BACKGROUND: Patients with skeletal angle Class III malocclusion usually have inadequate hard and soft tissue volume at the mandibular anterior teeth. The labial proclination at the teeth may lead to gingival recession. The purpose of this study was to explore whether periodontal phenotype modification therapy with soft tissue augmentation (PhMT-s) can prevent gingival recession in these patients.
METHODS: Four patients with skeletal Class III malocclusion and a thin periodontal phenotype underwent surgical-orthodontic treatment. Prior to tooth movement, they underwent a minimally invasive vestibular incision with subperiosteal tunnel access combined with autogenous connective tissue grafts for periodontal phenotype modification with soft tissue augmentation (PhMT-s). The labial gingival thickness of the anterior mandibular teeth was measured at three distinct levels: at the cementoenamel junction (GT0), 3 mm apical to the CEJ (GT3), and 6 mm apical to the CEJ (GT6). These measurements were taken at baseline, three months following PhMT-s, and after tooth decompensation. Additionally, a biopsy sample was obtained from the PhMT-s site of one patient. All sections were subsequently stained using hematoxylin and eosin, Masson trichrome, Sirius Red, and immunohistochemistry.
RESULTS: The thickness of the labial gingiva was increased about 0.42 to 2.00 mm after PhMT-s. At the end of pre-orthognathic surgical orthodontic treatment, the thickness of the labial gingiva was increased about - 0.14 to 1.32 mm compared to the baseline and no gingival recession occurred after the pre-orthognathic surgical orthodontic treatment. The histologic results demonstrated that the grafts obtained from the PhMT-s site exhibited increased deposition of collagen fibers. Moreover, the proportion of type III collagen increased and the grafts displayed significantly reduced positive expression of CD31 and OCN.
CONCLUSIONS: PhMT-s increased the thickness of the soft tissue, stabilizing the gingival margin for teeth exhibiting a thin periodontal phenotype and undergoing labial movement. This is attributed to the increased deposition of collagen fibers.

BACKGROUND: The aim of this study was to assess the outcomes of the combination technique of strip free gingival grafts (SFGG) and xenogeneic collagen matrix (XCM) in augmenting the width of keratinized mucosa (KMW) around dental implants, and compare its efficacy with the historical control group (FGG).
METHODS: Thirteen patients with at least one site with KMW ≤ 2 mm after implant surgery were included and received SFGG in combination with XCM. Another thirteen patients with the same inclusion and exclusion criteria from the previous trial received FGG alone. The same outcomes as the previous trial were evaluated. KMW, thickness of keratinized mucosa (KMT), gingival index (GI) and probing depth (PD) were measured at baseline, 2 and 6 months. Postoperative pain, patient satisfaction and aesthetic outcomes were also assessed.
RESULTS: At 6 months after surgery, the combination technique could attain 3.3 ± 1.6 mm of KMW. No significant change could be detected in GI or PD at 6 months compared to those at 2 months (p > 0.05). The postoperative pain and patient satisfaction in VAS were 2.6 ± 1.2 and 9.5 ± 1.2. The total score of aesthetic outcomes was 3.8 ± 1.2. In the historical FGG group, 4.6 ± 1.6 mm of KMW was reported at 6 months, and the total score of aesthetic outcomes was higher than the combination technique (4.8 ± 0.7 vs. 3.8 ± 1.2, p < 0.05).
CONCLUSIONS: The combination technique of SFGG and XCM could increase KMW and maintain peri-implant health. However, this combination technique was associated with inferior augmentation and aesthetic outcomes compared with FGG alone.
BACKGROUND: This clinical trial was registered in the Chinese Clinical Trial Registry with registration number ChiCTR2200057670 on 15/03/2022.

OBJECTIVE: this study aims to compare the clinical outcomes of traditional and digital crown extension guides in the aesthetic restoration of anterior teeth. Additionally, the study will analyze the differences in the results of various digital crown extension guides in anterior aesthetic restorations.
METHODS: Sixty-two patients who required aesthetic restoration of their anterior teeth were selected for this study. The patients had a total of 230 anterior teeth and were randomly divided into three groups: a control group of 22 cases who received diagnostic wax-up with pressure film, an experimental group 1 of 20 cases who received 3D printed digital models with pressure film, and an experimental group 2 of 20 patients who received digital dual-positioning guides. The control group had a total of 84 anterior teeth, experimental group 1 had 72 anterior teeth, and experimental group 2 had 74 anterior teeth. The study compared three methods for fabricating crown extension guides: the control group used the diagnostic wax-up plus compression film method, while experimental group 1 used compression film on 3D printed models and experimental group 2 used 3D printed digital dual-positioning crown extension guides. After the crown lengthening surgery, the control group patients wore DMG resin temporary crown material for gingival contouring, while the experimental group patients wore 3D printed resin temporary crowns for the same purpose. The patients were followed up in the outpatient clinic after wearing temporary crowns for 1 month, 3 months, and 6 months, respectively. The clinical results were evaluated in terms of marginal fit, red aesthetic index, and white aesthetic index.
RESULTS: Based on the statistical analysis, the experimental group required significantly fewer follow-up visits and less time for guide design and fabrication compared to the control group. Additionally, the surgical time for the experimental group was significantly shorter than that of the control group. During the postoperative period between the 1st and 3rd month, the PES index scores for the marginal gingival level, proximal, and distal mesiodistal gingival papillae of the experimental group showed a trend of superiority over those of the control group. By the 6th month, the marginal gingival level exhibited a significant difference between the experimental and control groups. The experimental group demonstrated superior results to the control group in terms of shape, contour, and volume of the teeth, color, surface texture, and transparency of the restorations, and features during the 1st and 3rd postoperative months. In the 6th month, the comparative results indicated that the experimental group continued to exhibit superior outcomes to the control group in terms of the shape, color, surface texture, and transparency of the restorations, as well as the characteristics of the teeth. Additionally, the experimental group demonstrated significantly fewer gingival alterations than the control group at 1 month, 3 months, and 6 months post-procedure, with this difference being statistically significant. Furthermore, the combination of 3D printing technology and restorative techniques was utilized, resulting in consistent patient satisfaction.
CONCLUSIONS: Digitalisation plays an important role in anterior aesthetic restorations. The use of digital technology to manage the entire process of anterior cosmetic restorations can improve restorative results, reduce the number of follow-up appointments, shorten consultation time, and achieve better patient satisfaction.

BACKGROUND: Currently, the treatment of epulis is primarily surgical excision, which would greatly affect the aesthetics of patients if happened in the anterior region. It\'s challenging for clinicians to balance the aesthetic after surgery and less surgical trauma. To overcome this disadvantage, the authors propose the modified coronally advanced flap technique which applies the principles of minimally invasive surgery to provide satisfactory therapeutic results in fibrous epulis.
METHODS: We report a case of an 18-year-old female with the chief complaint of a gingival swelling in the right upper anterior region. After the initial periodontal therapy, the modified surgical approach was applied to this patient. Unlike conventional coronally advanced flap technique, an additional incision was made, and the free portion was rotated into the adjacent space to completely cover the trauma, which avoided the use of the second operative zone.
RESULTS: The gingiva recovered with normal color, contour, and consistency after surgery, the papilla filled up the proximal space well and was in good harmony with the adjacent papillae. The surgical results remained stable during the follow-up period.
CONCLUSIONS: The use of modified coronally advanced flap technique allows the clinician to successfully resume the natural appearance of gingiva in the treatment of fibrous epulis, as well as simplify the surgical approach, shorten the operative time, and demonstrate no tendency of recurrence.
CONCLUSIONS: Why is this case new information? This novel technique not only removes the epulis, but also takes into account the postoperative aesthetics of the surgery at the same time. This minimally invasive surgical technique reduces operative time and increases patient comfort. Keys to successful management of this case are as follows: (i) Adequate preoperative assessment of the location of the additional incision; (ii) tension-free coronal flap advancement. What are the primary limitations to success in this case? Clinical studies with long-term outcomes of this approach are needed. This procedure may be limited to larger gingival tumors.

OBJECTIVE: To analyze the histopathological characteristics of peri-implant soft tissue in reconstructed jaws and the changes after keratinized mucosa augmentation (KMA) with free gingival graft (FGG).
METHODS: Twenty patients were enrolled in this study. Five patients of them, who were periodontal and systemic healthy and referred for crown lengthening before restoration with healthy keratinized gingiva collected were enrolled as healthy controls. 15 patients of them were with fibula or iliac bone flaps jaw reconstruction (10 with fibula flap and 5 with iliac flap), who were referred to FGG and implant exposures before restoration. Soft tissue was collected before FGG in reconstructed jaws, and in 5 patients (3 with fibula flap and 2 with iliac flap) 8 weeks after FGG if a second surgery was conducted. Histological analysis with hematoxylin-eosin stain and immunological analysis to interlukin-1 (IL-1), interlukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were performed.
RESULTS: Thickness from the bottom of stratum basale to the top of stratum granulosum and thickness of keratinized layer in reconstructed jaws were significantly lower compared with that of natural healthy keratinized gingiva [0.27 (0.20, 0.30) mm vs. 0.36 (0.35, 0.47) mm, P<0.05; 16.49 (14.90, 23.37) μm vs. 26.37 (24.12, 31.53) μm, P<0.05]. In the reconstructed area, thickness from the bottom of stratum basale to the top of stratum granulosum increased after KMA with FGG [0.19 (0.16, 0.25) mm vs. 0.38 (0.25, 0.39) mm, P=0.059] and the thickness of keratinized layer significantly increased after KMA with FGG [16.42 (14.16, 22.35) μm vs. 28.57 (27.16, 29.14) μm, P<0.05], which was similar to that in the control group. Furthermore, the number of positive cells of IL-1, IL-6 and TNF-α significantly increased after KMA [0.67 (0.17, 8.93) vs. 11.00 (9.16, 18.00); 13.00 (8.50, 14.14) vs. 21.89 (15.00, 28.12); 0.22 (0.04, 0.63) vs. 2.83 (1.68, 5.00), respectively, P<0.05] as well as the average optical density value [0.15 (0.14, 0.17) vs. 0.18 (0.17, 0.21); 0.28 (0.26, 0.33) vs. 0.36 (0.33, 0.37); 0.23 (0.22, 0.29) vs. 0.30 (0.28, 0.42), respectively, P<0.05], which was similar to that in the healthy keratinized gingiva.
CONCLUSIONS: The lack of rete pegs and inflammatory factors were common in soft tissue with jaw reconstruction. FGG can improve the quality of the epithelium and may improve the stability of the mucosa around implants.

OBJECTIVE: The free gingival graft (FGG) has been identified as the most effective method for increasing keratinized mucosa width (KMW). However, the challenge emerges in cases of extensive keratinized mucosa deficiency, where efficient utilization of the patient\'s limited keratinized tissue to achieve optimal results is crucial. This article introduces a modified geometric technique to address this clinical issue.
METHODS: Utilizing geometric principles, the modified technique involves dividing the rectangular graft into two triangular or trapezoidal sections, which are then reassembled to form an approximate diamond shape. Through strategic cut and splice, the graft is reshaped to suit the recipient site.
CONCLUSIONS: Preliminary observations in cases employing the modified geometric technique have increased the KMW around implants. This method enhances graft utilization and offers a viable clinical option for surgical plans aimed at widening keratinized mucosa in instances of large-area KMW deficiency.
CONCLUSIONS: This article proposed a modified method to increase KMW, which may be an optimal choice for patients with insufficient KMW in large area, avoiding the waste of limited graft, decreasing patient morbidity, and effectively widening keratinized mucosa.

In recent years, clinicians have paid more attention to the biological and esthetic effects of the 2 mm keratinized mucosa width (KMW) around dental implant. How to increase the keratinized mucosa is the focus of clinicians. While the free gingival graft (FGG) is still the gold standard of keratinized mucosa augmentation, alveolar ridge preservation (ARP), connective tissue graft (CTG) and apically positioned flap (APF) can also be used to obtain more than 2 mm keratinized mucosa width when they are used before implantation, with implantation, within the implant-healing phase, with second stage of implantation or after rehabilitation according to different indications. This article comprehensively summarizes the influencing factors of timing and surgical procedures for keratinized mucosa augmentation, providing guidance for clinicians to treat peri-implant keratinized mucosa deficiencies.
近年，种植位点周围2 mm角化龈宽度（KMW）的生物学作用和美学作用已逐渐受到重视，如何对角化龈不足的患者进行增量受到临床医师越来越广泛的关注。游离龈移植（FGG）是角化龈增量的金标准，但种植术前、种植手术同期、种植体骨整合期、种植二期手术以及修复负载后还可根据不同的适应证使用位点保存术（ARP）、上皮下结缔组织移植（CTG）以及根向复位瓣（APF）等方式获得2 mm以上的角化龈增量效果。本文总结对种植患者不同时期进行角化龈增量的考量因素以及术式选择，以期为种植体周围角化龈不足的防治策略提供参考。.

OBJECTIVE: The keratinized gingiva plays an important role in maintaining healthy periodontal and peri-implant tissue. Acellular dermal matrix (ADM), as a substitute biomaterial, has a porous structure and good biocompatibility. 3D-bioprinting has the potential for tissue engineering because it enables precise loading of cells layer-by-layer. Herein, we bioprinted ADM scaffold encapsulating gingival fibroblasts (GFs) and evaluated its efficacy in keratinized gingiva augmentation in vivo to assess its potential for clinical periodontal tissue regeneration.
METHODS: GFs were extracted from the gingiva of beagles and transfected with a green fluorescent protein (GFP). The ADM scaffold (ADM cell-free group) was constructed using ADM, gelatin, and sodium alginate mixed at an appropriate ratio via 3D-bioprinting. The ADM cell scaffold (ADM cell group) was established by adding extra GFs in the same manner. Six beagles were divided into blank control, ADM cell-free, and ADM cell groups; and implant surgery was performed. The keratinized gingiva was clinically and histologically evaluated at baseline and after 2 months.
RESULTS: GFs transfected with GFPs expressed green fluorescence and were present in new tissue in the ADM cell group and not observed in the ADM cell-free group. At 2 months after surgery, the keratinized gingival augmentation in the ADM cell group was significantly more than that in the ADM cell-free group. Attached gingival augmentation was also observed more in the ADM cell group than that in the ADM cell-free group. Histological staining showed that the tissue in the ADM cell group displayed a more integrated structure and higher expression of COL I, COL III, and VEGF-A than those in the ADM cell-free group.
CONCLUSIONS: 3D-bioprinted GF-encapsulated ADM scaffolds increased the amount of keratinized gingiva in vivo, suggesting that 3D-bioprinting has great potential for oral soft tissue regeneration.

OBJECTIVE: To assess the clinical efficacy of xenogeneic collagen matrix (XCM) plus apically positioned flap (APF) in augmenting the keratinized mucosa (KM) width (KMW) and thickness (KMT) around posterior mandibular implants and compare it with free gingival graft (FGG) plus APF.
METHODS: Thirty patients with KMW ≤ 2 mm in the posterior mandibular implant site were randomly allocated to the FGG group (FGG plus APF) or the XCM group (XCM plus APF). Clinical assessments, including KMW and KMT, shrinkage rate of established KM, and peri-implant soft tissue health, were evaluated during a 6-month follow-up. Additionally, the esthetic outcomes and patient-reported postoperative morbidity were investigated.
RESULTS: At 6 months, the KMW measured 3.60 ± 0.79 mm in the FGG group and 3.28 ± 0.96 mm in the XCM group (p = 0.186). Both groups showed a tendency for graft contraction (FGG, 42.11%; XCM, 53.22%). The KMT measured 1.24 ± 0.34 mm in the FGG group and 0.95 ± 0.29 mm in the XCM group, with statistical difference (p = 0.002). No difference in the peri-implant soft tissue health was observed between the two groups (p > 0.05), but the esthetic outcomes were better in the XCM group (p < 0.05).
CONCLUSIONS: XCM plus APF rendered a similar clinical efficacy in augmenting KMW as that with FGG plus APF, but with higher shrinkage. XCM plus APF was inferior with respect to FGG plus APF in augmenting KMT. The esthetic outcomes were better with XCM plus APF than FGG plus APF. Clinical relevance XCM plus APF graft was inferior with respect to FGG plus APF in augmenting KMT.
BACKGROUND: Trial registration number: ChiCTR2200058027 and date: 03/27/2022.

舌侧牙龈退缩虽较少见，但可能给患者带来牙齿敏感等不适。下颌牙齿舌侧的解剖结构较特殊，膜龈手术治疗难度大。本文介绍1例下前牙舌侧牙龈退缩的病例，患者接受了隧道技术联合上皮下结缔组织移植术，术后舌侧退缩的根面得到很好的覆盖，且软组织稳定，牙龈厚度增加明显。术后随访1年效果良好，证实隧道技术联合上皮下结缔组织移植术可以很好地治疗舌侧牙龈退缩。.