Development of an exostosis following a free gingival graft: case report

Complications and treatment errors in root coverage procedures

Root coverage procedures have become very common in clinical dental practice. Even though these techniques are considered safe, the clinician may face several issues during the therapy due to their surgical nature. Some of these issues can be defined strictly as complications inherent to the procedure, whereas others are medical errors or treatment errors. This review will focus on describing treatment errors and complications that may arise during different phases of the root coverage therapeutic process and on how to prevent and manage them.

Unusual complications at the recipient site following periodontal plastic surgery procedures: a systematic review

OBJECTIVE

To identify and describe unusual soft tissue complications of periodontal plastic surgery procedures at the recipient site after periodontal grafts.

MATERIALS AND METHODS

Two independent reviewers performed a comprehensive search in MEDLINE, Cochrane, periodontics journals, reference lists, and grey literature for articles dated up to July 2021. Publications related to surgical interventions only around the teeth with an unusual complication at the recipient site were selected. No restrictions were made in the number of cases, follow-up period, or language. The Cochrane Collaboration's tool for assessing risk of bias, the Newcastle-Ottawa Scale (NOS), and two validated case report/series checklists were used to critically appraise the studies.

RESULTS

A total of 1434 articles were examined, of which 28 met the inclusion criteria: one RCT, two cohort studies, and twenty-five case reports/series. The periodontal plastic surgery procedures described in these articles were conducted to treat lack of attached gingiva and gingival recessions. The following unusual complications were found: bone exostosis, epithelial inclusion, root resorption, abscess, overgrowth, "liver clot" formation, and oroantral communication.

CONCLUSION

Bone exostosis and epithelial inclusions were the most prevalent unusual complications following treatment with subepithelial connective tissue graft, free gingival graft, and acellular dermal matrix allograft. Due to the nature of the reports, the clinical recommendations for diagnosis and treatment cannot be homogenized. Clinical studies reporting complications are required to develop management protocols (PROSPERO CRD42021230875).

CLINICAL RELEVANCE

Clinicians need to know the main complications that can occur in mucogingival surgeries as well as their clinical management to provide a successful and predictable treatment.

Complications in the Use of Deepithelialized Free Gingival Graft vs. Connective Tissue Graft: A One-Year Randomized Clinical Trial

In the treatment of gingival recession, different surgical options have been described: free gingival grafts (FGG), connective tissue Grafts (CTG), and a more recent technique, de-epithelialized free gingival graft (DFGG). They are not procedures exempt from the appearance of complications. Most publications refer to postoperative complications, and there is limited literature regarding the development of late complications (weeks or months). Our working group carried out a study to describe the development of late complications associated with the use of DFGG in comparison with CTG, providing an incidence rate and a classification. Sixty-eight patients with mucogingival problems were selected, and divided into two groups: the Test Group, for which we used DFGG + Coronal Advancement Flap (CAF), and the Control Group (CTG + CAF). All patients were treated at the University of Seville’s dental school to solve mucogingival problems for aesthetic and/or functional reasons. A classification is proposed based on its severity; Major and Minor. Major complications included reepithelialization of the graft, epithelial bands, cul-de-sac, epithelial cysts, and bone exostoses. Minor complications included the graft´s color changes and superficial revascularization. Late major complications were only associated with the use of the DFGG, and the late minor complications developed with the use of the DFGG were much higher than those associated with CTG. CTG appears to be a safer procedure than DFGG in terms of late complications.

Late complications after root coverage with two types of subepithelial connective tissue grafts, clinical and histopathological evaluation: A prospective cohort study

AIM

This prospective cohort study evaluated late complications (LC) on recipient sites comparing two types of connective tissue grafts (CTG).

MATERIALS AND METHODS

Participants (n: 60) were treated with coronally advanced flap (CAF) plus CTG harvested by de-epithelialized technique (DE) (n:31) or two-parallel incision (PI) (n:29). Areas were evaluated to identify white discharge associated or not with gingival cul-de-sac. Patients were ordered in groups with (DE+and PI+) or without (DE- and PI-) LC. Biopsies for histopathological analysis in LC areas were proposed.

RESULTS

Six cases exhibited LC, 5 in DE graft (DE+) and 1 in PI graft (PI+) group; 2 were diagnosed at 3 months postoperatively, 3 at 6 months and one at 12 months. The relative risk for LC was 1.7 times greater for DE graft (p: 0.01; CI: 1.10 to 2.72; RR>1). Differences were not observed for clinical outcomes after both types of CTGs (p > 0.05). Biopsies showed deep invagination of the epithelial lining suggesting cyst-like area/ cavity with keratin content and consolidated in fibrous connective tissue. After 24 months biopsied areas presented no recurrence of LC, in non-biopsied patients the clinical condition remained unchanged.

CONCLUSIONS

Considering the limitations of this study, LC on recipient sites demonstrated no statistical difference between two types of CTG.

Morphological and Molecular Characterization of Human Gingival Tissue Overlying Multiple Oral Exostoses

Gingival and osseous augmentations are reported as hypertrophic or hyperplastic reactions to different factors including chronic traumatisms and surgeries such as free gingival graft (FGG) that induce an abnormal growth of both hard and soft tissues in genetically predisposed subjects. Since an imbalance in collagen turnover plays a key role in the development of gingival overgrowth leading to an accumulation of collagen in gingival connective tissue, in this study we described the histological and molecular features of three oral overgrowths obtained from a 34-year-old woman previously operated for FGG in order to evaluate a possible relationship between exostoses and overgrown tissue. Healthy and overgrown gingiva were analyzed by histological methods, and the expression of genes and proteins involved in collagen synthesis, maturation, and degradation was assessed in cultured fibroblasts obtained from gingival fragments at the molecular level. Our results show that general morphology and collagen content were similar in healthy and overgrown gingivae. However, fibroblasts obtained from the overgrown gingiva revealed an anabolic phenotype characterized by an increased collagen turnover and maturation. These findings indicate that an exostosis could act as a mechanical stimulus stretching the overlying connective tissue and triggering an anabolic phenotype of gingival fibroblasts and suggest to use minimally invasive surgical techniques to avoid traumatizing the periosteal tissues for the eradication of the exostosis with minimal relapses.

Assessment of thickness of palatal masticatory mucosa and maximum graft dimensions at palatal vault associated with age and gender - a clinical study

BACKGROUND

Periodontitis is a multifactorial inflammatory disease which leads to alveolar bone loss, followed by exposure of root surfaces, which results in an unaesthetic appearance. Palatal masticatory mucosa is widely used as a donor tissue for root coverage procedures, to achieve an aesthetic appearance and to meet patient's needs. Obtaining sufficient volume of tissue without injuring the vessels is necessary.

AIM

Purpose of this study was to determine thickness of palatal masticatory mucosa in association with age and gender in healthy subjects who were aged 14-59 years.

MATERIALS AND METHODS

Thirtysix healthy subjects were included under two groups (aged 14-29 years and 30-59 years). Each group consisted of 9 males and nine females. Transgingival probing was done by using a UNC-15 (University of North Carolina) periodontal probe under LA (local anaesthesia) and measurements were taken from 15 different sites on palatal masticatory mucosa. Maximum available length and height of the palatal vault were also measured. All measurements were made by using a Boley gauge to the nearest millimetre.

RESULTS

Students t-test was used to determine the difference in mucosal thickness between two groups. Two-way ANOVA test was used to measure the height of palatal vault between the groups. The results showed that younger age group had thinner palatal masticatory mucosa of thickness which was between 2.3 mm to 2.65 mm and that younger females had thinner mucosa than males. The mean height which was measured from second premolar area to the second molar area was significantly greater in men (14.03 mm) than in women (13.25 mm).

CONCLUSION

Palatal masticatory mucosa was thicker in older age group than in younger age group and it was thin in females as compared to that in males. The most appropriate donor site for carrying out grafting procedures is distal canine to mid palatal aspect of 1st molar area, with minimum height of 5 mm to 8 mm in the premolar area in all cases.

Alveolar bone exostoses subsequent to orthodontic implant placement

Alveolar bone exostoses (ABE), also known as a buttress bone formation, are not uncommon to the literature. Although, exostoses in response to the trauma from occlusion are a popular concept proposed more than 45 years ago, still the aetiological factors behind this development are unclear. Various risks and complications associated with orthodontic implants have been published, but buttress bone formation subsequent to this procedure has not been reported till date. This article describes a case of ABE, subsequent to the placement of orthodontic mini implants, where after careful evaluation, resective osseous surgery was performed.

Bony exostoses developed subsequent to free gingival grafts: case series

Bony exostosis (BE) is described as a benign localised overgrowth of bone of unknown aetiology. Buccal bony exostosis (BBE) development secondary to soft tissue graft procedures has been reported in a small number of cases. The dental literature describes BBE development also at sites where free gingival grafts (FGG) have been used to increase the amount of gingiva. The following case series describes BBE development at nine sites (five cases) at which FGG was performed to increase the width of the attached gingiva. The presence of exostoses has been recognised during postoperative visits. Histological examination revealed osseous enlargements compatible with the diagnosis of exostoses at two re-entry procedures. In conclusion, based on previous reports, periosteal trauma, eg fenestration, seems to be the main aetiologic agent associated with the development of BBE in areas where FGG were placed.

Osteomas exofíticos múltiplos de ossos craniofaciais não associados à Síndrome de Gardner: relato de caso

Osteomas exofíticos são protuberâncias de osso maduro que necessitam ser cuidadosamente diferenciados de outras lesões. Os autores apresentam relato de paciente do sexo masculino, com 44 anos de idade, apresentando osteomas exofíticos múltiplos localizados na região vestíbulo-maxilar em ambos os lados, região de pré-molares e molares não associados à Síndrome de Gardner.

Exostosis following a free gingival graft

BACKGROUND

There have been few cases reported of exostoses following a free gingival graft. In 1980, a free gingival graft was placed on the facial level of 33-34, developing over the years a significant enlargement. In 1999, since the patient felt progressively uncomfortable with the enlarged area, its surgical reduction was proposed.

METHOD

Under local anesthesia, the hard tissue developed under the previously-grafted area, was significantly reduced. The specimen, together with a fragment of the covering soft tissue, was sent for histological analysis.

RESULTS

The surgical wound healed uneventfully, and the patient was satisfied with the results. The histology showed the presence of mature bone surrounded by a dense connective tissue, whereas the gingival tissue showed acanthosis and fibrosis.

CONCLUSION

The development of exostoses following a free gingival graft can be considered an unpredictable, albeit infrequent side-effect of this procedure. The fact that most of these exostoses appear in the cuspid-premolar area, deserves further consideration.

Spontaneous bony exposure: a report of 4 cases of idiopathic exposure and sequestration of alveolar bone

This paper describes 4 cases of spontaneous exposure and sequestration of alveolar bone. While one case was associated with an allergic mucositis, the other three were idiopathic involving large lingual exostoses.