Mucogingival Surgery Research Articles

Double mucogingival surgery to preserve teeth with poor prognosis: a case report

Double mucogingival surgery to preserve teeth with poor prognosis: a case report

Modern aspects and clinical perspectives of changing the biotype of the mucous membrane in the projection of the dental implant

Today, there is a growing scientific interest in the condition of the soft tissues surrounding dental implants and their impact on the long-term prognosis of implant treatment. It is known that risk factors for the development of peri-implantitis include deficiency or complete absence of attached keratinized gum in the implant area. The paper provides a comparative literature analysis of various methods of mucogingival surgery in the field of dental implants. The paper presents a comparative literature analysis of various methods of mucogingival surgery in the field of dental implants. It is shown that information on the terms of use of dental implants and the conditions of their functioning is quite contradictory. Loss of implants occurs for a number of reasons, among which an important place is occupied by periimplantitis, progressive loss of bone tissue and attached gum in the periimplant zone. The risk of remote postoperative complications remains very high. Complications may be associated with the fact that in clinical practice the features of the histostructure of the gum in the adentia zone are not taken into account. It is concluded that soft tissue plastic surgery as one of the stages of surgical preparation after reconstructive interventions on the jaws is justified according to the literature. At the same time, the problem of creating a peri-implant “buffer” zone, despite significant advances in the development of new technologies for its formation, has not been finally resolved. Discussions continue about the role of attached keratinized gum around implants.

Indications and decision making in single and multiple treatment of the anterior sector

Gingival recessions, characterized by apical displacement of the gingival margin and exposure of the root surface, pose both esthetic and functional challenges. This paper reviews the indications and decision making in the management of anterior gingival recessions, a crucial aspect in esthetic and restorative dentistry. Over the years, the evolution of mucogingival surgery towards periodontal plastic surgery has led to the development of various surgical techniques, such as connective tissue grafts and advanced coronal flaps. These techniques aim to provide effective and durable root coverage, adapting to the specific anatomical characteristics of each patient. The selection of the most appropriate surgical technique depends on a detailed evaluation of local anatomical factors and the patient's esthetic expectations. While it is possible to maintain periodontal health with a minimal amount of keratinized gingiva, gingival recessions remain common, especially in individuals with thin periodontal phenotypes. An interdisciplinary approach is essential to ensure outcomes that optimize both periodontal health and esthetics in the long term

Arginine-loaded globular BSAMA/fibrous GelMA biohybrid cryogels with multifunctional features and enhanced healing for soft gingival tissue regeneration

Mucogingival surgery has been widely used in soft gingival tissue augmentation in which autografts are predominantly employed. However, the autografts face grand challenges, such as scarcity of palatal donor tissue and postoperative discomfort. Therefore, development of alternative soft tissue substitutes has been an imperative need. Here, we engineered an interconnected porous bovine serum albumin methacryloyl (BSAMA: B, as a drug carrier and antioxidant)/gelatin methacryloyl (GelMA: G, as a biocompatible collagen-like component)-based cryogel with L-Arginine (Arg) loaded as an angiogenic molecule, which could serve as a promising gingival tissue biohybrid scaffold. BG@Arg cryogels featured macroporous architecture, biodegradation, sponge-like properties, suturability, and sustained Arg release. Moreover, BG@Arg cryogels promoted vessel formation and collagen deposition which play an important role in tissue regeneration. Most interestingly, BG@Arg cryogels were found to enhance antioxidant effects. Finally, the therapeutic effect of BG@Arg on promoting tissue regeneration was confirmed in rat full-thickness skin and oral gingival defect models. In vivo results revealed that BG@Arg2 could promote better angiogenesis, more collagen production, and better modulation of inflammation, as compared to a commercial collagen membrane. These advantages might render BG@Arg cryogels a promising alternative to commercial collagen membrane products and possibly autografts for soft gingival tissue regeneration.

A novel surgical technique to resolve mucosal fenestration of a root apex: Apical tunnel surgery: A case report.

Endodontic surgery, which includes apex resection, retro-fill and some regeneration procedures, is a traditional way to deal with apex fenestration. The endodontic surgery could bring large flap, curtate root length, non-healing mucosa and soft tissue deficiency in the apex area. Other treatment options might be considered according to different etiological factors. Mucogingival surgery provides some ideas in accumulation of soft and hard tissues, especially some unique methods such as "tunnel technique" bringing us a view of minimal invasive surgery approach. A novel surgery named "apical tunnel surgery" was reported here to resolve a root apex exposure with the tunnel-like technique. A young female complained about root exposure of upper right anterior tooth without history of trauma or orthodontic treatment. The intraoral examination revealed a buccal root apex exposure about 3mm in diameter of #12 (FDI teeth numbering system). The tooth was slightly dark with Class 1 mobility. The periodontal situation was good and the occlusion check revealed no traumatic bite on #12. The cone-beam computed tomography (CBCT) showed a bone fenestration from the buccally lower 1/2 root surface to the apex and bone absorption around the apex. It also revealed a bone contour deficiency in #12 area. Root canal treatment, root surface debridement, and soft tissue combined with hard tissue accumulation were carried out in one tunnel-like surgery. Examination of 12-month follow-up showed a healed and thickened mucosa in the buccally apical region and CBCT showed the continuous lamina dura occupied the buccal aspect of #12 root apex. This new apical tunnel surgery provided soft and hard tissue accumulation in one minimal invasive way in the apex exposure case caused by bone fenestration and thin mucosa.

Cosmetic Makeover of Periodontally Compromised Patients using Flexible Gingival Mask and Porcelain Laminate Veneers: Report of Two Cases

Chronic periodontal disease can lead to advanced gingival tissue loss that can result in problems with esthetics, phonetics, food impaction and tooth sensitivity. One of the most difficult problem encountered in the management of periodontal disease is loss of interdental papillae which leaves unsightly “black triangles” between the teeth. The first step in the management of these problems is surgical correction of the defect. In cases where mucogingival surgery is unpredictable due to generalized recession and loss of large volume of gingival tissue, removable gingival prosthesis is an excellent alternative to correct the deformities remaining after the control of destructive periodontal disease specially in the maxillary anterior region. Gingival prostheses may be fixed or removable. It can be made from a range of materials like acrylic, silicones, porcelain- based materials and flexible resin denture material. This report describes two clinical situations in which combined periodontal/prosthodontic rehabilitation was done for patients with advanced periodontal disease. Accurately fitting flexible gingival prostheses and porcelain laminate veneers were fabricated to restore advanced gingival tissue loss in esthetic area following periodontal flap surgery. The flexible gingival masks not only help to achieve excellent cosmetic results but also reinstate the functional and psychological wellbeing of the patient.

Minimally invasive prosthodontics using the concept of prosthetically guided orthodontics.

This case report aims to present how digital technology can be employed to plan the orthodontic movement of teeth into their final positions for prosthodontic rehabilitation. An interdisciplinary approach to treatment planning and the result of prosthodontic treatment involves the cooperation of an orthodontist and a prosthodontist. When planned to achieve optimal results for a minimally invasive and functional prosthodontic treatment, orthodontic pretreatment provides superior esthetic results and favorable long-term success. The orthodontic movements of the teeth were planned so that the prosthodontist could reconstruct an optimally functional and esthetic occlusion while preserving the hard dental tissues. The orthodontic pretreatment minimized the need to prepare the teeth, avoiding any mucogingival surgery to improve the gingival architecture. In complex clinical cases, it is essential to evaluate the advantages of an orthodontic pretreatment before starting a prosthodontic treatment. This pretreatment can help preserve dental tissues, reduce or eliminate the need for surgical intervention, and achieve long-term stability and esthetic results. This case clearly shows the benefits of orthodontic pretreatment for prosthodontic outcomes. With modern digital tools, such an orthodontic pretreatment should become standard clinical practice when planning a complex clinical case.

ИЗМЕНЕНИЕ БИОТИПА ДЕСНЫ В ПРОЕКЦИИ ДЕНТАЛЬНЫХ ИМПЛАНТАТОВ

Deficiency of keratinized gum in the peri-implant zone contributes to bone recession and visualization of implant necks and abutments through its thin layer. To develop clinically effective and scientifically based protocols for the prevention and treatment of pathology of tissues surrounding implants, it is necessary to study the risk factors for the occurrence of mucositis and peri-implantitis, one of which is the deficiency or complete absence of attached keratinized gum in the implant area, as a result of which the mobile mucous membrane is constantly displaced during eating, talking, performing hygiene procedures. The gums are easily injured, which leads to rapid colonization of pathogenic microflora and the development of initial inflammation in the form of mucositis. The inflammatory process is launched, which in turn leads to an increase in the activity of osteoclasts. It should be noted that the rate of development of the inflammatory process in the area of implants is much higher than in the area of teeth. Due to the absence of the periodontal ligament, the inflammatory infiltrate directly spreads to the alveolar bone and penetrates into the medullary spaces. The gum contour in the area of installed implants must be aesthetic, stable and dense. This together will not only provide a cosmetic effect, but will also prevent the development of early and late complications of dental implantation. The paper provides an analysis of various methods of mucogingival surgery in the field of dental implants using an allogeneic graft of the “Alloplant” series. Engraftment of mucosal autografts from the tubercle of the upper jaw after surgery is accompanied by severe inflammation, which can lead to scarring of the mucosa or exposure of the bone. Allografts transplanted to patients to thicken the gums in the area of implantation are completely replaced after 6 months without signs of rejection or inflammatory processes by a full-fledged connective tissue regenerate covered with stratified squamous keratinizing epithelium. In the surgical area, gum tissue is formed in thickness, which can be classified as a “thick” gum phenotype.

Dental Soft Tissues and Palatal Masticatory Mucosa from the Periodontal and Radiographic Perspectives: A Review Article

This review article delves into the advancements in the assessment and management of palatal masticatory mucosa, with a particular emphasis on the thickness of the palatal mucosa and its implications for periodontal and peri-implant surgeries. It highlights the pivotal role of cone beam computed tomography (CBCT) in evaluating Thickening of the palatal mucosa, despite its inherent limitations in soft tissue visualization. The paper discusses the evolution of mucogingival surgery, including the classification of marginal tissue recession and soft tissue grafts, and examines the histology of palatal mucosa. It also evaluates the indications, predictability, and clinical as well as aesthetic outcomes of free gingival graft (FGG) & connective tissue graft (CTG) procedures. Various methodologies to measure palatal mucosa thickness are explored, alongside strategies to overcome CBCT's limitations in soft tissue assessment. The review underscores the significance of a comprehensive understanding of palatal masticatory mucosa's anatomy and histology, alongside the surgical techniques available for managing mucogingival deficiencies. It aims to enhance the predictability and aesthetics of periodontal and peri-implant surgeries through advancements in diagnostic and surgical techniques, coupled with a deeper understanding of tissue biology.

Impact of periodontal phenotype on the outcome of subgingival instrumentation in Stage II and III, Grade A and B periodontitis.

The influence of periodontal phenotype (PP) has been documented in the outcomes of various surgical periodontal interventions such as crown lengthening, mucogingival surgery, implant restoration, and open flap debridement. Previous studies with smaller sample sizes have assessed the role of PP on the outcome of nonsurgical periodontal therapy with inconsistent results. The aim of the current interventional study is to estimate the influence of PP on the outcome of subgingival instrumentation in Stage II and III, Grade A and B periodontitis. Fifty-two patients (n = 27 thick PP and n = 25 thin PP) underwent subgingival instrumentation using ultrasonic scalers and curettes under local anesthesia in a single sitting, and periodontal parameters were recorded at baseline, 2, 4, and 6 months. The McNemar and Chi-square tests were applied for categorical data, whereas the Wilcoxon signed-rank test and Mann-Whitney U-test were applied for continuous data in intra- and intergroup comparisons, respectively. Significantly better improvements in deeper pockets (>5 mm) with thick PP were observed. Loss of attachment was found in thin, bleeding on probing (BOP)-negative sites with an initial probing depth of ≤3 mm. However, BOP-positive sites belonging to both groups exhibited higher improvements in terms of clinical parameters. Probing depth, PP, and periodontal inflammation recorded in terms of BOP influence the gain in clinical attachment following subgingival instrumentation.

Orthodontic space closure after loss of maxillary incisors and periodontal breakdown of the edentulous area and on adjacent teeth

The closure of an edentulous space with the orthodontic movement of adjacent teeth even if affected by severe loss of periodontal support is a treatment option nowadays supplanted by the implant-born crown substitution and periodontal regenerative/reconstructive therapy. Nevertheless it is important not to forget some fundamentals of dental research that still justify, even more when combined with the most recent innovations in the field of mucogingival surgery and guided tissue regeneration, the alternative of orthodontic space closure. The latter indeed represents a valuable alternative in many malocclusions complicated by lost maxillary incisors, first of all in the growing patients and when the gingival margins are visible during speech and smile.This article will outline crucial details about the orthodontic management of the reduced periodontal tissues in the pressure area.

Effectiveness of soft tissue augmentation using subepithelial connective tissue graft in comparison with free gingival graft and no graft for increasing the width of keratinized mucosa around dental implants: a meta-analysis

The soft tissues around dental implants are important to prevent inflammatory peri-implant diseases and ensure the long-term survival of a dental implant. Periodontal plastic surgery has evolved from traditional mucogingival surgery, according to Zuhr et al as a result of the development of subepithelial connective tissue grafts/free gingival grafts. So, the aim of this review was to compare the effectiveness of soft tissue augmentation using subepithelial connective tissue graft in comparison with free gingival graft and no graft for increasing the width of keratinized mucosa around dental implants. The review was according to PRISMA protocol. A comprehensive search of the specialized databases was performed to include the studies. Quality assessment and meta-analysis were carried out. 10 articles included. Two articles evaluated KTW with FGG and SCTG; FGG and no graft (3); SCTG and no graft (5). All the included studies assessed either primary or secondary outcome measures. In the end, it was concluded that for soft tissue volume augmentation, SCTG is a treatment choice for an increase in KTW at implant sites.

Evaluation of the Effect of Hyaluronic Acid Injection on the Reconstruction of Reduced Interdental Papillae in Patients Referred to Shiraz School of Dentistry.

The occurrence of papillary defects adjacent to teeth or dental implants causes both the dental staff and the patients to be concerned about the esthetic issues. Interdental papilla reconstruction surgery is one of the most difficult and unpredictable mucogingival surgeries. The present study aimed to investigate the efficacy of hyaluronic acid injection in the reconstruction of the interdental papilla. This clinical trial study was conducted on four patients with 20 deficient interdental papillae who met the inclusion criteria. At first, local anesthesia was applied. Afterward, 0.2 mL of 1.6% hyaluronic acid (HA) gel was injected (at the tip of the papilla and 2-3 mm below the tip of the papilla) three times every two weeks. At baseline, three, and six months later, clinical photography was taken under standard conditions. The papilla height (the distance between the interdental papilla tip and the basis), black triangle area, and the distance between the interdental papilla tip and contact point of adjacent teeth were all measured using Image J software. The effectiveness of using HA gel in reducing the black triangle area was 85.06%. Furthermore, the papilla length increased by 70.256% while contact to papilla distance decreased by 83.026%. At different times, the values of the studied variables in the three levels were significantly different (p< 0.05). Injection of HA with 1.6% concentration at two points of the interdental papilla was effective in interdental papilla reconstruction at the aesthetic zone, especially in long-term, follow-ups (especially 6 months).

Periodontal Practice and Referral of Patients by General Dental Practitioners in Province No.1 Nepal

Introduction: General dental practitioners and periodontists working in a close alliance is considered to bestow effective outcome in the context of diagnosis and management of periodontal diseases. Recently, general practitioners are inclined to render the majority of non-surgical procedures by themselves and avoid surgical part. This obscures functional as well as esthetic demand contributing to periodontally challenged conditions. In advanced stages, no matter how efficiently a skilled periodontist handles the case, redemption is not possible.&#x0D; Objectives: To assess the periodontal practice and referral of patients by general dental practitioners to periodontists.&#x0D; Methodology: An online survey using Google Forms was conducted among the general dental practitioners working in private clinics in province no.1, Nepal from November 2021 to January 2022. A total of 64 general dental practitioners were surveyed using a self-administered questionnaire. Descriptive statistics were calculated.&#x0D; Results: The response rate for the present study was 51.2% out of which only 17.2% referred patients to periodontists for non-surgical periodontal therapy and scaling was the most performed procedure by all the practitioners themselves. However, 92.2% referred patients to periodontists for surgical procedures and a majority of the referrals were for mucogingival surgeries. Majority of them expressed satisfaction regarding the number of continuing dental education programs being conducted despite minimum participation.&#x0D; Conclusion: Majority of the general dental practitioners seemed to perform non-surgical periodontal therapy by themselves while considering referral for surgical interventions. Also, minimum participation despite remarkable satisfaction in the conduction of continuing education programmes calls for a need to explore the inadequacy.

Application and research progress of autologous soft tissue substitute materials in gingival augmentation of natural teeth

Subepithelial connective tissue or free gingival grafts are often used in traditional mucogingival surgery to treat gingival recession and keratinized gingival insufficiency. However, due to the disadvantages of autologous soft tissue grafts, such as the preparation of the second surgical site, the limited amount of tissue in the donor site, and postoperative discomfort for patients, the research on autologous soft tissue substitute materials has attracted extensive attention. A variety of donor-substitute materials from different sources are currently used in membranous gingival surgeries, including platelet-rich fibrin, acellular dermal matrix, xenogeneic collagen matrix, etc. This paper reviews the research progress and application of several different types of substitute materials in soft tissue augmentation for natural teeth, providing a reference for the application of autologous soft tissue substitutes in clinical gingival augmentation surgery.

Injectable Platelet-Rich Fibrin and Microneedling—A Non-Surgical Approach for Gingival Augmentation: A Randomized Controlled Clinical Trial

Aim: The present study aimed to assess the efficacy of combining microneedling (MN) and injectable platelet-rich fibrin (i-PRF) administration with i-PRF alone in augmenting the thickness of gingiva to manage thin periodontal phenotype. Methodology: The clinical trial involved 36 patients who were diagnosed with thin periodontal phenotype. They were randomized under two groups: MN + i-PRF versus i-PRF alone, carried out as a split-mouth trial. One quadrant was treated only with i-PRF delivery through the gingival sulcus, while the contralateral side was treated with MN and i-PRF in 3 sessions at 10-day intervals. The primary parameter measured was the thickness of the gingiva, at baseline and 3 months following therapy. Statistical analysis was performed using the Mann-Whitney U test. Wilcoxon’s signed ranking test for inter-group and intra-group analysis, respectively. Results: The study results showed a significantly greater increase in gingival thickness (GT) in sites where both MN and i-PRF injection was done, compared to i-PRF alone, with a p value of .04. Conclusion: Both treatment modalities showed improvement in GT, being a minimally invasive alternative for mucogingival surgery. Adjunctive MN was found to be more beneficial than i-PRF alone. However, further research should be carried out to address the drawbacks of the study and for a better understanding 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 free gingival graft

Recession defects are widely prevalent in the adult population, with some patients being impacted by complications, including the difficulty of cleaning such sites and the risk of continued recession progression. The free gingival graft (FGG) is a form of mucogingival surgery that attempts to improve the height of the keratinized tissue (KT), as well as augment the thickness of the gingival phenotype to facilitate meticulous oral hygiene. This article discusses the indications for the surgery, the procedure, including post-operative care, and possible modifications of the technique. CPD/Clinical Relevance: Professional intervention involving a free gingival graft may be the only way to empower patients to clean the recession site without discomfort.

Effect of fibrin-rich plasma and collagen sponge on healing of the palatal mucosa.

The purpose was to evaluate the variation in thickness and early healing of the donor area of the palate with the placement of a collagen sponge and the use of fibrin-rich plasma (L-PRF). Thirty patients who required mucogingival surgery treatment were selected and distributed into 2 groups. After obtaining the free palate graft, L-PRF was placed in Group A, and a collagen sponge was placed in Group B. The healing process of the palate was evaluated at 24 hours and 7, 14, 21 and 28 days postsurgery. The thickness of the donor area (palate) was evaluated using an acrylic splint. These measurements were made before and 4 months after surgery. In the collagen sponge group, less gain of the palatal mucosa was observed, with a mean difference of 0.1 ± 0.8 mm (CI: -0.341-0.518) (p=0.691), whereas in the fibrin-rich plasma group, a mean difference of 0.0 ± 0.5 mm (CI: -0.229-0.229) (p=0.934) was found; however, when comparing the gain of the palatal mucosa in both groups, no significant difference was observed (p=0.932). The healing index at 24 hours indicated the presence of clots, on Day 28 vascularisation and total epithelialisation (100.0%), and finally, the collagen sponge group on Day 14 presented 93.3% partial vascularisation of connective tissue and 33.3% L-PRF (p=0.001). There was no statistically significant difference in the thickness of the palatal mucosa after the use of L-PRF and the collagen sponge. Key words:Palate thickness, connective tissue graft, fibrin-rich plasma, collagen sponge, palate healing.

The Posterior Extension of the Palatal Rugae as an Anatomical Constraint for Soft Tissue Grafts in a Saudi Arabian Population.

Background The purpose of this study was to investigate the distal extension of the palatal rugae area as an anatomical constraint on the harvesting of palatal soft tissue grafts in a Saudi Arabian population. Additionally, factors that could affect or predict the extension were considered. Methods Three hundred seventy-four (374) dental casts from Saudi nationals currently residing in Riyadh (170 males and 204 females) were included. Two independent observers used a standardized probeto measure the posterior extent of the rugae on each stone castbilaterally on a horizontal base. A sharp graphite pencil was used to mark the measurements from the origin of the rugae to their terminal ends on the cast, and a magnification lens was used to identify them. Using this technique, the most posterior extension of the rugae was marked and then analyzed. The normal approximation test for binomial distribution was used to determine the proportion of the subjects with rugael extensions beyond the mesial end of the upper second premolar, and logistic regression was used to seethe association of this extension with other factors. Results The asymptotic chi-squared (p = 0.0002) McNemar tests revealed that the posterior distal extension of the rugae was not the same on both sides.A normal approximation test for the left side with 95% confidence intervals (CIs) with the "rugael extension proximal to the mesial end of the upper second premolar"category considered "success"found that the proportion of upper second premolars with rugael extensions proximal to the mesial end was not significantly different to the proportion of rugael extensionsbeyond the mesial end of the upper second premolars (95% CI: 48.69%-58.79%,p= 0.147). Conversely, the proportion of the upper second premolars with rugael extensions proximal to the mesial end was significantly lower than that beyond the mesial end on the right (95% CI: 35.92%-45.89%,p= 0.00004).Gender, age, and palatal shape did not significantly affect the posterior extension of palatal rugae. Conclusions The palatal rugae on the left side of a sample of the Saudi Arabian population do not considerably extend beyond the upper second premolarmesial aspect, which may provide reliablesoft tissue grafts for esthetic mucogingival surgery.