CONTEMPORARY ESTHETIC PERIODONTICS
Figure 9. Radiograph showing integrated implant with completed restoration
long junctional epithelium 9. Meticulous root debridement and surgical technique have been found to be the determining factor for predictability and success of the procedure 10. Enamel Matrix Derivative, as Emdogain ® has been found to enhance root coverage and healing by repair through connective tissue attachment 11, 17. Root conditioning with Citric Acid has heterogeneous results in soft tissue grafting and improvement of healing by connective tissue attachment versus long junctional epithelium 12-16. 2.1.1. Membranes When using membranes to augment soft tissue, the amount of connective tissue attachment achieved is similar to an autogenous connective tissue graft that is applied to and covered by a coronolly advanced flap at the recipient site 19, 20. Guided tissue regeneration( GTR) results in better histological outcomes, regardless whether resorbable or non-resorbable membranes used 11, 21. Guided tissue regeneration requires space and the limitation in root coverage is the surgical space available for clot stabilization and selective cell repopulation 1. 2.1.2. Bio-Modifiers When using Emdogain ®, an enamel matrix protein derivative, during guided tissue regeneration procedures or with a connective tissue graft, no additional benefits were observed. However, Emdogain ® with a coronally positioned flap alone led to regeneration, which could be histologically verified. The heterogeneous results reported by different studies are due to variation in study design and strength 17. 2.1.3. Platelet Rich Plasma and Platelet Derived Growth Factor( PDGF) The use of recombinant growth factors has demonstrated regeneration histologically and by micro-computed tomography( CT) with Tricalcium Phosphate in randomized controlled clinical trials 22, 23.
Figure 10. Clinical preoperative photograph of the maxillary right posterior region showing decreased vestibular depth, frenum pull, and lack of keratinized gingiva associated with an FPD with teeth # 16 & 14 as abutments and tooth # 15 as a pontic
2.1.4. Soft Tissue Allo- and Xeno-Graft By using a soft tissue substitute in lieu of an autogenous graft, the patient does not have the increased morbidity of a second surgical donor site 25. Allogenic acellular dermal matrix and xenogenic collagen matrix( MUCOGRAFT ®) have been used in periodontal plastic surgery and regeneration has been shown 24. The three dimensional scaffold of the graft allows for space maintenance angiogenesis and fibroblast proliferation. Histology at 6 months showed healing comparable to“ scar tissue”, dense connective tissue with predominantly elastic fibers 27. Free gingival( FGG) and connective tissue( CTG) autografts have been successful in augmenting keratinized tissue around teeth. FGG are taken from an adjacent edentulous ridge or palate and may differ in appearance, presenting esthetic challenges. Since CTG are being mostly covered by the flap of the recipient sites, their esthetic appearance blends with adjacent tissue better during healing, however, post operative shrinkage compromises treatment outcomes. 2.1.5. Implants Not much human histology is currently available on the management of gingival deficiencies on dental implants 1. Past research has focused on implant surface modification and bone grafting to improve osseous integration and treat periimplantitis.
3. Cases Reports 3.1. Case 1 Background 29-year-old white male patient with noncontributory medical history, no known drug allergies, and no social factors presents with chief complaint of a fractured front tooth. Diagnosis upon examination reveals a fractured tooth # 21 with presence of a mucogingival defect( recession) and absence of adequate keratinized gingiva( Figs. 1-2). The prognosis is hopeless. The etiologic factors include trauma and thin morphotype. Treatment plan and
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