A systematic review assessing soft tissue augmentation techniques

Clinic for Fixed and Removable Prosthodontics and Dental Material Science, University of Zurich, Zurich, Switzerland.
Clinical Oral Implants Research (Impact Factor: 3.89). 10/2009; 20 Suppl 4(Suppl 4):146-65. DOI: 10.1111/j.1600-0501.2009.01784.x
Source: PubMed


The aim of the present review was to systematically assess the dental literature in terms of soft tissue grafting techniques. The focused question was: is one method superior over others for augmentation and stability of the augmented soft tissue in terms of increasing the width of keratinized tissue (part 1) and gain in soft tissue volume (part 2).
A Medline search was performed for human studies focusing on augmentation of keratinized tissue and/or soft tissue volume, and complemented by additional hand searching. Relevant studies were identified and statistical results were reported for meta-analyses including the test minus control weighted mean differences with 95% confidence intervals, the I-squared statistic for tests of heterogeneity, and the number of significant studies.
Twenty-five (part 1) and three (part 2) studies met the inclusion criteria; 14 studies (part 1) were eligible for comparison using meta-analyses. An apically positioned flap/vestibuloplasty (APF/V) procedure resulted in a statistically significantly greater gain in keratinized tissue than untreated controls. APF/V plus autogenous tissue revealed statistically significantly more attached gingiva compared with untreated controls and a borderline statistical significance compared with APF/V plus allogenic tissue. Statistically significantly more shrinkage was observed for the APF/V plus allogenic graft compared with the APF/V plus autogenous tissue. Patient-centered outcomes did not reveal any of the treatment methods to be superior regarding postoperative complications. The three studies reporting on soft tissue volume augmentation could not be compared due to lack of homogeneity. The use of subepithelial connective tissue grafts (SCTGs) resulted in statistically significantly more soft tissue volume gain compared with free gingival grafts (FGGs).
APF/V is a successful treatment concept to increase the width of keratinized tissue or attached gingiva around teeth. The addition of autogenous tissue statistically significantly increases the width of attached gingiva. For soft tissue volume augmentation, only limited data are available favoring SCTGs over FGG.

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Available from: Marcel Zwahlen, Nov 10, 2014
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    • "In patients with fixed partial prosthesis , where abutments had minimal amount of keratinized tissue (1 mm), the use of connective tissue grafts (CTGs) resulted in significant gingival augmentation, which favoured plaque control, reduced gingival inflammation and attachment loss, when compared with equivalent nongrafted sites (Orsini et al. 2004). Both surgical procedures are, however, associated with patient morbidity due to the need of harvesting an autograft from the palate and hence, the use of soft tissue substitutes of allogenic or xenogeneic origin has been tested (Thoma et al. 2009). A xenogenic collagen matrix (CM) of porcine origin has been recently investigated in the treatment of recession defects around teeth (McGuire & Scheyer 2010; Jepsen et al. 2013). "
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    ABSTRACT: Aim: To evaluate histologically the healing of a xenogeneic collagen matrix (CM) used to augment the width of keratinized tissue around teeth. Materials and methods: The gingiva on the buccal aspect of mandibular and maxillary premolars was surgically excised on 12 minipigs. After 1 month of plaque accumulation, the resulting defects were randomly treated by a periosteal retention procedure (control site) or by placing a collagen matrix after an apically repositioned flap (CM) (test site). Clinical and histological outcomes were evaluated at 1, 4 and at 12 weeks. Results: Clinically, no gain of keratinized tissue was noted in either group. Histometrically, the thickness of the gingival unit was significantly higher in the test group at 1 month, although these differences were not significant at 3 months. There was a tendency in the test group towards less bone resorption (0.7 mm) and apical displacement (0.5 mm) of the gingival margin at 3 months. Conclusions: The tested CM demonstrated uneventful healing, being resorbed within the surrounding tissues in absence of significant inflammation. When compared with periosteal retention alone, the CM group attained similar clinical and histological outcomes.
    Clinical Oral Implants Research 08/2014; 26(5). DOI:10.1111/clr.12441 · 3.89 Impact Factor
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    • "However, the additional influence of the thickness and also possibly the quality or histological composition of the graft would be of great interest for future research. As different methods and parameters were being used for the evaluation of soft tissue augmentation procedures, it is difficult to compare the outcome of the published studies (Thoma et al. 2009; Ronay et al. 2011). A novel approach for the measurement of contour changes has recently been introduced and applied in different studies including the present one (Windisch et al. 2007; Fickl et al. 2009; Strebel et al. 2009; Thoma et al. 2010; Schneider et al. 2011). "
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    ABSTRACT: Objectives To test whether or not vascularized interpositional periosteal-connective tissue grafts are as successful as free subepithelial connective tissue grafts in augmenting volume defects in the anterior maxilla.Material and methodsTwenty subjects with Seibert class 1 ridge defects in the anterior maxilla were randomly, equally assigned to augmentation by vascularized interpositional periosteal-connective tissue graft (test) or free subepithelial connective tissue graft (control). Clinical periodontal parameters at teeth adjacent to the gap were recorded, and conventional impressions were taken prior to surgery (baseline = t0) and 1 (t1), 3 (t3) and 6 (t6) months after surgery. The casts were optically scanned, digitized and analyzed for ridge contour changes in the augmented area. Data were subjected to nonparametric statistics.ResultsThe contour changes in labial distance between baseline and follow-up for the control group were (median, range) 1 mm, 0.37–1.45 (t0–t1); 1.18 mm, 0.39–1.40 (t0–t3); and 0.63 mm, 0.28–1.22 (t0–t6) and for test group 1.21 mm, 0.74–2.47 (t0–t1); 1.26 mm, 0.50–1.71 (t0–t3); and 1.18 mm, 0.16–1.75 (t0–t6). Significantly less shrinkage of the graft was observed in the test group after 6 months (P = 0.03). Clinical periodontal parameters at the neighboring teeth were stable over the follow-up period and did not differ between groups.Conclusions Augmentation of single tooth gaps with moderate ridge defects in the anterior maxilla was successfully performed using both techniques. However, after 6 months, sites treated by the pediculated graft were superior in maintaining the initially augmented volume and showed less shrinkage of the graft. This could be attributed to better perfusion of the pediculated graft.
    Clinical Oral Implants Research 04/2014; 26(6). DOI:10.1111/clr.12368 · 3.89 Impact Factor
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    • "Even though, in addition, sufficient longterm data are missing it needs to be stated that the application of acellular dermal substitutes seems to be presently widespread and accepted by many clinicians as an approved alternative to SCTGs in gingival recession treatment (Gapski et al. 2005, Cairo et al. 2008, Moslemi et al. 2011, Schlee & Esposito 2011). As on the other hand, only few short-term observations from clinical case series exist, scientific evidence is weak if ADM is supposed to be used for soft tissue ridge augmentation procedures (Thoma et al. 2009). Care needs to be taken, moreover, if bigger dimensioned grafts are required: Folded or layered ADM might impede vascularization and lead to extensive shrinkage (Batista et al. 2001, Wei et al. 2002). "
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    ABSTRACT: Soft tissue replacement grafts have become a substantial element to increase tissue volume in plastic periodontal and implant surgery. Autogenous subepithelial connective tissue grafts are increasingly applied in aesthetic indications like soft tissue thickening, recession treatment, ridge preservation, soft tissue ridge augmentation and papilla re-construction. For the clinical performance of connective tissue graft harvesting and transplantation, a fundamental understanding of the anatomy at the donor sites and a sound knowledge of tissue integration and re-vascularization processes are required. Possible donor sites are the anterior and posterior palate including the maxillary tuberosity, providing grafts of distinct geometric shape and histologic composition. The selective clinical application of different grafts depends on the amount of required tissue, the indication and the personal preference of the treating surgeon. One of the main future challenges is to volumetrically evaluate and compare the efficacy and long-term stability of soft tissue autografts and their prospective substitutes. The aim of this review was to discuss the advantages and shortfalls of different donor sites, substitute materials and harvesting techniques. Although standardized recommendations regarding treatment choice and execution can hardly be given, guidelines for predictable and successful treatment outcomes are provided based on clinical experience and the available scientific data.
    Journal Of Clinical Periodontology 04/2014; 41 Suppl s15(s15):S123-S142. DOI:10.1111/jcpe.12185 · 4.01 Impact Factor
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