[Histopathological characteristics of peri-implant soft tissue in reconstructed jaws with vascularized bone flaps]

OBJECTIVE

To analyze the histopathological characteristics of peri-implant soft tissue in reconstructed jaws and the changes after keratinized mucosa augmentation (KMA) with free gingival graft (FGG).

METHODS

Twenty patients were enrolled in this study. Five patients of them, who were periodontal and systemic healthy and referred for crown lengthening before restoration with healthy keratinized gingiva collected were enrolled as healthy controls. 15 patients of them were with fibula or iliac bone flaps jaw reconstruction (10 with fibula flap and 5 with iliac flap), who were referred to FGG and implant exposures before restoration. Soft tissue was collected before FGG in reconstructed jaws, and in 5 patients (3 with fibula flap and 2 with iliac flap) 8 weeks after FGG if a second surgery was conducted. Histological analysis with hematoxylin-eosin stain and immunological analysis to interlukin-1 (IL-1), interlukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were performed.

RESULTS

Thickness from the bottom of stratum basale to the top of stratum granulosum and thickness of keratinized layer in reconstructed jaws were significantly lower compared with that of natural healthy keratinized gingiva [0.27 (0.20, 0.30) mm vs. 0.36 (0.35, 0.47) mm, P<0.05; 16.49 (14.90, 23.37) μm vs. 26.37 (24.12, 31.53) μm, P<0.05]. In the reconstructed area, thickness from the bottom of stratum basale to the top of stratum granulosum increased after KMA with FGG [0.19 (0.16, 0.25) mm vs. 0.38 (0.25, 0.39) mm, P=0.059] and the thickness of keratinized layer significantly increased after KMA with FGG [16.42 (14.16, 22.35) μm vs. 28.57 (27.16, 29.14) μm, P<0.05], which was similar to that in the control group. Furthermore, the number of positive cells of IL-1, IL-6 and TNF-α significantly increased after KMA [0.67 (0.17, 8.93) vs. 11.00 (9.16, 18.00); 13.00 (8.50, 14.14) vs. 21.89 (15.00, 28.12); 0.22 (0.04, 0.63) vs. 2.83 (1.68, 5.00), respectively, P<0.05] as well as the average optical density value [0.15 (0.14, 0.17) vs. 0.18 (0.17, 0.21); 0.28 (0.26, 0.33) vs. 0.36 (0.33, 0.37); 0.23 (0.22, 0.29) vs. 0.30 (0.28, 0.42), respectively, P<0.05], which was similar to that in the healthy keratinized gingiva.

CONCLUSION

The lack of rete pegs and inflammatory factors were common in soft tissue with jaw reconstruction. FGG can improve the quality of the epithelium and may improve the stability of the mucosa around implants.

The effects of injectable platelet-rich fibrin application on wound healing following gingivectomy and gingivoplasty operations: single-blind, randomized controlled, prospective clinical study

OBJECTIVES

The aim of this study was to evaluate the effects of wound healing using injectable platelet-rich fibrin (IPRF) after gingivectomy and gingivoplasty.

MATERIALS AND METHODS

In this clinical study, 46 systemically healthy patients with chronic inflammatory gingival enlargement were randomly treated with gingivectomy-gingivoplasty + I-PRF (n=23) or gingivectomy-gingivoplasty alone (n=23). The primary outcome was to evaluate the effect of I-PRF on wound healing over a 3-week follow-up period. Samples collected from gingival crevicular fluid (GCF) were processed using enzyme-linked immunosorbent assay (ELİSA) to measure VEGF and FGF-10 biomarkers. The surgical areas were stained with Mira-2 tone and evaluated in ImageJ. Wound healing was evaluated with Modified Manchester Scar (MMS) scale and Landry, Turnbull, and Howley (LTH) index.

RESULTS

VEGF values of the control group at baseline, week 2, and week 3 were significantly higher than the test group. In weeks 2 and 3, FGF-10 values were found to be significantly higher in the control group than the test group. The amount of staining was found to be significantly higher in the control group than in the test group on days 3, 7, and 14. LTH values of the control group were significantly lower than the test group and MMS values were significantly higher than those of the test group.

CONCLUSIONS

I-PRF applications revealed positive effects on epithelial wound healing after gingivectomy and gingivoplasty operations.

CLINICAL RELEVANCE

Platelet concentrates such as I-PRF accelerate wound healing and contribute to the patient's comfort and quality of life. I-PRF application may have positive effects on wound healing after gingivectomy and gingivoplasty operations.

Keratinized tissue augmentation using collagen-based soft tissue substitute with/without epidermal growth factor on buccally positioned implants: a pilot preclinical study

OBJECTIVES

To investigate the effect of epithelial growth factor (EGF) with collagen matrix (CM) on the gain of KT for buccally positioned implants in dogs.

MATERIALS AND METHODS

In five dogs, four implants were placed buccally with the whole part of KT excision on the buccal side (two implants per each hemi-mandible). After one month, KT augmentation was performed: 1) free gingival grafts (FGG), 2) collagen matrix (CM) only, 3) CM soaked with 1 μg/g of EGF, and 4) CM soaked with 10 μg/g of EGF (n = 5 in each group). The experimental animals were sacrificed three months post-KT augmentation. Clinical, histologic, and histomorphometric analyses were performed.

RESULTS

The clinical KT zone was the highest in group FGG (5.16 ± 1.63 mm). Histologically, all groups presented buccal bony dehiscence. Regarding newly formed KT, no specific difference was found among the groups, but robust rete pegs formation in some specimens in group FGG. Histomorphometric KT height (4.66 ± 1.81 mm) and length (5.56 ± 2.25 mm) were the highest in group FGG, whereas similar increases were noted in the rest. The buccal soft tissue thickness at the coronal part of the implant did not exceed 2 mm in all groups.

CONCLUSION

All groups presented increased KT zone, but FGG treatment was more favored. The addition of EGF to CM appeared not to enhance KT formation.

CLINICAL RELEVANCE

FGG treatment was more favorable to re-establish the KT zone than other treatment modalities.

Soft-Tissue Reconstruction at Anterior Implant Sites With Soft-Tissue Dehiscences

The treatment of a peri-implant soft-tissue dehiscence (PSTD) can be quite challenging for many clinicians and leave gravely disappointing esthetic remarks for patients to bear. The present article describes the treatment of two adjacent PSTDs in the forefront of the anterior region, where papilla deficiency also was exhibited. The case was treated with a coronally advanced flap and connective tissue graft (CTG) with submerged healing. The implant-supported crowns and abutments were removed, and soft-tissue augmentation was performed using a CTG that was sutured to the buccal site of the implants. The flap was released and sutured over the implants, which were submerged aiming for a closure by primary intention. After 3 months, a combination of an apically positioned flap and roll flap was performed to increase keratinized mucosa width around the implants and augment the peri-implant papilla. Clinical and esthetic satisfactory outcomes were obtained at 1 year.

Effects of ozone therapy on periodontal and peri-implant surgical wound healing: a systematic review

OBJECTIVE

To evaluate the effectiveness of the use of adjuvant ozone therapy in the healing process of wounds resulting from periodontal and peri-implant surgical procedures by answering the following focused question: "Can adjuvant ozone therapy improve wound healing outcomes related to periodontal and peri-implant surgical procedures?".

METHOD AND MATERIALS

MEDLINE (via PubMed), EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) databases were searched, without language restriction, for peer-reviewed articles published until 23 March 2022, in addition to manual search. Only controlled clinical trials (randomized or not) were considered. The risk of bias was evaluated by the Cochrane risk-of-bias tool for RCTs - version 1 (RoB1). Data were pooled into evidence tables and a descriptive summary was presented.

RESULTS

Of the 107 potentially eligible records, only seven studies were included. Four addressed free/deepithelialized gingival grafts with a palatal donor area, two evaluated implant sites, and one comprised gingivectomy and gingivoplasty. A total of 225 patients were evaluated in the included studies, considering control and test groups (ozone and other adjuvant therapies for comparison). Ozone therapy had a positive effect on outcomes directly or indirectly related to periodontal/peri-implant surgical wound healing. Furthermore, it could also increase the stability of immediately loaded single implants installed in the posterior mandible.

CONCLUSION

In general, ozone therapy seems to both accelerate the healing processes of periodontal/peri-implant wounds and increase the secondary stability of dental implants; however, considering the limited evidence available and the risk of bias in the included studies (none classified as low risk), a definitive conclusion cannot be drawn. (Quintessence Int 2023;54: 100-110; doi: 10.3290/j.qi.b3512007).

Crown Lengthening Techniques and Modifications to Treat Excessive Gingival Display

Dental aesthetics are a fundamental treatment goal in dentistry, in which even minute deviations from the ideal may necessitate corrective treatment or constitute a suboptimal clinical outcome. A well-defined protocol that adheres to sound biological and surgical principles is necessary to harmoniously integrate the dental and periodontal components. This article reviews clinical and aesthetic guidelines based on these principles for clinical crown lengthening.

Evaluation of the effects of platelet-rich fibrin, concentrated growth factors, and autologous fibrin glue application on wound healing following gingivectomy and gingivoplasty operations: a randomized controlled clinical trial

OBJECTIVE

The aim of this study was to evaluate the effect of platelet-rich fibrin (PRF), concentrated growth factors (CGF), and autologous fibrin glue (AFG) application on early wound healing after gingivectomy and gingivoplasty operations.

METHOD AND MATERIALS

In this split-mouth study, gingivectomy and gingivoplasty surgery were performed on 19 patients. The postoperative PRF, CGF, and AFG applied areas were compared with the control regions. On days 0, 7, 14, and 28, the surgical area was stained with a plaque-disclosing agent and evaluated in the ImageJ program. Wound healing was evaluated with H2O2 test, visual analog scale for pain, and Landry, Turnbull, and Howley (LTH) wound healing index on days 7, 14, and 28. The patients were asked to evaluate their esthetic perceptions on a visual analog scale.

RESULTS

The amount of staining at days 7 and 14 was found to be significantly higher in the control group than in the test groups, but there was no difference between the test groups. LTH index values of the control group at days 7, 14, and 28 were found to be significantly lower than the test groups. There was no significant difference between the groups in the epithelialization assessment performed with the H2O2 test. It was observed that the use of platelet concentrate at day 7 reduced postoperative early pain. Patients were highly satisfied with postoperative esthetics.

CONCLUSION

After gingivectomy and gingivoplasty operations, PRF, CGF, and AFG application were found to have positive effects on wound healing. However, PRF, CGF, and AFG applications were not superior to each other in terms of secondary wound healing.

Idiopathic Gingival Fibromatosis in a Pediatric Patient

Idiopathic gingival fibromatosis (IGF) is a rare, benign, slow-growing proliferation of the gingival tissues involving both maxillary and mandibular gingiva. It is exacerbated during the eruptive phase of both primary and permanent dentitions. The purpose of this article is to report the case of a 10-year-old boy who presented with IGF whose gingival enlargement covered the occlusal surfaces of many teeth and displaced the erupting dentition, compromising the patient's cosmetics, function, speech and development. The treatment involved gingivectomy and gingivoplasty, combining both surgical and laser methods. The case showed remarkable esthetic and functional im provement, without signs of recurrence one year post-treatment.

Alveolar bone grafting and gingivoperiosteoplasty in bilateral cleft lip and palate

PURPOSE OF REVIEW

Gingivoperiosteoplasty (GPP) and alveolar bone grafting (ABG) procedures have a vast history. There have been many publications regarding ABG and secondary ABG, with and without presurgical infant orthopedics (PSIO), in bilateral cleft lip and palate patients. There is little long-term data available describing results of both techniques.

RECENT FINDINGS

The interdisciplinary approach to primary and secondary surgical procedures has proven to be beneficial for patients with bilateral cleft lip and palate. In the neonates, naso-alveolar molding (NAM) has been found to optimize the aesthetic outcome as well as re-approximating the arches to facilitate GPP. During the mixed dentition stage, arch preparation/expansion before the secondary ABG procedure improves arch morphology, restores the functional interarch relationship, and facilitates surgery.

SUMMARY

This review aims to highlight the key points of both the procedures and why combining both procedures along with PSIO procedures such as NAM might be helpful for the patients in the long term.

Modified Tunnel Technique and Double-Layer Acellular Dermal Matrix to Treat Multiple Teeth and Implant: 3.5-Year Results

Recession defects can affect both tooth and implant sites. The objective of connective tissue grafting is to correct recession defects and develop a soft-tissue architecture that is both stable and natural in appearance. By protecting the integrity of the interdental papillae, tunnel techniques are intended to maximize esthetic results. The use of an acellular dermal matrix (ADM) allows treatment of multiple adjacent recession defects without the need for a palatal donor site. The dental literature is scarce on the use of ADMs to treat recession affecting implant sites. The purpose of this article is to discuss and demonstrate the use of a modified tunnel technique and a double layer of an ADM in the treatment of recession defects affecting multiple teeth and an implant.

One-Year Outcomes of a Piscine Soft Tissue Alternative Used in Mucogingival Procedures: A Clinical Case Series

The free gingival graft (FGG) has been used predictably for gingival procedures aimed to increase the width of keratinized tissue (KT). Several soft tissue alternatives, such as xenografts and allografts, have been studied and proven to be successful with varying degrees. This pilot clinical case series evaluated the efficacy, safety, and initial clinical outcomes (measuring KT width) of a piscine xenograft material (Omega3 Wound, Kerecis) compared to the FGG (harvested from the patient palate) in correcting mucogingival deformities around teeth. A convenience sample of six subjects with unilateral or bilateral lack of KT were enrolled in the study. The primary objective of this pilot study was to determine the gain in width of KT. Secondary objectives included investigating the probing depth, recession depth, bleeding on probing, and inflammation score. There were three FGG sites and six xenograft sites. In bilateral-site treatments, FGG or piscine xenograft were randomly assigned. For unilateral sites, the piscine xenograft was used. Postoperatively, the patients returned for follow-up at 1, 2, 4, 12, 24, 48, and 52 weeks. All six subjects completed the 12-month study and reported uneventful healing. On average, the xenograft sites had a 3.25-mm gain in KT width, and the FGG had an average gain of 3.67 mm. This pilot clinical series showed the piscine xenograft to be safe and efficacious during healing and to increase the width of KT. Future studies may include a more robust study design with a greater number of subjects.

Treatment of Multiple Mandibular Gingival Recession Defects Using MCAT Technique and SCTG With and Without rhPDGF-BB: A Randomized Controlled Clinical Trial

The aim of this randomized controlled trial was to compare the clinical outcomes of modified coronally advanced tunnel technique (MCAT) with subepithelial connective tissue graft (SCTG) with and without recombinant human platelet-derived growth factor-BB (rhPDGF-BB) for mandibular multiple recessions. Twenty-four Miller Class I and III recessions were randomly assigned to a group: test (MCAT+SCTG+rhPDGF-BB) or control (MCAT+SCTG). After 6 months, mean recession-depth reduction was higher in the test group (2.08 ± 0.90 mm) than the control (1.83 ± 0.93 mm). Mean root coverage was achieved, favoring the test group (82.6% ± 23.69%) instead of the control (56.2% ± 28.55%). Complete root coverage for the test group was 58.3%, which was significantly superior to control (16.7%). The use of rhPDGF-BB+SCTG using MCAT offered an advantage of a minimally invasive, predictable method for achieving optimal outcomes.

Long-term Case Reports Demonstrating Use of Porcine Collagen Matrix to Augment Width and Thickness of Keratinized Gingiva

Gingival augmentation therapy is intended to create a healthy band of attached keratinized tissue to inhibit further gingival recession, facilitate plaque control, and improve patient comfort. Although an effective treatment for gingival augmentation procedures, the often-used autogenous epithelialized palatal graft has several drawbacks, including the need for a second surgical site to harvest the graft, the risk of such complications as damage to neurovascular tissue and poor healing of the donor site, and potential color and texture discrepancies of the grafted site. The use of a resorbable xenogeneic collagen-based matrix may be considered as a treatment alternative to augment soft tissue. The authors describe the application of such a graft that is made from purified porcine type I and type III collagen and processed without the addition of chemical cross-linkers. Two cases are presented that demonstrate the clinical advantages of this material compared to autogenous palatal grafts when augmenting the width and thickness of attached keratinized gingiva.

The Modified Apically Repositioned Flap Technique and Its Potential to Create Attached Gingiva in Areas with No Keratinized Tissue: A Long-Term (1 to 11 Years) Retrospective Case Series Study

The modified apically repositioned flap (MARF) technique has been previously published as a successful method to increase the zone of attached gingiva with numerous advantages, such as simplicity, predictability, and long-term stability. However, this technique has only been used in areas with at least 0.5 mm of attached gingiva, presurgically. In the current study, the MARF technique was utilized in 21 sites (teeth) with no attached gingiva and only mucosa comprising the marginal tissue. The long-term follow-up results over the course of 1 to 11 years (average follow-up: 3.2 years) show a statistically significant increase of 3.6 ± 0.8 mm for keratinized tissue and of 2.21 ± 0.83 mm for attached gingiva, and no increases in probing depths or marginal tissue recession. These results indicate that the MARF procedure has generated keratinized tissue and attached gingiva in areas with a presurgical absence of these tissues.

Multidisciplinary Approach to Smile Restoration: Gingivoplasty, Tooth Bleaching, and Dental Re-anatomization

This article reports on the case of a patient who underwent a multidisciplinary treatment in smile design that entailed dental cosmetic techniques involving esthetic periodontal surgery, teeth bleaching, and re-anatomization of the upper incisors. The male patient presented with a chief complaint of an excessive gingival display while smiling, as well as small, darkened teeth with spaces between them. After diagnosis and patient consent, therapy began in the following stages: periodontal plastic surgery with probing, bleeding points delimitation, beveled incision, removal of the gingival band with periodontal curettes, and finishing with an electric scalpel. After 21 days following surgery, dental bleaching using a combined technique that included two sessions of in-office bleaching (35% hydrogen peroxide) and 2 weeks of at-home bleaching (carbamide peroxide 16% for 4 hours per day) was carried out, followed by dental re-anatomization using resin composite. Diagnostic waxing, mock-up, fabrication of a palatal silicone index, incremental sculpturing, and structuring the restoration of the palatal shell to the vestibular surfaces was then completed, followed by occlusal adjustment, finishing, and polishing. The multidisciplinary intervention was fundamental for the accomplishment of the proposed treatment that combined biological, functional, and esthetic concepts.

Evaluation of in-office tooth whitening treatment with violet LED: protocol for a randomised controlled clinical trial

INTRODUCTION

In-office tooth whitening treatment using violet light emited diode (LED) (405 nm) is a novel bleaching method that causes less sensitivity while offering the same effectiveness as the gold standard (35% hydrogen peroxide, H₂O₂). This study describes a protocol for the first randomised controlled clinical trial to compare the effects of the two methods.

METHODS AND ANALYSIS

Eighty patients will be divided into four groups: G1 violet LED; G2 violet LED +35% carbamide peroxide; G3 35% H₂O₂ and G4 violet LED +gingivoplasty. Colour will be measured at baseline, immediately after the first session and at the 15 and 180 days follow-up using the Vita Classical and the digital Easyshade V spectrophotometer (Vita, Zahnfabrik, Germany). Sensitivity after whitening will be measured using the Visual Analogue Scale at baseline and at each session in all groups and in all follow-ups. The tissue removed during gingivoplasty (G4) will be submitted to immunohistochemical analysis for the determination of inflammatory changes caused by violet LED. The Psychosocial Impact of Dental Aesthetics Questionnaire (PIDAQ) will be evaluated before, as well as at established time point controls. The results will be expressed as mean and SD values. After determining the normality of the data, a one-way repeated-measures analysis of variance will be used for the comparison of data with normal distribution and the Kruskal-Wallis test will be used for data with non-normal distribution. A p<0.05 will be considered indicative of statistical significance. After determining the normality of the data, the Kruskal-Wallis test will be used for non-parametric data. Multivariate analysis of variance (MANOVA) and the Wilcoxon test will be used for comparing data from the PIDAQ.

ETHICS AND DISSEMINATION

This protocol has been approved by the Human Research Ethics Committee of UniversidadeNove de Julho (certificate: 2.034.518). The findings will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT03192852; Pre-results.

Conservative Approach for Treatment of Maxillary Lateral Incisor Agenesis With the Deciduous Tooth Retained: 18-Month Follow-Up

This case describes a female patient with agenesis of the maxillary right lateral incisor, with her permanent canine in its position and the deciduous canine retained. Additionally, she presented with a maxillary left peg lateral incisor. To solve her functional and esthetic complaints, a multidisciplinary approach involving perio-restorative procedures was proposed. Periodontal surgeries were performed to align the gingival contour, and the restorative approach utilized ceramic veneers. At the 18-month clinical and radiographic follow-up, the treatment outcome was stable, with maintenance of the clinical results achieved and without any sign of deciduous tooth resorption.

Excessive Rapid Palatal Expansion with Latham Appliance for Distal Repositioning of Protruded Premaxilla in Bilateral Cleft Lip and Alveolus

Objective:

This article reports a case of bilateral cleft lip and alveolus (BCLA) for which excessive rapid palatal expansion with a Latham appliance was performed for preoperative alignment of the protruded premaxilla. Postoperative changes of maxillary width were investigated with serial plaster casts.

Patient and Results:

A 3-month-old girl presented with complete BCLA in which the premaxilla was markedly protruded. Preoperative alignment of the protruded premaxilla with a Latham appliance was planned to facilitate primary lip repair. The appliance was placed when the patient was 4.5 months old. The necessary palatal expansion was estimated to be 7.0 mm in order to move the premaxilla backward into the ideal position. After palatal expansion and posterior repositioning of the protruded premaxilla, the primary operation, including cheiloplasty and gingivoperiosteoplasty, was performed when the patient was 7 months old. Excessive maxillary expansion might be a cause of transverse maxillomandibular discrepancy. Measurement with serial plaster casts demonstrated that maxillary widths increased from 42.3 mm pretreatment to 49.0 mm after orthopedic treatment but relapsed markedly to 43.5 mm at 3 months after the primary operation. Therefore, the net change of maxillary widths was only 1.2 mm. After alignment of the protruded premaxilla, tension-free soft tissue repairs were performed, and a harmonious alveolar arch was obtained without change in maxillary width.

Conclusion:

These results indicate that this method is useful for preoperative management of BCLA with protruded premaxilla.

Prepubertal Midface Growth in Unilateral Cleft Lip and Palate following Alveolar Molding and Gingivoperiosteoplasty

Objectives

To examine the long-term effect of nasoalveolar molding and gingivoperiosteoplasty (modified Millard type) on midface growth at prepuberty.

Procedures

In this retrospective study, 20 consecutive patients with a history of complete unilateral cleft lip and palate were evaluated. Ten patients had nasoalveolar molding and gingivoperiosteoplasty performed at lip closure; 10 control patients had nasoalveolar molding but no gingivoperiosteoplasty because of late start in treatment or poor compliance. A single surgeon (C.B.C.) performed all surgical procedures. Standardized lateral cephalometric radiographs were evaluated at two time periods: T1 at pre–bone-grafting age and T2 at prepuberty age. Superimposition and cephalometric analysis were undertaken to investigate the two groups. Two cephalometric reference planes, sella-nasion and basion-nasion, were used to assess the vertical and sagittal relations of the midface (ANS-PNS). The reference landmarks were procrustes fitted. The mean location and variance of ANS and PNS landmarks were computed. All results were analyzed by permutation test.

Results

No significant difference in mean location or variance of ANS-PNS in both vertical and sagittal planes at both T1 and T2 periods were found between the two groups (p > .05).

Conclusions

The results suggested that midface growth in sagittal or vertical planes (up to the age of 9 to 13 years) were not affected by presurgical alveolar molding and gingivoperiosteoplasty (Millard type).

Timing of soft tissue management around dental implants: a suggested protocol

Survival of dental implants depends on several factors; soft tissue (ST) management around dental implants is one of the foremost. Several studies have suggested techniques for ST management around dental implants, but none of them has discussed a suitable timetable for this process. This study aimed to review published articles related to the timing of ST management around dental implants and suggest a customized treatment protocol. A search of the PubMed database was conducted; the search was limited to English-language articles published from January 1995 to July 2015 with available full texts. Only in vivo studies and clinical trials in relation to the terms soft tissue management, management timing, keratinized mucosa, free gingival graft, connective tissue graft, soft tissue, augmentation, and dental implant were included. A total of 492 articles were reviewed, and eventually 42 articles were thoroughly evaluated. Those with treatment protocols in terms of the timing of ST grafting were selected and classified. ST management around dental implants may be done prior to the surgical phase, after the surgical phase, before loading, or even after loading. A thick gingival biotype is more suitable for implant placement, providing more favorable esthetic results. A treatment plan should be based on individual patient needs as well as the knowledge and experience of the clinician. The width and thickness of keratinized tissues, the need for bone management, and local risk factors that influence esthetic results determine the appropriate time for ST augmentation procedures.

Periodontal and Restorative Treatment of Gingival Recession Associated with Non-Carious Cervical Lesions: Case Study

The association between the presence of gingival recession and non-carious cervical lesions is a common finding in dentistry. These diseases have multifactorial etiology and the treatment should be multidisciplinary. Although traditionally the majority of professionals treat non-carious cervical lesions only with conventional restorative procedures, in most cases a combination of periodontal and restorative treatments provides the best functional and esthetic results. Thus, the objective of this case report was to present a new option for treatment, which consists of a subepithelial connective tissue graft associated with a coronally advanced flap placed on dentin and non-carious cervical lesions restored with lithium disilicate partial veneers. A patient complaining about the esthetic aspects of her teeth and cervical dentin hypersensitivity was submitted to occlusal adjustments and daily diet analysis in order to manage etiologic factors. Experienced operators then performed restorative and surgical treatments. Periodontal clinical attachment level (probing depth + gingival margin), bleeding on probing, plaque index, and the integrity of the restorations were observed. During the monitoring period, the treatment was effective, with good functional and esthetic results. The hypersensitivity disappeared, and neither inflammatory characteristics in gingival tissue nor failures in restorations were noted. It might be concluded that treatment with a combination of techniques can be effective and predictable for patients with gingival recession and non-carious cervical lesions that may or may not require restorative procedures under controlled conditions.

[Unilateral idiopathic gingival fibromatosis--a case report]

Gingival fibromatosis is a painless gingival overgrowth. It may result in difficulties with proper dental hygiene keeping, mastication and occlusion. Herein, a case of a 10-year-old patient was described. The patient reported to the Department of Periodontology and Oral Medicine of the Jagiellonian University Medical College in Krakow due to the problems with permanent teeth eruption (23-26), chewing and dental hygiene maintaining. Based on medical history, clinical examination, diagnostic tests and histopathological study of gingival tissue biopsies the patient was diagnosed with unilateral idiopathic gingival fibromatosis. After oral cavity hygienization, patient un- derwent dental surgery procedures by gingivectomy and gingivoplasty. The follow-up examination 2 and 6 months post operation showed un- eventful healing, proper tooth eruption, improved oral hygiene and chewing function. Twelve months post surgery no recurrence was noted. Due to the etiological diversity of gingival lesions occurring as an overgrowth, accurate medical history, clinical examination, laboratory tests and histopathological study are needed. Accurate diagnos- tics is crucial mainly to exclude he- matological and oncological diseases. Gingivectomy being the "gold method" of gingival fibromatosis treatment was effective and sufficient to cure the case presented in this article.

Gingivoperiosteoplasty

Cleft surgeons seek to provide the best results in the fewest surgeries. Gingivoperiosteoplasty (GPP) is one option to achieve this goal. Although it may normalize early form and function and obviate secondary alveolar bone grafting, it has been associated with iatrogenic dentofacial restriction requiring more extensive treatment later. GPP technique associated with nasoalveolar molding (NAM) uses passive presurgical molding with strict patient-selection criteria. Data on the benefits of NAM-GPP are favorable but long-term outcome studies are required before its final role in cleft care is determined. This article describes the history, technique, perioperative care, and preliminary outcomes of NAM-GPP.

Management of phenytoin-induced gingival enlargement: a case report

Gingival enlargements may adversely affect speech, mastication, tooth eruption, and esthetics. These enlargements can occur as a result of the administration of certain anticonvulsants, immunosuppressants, and calcium channel blockers. The present case report describes the treatment of a patient with a phenytoin-induced gingival enlargement. A case of gingival enlargement should be treated in a step-wise manner, including consultation with the patient's physician, substitution of the drug, nonsurgical therapy, surgical therapy (if needed), and supportive periodontal therapy after every 3 months. In this case, healing was uneventful, and no recurrences occurred 3 months postoperatively.

Managing esthetic implant complications

Dental implant success today is judged not only by osseointegration but also by esthetic results. Cosmetic predictability can often be difficult to attain, and esthetic implant failures can be multifactorial. Once esthetic implant failures occur, many cannot be fully corrected. Some complications must be addressed by an interdisciplinary dental team. In this summary of case reports, surgical considerations are provided, including cases of facial asymmetry/recession due to facial implant placement or bone loss resulting from technique/treatment failures, as well as papillary deficiencies. Restorative considerations for correcting failures are also discussed.

Esthetic rehabilitation of anterior discolored teeth with lithium disilicate all-ceramic restorations

The esthetic treatment of darkened anterior teeth represents a great challenge to dentists, because dental materials ideally should match the natural teeth. The optical behavior of the final restoration is determined by the color of the underlying tooth structure, the color of the luting agent, and the thickness and opacity of the ceramic material used. This article reports a case in which veneers and full crowns made of heat-pressed, lithium disilicate glass-ceramic were used for the esthetic rehabilitation of anterior discolored teeth. The patient was referred for treatment with defective anterior composite resin restorations, provisional acrylic resin crowns, darkening of the gingival margins, and uneven gingival contours. The multidisciplinary treatment plan included dental bleaching, periodontal plastic surgery to create gingival symmetry, and indirect all-ceramic restorations using high-opacity lithium disilicate glass-ceramic ingots. The treatment was successful and an excellent esthetic result was achieved.

Systematic analysis of an anterior wear case to fulfill esthetic and functional objectives

It is beneficial to have a system in place for analysis of clinical data collected from a patient's initial examination. This system has four diagnostic categories that enable the clinician to thoroughly assess the clinical findings and establish a comprehensive diagnosis. An optimal treatment plan can be formulated to positively affect the prognosis of the presenting conditions. With the patient's treatment goals in mind, the clinician can determine the minimum amount of dentistry needed to increase long-term prognosis.

Collaborative care for better aesthetic outcomes

Considering the ever increasing demand for youthful and attractive smiles, collaborative patient care among restorative clinicians and periodontists is paramount. Successful aesthetic rehabilitation often demands a multidisciplinary approach and requires more than a prescribed treatment plan. "Beginning with the end in mind" not only helps the patient actualize treatment possibilities-thus making them a part of and engaged in their dental care from the start--but also provides clinicians with the appropriate data vital to accomplishing any required surgical and restorative procedure. Conjoint treatment planning will help each clinician accomplish treatment objectives more effectively while achieving a functional and aesthetic outcome for optimal patient care. The lines of communication between clinicians must remain open and accessible at all times. As demonstrated, many practitioners involved with complex dental treatment will utilize many levels of education, communication, and

Management of idiopathic gingival fibromatosis: report of a case and literature review

Gingival hyperplasia is a rare condition and is of importance for cosmetic and mechanical reasons. Idiopathic gingival fibromatosis, a benign, slow-growing proliferation of the gingival tissues, is genetically heterogeneous. The enlargement is most intense during the eruption of the primary and permanent teeth, and minimal or nondetectable growth is observed in adults. The genetic aspect, clinical feature, histopathology, immunohistochemistry, and treatment aspects are reviewed. The purpose of this paper was to report a case of idiopathic gingival fibromatosis in a 13-year-old female who had a negative family history for a similar type of gingival enlargement. The diagnosis was established through history, clinical examination, and histopathology using both hematoxylin and eosin and Van Giesen stain (a special stain for collagen). Surgical treatment, which included both gingivectomy and gingivoplasty, was carried out. The case showed remarkable esthetic and functional improvement. The patient returned after a year and showed no recurrence.

Rapid orthodontic extrusion using an interocclusal appliance for the reestablishment of biologic width: a case report

A multidisciplinary treatment of a case of subgingival fracture in a maxillary anterior tooth is presented. This case report describes a simple method involving an interocclusal appliance and an elastic band for rapid orthodontic extrusion to reestablish biologic width. In addition, a simple technique for surgical recontouring following the coronal displacement of the gingival margin prior to restoration of fractured tooth is explained.

Multidisciplinary treatment of a fractured root: a case report

AIM

To describe the orthodontic, periodontal and prosthetic management of a case with a 3 mm root fracture below the crest of the alveolar bone.

METHODS

The root was extruded and periodontal surgery carried out to improve aesthetics and dental function.

CONCLUSION

A multidisciplinary approach to the management of dental root fractures is necessary for successful treatment.

A case report of idiopathic gingival fibromatosis: diagnosis and treatment

Idiopathic gingival fibromatosis is a rare condition characterized by a generalized enlargement of the buccal and lingual aspects of the attached and marginal gingiva. This report addresses the diagnosis and treatment of a case of idiopathic gingival fibromatosis in a 27-year-old male. The patient presented with gingival enlargement involving the maxillary and mandibular arches, deep bite, generalized malpositioning of teeth, and difficulty in speech and mastication. Biopsy supported the diagnosis of gingival fibromatosis. Treatment included gingivectomy using an electrosurgical technique. Even though recurrence cannot be predicted, the psychological and functional benefits far outweigh the risk of recurrence.

Integrated clinical treatment of gingival recession secondary to root perforation: case report

Among the factors that influence the success of treatment of a root perforation, its location and possibility of contamination are determinant because the interaction of these 2 factors may result in significant periodontal injury. The management of cases of hard-to-reach contaminated perforations depends on the choice of an adequate technique. In the case reported in this article, controlled orthodontic tooth extrusion was successfully performed to treat gingival recession secondary to root perforation. The outcomes showed that this technique preserves the zone of attached gingiva, maintains the crown height, and prevents the involvement of the supporting bone tissue. The favorable clinical and radio?graphic conditions after 7 years of follow-up demonstrate the viability of this treatment approach.

Reactive repositioning of pathologically migrated teeth following periodontal therapy

Pathologically migrated teeth generally require orthodontic correction, as well as restorative options, as treatment. The term reactive positioning has been used to describe tooth movement that occurs without the use of appliances after periodontal treatment. This article describes the case of a young woman with periodontal attachment loss and distolabial pathologic migration of the maxillary central incisors, with midline diastema formation. Papilla preservation flap surgery was performed on the maxillary anterior segment, which spontaneously resolved the midline diastema without orthodontic treatment. This article also explores the possible mechanisms (hypotheses) for such an outcome of a simple periodontal surgery.

Periodontal maintenance therapy: an integral part of dental practice. Case reports on three periodontally involved patients

Periodontal maintenance therapy is an integral aspect of any general dental or specialist practice. Numerous studies have indicated that periodontal therapy in the absence of a carefully designed maintenance program invariably results in the relapse of the disease condition. Accordingly, dental practices that provide periodontal care without a maintenance program deal with significant patient management and disease management issues. In this article, three cases are presented with varying levels of disease severity but all sharing the common trait of having being enrolled in a good maintenance program with positive treatment outcomes.

The concept of the interdental gingival midpoint line in cervical line management

The first purpose of this study was to investigate the relationship between the lowest cervical point and the interdental gingival midpoint (IGM) line in the maxillary anterior region. After marking the lowest cervical points and the mesial and distal interdental gingival midpoints on study models of 77 patients, the shortest distances from the IGM lines that connect both interdental gingival midpoints to the lowest cervical points were measured on silicone impressions. The findings showed that the average position of the lowest cervical points in the central incisors coincides with the IGM line. This position is located 0.24 mm palatally in the lateral incisors, and in the canines 0.3 mm facially from the IGM line. The second purpose of the study was to verify the IGM line concept in cervical line management through some clinical cases. In a thick-flat biotype case using a clinical crown lengthening procedure, the lowest cervical points were adjacent to the IGM lines following long-term coronal gingival growth. In a short-term observation of a thin-scalloped biotype case, untouched facial gingiva increased following interdental gingival augmentation. In a case of Miller class 1 gingival recession, a coronally advanced flap combined with the roll technique was performed based on the IGM line concept. According to the results obtained from this study and these cases, it seems that the IGM line could become a diagnostic standard in cervical line management in periodontal plastic surgery.

Collaborative development of a natural-looking smile: case presentation

Sophisticated patients want their dental concerns treated without appearing as if they have been restored. This case presentation describes the planning and treatment steps for the recreation of an aesthetic smile. The patient had dento-facial asymmetries and an elevated occlusal risk of fracture due to bruxism. Lithium disilicate glass ceramic in a pressed version with stocked veneering porcelain was selected as an ideal restorative material for natural aesthetics and to fulfill the strength requirements for the maxillary anterior restorations.

In-office treatment of dentinal hypersensitivity

Dentinal hypersensitivity is a common dental complaint, especially in periodontal patients. It is believed to be mediated by a hydrodynamic mechanism in which various stimuli result in increased fluid flow in dentinal tubules, thereby generating action potentials in associated nerve fibers. Although it is often perceived as mild discomfort by the patient, it can be severe. A variety of interventions has been used, although few have been subjected to rigorous study. This article surveys those in-office treatments that are available, and suggests directions for research so that clinicians may treat patients based on best evidence. Until such evidence is available, it seems prudent to employ therapies that are least likely to cause harm and are reversible.

The peri-implant papilla: realities on papilla preservation and reformation

The purpose of this article is to provide clinicians with an understanding of the biologic parameters influencing peri-implant papilla preservation and reformation. The article reviews peri-implant papilla reconstruction techniques with emphasis on presurgical bone and soft tissue biotype assessment. Hard tissue management via surgical and orthodontic procedures is also summarized. Finally, the article discusses important implant selection and positioning characteristics, soft tissue augmentation, and emergence profile considerations in the esthetic peri-implant zone.

Lasers in cosmetic dentistry

Lasers have become a necessary instrument in the esthetic restorative armamentarium. This article presents smile design guidelines for soft tissue lasers, as well as an overview of hard tissue procedures that may be performed using all-tissue lasers. The goal is to help dentists determine the appropriate laser for a given clinical situations.

Multidisciplinary care: periodontal aspects to treatment planning the anterior esthetic zone

The field of periodontology has changed dramatically during the past 30 years. The goal of periodontal therapy is not only to establish and maintain the dentition and the periodontium free of any oral infections, but also to provide an environment with optimal function and esthetics. Esthetics has become an integral portion of the overall treatment goal in periodontics. This article discusses the role of periodontal plastic and reconstructive surgery in treatment planning the anterior esthetic zone in interdisciplinary dental care.

Role of platelet-rich plasma in soft tissue root-coverage procedures: a review

The aim of this article was to review the current evidence on the role of platelet-rich plasma (PRP) in enhancing root-coverage techniques and discuss the rationale for its use in these applications. Sound biologic rationale and a multitude of basic science research support the use of PRP to promote soft tissue healing, although evidence of its role in enhancing periodontal applications, especially root coverage, is limited. Current scientific research has yet to elucidate all of the mechanisms by which PRP can affect soft tissue healing and assess its capacity to stimulate regeneration. Furthermore, clinical evidence on the use of PRP in root-coverage procedures is extremely limited, with only 2 randomized controlled trials published as of May 2007. A pertinent review of medical and dental literature relating to PRP and its role in wound healing and enhancement of root-coverage procedures was performed. Preliminary reports in this area suggest that the potential benefits of PRP in root-coverage procedures may be improved esthetics, decreased patient morbidity, and accelerated wound healing. An appropriate assessment of the effects of PRP and its possible use in enhancing root-coverage procedures cannot be made at this time because of inadequate clinical evidence.

Amelogenesis imperfecta: report of a successful transitional treatment in the mixed dentition

The term amelogenesis imperfecta is applied to a clinically heterogeneous group of hereditary disorders that interfere with the normal development of dental enamel. These disorders cause a deficiency in the enamel's quantity and/or the quality that may result in poor dental esthetics. The purpose of this paper was to describe a case of hypoplastic amelogenesis imperfecta in an 8-year-old girl whose dissatisfaction with the appearance of her teeth led to impaired social functioning. Since the patient was in the mixed dentition stage, a temporary treatment aiming to improve dental esthetics, preserve oral function, and allow for the recovery of the patient's self-confidence was performed by a multidisciplinary team.

Provisional restorations: a key determinant for implant site development

Provisional restoration and interim prosthesis have a significant role in reconstructive dentistry. Esthetics and function of the appliance or restoration are usually the key elements considered in the design and fabrication. While esthetics and function certainly need to be addressed, it is also essential to understand the impact of an interim prosthesis on early hard and soft tissue healing following bone grafting and alveolar ridge augmentation procedures.

[Reconstruction of soft and hard tissue around the tooth in aesthetic areas: a case report]

Gingival recession or root exposure is associated with the loss of soft and hard tissue around the root. Gingival recession not only leads to aesthetic problem, but also affects tooth function, and even causes the loss of tooth. A case was diagnosed as gingival recession of upper incisor and periodontal- endodontic combined lesion. This report included the history of disease, clinical examination, X-ray film, treatment planning, root canal treatment and sequence of periodontal disease treatment (initial therapy, local drug therapy, bone graft and guided tissue regeneration combined with double laterally positioned flaps, subepithelial connective tissue graft and coronal positioned flap). The reasons of gingival recession, the methods of root coverage and the reconstruction of soft and hard tissue were also discussed on the basis of this case.