Soft Tissue Grafts Research Articles

The influence of soft-tissue volume grafting on the maintenance of peri-implant tissue health and stability

BackgroundTo investigate the influence of soft-tissue volume grafting employing autogenous connective tissue graft (CTG) simultaneous to implant placement on peri-implant tissue health and stability.Material and methodsThis cross-sectional observational study enrolled 19 patients (n = 29 implants) having dental implants placed with simultaneous soft-tissue volume grafting using CTG (test), and 36 selected controls (n = 55 implants) matched for age and years in function, who underwent conventional implant therapy (i.e., without soft-tissue volume grafting). Clinical outcomes (i.e., plaque index (PI), bleeding on probing (BOP), probing depth (PD), and mucosal recession (MR)) and frequency of peri-implant diseases were evaluated in both groups after a mean follow-up period of 6.15 ± 4.63 years.ResultsSignificant differences between test and control groups at the patient level were noted for median BOP (0.0 vs. 25.0%; p = 0.023) and PD scores (2.33 vs. 2.83 mm; p = 0.001), respectively. The prevalence of peri-implant mucositis and peri-implantitis amounted to 42.1% and 5.3% in the test and to 52.8% and 13.9% in the control group, respectively.ConclusionSimultaneous soft-tissue grafting using CTG had a beneficial effect on the maintenance of peri-implant health.

Miniplate Suture Button Augmentation for Soft Tissue Graft Tibial Fixation in Anterior Cruciate Ligament Reconstruction

Background: Anterior cruciate ligament (ACL) reconstruction requires reliable and rigid graft fixation. Tibial-sided fixation is frequently cited as the “weak point” of the femur-graft-tibia construct. Some authors have recommended supplemental fixation with a staple or screw suture to post improve the strength and stiffness of the fixation. However, with these fixations, there is a risk for symptomatic hardware. Miniplate is flatter than screw or staple and does not penetrate the bone when attached. It is used as a button for suspensory fixation to enhance interference screw tibial fixation. Objective: To evaluate the clinical outcomes of the miniplate suture button for supplemental soft tissue graft tibial fixation in ACL reconstruction. Materials and Methods: A retrospective study was carried out between August 2016 and December 2019. A total of 40 patients had undergone primary ACL reconstruction, performed with hamstring tendon grafts that were secured using a miniplate suture button for supplemental interference screw tibial fixation. A total of 18 patients were excluded, leaving 22 patients at 1-year follow-up. Results: At least 1-year follow-up, the remaining 22 patients had significant difference between preoperative and postoperative outcome of anterior drawer test, Lachman test and pivot shift test (p<0.05). Lysholm knee scores improved significantly from 54.0±12.53 to 90.04±5.38. However, 3 patients (13.6%) experienced symptomatic hardware pain and 3 patients (13.6%) tendered around the miniplate site. There were no radiographic changes in miniplate displacement, deformed or broken plate, and bony reaction around miniplate. Conclusion: The use of a miniplate suture button as a supplemental fixation showed adequate fixation strength and showed good results in postoperative manual ligament laxity test and functional scores at minimum 1-year follow-up. However, there is still symptomatic pain at the hardware site. Keywords: Anterior cruciate ligament reconstruction, Supplemental fixation, Suture button

Retrospective long-term clinical evaluation of implant-prosthetic rehabilitations after head and neck cancer therapy.

To assess clinical and patient-reported outcomes of implant-prosthetic rehabilitations in patients with a history of head-neck cancer (HNC), treated with tumor resection without (TR) or with adjuvant radiotherapy (TR/RT). A healthy cohort rehabilitated with the same reconstructive protocols served as control group (C). A total of 28 women and 29 men were considered in the present retrospective study. Participants received 322 implants, finally supporting 79 prosthetic reconstructions. Primary outcome was the assessment of implant and prosthetic survival rates. Furthermore peri-implant soft tissue parameters (attached peri-implant mucosa, AM; modified bleeding and plaque indices, mBI/mPI; probing depth, PD) and prosthetic technical complications were documented. Patient-reported outcome measures (PROMs) by means of visual analog scales (VAS) and the Oral Health Impact Profile German 14 form (OHIP G14) were collected. For statistical purposes Chi-square and Mann-Whitney-U-Test were adapted. After a mean follow-up of 81.2±50.3months, implant survival rate was 98.1% (HNC-TR), 98.2% (HNC-TR/RT) and 100.0% (C), respectively (four implants failed in the HNC groups). HNC-TR/RT showed significant higher mPI and mBI compared to C. Within HNC-TR/RT, vestibuloplasty significantly reduced mBI and PD values. No failures occurred at the prosthetic level. Overall, higher VAS scores were reported for bar- compared with Locator-retained prostheses. Furthermore, increased OHIP G14 values resulted for HNC-TR/RT. High survival rates on implant and prosthetic level were observed. The use of soft tissue grafts resulted in stabilization of the peri-implant mucosa in irradiated patients. In terms of retention and chewing ability, participants preferred bars over Locator attachments.

Ultrasonographic tissue perfusion analysis at implant and palatal donor sites following soft tissue augmentation: A clinical pilot study

To describe the application of power Doppler Ultrasonography (US) for evaluating blood flow at implant and palatal donor sites following soft tissue augmentation with the connective tissue graft (CTG). Five patients exhibiting a peri-implant soft tissue dehiscence received treatment with a coronally advanced flap and corresponding CTG. Power Doppler US was used for assessing blood volume at baseline, 1week, 1month, 6months and 12months post-surgery for assessing blood-flow dynamics at the implant and palatal donor sites. The speed-weighted and power-weighted colour pixel density (CPPD) were computed from colour velocity (CV) and colour power (CP), respectively. A mean increase in CV of 199.25% was observed at the midfacial region of the implant sites after 1week compared to baseline. CV and CP were increased in all sites at 1week and 1month. At 6 and 12months, the mean CV appeared lower than baseline at the implant sites. CCPD was increased at the palatal donor sites and at the great palatine foramen areas at the 1-week and 1-month post-operative evaluations. Power Doppler US is a non-invasive and valuable tool for estimating tissue perfusion and CPPD variation during different phases of intra-oral soft tissue graft healing.

Alveolar Ridge Preservation in the Esthetic Maxillary Zone: Tuberosity Punch Technique of Gingiva and Bone: A Pilot Study

This paper aims to present an alveolar ridge preservation technique, using an autologous punch formed of hard and soft tissues harvested from the tuberosity area. Ten residual sockets in the anterior maxilla were filled with a punch of hard and soft tissues harvested from the tuberosity area. Clinical and radiographical data were collected at the surgical extraction time 0 (T0) and 5 months during implant placement (T1), from clinical and radiological measurements using cone-beam computed tomography scans and periapical radiographs. Core biopsy was harvested during implant placement for histological and histomorphometrical analysis. Clinically, the alveolar ridge presented a mean width of 10.3 mm before extraction which decreased to 8.85 mm at T1, where the mean horizontal loss is 1.45 mm (standard deviation [SD] 1.03 mm). The initial ridge mean height was 11.25 mm and increased to 12.85 mm after 5 months, where the mean vertical gain is 1.6 mm (SD 0.65 mm). The radiological evaluation shows a reduction in the horizontal dimension with a mean of 1 mm; however, the sockets show stability in the vertical dimensions. Histology showed a new lamellar bone formation with some areas of woven bone. Histomorphometric analysis showed that the percentage of new bone formed was 42.44 ± 5.54% and 48.62 ± 8.66% of the connective tissue and 8.94 ± 5.28% of the residual autogenous bone. At T1, the extraction sockets showed significantly lower vertical and horizontal bone changes, compared to T0. The described preservation punch technique resulted in greater stability in the horizontal and vertical dimensions after 5 months. Clinical and radiological results show that the punch of hard and soft tissue graft reduces hard and soft tissue dimensional alteration after tooth extraction. In addition, using autogenous bone showed histological new bone formation.

Free Gingival Graft and Collagen Matrix Revascularization in an Enoral Open Wound Situation

Vestibuloplasty with free gingival grafting is a frequently performed surgical procedure to generate sufficient keratinized mucosa (KM) around dental implants. Avascular porcine collagen matrices (CM) have been proclaimed to be sufficient substitutes as alternatives to free gingival grafts (FGGs). However, the process of graft integration and vascularization is still incompletely understood. In 18 patients a vestibuloplasty in the lower edentulous jaw situation was performed during implant exposure, either with FGGs from the palate or a porcine CM (mucoderm). Tissue perfusion of the soft tissue grafts was measured using laser-doppler-spectrophotometer intraoperatively and on postoperative days 2, 5, 10, 30 and between days 60 and 90. With graft perfusion expressed by oxygen saturation [SO2%], the relative amount of hemoglobin [rHb], blood flow, and velocity [AU] was detected and compared between groups and the surrounding mucosa. Healing was uneventful in both groups, with mature KM around dental implants after healing. Blood flow and velocity significantly increased until postoperative day 10, comparable to perfusion values of the surrounded mucosa. Intergroup comparisons revelated no significant differences concerning the flow between CM and FGGs. Oxygen saturation also significantly increased within the first 5 postoperative days in both groups. Hemoglobin content did not show any differences during the investigated period. The perfusion mainly progresses within the first postoperative week with only minimal further detectable alterations until the final investigation, comparable in both groups. Although integration of FGGs (revascularized) and the CM (new tissue formation) is biologically different, both transplants show comparable perfusion patterns, leading to sufficient KM.

Influence of Immediate Implant Placement and Provisionalization with or without Soft Tissue Augmentation on Hard and Soft Tissues in the Esthetic Zone: A One-Year Retrospective Study.

The purpose of this clinical research was to evaluate peri-implant marginal changes around immediate implants placed either with the application of SCTG or XCM or without soft tissue grafting. A total of 48 patients requiring a single implant-supported restoration in the anterior jaw were selected for inclusion. Three surgical procedures were performed, as follows: type 1 implant with subepithelial connective tissue graft (SCTG), type 1 implant with xenogenic collagen matrix (XCM), and type 1 implant without soft tissue augmentation (NG) (control group). The marginal change of peri-implant soft tissue, facial soft tissue thickness (FSTT), peri-implant health status, esthetics, and patient satisfaction were assessed at one year after surgery. All of the placed implants showed a survival rate of 100%. No significant differences in FSTT were recorded between the SCTG group and the XCM group after treatment (P > 0.05), while the NG group presented a significant difference (P < 0.05). Patients in the NG group lost significantly more in the buccal marginal level than did patients in the SCTG group and those in the XCM group (P < 0.05). The favourable success rate recorded in all groups confirmed immediate tooth replacement as a choice of treatment for a missing anterior single tooth. The NG group presented significant changes of FSTT and buccal marginal level, while XCM constituted a viable alternative to SCTG.

Patient-Reported Activity Levels Correlate With Early Cartilage Degeneration After Anterior Cruciate Ligament Reconstruction

Background: The association between activity level after anterior cruciate ligament (ACL) reconstruction (ACLR) and development of posttraumatic osteoarthritis (PTOA) remains unclear. This study investigated the relationship of patient-reported outcomes and progressive cartilage degenerative changes at 3 years after ACLR. Hypothesis: Higher activity levels, as measured by Marx scores, are significantly correlated with early cartilage degeneration after ACLR. Study Design: Cohort study; Level of evidence, 2. Methods: A total of 35 patients (16 women; mean age, 31.0 ± 7.6 years) with isolated ACLR and without pre-existing arthritis were prospectively enrolled. Patients reported Marx activity scores and Knee injury and Osteoarthritis Outcome Score (KOOS) scores and underwent T1ρ magnetic resonance imaging (MRI) preoperatively, 6 months, 1 year, 2 years, and 3 years after ACLR with soft tissue graft (22 autograft). The change in cartilage relaxation times between preoperative and 3-year imaging was used to identify cartilage degeneration, defined as an increase in T1ρ values by 14.3%. Correlation between Marx activity levels, KOOS scores, and T1ρ degeneration was performed with the Spearman rank test. The Fisher exact test was used to test for association between Marx activity score cutoffs and degeneration. The Student t test was used to compare Whole-Organ Magnetic Resonance Imaging Score (WORMS) and T1ρ relaxation times. Significance was defined as P < .05. Results: Sixteen patients (45.7%) showed evidence of cartilage degeneration at 3 years, most frequently in the medial compartment (n = 12; 34%). Higher Marx activity scores at 3 years correlated with cartilage degeneration in the medial femur (rho = 0.34; P = .045), and medial tibia (rho = 0.43; P = .01). A Marx score of 11 or greater at 3 years was significantly associated with medial compartment degeneration (P = .03), with a positive predictive value of 52.6%. No Marx score cutoff at years 1 or 2 predicted future cartilage degeneration. The KOOS Quality of Life score was inversely correlated with cartilage degeneration (rho = 0.38; P = .02). WORMS did not correlate with degeneration of the medial compartment. Conclusion: Increased activity at 3 years after ACLR was significantly associated with increased risk of medial compartment PTOA. While further research is needed to fully define these relationships, patients may be counseled that return to Marx activity levels of greater than 11 may be associated with a higher risk of medial compartment cartilage degeneration.

Soft tissue grafting with the tunnel technique in the mandibular anterior: Myths and realities.

To address the myths and realities of soft tissue grafting with the tunnel technique in the mandibular anterior region. Myths associated with use of the tunnel technique for soft tissue grafting in the mandibular anterior region are identified and examined. Explanations for the misunderstandings are presented and documented with case examples and evidence from scientific studies. Six myths are described and the realities are presented. This report demonstrates that the tunnel technique can be successfully used in the mandibular anterior region in the presence of anatomic features thought to favor the use of more invasive surgical methods. Soft tissue grafting in the mandibular anterior region has complicating anatomical features including a strong frenal attachment, shallow vestibule and thin tissue. These features may be successfully managed with a free gingival graft, but that procedure results in an uncomfortable experience for the patient. The tunnel technique, especially when combined with an acellular dermal matrix, dramatically improves the patient experience and esthetic outcome without compromising the clinical outcome.

A Challenging Approach: Implant Placement in Fresh Extraction Socket with Buccal Plate Defect Using a Novel Technique

As Dental implants have emerged to be one of the best means of rehabilitating a missing tooth, there have been various new advancements taking place in implant dentistry in recent years. It is extremely important to preserve the facial bone and the soft tissue, especially in the esthetic zone. Various such procedures maintain the width of the soft tissue and underlying bone in the esthetic areas. Conventionally it was advisable to wait for at least 3 months after the implant placement, before prosthetically rehabilitating the patient. However, with recent advances, we can provide the patient with immediate implants. This review aims to discuss a technique, which discusses on how we are able to place dental implants in fresh extraction sockets, with a buccal plate defect incorporating a novel surgical method along with usage of both hard and soft tissue grafts, which will enable us to achieve pleasing esthetics for the patient, without causing future facial bone resorption.

Comparison of Bone Healing in Immediate Implant Placement versus Delayed Implant Placement.

Introduction:Today, modern surgical and regenerative techniques with implant immediately placed into the prepared socket, predictable gap repair with bone substitutes and soft tissue grafts, have helped to eliminate concerns about bone deficiencies and allowed implant placement according to prosthodontic needs.Materials and Methods:The present in vivo study was designed to evaluate and compare the implant healing after immediate implant placement with or without bone graft and implant healing after delayed implant placement with or without bone graft. Crestal bone levels were compared in both the groups at preoperatively and postoperatively on immediate postoperatively, at 3rd month, and at 6th month.Results:Immediate implant group has more crestal bone level reduction at 3rd and 6th months as compared to the delayed implant group. Immediate implant with bone graft group has insignificant crestal bone level reduction at 3rd and 6th months as compared to immediate implant without bone graft group. Delayed implant with bone graft group has insignificant crestal bone level reduction at 3rd and 6th months as compared to delayed implant without bone graft group.Conclusion:It was concluded from this study that clinical and radiographical bone healing in the delayed implant group with or without bone graft (Group Y) appears to be better than the immediate dental implant group with or without bone graft (Group X).

A Comparative Study on Mastoidectomy Cavity Obliteration with Soft Tissue Graft and Cartilage Graft in Canal Wall Down Mastoidectomy

A Comparative Study on Mastoidectomy Cavity Obliteration with Soft Tissue Graft and Cartilage Graft in Canal Wall Down Mastoidectomy

Outcome measurements following palatal soft tissue graft harvesting: A review.

BackgroundFree gingival graft (FGG) and connective tissue graft (CTG) are two of the most commonly techniques performed in periodontal and peri-implant plastic surgery. Although several outcome measurements have been proposed for evaluation of palatal wound healing and patient morbidity, a comprehensive review about these variables is lacking. The objective of this review is to present comprehensive information about outcome measurements related to postoperative palatal wound healing and postoperative patient-reported morbidity after FGG or CTG procedures. Material and MethodsAn electronic search of English language dental literature in the Medline database via PubMed access was conducted from May 1994 to May 2020 following the PRISMA guidelines. Electronic search strategy complemented by hand search of impacting related dental journals, and the reference list of all included studies were used to complete data collection considering only clinical trials. Finally, inclusion criteria were applied to identify articles after full-text evaluation. ResultsA total of 111 articles were identified. After the exclusion of 34 articles based on title and abstract evaluation, 77 articles were full text screened. Following, 46 articles were excluded since they evaluated other surgical areas. Finally, 31 studies were selected and included for final evaluation. Outcome measurements were classified in variables collected by indexes and systems assessed professionally and patient-centered measurements. Visually-assessed measurements include indexes, photographs, bleeding and use of laboratory-aided measurements. Patients-centered outcomes comprise pain, discomfort and quality-of life, among others. ConclusionsThe most commonly used outcome measurements related to postoperative palatal wound healing are hydrogen peroxide test, tissue color match, visual inspection, and bleeding evaluation. Pain perception, analgesic consumption, discomfort sensation, burning sensation, and changes in feeling habits are the most commonly used outcome measurements related to postoperative patient-reported morbidity. Key words:Morbidity, patient comfort, periodontics, tissue harvesting, wound healing.

Hamstring Autograft ACL Reconstruction With and Without Internal Brace: A Matched Cohort Comparison

Re-injury is a major concern in patients undergoing anterior cruciate ligament reconstruction (ACLR). The use of ligament augmentation devices was first introduced in 1980 in effort to increase the tensile strength of the soft tissue graft and promote optimal healing following ACLR. More recently, the use of suture tape for ligament augmentation with hamstring autograft ACLR has been described in order to provide biomechanical support during graft healing phases. The purpose of this study was to compare (1) rates of complication and reoperation, (2) rate of ACL failure, and (3) patient reported outcomes (PRO) among matched patients following hamstring autograft ACLR with and without internal brace augmentation at a minimum 2-year clinical follow-up. A 2:1 matched cohort comparison was performed on patients who underwent hamstring autograft ACLR with and without internal brace augmentation at a single institution between August 2011 and April 2017. Patients were matched by age (±2 years), sex, and concomitant meniscus injury. Individual medical records were reviewed for patient demographics, additional injuries, intraoperative details, and concomitant procedures. Physical exam findings at latest follow-up were recorded. PRO consisting of Tegner Activity Score, Lysholm score, and International Knee Documentation Committee (IKDC) score were collected preoperatively and at a minimum of 2 years postoperatively. Thirty-six patients (mean age 25.3 years, range 13-44) who underwent ACLR with internal brace augmentation and 72 patients (mean age 24.3 years, range 13-43) without internal brace augmentation were included in this study. Overall, 5/36 (14%) internal brace patients and 8/72 (11%) matched control patients underwent reoperation. One patient in each group experienced ACL failure and underwent revision ACLR. There were no statistically significant differences between the internal brace and control groups for preoperative and postoperative Tegner activity scores (7.2 to 7.1, 6.9 to 6.6), postoperative IKDC scores (94.4 and 94.1), and Lysholm scores (95.6 and 94.8) at an average follow-up of 26.1 and 33.7 months, respectively. Hamstring autograft ACLR with and without internal brace augmentation resulted in excellent clinical and patient reported outcomes at a minimum two-year follow-up. In this matched-cohort comparison, no significant differences were observed in rates of complication and reoperation, rate of ACL failure, and PRO between cohorts. Additional larger studies are required to determine the potential clinical benefit of internal brace augmentation in ACLR.

Radiosurgery in periodontics: Have we forgotten it?

Radiosurgery (RS) has evolved from electrosurgery and uses ultra-high-frequency radio waves at a frequency ranging from 3 to 4 MHz. It is used to address numerous soft-tissue concerns in dentistry and as well as medicine with excellent and predictable results. A review of the indexed literature disclosed that RS has been employed for various periodontal procedures such as gingivectomy, gingivoplasty, crown lengthening, minimally invasive closed osteotomy, frenectomies, operculectomies, depigmentation, gingival curettage, periodontal flap procedures, mucogingival surgeries, harvesting soft-tissue grafts, and also in implantology. Reduced lateral heat production with minimal tissue damage, faster healing, availability of specialized electrodes, increased perception, and cost-effectiveness are some of the notable advantages of RS. The evidence available implies that RS when used appropriately might be a better and economical alternative to a scalpel, electrosurgery, and laser. Inadequate knowledge on the use of this treatment modality due to short of research conducted in this area could be the reason behind it becoming obsolete. This review is an attempt to reminiscence the uses of this versatile tool in periodontal therapy and reinstate its use in present-day clinical practice.

Postextraction Ridge Width Alterations Following Socket Seal Surgery—A Retrospective Study

Background and objectives: Preservation of alveolar ridge contour following tooth extraction is important to allow for restoration with prosthetics and implants. Socket seal surgery was introduced more than two decades ago for preservation of the form, volume and bone quality of the postextraction ridge. The aim of this retrospective study was to assess the changes in alveolar ridge contour following socket seal surgery and to evaluate the survival of the soft tissue grafts sealing the extraction site. Materials and Methods: Digital images of the extraction sites treated with the socket seal surgery were obtained immediately after extraction and after a healing time of 6 months to measure the changes in the alveolar width. In addition, the sites were photographed 1 week postsurgery to evaluate the vitality of the soft tissue grafts. Results: The overall mean loss of buccal width following socket seal surgery was 5.3% (SD = 13.4%). The mean change in width at the incisor area (1.5% ± 13.1) was significantly lesser than those in the canine area (−17.0% ± 2.1, p &lt; 0.01) or premolar area (−10.5% ± 11.2, p &lt; 0.01). One-week post-surgery 69% of the grafts were vital, and 31% were partially vital. Complete necrosis of the grafts did not occur. Conclusions: Our results suggest that socket seal surgery has a beneficial effect on alveolar dimensional changes 6 months following tooth extraction and that the teeth that benefit mostly from socket seal surgery are incisors.

Treatment of Gingival Recession with Hypersensitivity using Free Soft-tissue Graft Procedures

Background The main goal of root coverage procedure is complete coverage of the recession defect with a good esthetic result related to the adjacent soft tissues and minimal probing depth after the healing process. Purpose The aim of this study was to compare the efficiency of surgical and nonsurgical treatment options in patients with gingival recession and dentin hypersensitivity (DH). Material and methods 60 patients with gingival recession Miller Class I and II with hypersensitivity and esthetic concerns were included. 30 of them were treated with free soft-tissue graft procedures and control group of 30 people were treated with anti-hypersensitivity gel. Surgically treated patients were separated in two groups: 20 of them- with coronally advanced flap with sub-epithelial connective tissue graft and 10 of them- with free gingival graft. Results We achieved full coverage on the exposed root surfaces in 18 patients treated with coronally advanced flap and de-epithelized graft and partial root coverage in two of them. Patients treated with free gingival graft procedure achieved full root coverage in 6 of them and partial on 4 of them (GR=1 mm after surgery). Surgical treatment led to resolution of the esthetic issues of the patients and elimination or reduction of the DH. In control group there were partial elimination of root sensitivity. Conclusion: In surgical treated group with both techniques we achieved resolution of DH and coverage of the root surface with healthy keratinized tissues. Surgery may be considered for treatment options of DH depending on the indications.

Multidisciplinary approach for improving aesthetics in a cleft lip and palate patient

A 27-year-old woman with a right-sided cleft lip and palate and a left sided cleft lip and congenitally missing teeth #s12 and 11. After primary treatment of the cleft during childhood and adolescence, the teeth were still missing and a large defect in the alveolar crest remained. Patient’s chief complaint was poor aesthetics in the upper anterior region. This case presentation describes how, with a multidiscipline approach by means of orthodontics, soft tissue grafting and a tooth-supported fixed partial denture the conditions were treated to achieve as good aesthetical result as possible. Keywords: Cleft Lip and palate, Ridge augmentation, Multidiscipline approach.

“V‐Reverse” Suturing Technique for Tunnel Soft Tissue Graft and Flap Stabilization: Technique Illustration

In periodontal and peri-implant plastic procedures, proper stabilization of the graft and the flap plays a crucial role in the outcomes. While the coronally advanced flap allows for better access with the possibility of suturing the graft to the periosteum and the de-epithelialized papillae, there is little evidence regarding what is the best approach in stabilizing the graft and the flap when performing the tunnel techniques (TUN). The purpose of this technical note is to describe a new suturing technique "V-reverse" for stabilization of the graft and the flap during a TUN procedure. The V-reverse suturing technique was used to enhance the stabilization of the graft and the flap during root coverage procedures, papilla augmentation, and immediate implant placement. Other advantages of this technique include reduced flap and graft micromotion; simple, easy, and fast procedure; and high patient compliance. The present article describes three main clinical scenarios in which V-reverse suturing technique is used to stabilize TUN + connective tissue graft for root coverage procedures, papilla augmentation, and immediate implant placement.

Immediate implant placement with or without connective tissue graft: A systematic review and meta-analysis.

To assess the effect of connective tissue graft (CTG) in terms of vertical mid-facial soft tissue change when applied at the buccal aspect following single immediate implant placement (IIP). Two independent reviewers conducted an electronic literature search in PubMed, Web of Science, EMBASE and Cochrane databases as well as a manual search to identify eligible clinical studies up to January 2020. Randomized controlled trials (RCTs) and non-randomized controlled studies (NRSs) comparing IIP with CTG and without CTG over a mean follow-up of at least 12months were included for a qualitative analysis. Meta-analyses were performed on data provided by RCTs. Out of 1814 records, 5 RCTs and 3 NRSs reported on 409 (IIP + CTG: 246, IIP: 163) immediately installed implants with a mean follow-up ranging from 12 to 108months. Only 1 RCT showed low risk of bias. Meta-analysis revealed a significant difference in terms of vertical mid-facial soft tissue change between IIP + CTG and IIP pointing to 0.41mm (95% CI [0.21; 0.61], p<.001) in favour of soft tissue grafting. This outcome was clinically relevant since the risk for ≥1mm asymmetry in mid-facial vertical soft tissue level was 12 times (RR 12.10, 95% CI [2.57; 56.91], p=.002) lower following IIP + CTG. Soft tissue grafting also resulted in a trend towards less bleeding on probing (MD 17%, 95% CI [-35%; 1%], p=.06). Meta-analyses did not reveal significant differences in terms of pink aesthetic score, marginal bone level change and probing depth. Results were inconclusive for horizontal mid-facial soft tissue change and papilla height change. Based on GRADE guidelines, a moderate recommendation for the use of a CTG following IIP can be made. CTG contributes to mid-facial soft tissue stability following IIP. Therefore, CTG should be considered when elevated risk for mid-facial recession is expected in the aesthetic zone (thin gingival biotype, <0.5mm buccal bone thickness).