Clinical assessment of free gingival graft effectiveness on the maintenance of periodontal health

Periodontal outcomes of surgically exposed and orthodontically aligned buccally impacted maxillary canines: A systematic review and meta-analysis

OBJECTIVE

To compare the periodontal outcomes of surgically exposed and orthodontically aligned buccally impacted maxillary canines to spontaneously erupted maxillary canines.

DATA SOURCES

An unrestricted search was carried out of indexed databases (Medline, EMBASE, Web of Science and Scopus), reference lists of included studies, and grey literature published until December 2023.

DATA SELECTION

Observational and experimental studies that addressed the focused question 'Do periodontal outcomes of buccally impacted maxillary canines that were surgically exposed and subsequently extruded and aligned using orthodontic alignment, differ from those of spontaneously erupted maxillary canines?' were included.

DATA EXTRACTION

Study screening, selection and data extraction were performed independently by two authors, with disagreement resolved by a third reviewer. The risk of bias was assessed using the JBI Critical Appraisal Checklist and GRADE approach.

RESULTS

A total of 857 citations were found and five studies were eligible for inclusion. Supragingival plaque accumulation and gingival inflammation were similar between impacted canines and their contralaterals in most studies. Meta-analyses revealed no significant differences in keratinised tissue width (prospective studies: MD = -0.28, 95% confidence interval [CI] = -1.13-0.56, I² = 78%; retrospective studies: MD = 0.61, 95% CI = -1.51-2.72, I² = 94%). However, a meta-analysis of prospective studies showed slightly greater mean probing depth for impacted canines compared to their contralateral canines (prospective studies: MD = 0.16, 95% CI = 0.04-0.28, I² = 0%). The evidence certainty for keratinised tissue width and probing depth outcomes was low.

CONCLUSION

Surgically exposed and orthodontically aligned buccally impacted canines have slightly greater probing depths, potential bone loss and increased clinical crown length, compared to their counterparts. However, these small differences (<1 mm) are unlikely to be clinically significant.

Augmentation of keratinized tissue using autogenous soft-tissue grafts and collagen-based soft-tissue substitutes at teeth and dental implants: Histological findings in a pilot pre-clinical study

AIM

To histomorphometrically assess three treatment modalities for gaining keratinized tissue (KT) at teeth and at dental implants.

MATERIALS AND METHODS

In five dogs, the distal roots of the mandibular second, third and fourth premolars were extracted. Dental implants were placed at the distal root areas 2 months later. After another 2 months, KT augmentation was performed at both distal (implants) and at mesial root (teeth) areas in the presence (wKT groups) or absence (w/oKT groups) of a KT band at the mucosal/gingival level. Three treatment modalities were applied randomly: apically positioned flap only (APF), free gingival grafts (FGGs) and xenogeneic collagen matrices (XCMs). A combination of the above produced six groups. Two months later, tissue sections were harvested and analysed histomorphometrically.

RESULTS

The median KT height and length were greatest at implants with FGG in both wKT (3.7 and 5.1 mm, respectively) and w/oKT groups (3.7 and 4.6 mm), and at teeth with FGG in wKT groups (3.7 and 6.1 mm) and with APF in the w/oKT groups (3.9 and 4.4 mm). The XCM and APF produced more favourable results at teeth than at implants.

CONCLUSIONS

FGG was advantageous in gaining KT, especially at implants.

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

BACKGROUND

The aim of this systematic review was two-fold: (i) to evaluate the long-term (≥5 years) stability of the gingival margin position, keratinized tissue width (KTW) and gingival thickness (GT) in sites that underwent root coverage (RC) or gingival augmentation (GA); and (ii) to assess the influence of different local variables on the long-term stability of dental and gingival tissues.

MATERIALS AND METHODS

Randomized controlled trials (RCTs) and non-RCTs reporting short-term (i.e., 6-12 months after baseline surgical intervention) and long-term (≥5 years) follow-up data after surgical treatment of adult patients presenting single or multiple mucogingival deformities, defined as sites presenting gingival recession defects (GRDs) and/or (KTW) deficiency (i.e., <2 mm), were considered eligible for inclusion. MEDLINE-PubMed, EMBASE and Cochrane Central Register of Controlled Trials databases were searched for articles published up to 15 May 2023. Mixed-effects multiple linear regression was used to assess the association between KTW, type of surgical procedure and time (i.e., independent variables) on the stability of the gingival margin in sites that received RC or GA therapy.

RESULTS

Of the 2569 potentially eligible records, 41 (reporting 40 studies) met the eligibility criteria. Graphical estimates including data from all RC procedures found an upward trend in recession depth (RD) increase over time. Conversely, it was observed that in 63.63% of RC studies and in 59.32% of RC treatment arms KTW increased over time, particularly in sites treated with subepithelial connective tissue grafts (SCTGs). Conversely, sites that underwent GA procedures generally exhibited an overall reduction of KTW over time. However, sites treated with free gingival grafts (FGGs) showed a decrease in RD after 10 years of follow-up. Three main findings derived from the pooled estimates were identified: (i) Gingival margin stability was associated with the amount of KTW present during short-term assessment (i.e. the greater the KTW at 6-12 months after treatment, the more stable the gingival margin). (ii) The use of autogenous soft-tissue grafts was associated with lower RD increase over time. (iii) Treatment approaches that contribute to the three-dimensional enhancement of the gingival phenotype, as clearly demonstrated by FGG, were associated with gingival margin stability.

CONCLUSIONS

The extent of apical migration of the gingival margin appears to be directly related to the amount of KTW and GT upon tissue maturation. Interventions involving the use of autogenous grafts, either SCTG or FGG, are associated with greater short-term KTW gain and lower RD increase over time.

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.

Clinical comparison between different surgical techniques used to manage advanced gingival recession (Miller's class III & IV)

Advanced gingival recession is considered a complex soft tissue problem, which is increased in severity with age, and has multiple etiological factors. Therefore, the treatment is very complicated with low predictability. However, in the last decade, many clinical trials have shown highly predictable results when managing advanced recession cases by surgical intervention.

The present review shows different surgical techniques with their clinical outcomes in order to choose the most suitable technique required by the clinical condition. Although there are relatively few studies, modified tunnel technique and coronal advanced flap (CAF) showed the highest percentage of root coverage (%RC) during the first year (up to 86%). These techniques are primarily indicated to manage advanced recession in the esthetic zone. Pedicle buccal fat pad (PBFP) also had a good percentage of root coverage when used in the maxillary posterior area, as it has a high blood supply with minimal risk for infection and necrosis. Free gingival graft (FGG) can be used in the mandibular anterior area, as it creates a band of keratinized tissue that can resist recession with a fair percentage of root coverage. However, color match and graft shrinkage are the main problems of this procedure.

The effect of orthodontic treatment on the periodontium and soft tissue esthetics in adult patients

OBJECTIVE

Most patients seek orthodontic treatment to achieve an esthetic outcome. Orthodontic treatment has possible negative sequelae. The aim of this study is to assess these possible effects on the periodontium and tissue esthetics.

METHODS

One hundred fifty-six patients who have completed orthodontic treatment at Jordan University of Science and Technology clinics were recruited. They were divided into extraction and nonextraction subgroups. Another 155 patients never undergoing orthodontic treatment were assessed. The height of papilla, width of keratinized gingiva, gingival recession, degree of tooth display, smile line, crestal bone level, and proximal caries were assessed. Chi- square test was used for categorical/discrete variables while independent t-test was used for continuous variables. The level of significance was set at (p ≤ 0.05).

RESULTS

The mean age was 22 years with no significant difference between the groups. There was a significant difference between "ortho" and "nonortho" groups in tooth display and keratinized gingiva (p = 0.006 and <0.001, respectively). The overall crestal bone level, smile line, recession, and papilla fill did not show any significant differences (p = 0.200, 0.067, 0.120, and 0.066, respectively). The crestal bone level in the upper and lower anterior segments was significantly lower in the "ortho" treated group compared to the "nonortho" treated group (p = 0.002 and 0.005, respectively). A significant difference between "extraction" and "nonextraction" groups was in the width of keratinized gingiva (p = 0.003) and the number of teeth displayed (p < 0.001). Despite reaching statistical significance these differences are not necessarily of clinical significance.

CONCLUSION

Orthodontic treatment clearly affects the periodontal tissues; however, the detrimental effects appear to be minimal. Patients with history of orthodontic treatment might have lower crestal bone levels at certain sites and this should not be confused with periodontal disease.

Comparative assessment between bio-adhesive material and silk suture in regard to healing, clinical attachment level and width of keratinized gingiva in gingival recession defects cases

The objective of this study was to compare the silk suture with a cyanoacrylate adhesive to stabilize the free gingival graft in conjunction with Er: YAG laser-assisted recipient site preparation to augment the keratinized tissue in gingival recession cases. This randomized trial comprised of 300 recession defects patients. All the included patients were diagnosed using Miller class I and II gingival recession defects classification. Group I sites were treated with a free gingival graft (FGG) harvested using an Er: YAG laser and further sutured with silk. Group II sites were stabilized with isoamyl 2 cyanoacrylate bio-adhesive material. Clinical parameters, such as gingival recession depth, clinical attachment level, gain in gingival tissue thickness, and width of keratinized gingiva were recorded at baseline, and at third month, sixth month, and 12th month postoperatively. The mean changes in gingival recession from months 3 to 6 and months and 6 to 12 were significant (p < 0.05) in both groups. However, the improvement in recession depth was better in group II than in group I. The mean change in clinical attachment level did not differ significantly between the groups at the different time intervals. However, values tended to be higher in group II than in group I. The width of the keratinized gingiva tended to be higher from baseline to 3 months, baseline to 6 months, baseline to 12 months, 3 to 6 months, and from 6 to 12 months in group II as compared with group I (p > 0.05). Cyanoacrylate could be used as a substitute to silk sutures to stabilize FGGs. Cyanoacrylate was easy to apply, consumed less operating time, and was considered equally efficacious for stabilizing FGGs.

Treatment of Gingival Recession: When and How?

Gingival recession is a common finding in daily clinical practice. Several issues may be associated with the apical shift of the gingival margin such as dentine hypersensitivity, root caries, non-carious cervical lesions (NCCLs), and compromised aesthetics. The first step in an effective management and prevention program is to identify susceptibility factors and modifiable conditions associated with gingival recession. Non-surgical treatment options for gingival recession defects include establishment of optimal plaque control, removal of overhanging subgingival restorations, behaviour change interventions, and use of desensitising agents. In cases where a surgical approach is indicated, coronally advanced flap and tunnelling procedures combined with a connective tissue graft are considered the most predictable treatment options for single and multiple recession defects. If there is a contraindication for harvesting a connective tissue graft from the palate or the patient wants to avoid a donor site surgery, adjunctive use of acellular dermal matrices, collagen matrices, and/or enamel matrix derivatives can be a valuable treatment alternative. For gingival recession defects associated with NCCLs a combined restorative-surgical approach can provide favourable clinical outcomes. If a patient refuses a surgical intervention or there are other contraindications for an invasive approach, gingival conditions should be maintained with preventive measures. This paper gives a concise review on when and how to treat gingival recession defects.

Improvement of Periodontal Parameters with the Sole Use of Free Gingival Grafts in Orthodontic Patients: Correlation with Periodontal Indices. A 15-Month Clinical Study

The aim of this study was to evaluate the changes in periodontal parameters solely using free gingival grafts during orthodontic treatment without any oral hygiene re-enforcement. Methods: A total of 19 patients underwent periodontal examination before orthodontic treatment. Patients received oral hygiene instruction and professional hygiene therapy. Where needed; full periodontal treatment was completed. Only periodontally stable patients were included in the study. Periodontal indices and keratinized tissue were recorded at time 0 (T0) (delivery of orthodontic appliances), and at three months (T1) during orthodontic therapy; when surgery was performed. At T1; orthodontically treated sites with minimum keratinized tissue (≤1 mm) received a free gingival graft to enhance the band of keratinized tissue. At three months after surgery (T2), new measurements were recorded. The orthodontics-treated sites after three months (T1) were used as control. The same sites were used as a test three months after mucogingival correction (T2). Between T1 and T2; orthodontics was suspended; no professional oral hygiene was performed; and no additional oral hygiene instructions were given to the patient. No oral hygiene procedures were administered for 15 months (T3), when the final recordings were taken. Results: The results showed that there was a worsening of gingival index (GI) and plaque index (PI) of the treated sites between T0 and T1 during initial orthodontics treatment; whereas there was an improvement of the gingival inflammation at T2 when compared with T1. At T2; there was also a statistically significant improvement in GI and PI compared with T0. A T3 improvement in periodontal parameters was sustained. A non-parametric test (Wilcoxon signed-rank test) was used for statistical analysis. Conclusions: Augmentation of the width of keratinized gingiva; as the sole treatment; favors the improvement of GI and PI during orthodontic therapy.

Augmentation of keratinized tissue at tooth and implant sites by using autogenous grafts and collagen-based soft-tissue substitutes

AIM

To investigate the effect of three treatment modalities on the gain of keratinized tissue (KT) at tooth and implant sites in dogs.

MATERIALS AND METHODS

In five dogs, the distal roots of the mandibular second, third and fourth premolars were extracted, while the mesial roots were maintained. After 2 months of healing, implants were placed with KT excision. After another 2 months of healing, free gingival grafts, collagen-based matrices and apically positioned flap only were applied. The height of KT was measured during implant placement, immediately before soft-tissue grafting and after 10, 30 and 60 days.

RESULTS

Two months after KT excision, spontaneous KT regrowth was greater at tooth sites than at implant sites (median, 2.0 mm vs. 1.1 mm). The outcomes of soft-tissue grafting at implant sites favoured the free gingival graft treatment, with a greater final median height (5.0-5.5 mm) and increase in KT (4.0-4.2 mm). Locations of the recipient sites significantly influenced KT regeneration at both tooth and implant sites.

CONCLUSIONS

At implant sites, the free gingival graft treatment led to higher KT regeneration. At tooth sites, however, the differences between the three treatment modalities seemed clinically irrelevant.

Free Gingival Graft as a Single Step Procedure for Treatment of Mandibular Miller Class I and II Recession Defects

BACKGROUND

Gingival recession is a frequent issue encountered by both the clinician and the patient. This study was aimed to assess the predictability of the free gingival graft as a single step procedure in terms of root coverage and aesthetics in Miller Class I and II mandibular gingival recession. 

METHODS

Ten patients (4 males, 6 females) aged 25-30 years with a total of 12 mandibular sites having Miller class I and II recession were selected. All recession sites were treated with single step free gingival graft procedure. Clinical parameters like recession depth, recession width, width of attached gingiva, probing depth and clinical attachment level were recorded at baseline, 6 and 9 months. Visual analog score at 1, 6 and 9 months postoperatively was provided. 

RESULTS

There was a reduction in mean recession depth from 3.66±1.20 to 0.91±0.99 mm suggesting coverage of 82% over a period of 9 months. There was statistically significant gain in clinical attachment level and width of attached gingiva. Aesthetically, it was acceptable by patients as measured by visual analog scores. 

CONCLUSION

Free gingival graft as a single step procedure is acceptable in terms of root coverage and aesthetics.

Buccinator muscle repositioning

Anatomical aberrations and abnormalities are frequently associated with functional, psychosocial, and emotional problems. One such aberration is crestal attachment of frenum or muscle on the alveolar processes of the jaws. Crestal attachment of buccinator muscle is a rare phenomenon, which may pose various problems in routine oral exercises/functions or restoring the edentulous area. A case of abnormal buccinator muscle attachment is presented here, which was relocated apically by surgical means using an acrylic stent. The healing was uneventful and significant apical repositioning was observed. A fixed bridge was fabricated and the long-term results of the restorative therapy were assured because the patient could maintain the oral hygiene well after the muscle repositioning operation.

Free gingival autograft for augmentation of keratinized tissue in apical to gingival recession - A case report

BACKGROUND

The treatment of the mucogingival problem is one of the main objectives of the periodontal therapy. The insufficient or absent attached gingiva increases the risk of development of gingival recessions.

METHOD

One patient with Miller class II gingival recession and small vestibule depth in the frontal mandibular region was selected for treatment. Autogenous free gingival grafts harvested from the palatal mucosa were used to gain the attached gingiva.

RESULT

The initial healing completed in 2 weeks without complication. The augmentation of the attached gingival tissue using the free gingival graft technique led to gain of attached gingiva in the treated regions.

CONCLUSION

The limitations of the apical mucosal flap displacement for preparation of recipient site in situations with inadequate vestibule depth and small alveolar bone height require a graft with small width. The result from the presented case report with application of the free gingival graft indicates that it could be applied when augmentation of the attached gingiva tissue.

Mucogingival surgery: where we stand today

Mucogingival problems are developmental and acquired aberrations in the morphology, position, and/or the amount of gingiva surrounding teeth. According to an academic report by American Academy of Periodontology, mucogingival therapy should be advocated for gingival augmentation and to create adequate vestibular depth in areas with insufficient attached gingiva. This paper provides an overview on mucogingival surgical procedures from its inception to the current time.

A pilot study to evaluate a tissue-engineered bilayered cell therapy as an alternative to tissue from the palate

BACKGROUND

This study evaluated the safety and effectiveness of a tissue-engineered skin product composed of viable neonatal keratinocytes and fibroblasts and compared it to a free gingival graft (FGG) in a procedure to enhance keratinized tissue (KT) and wound healing around teeth that do not require root coverage.

METHODS

Twenty-five subjects were enrolled who had at least two non-adjacent teeth in contralateral quadrants exhibiting an insufficient zone of attached gingiva requiring soft tissue grafting where root coverage was not desired. One tooth was randomized to receive an FGG, and the other was randomized to receive bilayered cell therapy (BCT). The amount of KT was measured at baseline and 3 and 6 months, and the texture and color of the grafted tissue were compared to the surrounding tissue at months 1, 3, and 6. A questionnaire was used to determine subject preference at 6 months. Biopsies and persistence studies were performed on a subset of the subjects.

RESULTS

The FGG generated statistically significantly (P <0.001) more KT than the test device (BCT) (4.5 +/- 0.80 mm versus 2.4 +/- 1.02 mm); no significant difference in recession or clinical attachment level was detected between treatment groups (P = 0.212 and P = 0.448, respectively); and no significant differences were detected at any time point for bleeding on probing (BOP), resistance to muscle pull, or inflammation. The BCT group had significantly better color and texture match with surrounding tissue (P <0.001), and subject preference was significantly greater for the BCT group (P = 0.041). No device-related adverse events or safety issues occurred during the course of the study.

CONCLUSIONS

The tissue-engineered graft BCT was safe and capable of generating de novo KT without the morbidity and potential clinical difficulties associated with donor-site surgery. The amount of KT generated with FGG was greater than generated with BCT; however, 24 of 25 test sites demonstrated an increase in KT at 6 months, with more than three-quarters of the sites yielding > or =2 mm bands of KT.

Free gingival grafts to increase keratinized tissue: a retrospective long-term evaluation (10 to 25 years) of outcomes

BACKGROUND

Gingival augmentation procedures are indicated primarily to increase an insufficient amount of gingiva and sometimes to halt the progression of gingival recession. The aim of this retrospective long-term study was to evaluate changes in the amount of keratinized tissue (KT) and in the position of the gingival margin after free gingival graft procedures over a period of 10 to 25 years.

METHODS

One hundred three subjects presenting with 224 sites completely lacking attached gingiva associated with gingival recessions were treated in a private practice. The experimental sites were treated with gingival augmentation procedures (free gingival grafts). The grafts were positioned at the presurgical level of the gingival margin or in a submarginal position. Clinical variables, including recession depth, amount of KT, and probing depth (PD), were measured at baseline (T(0)), 1 year after surgery (T(1)), and at the end of the follow-up period (10 to 25 years) (T(2)) and analyzed using descriptive statistics and multilevel models.

RESULTS

From T(0) to T(1), the gingival margin shifted coronally 0.8 mm, and KT increased 4.2 mm. From T(1) to T(2), the gingival margin shifted coronally 0.6 mm, and the overall KT decreased 0.7 mm. PD remained stable.

CONCLUSION

Gingival augmentation procedures performed in sites with an absence of attached gingiva associated with recessions provide an increased amount of KT associated with recession reduction over a long period of time.

Long-Term Outcome Following Treatment of Multiple Miller Class I and II Recession Defects in Esthetic Areas of the Mouth

BACKGROUND

Multiple recession defects can be successfully treated using envelope-type coronally advanced flaps. The aim of the present study was to evaluate the long-term (5 years) stability of clinical outcomes achieved with the surgery and the association between patient variables and long-term stability.

METHODS

Seventy-three Miller Class I and II gingival recessions affecting 22 young, systemically healthy subjects were treated with coronally advanced flaps with no releasing incisions. All patients were instructed to perform a coronally directed roll technique to minimize the toothbrushing trauma to the gingival margin. The clinical reevaluation was made 1 year after the surgery. At this point, 13 patients took part in a supportive periodontal care program consisting of oral hygiene instructions, control of toothbrushing technique, and professional tooth cleaning every 4 months. The remaining nine patients did not participate and received only sporadic care by general dentists. At 5 years post-surgery, all patients were reexamined.

RESULTS

At the 5-year examination, 94% of the root surfaces initially exposed due to gingival recession were still covered with soft tissue, and 85% of the treated recession defects showed complete coverage. Complete root coverage in all recessions was maintained in 15 out of 22 patients (68%). The long-term stability of the soft-tissue margin in the treated sites was significantly influenced by the patient's regular participation in the recall program and the susceptibility to gingival recession in other areas of the mouth. A statistically significant increase of keratinized tissue (0.80 +/- 0.64 mm) was observed between the 1- and 5-year observation visits, and the average increase of keratinized tissue between the baseline and the 5-year follow-up amounted to 1.38 +/- 0.90 mm. This increase was significantly affected by the baseline keratinized tissue (KT) and recession (REC) depth: in particular, the 5-year increase in the amount of keratinized tissue was greater in sites with a greater recession depth and lower amount of keratinized tissue at baseline.

CONCLUSIONS

1) The successful root coverage results obtained with the coronally advanced flap for multiple recession defects were well maintained over the 4-year observation period. 2) Negative patient characteristics such as a lack of compliance with a supportive care program and individual susceptibility to gingival recession were significantly associated with the recurrence in gingival recession. 3) The increase in keratinized tissue height that followed the coronally advanced flap procedure may be attributed to the tendency of the mucogingival line to regain its genetically determined position.

A 2-Year Follow-Up of Root Coverage Using Subpedicle Acellular Dermal Matrix Allografts and Subepithelial Connective Tissue Autografts

BACKGROUND

Coverage of roots exposed by gingival recession is one of the main objectives of periodontal reconstructive surgery. A large variety of mucogingival grafting procedures are available. However, the long-term effectiveness of this procedure is still not clear. This study compared the effectiveness of sub-pedicle acellular dermal matrix allografts with subepithelial connective tissue autografts in achieving root coverage 2 years postoperatively.

METHODS

One hundred one (101) patients were treated with dermal matrix allografts (mean age, 28.4+/- 0.7 years; mean recession, 4.2 mm) and 65 patients treated with connective tissue graft (mean age, 30.1+/- 1.4 years; mean recession, 4.9 mm). All patients underwent full periodontal evaluation and presurgical preparation, including oral hygiene instruction and scaling and root planing. The exposed roots were thoroughly planed and covered by a graft without any further root treatment or conditioning. There were no differences in the average age, time of follow-up, or gender between the two groups. Patients were evaluated periodically between 1 and 2 years. Residual recession and defect coverage were assessed.

RESULTS

Mean residual root recession after root coverage with acellular dermal matrix allograft was 0.2 +/- 0.04 mm, with defect coverage of 95.9% +/- 0.9%. Frequency of defect coverage was 82.2%. Root coverage was 98.8% +/- 0.2%, resulting in a frequency of root coverage of 100%. Gain in keratinized gingiva was 2.2+/- 0.04 mm and attachment gain was 4.5+/- 0.1 mm per patient. Connective tissue autografts resulted in mean residual root recession of 0.1+/- 0.04 mm, with percent defect coverage of 97.8%+/- 0.6% and frequency of defect coverage of 95.4%. Root coverage was 99.1%+/- 0.2%, and frequency of root coverage was 100%. Gain in keratinized gingiva was 3.0+/- 0.1 mm and attachment gain was 5.3+/- 0.2 mm per patient. No significant differences in final recession and root coverage between the two treatment methods were found. However, autografts resulted in significant increases in defect coverage, keratinized gingival gain, attachment gain, and residual probing depth. The clinical results were stable for the 2-year follow-up period.

CONCLUSIONS

These results indicate that coverage of root by sub-pedicle acellular dermal matrix allografts or subepithelial connective tissue autografts is a very predictable procedure which is stable for 2 years postoperatively. However, subepithelial connective tissue autografts resulted in significant increases in defect coverage, keratinized gingival gain, attachment gain, and residual probing depth.

Esthetic and Dimensional Evaluation of Free Connective Tissue Grafts in Prosthetically Treated Patients: A 1-Year Clinical Study

BACKGROUND

The aim of this study was to evaluate the predictability of the free connective tissue graft in prosthetically treated patients needing gingival augmentation. The following outcome variables were studied 1) dimensional changes of free connective gingival grafts; 2) color blending with adjacent tissues; and 3) periodontal and marginal health status, when compared to a non-surgical control group.

METHODS

Two groups of patients without periodontitis were investigated. The test group (group A) consisted of 16 patients. The inclusion criteria for surgical correction were: 1) at least 1 site lacking (<1 mm) keratinized tissue and/or lacking vestibular depth; 2) insufficient plaque control; and 3) the selected site was scheduled to undergo or had already received a fixed prosthetic restoration. The control group (group B) included 14 patients with the same inclusion criteria, but declining to undergo surgery. Group A patients were treated with a free connective tissue graft to augment the keratinized tissue at the selected sites. The size of the graft was recorded at baseline (surgical intervention) and the width of keratinized tissue was measured at 1, 4, 26, and 52 weeks. Gingival inflammation and plaque accumulation were assessed at baseline and 52 weeks in both groups. Probing depth and clinical attachment levels were recorded at baseline and 26 and 52 weeks in both groups. Evaluation of the esthetic results was carried out at the end of the study. All patients in both groups received oral hygiene instructions and supragingival plaque and calculus removal before and at the end of the investigation.

RESULTS

In group A, the results showed a mean amount of keratinized tissue of 5.81 +/- 1.42 mm at 26 weeks and 5.25 +/- 1.34 mm at 52 weeks. Mean shrinkage of the graft was 10.2% (P = 0.001) at 1 week, 28.4% (P = 0.0004) at 4 weeks, 37.2% (P = 0.0004) at 26 weeks, and 43.25% (P = 0.0004) at 52 weeks. All the dimensional changes were statistically significant, when compared to baseline. Evaluation of color blending with the surrounding gingiva demonstrated an "excellent result" at 52 weeks with an 87.5% agreement among the three masked examiners. In the test group, the periodontal indices improved or remained stable; in the control group, there was a minor improvement of the indices, with three patients showing a worse gingival inflammation score and two a worse plaque score.

CONCLUSION

Although these results are not conclusive, mostly due to a lack of a large enough sample population, the statistically significant results shown in this investigation tend to support the use of gingival augmentation procedures in prosthetic patients with insufficient keratinized gingiva and/or shallow or absent vestibules, when they cannot demonstrate adequate plaque control.

Surgical Therapies for the Treatment of Gingival Recession. A Systematic Review

BACKGROUND

A variety of soft tissue augmentation procedures directed at root coverage have been documented in the literature utilizing autogenous or allogenic soft tissue grafting or guided tissue regeneration (GTR).

RATIONALE

The purpose of this systematic review was to assess the literature regarding the efficacies of various surgical gingival augmentation procedures relative to clinical and patient-oriented outcomes.

FOCUSED QUESTION

What is the effect of surgical therapy for root coverage in patients with gingival recession compared with other treatment modalities or baseline values?

SEARCH PROTOCOL

PubMed and the Cochrane Oral Health Group Trials Register were searched to identify human studies in English investigating the therapeutic use of a soft tissue surgical procedure to treat gingival recession. Searches were performed for articles published by April 2002.

SELECTION CRITERIA

Initial screening of identified abstracts accepted all studies evaluating surgical intervention of gingival recession. Independent review by 2 reviewers evaluated full-text reports regarding study characteristics. Only those studies determined to be randomized clinical trials (RCTs) were included in the final analysis. DATA ANALYSIS AND COLLECTION: Outcome measures included changes in root coverage, clinical attachment levels (CAL), probing depth (PD), and width of keratinized tissue (KT). The only data suitable for meta-analysis were comparisons of the efficacy of connective tissue grafts with GTR.

MAIN RESULTS

1. Thirty-two articles (total study population: 687) met the criteria for RCTs: 11 (population: 286) related to various autogenous soft tissue augmentation procedures; 18 (population: 360) to GTR; and 3 (population: 41) to allogenic soft tissue augmentation. 2. Meta-analysis identified greater gains in both root coverage and keratinized tissue width for connective tissue graft procedures compared to GTR. 3. No other data were compatible with meta-analysis.

REVIEWERS' CONCLUSIONS

1. Soft tissue augmentation procedures are effective means of obtaining root coverage. 2. Connective grafting techniques appear to have an advantage over GTR. 3. There is a need for further efficacy studies and for investigation of these procedures relative to patient-oriented outcomes such as esthetics, root sensitivity, and postoperative morbidities.

Coverage of previously carious roots is as predictable a procedure as coverage of intact roots

BACKGROUND

Coverage of roots exposed by gingival recession is one of the main objectives of periodontal reconstructive surgery. A variety of highly predictable and esthetically acceptable mucogingival grafting procedures are available for treating intact root surfaces. One of the indications for root coverage procedures is prevention of root caries. However, little is known about the ability to treat previously carious roots by mucogingival grafting, and even less is known about the outcome of such treatment.

METHODS

Sixty patients with gingival recession were treated with subepithelial connective tissue grafts. During initial examination, 33 intact teeth with longstanding gingival recessions of 4.09 +/- 0.16 mm (mean +/- SEM) and 27 teeth with carious roots (restored and unrestored) and longstanding gingival recessions of 3.44 +/- 0.22 mm (mean +/- SEM) were found. Prior to grafting, any carious dentin and plastic restorations were removed. The exposed roots were thoroughly planed and covered by a subepithelial connective tissue graft without any further root treatment or conditioning. Patients were evaluated periodically between 1 and 6 years. Residual recession, defect coverage, and caries incidence were assessed.

RESULTS

Recession was reduced to a similar extent on all teeth whether root caries was present (0.31 +/- 0.11 mm) or not (0.15 +/- 0.04 mm). This resulted in comparable defect coverages of 92.41 +/- 2.38% for previously carious roots and 97.46 +/- 0.79% for intact roots. In 44 cases, complete coverage of the recession was achieved. The results were stable, and no further recessions or recurrent caries were found during the periodic evaluations.

CONCLUSIONS

These results indicate that coverage of previously carious roots with subepithelial connective tissue grafts is a very predictable procedure with results similar to those found on intact roots. This procedure may provide a definitive biological alternative for conventional restorative treatment modalities for root caries. Moreover, the results are more esthetic, biologically acceptable, and maintainable.

Periodontic and orthodontic treatment in adults

The purpose of this article is to provide an update of the interrelationship between periodontics and orthodontics in adults. Specific areas reviewed are the reaction of periodontal tissue to orthodontic forces, the influence of tooth movement on the periodontium, the effect of circumferential supracrestal fiberotomy in preventing orthodontic relapse, the effect of orthodontic treatment on the periodontium, microbiology associated with orthodontic bands, and mucogingival and esthetic considerations. In addition, the relationship between orthodontics and implants (eg, using dental implants for orthodontic anchorage) is discussed.

Root coverage and pocket reduction as combined surgical procedures

BACKGROUND

One of the main objectives of periodontal reconstructive surgery is the coverage of exposed roots due to gingival recession. A large variety of mucogingival grafting procedures are available that give highly predictable and esthetically acceptable results when treating intact root surfaces. However, these procedures call for a second surgery site in the palate. The present study examines a series of cases in which connective tissue, obtained from the tuberosity during pocket reduction procedures in the posterior region of the maxilla, was used for root coverage.

METHODS

Forty-four teeth from 25 patients with gingival recession of 3.30 +/- 0.14 mm (mean +/- SEM) were treated with subepithelial connective tissue grafts using connective tissue obtained from the tuberosity area during pocket reduction procedures in the posterior region of the maxilla.

RESULTS

The mean root coverage recession after treatment was 0.16 +/- 0.06 mm, with effectiveness of coverage at 95.0% +/- 1.84 and a predictability of 84.1%. Periodontal probing depth reduction at the donor site was 4.08 +/- 0.24 mm.

CONCLUSIONS

These results indicate that the subepithelial connective tissue graft obtained from the tuberosity area during pocket reduction procedures in the posterior region of the maxilla provides a very predictable and esthetic root coverage without the need for a second surgical site.

Interrelationship between periodontics and adult orthodontics

The purpose of this review article is to provide the dental practitioner with an understanding of the interrelationship between periodontics and orthodontics in adults. Specific areas reviewed are how periodontal tissue reacts to orthodontic forces, influence of tooth movement on the periodontium, effect of circumferential supracrestal fiberotomy in preventing orthodontic relapse, effect of orthodontic bands on the periodontium, specific microbiology associated with orthodontic bands, mucogingival considerations and time relationship between orthodontic and periodontal therapy. In addition, the relationship between orthodontics and implant restorations (e.g., using dental implants as orthodontic anchorage) will be discussed.

A critical evaluation of methods for root coverage

Gingival recession is the exposure of root surfaces due to apical migration of the gingival tissue margins. Although it seldom results in tooth loss, marginal tissue recession is associated with thermal and tactile sensitivity, esthetic complaints, and a tendency toward root caries. This article reviews the current surgical procedures for the coverage of exposed root surfaces, including their advantages and disadvantages. Today, the outcome of root coverage procedures is predictable, aesthetically acceptable, and, together with the use of guided tissue regeneration, at the forefront of regenerative procedures.

Mucosal considerations for osseointegrated implants

Tissue resistance is determined by the nature of cells and intercellular contacts irrespective of the presence or absence of keratinization, masticatory mucosa, or skin. However, these tissues are more easily maintained and less vulnerable to inflammation when in contact with dental implants. Lack of masticatory mucosa and the presence of alveolar mucosa embracing the implant are often associated with plaque, which can induce inflammation resulting in subsequent peri-implant destruction. To facilitate proper mechanical oral hygiene maintenance, transplantation of autogenous masticatory mucosal grafts at the implant sites was performed in patients without attached gingiva, unfavorable vestibulum with submucosal muscular activity, and uncontrolled peri-implant mucositis. The rationale for having attached mucosa around osseointegrated implants and illustration of possible methods of mucosal management in the different phases of implant rehabilitation are presented.

Changes of facial gingival dimensions in children. A 2-year longitudinal study

Facial gingival surfaces of maxillary and mandibular anterior teeth were monitored to evaluate changes of the width of the keratinized and attached gingiva. 96 children 6 to 12 years of age were examined 2 x with an interval of 2 years. Measurements included dental plaque, gingival inflammation, probing depth, and width of keratinized and attached gingiva. In addition, study models were used to determine the facial/lingual position of the teeth. The results of this report, evaluating well-aligned teeth only, showed that during the 2-year observation period, increases in widths of the facial keratinized and attached gingiva took place. Increases occurred for the various teeth regions examined, and for deciduous as well as permanent teeth. During transition from the deciduous to the permanent dentition, patterns of change were variable. The increase of gingival widths was greatest for sites with the smallest baseline width of attached gingiva, and smallest for sites with the greatest baseline width. It was concluded that in well-aligned teeth, a conservative, monitoring approach prior to a corrective, surgical intervention seems prudent in children of this age with a minimal zone or absence of attached gingiva.

Significance of the width of keratinized gingiva on the periodontal status of teeth with submarginal restorations

The purpose of this clinical study was to evaluate the periodontal condition of teeth having submarginal restorations associated with either narrow or wide zones of keratinized gingiva. Fifty-eight teeth in 26 individuals were selected and then divided into two groups according to the width of the keratinized gingiva at the midfacial aspect of the tested tooth. Group I consisted of 30 teeth with greater than or equal to 2.0 mm, and Group II consisted of 28 teeth with less than 2.0 mm of keratinized gingiva. Each group was equally subdivided into subgroup "A" having teeth with a full coverage, subgingival type of restoration for at least 2 years, and subgroup "B" representing contralateral homologous teeth, in the same individual, with no subgingival restoration. Clinical examination of individual teeth included determination of plaque and gingival indices, gingival fluid, probing depth, bleeding tendency and bone level. Data were subjected to statistical analysis using the Student t test and a two-way analysis of variance to determine any significant differences in variables between teeth with and without subgingival restorations, in narrow and wide zones of keratinized gingiva. The findings were: (1) teeth with subgingival restorations and narrow zones of keratinized gingiva showed statistically significant higher gingival scores than teeth having submarginal restorations with wide zones of keratinized gingiva. (2) Teeth without subgingival restorations showed no statistical difference between narrow and wide zones of keratinized gingiva (P greater than 0.05).

A longitudinal study of untreated mucogingival defects

A study was conducted to observe the changes in areas with untreated mucogingival defects over a 4-year period. Upon entering dental school, a group of freshman students were assessed for Plaque Index, Gingival Index, probing depth, and width of keratinized gingiva. These same students were reassessed for the same parameters at the end of their senior year. Of the 112 sites in 39 individuals, 33 sites revealed a slight increase in keratinized gingiva, 69 sites were unchanged, and 10 sites showed a slight decrease. These changes were minimal and not statistically significant. The Plaque Index, Gingival Index, and probing depth mean values showed a small but statistically significant improvement. In this group of students with a high degree of oral hygiene, areas with inadequate zones of attached gingiva were able to be maintained without further recession and without surgery.

Longitudinal observation of "unattached," mobile gingival areas

Facial gingival surfaces over cuspids and bicuspids in 20 patients were monitored for 5 years to evaluate the importance of attached gingiva in the maintenance of a stable periodontium. 43 surfaces "at risk" were compared to 36 "non-risk" surfaces within these patients. Surfaces "at risk" had to meet the following 3 criteria as established by both of 2 independent examiners: width of keratinized gingiva less than or equal to 1.0 mm; absence of attached gingiva; mobility of the gingival margin. During the 5 years of observation, "non-risk" surfaces showed a trend toward decrease in mean width of keratinized gingiva, while this measurement remained unchanged for the surfaces "at risk" Probing depths remained unaltered for both groups. A trend toward gingival recession and loss of probing attachment was observed for both "risk" and "non-risk" surfaces. Thus, this study failed to demonstrate that "unattached" and mobile facial gingival surfaces are more susceptible to periodontal breakdown than "attached" surfaces.

A longitudinal evaluation of varying widths of attached gingiva

32 patients with bilateral areas of inadequate attached gingiva on the facial surface of homologous contralateral teeth have been followed for 6 years. Treatment consisted of scaling, root planing, oral hygiene and maintenance at 3- to 6-month intervals or as needed to control inflammation. A free gingival graft was placed on one side (experimental), while the other side served as the unoperated control. Areas of inadequate attached gingiva on control sides, to include those with recession and no attached gingiva, did not demonstrate additional recession or further loss of attachment. Gingival inflammation and plaque were significantly reduced. On experimental sides, the dimension of keratinized and attached gingiva increased and was stable over 6 years. Areas which began with recession and no attached gingiva exhibited a reduction in recession and gain in clinical attachment following the placement of a gingival graft. Examination of patients who had discontinued participation in the study for a period of 5 years revealed a re-establishment of gingival inflammation on the control sides associated with additional recession. Similar changes were not observed in areas treated by a free graft. The findings demonstrate that it is possible to maintain periodontal health and attachment through control of gingival inflammation despite the absence of attached gingiva.

Recession in sites with inadequate width of the keratinized gingiva. An experimental study in the dog

The present investigation was performed to assess the inflammatory response in gingival units subsequent to the placement of restorations with subgingivally located margins. 3 beagle dogs were used. Cotton floss ligatures were placed around the neck of the mandibular third and fourth premolars of all dogs. The ligatures were exchanged once a month during the first 6 months of experiment. When 40-50% of the height of the supporting tissues had been lost in an experimental periodontitis the ligatures were removed but the animals allowed to accumulate deposits for another 60 days. The inflamed periodontal tissues were subsequently excised using either an "apically placed flap" procedure or a "gingivectomy" procedure. In the flap procedure the main part of the keratinized gingiva was preserved while in the gingivectomy procedure the keratinized part of the gingiva was removed in toto. Following scaling and root planing the animals were during a maintenance period of 4 months placed on a program involving chlorhexidine application and mechanical tooth cleaning twice daily. On Day 0 a notch was prepared in the buccal surface of each root at the level of the gingival margin. Furthermore, steel bands were placed along the buccal surface of each root of the third and fourth premolars and secured with an apical margin at the level of 1 mm apical to the notch. The bands were cemented to the root surfaces by a cement. The dogs were allowed to accumulate plaque and calculus for 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of inflammation on periodontal attachment levels in miniature swine with mucogingival defects

Previous authors have postulated that a dense band of keratinized, attached gingiva prevents the spread of inflammation from the gingival margin to the subjacent attachment apparatus. Chronically inflamed mucogingival defects were created over the vestibular surface of 12 central incisors in miniature swine. The untreated contralateral incisors were identified as paired controls. Placement of horizontal reference notches on the tooth surfaces was followed by measurement of Probing Depth (PD) and Probing Attachment Level (PAL) on the vestibular aspect of each experimental and control tooth. No plaque removal was accomplished at any time during the study. One year following the attainment of baseline data, all measurements were repeated. Results show an increase in PD and a loss of PAL in both experimental and control regions. No difference in increase of PD or loss of PAL between the groups could be discerned.

Revascularization of gingival autografts placed on different receptor beds. A fluoroangiographic study

The revascularization of gingival autografts, placed either on fenestrated periosteum or on non-fenestrated periosteum, has been compared by means of 12 fluorescein angiographs, taken 8, 10 and 12 days postoperatively on 12 patients, 18-32 years of age. The grafts placed on periosteum (P-zone) showed a mean increase of fluorescence of 10.6% between the 8th and 10th day and of 19.4% between the 10th and 12th day. At that time the circulatory system in the graft seemed to be established for 97.7%. The grafts placed on fenestrated periosteum (B-zone) showed a mean increase of fluorescence of 13.2% between the 8th and the 10th day and of 13.5% between the 10th and 12th day. The revascularization reached 96.1% at that time. Between both groups no statistically significant difference has been found. It can be concluded that a periosteal receptor side is not a prerequisite for the formation of an even circulatory pattern in gingival autografts.

Role of attached gingiva for maintenance of periodontal health. Healing following excisional and grafting procedures in dogs

The present study was undertaken to analyze the role of attached gingiva for the maintenance of periodontal health in sites with normal and reduced height of the supporting apparatus. Furthermore, the effect of excision and grafting of gingiva on some parameters describing dimensions and location of the periodontal tissues was evaluated. 7 beagle dogs were used. A baseline examination comprised assessments of dental plaque, gingival conditions, attachment level, position of the gingival margin and width of the keratinized and the attached gingiva. In the right side of the jaws (experimental side) a 6-month period of periodontal tissue breakdown was followed by surgical excision of the entire zone of the gingiva. After another 4-month period of healing with daily plaque control, a gingival graft was inserted in one quadrant of the experimental side to regain a zone of attached gingiva while the other quadrant of the experimental side was left ungrafted. In the left side of the jaws (control side), the teeth were subjected to daily meticulous plaque control during the entire study. In one of the control quadrants the entire zone of the keratinized and attached gingiva was excised at a time point corresponding to the grafting procedure in the experimental side, while the gingiva in the remaining control jaw quadrant was left unoperated. Clinical examinations of all control and experimental tooth units were repeated at certain time intervals during the course of the study. The final examination was carried out 4 months after grafting. The results of the experiment showed that in sites exposed to careful plaque control measures gingival health could be established and maintained without sign of recession of the gingival margin or loss of attachment, independent of (1) presence or absence of attached gingiva, (2) width of keratinized gingiva or (3) height of the supporting attachment apparatus. Following surgical excision of the entire gingiva, all buccal sites regained a zone of keratinized gingiva, but most sites were lacking attached gingiva. Furthermore, grafting of gingival tissue significantly increased the width of the keratinized and the attached gingiva but had no obvious effect on the position of the gingival margin or the level of the attachment.

Chronic mucogingival defects in miniature swine

Controversy surrounds the importance of keratinized gingiva in maintaining periodontal health. A well-defined animal model system is necessary to evaluate longitudinally the role of keratinized gingiva when plaque control is inadequate or where dental procedures (restorative, prosthetic or orthodontic) alter the periodontal environment. Facial gingiva was excised from eight primary incisors in miniature swine. Contralateral teeth were used as controls. The experimental teeth exhibited mucogingival defects at 3 and 6 month observation periods. The secondary teeth erupting into the experimental regions also exhibited recession and chronic mucogingival defects. The marginal tissue in regions devoid of keratinized gingiva demonstrated clinical signs of inflammation. No progressive gingival recession was present. Excision of keratinized gingiva to produce mucogingival defects in swine provides a convenient model system for evaluating the effect of dental procedures on periodontal health where little or no keratinized gingiva is present.