SURGICAL PERIODONTICS

Case Presentation:

A 43-year-old female presented to the office for periodontal treatment. After informed consent was obtained, the surgical periodontal treatment was rendered. The #22 and #27 teeth areas were diagnosed with mucogingival deformities—lack of keratinized tissue. Following the standard of care protocol, #22 was treated with the piscine xenograft and #27 served as the control site and was grafted with AFGG. Standard post‐surgical instructions were given to the patient. The surgical site healed within normal limits and the first signs of keratinization were seen in week 4 of follow-up. At the 6- and 9-month follow-ups, the change in the width of the KT was 4 mm. The patient was satisfied with the esthetic result of the procedure.

Conclusion:

The piscine xenograft healed with no adverse clinical events. In the test site, there was a change in the width of KT of 4 mm, with favorable esthetic results assessed by the subject. Future studies are needed to confirm the current results.

KEYWORDS: soft tissue regeneration, keratinized tissue, patient-centered outcomes.

BACKGROUND

Gingival augmentation procedures around natural teeth are performed to facilitate plaque control, to improve patient comfort, to prevent future recession, and in conjunction with other dental specialties.^1,2 Although the exact amount of keratinized tissue (KT) necessary for periodontal health remains controversial, the current consensus suggests that ‡2 mm of KT and ‡1 mm of attached gingiva is necessary around teeth. It appears that a minimal dimension of attached gingiva might be appropriate only for the plaque-free non-restored environment without prominent roots.¹

Due to its high level of success, the autogenous free gingival graft (AFGG), developed a half century ago, remains a gold standard.^7-11 Autografts show predictable clinical outcomes, but require a secondary harvest site that frequently adds to the patient’s discomfort and offers a limited quantity of donor tissue.¹² AFGGs may also produce an undesirable esthetic result, colloquially referred to as a “tire patch,” which is off-color and texturally distinct from surrounding tissues.¹³

In order to overcome these issues with autogenous tissue, alternative material (primarily of allogenic origin) have been developed.^1,14  Many xenografts are processed from different species. Religious concerns or the possibility of viral transmission can impede the utilization of some of materials used as soft tissue alternatives (eg, bovine, porcine). A piscine xenograft can serve as a substitute for those particular situations.

Omega-3 Wound™ is a piscine acellular dermal matrix membrane used in surgical and medical fields.¹⁵ Its composition and allergenic potential were studied and there are no known disease transmission risks from fish to human.^16,17 To the authors’ knowledge, there are no publications evaluating the use of piscine membrane in the field of dentistry. However, its promising results are reported in the medical field, in particular in the wound healing processes.^15-17 This case report presents the clinical results in the change of the width of KT after a soft-tissue augmentation procedure using Omega-3 Wound™ piscine acellular dermal matrix. The primary outcome was the change in the width of KT at 6 months follow-up.

CLINICAL PRESENTATION

A 43-year-old female with no medical conditions and no known allergies presented to the office for periodontal treatment. No significant findings were identified during the extra-oral examination. During the dental history report, the patient mentioned she received non-surgical periodontal therapy and regular periodontal maintenance. Plaque control was good, and the patient reported brushing two times a day and flossing one time a day.

The periodontal examination revealed generalized probing depths between 1-3 mm throughout. There was no mobility or furcation involvement. The #22 and # 27 teeth areas presented with recession on the buccal site, with a lack of KT and a lack of attached gingiva. Frenum insertion was aberrant on the buccal surface of tooth #22. On the buccal surface of tooth #22 was a discolored composite restoration with recurrent caries (Figure 1). Tooth #22 was slightly malpositioned buccally (Figure 2). Periapical radiographs and CBCT of the area revealed generalized mild horizontal bone loss.

The periodontal diagnosis was generalized slight chronic periodontitis and mucogingival defects and conditions around the teeth: gingival recession, lack of KT and attached gingiva, and the presence of aberrant frenum attachment. Based on the Miller classification this was categorized as Miller class III defect.¹⁸

CASE MANAGEMENT

The treatment plan was as follows: Phase I-pre-sugical phase consisting of oral hygiene instructions, control of the inflammation, and four quadrants of scaling and root planing combined with occlusal therapy. Phase II-surgical phase that involved correcting the mucogingival deformities in the designated areas and implant placement in the edentulous areas. Phase III-implant-supported fixed partial dentures and fabricating an occlusal guard. Phase IV-maintenance phase, involving a strict supportive periodontal therapy (SPT).

In order to correct the mucogingival deformities, the piscine xenograft was chosen by the patient as a possible alternative for the soft tissue augmentation procedures to increase the amount of KT. After institutional ethical approval was obtained, the patient consented to participation in the case study. The selected treatment plan included correcting the mucogingival deformities using the piscine xenograft for site #22 and AFGG for tooth #27.

Preoperative measurements were taken as indicated in the periodontal chart (Figure 3). Preparation of the recipient bed was done according to the standard of care for soft tissue alternatives to increase KT and included the standard of care steps for this particular procedure: scaling and root planing using hand and rotary instruments; one carpule/site of 2% lidocaine (Xylocaine, AstraZeneca) (1:100,000) was given for local anesthesia as buccal infiltrations; vertical incisions were made on the mesial and distal areas of the gingival margin of #22 using a #15 blade; the vertical incisions were connected with a horizontal incision positioned at the mucogingival junction. A split-thickness flap was elevated, removing the aberrant frenum insertion and preparing the recipient bed, allowing for a minimum 7 mm of height in order to compensate for the future shrinkage of the soft tissue material. The flap was sutured apically to the periosteum using simple interrupted Vicryl 5-0 (Ethicon, Johnson & Johnson) (Figure 4). The same protocol was followed for the control site.

The xenograft was prepared following the instructions from the manufacturer. It was hydrated in saline solution for 1 minute and shaped according to the area aimed to augment, and matching the recipient bed (Figure 5). The graft was positioned buccally and stabilized using simple interrupted sutures to the adjacent mucosa. Following standard of care protocol, an AFGG was harvested from the palate. One “X” mattress sling suture using Vicryl 5-0 (Ethicon, Johnson & Johnson) was used to secure the lateral movement of both grafts (Figure 6). No periodontal dressing was placed.

Postoperative care was prescribed using analgetics (Ibuprofen 600 mg Advil, Pfizer), antibiotic Amoxicillin 500 mg for 7 days. The patient was instructed to rinse with 0.12% chlorhexidine mouth wash (Peridex, 3M ESPE) twice a day for 14 days.

The patient presented at the 1-week follow-up, 3-week follow-up, and then every month during the first 6 months of healing. Postoperative measurements were taken and clinical photographs were used to document the progressive healing of both sites. At the 9-month follow-up, the patient was surveyed regarding esthetics: the shape and color on a scale from 1 (low esthetics) to 5 (high esthetics) of the clinical outcome.

CLINICAL OUTCOMES
No adverse events, such as allergies or complications, occurred during the healing period. Surgical site examinations showed signs of normal healing and first signs of keratinization were seen in the week 4 follow-up (Figure 7). At the 6- and 9-month follow-ups, change in the width of the KT was 4 mm (Figure 8). Probing depth remained the same. The patient’s perception regarding the shape and color of the final clinical outcome for the test side was evaluated as 5 for the shape and 4 for the color, compared with the control site that was evaluated with 1 for both variables (Figure 9).

DISCUSSION
The current outcome presented favorable results from different perspectives, with similar result to other alternative materials when compared with AFGG.^1,5,6 As described by Agudio et al,⁷ the augmentation procedures were effective in halting the progression of recession over a long period of time (10 to 25 years).

No root coverage was expected from this procedure, but the defective composite restoration was removed and a new one was placed. The selected location was challenging to treat considering the malposition of the canine and the lack of KT to start with. Compared with other xenograft materials, the piscine alternative handled relatively well, was not friable during suturing, and it did not tear.

One of the limitations of this report is the study design (case study), but it certainly provided valuable information regarding future studies. A randomized clinical trial has been designed to provide further evidence.

The clinical outcomes of this procedure are encouraging, as Omega‐3 Wound™ piscine xenograft might be an alternative graft material that could be used as a substitute for AFGG. 

Table 1. Overview of the advantages and disadvantages of the autogenous grafts and soft tissue alternatives.

AUTHORS

Irina F. Dragan, DDS, MS
Assistant Professor
Department of Periodontology
Tufts University School of Dental Medicine
One Kneeland Street, Boston, MA 02111
email: irina.dragan@tufts.edu

Mariana Caramida, DDS, PhD student
Assistant Professor
Department of Oral Health and Community Dentistry
Faculty of Dentistry
Carol Davila University of Medicine and Pharmacy
Str. Eforie, Nr.4-6, Bucuresti, Romania
email: mariana.caramida@gmail.com

Miha Pirc, DMD
Private practice - Ljubljana, Slovenia
email: miha.pirc@hotmail.com

Hilmar Kjartansson, MD, FACEM
Clinical Director Emergency Medicine
University Hospital of Iceland
Director of Research and Development
Kerecis Ltd
Isafjordur, Iceland
email: hk@kerecis.com

Nadeem Karimbux, DMD, MMSc
Associate Dean of Academic Affairs
Professor of Periodontology
Tufts University School of Dental Medicine
One Kneeland Street, Boston, MA 02111
email: nadeem.karimbux@tufts.edu

Corresponding author: 
Direct correspondence and requests for reprints to Dr. Irina F. Dragan, Department of Periodontology, Tufts University School of Dental Medicine, One Kneeland Street, Suite 747, Boston, MA 02111. 

REFERENCES

1. Kim DM, Neiva R. Periodontal soft tissue non-root coverage procedures: a systematic review from the AAP Regeneration Workshop. J Periodontol. 2015;86(2 Suppl):S56-72.
2. Consensus report. Mucogingival therapy. Ann Periodontol. 1996;1(1):702-706.
3. Lang NP, Loe H. The relationship between the width of keratinized gingiva and gingival health. J Periodontol. 1972;43(10):623-627.
4. Wennstrom JL. Mucogingival therapy. Ann Periodontol. 1996;1(1):671-701.
5. Wilson RD. Marginal tissue recession in general dental practice: a preliminary study. Int J Periodontics Restorative Dent. 1983;3(1):40-53.
6. Nevins M, Nevins ML, Kim SW, Schupbach P, Kim DM. The use of mucograft collagen matrix to augment the zone of keratinized tissue around teeth: a pilot study. Int J Periodontics Restorative Dent. 2011;31(4):367-373.
7. McGuire MK, Scheyer ET, Nunn ME, Lavin PT. A pilot study to evaluate a tissue-engineered bilayered cell therapy as an alternative to tissue from the palate. J Periodontol. 2008;79(10):1847-1856.
8. Marquez IC. The role of keratinized tissue and attached gingiva in maintaining periodontal/peri-implant health. Gen Dent. 2004;52(1):74-78; quiz 79.
9. Hall WB. The current status of mucogingival problems and their therapy. J Periodontol. 1981;52(9):569-575.
10. Hangorsky U, Bissada NF. Clinical assessment of free gingival graft effectiveness on the maintenance of periodontal health. J Periodontol. 1980;51(5):274-278.
11. McGuire MK. Periodontal plastic surgery. Dent Clin North Am. 1998;42(3):411-465.
12. Nevins M, Nevins ML, Camelo M, Camelo JM, Schupbach P, Kim DM. The clinical efficacy of DynaMatrix extracellular membrane in augmenting keratinized tissue. Int J Periodontics Restorative Dent. 2010;30(2):151-161.
13. McGuire MK, Scheyer ET. Randomized, controlled clinical trial to evaluate a xenogeneic collagen matrix as an alternative to free gingival grafting for oral soft tissue augmentation. J Periodontol. 2014;85(10):1333-1341.
14. McGuire MK, Nunn ME. Evaluation of the safety and efficacy of periodontal applications of a living tissue-engineered human fibroblast-derived dermal substitute. I. Comparison to the gingival autograft: a randomized controlled pilot study. J Periodontol. 2005;76(6):867-880.
15. Kjartansson H, Olafsson IH, Karason S, Thorisson H, Baldursson BT, Gunnarsson E, Jo-rundsson E, Sigurjonsson GF. Use of Acellular Fish Skin for Dura Repair in an Ovine Model: A Pilot Study. Open Journal of Modern Neurosurgery. 2015;5:124-136.
16. Baldursson BT, Kjartansson H, Konradsdottir F, Gudnason P, Sigurjonsson GF, Lund SH. Healing rate and autoimmune safety of full-thickness wounds treated with fish skin acellular dermal matrix versus porcine small-intestine submucosa: a noninferiority study. Int J Low Extrem Wounds. 2015;14(1):37-43.
17. Yang CK, Polanco TO, Lantis JC, 2nd. A Prospective, Postmarket, Compassionate Clinical Evaluation of a Novel Acellular Fish-skin Graft Which Contains Omega-3 Fatty Acids for the Closure of Hard-to-heal Lower Extremity Chronic Ulcers. Wounds. 2016;28(4):112-118.
18. Miller PD, Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent. 1985;5(2):8-13.

FIGURES

Figure 1. Initial presentation. Mucogingival deformities on tooth #22.

Figure 2. CBCT exposed the area of tooth #22 revealing buccal positioning

Figure 3. Initial periodontal chart

Figure 4. Recipient bed preparation and apical suture of the partial thickness flap.

Figure 5. Preparation of the piscine xenograft Omega‐3 Wound™, soft tissue alternative material.

Figure 6. Stabilization of the piscine xenograft achieved with multiple sutures.

Figure 7. Healing in various stages of the piscine xenograft during the first month.

Figure 8. Final healing of the piscine xenograft at 6 and 9 months.

Figure 9. Patient’s perception regarding the shape and color of the final clinical outcomes.