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Impairment or loss of interdental papilla is a common issue in patients with periodontal disease, leading to phonetic, functional, and aesthetic concerns. Numerous techniques have been explored to reconstruct and regenerate interdental papillae, but consistent success remains challenging. This article presents a novel surgical approach that applies the principles of the Connective Tissue Graft (CTG) wall technique to enhance papilla volume when interdental clinical attachment loss is present in the aesthetic zone. The case of a 35-year-old woman with an RT3 recession defect associated with loss of interdental hard and soft tissues is discussed. The patient underwent a procedure involving palatal incisions, application of amelogenins, and a trapezoidal shape CTG fixed at the base of the papilla under a coronally advanced flap. This approach aimed to stabilize the blood clot and prevent soft tissue collapse into the defect area, enhancing the position and volume of the interdental papilla. Results at 6- and 12-months follow-up indicated significant improvement in papilla appearance and complete root coverage. This case suggests that the modified CTG wall technique can effectively treat buccal and interdental gingival recessions associated with horizontal or infrabony defects. Further clinical trials are necessary to confirm these findings and establish the most effective approach for interdental papilla reconstruction. Keywords: interdental papilla, connetive tissue graft, periodontal therapy, amelogenins, connective tissue graft-wall technique, papilla reconstruction

Treatment of gingival recessions affecting mandibular incisors is scarcely documented. Despite a shallow vestibule depth being considered a poor anatomical condition, it has never been measured nor deemed a clinical parameter affecting the outcome of root coverage procedures. This study describes a vertically and coronally advanced flap (V-CAF) + connective tissue graft (CTG) technique to obtain root coverage and increased vestibule depth in the treatment of gingival recessions affecting mandibular incisors. Twenty patients with single gingival recessions were treated. The results showed that V-CAF+CTG is effective in increasing residual vestibule depth and in reducing recession depth. Immediately after surgery, a vestibule-depth increase of 5.9 ± 1.2 mm was reported, which was statistically significant compared to baseline, and it remained stable after 12 months (4.8 ± 1.1 mm). The mean percentage of root coverage was 98.3% ± 5.2% for all treated recessions, and complete root coverage (CRC) was achieved in 90% of cases (18 of 20). V-CAF+CTG could be considered a successful technique in terms of vestibule depth increase and CRC for the treatment of single gingival recessions in the mandibular incisors.

Purpose: To report the 5-year clinical and aesthetic outcomes of a novel surgical-prosthetic approach for the treatment of buccal soft tissue dehiscence around single dental implants. Materials and methods: Twenty patients with buccal soft tissues dehiscence around single implants in the aesthetic area were treated by removing the implant-supported crown, reducing the implant abutment, coronally advanced flap in combination with connective tissue graft and final restoration. After the first year, patients were recalled three times a year until the final clinical re-evaluation performed 5 years after the final prosthetic crown. Complications, bleeding on probing (BoP), peri-implant probing depth (PPD), clinical attachment level (CAL), keratinized tissue height (KTH), soft tissue coverage and thickness (STT), patient satisfaction (VAS) and aesthetic assessment (PES/WES) were evaluated 5 years after the final restoration. Results: Of the 20 patients enrolled in the study, 19 completed the study at 5 years. A total of 99.2% mean soft tissue dehiscence coverage, with 79% of complete dehiscence coverage, was achieved at 5 years. A statistically significant increase in buccal soft tissue thickness (0.3 mm 0.1-0.4 P 0.001) and keratinized tissue height (0.5 mm 0.0-1.0; P 0.001) at 5 years with respect to 1 year was demonstrated. The patient aesthetic evaluation showed high VAS scores with no statistical difference between 1 year and 5 years (8.75 ± 1.02 and 8.95 ± 0.91 respectively). A statistical significant PES/WES score improvement was observed between baseline and 5 years (9.48 ± 2.68; P 0.001), but not between 1 and 5 years. Conclusions: Successful aesthetic and soft tissue dehiscence coverage outcomes were well maintained at 5 years. The strict regimen of post-surgical control visits and the emphasis placed on the control of the toothbrushing technique could be critical for the successful long-term maintenance of soft tissue dehiscence coverage results. Keywords: aesthetics, connective tissue, dental implant, mucogingival surgery, soft tissue dehiscence Conflict-of-interest statement: The authors declare that they have no conflict of interest.

The present case report describes a modification of the connective tissue graft wall technique with enamel matrix derivative applied to treat deep vertical bony defects. The technique presented uses a palatal incision to gain access to the bony defect. Deep infrabony defects affecting two maxillary central incisors associated with interdental and buccal gingival recession were treated. At 1 year after surgery, 9 and 6 mm of interdental clinical attachment level gain were seen in cases 1 and 2, respectively. The position of the interdental papilla was improved, and complete root coverage was achieved. Radiographs demonstrated bone fill of the infrabony components of the defects. This report encourages the possibility to improve, in one surgical session, regenerative and esthetic parameters in the treatment of deep infrabony defects.

The aim of the present case series study was to evaluate the short- and longterm (3 years) soft tissue stability of a surgical technique combining transmucosal implant placement with submarginal connective tissue graft (CTG) in an area of shallow buccal bone dehiscence. A sample of 20 patients were treated by positioning a transmucosal implant in an intercalated edentulous area. A CTG sutured to the inner aspect of the buccal flap was used to cover the shallow buccal bone dehiscence. Clinical evaluations were made at 6 months (T1) and 1 (T2) and 3 (T3) years after the surgery. Statistically significant increases in buccal soft tissue thickness and improvement of vertical soft tissue level were achieved at the T1, T2, and T3 follow-ups. A significant increase in keratinized tissue height was also found at T3. No significant marginal bone loss was recorded. The submarginal CTG technique was able to provide simultaneous vertical and horizontal soft tissue increases around single implants with shallow buccal bone dehiscence and no buccal mucosal recession or clinical signs of mucositis or peri-implantitis at 1 and 3 years.

The aim of this parallel double-blind randomized controlled clinical trial was to describe a modified approach using the coronally advanced flap (CAF) with triangular design and to compare its efficacy, in terms of root coverage and esthetics, with a trapezoidal type of CAF. A sample of 50 isolated Miller Class I and II gingival recessions with at least 1 mm of keratinized tissue apical to the defects were treated with CAF. Of these recessions, 25 were randomly treated with trapezoidal CAF (control group) while the other 25 (test group) were treated with a modified triangular CAF. The clinical and esthetic evaluations, made by the patient and an independent periodontist, were performed 3 months, 6 months, and 1 year after the surgery. No statistically significant difference was demonstrated between the two CAF groups in terms of recession reduction, complete root coverage, or 6-month and 1-year patient esthetic scores. Better 3-month patient esthetic evaluations and better periodontist root coverage, color match, and contiguity assessments were reported after triangular CAF. Trapezoidal CAF was associated with greater incidence of keloid formation. Single-type gingival recessions can be successfully covered with both types of CAF. The triangular CAF should be preferred for esthetically demanding patients.

The aim of the present case series article was to provide a standardized approach for the early restorative phase after a crown-lengthening surgical procedure. Different advantages can be ascribed to this approach: the clinician can prepare a definitive prosthetic finishing line in the supragingival location; the early postsurgical temporization allows the conditioning of soft tissues, especially the interdental papillae, during their maximum growing phase; and the clinician can choose the time for the definitive prosthetic rehabilitation in a patient-specific manner according to the individual potential and duration of the soft tissue rebound. In this study, this standardized approach was applied to the treatment of two esthetic cases requiring crown-lengthening procedures.

The case reports in this article describe a surgical approach for improving root coverage and clinical attachment levels in Miller Class IV gingival recessions. Two gingival recessions affecting maxillary and mandibular lateral incisors associated with severe interdental hard and soft tissue loss were treated. The surgical technique consisted of a connective tissue graft (CTG) that was placed below a coronally advanced envelope flap and acted as a buccal soft tissue wall of the bony defect treated with enamel matrix derivative (EMD). No palatal/lingual flap was elevated. In the first clinical case, 6 months after surgery a ceramic veneer was placed to correct tooth extrusion and improve the overall esthetic appearance. One year after the surgery in both cases, clinically significant root coverage, increase in buccal keratinized tissue height and thickness, improvement in the position of the interdental papilla, and clinical attachment level gain were achieved. The radiographs demonstrate bone fill of the intrabony components of the defects. This report encourages a novel application of CTG plus EMD to improve both root coverage and regenerative parameters in Miller Class IV gingival recessions.

A major esthetic concern is soft tissue defects around implant restorations, which often result in an extra long prosthetic crown. This report describes a modified prosthetic-surgical approach to the treatment of peri-implant horizontal and vertical soft tissue defects in an esthetically demanding patient. One month before surgery, the implant crown restoration was removed, the preexisting implant abutment was reduced, and a short provisional crown, at the level of the homologous contralateral incisor, was applied. A bilaminar technique, consisting of an envelope coronally advanced flap covering two connective tissue grafts, was used to treat the soft tissue defects around the implant site. Four months after surgery, a new implant abutment and provisional crown were applied for soft tissue conditioning before the final impression. Nine months after surgery, the peri-implant soft tissue margin was 4 mm more coronal compared with baseline and at the same soft tissue margin level of the right central incisor. A 2.2-mm increase in buccal soft tissue thickness measured 1.5 mm apical to the soft tissue margin was accomplished. The emergence profile of the replaced tooth faithfully reproduced that of the healthy homologous contralateral central incisor. Two years after surgery, the soft tissue margin was stable and the esthetic appearance of the implant site was well maintained. This report demonstrates the possibility of fully correcting severe vertical and horizontal peri-implant soft tissue defects and achieving high patient satisfaction through a combined mucogingival and prosthetic treatment.

The presence of a localized alveolar ridge defect, especially in the maxillary anterior dentition, may complicate an esthetic rehabilitation. The goal of this case report is to describe a novel subepithelial connective tissue graft technique for soft tissue augmentation in Class III ridge defects. Surgical intervention consisted of in situ maintenance of a connective tissue "platform" at the edentulous space, which facilitated the stabilization and suturing of the connective tissue grafts used for soft tissue augmentation. Adequate graft thickness to treat the deep horizontal soft tissue loss was obtained by doubling the width of a de-epithelialized free gingival graft that was subsequently folded on itself. The soft tissue conditioning at the level of the pontic began 9 months after surgery by shaping the soft tissue with a bur and filling the space with flowable composite resin applied above the pontic. The final prosthetic phase began 14 months after surgery. A reproduction of the anatomical cementoenamel junction in the provisional and definitive restorations was performed to improve the soft tissue emergence profile. Nine months after surgery, a soft tissue augmentation of 5 mm in the vertical and 4 mm in the horizontal dimension was accomplished. The suggested surgical technique was able to accomplish horizontal and vertical soft tissue augmentation in a single surgical step.