The gingival thickness (GT) and keratinized tissue width (KTW) constitute the gingival phenotype, a concept that has received a great deal of appreciation in recent years. Gingival phenotype modification has been achieved via different surgical techniques and grafting materials. Despite the superiority of autogenous grafts, their increased patient morbidity and limited recourse has led to the development of graft substitutes. The human dermal matrix is a notable example that, depending on its processing method, can become freeze-dried or solvent-dehydrated acellular dermal matrix (FDADM and SDADM, respectively). This article reports the 9-year outcomes of a randomized clinical trial regarding gingival phenotype modification following root coverage with FDADM and SDADM. Twelve of the original 20 patients were available at the 9-year follow-up. Overall, the outcomes of gingival phenotype modification were maintained in both groups and at all sites after 9 years. For KTW, an incremental increase was observed over time in both groups, and minimal or no changes were noted in GT from the 1-year recall to the 9-year recall. However, the gingival margin level showed an apical shift for both groups.

The coronally advanced flap technique is one of the most commonly used approaches for treating gingival recession. Several modifications of the technique have been proposed over the years, making it a highly predictable treatment option for gingival recession; however, as dental implants are structurally and biologically different from natural teeth, a further modification of the conventional coronally advanced flap technique has been suggested to overcome the challenges posed by the treatment of peri-implant soft tissue dehiscences. The present article aims to describe the state of the art of the technique at implant sites presenting with peri-implant soft tissue dehiscences, and highlight the main differences between this and the coronally advanced flap approach in natural teeth. The timing of crown removal and abutment modification/replacement are discussed, along with the different methods for management of the flap and connective tissue graft that are recommended at implant sites. The outcomes of this approach compared to the conventional coronally advanced flap technique, and other approaches are also presented. Keywords: connective tissue graft, dental implants, gingival recession, soft tissue augmentation, surgical flap Conflict-of-interest statement: The authors do not have any financial interests, either directly or indirectly, in the products or information listed in the paper.

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.

When it comes to complete root coverage of exposed root surfaces, several limiting factors have been suggested. Although tooth malposition and papillae dimension are capable of influencing root coverage, they have not received sufficient emphasis in the literature. Therefore, the aim of the present commentary is to discuss the impact of tooth malposition and papillae dimension on rootcoverage outcomes. This commentary combines evidence from the literature with the authors' experience. Limited evidence is available in the literature regarding the influence of tooth malposition on root-coverage outcomes. Severe buccal displacement and tooth extrusion and/or rotation may limit the amount of achievable root coverage, and the cementoenamel junction should no longer be considered the landmark for root coverage in these cases. The relationship between papillae dimension and root coverage has been tested in different clinical conditions and by applying different root-coverage approaches, thereby resulting in contradictory outcomes. The clinical experience of the authors suggests that having wider papillae is advantageous for coronally advanced flap and tunnel flap preparations and connective tissue graft stabilization. Although scientific evidence and the authors' clinical experience suggest that papillae dimension can play a major role in determining the surgical management of soft tissues and the amount of achievable root coverage, further studies are necessary to evaluate to which extent papillae dimensions contribute to treatment outcomes.

This case report aimed to describe a soft tissue approach to restore a buccal soft tissue dehiscence (BSTD) combined with the loss of peri-implant papillae and loss of periodontal attachment on the adjacent teeth. The first step of the proposed approach was the removal of the crown and abutment to leave the interproximal soft tissue to fill the space previously occupied by the crown. After 3 months, during which time the patient was wearing a provisional restoration (a temporary Maryland bridge), the implant site was treated as an edentulous area with a soft tissue augmentation procedure: the most substantial modification with respect to the original connective tissue platform technique was the use of the wide mesial and distal papillae of the implant, once de-epithelialized on the occlusal surface, as a "partial" connective platform to suture the connective grafts and submerge the implant. At the 4-month reevaluation visit, a minor soft tissue defect remained in both apico-coronal and buccolingual dimensions, and thus a second surgery was performed to obtain further soft tissue augmentation. A flapless punch procedure was used to expose the implant head, and after conditioning the augmented peri-implant soft tissue with a new provisional crown, the definitive restoration was delivered. Complete coverage of the BSTD was achieved, and both papillae entirely filled the interproximal spaces. The results were well maintained up to the 5-year follow-up visit.

Soft tissue augmentation procedures are crucial to obtain a successful outcome in implant therapy. The aim of this case series was to describe the 1-year clinical outcomes of a porcine-derived acellular dermal matrix for buccal mucosal thickness augmentation at osseointegrated single implants with facial periimplant soft tissue deficiencies. Ten patients were included and treated with a prosthetic and surgical approach that combined a coronally advanced flap and a dermal matrix. Results showed the possibility to obtain an increase in buccal soft tissue thickness of 1.2 ± 0.18 mm at single implant sites in the esthetic area.

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 aim of this study was to evaluate the short- (1 year) and longer-term (3 years) effectiveness of a surgical procedure combining coronally advanced flap (CAF) with site-specific application of connective tissue graft (CTG) in the treatment of multiple gingival recessions (MGR). A total of 60 periodontally healthy subjects with esthetic complaints due to excessive tooth length presenting multiple (at least three) Miller Class I and II gingival recession defects (≥ 1 mm) affecting adjacent teeth in the maxilla and mandible were enrolled in the study. All recessions were treated with CAF. The CTG was applied in gingival defects with a baseline keratinized tissue height (KTH) < 1 mm or with KTH between 1 and 2 mm and gingival thickness < 1 mm. Complete root coverage (CRC) was obtained in 98.5% (263 of 267 recessions) and in 94.7% (256 of 267 recessions) of the sites at the 1- and 3-year follow-up visits, respectively. No statistically significant differences were found at 1 and 3 years in terms of CRC between sites with or without CTG and between sites belonging to the maxilla or mandible. A greater increase in KTH at 3 years was demonstrated in sites treated with CTG. This was ascribed to the tendency of the mucogingival line to regain its genetically determined position and not to graft exposure. The present study demonstrated that the proposed surgical technique combining CAF with site-specific application of CTG was an effective treatment modality for the management of MGR, obtaining 93% CRC in the CAF-treated sites and 100% CRC in the sites treated with CAF + CTG at 3 years.

The aim of this case report was to suggest an alternative minimally invasive surgical approach to an impacted maxillary canine using a 4-mm-long implant for a fixed prosthetic rehabilitation, avoiding tooth extraction or surgically forced extrusion and exploiting the 6 mm of coronal bone availability. At 4 years postloading, the implant was healthy and well integrated with stable marginal bone levels. The 4-mm length of the implant reduced operative times, postsurgical morbidity, possible complications, and costs. Short implants might be an alternative to traditional, more invasive surgical procedures used in the rehabilitative treatment of impacted maxillary canines.