Regeneration of gingiva following surgical excision

Abstract The present clinical trial was carried out in order to analyze whether a zone of keratinized and attached gingiva may regenerate following surgical excision of the gingiva. In addition the alterations occurring in the position of the “soft tissue margin” and the clinical attachment level were assessed. 6 patients, scheduled for periodontal surgery in the canine-premolar regions of both quadrants of the lower jaw, participated in the trial. A Baseline examination performed prior to surgery comprised assessments at the buccal surface of the teeth of dental plaque, gingivitis, probing depth, clinical attachment level, position of the “soil tissue margin” and width of the zones of keratinized and attached gingiva. The entire zone of keratinized and attached gingiva was removed surgically using either a “gingivectomy” or a “flap-excision” procedure. In the “gingivectomy” procedure the wounded area was left to heal by second intention, while in the “flap-excision” procedure the alveolar mucosa was repositioned in a coronal position to achieve complete coverage of the surgically exposed alveolar bone, During healing the patients' oral hygiene status was carefully supervised. All parameters included in the Baseline examination were assessed at reexaminations performed 1, 3, 6 and 9 months following surgery. Already 1 month after surgery all “gingivectomy” units and 9 out of the 14 “flap-excision” units demonstrated presence of a zone of keratinized gingiva. At the final examination (9 months following surgery) all surgically treated buccal areas had regained a zone of keratinized gingiva. However, a zone of attached gingiva reformed less frequently. The examination performed 3 months after surgery revealed that the “soft tissue margin” and the clinical attachment level had become displaced in apical direction, 0.9 and 0.4 mm, respectively. Between the 3-month and the 9-month examinations, however, no further alterations were observed and the gingival units were healthy, independent of the presence or absence of attached gingiva or the width of the zone of keratinized gingiva.     

Split palatal flap. II. A surgical approach for maxillary implant uncovering in cases with reduced keratinized tissue: technique and clinical results

It is generally accepted that a more ideal and functional soft tissue-implant interface can be established if there is an adequate zone of keratinized mucosa around endosseous dental implants. The purpose of this article was to describe a surgical procedure, based on the use of a split palatal flap, which predictably creates or increases the zone of keratinized tissue around implants at the time of implant uncovering. It is especially useful for maxillary implants with a nonexistent or minimal width of keratinized buccal tissue. The study comprised 34 implants in the maxillae of 8 patients, who were chosen because they had minimal or nonexistent buccal keratinized gingiva prior to implant uncovering. Following healing, between 2 and 5 mm of keratinized gingiva (mean 3.7 mm) could be measured buccally at all abutments. Postsurgical inconveniences were minimal. The use of a split palatal flap at implant uncovering minimizes the number of surgical stages and sites necessary, while predictably providing an adequate zone of buccal keratinized gingiva.     

The ultrastructural response to loading of the oral mucosa of the vervet monkey

The ultrastructural changes occurring within the epithelium of the palate, attached gingiva, tongue, buccal mucosa, and alveolar mucosa of the vervet monkey when a mechanical load was applied to the tissues was examined. The effect of the load was assessed in terms of changes in epithelial cell and nuclear shape, intracytoplasmic structures, cell membrane interdigitation, intercellular space, and changes in the shape of non-keratinocytes found within the epithelium. Loading produced a flattening of cells and nuclei throughout the epithelium. Intercellular space was reduced, cell membranes were flattened or else underwent increased interdigitation, tonofilaments became functionally oriented, and cytoplasmic vacuolation took place. The mitochondria appeared unchanged on loading. These changes were more marked in the nonkeratinized buccal and alveolar mucosa than in the keratinized palate, tongue, and attached gingiva. A histometric analysis which was carried out on the normal and loaded attached gingiva and alveolar mucosa revealed that the cells and nuclei of both tissue types underwent a significant change in width when loaded. Loading produced no significant change in the diameter of mitochondria in the basal and spinous layers.     

Rotated palatal flap. A surgical approach to increase keratinized tissue width in maxillary implant uncovering: technique and clinical evaluation

Although keratinized mucosa is not indispensible for the maintenance of periimplant tissue health if oral hygiene is adequate, its presence is generally advocated. The establishment of an adequate zone of gingiva that is firmly attached to the underlying periosteum and bone is important for the overall long-term success of implant-supported oral rehabilitation. The purpose of this study was to describe and evaluate a surgical approach for maxillary implant uncovering that augments the buccal periimplant keratinized tissue while avoiding a large zone of exposed implant-supporting bone by using a rotated palatal flap. The study comprised 40 implants that were uncovered in 13 patients using a combination of full-thickness buccally repositioned and rotated palatal flaps. Within each patient, the mean preoperative width of keratinized mucosa was 0.19 mm (SD 0.316), and the mean postoperative width was 3.45 mm (SD 0.489). The difference between post- and preoperative widths was 3.26 mm (SD 0.498), which was statistically significant according to a paired t test (P < .0001). The main advantages of this technique are simplicity and predictability, and it consistently provides a wider zone of keratinized gingiva in the buccal aspect of the future maxillary implant-supported restoration.     

植体周角化龈研究进展

种植牙周围角化龈对抵抗菌斑刺激及机械创伤起到屏障作用,无论从功能还是美观角度,对最终种植修复成功有着重要意义.早期研究表明,至少2 mm的角化龈(其中附着龈至少1mm)才能维护牙周健康.角化龈的存在有利于植体周围菌斑控制及后期维护,但关于角化龈确切的量与种植体周围感染的关系尚有争议.文章就近年来植体周角化龈的研究做一综...     

Increasing the width of keratinized mucosa around endosseous implant using acellular dermal matrix allograft

OBJECTIVES: To: (1) investigate the clinical efficacy of acellular dermal matrix allograft to achieve increased peri-implant keratinized mucosa around implants, and (2) evaluate the effect as to whether the increase of keratinized mucosa has a positive effect on oral hygiene. MATERIALS AND METHODS: There were 10 male patients, ranging from 43 to 53 years of age, with attached gingiva < or = 2 mm on the buccal aspect included in this study. Acellular dermal matrix allograft was used to increase the keratinized mucosa on the buccal side. RESULTS: The change of peri-implant pocket depth showed statistical differences among 3 measurements. The modified plaque index at 3 and 6 months showed statistical differences compared with the baseline measurements. The modified gingival index did not show any significant differences among all measurements. The width of peri-implant keratinized mucosa increased from a mean of 0.8 +/- 0.6 to 3.2 +/- 0.9 mm at 3 months and 2.2 +/- 0.6 mm at 6 months. CONCLUSIONS: It is concluded that the acellular dermal matrix allograft could be applied as a grafting material to increase the width of peri-implant keratinized mucosa. Its procedure appears to have some benefits for oral hygiene. Further randomized controlled trials over long periods of time are necessary to establish whether this procedure offers long-tem benefits to patients.     

120名汉族青年前段牙弓唇侧角化龈宽度的测量

目的 通过测量获取前段牙弓唇侧角化龈和附着龈宽度的相关数据,以期为牙周解剖和牙周手术提供参考.方法 选择20～30岁牙龈健康的汉族青年120人,分别测量前段牙弓唇侧龈缘高点处角化龈宽度及龈沟深度、邻间牙龈乳头尖端处冠根向角化龈宽度,并对数据进行统计学分析.结果 龈缘高点相应处角化龈宽度在上颌前段牙弓最宽可达(5.6±1.3)mm,在下颌前段牙弓最宽可达(4.5±1.1)mm,且以切牙区最宽,尖牙、第一前磨牙其宽度逐渐变窄,第二前磨牙开始增宽;上、下颌前段牙弓邻间牙龈乳头尖端相应处冠根向角化龈宽度范围分别为(6.2±1.3)～(8.9±1.4)mm及(5.8±1.0)～(7.6±0.9)mm.结论 本组汉族青年前段牙弓唇侧龈缘高点相应处角化龈宽度和附着龈宽度因人和牙位而异;由于唇系带的附着,两中切牙邻间牙龈乳头尖端相应处冠根向角化龈宽度最窄.     

Effects of mandibular orthognathic treatment on mucogingival tissues

Twenty-four patients receiving comprehensive orthognathic care including genioplasty were studied to evaluate the effect of orthognathic treatment on the mucogingival complex in the mandibular anterior region. Parameters measured prior to and after therapy were: width of keratinized gingiva, width of attached gingiva and gingival recession. A subjective assessment of tissue thickness was accomplished. A statistically significant decrease in width of both keratinized and attached gingiva was noted following orthognathic therapy in the mandibular anterior area. In six of 24 patients, gingival recession was a clinically significant finding. The actual pretreatment width of keratinized and/or attached tissue did not seem to be the critical factor in development of recession. Risk of recession appeared to increase when genioplasty was combined with mandibular advancement and tended to occur at sites in which the keratinized gingiva and underlying bone appeared thin.     

Use of reactive soft tissue for primary wound closure during immediate implant placement: a two-year retrospective study

Sockets with both hard and soft tissue defects present a challenge for immediate implant placement. A modified technique harnessing the reactive soft tissue in the extraction socket for primary closure has been reported to contribute to hard and soft tissue augmentation after immediate implantation. The aim of this study was to evaluate the effects of this novel technique on the hard and soft tissues of sockets with both buccal bone and soft tissue defects (group B) and to compare the outcomes with those obtained for sockets with intact soft tissue but buccal bone dehiscence (group A). Thirty-two implants placed in the posterior region were included: 17 in group A, 15 in group B. The implants were inserted immediately utilizing reactive soft tissue from the socket for primary closure in both groups. The changes in buccal bone dimensions after 6 months were generally comparable between the two groups. A keratinized mucosa reduction of 0.56 mm in group A and keratinized mucosa gain of 0.67 mm in group B were observed at 6 months (P = 0.009). The bone and soft tissue levels were well maintained in both groups after 2 years. This technique may be a potential treatment method for tissue augmentation during immediate implantation in posterior sockets, even when a buccal bony defect and mucogingival recession need to be repaired at the same time.     

Buccal periosteal inversion (BUPI) for defect closure and keratinized gingiva width preservation after tooth extraction – technique modification

IntroductionSeveral techniques and methods have been proposed to cover alveolar bone after tooth extraction when soft tissue is lacking. Some authors recommend soft tissue flap techniques, and others advocate different types of materials for socket covering. In this article, the authors use a modified buccal inversion technique for adequate coverage of the alveolar ridge to ensure its preservation and to minimize soft tissue shrinkage and loss of keratinized gingiva after tooth extraction. This local mucogingival-periosteal plastic procedure was named by the authors the “Buccal Periosteal Inversion technique” or simply BUPI.Materials and MethodsAfter extraction of a fractured, endodontically compromised lower right first molar, the BUPI technique was performed to cover the alveolus. After reflecting the two-sided full-thickness flap, the periosteum was split in the cranial direction. The inverted periosteum is used to provide tension-free defect closure of the postextractional defect. Detailed technique implementation and patient postoperative healing are presented here in detail.ResultsPostoperative evaluation at six weeks was presented with photos showing adequate surgical site healing, no signs of infection or dehiscence, and no crestal shift of the keratinized gingiva.ConclusionThe buccal periosteal inversion (BUPI) technique is a modified technique that allows full socket coverage, avoiding a keratinized gingiva shift in the crestal direction using only the periosteum as a cover material. By inverting the buccal ridge periosteum alone from its normal position, the osteoclastic effect on the buccal bony wall will be eliminated, and this procedure abolishes the need for additional alveolar coverage materials.     

Mucogingival surgery. The subperiosteal vestibule extension

A surgical technique to establish wide zones of attached mucosa was performed in 28 patients presenting with inadequate amounts of attached gingiva. The clinical results of the procedure were monitored over a period of 2 years. Biometric assessment of 112 mucogingival units immediately before and at 1, 3, 6, and 24 months after surgery revealed that the mean width of attached gingiva changed from 1.1 mm to 5.3 mm of attached tissue (gingiva plus vestibular mucosa). A surgically produced increase of 4.9 mm in width (P less than 0.001) and subsequent shrinkage of 0.7 mm or 14% (P less than 0.001) resulted in a total average gain of 4.2 mm of attached mucosa 2 years after surgery (P less than 0.001). A begin/end analysis of the coronal level of clinical periodontal attachment and the extent of gingival recession showed no clinically significant changes. The mean width of keratinized gingiva increased 0.8 mm during the 2-year postoperative period. The subperiosteal vestibule extension is recommended as an alternative to the free autogenous mucosa graft for establishing wide bands of attached mucosa in areas where loss of attached gingiva is associated with mechanical or microbial irritation of the marginal periodontium.     

Critical soft‐tissue dimensions with dental implants and treatment concepts

Dental implants have proven to be a successful treatment option in fully and partially edentulous patients, rendering long‐term functional and esthetic outcomes. Various factors are crucial for predictable long‐term peri‐implant tissue stability, including the biologic width; the papilla height and the mucosal soft‐tissue level; the amounts of soft‐tissue volume and keratinized tissue; and the biotype of the mucosa. The biotype of the mucosa is congenitally set, whereas many other parameters can, to some extent, be influenced by the treatment itself. Clinically, the choice of the dental implant and the position in a vertical and horizontal direction can substantially influence the establishment of the biologic width and subsequently the location of the buccal mucosa and the papilla height. Current treatment concepts predominantly focus on providing optimized peri‐implant soft‐tissue conditions before the start of the prosthetic phase and insertion of the final reconstruction. These include refined surgical techniques and the use of materials from autogenous and xenogenic origins to augment soft‐tissue volume and keratinized tissue around dental implants, thereby mimicking the appearance of natural teeth.     

The role of keratinized tissue and attached gingiva in maintaining periodontal/peri-implant health

Although the band of keratinized tissue and attached gingiva is determined genetically, it may be affected by the presence of plaque-associated inflammation or by the action of certain mechanical interventions. This article reviews variations in the width of keratinized tissue and attached gingiva and their clinical significance regarding periodontal/peri-implant health.     

Use of Implant Retained Splint for Vestibuloplasty: Alternative to Conventional Technique

It is generally agreed that firmly attached keratinized mucosa surrounding the implant and abutment is thought to provide additional protection against mechanical trauma. Inflammation of soft tissue can result in peri-implantitis [1] with marginal bone loss or hyperplasia of surrounding mucosa. The purpose of this article is to describe our experience in using the two dental implants placed in the canine region in completely edentulous mandible and implant retained denture as a stent for vestibuloplasty.     

Morphological changes in the attached and keratinized gingiva and gingival sulcus in the mixed dentition period

Abstract A longitudinal study was undertaken to examine the changes in the sulcus probing depth, keratinized and attached gingiva during the mixed dentition period. 54 children aged 7 to 9 years at the first examination were examined twice, with an interval of 5 years. Sulcus probing depth and keratinized gingiva were examined at the buccal aspect of the incisors, and either right or left cuspids and posterior areas. The width of the attached gingiva was obtained by substracting the probing depth from the width of the keratinized gingiva. When compared to primary predecessors, the permanent teeth had a deeper probing depth, narrower attached gingiva and at the maxillary teeth, a wider keratinized gingiva. When a pennanent tooth was present at both examinations, there was a significant increase in width of the attached gingiva with a corresponding decrease in probing depth, and a slight beginning of an increase in the width of keratinized gingiva. Previous and the present findings indicate that during the early years after eruption of the permanent tooth, an increase in width of the attached gingiva takes place, without occlusal migration of the marginal gingiva whereas, at later stages, this coronal migration takes place, concomitant to tooth eruption.     

Cross-sectional evaluation of the prevalence and factors associated with soft tissue scarring after the removal of miniscrews

Objective:To investigate the prevalence of distinguishable soft tissue scarring after the removal of temporary anchorage devices (TADs) such as orthodontic miniscrews and to analyze the factors associated with scar formation.Materials and Methods:The prevalence of soft tissue scarring in 66 patients (202 miniscrew removal sites) was clinically investigated at least 1 year after miniscrew removal. To determine the clinical factors associated with soft tissue scar formation, miniscrew stability; host factors including age, gender, and gingival biotype; and miniscrew-related factors such as insertion site, vertical position, and insertion period were evaluated.Results:The prevalence of a distinguishable scar remaining at least 1 year after miniscrew removal was 44.6%. Patients with flat gingiva showed a significantly higher prevalence of soft tissue scar formation than did those with pronounced scalloped gingiva (P < .05). Maxillary buccal removal sites showed a significantly higher prevalence of soft tissue scar formation than did those in the mandible or palatal slope (P < .05). Miniscrew sites at the alveolar mucosa showed a significantly lower prevalence of soft tissue scar formation than did those in the mucogingival junction or the attached gingiva (P < .01).Conclusion:The prevalence of distinguishable scarring after miniscrew removal was fairly high. On the basis of our results, patients with flat gingiva and buccal interdental gingival insertion sites are more susceptible to scar formation.     

Buccal periosteal inversion (BUPI) for defect closure and keratinized gingiva width preservation after tooth extraction – technique modification

IntroductionSeveral techniques and methods have been proposed to cover alveolar bone after tooth extraction when soft tissue is lacking. Some authors recommend soft tissue flap techniques, and others advocate different types of materials for socket covering. In this article, the authors use a modified buccal inversion technique for adequate coverage of the alveolar ridge to ensure its preservation and to minimize soft tissue shrinkage and loss of keratinized gingiva after tooth extraction. This local mucogingival-periosteal plastic procedure was named by the authors the “Buccal Periosteal Inversion technique” or simply BUPI.Materials and MethodsAfter extraction of a fractured, endodontically compromised lower right first molar, the BUPI technique was performed to cover the alveolus. After reflecting the two-sided full-thickness flap, the periosteum was split in the cranial direction. The inverted periosteum is used to provide tension-free defect closure of the postextractional defect. Detailed technique implementation and patient postoperative healing are presented here in detail.ResultsPostoperative evaluation at six weeks was presented with photos showing adequate surgical site healing, no signs of infection or dehiscence, and no crestal shift of the keratinized gingiva.ConclusionThe buccal periosteal inversion (BUPI) technique is a modified technique that allows full socket coverage, avoiding a keratinized gingiva shift in the crestal direction using only the periosteum as a cover material. By inverting the buccal ridge periosteum alone from its normal position, the osteoclastic effect on the buccal bony wall will be eliminated, and this procedure abolishes the need for additional alveolar coverage materials.     

A clinical and histologic evaluation of gingival fibroblasts seeding on a chitosan-based scaffold and its effect on the width of keratinized gingiva in dogs

Background: Finding biocompatible matrix materials capable of enhancing the procedures of gingival augmentation is a major concern in periodontal research. This has prompted the investigation of a safe grafting technique by means of synthetic or natural polymers. The objective of this study is to examine the effect of a gingival fibroblast cultured on a naturally derived (i.e., chitosan‐based) scaffold on the width of keratinized gingiva in dogs. Methods: Gingival fibroblasts were cultured from a small portion of hard palates of five dogs. A bilayered chitosan scaffold was seeded with the gingival fibroblasts and transferred to dogs. Surgery was performed bilaterally, and the regions were randomly divided into two groups: chitosan only (control site) and chitosan + fibroblast (test site). Periodontal parameters, including probing depth and width of keratinized and attached gingiva, were measured at baseline and 3 months after surgery. A histologic evaluation was also performed on the healed grafted sites. Results: Comparison of width of keratinized and attached gingiva in control and test sites showed that the mean width of keratinized and attached gingiva increased in each group after surgery. However, the difference between control and test groups was not statistically significant. Concerning the existence of the keratinized epithelium, exocytosis, and epithelium thickness, no significant difference was observed in test and control sites. The difference was significant in relation to rete ridge formation. Conclusion: The tissue‐engineered graft consisting of chitosan + fibroblast was applied to gingival augmentation procedures and generated keratinized tissue without any complications usually associated with donor‐site surgery.     

Role of attached gingiva for maintenance of periodontal health

The present study was undertaken to analyze the role of attached gingiva for the maintenance of periodontal health in sites with normal and reduced height of the supporting apparatus. Furthermore, the effect of excision and grafting of gingiva on some parameters describing dimensions and location of the periodontal tissues was evaluated. 7 beagle dogs were used. A baseline examination comprised assessments of dental plaque, gingival conditions, attachment level, position of the gingival margin and width of the keratinized and the attached gingiva. In the right side of the jaws (experimental side) a 6-month period of periodontal tissue breakdown was followed by surgical excision of the entire zone of the gingiva. After another 4-month period of healing with daily plaque control, a gingival graft was inserted in one quadrant of the experimental side to regain a zone of attached gingiva while the other quadrant of the experimental side was left ungrafted. In the left side of the jaws (control side), the teeth were subjected to daily meticulous plaque control during the entire study. In one of the control quadrants the entire zone of the keratinized and attached gingiva was excised at a time point corresponding to the grafting procedure in the experimental side, while the gingiva in the remaining control jaw quadrant was left unoperated. Clinical examinations of all control and experimental tooth units were repeated at certain time intervals during the course of the study. The final examination was carried out 4 months after grafting. The results of the experiment showed that in sites exposed to careful plaque control measures gingival health could be established and maintained without sign of recession of the gingival margin or loss of attachment, independent of (1) presence or absence of attached gingiva, (2) width of keratinized gingiva or (3) height of the supporting attachment apparatus. Following surgical excision of the entire gingiva, all buccal sites regained a zone of keratinized gingiva, but most sites were lacking attached gingiva. Furthermore, grafting of gingival tissue significantly increased the width of the keratinized and the attached gingiva but had no obvious effect on the position of the gingival margin or the level of the attachment.     

Autotransplantation of Maxillary Third Molar with Its Attached Buccal Cortical Plate Combined with a Connective Tissue Graft

IntroductionTooth replacement often leads to insufficient vertical volume in the recipient socket bone. The aim of this novel report is to present a successful fully guided autotransplantation of a maxillary right third molar (tooth #1) with its attached buccal plate. The procedure was combined with a palatal connective tissue graft to reconstruct a buccal hard and soft tissue defect of an irreparable maxillary right first molar (tooth #3).MethodsA 45-year-old man complaining of pain in tooth #3 came to the clinic. Tooth #3 was non-restorable due to an extensive caries and a vertical root fracture of the mesiobuccal root, leading to a total loss of the buccal cortical plate. Guided autotransplantation of tooth #1 was completed by using 3-dimensional surgical templates for implant burs and a 3-dimensional-printed replica. After positioning the donor tooth, the cortical plate was fixed to the recipient socket with osteosynthesis screws. A connective tissue graft was also harvested to increase the band of keratinized gingiva and the thickness of the buccal soft tissue. At 6-month follow-up, the screws were removed, showing excellent regeneration throughout the buccal area.ResultsAt 3-year follow-up, the transplanted tooth was asymptomatic, with a natural bone level and no signs of replacement or inflammatory root resorption.ConclusionsThe use of a donor tooth and its attached bone cortical plate combined simultaneously with a connective tissue graft appears to improve hard and soft tissues in a single procedure.