Donor site wound healing following free gingival graft surgery using platelet rich fibrin: A randomized controlled trial.

BACKGROUND: The primary purpose of this two-arm, parallel design, randomized controlled study is to compare healing of the palatal tissue donor site when platelet-rich fibrin (PRF) is used as a wound dressing compared to the use of a hemostatic agent. Secondary outcomes of patient pain perception and analgesic intake were also evaluated. METHODS: Seventy-four patients receiving free gingival grafts were randomized to receive either PRF (test) or hemostatic agent (control) as a palatal wound dressing by patients selecting a sealed envelope containing their group assignment (initially 37 envelopes for PRF group and 37 for hemostatic agent group). Patient pain assessment and analgesic consumption were documented using a 21-point numerical scale (NMRS-21) at 24, 48, and 72 hours post-surgery. At 1-, 2-, 3-, and 4-week follow-up appointments palatal early healing index (PEHI) scores including wound color, epithelialization, presence or absence of swelling, granulation tissue, and bleeding on gentle palpation were generated by direct intraoral examination by a blinded examiner unaware of the patients' treatment group. RESULTS: NMRS-21 pain scores showed a significant reduction in pain over time in both groups, with no significant difference between groups at any time point. No significant between-group difference was found in the amount of analgesics taken by patients at 24, 48, and 72 hours. There was significant improvement in PEHI scores over the 4-week time period in both groups, but there was no significant difference in PEHI score at each time point (1, 2, 3, 4 weeks) between groups.  CONCLUSIONS: Study findings suggest that there is no difference in early palatal wound healing, patient pain perception, or analgesic consumption between use of PRF or a hemostatic agent as donor-site wound dressings.

Prophylaxis of microvascular thrombosis using direct oral anticoagulants (DOAC) in microvascular free tissue transplantation - a pilot study.

INTRODUCTION: We conducted this pilot study to assess direct oral anticoagulants (DOACs) in the prevention of microvascular thrombosis. MATERIALS AND METHODS: Five patients undergoing microvascular free tissue transplantation received rivaroxaban or apixaban (depending on their home medication). We compared this group to 19 patients who received enoxaparin subcutaneously. We evaluated the rate of graft loss due to microvascular thrombosis and the number of transfusions administered intra- and postoperatively. RESULTS: There was no graft loss due to microvascular thrombosis in either of the groups. There was no significant difference in the number of intraoperative (study group mean 1.00 (SE 0.32) vs. control group mean 1.11 (SE 0.59); p = 0.876) and postoperative (study group mean 1.2 (SE 0.37) vs. control group mean 1.74 (SE 0.34); p = 0.310) red blood cell transfusions. CONCLUSION: Based on our results in this pilot study, DOACs can be used with microvascular flaps. Further studies with larger sample sizes should be performed to find an optimal medication regimen both for patients already taking DOACs and perhaps even for those not taking DOACs.

Long-term stability of gingival margin and periodontal soft-tissue phenotype achieved after mucogingival therapy: A systematic review.

BACKGROUND: The aim of this systematic review was two-fold: (i) to evaluate the long-term (≥5 years) stability of the gingival margin position, keratinized tissue width (KTW) and gingival thickness (GT) in sites that underwent root coverage (RC) or gingival augmentation (GA); and (ii) to assess the influence of different local variables on the long-term stability of dental and gingival tissues. MATERIALS AND METHODS: Randomized controlled trials (RCTs) and non-RCTs reporting short-term (i.e., 6-12 months after baseline surgical intervention) and long-term (≥5 years) follow-up data after surgical treatment of adult patients presenting single or multiple mucogingival deformities, defined as sites presenting gingival recession defects (GRDs) and/or (KTW) deficiency (i.e., <2 mm), were considered eligible for inclusion. MEDLINE-PubMed, EMBASE and Cochrane Central Register of Controlled Trials databases were searched for articles published up to 15 May 2023. Mixed-effects multiple linear regression was used to assess the association between KTW, type of surgical procedure and time (i.e., independent variables) on the stability of the gingival margin in sites that received RC or GA therapy. RESULTS: Of the 2569 potentially eligible records, 41 (reporting 40 studies) met the eligibility criteria. Graphical estimates including data from all RC procedures found an upward trend in recession depth (RD) increase over time. Conversely, it was observed that in 63.63% of RC studies and in 59.32% of RC treatment arms KTW increased over time, particularly in sites treated with subepithelial connective tissue grafts (SCTGs). Conversely, sites that underwent GA procedures generally exhibited an overall reduction of KTW over time. However, sites treated with free gingival grafts (FGGs) showed a decrease in RD after 10 years of follow-up. Three main findings derived from the pooled estimates were identified: (i) Gingival margin stability was associated with the amount of KTW present during short-term assessment (i.e. the greater the KTW at 6-12 months after treatment, the more stable the gingival margin). (ii) The use of autogenous soft-tissue grafts was associated with lower RD increase over time. (iii) Treatment approaches that contribute to the three-dimensional enhancement of the gingival phenotype, as clearly demonstrated by FGG, were associated with gingival margin stability. CONCLUSIONS: The extent of apical migration of the gingival margin appears to be directly related to the amount of KTW and GT upon tissue maturation. Interventions involving the use of autogenous grafts, either SCTG or FGG, are associated with greater short-term KTW gain and lower RD increase over time.

The effects of vertically coronally advanced flap and free gingival graft techniques on shallow vestibule: a randomized comparative prospective trial.

OBJECTIVES: The present study aimed to compare the influence of vertically coronally advanced flap (V-CAF) and free gingival graft (FGG) techniques on shallow vestibule depth (VD). MATERIALS AND METHODS: Parallel-arm randomized clinical trial was conducted on 38 sites treated with either FGG or V-CAF. Periodontal variables (VD, recession depth and width, probing depth, clinical attachment level, keratinized tissue height (KTH), and tissue thickness (TT)), clinician- and patient-based subjective variables were assessed. RESULTS: All periodontal variables showed significant improvements in both groups at all follow-up intervals compared to baseline (p < 0.05). Both groups increased VD compared to baseline. RC and CRC were similar after treatment for both techniques. FGG provided a greater increase in KTH (p < 0.001) and VD (VD1, p = 0.02 and VD2, p < 0.001) while V-CAF exhibited more TT gain (p = 0.002). Except overall tissue appearance that was better in V-CAF (p < 0.001), no inter-group significant difference existed in patient-based variables. CONCLUSIONS: Both techniques were significantly effective in VD increasing. While both techniques were equally successful in RC, V-CAF provided higher TT gain and better tissue appearance. V-CAF can be chosen instead of FGG in the treatment of recessions with shallow VD. CLINICAL RELEVANCE: It can be recommended to prefer V-CAF instead of FGG in the treatment of shallow vestibule. TRIAL REGISTRATION NUMBER: NCT05777811 (clinicaltrials.gov).

The clinical significance and application of the peri-implant phenotype in dental implant surgery: a narrative review.

Background and Objective: In recent years, the concept of the peri-implant phenotype has become a new standard for the clinical evaluation of the soft and hard tissues surrounding dental implants. Improving this phenotype enhances the likelihood of achieving long-term favorable results and is a necessary consideration during implant planning. Stable peri-implant tissue support is also crucial for the functional and aesthetic value of implant restoration. Herein, the authors review the clinical significance of the peri-implant phenotype and assess the timing of treatment strategies for improving peri-implant phenotype elements. Methods: A literature search was performed to retrieve papers on peri-implant tissue management and clinical outcomes published up to November 24th, 2022 in PubMed, Web of Science, EMBASE, and Scopus. Key Content and Findings: The optimal time to improve peri-implant bone thickness (PBT) is with augmentation procedures before implant surgery or at the same time as first-stage surgery. Similarly, issues associated with keratinized mucosa width (KMW) and mucosal thickness (MT) should be addressed before final restoration. The establishment of supracrestal tissue height (STH) depends on the MT and implant depth of the patient. Furthermore, special attention should be paid to the effect of the peri-implant phenotype on the prognosis of immediate implant placement in the aesthetic zone. Conclusions: The long-term success of implant restoration depends on careful planning that considers appropriate interventions for improving the peri-implant phenotype at different stages of treatment to reduce iatrogenic variables.

Three-dimensional mapping of the greater palatine artery location and physiology.

OBJECTIVE: To develop a novel technique for localizing and reconstructing the greater palatine artery (GPA) using three-dimensional (3D) technology. METHODS: A miniaturized intraoral ultrasound transducer was used to imaging landmarks including the GPA, gingival margin (GM), and palatal masticatory mucosa (PMM). A 5-mm-thick solid hydrogel couplant was integrated to replace traditional ultrasound gel and avoid bubbles when moving the transducer. RESULTS: A panorama image provided the relative localization of landmarks including the GPA, PMM, and hard palate. Short- and long-axis imaging of GPA was performed in five subjects including 3D mapping of GPA branches and surrounding tissues in a volume of 10 mm × 8 mm × 10 mm. Full-mouth Doppler imaging was also demonstrated on both the dorsal and ventral tongue as well as buccal mucosa and sublingual region on two subjects. CONCLUSIONS: This study can measure the vertical distance from the GM to the GPA and depth from PMM to GPA and visualize the GPA localization in a 3D manner, which is critical to evaluate the available volume of palatal donor tissues and avoid sectioning of GPA during surgical harvesting of the tissues. Finally, the transducer's small size facilitates full-mouth Doppler imaging with the potential to improve the assessment, diagnosis, and management of oral mucosa.

Abdominal wall hernia repair: from prosthetic meshes to smart materials.

Hernia reconstruction is one of the most frequently practiced surgical procedures worldwide. Plastic surgery plays a pivotal role in reestablishing desired abdominal wall structure and function without the drawbacks traditionally associated with general surgery as excessive tension, postoperative pain, poor repair outcomes, and frequent recurrence. Surgical meshes have been the preferential choice for abdominal wall hernia repair to achieve the physical integrity and equivalent components of musculofascial layers. Despite the relevant progress in recent years, there are still unsolved challenges in surgical mesh design and complication settlement. This review provides a systemic summary of the hernia surgical mesh development deeply related to abdominal wall hernia pathology and classification. Commercial meshes, the first-generation prosthetic materials, and the most commonly used repair materials in the clinic are described in detail, addressing constrain side effects and rational strategies to establish characteristics of ideal hernia repair meshes. The engineered prosthetics are defined as a transit to the biomimetic smart hernia repair scaffolds with specific advantages and disadvantages, including hydrogel scaffolds, electrospinning membranes, and three-dimensional patches. Lastly, this review critically outlines the future research direction for successful hernia repair solutions by combing state-of-the-art techniques and materials.

Blood-derived biomaterials for tissue graft biofabrication by solvent-based extrusion bioprinting.

This article provides an overview of the different types of blood-derived biomaterials that can be used as solvent additives in the formulation of inks/bioinks for use in solvent extrusion printing/bioprinting. We discuss the properties of various blood sub-products obtained after blood fractionation in terms of their use in tailoring ink/bioink to produce functional constructs designed to improve tissue repair. Blood-derived additives include platelets and/or their secretome, including signaling proteins and microvesicles, which can drive cell migration, inflammation, angiogenesis, and synthesis of extracellular matrix proteins. The contribution of plasma to ink/bioink functionalization relies not only on growth factors, such as hepatocyte growth factor and insulin growth factors, but also on adhesive proteins, such as fibrinogen/fibrin, vitronectin, and fibronectin. We review the current developments and progress in solvent-based extrusion printing/bioprinting with inks/bioinks functionalized with different blood-derived products, leading toward the development of more advanced patient-specific 3D constructs in multiple medical fields, including but not limited to oral tissues and cartilage, bone, skin, liver, and neural tissues. This information will assist researchers in identifying the most suitable blood-derived product for their ink/bioink formulation based on the intended regenerative functionality of the target tissue.

Local Concentrations of TGF-ß1 and IGF-1 Appear Determinant in Regulating Bone Regeneration in Human Postextraction Tooth Sockets.

Healing after tooth extraction involves a series of reparative processes affecting both alveolar bone and soft tissues. The aim of the present study was to investigate whether activation of molecular signals during the healing process confers a regenerative advantage to the extraction socket soft tissue (ESsT) at 8 weeks of healing. Compared to subepithelial connective tissue graft (CTG), qRT-PCR analyses revealed a dramatic enrichment of the ESsT in osteogenic differentiation markers. However, ESsT and CTG shared characteristics of nonspecialized soft connective tissue by expressing comparable levels of genes encoding abundant extracellular matrix (ECM) proteins. Genes encoding the transforming growth factor-ß1 (TGF-ß1) and its receptors were strongly enriched in the CTG, whereas the transcript for the insulin-like growth factor-1 (IGF-1) showed significantly high and comparable expression in both tissues. Mechanical stimulation, by the means of cyclic strain or matrix stiffness applied to primary ESsT cells (ESsT-C) and CTG fibroblasts (CTG-F) extracted from the tissue samples, revealed that stress-induced TGF-ß1 not exceeding 2.3 ng/mL, as measured by ELISA, in combination with IGF-1 up to 2.5 ng/mL was able to induce the osteogenic potential of ESsT-Cs. However, stiff matrices (50 kPa), upregulating the TGF-ß1 expression up to 6.6 ng/mL, caused downregulation of osteogenic gene expression in the ESsT-Cs. In CTG-Fs, endogenous or stress-induced TGF-ß1 ≥ 4.6 ng/mL was likely responsible for the complete lack of osteogenesis. Treatment of ESsT-Cs with TGF-ß1 and IGF-1 proved that, at specific concentrations, the two growth factors exhibited either an inductive-synergistic or a suppressive activity, thus determining the osteogenic and mineralization potential of ESsT-Cs. Taken together, our data strongly warrant the clinical exploration of ESsT as a graft in augmentative procedures during dental implant placement surgeries.

Aesthetic evaluation of free gingival graft applied by partial de-epithelialization and free gingival graft applied by conventional method: a randomized controlled clinical study.

OBJECTIVE: The aim of this clinical study was to compare the partially de-epithelialized free gingival grafts (d-FGGs) with the conventional free gingival grafts (FGGs) aesthetically using photographic analysis and Visual Analogue Scale (VAS). MATERIALS AND METHODS: A total of 30 defects were treated in 15 patients with attached gingiva insufficiency. In the split-mouth study, d-FGGs were applied on one side (test group), while FGGs were applied on the contralateral side (control group). Results of clinical periodontal parameters were evaluated in 6-month follow-up, and aesthetic evaluation results were evaluated in 1-, 3-, and 6-month follow-ups. RESULTS: Among the periodontal clinical parameters examined, only the keratinized tissue (KT) width was found to be statistically significantly higher in the test group compared to the control group. In the photo analysis evaluation, the ΔE value at the 3rd month was statistically significantly higher in the test group. In VAS evaluation, there was no significant difference between the two groups in the time periods examined. CONCLUSION: Photo analysis is an objective, sensitive, reproducible, and safe method that can be used in dentistry and medicine by detecting the slightest changes and giving more detailed and superior results than visual evaluation. The d-FGG application could provide acceptable aesthetic results by providing an appearance compatible with the gingival contour and gingiva in the adjacent region in creating keratinized gingiva. CLINICAL RELEVANCE: While the free gingival graft has color differences with the recipient area, the deep-thelialized gingival graft has a compatible appearance with the recipient area. Partially, de-epithelialized free gingival graft is a method with acceptable aesthetic results. TRIAL REGISTRATION: U.S. National Institutes of Health Clinical Trials: NCT04970524.

Histological and histomorphometric study of human palatal mucosa: Implications for connective tissue graft harvesting.

AIMS: To analyse the histological structure and histomorphometric characteristics of human hard palatal mucosa in order to determine the donor site of choice for connective tissue grafts from a histological point of view. MATERIALS AND METHODS: Palatal mucosa samples from six cadaver heads were harvested at four sites: incisal, premolar, molar and tuberosity. Histological and immunohistochemical techniques were performed, as was histomorphometric analysis. RESULTS: In the current study, we found that the density and size of cells were higher in the superficial papillary layer, whereas the thickness of the collagen bundles increased in the reticular layer. Excluding the epithelium, the mean percentage of lamina propria (LP) and submucosa (SM) was 37% and 63%, respectively (p < .001). LP thickness showed similar values in the incisal, premolar and molar regions, and a significantly greater thickness in tuberosity (p < .001). The thickness of SM increased from incisal to premolar and molar, disappearing in the tuberosity (p < .001). CONCLUSIONS: As dense connective tissue of LP is the tissue of choice for connective tissue grafts, the best donor site from a histological point of view is tuberosity because it is composed only of a thick LP without the presence of a loose submucosal layer.

Management of Stable Vitiligo-A Review of the Surgical Approach.

At present, vitiligo is the most common depigmenting skin disorder, characterized by clearly demarcated discolored patches of various shapes and sizes. Depigmentation results from the initial dysfunction and subsequent destruction of melanin-producing cells, called melanocytes, which are located in the basal layer of the epidermis and in hair follicles. This review concludes that the extent of repigmentation, regardless of the treatment method, is greatest in stable localized vitiligo patients. The aim of this review is to provide an overview of the clinical evidence for which the vitiligo treatment method (cellular or tissue) is more effective. The treatment relies on multiple factors, ranging from patient skin predisposition for repigmentation to the experience of the facility performing the procedure. Vitiligo is a significant problem in modern society. Although it is a typically asymptomatic and not life-threatening disease, it may have significant psychological and emotional impacts. Standard treatment relies on pharmacotherapy and phototherapy; however, the treatment of patients with stable vitiligo varies. The stability of vitiligo more than often implies the exhaustion of the potential for skin self-repigmentation. Thus, the surgical methods that distribute normal melanocytes into the skin are crucial elements of these patients' therapy. The most commonly used methods are described in the literature, with an indication of their recent progress and changes. In addition, information on the efficiency of the individual methods at specific locations is compiled in this study, and the prognostic factors indicating repigmentation are presented. Cellular methods are the best therapeutic option for large-sized lesions; although they are more exorbitant than tissue methods, they benefit from more rapid healing times and presenting fewer side effects. Dermoscopy is a valuable tool used to assess the further course of repigmentation, where it is of great value to evaluate the patient prior to and following an operation.

Effectiveness of Plasma-Rich Fibrin and De-Epithelialized Free Gingival Graft in the Treatment of Gingival Recessions.

Introduction/Aim: Soft tissue dehiscences such as gingival recessions are a very common problem that we face in modern periodontics. This clinical study aimed to analyze the effectiveness of surgical procedures using a de-epithelialized gingival graft (DGG) combined with a coronally advanced flap and to evaluate the application of plasma-rich fibrin (PRF). Methods: The study included 40 teeth (20 patients) with Miller class I and II gingival recessions. Twenty recessions (20 patients) were treated utilizing the de-epithelialized gingival graft in combination with the coronally advanced flap, and on the opposite side of the jaw, the same number of recessions were treated utilizing plasma-rich fibrin combined with the coronally advanced flap. To evaluate tissue condition and the clinical parameters before and after the surgical procedure, the following parameters were used: the degree of epithelial attachment (DEA), the width of keratinized gingiva (WKG), and the vertical depth of recession (VDR). Results: based on the achieved results and the analysis of clinical parameters, a statistically significant reduction in the vertical depth of recession was proven in both groups, with very similar mean percentages of root coverage, with the difference being that the stability of the soft tissues of the treated region was more visible in the DGG. Conclusion: using modern surgical procedures allows the regeneration of not only the soft tissues but also deeper periodontal tissues.

Gingival pedicle with split-thickness tunnel technique: A retrospective case series for single mandibular anterior recessions.

INTRODUCTION: Gingival recessions in the mandibular anterior sextant are a common clinical finding, but mucogingival treatment in this location is particularly challenging, due to several anatomical and surgical difficulties. In the present case series, a novel technique, called gingival pedicle with split-thickness tunnel (GPST), was retrospectively evaluated. CASE SERIES: Fifteen patients presenting with a single buccal RT1 or RT2 gingival recession of a depth of ≥3 mm in the mandibular anterior sextant were treated by means of the GPST technique. Clinical periodontal parameters at baseline and at the last follow-up evaluation visit (6-84 months) were compared. Early healing was uneventful in all cases, and no complications such as flap dehiscence or loss of connective tissue graft were observed. Mean root coverage (mRC) was 98.1% ± 7.38%, corresponding to a statistically significant recession reduction (ΔRD) of 4.53 ± 1.19 mm. Complete root coverage was achieved in 14 of 15 cases. The gain in keratinized tissue width amounted to 3.13 ± 0.99 mm and was statistically significant, whereas no significant change in periodontal probing depth was observed after treatment. CONCLUSION: In conclusion, treatment with GPST technique seems to achieve a favorable and predictable clinical improvement in gingival recessions on mandibular anterior teeth. Why are these cases new information? Limited information is available about the management of isolated deep labial recessions in the mandibular anterior teeth. A novel surgical approach, called GPST technique, is described in a case series to specifically address this type of defect. What are the keys to successful management of these cases? Horizontal incision ≥ RECwidth Cut-back preparation helps to mobilize the flap without tension. CTG width ≥ 3 times RECwidth CTG height ≥ RECdepth Proper graft and flap stabilization need to be achieved. What are the primary limitations to success in these cases? Limited mesio-distal dimensions, which do not allow to obtain a pedicle with adequate horizontal width Very thin biotype may not be suitable because of the risk of inadequate flap vascularization.

Incision-free, coronally advanced flap with subepithelial connective tissue graft placed by the molar or canine access (MOCA) technique: 13 case series.

INTRODUCTION: Root coverage procedures are not always predictable, and outcomes depend on several factors. This technique provides a predictable alternative to managing facial gingival recessions. CASE SERIES: A new grafting technique is introduced that requires no incisions at the recipient site, thereby preserving the integrity of the local blood supply to optimize the healing process. The graft is placed through the gingival sulcus via a molar or canine access (MOCA) approach, and there is minimal tension on the coronally advanced flap through use of suspension sutures. Thirteen non-smoking patients, between the ages of 27 and 57, with Cairo RT1 facial recession were studied, with a follow-up period of 1-60 weeks. This paper explains the step-by-step technique and highlights 13 cases. CONCLUSION: Complete root coverage was achieved in all 13 cases, although one case showed initial altered healing. While MOCA is technique sensitive, it provides optimal root coverage results. With no incisions at the recipient site, there is no uneven texture or scar formation, and healing proceeds with minimal interruption. Why is this case series new information? MOCA is a unique approach to introduce grafts into non-incised sites of recession that can be one, two, or three teeth away at molars or canines. Non-incised approach minimizes interruption to blood supply. Coronally advanced flaps are secured in place with composite-fastened suspension sutures for tension-free flap closure. What are the keys to successful management of these cases? Good quality and quantity of connective tissue graft Early diagnosis and treatment of recession Expert surgical technique What are the key limitations to the success of these cases? The quality of the donor site is variable among patients. A technique-sensitive approach Advanced recession might warrant a second surgery.

Cyanoacrylate and hyaluronic acid combination on palatal donor site management after de-epithelialized graft harvesting.

BACKGROUND: Although soft tissue substitutes showed promising improvement in the past decade, epithelialized gingival graft (EGG) is still widely used in periodontal plastic surgery applications. Donor site management after EGG harvesting has been challenging for clinicians. This study aimed to compare the effectiveness of cyanoacrylate, hyaluronic acid, and their combination in palatal donor site management after EGG harvesting. METHODS: Data from 89 patients were included and categorized as gelatin sponge (GS), gelatin sponge with either cyanoacrylate (GS + CY), hyaluronic acid (GS + HA), or both (GS + CY + HA). The data of pain perception (PP), quantity of analgesics (QA), secondary bleeding (SB), epithelization level (EL), and color match (CM) were assessed retrospectively. RESULTS: The GS + CY and GS + HA + CY groups showed lower PP scores compared to the GS and GS + HA groups (p < 0.05). The QA was higher in the GS group compared to the GS + CY and GS + HA + CY groups (p < 0.001). All study groups showed greater EL than GS group on day 7 (p < 0.001). On day 14, full EL was present in 81% of the patients in the GS + HA + CY group, which was higher than the other groups (p < 0.001). All study groups reported lower SB in the first 3 days, which was lower compared to the GS group (p < 0.001) and showed higher CM scores than the GS group on days 7 and 14 (p < 0.001). CONCLUSIONS: CY application reduces pain and analgesic intake and HA may support the wound healing with increased EL. Using the CY-HA combination provides additional benefits for donor site management.

Wound healing dynamics, morbidity, and complications of palatal soft-tissue harvesting.

Palatal-tissue harvesting is a routinely performed procedure in periodontal and peri-implant plastic surgery. Over the years, several surgical approaches have been attempted with the aim of obtaining autogenous soft-tissue grafts while minimizing patient morbidity, which is considered the most common drawback of palatal harvesting. At the same time, treatment errors during the procedure may increase not only postoperative discomfort or pain but also the risk of developing other complications, such as injury to the greater palatine artery, prolonged bleeding, wound/flap sloughing, necrosis, infection, and inadequate graft size or quality. This chapter described treatment errors and complications of palatal harvesting techniques, together with approaches for reducing patient morbidity and accelerating donor site wound healing. The role of biologic agents, photobiomodulation therapy, local and systemic factors, and genes implicated in palatal wound healing are also discussed.

Periodontal phenotype modification of complexes periodontal-orthodontic case scenarios: A clinical review on the applications of allogenous dermal matrix as an alternative to subepithelial connective tissue graft.

OBJECTIVES: The aim of this review is to address the potential applications of allogenous dermal matrix (ADM), as an alternative to subepithelial connective tissue graft (SCTG), in promoting periodontal phenotype modification (PPM) of challenging periodontal-orthodontic clinical scenarios. OVERVIEW: The rationale behind the need of changing thin to thick gingival tissues is associated to the superior and more stable treatment outcomes promoted by PPM therapy. PPM, via soft tissue grafting, leads to clinical and histological changes of the pre-established original genetic conditions of the gingiva. Although SCTG-based procedures are recognized as the "gold standard" for the treatment of sites requiring root coverage and gingival augmentation, ADM has been recognized as the most suitable alternative to SCTG, particularly in clinical scenarios where the use of autogenous grafts is not possible. Thus, ADM is considered an optimal option for the treatment of patients with a history (or in need) of orthodontic tooth movement, due its two-fold potential indication: (1) the promotion of periodontal soft tissue phenotype modification; and (2) its use, as a barrier membrane, in hard tissues augmentation procedures. CONCLUSIONS: ADM is a viable option for soft tissue augmentation, as well as for treatment approaches involving buccal bone gain. CLINICAL SIGNIFICANCE: Periodontal phenotype modification therapy, when applied in challenging periodontal-orthodontic clinical scenarios, promotes root coverage and prevents the onset and development clinical attachment loss.

Soft Tissue Augmentation Using De-Epithelialized Free Gingival Graft Compared to Single-line Incision Subepithelial Connective Tissue Graft in the Management of Miller Class I and II Gingival Recession: A Randomized Controlled Clinical Trial.

Aims: The purpose of this randomized controlled clinical trial was to clinically assess soft tissue augmentation and compare patients' morbidity and root coverage outcomes of coronally advanced flap (CAF) with subepithelial connective tissue graft (SCTG) versus de-epithelialized free gingival graft (DFGG) in the management of Miller Class I and II gingival recession. Materials and Methods: Twenty-eight patients with Miller's Class I or II gingival recession (GR) defects were randomly assigned into two equal parallel groups treated with either CAF + SCTG, harvested using single-line incision technique (control), or CAF + DFGG (test). Gingival thickness (GT), recession depth, recession width, percentage of root coverage, keratinized tissue width, pocket depth, and clinical attachment level were measured at baseline and 3 and 6 months postoperatively. Patient-reported outcomes were assessed postoperatively, including pain, stress, bleeding, and inability to chew. Patients' overall satisfaction and root coverage esthetic scores were recorded at 6 months. Results: Both groups demonstrated a statistically significant improvement in all clinical outcomes after 3 and 6 months compared to baseline. DFGG showed a statistically significant increase in GT after 6 months. No statistically significant difference was detected in other clinical outcomes between both groups at different time intervals. Both treatments achieved 92.9% complete root coverage. Patients treated with CAF + DFGG reported significantly higher stress and inability to chew scores after 2 weeks than those treated with SCTG. There were no significant differences in patient satisfaction between both groups. Conclusions: CAF + SCTG and CAF + DFGG were both effective and can be applied safely in treating Miller Class I and II GRs.

Minimally invasive tunneling of a de-epithelialized connective tissue graft to improve gingival phenotype of lingual recession defects: A case report.

BACKGROUND: This case report describes a minimally invasive technique to increase the functional resistance of mandibular anterior lingual recession defects to inflammation. There are only a few case reports that describe the soft tissue augmentation of lingual gingival recession, of which none describe a tunneling technique without coronal advancement of the flap to treat a long span of multiple recession defects. Soft tissue augmentation of lingual recession defects is challenging due to the proximity to the tongue, frenum, vital structures, pre-existing thin phenotype, and limited access during surgery. METHODS AND RESULTS: A 30-year-old male was referred for the treatment of gingival recession on the lingual surfaces of teeth #22-27, with a diagnosis of recession type 2 (RT2). Mucogingival surgery included the preparation of the recipient site with a tunneling protocol, where apical muscular attachment was left undisturbed to isolate the flap from the movement of the tongue during normal function. As the goal was to not coronally advance the tunneled flap, the interdental papillae were not elevated and left intact, further optimizing blood supply. A free gingival graft was harvested, de-epithelialized extra-orally, and the resulting connective tissue graft (CTG) was fed through the tunnel and stabilized with sling sutures. Partial root coverage was achieved ranging from 50% to 90% at 4 months, consistent with the initial diagnosis of RT2. There was also a visually appreciable increase in gingival thickness and in the vestibular depth. CONCLUSION: A de-epithelialized CTG via tunneling without disturbing the deeper muscular attachment is a conservative method to improve phenotype of lingual recession defects. KEY POINTS: Why is this case new information? There are only a few case reports that describe soft tissue augmentation of lingual recession defects, of which none describe a tunneling technique without coronal advancement of the flap to treat a long span of multiple recession defects. This case report introduces a minimally invasive technique to increase the functional resistance of mandibular anterior lingual recession defects to plaque and calculus. What are the keys to successful management of this case? Control of gingival inflammation before and after surgery, with regular maintenance visits and oral hygiene instructions. Precise tunneling, leaving deeper muscular attachment on the floor of the mouth undisturbed. Connective tissue graft of even thickness that is fibrous in quality. What are the primary limitations to success in this case? A shallow lingual vestibule will not allow the clinician to leave deeper muscular attachment apical to tunneling undisturbed.