Download Oral soft tissue regeneration utilizing absorbable scaffolds

Oral soft tissue regeneration utilizing
absorbable scaffolds
Rodrigo Neiva1, Bruna Tanello2
Department of Periodontology, College of Dentistry, University of Florida, Gainesville, FL, USA
1
DDS, MS, Graduate Program Director
Department of Periodontology, College of Dentistry, University of Florida
2
DDS, AstraTech Implant Fellow
KEYWORDS
ABSTRACT
Bilayer Collagen Matrix,
Biomaterials, Connective tissue
graft, Free gingival graft.
Background Oral soft tissue regeneration procedures are performed to facilitate plaque control,
to improve patient comfort, to prevent future recession, and in conjunction with restorative,
orthodontic, prosthetic, and implant dentistry. Recent evolutions in the field of periodontology
have shown that oral soft tissue regeneration may no longer be solely dependent on palatal
tissue. The aim of this paper is to discuss traditional and current treatment approaches for
oral soft tissue regeneration.
Methods Literature review and presentation of current alternative methods for oral soft tissue
regeneration that do not depend on the use of palatal tissue for grafting. A case reporting
the use of an absorbable soft tissue scaffold (Mucograft, Geistlich Pharma AG) to promote
gingival regeneration is also presented.
Results The patient was successfully treated without palatal tissue harvesting. Stable results
were confirmed at the 12 months follow up. The patient was also extremely satisfied with the
final results, that were not only acceptably functional, but also esthetic.
Conclusion This paper demonstrates that alternative methods have the potential to minimize
the need for palatal tissue harvesting during oral soft tissue regeneration. These materials
may still not be capable of producing the same results observed when autogenous tissue
is used. However, they are capable of positively influence soft tissue development, wound
healing, and regeneration. Future development of these materials and surgical techniques
associated with their application may improve these outcomes.
Introduction
Oral soft tissue regeneration procedures are
performed to facilitate plaque control, to improve patient
comfort, to prevent future recession, and in conjunction
with restorative, orthodontic, prosthetic, and implant
dentistry. These procedures are also indicated in
order to reconstruct oral soft tissue that was lost due
to pathology, such as excisional biopsy procedures.
Recent evolutions in this field of periodontology have
shown that oral soft tissue regeneration may no longer
be solely dependent on palatal tissue. The aim of this
paper is to discuss traditional and current treatment
approaches for oral soft tissue regeneration.
Mucogingival deformities
The oral cavity is covered by two main types of soft
tissues: oral mucosa and gingival tissues. Gingival
tissues have unique features when compared to
other soft tissues. Gingival epithelium is comprised of
stratified squamous keratinizing epithelium and covers
the neighboring areas of teeth and the palate. It is
limited by the mucogingival junction and the gingival
Italian Journal of Dental Medicine vol. 1/1-2016
margin and also merges with the palatal epithelium at
the borders of the palate. Gingival tissues are firmly
attached to underlying structures, and are capable of
resisting trauma from mastication and tooth brushing.
Oral mucosa is covered by non-keratinized stratified
squamous epithelium that can be easily injured
during oral hygiene and mastication. Oral mucosa is
also mobile and not firmly attached to the underlying
structures. The 2012 Glossary of Periodontal Terms
of the American Academy of Periodontology defines
mucogingival deformities as “A departure from
the normal dimension and morphology of, and/
or interrelationship between gingiva and alveolar
mucosa; the abnormality may be associated with
a deformity of the underlying alveolar bone”. This
is characterized by the absence of gingival tissues
around a tooth or teeth, which may be associated or
not with gingival recession. When gingival tissues are
absent or lost, oral mucosa is present. Oral mucosa
is not adapted for masticatory forces or oral hygiene,
which results in trauma being transmitted to tooth
supporting structures and possible deterioration.
23
Figure 1 Preoperative photograph demonstrating the initial
appearance of the lesion on tooth #11
Figure 2 Excisional gingival biopsy
Figure 3 Affected tooth following biopsy removal
Figure 4 BCM application over the biopsy site
Hence, treatment is needed in order to reverse this
condition and to protect tooth supporting structures.
Periodontology (22-25). During the development of
these systematic reviews it was determined, based on
current knowledge, that under optimal plaque control
conditions and absence of clinical inflammation, there
is no need for a minimum amount of keratinized tissue
for preventing attachment loss. In other words, gingival
tissues are only necessary where plaque control is
inadequate, resulting in soft tissue inflammation (2223). Very rarely, patients are capable of maintaining
adequate plaque control. When plaque control is
inadequate clinical inflammation develops, resulting
in attachment loss and gingival recession, unless
there is a minimum amount of keratinized tissue (KT).
A minimum amount of 2 mm of KT with 1 mm of
attached gingiva has been recommended under these
circumstances (22-23).
There are other clinical scenarios of traumatic
etiology, such as the presence of subgingival restorative
margins or clasp from removable appliances, specific
orthodontic tooth movement or anatomical situations
where the literature does not provide guidelines
on the needed minimum amount of KT. There is
lack of evidence on the interplay between gingival
inflammation and /or direct mechanical trauma (e.g.
Periodontal biotype
Periodontal biotype includes soft tissue and bone
thickness. Periodontal biotype is influenced by
genetics, but may also be influenced by tooth eruption
patterns and orthodontic movement, affecting tooth
position within the arch. Teeth positioned more buccally
within the arch may be more prone to mucogingival
deformities. Although there is consensus on the need
of a minimum tissue thickness, there is no evidence
defining this thickness. In fact, a valid measurement
of tissue thickness has not been developed. Certain
surgical techniques may enhance soft tissue thickness,
but are unlikely to change it. The development of a
thicker gingival biotype may result in better esthetic
outcomes, and possibly create tissue that would be
more resistant to traumatic injuries.
Oral soft tissue regeneration
The American Academy of Periodontology
(AAP) published in 2015 consensus reports on all
available regenerative strategies utilized currently in
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Figure 5 Sequence of the gradual evolution of soft tissue regeneration
(1-6). CTG have been proposed as an alternative to the
FGG, although the amount of epithelium keratinization
achieved is less predictable (7). However, GTGs
are significantly superior for root coverage. These
procedures usually result in better esthetic outcomes
when compared to FGGs, and may also result in better
enhancement of patient’s gingival biotype, depending
on the thickness of the connective tissue harvested
from the palate and used during grafting procedures.
Alternative methods
Figure 6 Clinical presentation 6 months after biopsy
demonstrating no recurrence of the lesion
tooth brushing) in sites with minimum KT as the
etiology of progressive recessions (22-23).
Treatment approaches
Autogenous gingival grafts harvested from the
patient’s palate have been considered to be the “gold
standard” methods of correction of mucogingival
deformities. These surgical procedures may be limited
by the donor site availability, which may also influence
the frequency and severity of surgical complications
in the form of post-operative bleeding and substantial
discomfort. Palatal soft tissue grafts are used in two
ways: by keratinized epithelium transplantation, Free
Gingival Graft (FGG), or transplantation of gingival
connective tissue, Connective Tissue Graft (CTG).
The use of a FGG has been shown to predictably
increase the width of KT. Free gingival grafts undergo
contraction during the healing process. Hence,
clinicians should plan for graft dimension accordingly,
considering that the average contraction of FGG’s range
from 25-40% has been reported. This procedure is
mostly indicated in non-esthetic areas since blending
with the surrounding tissues is usually inadequate. The
reported KT augmentation ranges from 3.1 to 5.6 mm
Italian Journal of Dental Medicine vol. 1/1-2016
Alternative graft techniques and biomaterials have
been studied and applied in clinical practice with
the purpose of avoiding donor site morbidity and to
overcome limited availability of autogenous tissue. The
scientific evidence on the efficacy of these alternative
techniques is limited, but under specific situations,
these materials can be considered as an adequate
replacement of palatal grafts. Obvious advantages
of alternative methods include unlimited supply, less
surgical complications, and less discomfort for the
patient. The most accepted alternative methods
include the following.
• Living Cellular Construct (LCC) is a bioengineered
construct composed of living allogeneic human
fibroblasts and keratinocytes, bovine collagen and
human extracellular proteins (Apligraf®, Organogenesis
Inc). This material has been used for gingival
augmentation around teeth. It has been tested in 2
randomized clinical trials and 1 case series reporting
average gains in keratinized tissue ranging from 1.3 to
1.8 mm (14-16).
• Acellular Dermal Matrix (ADM) is a commercial
product made of processed human dermis
(AlloDerm®, BioHorizons; PerioDermTM, Dentsply).
The use of allogeneic dermal grafts for keratinized
gingival tissue augmentation have reported conflicting
results, with limited gains in the width of keratinized
tissue. The esthetic outcome of this procedure has also
been reported as compromised with the appearance
25
KT of 2.5 mm (11-13). In two studies, patient reported
outcomes were analyzed in comparison with control
treatment using autogenous grafts demonstrating
significant pain reduction, less analgesic drug
consumption and better patient’s acceptance (12,
13). This product offers unique flexibility of use since
it can be used either internally, as a connective tissue
replacement material, or externally, as a free gingival
graft replacement and/or biologic wound dressing
material.
Case report
Figure 7 BCM application over the exposed root surface
Figure 8 Immediate post-op demonstrating CAF on #6 and
11, and SF on #9
of scar tissue formation, which has been confirmed
histologically. This material is primarily used internally,
to thicken tissues, and for root coverage procedures.
• Bilayer Collagen Matrix (BCM) is a completely
absorbable xenogeneic type I and III collagen soft
tissue scaffold of porcine origin (Mucograft® Seal,
Geistlich Pharma AG). Its use as grafting material for
gingival augmentation around teeth has been tested in
3 randomized clinical trials reporting an average gain in
26
This case illustrates the use of an alternative method
of oral soft tissue regeneration. The material used in
this case was a BCM. The advantage of this material is
that not only it can be used as alternative to CTG but it
can also be used as an alternative to FGG, since it can
be left exposed without complications.
The patient was a 39 year-old Caucasian male,
who presented with gingival enlargement of bluish
appearance associated with the gingival margin of
tooth #11 (Fig. 1). The enlargement appeared to have
started to develop 6 months prior to initial consultation.
The patient did not report any discomfort. The
tooth was vital, and no radiographic changes were
observed. An oral pathologist was consulted, and he
recommended and excisional biopsy of the lesion,
which was immediately performed (Fig. 2).
The specimen was placed in 10% buffered formalin
for fixation, and sent out for histopathology. Histologic
results confirmed the diagnosis of pyogenic granuloma.
Based on the location of the lesion, excisional biopsy of
the area would have probably resulted in the creation
of a large recession defect on the tooth (Fig.3). Hence,
decision was made to use BCM as an absorbable soft
tissue scaffold to maximize the regenerative potential
of the area, and to minimize the severity of the gingival
recession following biopsy removal. The material was
cut to shape, and easily secured in place using 6.0
polypropylene sutures (Fig. 4).
Follow-up photographs demonstrate that the material
was gradually replaced by new soft tissue formation.
Not only the extent of the recession defect was
substantially minimized, but it also resulted in the
formation of keratinized wound margins, where no
keratinized epithelium was left following biopsy (Fig. 5).
Three months later, the patient presented for
reconstruction of the gingival recession defect created
after biopsy removal. The patient also presented a preexisting similar recession defect on tooth #6 and less
severe gingival recession on tooth #9 (Fig. 6). Both
canines were treated with Coronal Flap Advancement
(CFA) following the Zucchelli approach (26), and
BCM was once again used. BCM was adapted over
the exposed root surfaces and stabilized with internal
periosteal 4.0 chromic gut sutures (Fig. 7). Flap
Italian Journal of Dental Medicine vol. 1/1-2016
same results observed when autogenous tissue is used,
however, they are capable of positively influence soft
tissue development, wound healing, and regeneration.
Future development of these materials and surgical
techniques associated with their application may
improve these outcomes.
References
Figure 9 Post-op photograph at 14-day follow up showing
excellent wound healing due to high biocompatibility of
BCM with the oral tissues
Figure 10 Stability of regenerated gingival tissues 12
months after treatment
advancement was achieved with periosteal releasing
incisions. Flaps were stabilized with a combination of
sling and suspensory sutures with 6.0 polypropylene
sutures. Tooth #9 was treated with a semilunar flap
(SF) as described by Tarnow (27) (Fig. 8). Uneventful
healing was observed at 14 days, demonstrating high
level of biocompatibility of BCM with oral soft tissues.
Sutures were removed, and the patient was instructed
on oral hygiene procedures to minimize pressure and
trauma of the treated sites (Fig. 9). The patient was
then referred to a restorative dentist for treatment of
the non-carious class V lesion on the facial aspect of
tooth #6. The area was restored with glass ionomer.
The patient returned one year later for re-evaluation.
Stability of all treated sites was confirmed. BCM in
conjunction with CFA resulted in substantial coverage
of the exposed root surfaces and clinical attachment
level gains of 3-4 mm (Fig. 10). The patient was
extremely satisfied with the results.
Conclusions
This paper demonstrates that alternative methods
have the potential to minimize the need for palatal
tissue during oral soft tissue regeneration. These
materials may still not be capable of producing the
Italian Journal of Dental Medicine vol. 1/1-2016
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