Connective Tissue Graft Technique Research Articles

Inter-implant Papilla Reconstruction using the Iceberg and 'Garage' Connective Tissue Graft Technique. A Case Report and Technique Illustration.

A 45-year-old female patient presented with a lack of inter-implant papilla after a partially edentulous anterior area was rehabilitated with dental implants. The soft tissue phenotype and inter-implant papilla was augmented using the 'iceberg' connective tissue graft, followed by a second surgical procedure where a strip gingival graft was combined with a connective tissue graft inserted underneath a pouch prepared into the previous 'iceberg' connective tissue graft at the level of the crest ('garage' approach), further enhancing soft tissue volume in that region. This technique aims to improve mucosal thickness and supracrestal tissue height while addressing esthetic concerns associated with multiple implant placements in the anterior region. The final esthetic outcome was excellent, harmonious soft tissue with appropriate thickness, symmetry with adjacent teeth, well-shaped interdental and inter-implant papilla with high patient satisfaction, making this approach a valuable addition to a surgeon's armamentarium. Future clinical studies are needed to evaluate the performance of this novel approach.

Creeping attachment post-gingival recession treatment using a vestibular incision subperiosteal tunneling access technique combined with a connective tissue graft

Background: The exposed roots of teeth due to gingival recession can generate dentin hypersensitivity and esthetic problems because a patient feels that the teeth, especially the anterior teeth, look long. Recession in thin anterior gingiva often brings unsatisfactory treatment results, so mucogingival surgery, such as vestibular incision subperiosteal tunneling access (VISTA) with the addition of a connective tissue graft (CTG), can be chosen as an appropriate treatment technique. Purpose: This case report describes the creeping attachment phenomenon after treatment of anterior gingival recession with VISTA and CTG techniques. Case: A 28-year-old female patient came with Miller Class I gingival recession in thin anterior gingiva and malposition teeth, complaining about pain and esthetic problems. Case management: The patient was treated with a VISTA technique combined with CTG. The creeping attachment phenomenon seen at three months postoperatively obtained good root coverage so that the patient’s complaints were resolved even though periodic control was needed to evaluate oral hygiene. Conclusion: VISTA and CTG techniques are appropriate for treating anterior mandibular gingival recession with minimal trauma and provide significant results.

The 'Iceberg' Connective Tissue Graft Technique for Peri-implant Papilla Augmentation Following Interproximal Bone Reconstruction.

Implants with deficient papillae and black triangles are common findings. The treatment of these esthetic complications is considered to be challenging with limited predictability. Therefore, the present report aims to describe a novel technique for papilla augmentation: the 'iceberg' connec- tive tissue graft (iCTG) after extraction and interproximal bone reconstruction in the anterior region. A 35-year-old patient presented with a hopeless tooth with interproximal clinical attachment loss extending to the apical third of the adjacent tooth. Interproximal bone reconstruction was performed through alveolar ridge preservation by directly applying recombinant human platelet-derived growth factor-BB (rhPDGF-BB) to the exposed root surface of the adjacent tooth. A mixture of autogenous bone chips (obtained from the ramus) and bovine bone xenograft particles (previously mixed with the growth factor) was also used. The patient was able to return for implant therapy only 2 years later, at which time an incomplete regeneration of the interproximal bone was observed. Therefore, to compensate the interproximal deficiency, the iCTG approach was utilized, involving a double layer of CTG with different origins. Two small grafts from the tuberosity were sutured to the mesial and distal ends of a wider CTG harvested from the palate, aiming to gain additional volume at the inter- proximal sites. The composite graft was then sutured on top of the implant platform, and the flap was then released and closed by primary intention. After conditioning the peri-implant tissues, the case was finalized with a satisfactory outcome. The described iCTG could be an effective approach for reconstructing peri-implant papillae following interproximal bone reconstruction.

Root coverage of a maxillary lateral incisor with gingival recession, gingival stillman\u2019s cleft, bony exostosis, and denture stomatitis: a case report with 3-year follow-up

BackgroundCoronally advanced flap combined with connective tissue graft is considered as the golden standard of root coverage. Although Miller class I recession is considered to get complete root coverage, there are some uncommon conditions in different cases. This case reported a maxillary lateral incisor with a gingival recession, a stillman’s cleft, a bony exostosis and a denture stomatitis.Case presentationA 27-year-old female with a gingival recession, a stillman’s cleft and a bony exostosis was treated by coronally advanced flap combined with connective tissue graft technique, and the complete coverage was achieved. Later a denture stomatitis occurred when an acrylic removable partial denture was used, however the gingival margin was not affected. The denture stomatitis disappeared when a new denture with casting palatal plane was produced. In this case of 3-year follow-up, the gingival contour remained stable and the outcome was satisfactory.ConclusionCoronally advanced flap combined with connective tissue graft technique is a classic manner to treat gingival recession especially for a long term stability, even when there is a gingival stillman’s cleft, a bony exostosis and a denture stomatitis.

Clinical Outcomes of the Double Lateral Sliding Bridge Flap Technique with Simultaneous Connective Tissue Graft in Sextant V Recessions: Three-Year Follow-Up Study

The presence of isolated or multiple gingival recessions in the mandibular anterior region is a challenge for the clinician, as they may be associated with a shallow vestibule, high frenum insertion and/or little or no attached gingiva. Only limited evidence is available on the use of the double lateral sliding bridge flap technique with connective tissue graft (CTG) technique for treating gingival recessions in the mandibular anterior region. The aim of this study was to describe and evaluate the clinical and esthetic outcomes of the double lateral sliding bridge flap technique with CTG on isolated and multiple gingival recessions at the level of the mandibular incisors. Nine patients required treatment of gingival recessions in the mandibular incisors at the University of Salamanca (Spain) (seven females, two males; mean age: 27.9 ± 6.9) with a total of 14 isolated (42.9%) and multiple (57.1%) Miller class II and III gingival recessions. After a mean follow-up of 36 months, the mean percentage of root coverage was 80.5% for all treated recessions. Statistically significant differences (p < 0.05), were observed for reduction in recession depth, increased width of keratinized tissue and increased gingival thickness, this being dependent on the Miller class. The esthetic outcome was acceptable, with a final mean esthetic score of 7.4 out of 10. The double lateral sliding bridge flap surgical technique with CTG is an effective procedure for the coverage of isolated and multiple gingival recessions in the anterior mandibular region, as it offers satisfactory esthetic results.

A new digital evaluation protocol applied in a retrospective analysis of periodontal plastic surgery of gingival recessions

This research aimed to develop a new digital evaluation protocol to objectively quantify the volumetric changes of root coverage periodontal plastic surgery when combined with connective tissue graft. Consecutive patients with Cairo recession type 1 (RT1) or Cairo recession type 2 (RT2) were treated. Accurate study models obtained at baseline and follow-ups were optically scanned. Healing dynamics were measured by calculating volume differences between time points. Nineteen patients were treated between December 2014 and January 2019. At 3-month follow-up, root coverage was 95.6% (± 14.5%) with tunnel and connective tissue graft (TUN + CTG) technique, and 88.9% (± 20.5%) with the vestibular incision subperiosteal tunnel access and connective tissue graft (VISTA + CTG) technique. Recession decreased 1.33 (± 0.86) mm and 1.42 (± 0.92) mm, respectively (p = 0.337). At 6-month follow-up, root coverage was 96.5% (± 10.4%) with the TUN + CTG and 93.9% (± 10.3%) with the VISTA + CTG. Recession decreased 1.35 (± 0.85) mm and 1.45 (± 0.82) mm, respectively (p = 0.455). Complete root coverage was achieved in 86.7% (± 0.4%) with TUN + CTG and 70.6% (± 0.5%) with VISTA + CTG. No statistically significant differences were found between techniques. The digital protocol presented proved to be a non-invasive technique for accurate measurements of clinical outcomes. Both techniques reduce gingival recessions, with no statistically significant differences.

Vertically Coronally Advanced Flap (V-CAF) to Increase Vestibule Depth in Mandibular Incisors.

Treatment of gingival recessions affecting mandibular incisors is scarcely documented. Despite a shallow vestibule depth being considered a poor anatomical condition, it has never been measured nor deemed a clinical parameter affecting the outcome of root coverage procedures. This study describes a vertically and coronally advanced flap (V-CAF) + connective tissue graft (CTG) technique to obtain root coverage and increased vestibule depth in the treatment of gingival recessions affecting mandibular incisors. Twenty patients with single gingival recessions were treated. The results showed that V-CAF+CTG is effective in increasing residual vestibule depth and in reducing recession depth. Immediately after surgery, a vestibule-depth increase of 5.9 ± 1.2 mm was reported, which was statistically significant compared to baseline, and it remained stable after 12 months (4.8 ± 1.1 mm). The mean percentage of root coverage was 98.3% ± 5.2% for all treated recessions, and complete root coverage (CRC) was achieved in 90% of cases (18 of 20). V-CAF+CTG could be considered a successful technique in terms of vestibule depth increase and CRC for the treatment of single gingival recessions in the mandibular incisors.

Modified Semilunar Advanced Flap with Connective Tissue Graft Technique for Root Coverage: A Case Report

Modified Semilunar Advanced Flap with Connective Tissue Graft Technique for Root Coverage: A Case Report

Aesthetic‐And patient‐related outcomes following root coverage procedures: A systematic review and network meta‐analysis

Aim of this systematic review (SR) of randomized controlled trials (RCTs) was to evaluate effect of different flap designs and graft materials for root coverage, in terms of aesthetics, patient satisfaction and self-reported morbidity (post-operative pain/discomfort). A comprehensive literature search was performed. A mixed-modelling approach to network meta-analysis was utilized to formulate direct and indirect comparisons among treatments for Root Coverage Esthetic Score (RES), with its individual components, and for subjective patient-reported satisfaction and post-operative pain/discomfort (visual analogue scale (VAS) of 100). Twenty-six RCTs with a total of 867 treated patients (1708 recessions) were included. Coronally Advanced Flap (CAF) + Connective Tissue Graft (CTG) (0.74 (95% CI [0.24, 1.26], p=.005)), Tunnel (TUN) + CTG (0.84 (95% CI [0.15, 1.53]), p=.01) and CAF+Graft substitutes (GS) (0.55 (95% CI [0.006, 1.094], p=.04)) were significantly associated with higher RES than CAF. No significant difference between CAF+CTG and TUN+CTG was detected (0.09 (95% CI [-0.54, 0.72], p=.77)). Addition of CTG resulted in less natural tissue texture (-0.21 (95% CI [-0.34, -0.08]), p=.003) and gingival colour (-0.06 (95% CI [-0.12, -0.03], p=.03)) than CAF. CTG techniques were associated with increased morbidity. Connective tissue graft procedures showed highest overall aesthetic performance for root coverage, although graft integration might impair soft tissue colour and appearance. Additionally, CTG-based techniques were also correlated with a greater patient satisfaction and morbidity.

Tunnel/Pouch versus Coronally Advanced Flap Combined with a Connective Tissue Graft for the Treatment of Maxillary Gingival Recessions: Four-Year Follow-Up of a Randomized Controlled Trial.

Background: The long-term stability after soft tissue graft for covering gingival recession remains a pivotal goal for both patient and periodontist. Therefore, the aim of this study was to compare the four-year outcomes of the coronally advanced flap (CAF) versus the pouch/tunnel (POT) technique, both combined with connective tissue graft (CTG), for gingival recession treatment. Methods: Forty patients were initially randomly assigned to the control group (CAF + CTG; N = 20) and the test group (POT + CTG; N = 20). Clinical outcomes included mean root coverage (MRC) and complete root coverage (CRC), gingival thickness (GT), and keratinized tissue (KT) gain. Esthetic outcomes were also analyzed using the pink esthetic score (PES) and patient-reported outcome measures (PROMs). All outcomes initially assessed at six months were extended to four years post-surgery. Results: No significant differences were observed between the two patient groups in terms of MRC and CRC. At four years, significantly greater GT and KT gain were noted in the POT + CTG group, and tissue texture enhancement was also more prominent in the test group. Conclusions: The POT + CTG technique allows for long-term clinical coverage of gingival recessions comparable to that of the CAF + CTG technique, but it potentially improves gingival thickness, keratinized tissue and esthetic results.

Periosteum eversion technique versus subpedicle connective tissue graft technique for root coverage of gingival recessions: A randomized split-mouth study.

Introduction:The connective tissue graft (CTG) with pedicle flap as subpedicle CTG technique (SPCTGT) is considered the gold standard technique in the treatment of gingival recessions. The aim of this study was to compare periosteum eversion technique (PET) with SPCTGT for root coverage of gingival recessions.Materials and Methods:Ten patients having bilateral gingival recessions of Miller class I and II were selected. The left or right side was randomly assigned into PET group and SPCTGT group. Before and after 1 year of surgery, depth of gingival recession (DGR), width of keratinized gingiva (WKG), width of attached gingiva (WAG), and probing depth (PD) were measured and compared. Pre- and post-groups were compared by paired t-test. Two independent groups were compared by independent Student's t-test. A two-tailed (α =2) P < 0.05 was considered statistically significant.Results:Comparing the pre to post mean of PET and SPCTGT showed decrease (net improvement) in DGR (−5.80 ± 0.42 vs. −4.65 ± 0.39, mean difference = −1.15 ± 0.57, t = 2.02, P = 0.058) and in PD (−1.05 ± 0.12 vs. −0.60 ± 0.12, mean difference = −0.45 ± 0.17, t = 2.64, P = 0.017); and increase (net improvement) in WKG (5.80 ± 0.42 vs. 4.80 ± 0.41, mean difference = 1.00 ± 0.58, t = 1.71, P = 0.104) and in WAG (5.60 ± 0.32 vs. 4.90 ± 0.24, mean difference = 0.70 ± 0.41, t = 1.73, P = 0.101). PET showed 19.8% and 42.9% higher decrease in DGR and PD; and 17.2% and 12.5% higher increase in WKG and WAG, respectively, than SPCTGT.Conclusions:The study found that both the modalities were effective in the management of root coverage of gingival recessions. However, PET was found more effective than SPCTGT.

Evaluation of Color and Width of Attached Gingiva Gain in Two Surgical Techniques: Free Gingival Graft and Connective Tissue Graft Covered By Thin Mucosal Flap, a Clinical Trial.

Statement of the Problem:The periodontal health and marginal stability of gingiva can be negatively affected by a number of dental conditions in association with deficiency of attached gingiva. Purpose:This study aimed to compare the color and width of tissue grafted by two surgical techniques of keratinized gingival augmentation, namely free gingival graft(FGG) and connective tissue graft (CTG) covered by thin mucosal flap . Materials and Method: This clinical trial was performed on 15 adult individuals. The patients showed less than 2mm keratinized gingiva on two different recipient sides. One side was to be treated with CTG as the test group and the other side to be treated with FGG as the control group. The amount of keratinized gingiva before the surgery, size of grafted tissue during the surgery and 6 month after the surgery was documented. Six months after healing, the test and control sides were compared in terms of the width of generated gingiva on both sides, and the color match of the grafted areas with the surrounding gingiva or mucosa. The color of the grafted areas was determined and compared by using both professional evaluation and digital evaluation. Results: In digital evaluation, ∆E (which shows color mismatch) was higher in FGG. In professional evaluation, visual analogue scale (VAS) was used by two blinded periodontists. The mean VAS in FGG was less than CTG. The mean increase of gingival width was higher in CTG. The increased width in CTG technique was more than that in FGG technique. This difference was statistically, but not clinically, significant. Conclusion:Higher ∆E in control side and higher mean VAS CTG both showed better color adaptation of CTG side. FGG can be used in case of increasing keratinized gingiva, vestibular depth, and in patients with low smile line without esthetic concerns. However, using connective tissue in the underlying thin mucosal layer is preferred for gingival augmentation if there are adequate vestibule depth and esthetic concerns, like in maxillary canine.

Autogenous soft tissue grafting for periodontal and peri-implant plastic surgical reconstruction.

This state-of-the-art review presents the latest evidence and the current status of autogenous soft tissue grafting for soft tissue augmentation and recession coverage at teeth and dental implant sites. The indications and predictability of the free gingival graft and connective tissue graft (CTG) techniques are highlighted, together with their expected clinical and esthetic outcomes. CTGs can be harvested from the maxillary tuberosity or from palate with different approaches that can have an impact on graft quality and patient morbidity. The influence of CTGs on soft tissue thickness and keratinized tissue width are also discussed.

Er-Yag Laser Root Preparation During Subepithelial Connective Tissue Graft Procedures.

Areas of gingival recession cause either an esthetic problem and or root sensitivity. Obtaining predictable root coverage has become an important part of periodontal therapy. A deep, long – standing recession promoted by ANUG was treated using subepithelial connective tissue graft technique combined with decontamination of root surface by using Er:YAG laser. Our clinical findigs suggest that this technique is a predictable procedure to treat gingival recession and promote root decontamination.

Clinical efficacy of periosteal pedicle graft with subepithelial connective tissue graft in gingival recession coverage.

Introduction:Correction of gingival recession (GR) involves eliminating the cause of recession and it often requires surgical correction. Subepithelial connective tissue graft (SCTG) technique by Langer and Langer provides excellent esthetics and is considered most predictable in obtaining marginal tissue recession coverage. However, the requirement of a second surgical procedure for harvesting CTG remote from planned site of recession coverage increases the chances of postoperative infection. There is also a limitation in the amount of graft that can be harvested and an increased operative time contributing to patient discomfort.Materials and Methods:Overcoming these difficulties has become possible with the introduction of “periosteal pedicle graft” (PPG). The study is a split-mouth design where patients with bilateral, isolated GR defects were treated using two different surgical techniques, i.e., PPG versus the SCTG in obtaining GR coverage. The objective was to analyze the comparative amount of root coverage and the gain in width of attached gingiva achieved by both the techniques.Results:All the clinical parameters evaluated were comparable between SCTG and PPG when recorded at 6 and 9 months posttreatment.Conclusion:Both techniques produced satisfactory and predictable results. PPG eliminated the need for the 2nd operative site, lesser intraoperative time, and hence, patient comfort was enhanced.

Treatment of multiple recessions with collagen matrix versus connective tissue: a randomized clinical trial

The objective of this study was to determine whether collagen matrix (CM) is an alternative to connective tissue graft technique (CTG) in the treatment of multiple gingival recessions (GR). The indication of CM for the treatment of multiple GR is not yet clear. More studies are needed to better understand this treatment modality, as an alternative to CTG. In this single-blind, split-mouth randomized clinical trial, fifteen patients with multiple Miller class I upper GR were selected and randomly assigned to control group (CTG) or test group (CM). Root coverage (RC) and patient-centered outcomes were evaluated at baseline and after 3, 6, and 12 months. A total of 82 GRs were treated. There was no significant difference regarding GR depth (GRD, primary outcome) between CTG (0.5 ± 0.9 mm) and CM groups (0.6 ± 1.0 mm) (p = 0.225). Percentage of RC was 82.14% in CTG and 77.7% in CM. Both groups demonstrated a gain in keratinized tissue width at 12 months (p < 0.05). Dentine hypersensitivity was effectively reduced in both groups. Postoperative pain was significantly higher in the CTG (p = 0.001). Esthetic satisfaction was high for both groups, with no significant difference (p > 0.05) between groups. After 12 months, both surgical treatments were able to promote RC, and GRD was similar in both CTG and CM groups.

Gingival recession coverage with a modified tunnel connective tissue graft technique – case report

Gingival recessions are a more and more common pathology of multifactorial aetiology. They may affect individual teeth or be generalised. Studies have shown that the incidence of gingival recession increases with age. Recession is accompanied by loss of the connective tissue attachment and exposure of tooth root surfaces, what may lead to tooth hypersensitivity, root caries, non-carious defects, impaired control of the dental plaque and unsatisfactory aesthetic outcomes. &lt;b&gt;Aim.&lt;/b&gt; The aim of the paper was to present treatment of a female patient with advanced gingival recessions in the area of upper canines with a modified tunnel technique, with a free connective tissue graft taken from the palate. &lt;b&gt;Material and methods.&lt;/b&gt; Treatment included a surgical method of gingival recession treatment consisting of a modified tunnel technique, with a free connective tissue graft harvested from the palate that was introduced via a tunnel into the donor site. &lt;b&gt;Results.&lt;b&gt; 2 years after the procedure recession coverage and increased zone of the attached gingiva was observed. &lt;b&gt;Conclusions.&lt;/b&gt; The modified tunnel connective tissue graft technique used to treat the gingival recession allowed to achieve satisfactory aesthetic outcomes and effective elimination of hypersensitivity, and it reduced the risk of tooth caries.

PC071: Connective tissue graft vs. tunnel technique with collagen matrix

PC071: Connective tissue graft vs. tunnel technique with collagen matrix

PC073: Coronally advanced flap combined with connective tissue graft technique for the treatment of deep gingival recession and root coverage: a case report

PC073: Coronally advanced flap combined with connective tissue graft technique for the treatment of deep gingival recession and root coverage: a case report

When Gingival Recession Is Rescued By Periodontal Plastic Surgery: A Clinical Case Report

Gingival recession is the most common mucogingival defect. It is characterized by the exposure of the tooth root surface resulting from displacement of the gingival margin below the cementoenamel junction. The denuded root surfaces compromise dental and gingival aesthetics with dentine hypersensitivity, caries proclivity, cervical abrasion and oral hygiene disability. When deciding root coverage, settled surgical techniques have been proposed and each procedure challenges to expand on limitations of the others. The purpose of this case report is to assess the esthetic correction of localized gingival recession using combined coronally positioned flap with connective tissue graft techniques. Long term evaluation, extended to two years after surgical treatment, is performed. The part of the prophylactic management to prevent potential future recessions is also enhanced. Significant increasing in keratinized and attached gingival tissues and reduction of height and width of recession were obtained. Gain of root coverage was 100% with great improvement in attachment level. Prevention of recession was accomplished and the results were stable after two years follow up. Patient-reported outcomes were satisfaction and esthetic appearance.