Connective Tissue Graft Research Articles

The Effectiveness of Subepithelial Connective Tissue Graft as a Barrier Membrane in Guided Bone Regeneration: A Case Report

The Effectiveness of Subepithelial Connective Tissue Graft as a Barrier Membrane in Guided Bone Regeneration: A Case Report

Modified Dual-Zone Therapeutic Concept of Single Immediate Implants with Bone Augmentation of the Bone Zone and Soft Tissue Augmentation of the Soft Tissue Zone: Technical Report with 3 Cases.

While the addition of a connective tissue graft (CTG) has been found to increase gingival thickness and reduce facial gingival recession in immediate implant placement and provisionalization, it is associated with significant loss of buccal bone thickness. Loss of buccal bone thickness is thought to be related to preparation of the facial CTG recipient site. This technical report presents a modification of the dual-zone therapeutic concept where the bone zone is grafted with bone graft, and the tissue zone is grafted with tuberosity CTG without elevation a facial partial or full-thickness envelope.

VISTA approach in conjunction with enamel matrix derivative, cortico-cancellous bone, and connective tissue graft for periodontal defect surgery: A case series.

The biggest challenge during periodontal regeneration in the anterior region is the prevention of soft-tissue recession. Minimally invasive surgeries, particularly papilla preservation techniques and soft-tissue augmentation, may significantly reduce such postoperative soft-tissue recession. This article presents the vestibular incision subperiosteal tunnel access approach for periodontal regeneration in the anterior region. A subperiosteal tunnel prepared from a single vertical vestibular incision adjacent to the defect is used for debridement, enamel matrix derivative application, defect grafting with cortico-cancellous tuberosity bone, and insertion of the connective tissue graft. Evaluation of six cases with up to 6 years of follow-up showed improvements in all clinical parameters. The probing pocket depth improved from 8.2±0.75 mm initially to 2.7±0.52 mm at follow-up, clinical attachment level improved from 8.5±0.83 mm initially to 2.7±0.52 mm at follow-up, and midfacial gingival recession of 1 mm at two sites was corrected. The papillae were stable at all sites, with an average distance of 4.8 mm from the incisal edge to the papilla tip. This technique seems to be a promising approach for achieving both esthetic and functional goals of periodontal regenerative surgery. However, experience in performing microsurgeries and harvesting tuberosity tissues may be a limitation.

Esthetic evaluation after root coverage with subepithelial connective tissue graft and a collagen matrix: a randomized clinical trial

Objective: To evaluate the esthetics of root coverage procedures in patients with bilateral type 1 gingival recessions who were grafted with a subepithelial connective tissue graft (SCTG) and a xenogeneic collagen matrix (XCM). Material and methods: A randomized, double-blind, controlled clinical trial was carried out to compare Pink Esthetic Score (PES) and Root Coverage Esthetic Score (RES). Three examiners evaluated a sequence of 100 photographs of 25 patients with 50 recessions, at baseline and 6 months after surgeries. The test group was treated with coronally-advanced flap (CAF)+XCM, while the control group was treated with CAF+SCTG. Results: The mean values of RES and PES for CAF+XCM were 8.15±0.5 and 8.52±0.51, respectively; and 8.34±1.12 and 8.92±1.33 for CAF+SCTG. The CAF+SCTG group presented more cases that achieved better scores for Gingival Margin Level (GML) (p < 0.001) and Gingival Margin Contour (GMC) (p = 0.024), while CAF+XCM presented more cases with a better soft tissue texture score (STT) (p < 0.001). Thus, both CAF+XCM and CAF+SCTG promoted improvements in general esthetic appearance after 6 months, with no statistical difference. Conclusions: CAF+SCTG and CAF+XCM improved esthetic outcomes, with no difference between PES and RES, after 6 months.

Xenogeneic collagen matrix vs. connective tissue graft for the treatment of multiple gingival recession: a systematic review and meta-analysis.

The aim of this systematic review (SR) compared the effect of xenogeneic collagen matrix (XCM) vs. connective tissue graft (CTG) for the treatment of multiple gingival recession (MGR) Miller Class I and II or Cairo type I. Five databases were searched up to August 2022 for randomized clinical trials (RCTs) comparing the clinical effects of XCM vs. CTG in the treatment of MGR. The random effects model of mean differences was used to determine reduction of gingival recession (GR), gain in keratinized tissue width (KTW), gain in gingival thickness (GT) and gain in clinical attachment level (CAL). The risk ratio was used to complete root coverage (CRC) at 6 and 12months. 10 RCTs, representing 1095 and 649 GR at 6 and 12months, respectively, were included in this SR. The meta-analysis showed no statistically significant difference in GR reduction, KTW gain GT gain or CAL gain between groups at 6months. However, at 12months of follow-up, differences favoring the control group were observed (p < 0.05). CRC was significantly higher in the CTG group at 6 and 12months. Regarding dentine hypersensitivity (DH), no statistically significant differences were found between groups at 6 and 12months of follow-up (p < 0.05). At 12months, CTG showed significantly superior clinical results in the treatment of MGR: however, this difference was not observed in the decrease of DH.

Patient Reported Outcome of Palatal Donor Site After Harvesting Connective Tissue Graft With or Without Platelet-rich Fibrin: A Prospective Clinical Study

Aim: To evaluate the palatal donor site after harvesting connective tissue graft with or without platelet-rich fibrin (PRF). Material and Methods: Forty-two patients requiring connective tissue grafting were randomly divided into two groups: the experimental palatal donor site ( n = 21) received PRF before suturing, and the control palatal donor site ( n = 21) was sutured without any PRF. Results: Among 42 enrolled patients requiring connective tissue grafting, 34 patients completed the study. After 10 days, there was an increase in the average thickness of the palatal surgical test site in PRF-treated patients, whereas it decreased in non-PRF-treated patients. Patients’ response and acceptance for the surgical treatment modality in terms of Patient Comfort Score (PCS) and Patient Appearance Score (PAS) showed less discomfort and better/pleasing appearance in the experimental group after treatment as compared with the control group. “Absolute contour match” of the healing lesion to adjacent mucosa was observed in 76.5% of experimental sites, and no “absolute contour match” was observed with the adjacent non-surgical tissue in the control group, whereas, at 3 and 12 weeks, a 100% “absolute match” with the adjacent tissue was observed for all esthetic parameters in both groups. Conclusion: PRF usage at the donor site seems to be a simple less-invasive approach of high significance resulting in more accelerated physiological healing phenomenon and better early healing response.

Modified interproximal tunneling technique with customized sub-epithelial connective tissue graft for gingival papilla reconstruction: report of three cases with a cutback incision on the palatal side

BackgroundGingival papilla defects, which cause an unpleasant appearance and involve the upper anterior teeth, may be triggered by several factors. Several noninvasive and invasive techniques have been proposed for gingival papilla reconstruction. The combination of interproximal tunneling and customized connective tissue grafts (CTGs) has shown promise in papilla augmentation. However, due to the narrowness and limited blood supply of the gingival papilla, the long-term outcomes of these techniques remain unpredictable. Therefore, achieving tension-free coronal advancement of the interdental papilla and proper placement of the CTG is crucial for successful long-term outcomes and could provide widely applicable methods for papilla augmentation.Case reportIn this study, we enrolled three patients with gingival papilla defects in the maxillary anterior teeth. For reconstruction, we proposed a modified interproximal tunneling (MIPT) technique combined with a CTG. A crucial modification based on previous studies involved adding a cutback incision to the base of the palatal vertical incision, resulting in tension-free healing. Additionally, the CTG was sutured upright to further enhance the height of the gingiva papilla. To evaluate the efficacy of the MIPT technique, the clinical parameters—including the Jemt papilla index and the distance from the tip of the papilla to the interproximal contact point—were examined using a periodontal probe (UNC15, Hu-friedy) at baseline and 12 months after surgery. All three patients achieved satisfactory papilla reconstruction 12 months after the surgery. These three cases were used to evaluate the efficacy of the MIPT technique combined with the customized CTG. An average increase in the Jemt papilla score from 1.6 to 2.8 and a reduction in the distance from the papilla tip to the contact point of adjacent teeth from 2 mm to 0.08 mm were observed 12 months after surgery.ConclusionThe preliminary results confirmed that this technique holds promise for gingival papilla augmentation between tooth/tooth or tooth/implant.

Comparison of Clinical Efficacy of Bio-Resorbable Xenogeneic Peritoneal Membrane with Connective Tissue Graft in the Management of Gingival Recession Defects: A Randomized Controlled Clinical Trial.

This randomized controlled trial was aimed to determine the clinical efficacy of xenogeneic collagen membrane derived from porcine peritoneum (XCM) in combination with a coronally advanced flap (CAF) in the management of gingival recession defects and to compare the outcomes to those of connective tissue graft (CTG). 12 systemically healthy individuals presenting with 30 isolated/multiple Cairo's RT 1/2 gingival recession defects in maxillary canines and premolars, were randomly treated either with CAF+XCM or CAF+CTG. Recession height (RH), gingival biotype (GB), gingival thickness (GT), width of keratinized gingiva (WKG) and attached gingiva (WAG) were recorded at baseline, 3, 6 and 12 months. Patient perception for pain, esthetics and modification of root coverage esthetic score (MRES) were also documented. From baseline to 12 months, both groups showed a significant reduction in mean RH (CAF+CTG: 2.73±0.79mm to 0.33±0.61mm and CAF+XCM: 2.73±0.88mm to 1.20±0.77mm). At 12 months, CAF+CTG sites had a MRC of 85.60±28.74%, whereas CAF+XCM sites had a MRC of 55.13±31.22%. CAF+CTG treated sites had significantly better outcomes, with greater number of sites achieving complete root coverage (n=11) and higher MRES scores than porcine peritoneal membrane group (P<0.05). Int J Periodontics Restorative Dent. doi: 10.11607/prd.6232.

Immediate Tooth Replacement in the Esthetic Zone with the Socket Shield Technique and a Novel Body-Shift Implant: A Pilot Study with Up to 3 Years of Follow-up.

Successful rehabilitation of the anterior maxilla remains a challenge, primarily due to postextraction ridge collapse, which can lead to gingival recession and a nonesthetic appearance. The socket shield technique presents a viable alternative for immediate dental implant placement in the esthetic zone. This pilot study aimed to evaluate the survival, complication rates, and marginal bone loss around body-shift implants placed in fresh extraction sockets with the socket shield technique to replace maxillary incisors. After socket shield preparation, 14 hopeless incisors were extracted and immediately replaced by a body-shift implant (Inverta, Southern Implants) at baseline. Patients were followed up for 12 to 39 months (mean: 18.1 ± 8.2 months). The average age was 52.3 ± 16.9 years, and the survival rate was 100%. One socket shield presented minimal internal exposure that was successfully treated with a connective tissue graft. The mean PES score was 12.9 ± 1.2. Mean interproximal marginal bone loss was -0.4 ± 0.5 mm. Body-shift implants can be a promising alternative for immediate tooth replacement combined with the socket shield technique. The superior esthetic outcomes remained stable, suggesting that the extra space created by the narrow cervical portion of the implant is beneficial for preserving the alveolar bone and limiting internal shield exposure.

Root coverage using modified tunneling technique with acellular dermal matrix for treatment of gingival recession associated with orthodontic treatment: A case report

Background: Gingival recession has a number of causes, including orthodontic therapy. The degree and extent of gingival recession and orthodontic therapy are strongly correlated. Care must be taken in choosing the best soft tissue grafting technique. Development of a number of new and improved surgical techniques, including the modified tunneling technique. Case Management: A-24-year-old female patient came to Periodontic Clinic Dental Hospital of Airlangga University with a chief complain of gingival recession in mandibular central incisors since 6 months ago. The patient complained about dental sensitivity. The dental history revealed that she had undergone fixed orthodontic therapy for 7 years. She revealed the fixed orthodontic appliance was put off since 8 months ago. The patient concern about her appearance and aesthetic problem. Gingival recession on buccal surface tooth 31 and 41 extending 1,5-2 mm apical of the incisors was found in clinical assessment. This case classified as Miller class III. The doctor planned root coverage procedure using modified tunnel technique. Acellular dermal matrix (Surederm®) was chosen as a gingival graft. Discussion: Creating a "tunnel" through the buccal mucosa to treat gingival recession enables coronal repositioning of the soft tissue with predictable root coverage and a pleasing appearance. Tissue graft implantation is made possible by a horizontal incision. Conclusion: In brief, root coverage using modified tunnel technique is effective and predictable treatment modality. Comparing with other root coverage method it give quite satisfying result. The use of Acellular Dermal Matrix (ADM) considered as an alternative to Connective Tissue Graft (CTG).

Preserving periodontal tissue in the treatment of a large peripheral ossifying fibroma: a case study.

Peripheral ossifying fibroma (POF) is a reactive, benign gingival enlargement. Its etiology is not fully known. It can be seen in many different sizes in the mouth. The histopathological appearance of POF is mineralized tissue and fibrous proliferation. All relevant soft and hard tissues must be removed to prevent recurrence. Periodontal tissue remaining after excision is important for tooth preservation. With large lesions, the loss of healthy periodontal tissue is also large. Periodontal surgical approaches are important to preserve the remaining periodontal tissue. The positive effects of autogenously obtained titanium-prepared platelet-rich fibrin (T-PRF) and connective tissue graft (CTG) on soft tissue are well known. A 34-year-old woman presented with a fibrous and pedunculated gingival mass in the upper left canine premolar region. The operation was performed with complete excision of the lesion down to the bone along with the surrounding healthy tissue. Periodontal treatment of the large defect created after excision of a large POF lesion was performed with laterally positioned flap, CTG and T-PRF. The periodontal tissue and defect were noted to heal in a healthy manner at the 6-month follow-up. POF is a benign lesion; however, it has a high recurrence rate. Complete elimination of the lesion is crucial to prevent recurrence. Periodontal surgical methods and biomaterials applied after surgical excision are significant to maintain the periodontal health of the remaining teeth and tissues.

Doppler ultrasonographic evaluation of tissue revascularization following connective tissue graft at implant sites.

To assess the Doppler ultrasonographic tissue perfusion at dental implant sites augmented with connective tissue graft (CTG) using coronally advanced flap (CAF) or tunnel technique (TUN). Twenty-eight patients presenting with isolated healthy peri-implant soft-tissue dehiscence (PSTD) were included in this randomized clinical trial. PSTDs were treated with either CAF + CTG or TUN + CTG. Ultrasound scans were taken at baseline, 1 week, 1 month, 6 months and 12 months. Tissue perfusion at the mid-facial, mesial and distal aspects of the implant sites was assessed by colour Doppler velocity (CDV) and power Doppler imaging (PDI). Early vascularization of the graft and the flap at 1 week and at 1 month were evaluated via dynamic tissue perfusion measurements (DTPMs), includingflow intensity (FI), mean perfusion relief intensity (pRI) and mean perfused area (pA). Regression analysis did not reveal significant differences in terms of mid-facial CDV and PDI changes between CAF and TUN over 12 months (p > .05), while significant differences between the two groups were observed at the interproximal areas (p < .001 for both CDV and PDI changes). Higher early DTPMs were observed at the TUN-treated sites in terms of mean FI of the graft (p = .027) and mean FI (p = .024) and pRI of the flap (p = .031) compared with CAF-treated sites at 1 week. Assessment of the FI direction showed that CTG perfusion at 1 week and at 1 month mainly occurred from the flap towards the implant/bone. Early tissue perfusion outcomes were found to be associated with the 12-month mean PSTD coverage and mucosal thickness gain. Doppler ultrasonography shows tissue perfusion changes occurring at implant sites augmented with CTG. The main differences in tissue perfusion between CAF and TUN were observed at the interproximal sites, with early perfusion associated with clinical and volumetric outcomes at 12 months.

Pre- and Postoperative Evaluation of Immediate and Early Implant Placement in Esthetic Areas with Pre-Extraction Facial Dehiscence: A Retrospective Clinical Study.

The clinical requirement for a good esthetic result for immediate implant placement is the absence of dehiscence in the anterior facial alveolar bone. In the presence of dehiscence, it is recommended to use a connective tissue graft in addition to immediate implant placement or to change to early implant placement. However, the literature focusing on dehiscence is scarce, and the influence of different placement times and combined use of connective tissue graft on postoperative esthetics in cases with dehiscence is unclear. Therefore, we quantitatively evaluated the pre-extraction dehiscence morphology and postoperative changes in the facial tissue of implants in three groups: immediate implant placement (Group I), immediate implant placement with connective tissue graft (Group IC), and early implant placement (Group E). To this end, 52 implants were obtained (20 in Group I, 16 in Group IC, and 16 in Group E). A wider dehiscence increases the risk of soft tissue regression, which was one reason for choosing early implant placement. A combination of immediate implant placement and connective tissue graft, or early implant placement, tended to result in less soft tissue regression due to the thicker postoperative facial soft tissue volume.

Allogenic Acellular Dermal Matrix and Xenogeneic Dermal Matrix as Connective Tissue Graft Substitutes for Long-Term Stability Gingival Recession Therapy: A Systematic Review and Meta-Analysis.

Connective tissue graft (CTG) serves as a gold standard for gingival recession therapy. Yet the availability of CTG is limited, and it increases patient morbidity. Allogenic acellular dermal matrix (AADM) and xenogeneic dermal matrix (XDM) have been proven to be effective substitutes of CTG although the long-term stability is unclear. The aim of this study was to analyze the long-term stability outcome of gingival recession therapy using AADM and XDM compared to CTG. This study follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were extracted independently from several online databases (PubMed, Scopus, and Embase). Five of 233 publications were included for final qualitative analysis and meta-analysis focusing on the mean difference of clinical parameters such as recession depth (RD), recession width (RW), probing depth (PD), clinical attachment loss (CAL), tissue thickness (TT), keratinized tissue width (KTW), and mean root coverage (MRC). Meta-analyses of RD, RW, CAL, TT, KTW, and MRC display an overall mean of 0.2 mm (95% confidence interval [CI]: -0.45 to -0.05), 0.29 mm (95% CI: -0.65 to 0.08), 0.2 mm (95% CI: -0.69 to 0.29), 0.25 mm (95% CI: -0.53 to 0.03), 0.26 mm (95% CI: -0.5 to 0.02), and 9.19% (95% CI: -13.95 to -4.43]), respectively, favoring the CTG. PD was the only parameter that favored the AADM or XDM with an overall mean of 0.03 mm (95% CI: -0.05 to 0.11). In all, if the long-term stability is the goal, the CTG is considered superior for gingival recession therapy. However, if it is contraindicated, the AADM and XDM might be considered as alternatives.

Considerations for Selecting Root Coverage Techniques in the Anterior Mandible.

The anterior mandible is the most challenging anatomical site for performing periodontal plastic surgeries. Increased demands for optimal root coverage and esthetic outcomes contribute to the development of pedicle flap-based surgical solutions, in contrast to the predominantly used free gingival graft. The aims of this study were to (1) summarize the current literature to identify the mostused techniques, indications, and their efficacy, and (2) provide a decision table for surgeons to navigate through the selection of appropriate techniques. Four main approaches were identified: free gingival graft, lateral sliding, tunneling, and coronally advanced flap. The flap approaches are mostly combined with a connective tissue graft. The decision table considers the patient's chief complaint, local anatomical factors, and technique sensitivity. The table provides a framework for supporting an evidence-based selection of surgical techniques and for studying novel methods to achieve predictable root coverage in the anterior mandible.

A new volume-stable collagen matrix (VCMX) to treat single gingival recession associated with partially restored non-carious cervical lesions: a case series.

Collagen matrixes have been developed as possible connective tissue graft substitutes to overcome patient discomfort, undesired palatal healing, and the limited amount of donor tissue. The aim of this case series is to assess a coronally advanced flap (CAF) with a new volume-stable collagen matrix (VCMX) to treat single gingival recession (GR) associated with partially restored non-carious cervical lesions (NCCL). Twelve patients diagnosed with single GR RT1 + NCCL (B+) were included in this study and received a restorative - partial resin composite with apical margin 1 mm beyond the estimated cementoenamel junction (CEJ) - and a surgical approach - CAF+VCMX. Clinical and patient-centered assessments were recorded at baseline and 6 months postoperatively from ten patients. Significant recession reduction (RecRed:2.1mm), clinical attachment level gain (CAL:1.34mm), and combined defect coverage (CDC) of 51.67% were observed at 6 months. The estimate root coverage (RC) was 69.48%, obtained using the estimated CEJ. No difference in keratinized-tissue width (KTW) was observed over time. A gain in gingival thickness (GT) of 0.42 mm was observed after 6 months (p=.002) and an improvement in patient satisfaction due to better esthetics (p<.001). Within the present study's limits, CAF plus VCMX provided significant improvement in treating single GR combined with partially restored NCCL (B+).

Comparative analysis of xenogeneic collagen matrix and autogenous subepithelial connective tissue graft to increase soft tissue volume around dental implants: a systematic review and meta-analysis

ObjectiveThe gold standard for a soft tissue augmentation around implants is a subepithelial connective tissue graft (CTG), but the xenogeneic collagen matrices (XCM) started to be used as an alternative. This systematic review aimed to assess the effectiveness XCM in comparison to CTG for the increasing the thickness of the soft tissue around implants.DataAll studies included at least two parallel groups comparing the use of CTG and XCM with a minimum follow-up of 3 months. As the primary outcome, the amount of soft tissue thickness gain after soft tissue augmentation with XCM or CTG was assessed. Secondary outcomes were clinical and patient-related outcomes; evaluation of aesthetic outcomes, patient-reported outcomes measures (PROMs) and complications. Eligible studies were selected based on the inclusion criteria. Meta-analysis was applied whenever possible. The quality of the evidence of studies including in meta-analysis was assessed using the GRADE approach.SourceA systematic literature search up to January 2022 was conducted using the following electronic databases: PubMed (MEDLINE), Scopus, Cochrane Library, LILACS, eLIBRARY.RU. Unpublished researches, the gray literature, nonprofit reports, government studies and other materials were reviewed electronically using an EASY search. An additional manual search was carried out in November 2022.Study selectionOf the 1376 articles from the initial search, 8 randomized controlled trials (RCTs) (306 patients and 325 implants) were included in this systematic review, and 7 studies were part of the meta-analysis. Meta-analysis revealed that XCM is less effective than the CTG in increasing soft tissue thickness around dental implants. However, XCM also provides soft tissue thickness gain and can be recommended for use in various clinical situations.Clinical significancePrevious systematic reviews and meta-analyses have shown that autologous grafts are more effective than collagen matrices in increasing soft tissue thickness, however, the latter can be used as an alternative. Studies included in previous systematic reviews varied in design, which could lead to limitations. The present systematic review and meta-analysis includes for the first time only randomized controlled clinical trials with collagen matrix of xenogeneic origin in the test group. Tight eligibility criteria were established, and the main parameter studied was soft tissue thickness. It was found that xenogeneic collagen matrix is effective for increasing soft tissue thickness around dental implants, however, the results obtained using an autogenous connective tissue graft are superior.

Anatomy-driven complexity classification for soft-tissue tunneling procedures.

The tunnel technique (TUN) preserves the integrity of the papilla by creating envelope flaps that allow for the insertion of a connective tissue graft, and/or biomaterials. (1) A comprehensive overview of tunneling flap procedures in the treatment of gingival recessions (GRs) for soft tissue coverage is presented and (2) A classification system for soft and hard tissue anatomy of GR sites which may aid the clinician in determining the surgical complexity is being introduced. A novel clinical classification system is proposed to illustrate complexity levels determined by soft and hard tissue anatomy of GR sites such as the mucogingival junction proximity to the gingival margin, bone morphotype, and mucosal margin thickness. TUN is highly effective in treating single/multiple GRs. Its limitations are related to variability in surgical site anatomy and operator expertise. A classification system based on anatomical soft and hard tissue variations has been proposed to help identify complexity levels encountered during tunneling procedures. Site-related factors directly impact the surgical variables related to tissue trauma, flap tension, soft tissue management, muscle pull, and wound stability during the healing of gingival recessions (GRs). The achievement of expedited and favorable wound healing is crucial to obtaining quantitative and qualitative success in the treatment of GR and the long-term stability of root coverage. A classification system based on anatomical soft and hard tissue variations has been proposed to facilitate tunneling procedures while respecting surgical principles.

Mixed-Thickness Tunnel Access (MiTT) through a Linear Vertical Mucosal Incision for a Minimally Invasive Approach for Root Coverage Procedures in Anterior and Posterior Sites: Technical Description and Case Series with 1-Year Follow-Up.

The goal of this article was to introduce a new root coverage (RC) technique, the mixed-thickness tunnel access (MiTT) technique, which approaches a full-split design and intends to augment soft tissues coronal to the gingival margin. It was shown step-by-step, and the results were presented in a case series. Healthy individuals (non-diabetics) and non-smokers with gingival recession (GR) type 1 or 2 (RT1 or RT2) were included. After evaluation, prophylaxis was performed 14 days before the surgical procedure. During the surgical appointment, one or two vertical incision(s) on the mucosa (around 1-2 mm apical to the MGJ), lateral to the papilla base, was/were performed after anesthesia. Initially, there was a partial incision to detach the mucosa of the muscles (split design). It was permitted (but not mandatory) to perform intrasulcular incisions. Through the vertical incision, internally, subperiosteal access from the MGJ toward the gingival margin (coronally) was performed to create a full-thickness tunnel. Then, communication from the vertical incision with the gingival sulcus and the papilla base occurred, keeping the papilla tip intact. A connective tissue graft was harvested and inserted through the linear incision or intrasulcularly. There were interrupted sutures. An adjunctive material may be applied (e.g., Endogain). The root coverage was measured using a periodontal probe and considered fully covered when the gingival margin was 1 mm coronal to the cementum-enamel junction (CEJ). Nine healthy individuals (seven females and two males) aged 19 and 43 were enrolled. They were treated following the MiTT steps. Four cases had a single GR; two patients had two teeth involved; and three others had three or four GR. There were seven cases of RT1 and two RT2. All RT1 cases achieved 100% RC, while the mean RC obtained for RT2 was around 80%. The MiTT technique can be considered a more straightforward approach for minimally invasive surgical techniques, which is a feasible option to treat RC with a high success rate, predictability, and esthetic preservation. Therefore, there is a technical sensitivity to performing the full-split design procedure.

Long-term stability (21-30 years) of root coverage outcomes using sub-epithelial connective tissue grafts at single or multiple gingival recessions: A longitudinal case series.

To evaluate outcomes and predictive factors for the long-term stability of root coverage using a sub-epithelial connective tissue graft. One-hundred and two healthy subjects (221 gingival recessions, GRs) were treated from 1987 to 1996. Keratinized tissue width (KTW), GR depth (RD), GR width (RW) and GR area (RA) were evaluated at baseline (M0) and at 1 month (M1), 1 year (M2), 11 years (M3), 21 years (M4) and 27 years (M5) after surgery. Primary outcomes consisted of complete root coverage (cRC) and relative dimensional changes in recession depth (measured in mm [c%-RD]), recession width (measured in mm [c%-RW]) and recession area (measured in mm2 [c%-RA]). cRC was 88.7% at 1 year (M2), 59.8% at M3, 44.4% at M4 and 51.9% at M5. Average c%-RD was 95.2% at 1 year, 81.9% at M3, 71.5% at M4 and 81.7% at M5. KTW increased after surgery and over time and was positively correlated with favourable outcomes. Increased baseline RA was associated with less favourable clinical outcomes. The sub-epithelial connective tissue graft is effective in the treatment of GRs and facilitates long-term stability of clinical outcomes. Wider baseline RA was a strong predictor of unfavourable short- and long-term RC outcomes.