Free Gingival Graft Procedures Research Articles

The role of periodontal plastic surgery in the aesthetic management of localized gingival overgrowth

The localized gingival overgrowths are often a broad clinical expression of an inflammatory response that occurs against the long-standing irritation and/or chronic trauma in the affected gingival site. These reactive gingival overgrowths have a high inclination for the anterior maxillary region. Management of such a lesion is more challenging in the anterior region due to an unaesthetic outcome after surgical excision. Various surgical procedures have been applied for the management of post-excisional unaesthetic mucogingival complications. The free gingival graft (FGG) procedure is an excellent and predictable surgical approach in the root coverage aesthetic procedures. The aesthetic outcome can be enhanced if the periodontal plastic surgical procedure is combined with excisional procedures at the same visit. The purpose of the present case report is to discuss and management of peripheral ossifying fibroma (POF) by combining immediate excision and an FGG for coverage of gingival defect for the best functional and aesthetic outcome. Keywords: Aesthetic, Free gingival graft, Periodontal plastic surgery, Peripheral ossifying fibroma, Reactive gingival lesions.

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

BACKGROUNDGingival recession is a frequent issue encountered by both the clinician and the patient. This study was aimed to assess the predictability of the free gingival graft as a single step procedure in terms of root coverage and aesthetics in Miller Class I and II mandibular gingival recession. METHODSTen patients (4 males, 6 females) aged 25-30 years with a total of 12 mandibular sites having Miller class I and II recession were selected. All recession sites were treated with single step free gingival graft procedure. Clinical parameters like recession depth, recession width, width of attached gingiva, probing depth and clinical attachment level were recorded at baseline, 6 and 9 months. Visual analog score at 1, 6 and 9 months postoperatively was provided. RESULTSThere was a reduction in mean recession depth from 3.66±1.20 to 0.91±0.99 mm suggesting coverage of 82% over a period of 9 months. There was statistically significant gain in clinical attachment level and width of attached gingiva. Aesthetically, it was acceptable by patients as measured by visual analog scores. CONCLUSIONFree gingival graft as a single step procedure is acceptable in terms of root coverage and aesthetics.

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

Gingival recession is a frequent issue encountered by both the clinician and the patient. This study was aimed to assess the predictability of the free gingival graft as a single step procedure in terms of root coverage and aesthetics in Miller Class I and II mandibular gingival recession.Ten patients (4 males, 6 females) aged 25-30 years with a total of 12 mandibular sites having Miller class I and II recession were selected. All recession sites were treated with single step free gingival graft procedure. Clinical parameters like recession depth, recession width, width of attached gingiva, probing depth and clinical attachment level were recorded at baseline, 6 and 9 months. Visual analog score at 1, 6 and 9 months postoperatively was provided.There was a reduction in mean recession depth from 3.66±1.20 to 0.91±0.99 mm suggesting coverage of 82% over a period of 9 months. There was statistically significant gain in clinical attachment level and width of attached gingiva. Aesthetically, it was acceptable by patients as measured by visual analog scores.Free gingival graft as a single step procedure is acceptable in terms of root coverage and aesthetics.

Evaluation of Patient Discomfort at the Palatal Donor Site Following Free Gingival Graft Procedures: A Randomized Controlled Clinical Trial

Background and aims. The purpose of this study was to compare the effects on patients’ discomfort of four different protective methods for donor sites after free gingival graft (FGG) surgery. Materials and methods. This study compared the effects of four different covering methods on discomfort (pain, chewing, speaking, appearance) of patients at the donor site. This study included 4 groups: Group A, periodontal dressing (PD); group B, Essix retainer, group C, modified Essix retainer and group D, modified Hawley retainer. A visual analog scale (VAS) was used to measure the experienced discomfort. Results. The mean VAS scores for pain were higher in group A compared to those in groups with retainers for both assessments, but there was only statistically significance at T1 (P>0.05). While bleeding was significantly more common in group A than in the other groups at T1 (after one week) and T2 (after two week) (P<0.05), the differences between groups B, C, and D were not significant (P>0.05). The present study showed that speaking and appearance VAS scores in the PD group were lower than those in groups with retainers (P<0.05). Conclusion. The complaints about the donor site after FGG surgery might decrease with the use of coverage techniques.

Effect of Topical Erythropoietin (EPO) on palatal wound healing subsequent to Free Gingival Grafting (FGG)

Free gingival grafting, the most predictable technique to increase the keratinized gingiva, leaves an open wound on the palate and the resulting discomfort during the healing phase is a significant concern. This study was intended to evaluate the effect of topical erythropoietin on healing of the donor site. Twelve patients lacking an attached gingiva at two sites in the mandible were included. In the test group, 1 mL of gel containing erythropoietin at a concentration of 4,000 IU mL-1 was applied to the donor site, whereas the control group was treated with 2 mL of the gel alone. On the second day after surgery, the same procedure was repeated. H2O2 was used to evaluate the amount of epithelialization. Clinical healing was compared using photographs and direct examination. The EPO group showed significantly better keratinization only on day 21. Comparison of clinical healing based on direct examination revealed significantly better healing in the test group on day 28. Furthermore, inflammation in the test group was lower than in the control group on the same day. Topical application of EPO improves palatal wound healing during the third and fourth weeks after free gingival graft procedures.

PC100: Increasing the width of keratinized attached gingiva around dental implants using free gingival graft procedure: case series

PC100: Increasing the width of keratinized attached gingiva around dental implants using free gingival graft procedure: case series

Evaluation of the effect of EDTA on root coverage at free gingival graft procedure

Background: The present study has been designed to compare the effect of root surface biomodification with EDTA for the treatment of buccal gingival recession with free gingival graft.
 Materials and methods: This randomized controlled parallel clinical trial, 34 patients of 40 existing tooth Miller Class I and Class II gingival recession were treated with free gingival graft (FGG). Forty teeth with recession were assigned randomly to receive the free gingival graft with or without the application of an EDTA gel. Pre-treatment (Day 0) and post-treatment 3. and 6. months gingival recession height(GRH), gingival recession width(GRW), probing depth (PD), clinical attachment level(CAL) and width of keratinized tissue WKT were measured.
 Results: In FGG+EDTA group statistically significant changes from baseline were found GRH decreased from 4.7±1.5 mm to 1.3±1.2 and WKT increased from 0.9 ± 0.9 mm to 5.5±1.8 mm. Also in FGG group, GRH decreased from 4.6±1.3 mm to 1.3±1.2 mm and WKT increased from 0.9 ± 0.7 mm to 5.4±1.5 mm. For FGG and FGG+EDTA, the average root coverage 74.14% and 69.26% was found.
 Conclusion: In the light of these data obtained with the root surface biomodification agent EDTA have no beneficial effect for root coverage. In the light of these data obtained with the root surface biomodification agent EDTA have no beneficial effect for root coverage.
 Keywords: Gingival recession, free gingival graft, EDTA, root coverage

Platelet-Rich fibrin as palatal bandage: A case report

Introduction PRF [Plasma-rich fibrin] consists of numerous growth factors and platelet cytokines that promote faster wound healing. The use of PRF bandage on donor site in FGGs [free gingival graft procedures] can significantly reduce morbidity and accelerate healing. The aim of the presented case report is to document the contribution of PRF in the healing of FGG donor site.Method and MaterialPRF was prepared and compacted as a dressing on the palatal wound. Post-operative follow-up was done every week for 1 month.Results and DiscussionIt was observed that wound healing was superior and accelerated compared to conventional FGG. Complete wound healing was observed in 2 weeks. The patient reported minimal pain during first 2 days post-operatively.Owing to the promising results delivered, a PRF palatal bandage is an efficacious method to safeguard the raw wound engendered as a result of FGG remarkably alleviating discomfort afflicted patients.

Topical simvastatin gel as a novel therapeutic modality for palatal donor site wound healing following free gingival graft procedure

Objective: Autogenous soft-tissue grafting is a commonly used procedure nowadays in dentistry. However, the prolonged healing time needed for the donor site leads to increase the patient’s pain and discomfort. Statin has been observed to be beneficial in reducing bacterial burden, improving epithelization and wound healing. The aim of this study was to evaluate intra-oral topical application of simvastatin/chitosan gel (10 mg/mL) over the palatal donor site following free gingival graft (FGG) procedure.Material and methods: Subjects indicated for FGG procedure were divided into four groups. Group I: Simvastatin suspension (S), group II: simvastatin/chitosan gel (SC), group III: chitosan gel (C), group IV: petroleum gel (P). Treatment was applied three times/day for the following 7 days. Wound healing was evaluated at day 3, 7 and 14 post-surgery. A visual analogue scale (VAS) was used to measure the experienced discomfort at 1, 3, 5, 7 and 14 days.Results: Statistical significant reduction in wound-healing scores was observed after 3 and 7 days for group II compared to other groups (p = .015). A significant reduction was also observed in VAS score for group II compared to other groups at day 1, 3, 5 and 7.Conclusion: Topical application of S/C gel could be used as a novel therapeutic modality that improved healing and reduced pain in the palatal donor site following FGG procedure.

Clinical Outcomes of Comparing Soft Tissue Alternatives to Free Gingival Graft: A Systematic Review and Meta-Analysis

ObjectivesThis systematic review and meta-analysis aimed to compare clinical outcomes and width of keratinized tissue (KT) around teeth, following the soft tissue alter- natives and free gingival graft (FGG) procedures. The specific graft materials that were explored were extracellular matrix membrane, bilayer collagen membrane, living cellular construct, and acellular dermal matrix. MethodsFour different databases were queried to identify human controlled clinical trials and randomized controlled clinical trials that fulfilled the eligibility criteria. Relevant studies were identified by 3 independent reviewers, compiling the results of the electronic and handsearches. Studies identified through electronic and handsearches were reviewed by title, abstract, and full text using Covidence Software. Primary outcome in the present study was change in the width of KT. Results of the included studies were pooled to estimate the effect size, expressed as weighted mean differences and 95% confidence interval. A random-effects model was used to perform the meta-analyses. ResultsSix hundred thirty-eight articles were screened by title, 55 articles were screened by abstracts, and 34 full-text articles were reviewed. Data on quantitative changes in width of KT were provided in 7 studies. Quantitative analyses revealed a significant difference in changes in width of KT between patients treated with soft tissue alternatives and patients treated with FGGs (P < .001). The weighted mean difference of changes in the width of KT was 21.39 (95% confidence interval: 21.82 to 20.96; heterogeneity I 5 70.89%), indicating patients who were treated with soft tissue alternatives gained 1.39 mm less KT width compared with the patients who received free gingival graft. ConclusionsBased on the clinical outcomes, the results of this systematic review and meta-analysis showed that soft tissue alternatives result in an increased width of KT. Patients in the soft tissue alternatives group obtained 1.39 mm less KT compared with those in the FGGs group.

Surgical diode laser excision for cellular fibroma

The use of lasers in periodontal treatment has been well documented over the past 10 years. Lasers can be used for initial periodontal therapy and surgical procedures. When used in deep periodontal pockets with associated bony defects, the laser not only removes the diseased granulation tissue and associated bacteria but also it promotes osteoclast and osteoblast activity, often resulting in bone regrowth. Laser is effectively used to perform gingivectomies, gingivoplasties, free gingival graft procedures, crown lengthening, operculectomy, pocket disinfection, and many more. Gingival depigmentation using laser ablation has been recognized as an effective, pleasant, and reliable technique. In terms of esthetic dentistry, the use of the Erbium laser in crown lengthening in the anterior has created an entirely new dimension in smile design.

ALTERNATIVE APPROACH IN THE TREATMENT OF A GINGIVAL CLEFT ASSOCIATED WITH LABIAL FRENULUM. A 3-YEAR FOLLOW-UP. (Case Report)

INTRODUCTION: The term Gingival cleft refers to a fissure in the gingival tissues and is usually caused by traumatic oral hygiene, abnormal frenula, trauma from occlusion, orthodontic, or pierce related trauma. Gingival clefts are classified depending on the extent of the inclusion of the gingival thickness into red and white. The recommended treatment approach for the incomplete white clefts is the gingivectomy of the affected keratinized tissue followed by a coronally advanced flap for the root coveradge, while the complete white clefts are treated with a laterally moved, coronally advanced flap, or a free gingival graft procedure. OBJECTIVE: This report presents a case with a spontaneous healing of an incomplete gingival cleft associated with a maxillary labial frenulum after an alternative frenuloectomy approach. METHODS: M.G. (45) with a localized chronic periodontitis, an abnormal papillary maxillary frenulum and an incomplete white cleft on the marginal gingiva of the left central incisor. An alternative frenuloectomy approach combined with a free gingival graft was selected for the correction of the abnormal frenulum. RESULTS:On the sixth month after the surgical procedure an almost complete recovery of the gingival margin was observed.The result at the third year demonstrates a stable gingival margin with a complete tissue recovery. CONCLUSION: The applied combined surgical approach led to a complete gingival recovery of the incomplete white gingival cleft without the commonly used gingivectomy and CAF. Further research is recommended to clarify the adjunctive benefits of the FGG in patients with gingival clefts associated with abnormal frenula.

Root esthetic score (RES) comparisons of FGG and PE-FGG procedures in Miller class II and III recessions in mandibular anterior teeth

Objective: Free gingival graft (FGG) is frequently chosen for the treatment of recessions in mandible. Mandibular anterior teeth are the most affected teeth and major causes of the recession are lack of keratinized tissue, high frena attachments and shallow vestibular depth. However, free grafts frequently result in a poor aesthetic appearance due to unsatisfactory chromatic, texture, tissue integration and apical disalignment of alveolar mucosa. Therefore, partly epithelialized free gingival graft (PE-FGG), with an apical de-epithelialized portion designed to overcome some of the aesthetic problems associated with the conventional FGG. The aim of this study was to compare the RES score of the PE-FGG and conventional FGG in Miller class II and III recessions. Material and Methods: 32 patients with 32 Miller class II and III recessions in mandibular anterior teeth were chosen. Sixteen mandibular central teeth were chosen for FGG procedure and sixteen mandibular central teeth were chosen for PE-FGG procedure. All patients were periodontally healthy women. Results: All patients completed the study and attended all recall visits. The mean RES score of the FGG and PE-FGG groups were 5,25±0,85 6,56±0,72 respectively. PE-FGG gave a better RES score and gingival color (p<0.05) than FGG but full root coverage was not achieved. Conclusion: The PE-FGG procedure resulted in excellent gingival color and better mucogingival alignmenet and RES score than FGG and can be used instead.

Full‐Mouth Rehabilitation of a Patient with Severely Worn Dentition and Uneven Occlusal Plane: A Clinical Report

Severe tooth wear is frequently multifactorial and variable. Successful management is a subject of interest in dentistry. A critical aspect is to determine the occlusal vertical dimension (OVD) and a systematic approach that can lead to a predictable and favorable treatment prognosis. Management of patients with worn dentition is complex and difficult. Accurate clinical and radiographic examinations, a diagnostic wax-up, and determining OVD are crucial. Using mini-implants as orthodontic anchorage may facilitate orthodontic movement of teeth to improve their position, which is necessary for favorable prosthetic treatment. A 46-year-old man was referred for restoration of his worn and missing teeth. After diagnostic work-up, provisional removable prostheses were fabricated for both jaws, evaluated clinically, and adjusted according to esthetic, phonetic, and vertical dimension criteria. Clinical crown lengthening and free gingival graft procedures were performed in appropriate areas. Drifting of the left posterior mandibular teeth was corrected using mini-implants as orthodontic anchorage. Two conventional implants were inserted in the right mandibular edentulous area. After endodontic therapy of worn teeth, custom-cast gold dowels and cores were fabricated, and provisional removable prostheses were replaced with fixed provisional restorations. Metal-ceramic restorations were fabricated, and a removable partial denture with attachments was fabricated for maxillary edentulous areas. An occlusal splint was used to protect the restorations. Full-mouth rehabilitation of the patient with severely worn dentition and an uneven occlusal plane was found to be successful after 3 years of follow-up. This result can encourage clinicians to seek accurate diagnosis and treatment planning to treat such patients.

Periodontal and Prosthetic Biologic Considerations to Restore Biological Width in Posterior Teeth

The biologic width is an essential dental space that always needs to be maintained to ensure periodontal health in any dental prosthetic restorations. An iatrogenic partial fixed prosthesis constructed in lower posterior teeth predisposed the development of subgingival caries, which induced violation of the biologic width in involved teeth, resulting in an uncontrolled inflammatory process and periodontal tissue destruction. This clinical report describes a periodontal surgical technique to recover a violated biologic width in lower posterior teeth, by crown lengthening procedure associated with free gingival graft procedure, to ensure the possibility to place a modified partial fixed prosthesis in treated area. The procedure applied to recover the biologic width was crown lengthening with some modifications, associated with modified partial fixed prosthesis to achieve health in treated area. The modified techniques in both surgical and prosthetic procedures were applied to compensate the contraindications to recover biologic width by osteotomy in lower posterior teeth. The result, after 4 years under periodic control, seems to achieve the projected goal. Treating a dental diseased area is necessary to diagnose, eliminate, or control all etiologic factors involved in the process. When the traditional methods are not effective to recover destructed tissues, an alternative, compensatory, and adaptive procedure may be applied to restore the sequelae of the disease, applying a restorative method that respects the biology of involved tissues.

Free Gingival Grafts to Increase Keratinized Tissue: A Retrospective Long‐Term Evaluation (10 to 25 years) of Outcomes

Gingival augmentation procedures are indicated primarily to increase an insufficient amount of gingiva and sometimes to halt the progression of gingival recession. The aim of this retrospective long-term study was to evaluate changes in the amount of keratinized tissue (KT) and in the position of the gingival margin after free gingival graft procedures over a period of 10 to 25 years. One hundred three subjects presenting with 224 sites completely lacking attached gingiva associated with gingival recessions were treated in a private practice. The experimental sites were treated with gingival augmentation procedures (free gingival grafts). The grafts were positioned at the presurgical level of the gingival margin or in a submarginal position. Clinical variables, including recession depth, amount of KT, and probing depth (PD), were measured at baseline (T(0)), 1 year after surgery (T(1)), and at the end of the follow-up period (10 to 25 years) (T(2)) and analyzed using descriptive statistics and multilevel models. From T(0) to T(1), the gingival margin shifted coronally 0.8 mm, and KT increased 4.2 mm. From T(1) to T(2), the gingival margin shifted coronally 0.6 mm, and the overall KT decreased 0.7 mm. PD remained stable. Gingival augmentation procedures performed in sites with an absence of attached gingiva associated with recessions provide an increased amount of KT associated with recession reduction over a long period of time.

Patient Outcomes Following Subepithelial Connective Tissue Graft and Free Gingival Graft Procedures

Subepithelial connective tissue grafts (CTGs) and free gingival grafts (FGGs) are common periodontal procedures with similar indications; however, they may differ regarding patient outcomes. Reports on postoperative periodontal patient outcomes are limited. The aim of this observational trial was to compare patient-based outcomes for CTGs and FGGs. Patients who received CTG or FGG completed postoperative questionnaires at 3 days and 3 weeks to assess pain, number of analgesic pills taken, and number of days pills were taken. Postoperative pain was assessed using a visual analog scale (VAS). Twenty-three subjects (12 CTGs and 11 FGGs) completed the study. Differences between CTG and FGG groups in VAS pain scores at 3 days did not reach statistical significance. The proportion of subjects reporting pain in the palate at 3 days was significantly greater for FGG (P <0.05). There were no significant intergroup differences at 3 weeks. For the FGG group, 3-week VAS pain scores were less than the 3-day ones (P <0.01). For the entire study population, the number of days analgesic pills were taken, total number of analgesic pills taken, and number of pills taken from day 3 to the end of the study correlated with the 3-week pain scores. FGG is associated with a greater incidence of donor site pain compared to CTG at the early postoperative period. Longer-term pain after soft tissue grafting is associated with greater analgesic usage. There is an opportunity to improve the postoperative protocols of soft tissue grafting, particularly for FGG.

Reconstruction of an alveolar cleft for orthodontic tooth movement

Bone grafting to repair an alveolar cleft has long been an integral part of the treatment of persons with unilateral and bilateral clefts of the lip and alveolus. The presence of the cleft places a limitation on the orthodontist who would like to move teeth in the area of the cleft. Various grafting materials have been placed in alveolar clefts in an attempt to solve this problem. The case to be presented is a patient with a Class II, Division 2, malocclusion with a left unilateral alveolar cleft and a repaired cleft lip. Ten months after initiating orthodontic treatment, a free gingival graft procedure was performed because of insufficient vestibular depth and the narrow width of the keratinized attached gingiva at the left maxillary lateral and central incisor region. Two months after periodontal surgery, a mix of decalcified freeze-dried bone allograft and a granular bioactive glass graft material (1:1) were applied subperiostally on the buccal aspect of the edentulous cleft region. Six months later, the teeth adjacent to the grafted alveolar cleft were orthodontically moved into the edentulous area. The treatment results indicated that orthodontic, periodontal, and surgical interventions resulted in a successful closure of the alveolar cleft as well as improved periodontal conditions of the teeth adjacent to the cleft area. From the orthodontic point of view, tooth movement can be achieved successfully into a bone graft made of freeze-dried bone and bioactive glass. (Am J Orthod Dentofacial Orthop 2000;117:156-63)

The Use of a New Topical Hemostatic Agent,

MICROFIBRILLARY COLLAGEN hemostat (MCH) is described in clinical use as a topical hemostatic agent for control of bleeding at the donor site of the free gingival graft procedures. On the basis of clinical trials, it is an excellent adjunct to periodontal surgical procedures.