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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