Comparison of the Histological Structure of an Anterior as well as a Posterior Biopsy From the Human Palate: A Comparative Study

AIM

To compare the histological structure of biopsies from the anterior and posterior regions of the human palate in order to gain insights into potential differences of soft tissue harvesting sites.

METHODS

This comparative study involved 20 participants, from each of whom four samples from the palatal mucosa were collected. The biopsies were histologically processed and subsequently analysed. The thickness of the epithelium, lamina propria, and the length of the rete pegs were measured using a microscope. In addition, parameters such as collagen fibres, elastic fibres, elastic connective tissue, loose connective tissue and the background were measured.

RESULTS

The mean epithelial thickness was 0.42 mm anteriorly and 0.37 mm posteriorly. The mean thickness of the lamina propria was 0.81 mm anteriorly and 0.85 mm posteriorly. Within the region of interest, collagen fibres were significantly less abundant anteriorly than posteriorly (p = 0.016). The loose connective tissue showed a significantly higher occurrence in the anterior compared with the posterior sampling site (p = 0.004).

CONCLUSION

This trial indicates no differences in terms of the thickness of the lamina propria. There was a higher concentration of collagen fibres and a lower concentration of loose connective tissue in the posterior region of the palate.

Efficacy of concentrated growth factor combined with coronally advanced flap in the treatment of gingival recession: a systematic review and meta-analysis

OBJECTIVES

This study aims to evaluate the efficacy of combining the coronally advanced flap (CAF) technique with concentrated growth factor (CGF) in the treatment of gingival recession (GR), and to compare this approach with other alternative treatments.

METHODS

This systematic review and meta-analysis included randomized controlled trials (RCTs) comparing CAF combined with CGF to other treatments for root coverage procedures. Included studies evaluated systemically healthy adults (> 18 years) with Miller Class I/II or Cairo RT1 gingival recessions. Primary outcomes were complete root coverage (CRC) and mean root coverage (MRC); secondary outcomes included changes in keratinized tissue width (KTW), gingival thickness (GT), clinical attachment level (CAL), recession width (RW), recession depth (RD), and probing depth (PD). A comprehensive search was conducted across multiple databases, including PubMed, Scopus, Cochrane Library, Web of Science, and Embase, up to November 9, 2024. The study protocol was prospectively registered in PROSPERO (CRD42024556815). Statistical analyses were performed using Review Manager 5.4.1.

RESULTS

Eight studies were included in the meta-analysis. Compared to CAF alone, the combination of CAF and CGF significantly improved CRC (OR = 1.79, P = 0.04), MRC (MD = 10.38%, P = 0.04), KTW (MD = 0.40 mm, P = 0.02), GT (MD = 0.26 mm, P < 0.00001), and CAL (MD = 0.36 mm, P = 0.03). CAF combined with connective tissue graft (CTG) showed superior efficacy for CRC compared to CAF + CGF (OR = 0.25, P = 0.009). However, no significant differences were found between CAF + CTG and CAF + CGF for MRC, CAL, KTW, RD, RW, or PD. Additionally, no significant differences were observed when comparing CAF + CGF with CAF + PRF across all clinical parameters (all P > 0.05).

CONCLUSIONS

The findings of this meta-analysis indicate that CAF/CGF improves clinical outcomes in treating GR compared to CAF alone, and CGF may be a viable alternative to CTG when CTG is not applicable. Further studies are needed to validate the efficacy of CAF/CGF in the treatment of GR.

CLINICAL SIGNIFICANCE

In cases where CTG is not applicable, CGF may serve as a viable alternative for the treatment of Miller class I and II GR.

Technique to Protect the Palatal Donor Area After Taking a Free Gingival Graft: The Patchwork Technique

The objective is to describe a technique to protect the donor area after taking a free gingival graft. A partial de-epithelialization of the palatal area is performed with a lentil bur mounted in a dental turbine. A partial thickness flap is then created to harvest the superficial connective tissue layer. Subsequently, two collagen sponges are placed into the wound. The sponges are compressed and secured by two sling stitches. Once hemostasis is obtained, a uniform layer of flow composite is placed and light-cured. Finally, a sling stitch is added to secure and compress the composite layer. Postoperatively, the donor area showed satisfactory healing after 14 days, with partial healing after the first revision and complete epithelialization during the second revision, with no reported pain or discomfort. Thus, the patchwork technique may be a more straightforward, predictable, and cost-effective alternative that protects the donor area, improves healing, and reduces pain.

Collagen Matrix Versus Subepithelial Connective Tissue for Recession Coverage: A Systematic Review

OBJECTIVE

To evaluate the outcome of collagen matrix (CMX) compared with subepithelial connective tissue graft (SCTG) in gingival recession coverage (RC) surgery.

METHODS

Review protocol was registered in PROSPERO. The search was conducted on MEDLINE, Cochrane Library, and Scopus databases. Randomized studies comparing CMX versus. SCTG or CMX versus. covering procedures without any filling material, for class I recession treatment were included. Risk of bias assessment and quantitative analysis were performed.

RESULTS

Of 168 records, 11 randomized clinical trials were included. The meta-analysis revealed no statistically significant difference in terms of %RC (p = 0.37); there was a statistically significant difference in terms of recession reduction (p = 0.02) and keratinized tissue width (p = 0.03) in favor of SCTG cases. CMX showed a statistically significantly better result compared to no grafting, regarding %RC (p = 0.003) and keratinized tissue thickness (p < 0.0001). The duration of the intervention was significantly shorter for CMX than for SCTG (p < 0.0001).

CONCLUSION

CMX can be considered a viable material, especially when a ΔKTt increase and a reduction of intervention duration is needed. The indications for the choice, however, may depend on the individual local condition. PROSPERO Registration: Registration in PROSPERO (International prospective register of systematic reviews): CRD42024555443.

Treatment of Submucous Alveolar Cleft With Hard- and Soft-Tissue Reconstruction in the Aesthetic Zone: A Case Report

OBJECTIVE

This case report offers information on accurate diagnostic and soft- and hard-tissue reconstruction periodontal surgery deal with "black triangles" in the aesthetic zone of anterior teeth caused by submucous alveolar cleft, which is rare and easily overlooked.

CLINICAL CONSIDERATIONS

Vertical and horizontal bone augmentation was conducted via guided tissue regeneration and alveolar bone grafting (ABG) at the cleft site where favorable bone grafting conditions were absent. A customized, vascularized interpositional periosteal-connective tissue (VIP-CT) flap was applied as the barrier membrane to maintain the stability of bone replacement graft and provide soft-tissue foundation for gingival papilla growth. Adjustment on the contact point position of the anterior teeth and the shapes of crowns induced growth of the gingival papillae with resin restoration. The radiological and clinical parameters, and smiling photographs demonstrated a satisfactory treatment outcome.

CONCLUSIONS

When the inflammation and local alveolar bone destruction in the anterior area are disproportionate, submucous alveolar cleft should be considered a potential etiology. Surgical treatment combined with resin restoration substantially improved the affected area.

CLINICAL SIGNIFICANCE

The hard- and soft-tissue defects can be improved through ABG and VIP-CT flap in a single surgery.

An Evaluation of Cellulose Hydrogels Derived from tequilana Weber Bagasse for the Regeneration of Gingival Connective Tissue in Lagomorphs

Cellulose hydrogels derived from agave bagasse were formulated to promote the regeneration of gingival connective tissue in lagomorphs. Three treatment modalities were randomly implanted in the gingival diastema area in 16 rabbits. The general characteristics were analyzed and histopathological studies were carried out at 4, 8, 12, and 16 weeks. A chi-squared test was performed using IBM-SPSS version 25, indicating that cellulose hydrogels implanted in lagomorph's gingival tissue showed the presence of greater angiogenesis and fibrogenesis at the four evaluation intervals during 16 consecutive weeks. The presence of inflammatory infiltrates had no significant impact. No significant changes were observed in body weight and water and food intake. This suggests that hydrogels contribute to the regeneration and/or repair of oral connective tissue, showing angiogenesis and fibrogenesis in 50 to 100% of rabbits tested with hydrogel cellulose membrane. Regarding angiogenesis, in the specimens where membranes were implanted, its presence predominated in all variants (50%), followed by diffuse angiogenesis (37.5%), and finally the absence of angiogenesis (12.5%).

Microsurgery in periodontics and oral implantology: a systematic review of current clinical applications and outcomes

OBJECTIVES

The aim of this systematic review was to comprehensively explore the current trends and therapeutic approaches in which an operating microscope (OM) is used in periodontics and dental implant surgeries.

MATERIALS AND METHODS

A systematic search strategy was built to detect studies including various surgical techniques performed under an OM. PubMed, EMBASE, and SCOPUS databases were searched. No limitations in terms of time and language were applied. The data regarding the study design, type of procedure, treatment groups, and surgical outcomes were collected and analyzed descriptively. In addition, a bibliometric analysis was performed concerning the co-authorship and keyword co-occurrence network.

RESULTS

Out of 1985 articles, finally, 55 met the inclusion criteria. Current periodontal and implant microsurgery trends consist of: periodontal therapy, dental implant microsurgery, soft tissue grafting and periodontal plastic surgery, bone augmentation, ridge preservation, and ortho-perio microsurgery. The bibliometric analysis revealed "guided tissue regeneration", "periodontal regeneration" and "root coverage" being the most repeated keywords (landmark nodes). 132 authors within 29 clusters were identified, publishing within the frameworks of "periodontal and implant microsurgery".

CONCLUSION

Within its limitations, this systematic review provides an overview of the latest trends in periodontal and implant microsurgery when considering the use of an OM as the magnification tool. Also, it discusses the reported success and outcomes of the mentioned procedures.

Harvest of epithelialized gingival grafts without application of hemostatic sutures: A randomized clinical trial using laser speckle contrast imaging

BACKGROUND

This randomized controlled trial with two parallel arms and a 1:1 allocation ratio aimed to compare early microvascular healing (primary outcome), surgical times, and patient-reported outcomes (PROM) after harvesting palatal epithelialized gingival grafts (EGG), where hemostasis was achieved with sutures and hemostatic sponges (control) or with a sutureless approach (test).

METHODS

From a total of 33 patients, 34 EGG were harvested. Thirty-two were randomized to the test/control group (n = 16) and two were excluded. Early palatal microvascular healing was assessed at 7, 14, and 30 days with laser speckle contrast imaging (LSCI). Postoperative bleeding, pain, discomfort, and analgesic consumption were assessed over 2 weeks with a dedicated questionnaire.

RESULTS

A faster onset and resolution of postharvest hyperemia was observed in the test group where peak blood flow was reached at 7 days. No significant blood flow differences were observed between the groups at any of the evaluated timepoints. The mean surgical time was 13 min shorter in the test (p = 0.00). No significant differences were observed for postoperative bleeding and analgesic consumption at any timepoint.

CONCLUSIONS

The tested approach represents a viable alternative to the standard one, providing no relevant differences in microvascular, clinical, and patient-related results, but with significantly shorter surgical times.

Impact of platelet-rich fibrin derivatives on patient morbidity and quality of life in palatal donor sites following free gingival graft surgery: a randomized clinical trial

OBJECTIVES

Platelet concentrates are biomaterials with significant potential in tissue regeneration, functioning as scaffolds with greater leukocyte inclusion and a flexible fibrin mesh. However these concentrates have different preparation methods and biological properties. The objective of this clinical investigation was to evaluate the effects of utilizing platelet-rich fibrin (PRF) materials (L-PRF and A-PRF) as a palatal bandage following free gingival graft (FGG) on patients' morbidity and oral health-related quality of life.

MATERIALS AND METHODS

Thirty-nine participants received FGG to promote keratinized tissue and treat gingival recession. Participants were randomly assigned to L-PRF, A-PRF, and control groups, with 13 participants in each. They used a visual analog scale (VAS) to rate their pain, analgesic medication use, dietary changes, discomfort, and bleeding at 1-7 days, 14 days and 1 month during the healing process. Patients' quality of life was assessed using the Oral Health Impact Profile (OHIP-14) at baseline, 1-7 days, 14 days, 1 month, and 6 months.

RESULTS

There was no difference in anxiety levels between the all groups. (p > 0.05). The control group had higher OHIP-14 total scores than the other groups, but the differences were not statistically significant, especially in the first seven days (p > 0.05). In addition, the PRF groups showed an improvement in quality of life after 14 days, 1 month, and 6 months (p < 0.05). Patients' pain and suffering decreased with healing. The control group took more postoperative analgesics than PRF groups. In addition, there was a significant decrease in patient complaints about medicine intake, bleeding, pain, perceived sensitivity, and dietary modifications in all groups during follow-up.

CONCLUSIONS

PRF palatal bandages may improve patient's quality of life, donor site healing, postoperative pain and morbidity.

CLINICAL RELEVANCE

This study found that preserving the palate in FGG and employing PRF materials that speed palate healing reduce discomfort and morbidity.

Polycaprolactone/gelatin/ZIF-8 nanofiber membrane for advanced guided tissue regeneration in periodontal therapy

The periodontal tissue regeneration strategy based on guided tissue regeneration (GTR) membranes is an effective therapy for periodontal defects. Traditional GTR membranes, however, primarily serve as physical barriers and lack antimicrobial and osteogenic functions. Herein, we developed a multifunctional nanofiber membrane with zeolitic imidazolate framework-8 nanoparticles (ZIF-8 NPs) loaded in a hydrophilic gelatin layer. The release of Zn2+ from the ZIF-8 NPs effectively promoted bone tissue repair and simultaneously enabled GTR membranes with >99 % antibacterial efficacies against Escherichia coli and Staphylococcus aureus. Additionally, the incorporation of gelatin enhances cellular adhesion and growth. Furthermore, in vivo studies revealed significant bone regeneration, with increased trabecular number and reduced separation. Owing to its multiple functions, excellent biocompatibility and desirable mechanical properties, this membrane has considerable potential in the field of periodontal therapy.

Achieving Clinical Success in Root Coverage and Aesthetic Improvement by Using Subepithelial Connective Tissue Grafts: A Report of Two Cases

Over the years, several modalities have been established to treat gingival recession. Nonetheless, subepithelial connective tissue grafts (SECTGs) remain a dependable technique for root coverage, mainly due to their superior vascularization. However, the procurement of the CTG is susceptible to technique sensitivity; consequently, various methodologies have emerged to harvest CTGs to mitigate donor site trauma. In this article, we present two clinical cases of gingival recession addressed by the application of SECTGs. Both instances involved patients in good health with localized gingival recession measuring 6 mm and 7 mm in the mandibular incisors. The grafts were procured from the hard palate to rectify the recession areas. This report emphasizes the importance of minimizing trauma to the donor site, alleviating postoperative discomfort, and achieving complete root coverage at the recipient site with a favorable aesthetic result. Follow-up assessments at the first, fourth, and eighth weeks revealed the achievement of full root coverage and the patients reported satisfaction with reduced postoperative discomfort.

Gene Therapeutic Drug pCMV-VEGF165 Plasmid ('Neovasculgen') Promotes Gingiva Soft Tissue Augmentation in Rabbits

Currently, an increasing number of patients are undergoing extensive surgeries to restore the mucosa of the gums in the area of recessions. The use of a connective tissue graft from the palate is the gold standard of such surgical treatment, but complications, especially in cases of extensive defects, have led to the development of approaches using xenogeneic collagen matrices and methods to stimulate their regenerative and vasculogenic potential. This study investigated the potential of a xenogeneic scaffold derived from porcine skin Mucoderm and injections of the pCMV-VEGF165 plasmid ('Neovasculgen') to enhance soft gingival tissue volume and vascularization in an experimental model in rabbits. In vitro studies demonstrated the biocompatibility of the matrix and plasmid with gingival mesenchymal stem cells, showing no toxic effects and supporting cell viability and metabolic activity. In the in vivo experiment, the combination of Mucoderm and the pCMV-VEGF165 plasmid (0.12 mg) synergistically promoted tissue proliferation and vascularization. The thickness of soft tissues at the implantation site significantly increased with the combined application (3257.8 ± 1093.5 µm). Meanwhile, in the control group, the thickness of the submucosa was 341.8 ± 65.6 µm, and after the implantation of only Mucoderm, the thickness of the submucosa was 2041.6 ± 496.8 µm. Furthermore, when using a combination of Mucoderm and the pCMV-VEGF165 plasmid, the density and diameter of blood vessels were notably augmented, with a mean value of 226.7 ± 45.9 per 1 mm2 of tissue, while in the control group, it was only 68.3 ± 17.2 per 1 mm2 of tissue. With the application of only Mucoderm, it was 131.7 ± 37.1 per 1 mm2 of tissue, and with only the pCMV-VEGF165 plasmid, it was 145 ± 37.82 per 1 mm2 of the sample. Thus, the use of the pCMV-VEGF165 plasmid ('Neovasculgen') in combination with the xenogeneic collagen matrix Mucoderm potentiated the pro-proliferative effect of the membrane and the pro-vascularization effect of the plasmid. These results indicate the promising potential of this innovative approach for clinical applications in regenerative medicine and dentistry.

Clinical outcomes of free gingival graft vs. palatal pedicle graft in peri-implant soft tissue phenotype modification: A randomized controlled trial comparing patient reports

Background

The importance of peri-implant soft tissues in maintaining tissue health and aesthetics has been recognized. A thickness of at least 2 mm is considered a protective factor against peri-implantitis. This study assessed clinical outcomes and complications at implant sites following soft tissue augmentation with either palatal free gingival graft (FGG) or palatal pedicle graft (PPG).

Methods

In this randomized controlled clinical trial, 42 patients with inadequate keratinized tissue width (KTW) were randomly assigned to two intervention groups: Group 1 received FGGs, while group 2 underwent PPGs. The KTW, vestibular depth, and surface shrinkage were recorded preoperatively and one and three months after the operation. Patient-reported outcome measurements were recorded at a two-week follow-up.

Results

Thirty-five patients completed the study (FGG group, n=17; PPG group, n=18). Group 2 demonstrated a higher increase in KTW and vestibular depth at 1 and 3 months (P<0.05). The surface shrinkage differences were not statistically significant between the study groups at baseline and three-month follow-up (P>0.05). The number of analgesics in each group was not significantly different two weeks after the operation; however, the Numeric Pain Rating Scale (NPRS) showed significantly higher pain scores on days 3 to 8 in group 1 patients.

Conclusion

The use of PPG in soft tissue augmentation demonstrated more KTW formation and less postoperative morbidity. There was no difference between the methods used to compare surface shrinkage.

Novel digital technique for measuring the volumetric healing process of free gingival grafts surrounding dental implants

The objective of the present study was to analyze and describe a new digital technique for analyzing the volumetric healing process of free gingival grafts in both donor and recipient locations surrounding a dental implant, as well as to compare the reliability of conventional and digital techniques for measuring the width of the free gingival graft in the recipient location throughout the healing process.

Materials and methods

Ten patients presenting with mucositis linked to a dental implant were included. A preoperative soft tissue width <2 mm, with probing pocket depth <5 mm, edema and inflammation and bleeding on probing was determined A digital impression was taken of both donor and recipient locations using an intraoral scan, generating a Standard Tessellation Language digital file both preoperatively (STL1) and after 1 week (STL2), 1 month (STL3), 3 months (STL4), and 6 months (STL5) of follow-up. Afterwards, the digital files (STL1-STL5) were aligned using a reverse engineering morphometric software, and Student's t-test was used to analyze changes in volume at the donor and recipient locations. Additionally, widths were measured both clinically and digitally so as to compare the reliability of these measurement techniques. The repeatability and reproducibility of both these measurement techniques were also analyzed using Gage R&R statistical analysis.

Results

Gage R&R found that the total variability of the digital technique was 0.6% (among the measures of each operator) and 7.6% (among operators); as variability was under 10%, the results were repeatable and reproducible. In addition, there were statistically significant differences between donor and recipient locations in healing process volume (mm3) after one week (p = 0.0110), one month (p = 0.0007), three months (p < 0.0001) and six months (p = 0.0004) of follow-up.

Conclusion

The digital measurement technique provided accurate, repeatable, and reproducible results when analyzing the volumetric and linear measures of the healing process in both the donor and recipient locations of a free gingival graft surrounding a dental implant, with significantly higher tissue volume in the recipient location.

Double vertical interrupted suture for optimal adaptation and stabilization of free gingival graft around dental implants: a case report

BACKGROUND

Free gingival graft is commonly used to augment the keratinized mucosa and vestibular depth around dental implants. The proper suturing technique is fundamental to achieve a successful result following free gingival graft. However, there are limited studies that focus on the details of the suturing methods to optimize graft adaptation. The purpose of this technical note is to describe a new suturing technique for optimal approximation and stabilization of free gingival graft around dental implants.

CASE PRESENTATION

Here, we present a 53-year-old Persian female with peri-implantitis and lack of keratinized mucosa around mandibular implants who was a candidate for free gingival graft. A new suturing technique, double vertical interrupted suture, was conducted in the interimplant areas. In addition, the suspensory cross-mattress sutures were added to ensure the adaptation of the graft over the implants. The proposed suturing technique is useful for soft tissue augmentation around multiple implants with concave or uneven recipient bed.

CONCLUSION

The present article describes a novel suturing technique for good adaptation and fixation of free gingival graft around dental implants.

Treatment of multiple adjacent gingival recessions using leucocyte- and platelet-rich fibrin with coronally advanced flap: a 12-month split-mouth controlled randomized clinical trial

OBJECTIVE

This split-mouth randomized study aimed to assess efficacy of leucocyte-platelet-rich fibrin (L-PRF) versus connective tissue graft (CTG) in achieving root coverage (RC) for multiple adjacent gingival recessions (MAGRs) throughout 12-month period.

MATERIALS AND METHODS

The study enrolled 59 teeth from 12 patients with Miller Class I MAGRs ≥ 2 mm on bilateral or contralateral sides. Patients were randomly assigned to receive coronally advanced flap (CAF) with either CTG (control) or L-PRF (test) treatment. Various parameters, including plaque and gingival index, clinical attachment level, recession depth, probing depth, recession width (RW), papilla width (PW), keratinized tissue width (KTW), gingival thickness (GT), percentage of RC, complete root coverage (CRC), and location of the relative gingival margin concerning the cemento-enamel junctions (GMCEJ) after CAF, were recorded at baseline, 3-, 6-, and 12-months post-surgery. On June 29, 2021 the study was registred to ClinicalTrials.gov (NCT04942821).

RESULTS

Except KTW and GT gain, all clinical parameters, RC, and CRC were similar between the groups at all follow-up periods (p > 0.05). The higher GT and KTW gains were detected in the control group compared to test group at 12 months (p < 0.05). Both RC and CRC were positively associated with initial PW and GMCEJ, but negatively with initial RW (p < 0.05).

CONCLUSIONS

The current study concludes that L-PRF were equally effective as CTG in treating MAGRs in terms of RC and CRC. Additionally, RC and CRC outcomes appeared to be influenced by GMCEJ, PW, and RW.

CLINICAL RELEVANCE

L-PRF could represent a feasible substitute for CTG in treating MAGRs.

Perio-prosthodontic pontic site management, part II: Pontic site reconstruction strategies to enhance the esthetic and biological outcomes

OBJECTIVE

Ridge deformities are present in most patients after tooth extraction; these defects make the management of future implant and pontic sites challenging to deal with. The restorative team should be able to diagnose and treat these deformities to allow for successful outcomes. Many approaches have been described to reconstruct pontic sites, each with specific indications. This article describes the different approaches to reconstructing pontic sites and their indications to allow for a proper esthetic and biological environment for future restorations.

CLINICAL CONSIDERATIONS

Depending on the severity of the defect, location, and the esthetic necessity, pontic site enhancement can be done through different approaches, some requiring soft tissue grafting, hard tissue grafting, or both. Understanding the indications of the treatment options is essential to allow the clinician to make the right therapeutic decision and achieve the best possible perio-prosthodontic outcomes.

CONCLUSIONS

An adequate balance between the soft tissue and prosthetics is essential to achieve successful results on implant-supported or tooth-supported fixed dental prostheses (FDPs). Selecting the right approach to treat ridge deformities is necessary to increase treatment success, reduce over-treatment, and create a biologically sound environment for restorations.

CLINICAL SIGNIFICANCE

Pontic site enhancement through reconstructive surgery will allow for esthetically pleasing and biologically stable results, allowing restorations to emulate natural structures lost after tooth extraction.

Treatment of Multiple RT1 Gingival Recessions Using a Coronally Advanced Flap Associated with L-PRF or Subgingival Connective Tissue Graft from Maxillary Tuberosity: A Randomized, Controlled Clinical Trial

The goal of plastic periodontal surgery is to obtain complete root coverage, increasing gingival thickness (GT), a positive prognostic factor for gingival margin stability over time. The aim of this study was to compare the effectiveness of the Coronally Advanced Flap (CAF) in RT1 (GR; gingival recession with no loss of interproximal attachment) when associated with a connective tissue graft from the maxillary tuberosity (tCTG) or with leukocyte and platelet-rich fibrin (L-PRF) membranes in obtaining root coverage and increasing the thickness and width of the keratinized tissue, along with aesthetic improvement, taking into account a number of patient-related outcomes. Thirty patients with two adjacent RT1 GRs (GRs with no loss of interproximal attachment) were each treated using CAF associated with tCTG (15 patients) or L-PRF. The main outcome was a GT increase; secondary outcomes were keratinized tissue width (KT), gingival recession (GR), probing depth (PD), clinical attachment level (CAL), root coverage percentage (RC%), complete root coverage (CRC), and root coverage esthetic score (RES). Patient-reported outcomes were discomfort (D), dentine hypersensitivity (DH), patient-related esthetic score (PRES), and overall treatment satisfaction (OTS). After 12 months, clinical and patient-reported parameters did not show significant differences between groups, with the only exception being a GT gain, which was significantly greater in the CAF + tCTG group. Our results showed that both techniques were effective in treating RT1 GRs, with comparable patient-related outcomes. However, the use of tCTG produces significantly thicker tissue, covering the exposed root surface.

Association of the Osseodensification Technique with Soft Tissue Substitute in a Limitrophe Edentulous Area: A Clinical Case Report with 5-Year Follow-Up

The osseodensification (OD) technique differs from conventional milling for dental implant installation in that it preserves the prepared bone and compacts it toward the apex and lateral walls of the socket, resulting in bone compaction. By enabling autografting, bone expansion, and high implant insertion torques, OD has become an increasingly popular option. The aim of this clinical case report is to demonstrate the predictability of combining OD with guided bone and tissue regeneration (GBR/GTR) techniques for bone expansion in the maxilla with reduced thickness, while avoiding other reconstructive surgeries. The report presents the treatment of a 32-year-old female patient who had cosmetic concerns regarding the anterior maxillary region. The patient was using an adhesive prosthesis with pontic on tooth 13 fixed between teeth 12 and 14. After the case was planned, it was decided that bone expansion in the region would be performed using the OD technique. The implant installation (AR Torque, 3.5 × 11.5 mm, Conexão®) and guided bone regeneration (GBR) were done with the assistance of L-PRF (Stick Bone, associated with L-PRF membrane). Following the osseointegration period, a provisional resin crown was fabricated, and a collagen matrix membrane (Mucoderm®) was used to increase vestibular soft tissue volume and shape the patient's gingival profile. After a period of 120 days, the final crown was created and observed for a span of 5 years. The results showed stability of the case along with maintaining its esthetic and satisfactory function. The use of the osseodensification technique coupled with a connective tissue graft substitute has been anticipated for a long time. It has proven to be an excellent alternative to autogenous grafts.

Electrospun methacrylated natural/synthetic composite membranes for gingival tissue engineering

New functional materials for engineering gingival tissue are still in the early stages of development. Materials for such applications must maintain volume and have advantageous mechanical and biological characteristics for tissue regeneration, to be an alternative to autografts, which are the current benchmark of care. In this work, methacrylated gelatin (GelMa) was photocrosslinked with synthetic immunomodulatory methacrylated divinyl urethanes and defined monomers to generate composite scaffolds. Using a factorial design, with the synthetic monomers of a degradable polar/hydrophobic/ionic polyurethane (D-PHI) and GelMa, composite materials were electrospun with polycarbonate urethane (PCNU) and light-cured in-flight. The materials had significantly different relative hydrophilicities, with unique biodegradation profiles associated with specific formulations, thereby providing good guidance to achieving desired mechanical characteristics and scaffold resorption for gingival tissue regeneration. In accelerated esterase/collagenase degradation models, the new materials exhibited an initial rapid weight loss followed by a more gradual rate of degradation. The degradation profile allowed for the early infiltration of human adipose-derived stromal/stem cells, while still enabling the graft's structural integrity to be maintained. In conclusion, the materials provide a promising candidate platform for the regeneration of oral soft tissues, addressing the requirement of viable tissue infiltration while maintaining volume and mechanical integrity. STATEMENT OF SIGNIFICANCE: There is a need for the development of more functional and efficacious materials for the treatment of gingival recession. To address significant limitations in current material formulations, we sought to investigate the development of methacrylated gelatin (GelMa) and oligo-urethane/methacrylate monomer composite materials. A factorial design was used to electrospin four new formulations containing four to five monomers. Synthetic immunomodulatory monomers were crosslinked with GelMa and electrospun with a polycarbonate urethane resulting in unique mechanical properties, and resorption rates which align with the original design criteria for gingival tissue engineering. The materials may have applications in tissue engineering and can be readily manufactured. The findings of this work may help better direct the efforts of tissue engineering and material manufacturing.

Differential molecular profiles and associated functionalities characterize connective tissue grafts obtained at different locations and depths in the human palate

The present study aimed to assess the molecular profiles of subepithelial connective tissue grafts (CTGs) obtained at different locations and depths in the human palate. Sixty-four CTGs belonging to anterior deep (AD), anterior superficial (AS), posterior deep (PD), and posterior superficial (PS) groups were subjected to RNA-Sequencing and their transcriptomes were analyzed computationally. Functional correlations characterizing the CTG groups were validated by cell biological experiments using primary human palatal fibroblasts (HPFs) extracted from the CTGs. A clearly more pronounced location-dependent than depth-dependent difference between the grafts, with a minimal number of genes (4) showing no dependence on the location, was revealed. Epithelial, endothelial, and monocytic cell migration was strongly (P < 0.001) potentiated by AD- and PS-HPFs. Moreover, significantly increased expression of genes encoding C-C and C-X-C motif chemokine ligands as well as significantly (P < 0.01) activated p38 signaling suggested immunomodulatory phenotype for AD- and PS-HPFs. Increased growth factor gene expression and significantly activated (P < 0.001) Erk and Akt signaling in HPFs originating from A-CTGs implied their involvement in cell survival, proliferation, and motility. Prominent collagen-rich expression profile contributing to high mechanical stability, increased osteogenesis-related gene expression, and strongly activated (P < 0.001) Smad1/5/8 signaling characterized HPFs originating from P-CTGs. The present data indicate that in humans, differences between palatal CTGs harvested from different locations and depths appear to be location- rather than depth-dependent. Our findings provide the basis for future personalization of the therapeutic strategy by selecting an optimal graft type depending on the clinical indications.

The natural CAD/CAM anterior implant single tooth restoration: A novel digital workflow

OBJECTIVE

To report a novel digital workflow to replace an anterior maxillary tooth lost due to trauma with an implant multilayer restoration by using the patient's extracted tooth as a final crown restoration using computer-aided design/computer-aided manufacturing (CAD/CAM) technology.

CLINICAL CONSIDERATIONS

Instead of using the patient's natural tooth as an immediate provisional restoration to achieve predictable results in terms of esthetics and soft tissue structure, a novel digital strategy was performed to obtain a natural final crown restoration by using the patient's tooth associated with a lithium disilicate customized implant abutment.

CONCLUSIONS

The perspective of using this strategic approach for implant restorative dental treatments in patients with traumatic root fractures in the anterior region has great potential as it helps to maintain the emergence profile of the natural dentition and esthetics.

CLINICAL SIGNIFICANCE

Optimal esthetic outcomes are challenging in implant dentistry regarding soft tissue structure and morphology factors. Using natural teeth from surgery to deliver the final restoration might be beneficial when an anterior tooth is lost due to trauma.

Effect of polydeoxyribonucleotide with xenogeneic collagen matrix on gingival phenotype modification: a pilot preclinical study

PURPOSE

To investigate the effect of xenogeneic collagen matrix (XCM) with polydeoxyribonucleotide (PDRN) for gingival phenotype modification compared to autogenous connective tissue graft.

METHODS

Five mongrel dogs were used in this study. Box-type gingival defects were surgically created bilaterally on the maxillary canines 8 weeks before gingival augmentation. A coronally positioned flap was performed with either a subepithelial connective tissue graft (SCTG) or XCM with PDRN (2.0 mg/mL). The animals were sacrificed after 12 weeks. Intraoral scanning was performed for soft tissue analysis, and histologic and histomorphometric analyses were performed.

RESULTS

One animal exhibited wound dehiscence, leaving 4 for analysis. Superimposition of STL files revealed no significant difference in the amount of gingival thickness increase (ranging from 0.69±0.25 mm to 0.80±0.31 mm in group SCTG and from 0.48±0.25 mm to 0.85±0.44 mm in group PDRN; P>0.05). Histomorphometric analysis showed no significant differences between the groups in supracrestal gingival tissue height, keratinized tissue height, tissue thickness, and rete peg density (P>0.05).

CONCLUSIONS

XCM soaked with PDRN yielded comparable gingival augmentation to SCTG.

Stem-cell based soft tissue substitutes: Engineering of crosslinked polylysine-hyaluronic acid microspheres ladened with gingival mesenchymal stem cells for collagen tissue regeneration and angiogenesis

BACKGROUND

The aim of this study was to construct crosslinked polylysine-hyaluronic acid microspheres (pl-HAM) ladened with gingival mesenchymal stem cells (GMSCs) and explore its biologic behavior in soft tissue regeneration.

METHODS

The effects of the crosslinked pl-HAM on the biocompatibility and the recruitment of L-929 cells and GMSCs were detected in vitro. Moreover, the regeneration of subcutaneous collagen tissue, angiogenesis and the endogenous stem cells recruitment were investigated in vivo. We also detected the cell developing capability of pl-HAMs.

RESULTS

The crosslinked pl-HAMs appeared to be completely spherical-shaped particles and had good biocompatibility. L-929 cells and GMSCs grew around the pl-HAMs and increased gradually. Cell migration experiments showed that pl-HAMs combined with GMSCs could promote the migration of vascular endothelial cells significantly. Meanwhile, the green fluorescent protein-GMSCs in the pl-HAM group still remain in the soft tissue regeneration area 2 weeks after surgery. The results of in vivo studies showed that denser collagen deposition and more angiogenesis-related indicator CD31 expression in the pl-HAMs+ GMSCs + GeL group compared with the pl-HAMs + GeL group. Immunofluorescence showed that CD44, CD90, CD73 co-staining positive cells surrounded the microspheres in both pl-HAMs + GeL group and pl-HAM + GMSCs + GeL group.

CONCLUSIONS

The crosslinked pl-HAM ladened with GMSCs system could provide a suitable microenvironment for collagen tissue regeneration, angiogenesis and endogenous stem cells recruitment, which may be an alternative to autogenous soft tissue grafts for minimally invasive treatments for periodontal soft tissue defects in the future.

Treatment of peri-implant soft tissue dehiscence around implants placed in calvarial bone graft maxilla and mandible 20 years ago: A case report

INTRODUCTION

Despite tissue augmentation and management prior implantation, long-term observation can reveal a change in peri-implant phenotype with some lack of keratinized mucosa (KM). The treatment approach of peri-implant dehiscence in multiple implants is not clearly defined. This report describes the different periodontal surgical approaches undertaken to promote the gingival margin stability and to prevent the peri-implant mucosal inflammation over time.

CASE PRESENTATION

A 64-year-old woman with peri-implant tissue dehiscence regarding implants placed 20 years ago in a calvarial bone grafted maxilla and mandible was treated. Right maxillary and mandible peri-implants soft tissue were treated with a large apically positioned partial-thickness flap (APPTF) combined to a free gingival graft (FGG) simultaneously. For the left maxillary, where a frenum was in tension associated with infection and pockets, a large APPTF followed by a FGG 4 months later were performed. The KM width (KMW) increased in three operated sites with a gain average of 2.2 mm. The plaque control record decreased from 68% to 21%. All the probing depths were lower than 3 mm. Bleeding on probing was significantly reduced. The gingival index (GI) went from 1.5 to 0.25.

CONCLUSION

In a multiple implants soft tissue dehiscence case, an APPTF associate to a FGG, delayed or not, seems to be a safety primary approach to improve the KMW and to stabilize the peri-implants soft tissue. Further, a connective tissue graft in a bilaminar approach could be an option to enhance soft tissue thickness and esthetic outcomes.

KEY POINTS

Why is this case new information? To the best of the authors' knowledge, there are very limited studies regarding multi-implant soft tissue dehiscence treatment. Relevant guidelines are not clearly defined. Despite peri-implant hard and soft tissue augmentation, after a long-term observation (20 years of function), we can observe a change in peri-implant soft tissue phenotype (PISTP) with periodontal complication. What are the keys to successful management of this case? Removal of peri-implant infection and tissue tension (frenum) by a large apically positioned partial-thickness flap (APPTF) before soft tissue augmentation procedure. In case of very thin peri-implant soft tissue, caution is needed to preserve the blood supply from the supra-periosteal plexus. Large APPTF and sufficient amount of keratinized mucosa (KM) should be grafted to compensate for the tissue shrinkage. What are the primary limitations to success in this case? High esthetic demand. A secondary bilaminar approach with a connective tissue graft (CTG) should be necessary to improve the esthetic outcomes. Patient compliance.

Post-extraction volumetric analysis of alveolar ridge contour using subepithelial connective tissue graft in esthetic zone: a randomized controlled clinical trial

OBJECTIVES

The aim of this randomized clinical trial was to assess the alveolar ridge contour after soft tissue augmentation using subepithelial connective tissue graft (SCTG) buccal to fresh extraction sockets in patients with thin buccal bone, versus minimally-traumatic extraction followed by spontaneous healing solely.

MATERIALS AND METHODS

Forty non-restorable maxillary teeth in the esthetic zone were randomly assigned into two groups: minimally-traumatic extraction with SCTG (test) and minimally-traumatic extraction followed by spontaneous healing (control). The outcomes assessed included linear volumetric change of buccal soft tissue contour, vertical tissue loss, gingival thickness (GT), and interdental papilla (IDP) height after 6 months.

RESULTS

The SCTG group showed a significant improvement (P < 0.001) in all outcomes after 6 months. The SCTG group showed a statistically significant (P < 0.001) gain in the buccal soft tissue volumetric change compared to the control group. The SCTG group showed a statistically significant increase in GT (P < 0.001) and IDP height (P < 0.05) after 6 months compared to the control group.

CONCLUSIONS

The use of SCTG buccal to extraction sockets in the anterior maxilla might be considered as a predictable approach for preserving the alveolar ridge contour.

CLINICAL RELEVANCE

SCTG buccal to extraction sockets might counteract post-extraction hard and soft tissue alterations in the esthetic zone.

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.

A prospective case series on the efficacy of a cross-linked collagen matrix to increase buccal soft tissue thickness at large edentulous gaps: One-year results

OBJECTIVE

The objective of this study is to assess profilometric changes following soft tissue augmentation with a cross-linked porcine-derived collagen matrix (CMX) at large edentulous gaps of at least two units.

MATERIALS AND METHODS

Systemically healthy, nonsmoking patients with a large edentulous gap of at least two units demonstrating a horizontal soft tissue defect, were enrolled in a prospective case series. Soft tissue augmentation was performed in a one-stage approach with a 6 mm thick CMX at the time of implant placement. The primary outcome was the change in buccal soft tissue profile (BSP) at a mesial, central, and distal area of interest (AOI) up to 1 year when compared to the preoperative situation based on superimposed digital surface models. Secondary outcomes included the horizontal dimension of the soft tissue defect, complications, and marginal bone loss (MBL).

RESULTS

Fifteen patients (eight females; mean age 58.73 years) were enrolled and 13 could be re-assessed at 1-year follow-up. The mean linear increase in BSP at 1 year was 0.66 mm (98.3% CI: 0.37-0.94), 0.80 mm (98.3% CI: 0.39-1.22), and 0.69 mm (98.3% CI: 0.32-1.06) at the mesial, central, and distal AOI, respectively. Substantial shrinkage of about 75% was observed in all areas between augmentation and 1-year follow-up. Even though 11 of 13 sites were fully augmented immediately postoperative, a soft tissue defect recurred in all sites at 1-year follow-up with a mean deficit of 2.30 mm. Altogether, 25% of the original soft tissue defect was eliminated by soft tissue augmentation. CMX was safe since no postoperative complications occurred and MBL was limited (0.70 mm).

CONCLUSION

CMX is efficacious for horizontal soft tissue augmentation at large edentulous gaps. However, considerable graft resorption may be expected, and the clinical relevance of the augmentation may be questionable since all patients demonstrated a recurring and considerable soft tissue defect 1 year after surgery.

Histological assessment and gene expression analysis of intra-oral soft tissue graft donor sites

AIM

To determine the structural and gene expression features of different intra-oral soft tissue donor sites (i.e., anterior palate, posterior palate, maxillary tuberosity and retromolar pad).

MATERIALS AND METHODS

Standardized mucosal tissue punch biopsies were collected from at least one donor site per subject. Histological processing was performed to determine tissue morphometry and quantify collagen composition. Site-specific gene distribution was mapped using targeted gene expression analysis and validated using real time polymerase chain reaction (qPCR).

RESULTS

A total of 50 samples from 37 subjects were harvested. Epithelial thickness did not differ between sites. However, lamina propria was thicker in the maxillary tuberosity (2.55 ± 0.92 mm) and retromolar pad (1.98 ± 0.71 mm) than in the lateral palate. Type I collagen was the predominant structural protein in the lamina propria (75.06%-80.21%). Genes involving collagen maturation and extracellular matrix regulation were highly expressed in the maxillary tuberosity and retromolar pad, while lipogenesis-associated genes were markedly expressed in the lateral palate. The retromolar pad showed the most distinct gene expression profile, and the anterior and posterior palate displayed similar transcription profiles.

CONCLUSIONS

Tissue samples harvested from the anterior and posterior palate differed morphologically from those from the maxillary tuberosity and retromolar pad. Each intra-oral site showed a unique gene expression profile, which might impact their biological behaviour and outcomes of soft tissue augmentation procedures.

Biomaterials derived from hard palate mucosa for tissue engineering and regenerative medicine

Autologous materials have superior biosafety and are widely used in clinical practice. Due to its excellent trauma-healing ability, the hard palate mucosa (HPM) has become a hot spot for autologous donor area research. Multiple studies have conducted an in-depth analysis of the healing ability of the HPM at the cellular and molecular levels. In addition, the HPM has good maneuverability as a donor area for soft tissue grafts, and researchers have isolated various specific mesenchymal stem cells (MSCs) from HPM. Free soft tissue grafts obtained from the HPM have been widely used in the clinic and have played an essential role in dentistry, eyelid reconstruction, and the repair of other specific soft tissue defects. This article reviews the advantages of HPM as a donor area and its related mechanisms, classes of HPM-derived biomaterials, the current status of clinical applications, challenges, and future development directions.

Assessment of palatal mucosal thickness and location of the greater palatine foramen using cone-beam computed tomography: a retrospective study

OBJECTIVES

This study aimed to measure the palatal mucosal thickness and examine the location of the greater palatine foramen using cone-beam computerized tomography (CBCT).

METHODS

In this study, cone-beam computed tomography (CBCT) images of the maxillary posterior region of 120 subjects were evaluated. The palatal mucosal thickness (PMT), palatal width and depth, and location of the greater palatine foramen (GPF) were determined on CBCT. The differences in the palatal mucosal thickness according to gender and palatal width/palatal depth were analyzed. The location of the GPF related to the maxillary molars was noted.

RESULTS

The mean palatal mucosal thicknesses from the canine to the second molar teeth were 3.66, 3.90, 4.06, 3.76, and 3.92 mm, respectively. The mean PMT at the second premolar was statistically thicker than at other regions (p < 0,001). There was no relationship between PMT and gender. However, the palatal depth and width of the males were greater than females. (p = 0.004 and p = 0.014, respectively) PMT in the low palatal vault group had statistically higher compared to the high palatal vault group. (p = 0.023) Greater palatine foramen was mostly observed between second and third molar teeth. (48%).

CONCLUSIONS

According to our results, first and second premolar regions can be preferable in soft tissue grafting procedures for safe and successful treatment outcomes. The measurement of the thickness of the palatal mucosa and the evaluation of the greater palatine foramen location before the surgical procedures are essential steps to harvest from the ideal donor site and to achieve optimal surgical outcomes.

Treatment of Advanced Gingival Recession Secondary to Surgical Failure with Large Size Deepithelized Gingival Graft Associated with a Modified Tunnel Flap

Objective

To describe the use of a large size deepithelized gingival graft (DGG) associated with full-split tunnel technique in a clinical case of advanced gingival recession secondary to surgical failure (GRSF). Clinical Considerations. The presented case report helped to achieve satisfactory root coverage, ideal keratinized tissue gain, improvement in soft tissue quality and esthetics, scar deformity correction, and vestibular depth deepening with a one-step procedure of large size DGG associated with full-split tunnel technique for a condition of deep gingival recessions of 7-11 mm caused by a failed bone implantation surgery.

Conclusions

The large size DGG associated with full-split tunnel technique provided a versatile one-step procedure to obtain ideal results for advanced GRSF. Clinical Significance. GRSF that is generally associated with inadequate keratinized tissue and scar formation could be rather difficult to deal with. The large size DGG associated with full-split tunnel technique, as a one-step procedure, provided a predictable and practical treatment modality.

Comparison of morbidity at the donor site and clinical efficacy at the recipient site between two different connective tissue graft harvesting techniques from the palate: A randomized clinical trial

Background

This study was conducted to compare the pain levels in patients and the clinical efficacy of grafts obtained using two techniques, namely de-epithelialized gingival graft (DGG) and subepithelial connective tissue graft (SCTG), in combination with coronally advanced flap (CAF) for the treatment of multiple adjacent gingival recessions.

Methods

Twelve patients were treated using DGG+CAF on one side and SCTG+CAF on the other. The patients' pain levels at the surgical site, the number of analgesics taken on days 3 and 7, the mean root coverage (MRC), the percentage of complete root coverage (CRC), color match, and gingival thickness (GT) at the graft recipient site were evaluated 6 months after surgery.

Results

The total number of analgesics taken during the 7-day period after surgery and pain levels at the surgical site from day 3 to day 7 were significantly higher in the DGG+CAF group compared to the SCTG+CAF group (P=0.001). In the 6-month follow-up, color match and CRC were significantly higher in the SCTG+CAF group, while GT was significantly higher in the DGG+CAF group. There was no significant difference in MRC between the two groups.

Conclusion

The pain and analgesic consumption levels were higher in the DGG+CAF group compared to the SCTG+CAF group, and the recipient site had a weaker color match. However, this technique can lead to a greater increase in the thickness of the grafted area.

The perspectives of a novel operative procedure for free gingival graft

Graft shrinkage, epithelial disintegration, and even necrosis are the well-known clinical complications during initial healing stage of free gingival graft (FGG) procedure. This article presented a novel operative prodecure for FGG in a dental implant with insufficient keratinized tissue over a 3-year follow-up period. Briefly, donor site for FGG harvested from maxillary tuberosity would minimize the volume of graft shrinkage. The new periosteum suture technique could secure FGG firmly adapted on the recipient site. With 1 mm gap between FGG and muco-gingival junction may improve plasmatic circulation and revascularization. The clinical findings of case report demonstrated that this novel operative procedure may provide a viable therapeutic alternative for FGG.

Wound healing dynamics, morbidity, and complications of palatal soft-tissue harvesting

Palatal-tissue harvesting is a routinely performed procedure in periodontal and peri-implant plastic surgery. Over the years, several surgical approaches have been attempted with the aim of obtaining autogenous soft-tissue grafts while minimizing patient morbidity, which is considered the most common drawback of palatal harvesting. At the same time, treatment errors during the procedure may increase not only postoperative discomfort or pain but also the risk of developing other complications, such as injury to the greater palatine artery, prolonged bleeding, wound/flap sloughing, necrosis, infection, and inadequate graft size or quality. This chapter described treatment errors and complications of palatal harvesting techniques, together with approaches for reducing patient morbidity and accelerating donor site wound healing. The role of biologic agents, photobiomodulation therapy, local and systemic factors, and genes implicated in palatal wound healing are also discussed.

Effect of collagen sponge and flowable resin composite on pain management after free gingival graft harvesting: A randomized controlled clinical trial

The aim of this study was to compare the effect of the application of a flowable resin composite coating, over a collagen sponge stabilized with suture, on postoperative pain after free gingival graft harvesting. Thirty-two free gingival grafts were harvested from the palate in 32 patients, who were subsequently randomized to have only a collagen sponge stabilized with sutures applied to the palatal wound (control), or to have the collagen sponge coated with a flowable resin composite (test). Patients were observed for 14 days, and the pain level was evaluated by using a numerical rating scale. The consumption of analgesics during the postoperative period and the characteristic of the graft were also analyzed. The patients in the test group reported having experienced significantly less pain statistically than the patients in the control group throughout the study. The consumption of analgesics was lower in the test group. The dimensions of harvested grafts in the control and test groups showed no significant differences in height, width, and thickness. In conclusion, the addition of flowable resin composite coating to the hemostatic collagen sponge on the palatal wound following free gingival graft harvesting helped to minimize postoperative pain.

The efficacy of a porcine collagen matrix in keratinized mucosa width augmentation: a 10-year follow-up clinical prospective study

PURPOSE

The aim of the present study was to evaluate the long-term effectiveness of a xenogeneic collagen matrix (CM) in pre-prosthetic augmentation of the keratinized mucosa width (KMW) at implant sites.

METHODS

All of the patients with localized implant-supported rehabilitation previously treated with vestibuloplasty and KMW augmentation with a non-cross-linked porcine CM were recalled. KMW was measured clinically in an apico-coronal direction from the mucogingival junction to the mucosal margin at the prosthetic zenith of each crown. Measurements were performed clinically by means of a PCP-UNC15 periodontal probe and rounded to the nearest mm. KMW values recorded at 1 year, 5 and 10 years from the soft tissue augmentation procedure were compared using a one-way repeated-measures ANOVA with Bonferroni multiple comparison post-hoc analysis. The level of significance was set at 0.05.

RESULTS

Measurements were conducted on 13 patients. All implants were in function with no signs of biological complications. All except one implant site showed KMW ≥ 2 mm. KMW decreased significantly from 1 year (3.33 ± 1.11 mm) to 5 years (2.77 ± 0.92 mm) (p = 0.001), and finally remained stable from 5 to 10 years (3.2 ± 0.99 mm) (p = 0.607). From a visual aspect, peri-implant soft tissues were characterized by a good texture and color blending compared to the adjacent teeth, highlighting good integration of the remodeled tissues and stability of the esthetic result.

CONCLUSIONS

The use of a CM in pre-prosthetic soft tissue augmentation at implant sites has proven to be effective in obtaining and maintaining at least 2 mm of KMW around dental implants over a follow-up of 10 years.

Gingival biotype modification with collagen matrix or autogenous subepithelial connective tissue graft: Histologic and volumetric analyses in a beagle model

Objectives

To evaluate the volumetric effect and biocompatibility of porcine tendon-derived type I collagen matrix graft (CG) in gingival biotype modification (GBM) compared with subepithelial connective tissue graft (SCTG) in a beagle model.

Methods

Surface analysis using scanning electron microscopy and a collagen degradation assay of CG was performed in vitro. Six adult dogs were used in in vivo experiment, and each received autologous SCTG or CG at the anterior side. Histometric and three-dimensional digital volume analyses were conducted to compare quantitative changes in CG and SCTG in GBM. Immunohistochemical analysis was performed for the qualitative evaluation of CG compared to SCTG.

Results

CG had a double-layered structure, and its degradation was slower than that of other well-reported materials. No critical problems were associated with the healing procedure. Changes in gingival thickness and volume in the CG and SCTG groups were equivalent, with no significant differences between the groups. Type I collagen and vascular endothelial growth factor expression levels were similar in both groups.

Significance

CG and SCTG had equivalent potential for GBM in terms of quantity and quality. Additionally, CG could be used as a reasonable substitute for SCTG, making surgery convenient and predicting successful clinical outcomes.

Histological and histomorphometric study of human palatal mucosa: Implications for connective tissue graft harvesting

AIMS

To analyse the histological structure and histomorphometric characteristics of human hard palatal mucosa in order to determine the donor site of choice for connective tissue grafts from a histological point of view.

MATERIALS AND METHODS

Palatal mucosa samples from six cadaver heads were harvested at four sites: incisal, premolar, molar and tuberosity. Histological and immunohistochemical techniques were performed, as was histomorphometric analysis.

RESULTS

In the current study, we found that the density and size of cells were higher in the superficial papillary layer, whereas the thickness of the collagen bundles increased in the reticular layer. Excluding the epithelium, the mean percentage of lamina propria (LP) and submucosa (SM) was 37% and 63%, respectively (p < .001). LP thickness showed similar values in the incisal, premolar and molar regions, and a significantly greater thickness in tuberosity (p < .001). The thickness of SM increased from incisal to premolar and molar, disappearing in the tuberosity (p < .001).

CONCLUSIONS

As dense connective tissue of LP is the tissue of choice for connective tissue grafts, the best donor site from a histological point of view is tuberosity because it is composed only of a thick LP without the presence of a loose submucosal layer.

In vitro and in vivo evaluation of a modified porcine acellular dermal matrix for soft tissue augmentation

OBJECTIVES

To evaluate the effects of a modified porcine acellular dermal matrix (P-ADM), subepithelial connective tissue graft (SCTG) and other commercial bovine acellular dermal matrix membrane materials (B-ADM) on gingival soft tissue augmentation in the oral esthetic zone.

MATERIAL AND METHODS

The characteristics of P-ADM were observed by scanning electron microscope (SEM), Hematoxylin and eosin (H&E) and Masson's trichrome staining (Masson staining). The biocompatibility of P-ADM was verified by CCK8, phalloidin and living/dead cell staining. Beagle dog models were constructed and the thickness of gingiva was analyzed by the intraoral scanner. The morphology was observed by H&E and Masson staining.

RESULTS

Scanning electron microscopy, H&E and Masson staining showed that the P-ADM was mainly composed of collagen fibers, with no component of nuclear. The results of CCK8, phalloidin and living/dead cell staining indicated that the P-ADM had good cytocompatibility and no cytotoxicity. Human gingival fibroblasts were able to adhere and stretch on the surface of the material with pseudopodia. The SCTG group outperformed the B-ADM and P-ADM groups in terms of effectiveness, according to the analysis of digital oral scanning data at various time points following incremental soft tissue surgery. Compared with the B-ADM group, the effect of soft tissue increment was better in the P-ADM group.

CONCLUSIONS

P-ADM, as a biocompatible biomaterial, can be used as an alternative biomaterial for oral soft tissue thickening. However, the results of this study need to be verified by more clinical trials.

Clinical outcomes of root coverage using porcine-derived collagen matrix with modified coronally advanced tunnel technique (MCAT) in multiple gingival recessions in smokers - a randomized controlled clinical trial

OBJECTIVES

Root coverage (RC) is an integral part in management of gingival recessions. Unlike isolated recessions, treating multiple recessions is the most challenging scenario especially in smokers who have reported reduced RC in terms of quantity and stability. Modified coronally advanced tunnel (MCAT) technique due to its improved vascularity along with use of porcine-derived collagen matrix (PDCM) (Mucograft™) with its bilayered dense collagen matrix may be a predictable alternative to conventional gold standard subepithelial connective tissue graft (SCTG). The purpose of this study was to compare the results of RC achieved using PDCM and SCTG with the MCAT approach in the treatment of multiple gingival recessions in smokers.

METHODOLOGY

This is a prospective randomized controlled clinical study registered under clinical trial registry (CTRI no. CTRI/2020/03/024238) including 28 patients with 64 recession defects. Smokers (≥ 10 cigarettes/day for ≥ 5 years) fulfilling the inclusion criteria were randomized into the SCTG and PDCM groups which were treated with SCTG using MCAT and PDCM using MCAT technique, respectively. Recession depth (RD), recession width (RW), width of keratinized tissue (WKT), thickness of keratinized gingiva (TKG), and %RC were assessed at baseline, 3, and 6 months. Complete RC (CRC) at 3 and 6 months, RC aesthetic scores (RCES) at 6 months.

RESULTS

Both groups showed significant improvement in all clinical parameters. Intergroup comparison of root coverage parameters in smokers showed better performance of the PDCM group in terms of RD, %RC, TKG, WKT, CRC (45.06%), and RCES (p < 0.001) compared to the SCTG group. Time taken for surgical procedure and visual analog pain scores were significantly lesser in the PDCM group.

CONCLUSION

PDCM showed good predictable results in terms of all RC parameters compared to SCTG and thus may be used as a predictable alternative to SCTG for RC in smokers.

CLINICAL SIGNIFICANCE

PDCM can be used as a potential alternative to gold standard subepithelial connective tissue graft in smokers with better patient compliance.

Effectiveness of Plasma-Rich Fibrin and De-Epithelialized Free Gingival Graft in the Treatment of Gingival Recessions

Introduction/Aim: Soft tissue dehiscences such as gingival recessions are a very common problem that we face in modern periodontics. This clinical study aimed to analyze the effectiveness of surgical procedures using a de-epithelialized gingival graft (DGG) combined with a coronally advanced flap and to evaluate the application of plasma-rich fibrin (PRF). Methods: The study included 40 teeth (20 patients) with Miller class I and II gingival recessions. Twenty recessions (20 patients) were treated utilizing the de-epithelialized gingival graft in combination with the coronally advanced flap, and on the opposite side of the jaw, the same number of recessions were treated utilizing plasma-rich fibrin combined with the coronally advanced flap. To evaluate tissue condition and the clinical parameters before and after the surgical procedure, the following parameters were used: the degree of epithelial attachment (DEA), the width of keratinized gingiva (WKG), and the vertical depth of recession (VDR). Results: based on the achieved results and the analysis of clinical parameters, a statistically significant reduction in the vertical depth of recession was proven in both groups, with very similar mean percentages of root coverage, with the difference being that the stability of the soft tissues of the treated region was more visible in the DGG. Conclusion: using modern surgical procedures allows the regeneration of not only the soft tissues but also deeper periodontal tissues.

Evaluation of esthetic outcome of delayed implants with de-epithelialized free gingival graft in thin gingival phenotype with or without immediate temporization: a randomized clinical trial

AIM

The current study investigates the effect of immediate temporization on the pink esthetics of delayed implants in patients with thin gingival phenotype in combination with a De-epithelialized Free Gingival Graft in the maxillary premolar area.

METHODOLOGY

The study population was randomly assigned into two groups. The two groups were treated with delayed implants with simultaneous placement of a de-epithelialized free gingiva graft. The test group was immediately temporized while the control group had no temporization. The pink esthetic score was assessed as the primary outcome. Additional secondary outcomes were assessed such as the keratinized tissue width and the soft tissue thickness.

RESULTS

Twenty implants were placed in the current study, split into 10 implants per group. The results showed that the Pink Esthetic Score of the IT group was 11.88 ± (1.13) and 11.33 ± (1.25) for the CTG group, which showed no statistical difference between the groups after 1 year of follow-up. There was also no significant difference between the two groups at 12 months regarding the keratinized tissue width and the soft tissue thickness.

CONCLUSIONS

Immediate and delayed temporizations have no effect on the Pink Esthetics of the delayed implants; however, immediate temporization allowed earlier provisional crown delivery. Soft tissue augmentation of the thin gingival phenotype improved esthetics for both groups. Trial registration Name of the registry: clinicaltrials.gov; trial registration number: NCT03792425. Date of registration: January 3, 2019. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT03792425?term=NCT03792425&draw=2&rank=1.

Accuracy of cone-beam computed tomography in determining gingival thickness: a systematic review and meta-analysis

OBJECTIVE

To assess the accuracy of cone-beam computed tomography (CBCT) for determining gingival thickness.

MATERIAL AND METHODS

Searches were undertaken in PubMed/MEDLINE, EMBASE, LILACS, Web of Science, Scopus, LIVIVO, and gray literature (Google Scholar and ProQuest) for studies considered eligible according to the following criteria: cross-sectional observational studies, which compared CBCT accuracy with that of transgingival probing when determining gingival thickness, in adult patients with good periodontal health. No language or time restrictions were applied in this systematic review. The risk of bias was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for analytical cross-sectional studies.

RESULTS

Six articles were included for qualitative synthesis, involving a pooled sample of 132 patients with a mean age of 29 years (18-51 years). Of these 6 studies, 5 were eligible for quantitative analysis. The meta-analysis showed no statistically significant difference between CBCT and transgingival probing measures of gingival tissue (mean difference of 0.10 (95% CI-0.17-0.38). No significant level of heterogeneity was detected (Tau²-P = 0.0662; I² = 0%; H²-P = 1.000; Q-P = 1.134). According to the GRADE criterion, confidence in the cumulative evidence was considered low.

CONCLUSIONS

CBCT is an accurate method for determining gingival tissue thickness, comparable to the reference standard (transgingival probing).

CLINICAL RELEVANCE

CBCT could be considered for gingival thickness measurement when bone thickness is also needed, and thereby aid in the assessment of gingival biotype without the discomfort and anesthesia needed in transgingival probing.

TRIAL REGISTRATION

This protocol was registered at the PROSPERO database (International Prospective Register of Systematic Review) under registration number CRD42022326970. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022326970 .

Comparison of the clinical efficacy of concentrated growth factor and advanced platelet-rich fibrin in the treatment of type I multiple gingival recessions: a controlled randomized clinical trial

OBJECTIVES

The purpose of this randomized controlled clinical trial was to compare and evaluate the clinical effects of concentrated growth factor (CGF) and advanced platelet-rich fibrin (A-PRF) applied together with coronally advanced flap (CAF) technique using a microsurgical approach in the treatment of type I multiple gingival recessions (GR).

MATERIALS AND METHODS

Sixteen patients with multiple recession defects (Cairo type I) were included in this randomized and controlled study. Forty-five gingival recession defects were randomly equally divided into three groups (n = 15): CAF + CGF (test site); CAF + A-PRF (test site), and CAF alone (control site). Clinical attachment level (CAL), vertical gingival recession (VGR), horizontal gingival recession (HGR), gingival thickness (GT), width of keratinized gingiva (KGW), percentages of the mean (MRC), and complete root coverage (CRC), patient esthetic score (PES), and hypersensitivity score (HS) were recorded at baseline and 6 months after surgery. Patient comfort score (PCS) was evaluated at the day of surgery.

RESULTS

Significant improvements were determined in CAL, VGR, HGR, KGW, and GT at 6 months when compared to baseline levels in intra-group comparisons for all groups, and also GT was increased in CAF + A-PRF and CAF + CGF compared to CAF alone at 6 months in intergroup comparisons (p < 0.05). At 6 months, MRC was detected 85.66 ± 22.68% in the CAF + CGF, 90.88 ± 20.87% in the CAF + A-PRF, and 75.10 ± 32,37% in the CAF alone, and a significant increase was detected in the CAF + A-PRF group compared to CAF alone (p < 0.05). CRC in CAF + CGF was 66.66%, in CAF + A-PRF 80% and in CAF alone was 53.33% (p > 0.05). PES and HS values showed significant improvement from baseline to 6 months for all groups and also in CAF + CGF and CAF + A-PRF compared to CAF alone at 6 months in intergroup comparisons (p < 0.05).

CONCLUSIONS

The present study showed that the use of A-PRF and CGF membranes in GR therapy may have an additional benefit in GT increase and also A-PRF may increase the percentages of MRC. The use of A-PRF and CGF membranes may be beneficial in terms of improving patient-related parameters.

CLINICAL RELEVANCE

A-PRF and CGF may be superior to CAF alone in terms of patient-related parameters and GT increase in multiple recession defects.

TRIAL REGISTRATION NUMBER

17578e02-00a9-4a41-8c8d-42a637143531.

Soft tissue esthetics around immediately provisionalized delayed implants with and without connective tissue graft: A randomized clinical trial pilot study

OBJECTIVE

Evaluate the peri-implant soft tissue esthetics following a single, immediately provisionalized, delayed implant with/-out subepithelial connective tissue graft (SCTG).

MATERIAL AND METHODS

The eligible patients were randomized into two groups. Immediate provisionalization was performed with (test group: SCTGG) or without SCTG (control group: NGG). The soft tissue esthetics was assessed by Pink Esthetic Score (PES) and Mucosal Scarring Index (MSI), at 6 and 12 months, following final implant restoration.

RESULTS

The SCTGG, compared to NGG, yielded a 0.2 increased PES at 12 months (95% confidence interval (CI): -1, 1.4) and a 0.2 decreased MSI score (95% CI -0.9, 0.5) with no statistically significant differences in PES and MSI between both groups (p > 0.05).

CONCLUSION

Soft tissue grafting around immediately provisionalized delayed implants could exhibit comparable results to immediate provisionalization alone in terms of peri-implant soft tissue esthetics using PES and MSI (ClinicalTrials.gov Identifier: NCT03770975).

[Assessment of microhaemodynamics and oxygenation in tissues after the vestibuloplasty with the use of a free dermal autograft in patients after the reconstructive jaw surgery with the use of the revascularized autografts]

Purpose of the study: to study the features of microhaemodynamics and oxygenation in soft tissues in the area of the plastically reconstructed jaw after the vestibuloplasty.

MATERIALS AND METHODS

The study included 40 patients aged 20 to 65 (21 males and 19 females). The patients were divided into two groups: I group (14 patients) - patients after reconstructive surgery with the use a fibula autograft without the inclusion of a musculocutaneous «islet»; II group (26 patients) - patients after reconstructive surgery with the use a fibula autograft with the inclusion of a musculocutaneous «islet». To correct the prosthetic bed soft tissues, all patients underwent vestibuloplasty with the use of a free dermal autograft. To study microcirculation in tissues, the laser Doppler flowmetry (LDF) method was used. Microcirculation status was assessed by microcirculation index characterizing the level of tissue blood flow; parameter «σ,» which determines the oscillability of the flow of red blood cells and by coefficient of variation, characterizing vasomotor activity of microvessels. According to the Wavelet analysis of LDF-grams the blood flow bypass was determined. An oxygenation study was carried out in the tissues of the plastically restored jaw by optical tissue oximetry, the results of which determined the oxygenation index and the specific oxygen consumption index.

RESULTS

According to LDF data after vestibuloplasty, it was found that in I group, the microcirculation in soft tissues of the plastically reconstructed jaw restored in 21 days, and in II group in 2 months, which persisted at 6 months. In I group, the level of oxygenation and specific oxygen consumption normalized in 21 days, and in II group in 2 months, which persisted at 6 months.

CONCLUSION

Based on the results of this functional study, it was found that before vestibuloplasty microcirculation and oxygenation indices in II group patients were lower than those in I group patients. After vestibuloplasty with the use of a free dermal autograft, microcirculation indices in II group patients restored in 2 months, while in I group patients those indices restored in 21 days.

Design of customized soft tissue substitutes for anterior single-tooth and posterior double-tooth defects: An in vitro study

OBJECTIVE

This study aims to validate the standardized procedure for designing soft tissue substitutes (STS) adapted to optimally fit single-tooth defects in the anterior jaws and double-tooth defects in the posterior jaw and to compare mathematically modeled average shapes.

MATERIALS AND METHODS

Casts from 35 patients with 17 single-tooth defects in anterior region and 21 double-tooth defects in posterior region were scanned. STS were designed and sectioned in 3D slices meshes. Thickness values were documented respecting mesial-distal and buccal-lingual orientations. Graphs were embedded into images, and hierarchical clustering was applied to group STS according to shape and thickness.

RESULTS

STS clustered into two groups per defect type. For anterior single defects, STS (n = 4) were either a small and thin oval: 7 mm buccal-lingual, 4-5 mm mesial-distal direction and 1.1-1.5 mm thick or a larger oval (n = 13): 9 mm buccal-lingual, 5-7 mm mesial-distal and 1.6 m thick. For posterior double tooth defects, STS (n = 10) were either narrow, long and thick: 6-7 mm buccal-lingual, 16-20 mm mesial-distal and 2.2 thick or a wide, thinner rectangle (n = 11): 9-11 mm buccal-lingual, 12-14 mm mesial-distal and 1.1-1.5 mm thick.

CONCLUSIONS

The study validated the standardized digital method to design grafts for soft tissue volume augmentation and identified four average shapes for anterior single-tooth and posterior double-tooth soft tissue defects.

CLINICAL SIGNIFICANCE

We developed and validated a standardized digital method to design an optimal geometrical shape of a soft tissue substitute for oral volume augmentation and combined it with mathematical modeling to identify average shapes for single-interior, and double-posterior tooth defects. The identified average shapes offer the possibility to produce better-fitted xenografts or synthetic STS blocks requiring minimal chair-side adaptation leading to reduced clinical time and patient discomfort and potentially improving soft tissue volume augmentation outcomes.

Comparison of Sub-epithelial Connective Tissue Graft and Platelet Rich Fibrin in Peri-implant Soft Tissue Augmentation: A Randomized Clinical Split-mouth Study

Aims and Background:

Gingival phenotype has a crucial impact on the peri-implant marginal bone stability. The aim of this clinical trial is to assess and compare the efficacy of the sub-epithelial connective tissue graft (SCTG) and platelet-rich fibrin (PRF) in improving the peri-implant soft tissue phenotype and enhancing esthetic outcomes.

Materials and Methods:

The present study was a split-mouth randomized controlled clinical trial. A total of ten patients who had bilateral missing teeth in the maxillary esthetic zone with a thin gingival phenotype were included in this study. For each study participant, one randomly selected site was treated with SCTG, while the other was treated with PRF membrane during dental implant placement. Treatment outcomes included the assessment of the facial gingival thickness using cone-beam computed tomography (CBCT) at the baseline (T0) and 6 months postoperatively (T1), and the Pink esthetic score (PES) at T1 and 3 months later after prosthesis placement (T2).

Results and Discussion:

Both treatment options resulted in a significant increase in gingival tissue thickness at T1 compared with T0, and in PES at T2 compared with T1 (p ˂ 0.05).

Conclusion:

PRF is an effective alternative to SCTG in augmenting peri-implant soft tissue phenotype and improving esthetic outcomes. This would help overcome the complications associated with harvesting the SCTG and increasing patients’ satisfaction.

Clinical Trial Registration ID: ISRCTN11961919.