outcomes of interdental papillary reconstruction using minimally invasive surgery, with injectable hyaluronic acid gel. METHOD AND MATERIALS: Seventeen patients were included, each with five sites of class 1 papillary recession (40 sites in the maxilla and 45 sites in the mandible). Subperiosteal tunneling was performed through a horizontal incision made apical to the base of the papilla without penetrating it. The free gingival sulcus was sealed by 000 retraction cord. A total of 0.2 to 0.6 mL hyaluronic acid was injected gradually. The incision was sutured with polyglycolic sutures. Treated sites underwent clinical and digital evaluation at three follow-up time points (1 month, 3 months, and 6 months). RESULTS: The interdental papillary defect height in the maxillary sites significantly reduced by 60%, 66%, and 42% at 1, 3, and 6 months, respectively. In mandibular sites, the reduction was 54%, 55%, and 40% at the same follow-up time points. Regarding interdental papillary defect surface area in the maxilla, the reduction was 65%, 71%, and 45% at 1, 3, and 6 months. In the mandible, a reduction of 60%, 64%, and 48% was noticed at the same time points. Regarding patients' pain level score, during the day of surgery, 16 patients reported pain; the average pain score out of 10 was 3.94, and 11 patients (64.7%) needed to take analgesics. The pain generally subsided in the following days. At the day of treatment, 12 out of the 17 patients (70.6%) reported mild difficulty in speaking and eating. No complication, hypersensitivity, or allergy was noted in any patient. CONCLUSION: Subperiosteal tunneling with hyaluronic acid injection demonstrates clinical improvements in papilla height and papillary recession surface area reduction after 3 months of follow-up, with reduction in improvement after 6 months. CLINICAL SIGNIFICANCE: Adjunctive use of hyaluronic acid injection with minimally invasive surgery in interdental papillary management may improve clinical and esthetic outcomes.

Treatment of excessive gingival display using conventional esthetic crown lengthening versus computer guided esthetic crown lengthening: (a randomized clinical trial).

BACKGROUND: Surgical guides have been proposed in an attempt to reach more predictable outcomes for esthetic crown lengthening. The objective of the present study was to evaluate the effectiveness of esthetic crown lengthening using 3D-printed surgical guides in the management of excessive gingival display due to altered passive eruption type 1B. MATERIALS AND METHODS: Sixteen patients diagnosed with altered passive eruption type 1B, were divided into two groups. In the control group, the procedure was carried out conventionally, and in the study group, a dual surgical guide was used. The parameters of wound healing (swelling, color, probing depth, bleeding index, and plaque index), pain scores, gingival margin stability, and operating time were assessed at 1 week, 2 weeks, 3 months, and 6 months postoperatively. RESULTS: There was no statistically significant difference in terms of wound healing, pain scores, and gingival margin stability between both groups at different time intervals (P = 1), however, there was a statistical difference between both groups in terms of operating time with the study group being significantly lower (P < 0.001). CONCLUSION: Digitally assisted esthetic crown lengthening helps shorten the operating time and reduces the possibility of human errors during the measurements. This will be useful in helping practitioners achieve better results. PRACTICAL IMPLICATIONS: The conventional method remains to be the gold standard. However, shorter operating time and lower margins for errors will help reduce costs as the chair side time is reduced as well as the possibility for a second surgery is lower. This will improve patient satisfaction as well.

Staged esthetic crown lengthening: Classification and guidelines for periodontal-restorative therapy.

OBJECTIVE: This article presents technical guidelines for perio-restorative esthetic crown lengthening, along with a discussion of the biologic rationale. A classification system is proposed to assist in treatment planning and sequencing the surgical and restorative phases. CLINICAL CONSIDERATIONS: When esthetic crown lengthening is performed as an adjunct to restorative therapy, the surgical approach must be determined by the anticipated position of the restorative margins. The removal of sufficient bone to achieve the desired clinical crown length and preserve the supracrestal gingival tissue dimensions is facilitated by the use of a surgical guide fabricated according to the design of the restorations. A staged approach allows sequencing the provisional restoration to minimize unesthetic sequelae during the healing period. Inadequate bone resection and/or alteration of the soft tissue dimensions results in delayed healing, leading to coronal gingival rebound and biologic width impingement. CONCLUSION: The identification and preservation of appropriate restorative and biologic landmarks is essential for success in pre-prosthetic esthetic crown lengthening treatment. A staged approach improves the esthetic management during the postsurgical healing and maturation period. CLINICAL SIGNIFICANCE: A restorative driven classification system for sequencing and staging adjunctive esthetic crown lengthening procedures is presented. Technical guidelines to enhance gingival margin predictability are suggested, accompanied by relevant evidence. In addition, wound healing timelines following gingival and osseous resection are provided.

Evaluation of advanced platelet-rich fibrin compared to subepithelial connective tissue graft in the surgical management of interdental papilla recession: a randomized controlled trial.

OBJECTIVES: The current study aims to compare advanced-platelet-rich fibrin membrane (A-PRF) to connective tissue graft (CTG) using Han and Takei's approach. MATERIALS AND METHODS: The defective papilla was randomly allocated to either the control group (CTG) or to the experimental group (A-PRF). Papilla height (PH) and percent change in the gingival black triangle (GBT) area were recorded at 1, 3, 6, 9, and 12 months. RESULTS: Thirty-two deficient IDPs with an initial papilla presence index (PPI) of 2 or 3 were included. At 12 months, the papilla-fill significantly increased in both groups (p < 0.001) without a significant difference between the study groups (p = 0.637). A mean gain in IDP height of 2.25 mm (± 0.97) in the CTG group and 1.86 mm (± 0.7) in the A-PRF group were recorded with a nonsignificant difference. Gingival black triangle fill showed a 57.98% fill in the CTG and 54.65% fill in the A-PRF group, with no statistically significant difference between the groups (0.956). Regarding postoperative pain patients, the CTG group consumed significantly more analgesics than the A-PRF group (11.75 ± 3.51 and 8 ± 3.08, respectively, with p = 0.003). CONCLUSION: Both CTG and A-PRF were found to be equally effective in increasing deficient IDP height with Han and Takei's surgical technique, with no significant difference. Within the current study's limitations, A-PRF seems to be a viable alternative to CTG in the treatment of GBTs. CLINICAL RELEVANCE: Multilayered A-PRF membrane can be used as a choice in the augmentation of receded papillae, using Han and Takei's technique.

Long-term stability of gingival margin and periodontal soft-tissue phenotype achieved after mucogingival therapy: A systematic review.

BACKGROUND: The aim of this systematic review was two-fold: (i) to evaluate the long-term (≥5 years) stability of the gingival margin position, keratinized tissue width (KTW) and gingival thickness (GT) in sites that underwent root coverage (RC) or gingival augmentation (GA); and (ii) to assess the influence of different local variables on the long-term stability of dental and gingival tissues. MATERIALS AND METHODS: Randomized controlled trials (RCTs) and non-RCTs reporting short-term (i.e., 6-12 months after baseline surgical intervention) and long-term (≥5 years) follow-up data after surgical treatment of adult patients presenting single or multiple mucogingival deformities, defined as sites presenting gingival recession defects (GRDs) and/or (KTW) deficiency (i.e., <2 mm), were considered eligible for inclusion. MEDLINE-PubMed, EMBASE and Cochrane Central Register of Controlled Trials databases were searched for articles published up to 15 May 2023. Mixed-effects multiple linear regression was used to assess the association between KTW, type of surgical procedure and time (i.e., independent variables) on the stability of the gingival margin in sites that received RC or GA therapy. RESULTS: Of the 2569 potentially eligible records, 41 (reporting 40 studies) met the eligibility criteria. Graphical estimates including data from all RC procedures found an upward trend in recession depth (RD) increase over time. Conversely, it was observed that in 63.63% of RC studies and in 59.32% of RC treatment arms KTW increased over time, particularly in sites treated with subepithelial connective tissue grafts (SCTGs). Conversely, sites that underwent GA procedures generally exhibited an overall reduction of KTW over time. However, sites treated with free gingival grafts (FGGs) showed a decrease in RD after 10 years of follow-up. Three main findings derived from the pooled estimates were identified: (i) Gingival margin stability was associated with the amount of KTW present during short-term assessment (i.e. the greater the KTW at 6-12 months after treatment, the more stable the gingival margin). (ii) The use of autogenous soft-tissue grafts was associated with lower RD increase over time. (iii) Treatment approaches that contribute to the three-dimensional enhancement of the gingival phenotype, as clearly demonstrated by FGG, were associated with gingival margin stability. CONCLUSIONS: The extent of apical migration of the gingival margin appears to be directly related to the amount of KTW and GT upon tissue maturation. Interventions involving the use of autogenous grafts, either SCTG or FGG, are associated with greater short-term KTW gain and lower RD increase over time.

Effects of the GingivalStat approach on early gingival margin remodeling following esthetic clinical crown lengthening: A case series.

OBJECTIVES: The aim of this case series is to present the potential applications of the GingivalStat approach, that is, the use of temporary gingival stabilizers, to favor early gingival margin remodeling and prevent the occurrence of gingival rebound following esthetic clinical crown lengthening. CLINICAL CONSIDERATIONS: Four patients requiring clinical crown lengthening were treated for esthetical and functional reasons. The surgical approach included: (a) gingival margin recontouring; (b) full-thickness flap elevation; (c) osteotomy (to achieve an adequate dimension between the alveolar bone crest and the CEJ) and osteoplasty (to reduce the bone thickness and improve the buccal bone anatomic profile, where indicated); (d) temporary gingival stabilizer placement using a block-out resin or a composite (the GingivalStat approach); and (e) flap repositioning, adaptation, and suture. One- to five-year follow-ups, reported in the different case scenarios, show evidence of clinically stable gingival margins around the treated teeth. CONCLUSIONS: Within the limits of this case series, it can be concluded that the GingivalStat approach appears as a further maneuver to cope with clinical crown lengthening procedures at esthetic sites. GingivalStat seems to favor gingival margin contour remodeling during the early phase of healing as well as prevent the occurrence of gingival rebound. CLINICAL SIGNIFICANCE: GingivalStat approach may guide gingival margin remodeling and prevent gingival rebound after wound healing of sites submitted to esthetic clinical crown lengthening.

Treatment of deep single RT2 and RT3 antero-mandibular gingival recessions with a combination of surgical techniques: A case series study.

OBJECTIVE: To evaluate root coverage (RC) in deep single antero-mandibular RT2 and RT3 gingival recessions (GR) and to investigate the influence of several factors in RC. MATERIALS AND METHODS: Fifteen single antero-mandibular GR with a minimum depth of 3 mm were consecutively treated with a new one-stage technique (laterally positioned flap with a tunnel access and a connective tissue graft). At baseline and at 12-month follow-up, the percentage of mean root coverage (%MRC), the recession reduction (RecRed), complete root coverage (CRC) and the gain of keratinized tissue width (KTW) were assessed. Descriptive, intergroup comparative and correlation analyses were performed. RESULTS: At 12 months, a %MRC of 77.29 ± 21.48% with a mean RecRed of 4.10 ± 1.51 mm was achieved. The %MRC was 84.71 ± 21.08% in RT2, and 62.43 ± 14.17% in RT3. The mean gain of KTW was 2.10 ± 0.89 mm, with a mean gain of 2.0 ± 1.03 mm for RT2 and 2.3 ± 0.57 mm for RT3. CRC was observed in six cases, all of them being RT2. A positive association was found between the %MRC and the initial position of the tooth and of both papillae. CONCLUSIONS: This technique might be a valuable approach for the treatment of deep single antero-mandibular RT2 and RT3 recessions, even in malpositioned teeth. CLINICAL SIGNIFICANCE: A combination of different surgical techniques could provide greater vascularization to the CTG especially in malpositioned teeth in sextant V with a large avascular area to be covered.

Long-term stability (21-30 years) of root coverage outcomes using sub-epithelial connective tissue grafts at single or multiple gingival recessions: A longitudinal case series.

AIM: To evaluate outcomes and predictive factors for the long-term stability of root coverage using a sub-epithelial connective tissue graft. MATERIALS AND METHODS: One-hundred and two healthy subjects (221 gingival recessions, GRs) were treated from 1987 to 1996. Keratinized tissue width (KTW), GR depth (RD), GR width (RW) and GR area (RA) were evaluated at baseline (M0) and at 1 month (M1), 1 year (M2), 11 years (M3), 21 years (M4) and 27 years (M5) after surgery. Primary outcomes consisted of complete root coverage (cRC) and relative dimensional changes in recession depth (measured in mm [c%-RD]), recession width (measured in mm [c%-RW]) and recession area (measured in mm2 [c%-RA]). RESULTS: cRC was 88.7% at 1 year (M2), 59.8% at M3, 44.4% at M4 and 51.9% at M5. Average c%-RD was 95.2% at 1 year, 81.9% at M3, 71.5% at M4 and 81.7% at M5. KTW increased after surgery and over time and was positively correlated with favourable outcomes. Increased baseline RA was associated with less favourable clinical outcomes. CONCLUSIONS: The sub-epithelial connective tissue graft is effective in the treatment of GRs and facilitates long-term stability of clinical outcomes. Wider baseline RA was a strong predictor of unfavourable short- and long-term RC outcomes.

Technical Note on Simplified Free Gingival Graft Using Tack Fixation (sFGG).

Free gingival graft (FGG) is the gold standard procedure for the reliable augmentation of lost keratinized mucosa (KM) around dental implants. This conventional surgical approach has its drawbacks, including limitations in manipulation, the requirement for suturing, postoperative discomfort, and pain. This case report aimed to evaluate the efficacy of a simplified free gingival graft (sFGG) in addressing the issue of inadequate keratinized mucosa around dental implants. Fixation tacks were used to perform the sFGG procedure. Initially, a partial-thickness flap was created and apically repositioned. The gingival graft was harvested from the palate with a narrow profile and securely affixed to the recipient site using 5 mm long fixation tacks. Significant gains in keratinized mucosa were achieved and successfully maintained within 1 year. Consequently, the sFGG technique emerges as a simple and reliable treatment approach for managing inadequate keratinized mucosa around dental implants.

A comparative study of cyanoacrylate-based tissue adhesive and surgical sutures on marginal flap stability following coronally advanced flap.

INTRODUCTION: The present study evaluated the biomechanical characteristics of cyanoacrylate-based tissue adhesive (TA) compared to surgical sutures in coronally advanced flap (CAF) procedures using an ex-vivo model. MATERIAL AND METHODS: Thirty-six half-pig mandibles were divided into three groups, n=12 each: (I) CAF fixed with sutures (sling and tag suture technique), (II) CAF fixed with TA, and (III) CAF fixed with sutures and TA. At mandibular premolars, gingival recession defects extending 3 mm apical to the cemento-enamel junction (CEJ) were created. CAF procedures were performed using a split-full-split approach, with coronal advancement of the flap to 1 mm above the marked CEJ and stabilization according to the respective groups I-III. Marginal flap stability against pull-of forces (maximum tensile force) was measured with a universal material testing machine until the CEJ became visible. RESULTS: The comparison between groups I-III demonstrated a significantly increased maximum tensile force for the TA (II) compared to the suture group (I) (p<0.001). A significantly increased maximum tensile force was found for the suture and TA (III) compared to the suture group (I) (p<0.001). There was also a significantly increased maximum tensile force in the suture and TA (III) compared to the TA group (II) (p<0.001). CONCLUSION: The results suggest that cyanoacrylate-based TA can increase marginal flap stability compared to sutures in CAF procedures. CLINICAL RELEVANCE: Cyanoacrylate-based TA can be considered a useful and valuable adjunct to conventional suturing techniques in periodontal plastic surgery, especially in cases where high flap stability is required. The results of this ex-vivo study can only be transferred to the clinical situation with limitations. Clinical long-term follow-up data must be generated.

Use of a hybrid soft tissue autograft for gingival phenotype modification lingual to mandibular incisors.

Presence of adequate dimensions of keratinized/attached gingiva (KT/AG) and gingival thickness (GT) is considered necessary to maintain optimal periodontal health and long-term stability of gingival margin. Gingival phenotype modification therapies to increase these two dimensions (GT and KT/AG) on the buccal aspect of teeth have been widely reported, but the literature on lingual gingival augmentation is scarce. The purpose of this paper is to report the outcomes of a case treated with an envelope flap combined with a hybrid soft tissue autograft (subepithelial connective tissue graft with an epithelial collar) for phenotype modification of gingiva lingual to mandibular incisors presenting with thin gingiva (<1 mm) and lack of AG in tooth # 31 and 42. At 12 months follow-up, a substantial gain in KT, AG and GT along with partial root coverage was achieved.

[A modified technique for expanding the attached keratinized gingiva zone using a free gingival graft "Danilov`s medallions"]. / Modifitsirovannaya metodika rasshireniya zony prikreplennoi keratinizirovannoi desny s pomoshch'yu svobodnogo desnevogo transplantata «medal'ony po Danilovu¼.

On a clinical example a modified technique for increasing the width of the attached keratinized gingiva zone is presented by taking medallions of a free gingival graft 1.5-2 mm thick from the hard palate using 5 mm mucotomes and transplanting them into the gum defect zones with a simultaneous vestibular deepening in the lateral regions of the jaws. This technology has been tested over a 5-year period with long-term clinical results.

Treatment of Maxillary Gingival Recessions Using the Modified Coronally Advanced Tunnel Technique in Combination with a Volume-Stable Collagen Matrix: A Prospective Case Series with a 12-Month Follow-up.

The aim of this case series was to evaluate the clinical performance of a new volume-stable collagen matrix (VCMX) in combination with the modified coronally advanced tunnel technique (MCAT) for the treatment of gingival recessions. Thirteen patients with a total of 33 maxillary RT1 single and multiple gingival recessions were included in the study. Probing pocket depth (PPD), recession width (RECW), recession depth (REC), height of keratinized tissue (HKT), and gingival thickness (GT) were assessed at baseline and at the 12-month follow-up. Postoperative healing was uneventful in all cases without any complications. At 12 months, mean root coverage (MRC) was 92.88%, with complete root coverage (CRC) in 87.88% of treated sites. The present findings suggest that VCMX in combination with MCAT results in predictable coverage of maxillary RT1 gingival recessions. Further studies with larger sample sizes and control groups are needed to support these preliminary outcomes.

Demineralized dentin matrix promotes gingival healing in alveolar ridge preservation of premolars extracted for orthodontic reason: a split-mouth study.

Objective: The purpose of this study was to prospectively evaluate the efficacy of a demineralized dentin matrix (DDM) in decreasing the initial inflammatory response of the gingiva and facilitating the repair and regeneration of soft tissue in alveolar ridge preservation. Methods: This clinical study employed a split-mouth design. Fourteen patients with a total of forty-four sites underwent extraction and alveolar ridge preservation (ARP) procedures. A Bilaterally symmetrical extraction operation were conducted on the premolars of each patient. The experimental group received DDM as a graft material for ARP, while the control group underwent natural healing. Within the first month postoperatively, the pain condition, color, and swelling status of the extraction sites were initially assessed at different time points Subsequently, measurements were taken for buccal gingival margin height, buccal-lingual width, extraction socket contour, and the extraction socket area and healing rate were digitally measured. Additionally, Alcian Blue staining was used for histological evaluation of the content during alveolar socket healing. Results: Both groups experienced uneventful healing, with no adverse reactions observed at any of the extraction sites. The differences in VAS pain scores between the two groups postoperatively were not statistically significant. In the early stage of gingival tissue healing (3 days postoperatively), there were statistically significant differences in gingival condition and buccal gingival margin height between the two groups. In the later stage of gingival tissue healing (7, 14, and 30 days postoperatively), there were statistically significant differences in buccal-lingual width, extraction socket healing area, and healing rate between the two groups. Furthermore, the histological results from Alcian Blue staining suggested that the experimental group may play a significant role in promoting gingival tissue healing, possibly by regulating inflammatory responses when compared to the control group. Conclusion: The application of DDM in alveolar ridge preservation has been found to diminish initial gingival inflammation after tooth extraction. Additionally, it has shown the ability to accelerate early gingival soft tissue healing and preserve its anatomical contour. Clinical trial registration: chictr.org.cn, identifier ChiCTR2100050650.

Evaluation of the Effect of Surgical Experience Level on the Success of the Coronally Advanced Flap (CAF) Technique.

PURPOSE: To investigate the effects of experience level on the clinical and esthetic results of coronally advanced flap (CAF) surgery. MATERIAL AND METHODS: A postgraduate student's first 40 CAF operations in the periodontology residency program were followed. The Miller Class I gingival recessions were divided into four chronologic groups (n: 10 in each). Clinical and esthetic evaluations were performed at baseline and after 6 months. The results of chronologic intervals were statistically compared. RESULTS: While the overall mean root coverage (RC) percentage was 73.6% and the complete RC was 60%, the mean RC percentages of the groups, respectively, were 45%, 55%, 86%, and 95%, showing that the mean and complete RC percentage increased as the experience level increased (P < .05). Similarly, as the experience level increased, closure of the gingival recession depth and width and esthetic scores increased, while the surgical time decreased significantly (P < .05). Complications were observed in three patients during the first interval and in two patients during the second interval, while no complications were observed in the other groups. CONCLUSIONS: This study showed that experience level can significantly affect the clinical and esthetic outcomes, operative time, and complication rates of CAF surgery. All education programs should determine how many of each surgical procedure residents must perform before they are considered experienced or expert surgeons who can work independently and predictably achieve safe, acceptable outcomes.

The "White Layer Approach": A Graftless Gingival Augmentation Technique following Vertical GBR with Occlusive Titanium Barriers.

Guided bone regeneration surgery always leads to a deformation of the soft tissues consequent to passivation of the flap. In this article, a graftless technique for the restoration of the vestibular depth and for the augmentation of adherent soft tissue, called the "white layer approach", is proposed after a vertical GBR procedure in posterior areas. Six patients (five males and one female) with vertical bone atrophy were enrolled in the study and underwent three-dimensional bone augmentation with titanium barriers. After 6 months, during the second-stage surgery, a 0.5 mm thick layer of white pseudo-periosteum was observed underneath the titanium barrier and over the newly formed bone. The buccal portion of the pseudo-periosteum was left intentionally exposed, in order to promote the spontaneous formation of new adherent gingiva and the restoration of the original depth of the fornix. The implant insertion was then planned 3 months after the WLA in a conventional procedure. The buccal adherent soft tissue height was measured from the crestal point to the most apical point, using a periodontal probe, before the barrier removal at 3 months after the white layer approach (WLA). In all patients, a gain in adherent soft tissue varying from 5 to 8 mm was observed; the average adherent soft tissue gain (ASTG) was 6.75 mm. The vertical bone height was measured by CT scans at baseline and before the implant placement, and showed an average vertical bone gain (AVBG) of 4.08 mm. Within the limitations of this study, vertical GBR with titanium occlusive barriers (OTB) associated with the white layer approach (WLA) may represent a simplified technique for hard and soft tissue augmentation in posterior areas, even without a free gingival graft.

Submerged Technique of Partially De-Epithelialized Free Gingival Grafts for Gingival Phenotype Modification in the Maxillary Anterior Region: A Case Report of a 34-Year Follow-up.

A coronally advanced flap combined with a subepithelial connective tissue graft is considered the gold standard for achieving root coverage on exposed root surfaces. Nevertheless, challenges arise when this technique is applied to multiple teeth and when the palatal soft tissue is very thin. Several surgical modifications have been reported to simultaneously achieve both single or multiple root coverage and widening of the keratinized gingiva. In this context, there have been no reported cases utilizing the submerged technique with partially de-epithelialized free gingival grafts. We intend to introduce a submerged technique involving partially de-epithelialized free gingival grafts for the modification of soft tissue phenotypes in the maxillary anterior region.

Preserving periodontal tissue in the treatment of a large peripheral ossifying fibroma: a case study.

Peripheral ossifying fibroma (POF) is a reactive, benign gingival enlargement. Its etiology is not fully known. It can be seen in many different sizes in the mouth. The histopathological appearance of POF is mineralized tissue and fibrous proliferation. All relevant soft and hard tissues must be removed to prevent recurrence. Periodontal tissue remaining after excision is important for tooth preservation. With large lesions, the loss of healthy periodontal tissue is also large. Periodontal surgical approaches are important to preserve the remaining periodontal tissue. The positive effects of autogenously obtained titanium-prepared platelet-rich fibrin (T-PRF) and connective tissue graft (CTG) on soft tissue are well known. A 34-year-old woman presented with a fibrous and pedunculated gingival mass in the upper left canine premolar region. The operation was performed with complete excision of the lesion down to the bone along with the surrounding healthy tissue. Periodontal treatment of the large defect created after excision of a large POF lesion was performed with laterally positioned flap, CTG and T-PRF. The periodontal tissue and defect were noted to heal in a healthy manner at the 6-month follow-up. POF is a benign lesion; however, it has a high recurrence rate. Complete elimination of the lesion is crucial to prevent recurrence. Periodontal surgical methods and biomaterials applied after surgical excision are significant to maintain the periodontal health of the remaining teeth and tissues.

Modified interproximal tunneling technique with customized sub-epithelial connective tissue graft for gingival papilla reconstruction: report of three cases with a cutback incision on the palatal side.

BACKGROUND: Gingival papilla defects, which cause an unpleasant appearance and involve the upper anterior teeth, may be triggered by several factors. Several noninvasive and invasive techniques have been proposed for gingival papilla reconstruction. The combination of interproximal tunneling and customized connective tissue grafts (CTGs) has shown promise in papilla augmentation. However, due to the narrowness and limited blood supply of the gingival papilla, the long-term outcomes of these techniques remain unpredictable. Therefore, achieving tension-free coronal advancement of the interdental papilla and proper placement of the CTG is crucial for successful long-term outcomes and could provide widely applicable methods for papilla augmentation. CASE REPORT: In this study, we enrolled three patients with gingival papilla defects in the maxillary anterior teeth. For reconstruction, we proposed a modified interproximal tunneling (MIPT) technique combined with a CTG. A crucial modification based on previous studies involved adding a cutback incision to the base of the palatal vertical incision, resulting in tension-free healing. Additionally, the CTG was sutured upright to further enhance the height of the gingiva papilla. To evaluate the efficacy of the MIPT technique, the clinical parameters-including the Jemt papilla index and the distance from the tip of the papilla to the interproximal contact point-were examined using a periodontal probe (UNC15, Hu-friedy) at baseline and 12 months after surgery. All three patients achieved satisfactory papilla reconstruction 12 months after the surgery. These three cases were used to evaluate the efficacy of the MIPT technique combined with the customized CTG. An average increase in the Jemt papilla score from 1.6 to 2.8 and a reduction in the distance from the papilla tip to the contact point of adjacent teeth from 2 mm to 0.08 mm were observed 12 months after surgery. CONCLUSION: The preliminary results confirmed that this technique holds promise for gingival papilla augmentation between tooth/tooth or tooth/implant.