De-epithelialized gingival graft versus subepithelial connective tissue graft in the treatment of multiple adjacent gingival recessions using the tunnel technique: 1-year results of a randomized clinical trial

Evaluation of platelet derived growth factor-BB levels in injectable platelet rich fibrin coated graft using gingival pedicle split thickness tunnel technique for isolated gingival recession: A randomized controlled trial

Background

Use of injectable-platelet rich fibrin (i-PRF) in the field of periodontal regeneration is quite well known due to its efficacy. The study was aimed to evaluate the platelet derived growth factor-BB (PDGF-BB) levels in cases of isolated gingival recession using gingival pedicle split thickness tunnel technique (GPST) and de-epithelialized gingival graft (DGG) with or without coating it with i-PRF.

Methodology

20 patients exhibiting Miller's class I/II isolated gingival recession were selected for this parallel arm randomized controlled trial. Recipient site was prepared using GPST technique, free gingival graft was harvested and de-epithelialized, further graft was coated with i-PRF and wound fluid samples from surgical site were collected at baseline, 3rd day and 7th day for group A. The same procedure without coating the graft in i-PRF was carried out for group B. Clinical parameters like probing depth, recession depth, recession width, width of keratinized gingiva, wound healing index (WHI), complete root coverage was recorded at baseline and after 4 months.

Results

Significant intergroup difference was seen in WHI and the levels of PDGF-BB from baseline to the last estimated time point (p < 0.05).

Conclusion

The study emphasizes on the use of novel GPST technique in conjunction with DGG coated with liquid PRF, which has shown sustained release of PDGF-BB resulting in better wound healing.

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.

Does vestibular incision improve the outcomes of vestibular incision subperiosteal tunnel technique: A randomized clinical trial for treatment of multiple adjacent type 1 gingival recession

OBJECTIVE

The purpose of this study was to compare the clinical outcomes of vestibular incision subperiosteal tunnel technique (VISTA) and tunnel approach combined with connective tissue graft (CTG) for treatment of type 1 (RT1) multiple gingival recession.

MATERIALS AND METHODS

Twenty-four patients with a total of 59 nonmolar recession teeth were randomly allocated to VISTA + CTG or Tunnel + CTG group. Recession depth and width, probing depth, clinical attachment level, width of keratinized tissue, gingival thickness, flap tension, mean root coverage (MRC), complete root coverage (CRC), patient-centered, and esthetic outcomes (root coverage esthetic scores, RES) were assessed at baseline and 12 months after surgery.

RESULTS

At 12 months, MRC of 91.13 ± 16.96% and 91.40 ± 13.53%, CRC of 70.97% and 67.86% were observed for VISTA + CTG and Tunnel + CTG group respectively, with no significant difference between the two groups (p > 0.05). High RES of 8.52 ± 1.46 and 8.82 ± 1.44 was obtained in VISTA + CTG and Tunnel + CTG group respectively, without showing a significant difference (p = 0.245), while less scar formation was observed in Tunnel + CTG group (p < 0.01).

CONCLUSIONS

Both procedures were effective for root coverage in RT1 multiple gingival recession at 12 months. Better esthetic result with less scar formation was obtained in tunnel approach combined with CTG without vestibular incision. (Registration number: ChiCTR-INR-16007845, registered on 19/12/2015, http://www.chictr.org.cn).

CLINICAL SIGNIFICANCE

VISTA + CTG and Tunnel + CTG were both effective for root coverage in RT1 multiple gingival recession, with satisfying esthetic outcomes. However, it is suggested in critical esthetic areas, treatment options of making vertical incisions should be carefully considered.

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.

Digitally measured exposed root surface area for predicting the effectiveness of modified coronally advanced tunnel combined de-epithelialized gingival grafting in the treatment of multiple adjacent gingival recessions

OBJECTIVES

To assess the predictive value of baseline digitally measured exposure root surface area (ERSA) on the effectiveness of modified coronally advanced tunnel and de-epithelialized gingival grafting (MCAT + DGG) technique for the treatment of multiple adjacent gingival recessions (MAGRs).

MATERIALS AND METHODS

A total of 96 gingival recessions (48 RT1 and 48 RT2) from 30 subjects were included. ERSA was measured on the digital model obtained by intraoral scanner. Generalized linear model was used to analyze the possible correlation of ERSA, Cairo recession type (RT), gingival biotype, keratinized gingival width (KTW), tooth type, and cervical step-like morphology on the mean root coverage (MRC) and complete root coverage (CRC) at 1-year after MCAT + DGG. The predictive accuracy of CRC is tested using receiver-operator characteristic curves.

RESULTS

At 1-year postoperatively, the MRC for RT1 was 95.14 ± 10.25%, which was significantly higher than 78.42 ± 22.57% for RT2 (p < 0.001). ERSA (OR:1.342, p < 0.001), KTW (OR:1.902, p = 0.028) and lower incisors (OR:15.716, p = 0.008) were independent risk factors for predicting MRC. ERSA and MRC showed significant negative correlation in RT2(r = -0.558, p < 0.001), but not in RT1(r = 0.220, p = 0.882). Meanwhile, ERSA (OR:1.232, p = 0.005) and Cairo RT (OR:3.740, p = 0.040) were independent risk factors for predicting CRC. For RT2, the area under curve was 0.848 and 0.898 for ERSA without or with other correction factors, respectively.

CONCLUSIONS

Digitally measured ERSA may provide strong predictive values for RT1 and RT2 defects treated with MCAT + DGG.

CLINICAL RELEVANCE

This study demonstrates that digitally measured ERSA is a valid outcome predictor for root coverage surgery, especially applicable for predicting RT2 MAGRs.

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.

Periodontal Phenotype Modification Using Subepithelial Connective Tissue Graft and Bone Graft in the Mandibular Anterior Teeth with Mucogingival Problems Following Orthodontic Treatment

Among the complications of orthodontic treatment, mucogingival problems with gingival recession in the mandibular anterior teeth are challenging for clinicians. Mucogingival problems can lead to esthetic deficits, thermal hypersensitivity, tooth brushing pain, and complicated plaque control. Herein, we present a case of a 16-year-old female with gingival recession in the left mandibular central incisor after orthodontic treatment. The preoperative clinical findings showed a thin soft tissue biotype with root prominence in the mandibular anterior area. The interdental area was relatively depressed. After reflection of the full-thickness flap, root coverage using a bone graft substitute and subepithelial connective tissue graft obtained from the palatal mucosa was performed. The 6-month and 5-year postoperative clinical findings showed improved soft tissue phenotype. The cross-sectional CBCT scans 5 years after surgery showed a well-maintained labial bone plate in the mandibular incisors. Within the limitations of this case report, for patients with gingival recession in the mandibular incisors after orthodontic treatment, a successful biotype modification can be achieved with a combined procedure using subepithelial connective tissue graft with bone graft substitutes.

Comparative histological evaluation of intra- and extraorally de-epithelialized connective tissue graft samples harvested from the posterior palate region

BACKGROUND

Autologous connective tissue graft (CTG) is generally considered the gold standard for peri-implant soft tissue phenotype modification and root coverage therapy. The presence of epithelial remnants in CTG has been associated with complications after soft tissue augmentation surgery. However, a specific method for de-epithelization that is patently superior has not been identified yet. This study aimed to evaluate the effectiveness of two different approaches to de-epithelialize CTG samples harvested from the posterior palate.

METHODS

Patients in need of periodontal or implant-related surgery that required harvesting a CTG from the posterior palate region were recruited. CTG samples harvested with an indirect approach were de-epithelialized using either an intraoral (IO group) or an extraoral (EO group) method. Tissue specimens were subsequently processed for histological analysis. The presence or absence of oral epithelial remnants was determined by two examiners using light microscopy.

RESULTS

Twenty-four patients, who provided a total of 46 analyzable CTG samples, were enrolled in this study. Histological assessment revealed that 19 out of 22 samples in the IO group were free of epithelial remnants. In the EO group, 20 out of 24 samples did not exhibit epithelial residues. These results translate into 86.4% and 83.3% of epithelium-free samples in the IO and EO groups, respectively.

CONCLUSIONS

Although the intraoral method may provide several practical advantages compared with the extraoral technique, both approaches for de-epithelialization of CTG samples harvested from the posterior palate region tested in this study were comparably effective. However, none of these methods ensured complete removal of the oral epithelium in a predictable manner, which should be considered in clinical practice.

Flipped autograft: A novel approach for management of wound dehiscence in implant dentistry. A case report

Introduction and importance

This case report describes a novel technique for management of peri-implant wound dehiscence that involves using auto graft from the same surgical site to seal the dehiscence defect.

Case presentation

A 21-year-old female was referred for extraction of a non-restorable lower left first molar and replacement by immediate dental implant. Following attachment of the cover screw bone graft biomaterial and collagen membrane was secured over the biomaterial and buccal flap was coronally positioned and sutured. Patient was seen 1 week after surgery for follow up where a minor wound dehiscence was discovered with some biomaterial particles exposed. Patient was advised to continue strict oral hygiene control and to wait for another week. After 2 weeks of the implant placement surgery patient came back for dehiscence management visit where an innovative flipped autograft technique was performed to seal the dehiscence defect.

Clinical discussion

Healing by primary intention was achieved that led to uneventful healing and hence a successful well-functioning restoration with clinically healthy soft tissue and optimal aesthetic outcome.

Conclusions

Peri-implant wound dehiscence can be successfully treated by the novel flipped autograft technique that yielded great aesthetic and functional results.

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This report is the first to demonstrate the management of wound dehiscence using flipped autograft technique

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Visibility and access, Primary closure with delicate manipulation and patient home care are the keys to successful management of this case.

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The primary limitations to success in this case are poor blood supply associated with thin thickness soft tissue flap and Failure to achieve primary closure

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

PURPOSE

To evaluate efficacy of platelet-rich fibrin (PRF) or connective tissue graft (CTG) in papilla reconstruction (PR) with the semilunar incision (SI) technique.

MATERIALS AND METHODS

The analysis consisted of 55 sites (27 CTG and 28 PRF) from 20 patients who underwent PR with either PRF or CTG placed in the maxillary anterior region with SI technique. Baseline (BL) and follow-up (T₁ , first month, T₃ , third month, T₆ , sixth month) clinical data including periodontal evaluations (gingival index (GI), plaque index (PI), pocket depth (PD), keratinized tissue width (KTW), gingival recession), papilla-associated recordings (alveolar crest-interdental contact point [AC-IC], alveolar crest-papilla tip [AC-PT], papilla tip-interdental contact point [PT-IC], papilla height loss [PHL], interdental tissue stroke [ITS] and papilla presence index [PPI]) and patient satisfaction were analyzed.

RESULTS

CTG provided better PR outcomes. GI, PI, and PD showed a slight increase at T₁ and then, turned to their BL levels. The other periodontal parameters showed significant improvement after both treatment modalities. No inter-group difference was found except for KTW, which was in favor of CTG.

CONCLUSION

Based on the results, CTG is recommended over PRF in PR treatment due to its superior outcomes with less recurrence risk.

CLINICAL SIGNIFICANCE

Connective tissue graft provides superior results than platelet-rich fibrin in papilla reconstruction with the semilunar incision technique.

Effect of 24% EDTA root conditioning on the outcome of modified coronally advanced tunnel technique with subepithelial connective tissue graft for the treatment of multiple gingival recessions: a randomized clinical trial

OBJECTIVES

To investigate effects of root conditioning with 24% ethylenediaminetetraacetic acid (EDTA) on the 12-month outcomes after treatment of multiple gingival recessions (GR) with modified coronally advanced tunnel (MCAT) and subepithelial connective tissue graft (SCTG).

MATERIALS AND METHODS

Twenty patients with 142 GR were treated (72 test sites: SCTG + EDTA and 70 control sites: SCTG). Average and complete root coverage (ARC, CRC), gain in keratinized tissue width (KTW), gain in gingival thickness (GT), root esthetic coverage score (RES), and patient-reported outcome measures (PROMs) were evaluated at 12 months post-operatively.

RESULTS

Differences between pre- and post-operative values were statistically significant only within but not between treatment modalities. At 12 months, ARC was 86.0% for SCTG + EDTA-treated and 84.6 for SCTG-treated defects (p = 0.6636). CRC was observed in 90.2% (tests) and 91.4% (controls) of all cases (p = 0.9903). Professional assessment of esthetic outcomes using RES showed highly positive results reaching the value of 8.9 in case of test sites and 8.7 for control sites (p = 0.3358). Severity of pain and swelling did not differ between sites, regardless of whether EDTA was used.

CONCLUSIONS

Test and control sites presented similarly positive outcomes related to root coverage, periodontal and esthetic parameters, and patient satisfaction and self-reported morbidity with no statistical differences between them 12 months after surgery. No significant differences in evaluated variables were observed between sites treated with and without 24% EDTA. Clinical relevance Considering the limitations of the present study, the use of 24% EDTA for root conditioning did not improve 12-month outcomes after treatment of multiple RT1 and RT2 gingival recessions with MCAT and SCTG. Trial registration ClinicalTrials.gov identifier: NCT03354104.

Modified coronally advanced tunnel technique with enamel matrix derivative in addition to subepithelial connective tissue graft compared with connective tissue graft alone for the treatment of multiple gingival recessions: prognostic parameters for clinical treatment outcomes

Objectives

To investigate factors that influence 12-month outcomes after treatment of multiple gingival recessions (GR) with modified coronally advanced tunnel (MCAT) and subepithelial connective tissue graft (SCTG) with enamel matrix derivative (EMD) (tests) or without (controls).

Materials and methods

Twenty patients with 150 GR were treated. Logistic regression models were used to identify baseline parameters that could predict 12-month average root coverage (ARC), complete root coverage (CRC), root esthetic coverage score (RES), gain in keratinized tissue width (KTW), and gain in gingival thickness (GT).

Results

The likelihood of ARC > 85% increased sevenfold (odds ratio [OR] = 7.33; 95% confidence interval [CI] = 2.43–12.12), of achieving CRC: 21-fold (OR = 21.23; 95% CI = 10.21–45.32), and of gaining RES = 10: tenfold (OR = 10.23; 95% CI = 5.78–32.23) in favor of EMD-treated sites. With each 1-mm² increase in baseline avascular exposed root surface area (AERSA), the odds of failure (ARC ≤ 85%, not achieving CRC and postoperative GT ≤ 2 mm) increased almost fourfold (OR = 3.56; 95% CI = 1.98–10.19), fourfold (OR = 4.23; 95% CI = 1.11–9.02), and nearly sixfold (OR = 5.76; 95% CI = 2.43–12.87), respectively. The greater the baseline GT, the more likely the chance of achieving CRC (OR = 10.23; 95% CI = 8.37–16.23) and RES = 10 (OR = 5.50; 95% CI = 3.34–16.43). All models exhibited fair to excellent discrimination and satisfactory calibration.

Conclusions

Based on logistic regression, EMD application improved postoperative ARC, CRC and RES; baseline AERSA predicted 12-month ARC, CRC, and GT gain, whereas baseline GT was a predictor of achieving CRC and perfect RES.

Clinical relevance

Additional use of EMD, lower baseline AERSA, and greater baseline GT significantly increase the odds of obtaining better outcomes 12 months after MCAT + SCTG technique.