Conference Paper

Soft tissue augmentation with a new regenerative collagen 3-d matrix with oriented open pores as a potential alternative to autologous connective tissue grafts

  • MVZ Zahnkultur Berlin-Brandenburg GmbH
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Background: Soft tissue augmentation is often required due to high expectations of a natural red-and-white esthetic but also to allow the generation of more complex tissues than with GBR alone. Since autologous grafts involve disadvantages such as the creation of a second surgical site with additional pain and morbidity and the limited availability of grafting material, resorbable collagen scaffolds were developed to offer an off-the-shelf alternative to autologous grafts. Aim/Hypothesis: To perform a first case series with a new regenerative collagen 3-D matrix with vertically oriented open pores as a potential alternative to autologous connective tissue grafts. Material and methods: A new 3-D regenerative collagen matrix was used in this case report (Mucomaix, Matricel GmbH, Herzo- genrath, Germany) that is CE-approved in Europe since 2013. This biodegradable 3-D matrix is composed of porcine collagen and elastin fibers and has a highly open porous structure that is intended to guide migrating cells and blood vessels into the matrix to support the soft tissue regeneration. It is not chemically crosslinked and is remodelled during the healing process. For this series the product size 15 X 20 mm with a thickness of 3 mm was used. The 3-D regenerative matrix was used for the treatment of the following clinical indications: Root coverage with coronally advanced flap technique, immediate implant placement with buccal soft tissue augmentation, and socket preservation with socket sealing. Surgical handling, soft tissue reaction during the healing process and final results will be discussed. Results: Due to the shape stability of the 3-D collagen matrix in the dry as well as in the wet state, the trimming and handling is very easy. The wet matrix is compressible and stretchable and due to its ‘memory-effect’ it regains its initial shape after a few seconds. After the placement of the dry matrix on the prepared recipient site the hydration of it was providing great handling properties. The primary healing phase was uneventful in all cases. During the healing, tissue inflammatory reactions were within normal limits and with no visible difference to those of autologus soft tissue grafts that would be used in these indications. The final results presented are satisfying in all cases. Since the new 3-D matrix does not provide a barrier layer, it is not indicated for open healing during e.g. socket sealing, because degradation of the exposed 3-D matrix would be too fast. However, the combination of the 3-D matrix with a slow degrading collagen membrane gave promising results also for this indication. Conclusion and clinical implications: The initial results obtained after clinical application of the new 3-D collagen matrix in closed-healing procedures to avoid connective tissue graft harvesting are very encouraging. However, further well designed clinical studies involving larger patient populations are needed to generate evidence-based data for validation of these early results.

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The success of cell-free in situ tissue engineering approaches depends on an appropriate recruitment of autologous cells from neighboring tissues. This identifies cellular migration as a critical parameter for the pre-clinical characterization of biomaterials. Here, we present a new method to quantify both the extent and the spatial anisotropy of cell migration in vitro . For this purpose, a cell spheroid is used as a cell source to provide a high number of cells for cellular invasion and, at the same time, to guarantee a controlled and spatially localized contact to the material. Therefore, current limitations of assays based on 2D cell sources can be overcome. We tested the method on three biomaterials that are in clinical use for soft tissue augmentation in maxilla-facial surgery and a substrate used for 3D in vitro cell culture. The selected biomaterials were all collagen-derived, but differed in their internal architecture. The analysis of cellular isodensity profiles within the biomaterials allowed the identification of the extent and the preferential directions of migration, as well as their relation to the biomaterials and their specific pore morphologies. The higher cell density within the biomaterials resulting from the here-introduced cell spheroid assay compared to established 2D cell layer assays suggests a better representation of the in vivo situation. Consequently, the presented method is proposed to advance the pre-clinical evaluation of cell recruitment into biomaterials, possibly leading to an improved prediction of the regeneration outcome.
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Background: Numerous surgical approaches for the treatment of single gingival recession (GR) defects are documented in the literature. The aim of this 5-year, split mouth-design, randomized clinical trial was to evaluate the effectiveness of coronally advanced flap (CAF) alone versus CAF with connective tissue graft (CAF+CTG) in the treatment of single Miller Class I and II GR defects. Methods: Thirty-seven patients with 114 bilateral, single Miller Class I and II GR defects were treated with CAF on one side of the mouth and CAF+CTG on the other side. Clinical measurements (GR length [REC], keratinized tissue width [KT], complete root coverage [CRC], and percentage of root coverage [PRC]) were evaluated before surgery and after 6, 12, 24, and 60 months. Results: There was a significant reduction of REC and increase of KT after surgery in both groups. CAF+CTG showed significantly better results for all evaluated clinical parameters in all observed follow-up periods. Miller Class I defects showed better results in terms of REC, CRC, and PRC, whereas Miller Class II showed better results in KT, both in favor of CAF+CTG. Miller Class I defects showed better results than Miller Class II GR defects regardless of the surgical procedure used. Conclusions: Both surgical procedures were effective in the treatment of single Miller Class I and II GR defects. The CAF+CTG procedure provided better long-term outcomes (60 months postoperatively) than CAF alone. Long-term stability of the gingival margin is less predictable for Miller Class II GR defects compared to those of Class I.
Background: The immediate implant placement and immediate restoration in the aesthetic zone is a proven method to provide a supply to patients as soon as possible. However, especially here it is necessary to create all the conditions thus a long-term success can be achieved. Objective: Is it possible to prevent recessions after immediate implants with a simultaneous insertion of a free connective tissue graft using the envelope technique. Materials and methods: There were placed immediate implants in 38 patients after flapless tooth extraction with preservation of the buccal crestal bone plate. In all cases, a free CTG was inserted buccally in an envelope technique to increase the thickness of the soft tissue. Most of the patients were provided with provisional screw-retained crowns immediately. After tooth extraction, it was measured the thickness of the buccal crestal bone, the entire thickness of the buccal tissue and the gingival height in relation to the adjacent teeth. The measurements were repeated 12 and 24 months later. Results: In this continuing study, 20 cases show an observation period of at least two years. 1. In all patients the buccal bone wall thickness was less than 1 mm. 2. During the observation period in any case we have seen a recession of the gingiva below the baseline. 3. The thickness of the gingiva decreased over time but remained above baseline. 4. No implant was lost. Conclusion: Within the limitation of this short-term two years examination it could be observed, that there is a prevention of buccal soft tissue recession after immediate implant placement.
A new method for covering localized areas of root exposure with free connective tissue grafts uses connective tissue obtained from the depth of the hard palate, leaving only a narrow surface defect at the donor site. The graft is positioned directly over the exposed root, but its major part is placed in an "envelope" previously created by an undermining partial thickness incision in the tissues surrounding the defect. In this way, both sides of the graft are in intimate contact with these tissues which offer support and nourishment. Clinical results 2 to 8 months postoperatively are favorable.