BACKGROUND:The aim of this case series was to introduce intraoral Er:YAG laser-assisted de-epithelialization of autogenous gingival graft (EL-DGG) for root coverage and alveolar ridge augmentation. METHODS:In conventional harvesting of de-epithelialized gingival grafts (DGGs) with a scalpel, the presence of residual epithelium has occasionally been observed, posing challenges to the reliable procurement of stable connective tissue grafts (SCTG). We utilized an Er:YAG dental laser, known for its minimal histological effect among dental lasers, to perform intraoral DGG in three cases involving root coverage or ridge augmentation. RESULTS:Complete root coverage was achieved in the two root coverage cases. In the ridge augmentation case, horizontal and vertical dimensional gains of 1.56 and 0.74 mm, respectively, were observed. A portion of the CTG obtained from the peripheral trimmed area was biopsied and histologically examined. De-epithelialization of this area was performed using the same protocol as in the clinical procedure, including both Er:YAG laser irradiation and adjunctive rotary brush application, suggesting that epithelial removal was achieved in the examined sample with minimal damage to the underlying connective tissue layer of dense collagen fibers. CONCLUSIONS:By effectively eliminating epithelial remnants and preserving connective tissue thickness in palatal grafts, EL-DGG can offer more favorable clinical outcomes in root coverage and ridge augmentation compared to conventional graft-harvesting methods. KEY POINTS:Selective epithelial removal: Intraoral Er:YAG laser-assisted de-epithelialization enables selective removal of palatal epithelium while preserving dense subepithelial connective tissue thickness. Histologic and clinical validation: Histologic analysis confirmed complete epithelial elimination with minimal lamina propria damage, resulting in stable root coverage and soft tissue augmentation. Advantage in thin phenotypes: This technique allows predictable graft harvesting even in thin palatal mucosa, supporting phenotype modification and ridge augmentation procedures. PLAIN LANGUAGE SUMMARY:Gum tissue taken from the roof of the mouth is commonly used to cover exposed tooth roots or rebuild areas where soft tissue has been lost. However, when preparing these grafts with a scalpel, small remnants of the surface epithelial layer may remain, while removing too much tissue can reduce the thickness and quality of the connective tissue needed for treatment. In this case series, we used an Er:YAG laser to remove the epithelial layer directly from the palate before harvesting the graft. This approach was used in three patients: two received treatment for exposed tooth roots, and one received soft tissue augmentation in an area with a missing tooth. Complete root coverage was achieved in both root coverage cases, and an increase in tissue volume was observed in the ridge augmentation case. Microscopic examination of a graft sample suggested that the epithelial layer was removed while the dense connective tissue underneath was largely preserved. These findings suggest that Er:YAG laser-assisted graft preparation may help clinicians obtain thick, stable connective tissue grafts while reducing unwanted epithelial remnants. Further studies involving more patients and longer follow-up are needed to confirm these potential benefits.
BACKGROUND:Advanced periodontitis associated with infrabony defects often requires surgical intervention when nonsurgical periodontal therapy proves to be insufficient. Combination regenerative therapy, including guided tissue regeneration, has been shown to facilitate periodontal regeneration and improve clinical outcomes in a predictable manner. METHODS:A 57-year-old female presented to the Division of Periodontology at Harvard School of Dental Medicine with complaints of tooth mobility and gingival bleeding. Comprehensive periodontal and radiographic examinations were performed to determine disease severity and extent. Initial periodontal therapy included patient education, oral hygiene instructions, nonsurgical scaling and root planing, and occlusal adjustment. Due to persistent deep periodontal pockets and infrabony defects, full-mouth osseous surgery and open flap debridement, combined with regenerative therapy using bone grafts and biologic agents, were subsequently performed. The patient was enrolled in supportive periodontal therapy at 3-month intervals thereafter. RESULTS:At the 1-year follow-up, significant clinical improvements were observed, including reductions in probing depths, furcation involvement, and tooth mobility. Radiographic evaluation demonstrated bone fill at infrabony defect sites treated with combination regenerative therapy. These outcomes were maintained over a 3-year follow-up period with strict supportive periodontal therapy during orthodontic treatment. CONCLUSIONS:Within the limitations of a single case report, this case highlights the potential effectiveness of surgical periodontal therapy combined with regenerative techniques in the interdisciplinary management of generalized stage IV, grade C periodontitis with infrabony defects. KEY POINTS:Surgery periodontal therapy with guided tissue regeneration led to radiographic bone fill, reduced probing depths, and improvements in tooth mobility and furcation involvement, even in a severe stage IV grade C case. Success was strongly associated with strict supportive periodontal therapy and good oral hygiene adherence. Advanced periodontitis can have predictable long-term outcomes with proper interdisciplinary treatment and maintenance. PLAIN LANGUAGE SUMMARY:This case demonstrates successful interdisciplinary ortho-perio management of stage IV, grade C periodontitis with infrabony defects using surgical periodontal therapy and regenerative techniques. Significant reduction in probing depths, decreased tooth mobility and furcation involvement, and radiographic bone fill were observed following treatment. Favorable outcomes were maintained over a 3-year follow-up with supportive periodontal therapy.
BACKGROUND:Titanium release from dental implants has been implicated in peri-implantitis; however, its integration into multivariable models for disease classification remains limited. This study aimed to develop and internally validate a titanium ion-integrated model for the classification of peri-implantitis. METHODS:This cross-sectional analysis with prospective recruitment included 120 participants (60 healthy implants and 60 peri-implantitis). Titanium ion concentrations in peri-implant crevicular fluid (PICF) and serum were quantified using inductively coupled plasma mass spectrometry. Candidate predictors comprised PICF and serum titanium levels, implant surface area, functional duration, occlusal load, and age. Multivariable logistic regression was used to derive the Titanium Release Score. Model discrimination was assessed using receiver operating characteristic analysis, while calibration was evaluated using the Hosmer-Lemeshow test. Internal validation was performed through bootstrap resampling (1000 iterations). RESULTS:Higher titanium concentrations in PICF (adjusted odds ratio [OR] = 1.52; 95% confidence interval [CI]: 1.22-1.90) and serum (adjusted OR = 1.79; 95% CI: 1.25-2.56) were associated with peri-implantitis. The model demonstrated good discriminative performance (area under the curve [AUC] = 0.87; 95% CI: 0.78-0.95). Internal validation showed an optimism-corrected AUC of 0.83. Calibration was acceptable (Hosmer-Lemeshow, p = 0.62). CONCLUSION:The titanium-integrated model demonstrated good discrimination between peri-implantitis and healthy implants within the constraints of a cross-sectional design. Titanium ion levels were associated with disease status alongside implant-related variables. These findings support the potential role of titanium measurements as adjunctive biomarkers for disease classification rather than predictors of future risk; however, external validation and longitudinal studies are required before clinical application. KEY POINTS:A titanium ion-integrated classification model was developed to estimate peri-implantitis risk using peri-implant crevicular fluid, serum titanium levels, and implant variables. The Titanium Release Score demonstrated good discrimination (area under the curve 0.87) and acceptable calibration with stable performance after bootstrap validation. Titanium ion burden showed an independent associative value for peri-implantitis, supporting its role as a biologically relevant risk indicator. PLAIN LANGUAGE SUMMARY:Peri-implantitis is a common complication of dental implants that leads to inflammation and progressive bone loss. Early detection of implants at risk remains a clinical challenge. This study developed a classification model that combines titanium ion levels measured in peri-implant crevicular fluid and blood with implant-related factors such as surface area, duration of function, and occlusal load. Titanium, although widely used in implants, may be released over time and contribute to inflammatory responses. The model demonstrated good accuracy in distinguishing healthy implants from those with peri-implantitis, suggesting that titanium levels may provide additional information beyond traditional clinical parameters. These findings highlight the potential role of titanium measurements in improving risk assessment. However, further validation in larger and more diverse populations is required before this approach can be applied in routine clinical practice.
BACKGROUND:Correction of peri-implant bone dehiscence (PIBD) and optimization of the peri-implant soft-tissue phenotype are critical for long-term peri-implant tissues stability. A simplified, one-stage, transmucosal variant of the subperiosteal peri-implant augmented layer (sSPAL) technique was appraised and evaluated. METHODS:Eight systemically healthy patients with posterior mandibular edentulous sites showing an overt dehiscence received tissue-level implants combined with sSPAL using particulate deproteinized bovine bone mineral within a periosteal pouch. Clinical (keratinized mucosa, marginal soft-tissue level, probing depth (PD), and bleeding/suppuration) and radiographic (peri-implant bone dehiscence, buccal bone thickness (BBT), and interproximal bone levels) parameters were assessed at 12 months. RESULTS:At the 12-month follow-up, all treated patients exhibited complete resolution of PIBDs and a BBT of ≥1.5 mm. Moreover, all implants presented a keratinized mucosa height ≥2 mm associated with stable soft-tissue margins, shallow PDs, minimal bleeding, and no suppuration. CONCLUSION:Within the limitations of this preliminary case series, sSPAL appears to be a feasible approach to modify the peri-implant phenotype by both reconstructing the hard-tissue component and providing adequate dimensions of the soft-tissue component. KEY POINTS:The study was performed in order to assess whether and to what extent sSPAL may allow to manage both hard- and soft-peri-implant phenotype components; The isolation of the coronal full-thickness portion of the flap as well as a careful dissection of the periosteal layer taking care of maintaining its integrity are of paramount importance in order to successfully perform the surgical procedure. Finally, the adaptation of the flap should allow for the displacement of the full-thickness portion of the flap around the healing abutment in order to create adequate dimension of the soft-tissue peri-implant phenotype; The absence of at least 6 mm of keratinized tissue above the edentulous ridge as well as a limited thickness of the mucosa lining the bone crest, thus not ensuring adequate dimensions of the soft-tissue phenotype on both buccal and lingual aspects of the implant, may represent a contraindication for the execution of sSPAL. PLAIN LANGUAGE SUMMARY:The present study pointed out the use of a novel surgical technique, namely the simplified subperiosteal peri-implant augmented layer technique (sSPAL), aimed at managing both hard and softperi-implant tissues in a single surgical intervention. The procedure derives from a published and validated two-stage technique (SPAL technique) aimed at correcting a peri-implant bone dehiscence (PIBD) simultaneously with implant placement. The present pilot study involved eight patients presenting one implant each that was treated with the sSPAL. No implant presented a PIBD at the 12-month CBCT examination, whereas seven of eight patients presented adequate (≥2 mm) dimensions of the peri-implant soft tissues. Therefore, despite taking into account the limitations of the present study due to its exploratory nature, it can be concluded that sSPAL may represent a valuable, simplified alternative to the conventional two-stage SPAL technique.
BACKGROUND:Periodontal regenerative therapy using recombinant human fibroblast growth factor-2 (rhFGF-2) combined with deproteinized bovine bone mineral (DBBM) has demonstrated favorable and predictable clinical outcomes for intrabony defects. However, long-term outcomes and potential challenges following such combination therapies remain poorly documented. METHODS:A 40-year-old woman with generalized stage III grade C periodontitis underwent periodontal regenerative therapy using rhFGF-2 combined with DBBM for a one-wall defect at the mandibular left first molar (#19). RESULTS:Favorable periodontal healing was maintained for approximately 4 years. However, for tooth #19, the probing depth gradually increased at 5 years 2 months post-surgery, and the patient developed discomfort and pulpal symptoms by 6 years 2 months. Clinical examination revealed an agglomerate of DBBM particles and a palpable external root resorption lesion. The tooth was extracted due to irreversible pulpal involvement. CONCLUSION:This case illustrates that despite favorable early healing, periodontal regenerative therapy may lead to rare late-onset complications such as external root resorption. Long-term follow-up and careful consideration of biomaterial interactions are essential when employing combination regenerative approaches. KEY POINTS:Periodontal regenerative therapy using rhFGF-2 and DBBM achieved favorable clinical outcomes for 4 years before unexpected late-onset external root resorption developed. Long-term persistence and partial separation of DBBM particles, along with the response of macrophage- or osteoclast-lineage cells, are associated with a potential for delayed resorptive pathology on adjacent root surfaces. Clinicians should recognize the possibility of late complications and carefully consider biomaterial interactions when selecting regenerative strategies and informing patients.
BACKGROUND:Peri-implant soft tissue thickness is a critical determinant of esthetic outcomes and long-term implant stability, particularly in the anterior maxilla. METHODS:A 28-year-old systemically healthy male presented with a missing maxillary central incisor and a thin gingival biotype. Following implant placement, a modified split flap-roll technique was performed. The surgical approach involved splitting the flap into epithelial and connective tissue components, followed by mobilization and rolling of the connective tissue into a labial pouch to enhance tissue thickness. RESULTS:Soft tissue thickness increased from less than 2 mm pre-operatively to approximately 4 mm at 3 months, with stable maintenance of approximately 3 mm at 9 months. Improved gingival contour, emergence profile, and uneventful healing were observed throughout the follow-up period. CONCLUSION:The modified split flap-roll technique may serve as an alternative approach for peri-implant soft tissue augmentation. Within the limitations of this case report, favorable clinical outcomes were observed; however, further controlled studies are required to establish its predictability and clinical effectiveness. CLINICAL SIGNIFICANCE:Modification of an existing roll flap technique Eliminates the need for a secondary donor site Allows soft tissue augmentation using a pedicled approach May provide an alternative option in selected cases KEY POINTS: The modified split flap-roll technique increased peri-implant soft tissue thickness from less than 2 mm to approximately 4 mm at 3 months, with stable maintenance at 9 months. The technique utilizes a pedicled connective tissue component, eliminating the need for a secondary donor site and potentially reducing patient morbidity. This approach may provide an alternative soft tissue augmentation option for selected esthetic-zone implant cases. PLAIN LANGUAGE SUMMARY:Dental implants placed in the front part of the upper jaw require healthy and adequate gum tissue to achieve a natural appearance and long-term stability. In some patients, the gum tissue around an implant is thin, which can affect both esthetics and treatment outcomes. This case report describes a modified surgical technique used to increase the thickness of the soft tissue around a dental implant without taking tissue from another area of the mouth. A 28-year-old patient with a missing upper front tooth and thin gum tissue underwent implant placement combined with a split flap-roll procedure. During surgery, tissue from the same surgical site was carefully separated, rolled, and repositioned to create additional volume around the implant. The soft tissue thickness increased from less than 2 mm before treatment to approximately 4 mm after 3 months and remained stable at approximately 3 mm after 9 months. Healing was uneventful, and the final esthetic result showed improved tissue contour and implant appearance. This technique may offer a less invasive alternative to conventional connective tissue graft procedures while avoiding the discomfort associated with a second surgical donor site.
Cemental tear, representing separation of cementum from the root surface, is a rare but challenging condition often mimicking vertical root fracture or endodontic–periodontal lesions. Despite advances in regenerative therapy, a predictable treatment protocol for cemental tears with non‐contained bone defects remains lacking. Minimally invasive regenerative surgical techniques, such as the entire papilla preservation technique (EPPT) and connective tissue graft (CTG) wall technique, may optimize wound stability and enhance clinical outcomes when combined with biologic agents. A 73‐year‐old male patient presenting with gingival swelling and suppuration in #8 was diagnosed with a two‐wall bone defect associated with a cemental tear (Class 3/Stage B) using cone‐beam computed tomography (CBCT). Regenerative therapy was performed using recombinant human fibroblast growth factor‐2 (rhFGF‐2), carbonate apatite (CO 3 Ap), and a CTG applied via the EPPT. Clinical parameters and radiographic findings were evaluated at baseline and 1, 3, 6, and 12 months postoperatively. Healing progressed without postoperative complications such as gingival recession or graft exposure. The probing pocket depth was reduced from 10 to ≤3 mm, and clinical attachment gain of 7 mm was achieved at 12 months. CBCT demonstrated complete radiographic bone fill and reformation of the proximal and labial bone walls. Combination regenerative therapy using rhFGF‐2, CO 3 Ap, and CTG with the EPPT achieved stable soft and hard tissue regeneration in an elderly patient with a cemental tear–associated two‐wall bone defect. This multidisciplinary, minimally invasive approach shows promise for managing complex non‐contained intrabony defects while maintaining gingival aesthetics. A multidisciplinary regenerative approach combining rhFGF‐2, CO 3 Ap, and CTG with EPPT resulted in favorable clinical and radiographic outcomes for a cemental tear–associated two‐wall bone defect. The CTG wall technique functioned as a protective barrier, minimized gingival recession, and promoted soft tissue stability. Cone‐beam computed tomography aided in the accurate diagnosis of cemental tear morphology and postoperative evaluation of bone regeneration. This case underscores the importance of flap design and biologic integration in achieving optimal periodontal and aesthetic results. This case report describes a new treatment method for repairing bone loss around a tooth caused by a “cemental tear,” a type of root surface damage that can lead to gum swelling and bone destruction. A 73‐year‐old male patient was treated with a combination of a growth factor (rhFGF‐2), a synthetic bone substitute (CO 3 Ap), and a small piece of gum tissue (CTG) using a minimally invasive surgical technique that preserves the entire gum papilla. Over 12 months, the treatment resulted in significant healing of both bone and gum tissues without recession. This approach may offer a reliable option for saving teeth with similar severe bone defects.
BACKGROUND:The generation of heat during osteotomy preparation is a significant risk factor for thermal osteonecrosis, which may lead to implant failure. While static surgical guides enhance placement accuracy, they can physically obstruct the flow of external coolant, paradoxically increasing the risk for thermal injury. METHODS:(1) Review of thermal necrosis and critical temperatures during osteotomy preparation. Advantages and disadvantages of static guided surgery. (2) Design and fabrication of static surgical guides with direct coolant channels to the osteotomy site. Variations include: Hollow-Guide, internal irrigation channels, external irrigation channels, and mesh-based guide fabrication. RESULTS:A new, simplified workflow is proposed to design and fabricate surgical guides for implant placement with the delivery of coolant directly to the osteotomy site with no obstruction and decreased risk of thermal injury and implant failure. CONCLUSIONS:This report details a novel approach to mitigating thermal injury during guided dental implant surgery. The application of a patient-specific, three-dimensional-printed surgical guide featuring an integrated Hollow-Guide design bypasses conventional coolant obstruction by delivering sterile saline directly to the osteotomy site via segmentation and selective hollowing. A simple workflow is described to integrate multidirectional irrigation to the surgical site and reduce the risk of thermal injury, subsequent osteonecrosis, and implant failure. While traditional static guides serve as a passive positioning jig, the Hollow-Guide acts as an active therapeutic device during implant preparation and placement. KEY POINTS:Static surgical guides significantly improve implant placement accuracy, but impede traditional delivery methods of irrigation and coolants to the surgical site. Maintenance of bone temperatures below a critical threshold is necessary to prevent thermal necrosis and implant failure. A digital workflow has been proposed to allow for irrigation directly at the osteotomy site without the need for complex internal or external irrigation channels. PLAIN LANGUAGE SUMMARY:Preparing the jawbone for dental implants generates significant heat from drilling. If the bone gets too hot, the tissue can die, ultimately leading to failure and loss of the implant. Dentists often use three-dimensional-printed surgical guides to ensure implants are placed in the correct anatomical position, but these templates can physically block external irrigation from reaching the drill site, increasing the risk of thermal damage. This article introduces a new design technique called the "Hollow-Guide." This method modifies the surgical guide to include built-in channels that allow sterile water or saline to flow directly to the bone during drilling. By solving the problem of blocked water flow, this new design helps keep the bone cool while maintaining the high accuracy of guided surgery. This simple workflow transforms the guide from a passive positioning tool into an active safety device that helps prevent bone damage and ensures better long-term success for dental implants.
BACKGROUND:Intentional replantation (IR) is a conservative treatment option for compromised teeth when the viability of the periodontal ligament (PDL) can be preserved. Maintaining viable PDL cells and using bioactive agents such as ethylenediaminetetraacetic acid (EDTA), platelet-rich fibrin (PRF), and injectable platelet-rich fibrin (i-PRF) may enhance the regenerative potential of replanted teeth. METHODS:A 59-year-old female patient presented with Grade III mobility and extrusion of maxillary tooth #9 following trauma. Clinical examination revealed a probing depth of 10 mm with bleeding on probing. After initial periodontal therapy and root canal treatment, the tooth was atraumatically extracted for IR. The extraoral time was limited to 10 min. Root surface instrumentation and 24% EDTA conditioning were performed only on the cervical and middle thirds of the root, while the apical PDL region was preserved without decalcification or curettage to maintain cell viability. i-PRF and PRF were prepared from the patient's venous blood. i-PRF was applied into the socket to enhance biological activity, and PRF was placed on the buccal aspect to support soft-tissue healing. After replantation, the tooth was stabilized with a rigid splint. RESULTS:Postoperative pain measured on the visual analog scale was 6 on day 1, 2 on day 3, and 0 on day 7. The initial 10 mm probing depth decreased to 4 mm at 1 month and 3 mm at 3 months, remaining stable throughout the 1-year follow-up. Radiographically, no ankylosis or root resorption was detected. The gingival index decreased from 2 to 0, and the periodontal tissues remained healthy and stable. CONCLUSIONS:This case demonstrates that IR performed with atraumatic extraction, a short extraoral period, and preservation of the apical PDL without decalcification can successfully retain a tooth with advanced mobility. The synergistic use of EDTA, PRF, and i-PRF created a favorable microenvironment for periodontal healing. This biologically oriented protocol represents one of the rare regenerative IR cases in which success was achieved without apical PDL decalcification. KEY POINTS:Preservation of viable periodontal ligament tissue is critical for successful intentional replantation. Limited apical socket preparation may facilitate passive reinsertion while minimizing compression of the apical periodontal ligament. Intentional replantation may be considered as a tooth-preserving treatment option in selected cases with trauma-related periodontal damage. PLAIN LANGUAGE SUMMARY:Saving teeth with severe damage is often difficult, especially when there is both gum tissue destruction and a history of dental trauma. In this case report, a severely mobile upper front tooth was treated using intentional replantation, a procedure in which the tooth is carefully removed and then placed back into its socket after treatment. During the procedure, special attention was given to preserving the living tissues attached to the root surface, since these tissues are important for healing. Additional regenerative materials derived from the patient's blood were also used to support recovery. Clinical and radiographic follow-up examinations showed reduced tooth mobility, decreased periodontal pocket depth, and satisfactory healing without signs of root resorption or fusion of the tooth to the bone. This case suggests that intentional replantation may help preserve selected teeth that would otherwise be considered for extraction when careful surgical techniques and appropriate biological support are used.
BACKGROUND:Soft tissue grafts are commonly used in periodontal surgery around teeth and implants. However, few studies have examined donor-site pain through patient-reported outcomes following soft tissue grafting. This study aimed to minimize donor-site pain during autologous gingival grafting using a three-dimensionally (3D)-printed stent and evaluate its effectiveness from a patient-centered perspective. METHODS:In this randomized controlled trial, 32 patients requiring autogenous gingival grafts were equally allocated to the control group (Omnivac stent) or the test group (3D-printed stent). Patient-reported outcomes were assessed using a visual analog scale (VAS) and the Oral Health Impact Profile-14 (OHIP-14) questionnaire on the day of surgery and at 1, 7, and 14 days postoperatively. RESULTS:Data from 16 control and 14 test patients were analyzed (two patients were lost to follow-up). The test group reported significantly lower VAS scores than the control group. Despite a lack of statistically significant temporal differences, marked reduction was observed on the day of surgery and on postoperative day 7. OHIP-14 scores were significantly lower in the test group than in the control group across all time points. Analysis of the individual OHIP-14 items at different intervals revealed significant reductions in discomfort-specifically in pronunciation, taste, mastication, and daily activities-when using 3D-printed stents. CONCLUSIONS:This study applied 3D-printed stents to reduce donor-site discomfort after autogenous soft tissue grafting and evaluated their effectiveness using patient-reported outcomes. Although 3D-printed stents may not directly reduce postoperative pain, they help alleviate discomfort during routine oral functions and daily activities. KEY POINTS:This study focuses on the free gingival graft, one of the most frequently employed soft tissue grafts in periodontal practice. While autogenous gingival grafting on the palatal side is currently considered the gold standard, it causes additional pain and discomfort in patients. This study demonstrates that three-dimensional technology can be used to improve stent design to reduce patient pain and discomfort. PLAIN LANGUAGE SUMMARY:This randomized controlled trial demonstrates that compared with a conventional stent, a customized 3D-printed palatal stent significantly improves patient-reported comfort and oral function after autologous gingival grafting, thereby enhancing postoperative quality of life.
BACKGROUND:In situations where orthodontic tooth movement is expected to exceed the preexisting alveolar envelope, surgically facilitated orthodontic therapy (SFOT) has been advocated to expand the alveolar housing and reduce periodontal risks. However, detailed descriptions of soft-tissue management during SFOT remain limited. METHODS:This technical note describes a surgical protocol incorporating a coronally advanced flap (CAF) within a segmental SFOT approach and illustrates its clinical application in patients undergoing orthodontic treatment requiring simultaneous periodontal phenotype modification. RESULTS:The proposed CAF-assisted SFOT protocol is based on three main principles: limiting the surgical intervention to the orthodontically involved segment, applying established mucogingival surgical principles to ensure predictable flap management, and using an acellular dermal matrix to contribute to both graft containment and soft-tissue thickening. CONCLUSIONS:The described technique provides a structured approach for integrating soft-tissue management into SFOT procedures and may facilitate simultaneous hard- and soft-tissue augmentation in orthodontic patients requiring phenotype modification. KEY POINTS:This case provides new information as it is, to the best of our knowledge, the first technical report describing the application of coronally advanced flap principles within a segmental surgically facilitated orthodontic therapy protocol. Successful management of this case relies on accurate interdisciplinary orthodontic-periodontal diagnosis, careful treatment planning, and appropriate flap management to ensure tension-free coronal advancement and graft stabilization. The primary limitation of this report is the absence of prospective clinical studies evaluating the long-term outcomes of this technique. PLAIN LANGUAGE SUMMARY:Orthodontic treatment sometimes requires moving teeth beyond the natural limits of the surrounding bone, which can increase the risk of gum recession and other periodontal problems. Surgically facilitated orthodontic therapy (SFOT) has been introduced to expand the supporting bone and make such movements safer, but there is limited information on how to manage the gums during these procedures. This report describes a surgical approach that combines SFOT with a commonly used gum surgery technique called a coronally advanced flap. The procedure focuses only on the area where teeth are being moved, applies well-established principles of gum surgery to ensure stable healing, and uses a soft-tissue substitute to help protect the graft and thicken the gums. This technique offers a structured way to address both bone and gum deficiencies at the same time during orthodontic treatment. While promising, further clinical studies are needed to confirm its long-term effectiveness.
BACKGROUND:The frontal envelope coronally advanced flap (CAF), designed for multiple adjacent gingival recessions (MAGR) of the anterior maxilla, involves tunneling of the midline papilla. However, when treating frontal and lateral MAGR in a single session, the tunneled midline papilla can act as a fixed point, which may limit coronal advancement or lead to mucosal folds in the gingival margin. METHODS:This case report introduces a modification of the CAF technique in which a V-shaped split-thickness surgical papilla is elevated at the midline to enhance flap mobility. Two patients with combined maxillary frontal and bilateral types 1 and 2 (RT1, RT2) MAGR ranging from 2-6 mm were treated using this approach. RESULTS:Postoperative healing was uneventful for both cases. In Case 1, complete and stable root coverage with excellent tissue integration and color match was observed at 18 months. In Case 2 (RT2 MAGR), near-complete root coverage was achieved at 6 months. CONCLUSION:Within the limitations of this case report, the modified CAF appears to be an effective approach for managing MAGR extending beyond the incisors and involving both maxillary quadrants. Clinicians may consider this modification when enhanced coronal flap mobility is required to treat extensive frontal and lateral MAGR in a single session. KEY POINTS:In the traditional frontal envelope coronally advanced flap, the tunneled midline papilla may act as a fixed point, which may restrict coronal advancement or lead to mucosal fold formation in the gingival margin. This case presents a modified design that enhances coronal flap mobility and achieves optimal root coverage in cases of extensive frontal and lateral maxillary anterior gingival recessions (MAGR). The success of this approach relies on midline papilla anatomy and precise incision placement, both of which support adequate flap stability, enhancing the predictability of root coverage outcomes. PLAIN LANGUAGE SUMMARY:Gum recession occurs when the gum margin moves downward, exposing part of the tooth root. When several neighboring teeth in the upper front region are affected, treatment can be particularly challenging because of the esthetic demands in this visible area. A commonly used surgical method, known as the coronally advanced flap (CAF), repositions the gum tissue to cover the exposed roots. However, in its traditional form, the tissue between the two front teeth is not lifted but tunneled, which can limit tissue movement and occasionally cause small folds along the gum line. This report describes a refined version of the CAF technique in which a small, V-shaped flap is gently lifted between the front teeth to improve tissue mobility and adaptation. Two patients were treated using this approach, both achieving favorable healing, stable root coverage, and a natural appearance that blended well with surrounding tissues. This modification may help clinicians manage wider areas of gum recession in the upper front region while maintaining esthetic harmony.
BACKGROUND:Sepsis-associated gingival necrosis is an uncommon oral manifestation that may result in extensive gingival recession after the resolution of the acute phase. METHODS:This report presents the 2-year follow-up of periodontal management in a 38-year-old woman with systemic lupus erythematosus, who developed septic shock accompanied by extensive gingival purpura and necrosis that resulted in widespread gingival necrosis during septic shock and subsequently underwent periodontal plastic surgery for persistent gingival recession. After recovery from the acute systemic condition, marked gingival recession persisted. Although pronounced spontaneous coronal migration of the gingival margin was observed during the first 6 months of follow-up, an esthetically unfavorable recession corresponding to Cairo recession type 1 persisted after 1 year. RESULTS:Connective tissue grafting was performed in the maxillary anterior region using a minimally invasive approach to minimize postoperative risk. Healing was uneventful, with no postoperative infection or adverse events despite the patient's immunosuppressed status. Satisfactory esthetic root coverage was achieved. CONCLUSION:This case suggests that periodontal plastic surgery may be a safe and effective treatment option for sepsis-associated gingival necrosis, even in patients with an immunocompromised status, when careful interdisciplinary collaboration and appropriate perioperative management are required. KEY POINTS:Sepsis-associated gingival necrosis can lead to severe recession that may not fully resolve spontaneously, especially in esthetic zones. A year of observation may reveal spontaneous coronal migration of the gingival margin, but surgical intervention should be considered when esthetic demands and functional stability persist. Well-timed periodontal plastic surgery can achieve stable and esthetic root coverage even in medically compromised patients with careful interdisciplinary management. PLAIN LANGUAGE SUMMARY:This case report describes the treatment and recovery of severe gum damage in a woman with systemic lupus erythematosus, an autoimmune disease. The patient developed septic shock, which was accompanied by extensive gum tissue damage. Although the acute condition improved, significant gum recession remained. Over the following months, the gum tissue showed gradual natural healing, but visible recession on the front surfaces persisted. After 1 year, periodontal plastic surgery was performed to restore the gum line, resulting in complete root coverage and satisfactory esthetic outcomes. This case highlights that some degree of gum recovery may occur naturally after severe tissue damage, particularly within the first year. However, surgical treatment may still be necessary to achieve optimal results. The findings also emphasize the importance of careful monitoring and preventive oral care in medically compromised patients, such as those receiving immunosuppressive therapy.
BACKGROUND:Peri-implant soft tissues are usually reduced when using a tissue punch in flapless static computer-assisted implant surgery (s-CAIS). The purpose of this article is to introduce a technique combining a minimally invasive guided roll flap (GRF) with s-CAIS to enhance buccal mucosal thickness and maintain peri-implant soft tissues. METHODS:A surgical template is used to define a crest-centered de-epithelialization window and to guide a palatal semilunar full-thickness pedicle that is rolled into a mid-buccal tunnel and stabilized. Osteotomy and implant placement are performed through the same template; the transmucosal profile is supported by an immediate provisional restoration, a sealing socket abutment, or an stock healing abutment. Clinical and volumetric outcomes were assessed over a 12-month follow-up. RESULTS:At 12 months, all implants demonstrated increased buccal mucosal thickness and adequate keratinized mucosa width. Volumetric analysis confirmed soft tissue volume augmentation compared to baseline. No vertical loss of adjacent papillae was observed. Clinical parameters, including PPD and BOP, remained stable, indicating maintained peri-implant health. CONCLUSIONS:This technique demonstrates the feasibility of combining s-CAIS with specific surgical approaches to potentially maintain or slightly improve peri-implant soft tissues. It offers clinicians an alternative method to the soft tissue punch, so the peri-implant soft tissues may be maintained or even augmented in a minimally invasive way. KEY POINTS:Static-computer assisted implant surgery integration: bridges the gap between flapless implant surgery and soft tissue management/augmentation. Enhanced peri-implant soft tissues: combines s-CAIS and modification of tissue phenotype. Minimally invasive: reduced patient morbidity due to no need for additional grafting donor sites. PLAIN LANGUAGE SUMMARY:Dental implants placed with flapless guided surgery can sometimes reduce the thickness of the surrounding peri-implant mucosa by the use of tissue punches. Soft tissues are essential for long-term implant health and appearance. This article presents a surgical approach that combines guided implant placement with a soft tissue management technique that repositions the site peri-implant mucosa to make it thicker instead of removing it. Using a surgical guide, the clinician knows exactly where to reshape the soft tissue and also use the same guide for implant placement. This minimally invasive approach helps to preserve or even improve the gum tissues around implants while maintaining the benefits of computer-guided surgery, potentially improving patient comfort and clinical outcomes.
BACKGROUND:A gummy smile can result from several factors, often leading to a disharmonious appearance and causing physical and psychological discomfort for the patient. This study aimed to evaluate changes in self-esteem and quality of life for patients, as well as the recidivism rate, following aesthetic crown lengthening (ACL) surgery. METHODS:Twenty-two periodontally healthy patients who expressed interest in undergoing ACL and met the procedural indications were selected. Before surgery, at 30 days, and 2 years postoperatively, the Oral Health Impact Profile - 14 items (OHIP-14) and the Rosenberg Self-Esteem Scale were used to assess patients' perceptions of quality of life and self-esteem. Crow dimensions, gingival phenotype, and the recidivism rate were assessed. RESULTS:ACL significantly improved the psychosocial parameters of patients (p < 0.05). Both self-esteem and quality of life showed improvement 30 days post-surgery (p = 0.02 and 0.00024, respectively). After 2 years, further improvements were observed in the self-esteem index compared to the 30-day results (from 11 [interquartile range {IQR}: 8.0-14.0] to 14 [IQR:12-15, p < 0.05]) and in the OHIP score (from 19 [IQR:14-27] to 6 [IQR: 0.0-8.0]). The clinical crown length established 30 days after surgery remained stable after 2 years (0.82 ± 0.11). CONCLUSIONS:ACL can enhance patients' quality of life and self-esteem, serving as a valuable procedure in aesthetic periodontics. PLAIN LANGUAGE SUMMARY:A "gummy smile," where too much gum tissue shows when a person smiles, can affect both appearance and confidence. This study looked at whether aesthetic crown lengthening surgery (a procedure that reshapes the gums and exposes more of the teeth) could improve how people feel about themselves and their daily lives. We followed 22 patients who underwent this surgery and measured their self-esteem and quality of life before the procedure, 1 month later, and again 2 years after the procedure. Results showed that patients felt noticeably better about their smiles and overall quality of life just 1 month after surgery. Even more encouraging, these benefits continued to grow over the course of 2 years, with patients reporting higher self-esteem and fewer problems related to their oral health. Importantly, the changes achieved by the surgery-such as the new tooth and gum proportions-remained stable, with no return of the gummy smile. These findings suggest that crown lengthening is not only an effective and lasting solution for improving the appearance of a gummy smile but also has meaningful, long-term benefits for patients' confidence and well-being.
BACKGROUND:The basic fibroblast growth factor (FGF-2) drug formulation, human recombinant FGF-2 and hydroxypropylcellulose, developed in Japan, has been confirmed to induce effective periodontal regeneration. However, in cases with minimal residual bone walls or vertical bone defects fused with furcation involvement, FGF-2 alone does not achieve ideal periodontal regeneration. Therefore, it is necessary to attempt to use FGF-2 in combination with bone grafting materials. Beta-tricalcium phosphate (β-TCP) has been developed as a bone graft material and has a long history of use. Its advantage lies in its ability to be absorbed early during wound healing and replaced by bone. In this study, we examined the effectiveness of the smallest particle-sized β-TCP in combination with FGF-2 for the severe deep and wide combined one- to three-walled bone defect and Class II furcation involvement. METHODS:FGF-2 with β-TCP was applied to an intrabony defect and Class II furcation involvement of a 40-year-old female patient with aggressive periodontitis (stage III and grade C). As far as possible, the incision line was not placed over the bone defect. The interdental papillae were dissected using a simplified papilla preservation technique. Full-thickness buccal and lingual mucoperiosteal flaps were reflected. After thorough debridement, FGF-2 with small-particle β-TCP was applied to the bone defects. RESULTS:Radiographic examination at 1 month demonstrated early radiographic bone fill. Over time, layered bone‑like radiopacity was observed extending from the remaining bone wall. In addition, by 6 months, a distinctive protruding bone‑like radiopacity arising from the alveolar crest of the adjacent tooth was observed extending toward the defect. At 41 months, substantial radiographic bone fill was evident. While Class II furcation involvement showed overall improvement, some sites exhibited only limited reparative changes. CONCLUSION:The combination of FGF-2 and small‑particle β‑TCP may promote periodontal regeneration in severe intrabony and furcation defects, although definitive confirmation of complete regeneration requires further investigation. KEY POINTS:The optimal β‑TCP particle size for use with FGF‑2 remains unclear. In this study, the smallest available β‑TCP granules were incorporated into the hydroxypropylcellulose‑based FGF‑2 formulation, functioning as a dispersed, space‑maintaining scaffold. Periodontal tissue regeneration using the smallest and rapidly absorbable β‑TCP granules in combination with FGF‑2 demonstrated favorable healing in complex, deep vertical bone defects and Class II furcation lesions. Although larger β‑TCP granules are generally considered advantageous because their greater porosity allows easier migration of undifferentiated mesenchymal cells from existing bone walls or periodontal ligament remnants, the small‑particle β‑TCP used with the FGF‑2 formulation behaved differently. When mixed with FGF‑2, the granules are suspended within the base carrier, creating a highly porous structure that facilitates mesenchymal cell migration. PLAIN LANGUAGE SUMMARY:Severe periodontal disease often destroys the bone supporting teeth, creating complex defects specifically between tooth roots that are notoriously difficult to treat and often lead to tooth extraction. The periodontal tissue regenerative drug using FGF-2 (basic fibroblast growth factor), one of the cell growth factors, helps promote the formation of new blood vessels and periodontal tissues, but it is often insufficient on its own for large or complex bone defects. In this case study, the combination of the gel‑based FGF‑2 formulation with small granules of beta‑tricalcium phosphate (β‑TCP) supported periodontal tissue regenerative healing. The key to this favorable healing response appears to be the combination itself: although the small‑particle β‑TCP remains dispersed within the FGF‑2 gel rather than forming a densely packed structure, this structure creates necessary space. This spacing likely allows the patient's own repair cells to migrate easily from the surrounding bone into the defect, facilitating effective natural healing and saving the tooth.
BACKGROUND:The management of multiple recession type 2 (RT2) gingival recessions remains a major clinical challenge because of interproximal attachment loss and limited predictability. This study aimed to present a graft-driven bottom‒up suturing concept for simultaneous root coverage and interdental papilla reconstruction. METHODS:Two systemically healthy patients with RT2 multiple gingival recessions in the mandibular anterior region were treated using a bilaminar approach with basal positioning of a connective tissue graft. Interproximal bone grafting and biologic adjuncts were used to provide structural support and enhance the healing environment. A modified vertical double-crossed suturing technique was applied to achieve graft-driven coronal advancement and tension control. Clinical outcomes were evaluated at 6‒12 months. RESULTS:At 12 months, root coverage reached 94.4% in one case and 100% in the other. Both cases demonstrated stable interdental papilla height and a keratinized tissue width gain of 2.00‒2.33 mm. Comparable favorable outcomes were observed with both recombinant human fibroblast growth factor-2 and enamel matrix derivative. CONCLUSIONS:The graft-driven bottom‒up suturing approach may represent a promising technique for the management of complex RT2 gingival recession defects. Surgical design and tension control appear to be key factors for achieving predictable root coverage and papilla reconstruction in challenging clinical scenarios. KEY POINTS:A graft-driven bottom‒up suturing approach can achieve favorable root coverage in recession type 2 multiple gingival recessions. This technique enables simultaneous reconstruction of interdental papillae in challenging anterior cases. Careful surgical design and tension control are critical factors for improving clinical outcomes in complex recession defects. PLAIN LANGUAGE SUMMARY:Gum recession, a condition in which the gums recede from the teeth, can be difficult to treat when the supporting tissue between teeth is also lost. In these cases, it is often hard to fully cover exposed roots or restore the natural shape of the gums. In these reports, we describe a new surgical approach used in two patients with multiple gum recessions in the lower front teeth. The technique uses a small piece of the patient's own tissue placed under the gum to support healing, along with a specific suturing method that gently moves the gum upward. After 12 months, both patients showed substantial root coverage and improvement in the shape of the gum between teeth, with stable results over time. These findings suggest that careful surgical design and control of tissue tension may help improve outcomes in challenging cases of gum recession.
BACKGROUND:The socket shield technique, one modality of partial extraction therapy, aims to preserve periodontal tissues and maintain the buccal alveolar bone volume following immediate implant placement or in prosthetic pontic sites, by the strategic maintenance of a tooth root fragment. This case report presents a 5 year-follow up of this technique, in a full maxillary implant-supported rehabilitation, evaluating the alveolar dimensional changes over time. METHODS:A 54-year-old patient underwent a full maxillary implant-supported rehabilitation. Partial tooth extraction was performed on the five anterior sites, numbers 6, 8, 9, 10, and 11. In each site where the socket shield technique was performed, changes in alveolar dimensions at the cervical, middle, and apical levels were measured using computed tomography at baseline, 1, 3, and 5-year follow-up intervals. In addition, the Pink Esthetic Score evaluation was performed. RESULTS:The mean values (mm) in the five evaluated sites, at each time period, were respectively: cervical = 7.92 ± 0.46; 8.38 ± 0.61; 8.28 ± 0.51; and 8.32 ± 0.47. Medium third = 7.84 ± 0.99; 8.18 ± 1.05; 7.22 ± 0.69; 7.24 ± 0.72. Apical = 6.84 ± 0.91; 6.88 ± 0.74; 6.40 ± 0.70; 6.40 ± 0.69. CONCLUSION:Despite its inherent limitations, this case report suggests that the socket shield technique can represent a promising alternative for the stability of peri-implant tissues, in pontic and implant sites. KEY POINTS:In this case report, the socket shield technique was able to preserve alveolar dimension in both implant and pontic sites at 5-year follow-up. Careful planning and execution are crucial to prevent interference between retained root fragments and prosthetic components. Patient satisfaction and favorable Pink Esthetic Scores demonstrated good esthetic outcomes with this technique. PLAIN LANGUAGE SUMMARY:Preserving bone and soft tissue volume and position after tooth extraction is a major challenge in implant dentistry, particularly in anterior sites. This case report illustrates the five-year follow-up of a patient who received a full-arch, implant-supported rehabilitation in the upper jaw using the socket shield technique. This approach preserves a portion of the tooth root to help maintain the natural contour of bone and soft tissues. Clinical and tomographic evaluations, along with esthetic scoring systems, were used to assess tissue stability and appearance over time. In this case report, after five years, the technique showed stable preservation of bone and gingival tissues, with favorable esthetic outcomes and high patient satisfaction. Although based on a single case, these findings suggest that the socket shield technique may be a useful option for achieving long-term tissue stability and esthetic success in challenging implant-supported rehabilitations.
May 9, 2026: This article published in Early View in error. The corrected article will republish shortly.
BACKGROUND:Radiotherapy for head and neck cancer is associated with adverse oral effects, including salivary gland hypofunction, radiation-related caries, and periodontal tissue alterations, which negatively impact oral health and quality of life. METHODS:A 56-year-old male previously treated with surgery, radiotherapy, and chemotherapy for oropharyngeal cancer presented with dentin hypersensitivity, gingival recession, and reduced keratinized tissue. A multidisciplinary rehabilitation was performed, including non-surgical periodontal therapy, free gingival grafting, restorative treatment of cervical lesions, prosthetic rehabilitation, and individualized preventive maintenance. RESULTS:Uneventful healing was observed at all surgical sites. The free gingival grafts resulted in increased keratinized tissue and vestibular depth, with stable periodontal conditions and resolution of dentin hypersensitivity. Clinical stability was maintained throughout a 24-month follow-up period, with no adverse radiation-related effects. CONCLUSIONS:Multidisciplinary oral rehabilitation, including mucogingival surgery and preventive care, can be safely and effectively performed in irradiated patients, improving periodontal stability, oral comfort, and quality of life. KEY POINTS:Head and neck radiotherapy can cause long-lasting oral complications that require careful and individualized dental management. Periodontal surgery, restorative treatment, and prosthetic rehabilitation can be safely performed in irradiated patients when properly planned and followed. Long-term preventive maintenance is essential to maintain oral health and minimize complications in head and neck cancer survivors.
