Subepithelial Connective Tissue Graft Procedure Research Articles

Tunnel technique with cross-linked hyaluronic acid in addition to subepithelial connective tissue graft, compared with connective tissue graft alone, for the treatment of multiple gingival recessions: 6-month outcomes of a randomized clinical trial.

The aim of this study was to investigate differences in clinical and esthetic outcomes in the treatment of multiple gingival recession types 1 and 2, using the modified coronally advanced tunnel technique (MCAT) combined with subepithelial connective tissue graft (SCTG), with or without cross-linked hyaluronic acid (HA). A total of 24 patients with 266 multiple gingival recessions (GR) were enrolled in the study (133 recessions per group). MCAT was combined with SCTG and HA on the test side, while MCAT with SCTG was used on the control side. Clinical parameters were measured at baseline and 6months post-operatively. Visual analogue scales (VAS) and questionnaires were used to assess patient-rated outcomes, and the root coverage esthetic score (RES) was used for professional esthetic evaluation. No significant improvement in root coverage was observed as a result of adding HA. After 6months, mean root coverage (MRC) was 85% for SCTG + HA group and 83% for SCTG group (p = 0.9819). Complete root coverage (CRC) was observed in 91% (test) and 93% (control) of the cases (p = 0.9001). Professional assessment of soft tissue texture (STT) using RES showed a significant difference (0.94 versus 0.69, p = 0.0219) in favor of the experimental group. Both treatments were similarly effective in treating multiple GRs and led to comparable improvements in clinical parameters. However, application of HA improved the appearance of soft tissue texture. Adjunctive application of HA in the MCAT + SCTG procedure may improve STT results.

Covering the Uncovered: Complete Root Coverage of Gingival Recession using Sub-Epithelial Connective Tissue Graft

Gingival recession is defined as the displacement of marginal tissue apical to cementoenamel junction, exposing the root surface. It is caused by traumatic toothbrushing, periodontitis, high frenal attachment, and injudicious orthodontic tooth movement. It leads to dentinal hypersensitivity, aesthetic problem, root caries, cervical abrasion and difficulty in oral hygiene maintenance. This can be managed by root coverage procedure which can be achieved by various surgical techniques. This case report shows successful management of Miller’s Class II gingival recession using sub-epithelial connective tissue graft procedure that was followed up for six months without any complications.

Allografts and Xenografts for Periodontal Plastic Surgical Procedures

The selection of surgical techniques and grafting materials is undoubtedly a critical component in the treatment of gingival recession defects. In order to provide top quality care, dental professionals are always in pursuit of treatment modality that provides maximal efficacy and predictability with minimal patient morbidity. The subepithelial connective tissue graft procedure, the gold standard, has been consistently proven to show excellent root coverage, but limited palatal tissue availability and potential morbidity associated with the harvesting process push dental practitioners to seek an alternative. The same holds true for peri-implant tissues—while autogenous grafts have served our purpose well, alternatives that can achieve similar results while avoiding a second intraoral wound (the donor sites) are preferred. The purpose of this review of recent studies is to evaluate the effectiveness and predictability of allografts and xenografts for root coverage procedures and around dental implants. The electronic database search was limited to the past 5 years and to the studies addressing root coverage procedures in the Miller class I and II gingival recession (even though the 2017 International Workshop suggested a new classification, the majority of research projects use the classic Miller classification). Search was also made for studies addressing soft tissue treatment around implants that were published during the same period. A total of 30 human clinical trials involving allografts (mainly acellular dermal matrix and placental membranes) and xenografts (porcine-derived collagen matrix) for treatment of gingival recession and a total of 19 clinical studies using allografts and xenografts to improve soft tissue quality around implants were selected. Based on the selected studies, acellular dermal matrix in combination with various flap designs appears to produce results similar to autogenous grafts in terms of mean root coverage and width of keratinized tissue. Other grafting materials, while less effective compared to autogenous grafts, still show some promise especially in patient-centered outcomes. For soft tissue quality improvement around implant sites, allografts and xenografts in general provide satisfactory clinical results. Multicenter, randomized clinical studies with large numbers of individuals and long-term outcomes may provide the most realistic answer for this topic.

Sub-epithelial connective tissue graft for the management of Miller's class I and class II isolated gingival recession defect: A systematic review of the factors influencing the outcome.

The aim of the present systematic review was to analyze the factors that affect the outcome of subepithelial connective tissue graft (SCTG) for managing Miller's class I and class II isolated gingival recession defect. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for systematic reviews were used. Quality assessments of selected articles were performed. Data on root surface condition, recession type defect, flap thickness, different flap designs, different harvesting techniques, presence/absence of the epithelial collar, graft thickness, flap tension, suturing techniques, and smoking-related outcomes on root coverage were assessed. The SCTG procedure provides the best root coverage outcomes for Miller's class I and class II recession. The critical threshold of flap thickness was found to be 1mm. Maximum root coverage was achieved by envelope and modified tunnel technique. SCTG with the epithelial collar does not provide additional gains than SCTG without the epithelial collar. The thickness of SCTG for root coverage was found to be 1.5-2mm. Greater flap tension and smoking adversely affect root coverage outcomes. Analysis of the factors discussed would be of key importance for technique selection, and a combined approach involving factors favoring outcomes of SCTG could be of clinical relevance in recession coverage.

Root Coverage Procedures for Multiple Recession Defects

The demand for root coverage in multiple gingival recession defects has increased in recent years. Compared to isolated recession, multiple gingival recession defects are much more challenging due to various limiting factors and require more sophisticated surgical techniques. This review aims to address recent progress in the management of multiple recession defects. The subepithelial connective tissue graft (SCTG) procedure, while effective, is limited due to tissue availability and patient preference to avoid a donor harvest site. Different surgical techniques and biological materials have been studied in an attempt to find ideal alternatives. Based on the studies reviewed, the SCTG procedure still remains the gold standard in terms of percent root coverage. Acellular dermal matrix allograft in conjunction with different flap designs has shown comparable, satisfactory results up to 1 year postoperatively. Other materials such as porcine collagen matrix and enamel matrix derivative also show some promise. Well-designed studies with long-term outcomes are still needed.

Gingival Cyst of the Adult as Early Sequela of Connective Tissue Grafting.

The subepithelial connective tissue graft (SCTG) is a highly predictable procedure with low complication rate. The reported early complications consist of typical postsurgical sequelae, such as pain and swelling. This case report describes the development and management of a gingival cyst following SCTG to obtain root coverage. Three weeks after SCTG procedure, a slightly raised, indurated, ~5 mm diameter asymptomatic lesion was evident. Excisional biopsy was performed and the histopathological evaluation confirmed the gingival cyst diagnosis. At the 1-year follow-up, the site had complete root coverage and normal tissue appearance and the patient remained asymptomatic.

Dimensional Changes During Early Healing After a Subepithelial Connective Tissue Graft Procedure

The subepithelial connective tissue graft (CTG) is a popular means to treat gingival recession and augment keratinized tissue. Studies exist that examine long-term outcomes of this procedure; however, changes in tissue dimensions during early healing (0 to 21 days postoperatively) are unknown. The aim of this study is to examine bucco-lingual tissue dimension (gingival tissue thickness [GT]) changes during early CTG healing using a non-invasive technique. Thirteen patients who had treatment planned for CTG on a single tooth were recruited for the study. Using a customized acrylic stent, GT was measured preoperatively, at surgery completion, and at 3, 7, 14, and 21 days postoperatively. CTG was performed using an envelope technique. GT changes were analyzed by repeated-measures analysis of variance. All CTG procedures were considered successful with no postoperative complications. GT increased 1.5 mm immediately after surgery (baseline) compared to the preoperative measurement. GT increased on average 96%, 47%, and 2% compared to baseline at days 3, 7, and 14, respectively. Day 3 and day 7 measurements were significantly different from baseline (P <0.001). At day 21, GT decreased 15% compared to baseline, with an average increase of 1.29 mm from preoperative measurements. The early postoperative healing of CTGs used for root coverage exhibits a significant but transient increase in bucco-lingual tissue dimension. The observed increase in bucco-lingual tissue dimension subsides by the end of the second postoperative week.

Assessment of Palatal Masticatory Mucosa: A Cross-sectional Study

To treat mucogingival problems palatal masticatory mucosa is used as a donor material. This study aimed to determine the thickness of donor palatal mucosa and associations of age and gender in Indian subjects aged 14 to 60 years by direct clinical technique. Forty systemically and periodontally healthy Indian subjects (20 males; 20 females; age range of 14 to 60 years) enrolled in this study. Under local anesthesia bone sounding technique was performed at 15 defined and predetermined points. The Wilcoxon test was used to determine the difference in mucosal thickness between the age groups and between genders. Significance of the difference between individuals of different body mass index (BMI) was assessed by independent t-test. With mean thickness of 2.0 to 3.7 mm, the younger age group demonstrated significantly thinner donor mucosa (mean 2.8±0.3 mm) than the older age group (mean 3.1±0.3 mm). Within the same age group though statistically not significant; males had thicker mucosa than females. From the canine to second premolar areas and in the sites furthest from the gingival margin mucosa thickness increased. When correlated with subject's BMI, in all probed sites males demonstrated significantly a thicker mucosa than females. Within each group subjects with high BMI demonstrated thicker donor mucosa. Current study showed that in both adult and young individuals, premolar and canine areas can be the right site for harvesting donor tissue. Even in young subjects subepithelial connective tissue (CT) graft can be harvested in adequate volume. Donor tissue thickness can be influenced by factors like genetics and race, which need to be further evaluated. Premolar and canine areas serve as appropriate choice to harvest palatal masticatory mucosa. Even in young patients the volume of donor tissue available is sufficient enough to consider the subepithelial CT graft procedure. Donor tissue thickness can be influenced by factors like genetics and race, which need to be further evaluated.

Full mouth re-restoration of partially edentulous dentition: A periodontic, endodontic, orthodontic and prosthodontic interrelationship-2 year follow-up

An interdisciplinary approach towards full mouth re-restoration of severely compromised dentition requires; complete understanding of the patient's problem through history and examination of the dentition. The treatment approach should begin with an appropriate diagnosis and predictable prognosis sequencing it with specialty treatment to obtain a successful result. This clinical case report describes the implementation of a diagnostically based treatment plan for treating the maxillary arch with flap surgery and intrusion, partially edentulous mandibular arch treated by extracting the hopeless teeth and replacing the missing with an over-denture. During follow-up esthetic management of the gingival recession with respect to upper right central incisor was done using a sub-epithelial connective tissue graft procedure and paramount importance was placed on supportive periodontal therapy during the follow-up period of 2 years. Clinical Relevance to Interdisciplinary Dentistry The article describes an interdisciplinary approach for a successful implementation of interdisciplinary treatment to resolve dental problems for an individual requiring full-mouth re-restoration. Describes an unique way of restoring lost aesthetics and function.

Subepithelial Connective Tissue Graft for Root Coverage: A Case Report of an Unusual Late Complication of Epithelial Origin

The subepithelial connective tissue graft (SCTG) is one of the most used and predictable periodontal plastic surgery procedures; reports of late complications are very rare. This article presents an SCTG case with a previously unreported late complication of epithelial origin, and we suggest a potential link between the patient's dermatologic condition and this complication. Late SCTG complications also are reviewed. A 19-year-old female presented with a 3-mm deep Miller Class I recession defect on the mandibular right central incisor. An SCTG procedure was performed for root coverage, with uneventful initial postoperative healing that resulted in complete root coverage. At 4 months, an asymptomatic solid white discharge was observed at sites along the original graft margin without evidence of inflammation. A month later, the somewhat reduced but still evident discharge was collected and submitted for microscopic examination. Cytologic examination revealed the discharge to be normal epithelial cells, suggesting a proliferative epithelial response. Follow-up indicated that the discharge was self-limiting and was no longer present at 9 months after surgery. This unusual late SCTG complication is consistent with reported epithelial invaginations and projections between graft and overlying flap. The patient had acne, a disease whose pathogenesis includes host predisposition to epithelial hyperproliferation; therefore, a possible association of this SCTG complication with the patient's systemic health is proposed. Epithelial cell discharge is a hitherto unreported, self-limiting, late complication of the SCTG procedure, and a potential association between this complication and the patient's dermatologic condition is suggested.

Morbidity and Economic Complications Following Mucogingival Surgery in a Hemophiliac HIV‐Infected Patient: A Case Report

This report describes the surgical treatment of a gingival recession in a hemophiliac HIV-infected patient. To our knowledge, mucogingival surgery has not been described previously in these patients. Under the supervision of the patient's hematologist, a subepithelial connective tissue graft procedure was carried out to treat the recession. The treatment was performed after substitution therapy with factor VIII concentrate, supported by local antifibrinolytic treatment with epsilonaminocaproic acid. One week after surgery, the grafted zone showed a normal healing, but an area of necrosis appeared at the donor palatal site with spontaneous bleeding. The administration of factor VIII concentrate had to be prolonged to arrest the hemorrhage. In total, 44,500 units of factor VIII concentrate were used, the cost of which reached around $20,000. After 1 month the donor site had re-epithelialized by secondary intention. The root coverage was around 85% successful. Because of the surgical risk and the high economic cost in the use of the factor VIII concentrate, we do not recommend performing mucogingival surgery in HIV-infected hemophiliacs unless it is absolutely necessary. Prevention and early treatment must be the goal in the management of these patients.

Thickness of palatal masticatory mucosa associated with age.

The palatal masticatory mucosa is widely used as a donor material in periodontal plastic surgery. However, there are relatively few studies investigating the volume or thickness of the palatal mucosa. The purpose of this study was to determine the thickness of palatal masticatory mucosa in Asian subjects aged 14 to 59 years by a direct clinical technique. The associations of age and gender with the thickness of palatal mucosa were also examined. Sixty-two systemically and periodontally healthy Asians (31 males; 31 females; age range 14 to 59 years) participated in this study. The younger age group (age 14 to 21 years) consisted of 32 subjects with a mean age of 16.8 years, whereas the older age group (age 30 to 59 years) consisted of 30 subjects with a mean age of 38.7 years. A bone-sounding method using a periodontal probe with minimal anesthesia and a prepared clear acrylic stent were utilized to assess the thickness of palatal mucosa at 15 measurement sites defined according to the gingival margin and mid-palatal line. Multiple linear regression analysis was performed to examine the associations of age and gender with the mean mucosal thickness at the subject level. The Wilcoxon test was used to determine the difference in mucosal thickness between the 2 age groups, and between gender at each measurement point. The mean thickness of palatal masticatory mucosa ranged from 2.0 to 3.7 mm. The younger age group had significantly thinner mucosa (mean 2.8 +/- 0.3 mm) than the older age group (mean 3.1 +/- 0.3 mm). Females had thinner mucosa than males in the same age group, but the difference was not statistically significant. Overall, the thickness of palatal mucosa increased from the canine to second molar areas and in the sites furthest from the gingival margin towards the mid-palate (with the exception of the first molar area, where significantly decreased thickness was observed). Within the limits of the present study, the canine and premolar areas appear to be the most appropriate donor site for grafting procedures in both young and adult individuals. The subepithelial connective tissue graft procedure can be considered as a treatment modality in young patients, since a sufficient volume of donor tissue can be obtained from the hard palate area. Other factors that may influence the thickness of palatal mucosa such as racial and genetic factors and body weight need to be further investigated.

A Subepithelial Connective Tissue Graft Procedure for Optimum Root Coverage

Since the beginning of Oral Implantology, preventive antibiotic therapy has been routinely prescribed. However, at present, due to the growing appearance of antimicrobial resistance, its use has been questioned, generating a great debate and an emerging controversy. The present systematic review aims to analyze the scientific literature to determine whether the preventive prescription of antibiotics in augmentation procedures with the insertion of implants in one or two phases decreases the incidence of postoperative infections and/or the survival rate of the implants.The MEDLINE database was searched (via PubMed) with the following keywords: (bone grafting OR alveolar ridge augmentation OR bone graft augmentation OR guided bone regeneration OR bone block) AND (dental implants OR dental implant OR oral implantology) AND (antibiotic prophylaxis OR antibiotics). The criteria used were those described by the PRISMA® Statement. The search was limited to randomised clinical trials, systematic reviews and meta-analyses published in the last 15 years (2005–2020).After reading the titles and abstracts of the resulting articles, only one systematic review meeting the described criteria and 4 randomised clinical trials were included.Prescription of 2 or 3 g of amoxicillin one hour before surgery is recommended to reduce the early failure rate of one-stage implants and to decrease the bacterial load of grafted bone particles in bone augmentation procedures with one or two-stage implants.