Journal of Indian Society of Periodontology
Journal of Indian Society of Periodontology
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   2019| September-October  | Volume 23 | Issue 5  
    Online since September 3, 2019

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The long-term risks and complications of bovine-derived xenografts: A case series
Angel Emmanuel Rodriguez, Hessam Nowzari
September-October 2019, 23(5):487-492
DOI:10.4103/jisp.jisp_656_18  PMID:31543624
The frequency of dental implant related surgeries that involve soft tissue and bone augmentation procedures has increased significantly. Bovine-derived substitutes have been by far the most commonly used xenografts in dentistry. Albeit literature is replete with clinical studies in favor of bovine-derived graft materials, bibliographical data reporting on risks and clinical complications is scarce. Clinical impression and concern for patient safety led to the report we have provided. The aim of the present case series was to raise awareness on the long-term risks and late clinical complications of bovine-derived graft materials. Patients were referred to a private practice due to bone augmentation complications. Demographics, significant medical and dental findings are reported. Complications included sinus and maxillary bone pathoses, displacement of the graft materials, oroantral communications, implant failure, foreign body reactions, encapsulation, chronic inflammation, soft tissue fenestrations and associated cysts. Bovine-derived graft materials were not biodegradable. Resolution of the associated lesions and symptoms was achieved after the removal of the bone graft materials. The surgical removal of the xenograft materials may require advanced clinical skills because of the different configurations clinicians might encounter of the non-resorbed and migrated particles. The authors' concern is that patient morbidity may not be reduced with xenografts, due to the inherent risks and associated complications. Clinicians seeking to provide functional and esthetic outcomes should be aware of the complications of the bovine-derived graft materials. The long-term safety of xenografts and their potential association with disease are valid concerns.
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Detection of Enterococcus faecalis in subgingival biofilms of healthy, gingivitis, and chronic periodontitis subjects
Chethana Kunthur Chidambar, Shrinidhi Maji Shankar, Pooja Raghu, Soumya Badravalli Gururaj, Kala Shashi Bushan
September-October 2019, 23(5):416-418
DOI:10.4103/jisp.jisp_44_19  PMID:31543613
Background: Enterococcus faecalis is a Gram-positive, facultative anaerobic coccus that can survive under harsh conditions. Studies have shown a positive relationship between biofilm formation and gelE gene expression in E. faecalis. The production of gelatinase (MMP 2) has been detected in 50% of E. faecalis isolates from endodontic and periodontal infections, which suggests its role in the pathogenesis of apical and marginal periodontitis. Although E. faecalis is not considered a periodontopathogen, this species has been more frequently detected in subgingival samples with periodontitis than from periodontally healthy subjects, suggesting that the local conditions in periodontitis may favor its colonization. Hence, the aim of the current study was to detect and compare the presence of E. faecalis in subgingival biofilms of healthy, gingivitis, and periodontitis subjects. Materials and Methods: A total of 100 subjects aged between 25 and 55 years, from the Outpatient Department of Periodontics were recruited for the study. All the subjects were screened for gingival and periodontal status using plaque index, gingival index, and clinical attachment loss. They were divided into three groups based on the clinical findings.
  • Group A: 18 healthy individuals (gingival index with score zero)
  • Group B: 34 gingivitis patients (gingival index with score >1)
  • Group C: 48 chronic periodontitis patients (clinical attachment loss >5 mm in >30% of sites).
Subgingival plaque samples of all the enrolled subjects were collected using a sterile curette, later poured into a transport medium (Viability Medium Goteborg Agar III) and sent for microbial culturing within 2 h for detection of E. faecalis. Results: E. faecalis was detected in 26.8% of all samples evaluated. There was a significantly higher frequency of E. faecalis in subgingival biofilms of periodontitis group (41.7%), compared to gingivitis (5.9%) and healthy group (0%). Conclusion: Enterococci may contribute to increased collagen and periodontal destruction and may further lead to disease progression in patients with chronic periodontitis.
  1 3,026 224
Ridge augmentation using sticky bone: A combination of human tooth allograft and autologous fibrin glue
Chaitanya Pradeep Joshi, Cynthia Bernardo D'Lima, Prerna Ashok Karde, Alefiya Shabbir Mamajiwala
September-October 2019, 23(5):493-496
DOI:10.4103/jisp.jisp_246_19  PMID:31543625
Alveolar ridge deficiency hampers placement of dental implants in functionally optimal position. This warrants hard-tissue augmentation using bone grafts. Lately, the use of autogenous tooth bone graft material is gaining a momentum. However, tedious and time-consuming chair-side preparation limits its use. Allograft using human extracted teeth can be a better alternative to tackle these practical issues. Hence, we prepared “Whole Human Tooth Allograft (whole tooth allograft [WTA])” following standard protocols of tissue bank at Tata Memorial Hospital, Mumbai, India. The efficacy of WTA was evaluated in a 43-year-old patient who reported with Seibert Class-III alveolar ridge deficiency in the right maxillary canine region. Three-dimensional changes were evaluated on clinical and radiographic parameters at baseline and at 4-month follow-up. A clinicoradiographic comparative analysis of height and width measurements revealed a successful three-dimensional alveolar ridge augmentation. The finding of the present case report underscores clinical safety and good bone-forming potential of WTA.
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An unusual presentation of dental calculus
Venkateshwarapuram Rengaswami Balaji, Thanvir Mohammed Niazi, Manikandan Dhanasekaran
September-October 2019, 23(5):484-486
DOI:10.4103/jisp.jisp_680_18  PMID:31543623
Calculus is a mineralized bacterial plaque that is formed on natural teeth surfaces where there is constant supply of saliva. Dental calculus is commonly seen over the buccal surfaces of maxillary molars and lingual surfaces of mandibular anterior teeth where the salivary duct opens into the oral cavity. This case report presents an unusual presentation of a large hard calcified mass in the left side of retromolar region associated with partially erupted tooth; hard mass was excised and examined histochemically which suggested the presence of calculus. Elimination of such nidus shall prevent formation of such calculus in such unusual position. This can also be achieved with proper oral hygiene measures.
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Au revoir
Ashish Kumar
September-October 2019, 23(5):389-390
DOI:10.4103/jisp.jisp_350_19  PMID:31543609
  - 1,410 119
Genotypic variations of Porphyromonas gingivalis in chronic periodontitis patients with and without diabetes: An in vitro study using arbitrarily primed-polymerase chain reaction and heteroduplex-polymerase chain reaction
Siladitya Sen, Kukkamalla Meena Anand
September-October 2019, 23(5):409-415
DOI:10.4103/jisp.jisp_406_18  PMID:31543612
Context: Diabetes has become an endemic throughout the world. Periodontitis is associated with diabetes, and it has been regarded as the sixth complication of diabetes. However, the role of diabetes on periodontopathic microbiota such as Porphyromonas gingivalis remains unclear. Aims: To compare the total number of different genotypes of P. gingivalis in chronic periodontitis patients with and without diabetes by using arbitrarily primed-polymerase chain reaction (AP-PCR) and heteroduplex-PCR. Settings and Design: This is a single-center comparative study. Materials and Methods: A total of 100 patients were included in this study. Patients were divided into two groups: Group A – patients having chronic periodontitis without diabetes (50) and Group B – patients having chronic periodontitis with diabetes (50). Subgingival plaque samples were collected from both groups of patients. Plaque samples were cultured for P. gingivalis. Positive culture samples and extracted DNA from samples by proteinase-K method were collected. Part of DNA samples were checked by AP-PCR using OPA-13 primer, and part of the DNA were checked using heteroduplex-PCR using P. gingivalis-specific Pg8 primer. Results were analyzed by polyacrylamide gel electrophoresis procedure. Statistical Analysis Used: Independent t-test and Chi-square test (SPSS 16) were used. Results: Thirty-four out of fifty samples of Group B patients were found positive for P. gingivalis, whereas 21 out of 50 samples in Group A were found positive for P. gingivalis. AP-PCR showed nine different genotypes in Group B and six different genotypes in Group A. Heteroduplex-PCR showed a total of seven different genotypes in Group B and five different genotypes in Group A. Conclusions: Results of this study show that, in diabetic condition, P. gingivalis shows increased variations in genotypes.
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Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in chronic periodontitis before and after nonsurgical therapy
Anirudh Balakrishna Acharya, Indrajith Padukone Shetty, Shrinidhi Jain, Ibbani Padakannaya, Swetha Acharya, Leena Shettar, Srinath Thakur
September-October 2019, 23(5):419-423
DOI:10.4103/jisp.jisp_622_18  PMID:31543614
Background: Various biomarkers have been evaluated for understanding the systemic inflammatory response (SIR) to periodontitis. Hematological markers have been reported to be useful biomarkers in a variety of diseases, including periodontal diseases. The role of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in periodontitis and their possible role in the SIR are not extensively documented. Therefore, this study assessed NLR and PLR in chronic periodontitis (CP) patients before and after periodontal treatment, which to the best of knowledge has not been reported in the literature. Materials and Methods: Sixty participants were grouped as systemically and periodontally healthy (H) (n = 30) and with CP (n = 30). Plaque index, gingival index, probing pocket depth, clinical attachment loss, leukocyte counts, platelet (PLT) counts, NLR, and PLR were estimated at baseline and also after treatment in the CP group. NLR was calculated as total neutrophil count/absolute lymphocyte count, and PLR was calculated as total PLT count/absolute lymphocyte count. The data were statistically analyzed. Results: Periodontal parameters differed significantly between groups H and CP at baseline and posttreatment. A pair-wise comparison of NLR and PLR between CP patients at baseline and posttreatment was significant. Correlation analyses were not remarkable. Receiver operating characteristics analyses provided significant NLR and PLR predictive cutoff values to differentiate between CP patients at baseline and posttreatment. Conclusion: NLR and PLR may serve as potential biomarkers of the SIR to CP to bridge the association between periodontal and systemic conditions.
  - 2,655 279
Higher interleukin-33 levels in aggressive periodontitis cases
Sujatha Pai Ballambettu, AR Pradeep, Meera Purushottam, Somdatta Sen
September-October 2019, 23(5):424-429
DOI:10.4103/jisp.jisp_217_19  PMID:31543615
Context: Interleukin-33 (IL-33) is a novel alarmin that warns immune cells of tissue destruction in injury or infection. Aims: This study is aimed at analyzing and correlating the concentration of IL-33 in the gingival crevicular fluid (GCF) and plasma of healthy subjects and chronic and aggressive periodontitis patients with intronic variant single nucleotide polymorphisms (SNPs), rs1157505 (C/G) and rs7044343 (C/T) in the IL-33 gene. Settings and Design: This is a cross-sectional, biochemical, genetic study. Materials and Methods: Ninety subjects were divided into Group H: subjects with healthy periodontium, Group CP: chronic periodontitis patients, and Group GAgP: generalized aggressive periodontitis patients, based on clinical parameters of periodontal inflammation. IL-33 concentration in GCF, as well as plasma, was quantified using enzyme-linked immunosorbent assay. The SNPs rs1157505 and rs7044343 were analyzed using polymerase chain reaction-restriction fragment length polymorphism. Results: A significant difference was found in IL-33 concentration in GCF and plasma between the three groups. GG genotype of IL-33 SNP rs1157505 was associated with the highest GCF and plasma IL-33 concentration and was significantly more in GAgP than healthy or CP groups. IL-33 SNP rs7044343 did not show any such association. All GAgP patients had the highest GCF and plasma concentration of IL-33. Conclusions: IL-33 may be a potential inflammatory marker of periodontitis. GG genotype of SNP rs1157505 may be associated with GAgP.
  - 1,574 144
Efficacy of an herbal antioxidant as an adjunct to nonsurgical periodontal therapy on procalcitonin levels in smokers with chronic periodontitis
M V N Sravya, Rekha Rani Koduganti, Veerendranath Reddy Panthula, Prasanna Jammula Surya, Himabindu Gireddy, Rajashree Dasari, Manasa Ambati
September-October 2019, 23(5):430-435
DOI:10.4103/jisp.jisp_742_18  PMID:31543616
Context: Smokers are at a higher risk of contracting periodontitis. This association is established and reported in many studies. Periodontitis is a polymicrobial disease, wherein smoking is an environmental factor which aggravates the damage caused to the tissues. Procalcitonin (ProCT) is a well-known marker for inflammatory and other infectious diseases and has been assessed in this study. It has been observed that the release of reactive oxygen species (ROS) is exaggerated in smokers. Antioxidants are administered to combat the harmful effects caused by the ROS, and Oxitard™ is a powerful herbal antioxidant that can counteract the action of free radicals. Aims: As smokers are more prone to tissue injury due to excessive release of ROS, this study aimed to understand the benefits of systemic administration of Oxitard after scaling and root planing (SRP) on serum ProCT levels in smokers with chronic periodontitis (CP). Settings and Design: This was a randomized interventional study, wherein forty patients participated. Materials and Methods: Forty smokers with CP aged, between 35 and 60 years, were equally divided into Group A (SRP + Oxitard) and Group B (SRP only), selected from an outpatient ward of a referral care hospital in Hyderabad. A written informed consent was obtained from all the patients, and the study was approved by the institutional ethical committee (DN0026-15). Statistical Analysis Used: Data were analyzed by GraphPad Prism software version 6.01 (GraphPad software incorporation, California, USA). Comparison within the groups was made by paired t-test and between the groups by unpaired t-test. P < 0.05 was considered of statistical significance. Results: Intragroup assessment showed an improvement in all the variables from baseline to 3 months, which was statistically significant (P < 0.0001). A comparison between the groups, however, yielded better results in Group A (Oxitard + SRP) over Group B. Conclusions: Oxitard administered systemically for 3 months after SRP was beneficial in improving both clinical and biochemical parameters.
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Coronally advanced flap with and without platelet-rich fibrin in the treatment of multiple adjacent recession defects: A randomized controlled split-mouth trial
Anushree Manohar Potey, Rajashri Abhay Kolte, Abhay Pandurang Kolte, Dhawal Mody, Girish Bodhare, Resham Pakhmode
September-October 2019, 23(5):436-441
DOI:10.4103/jisp.jisp_387_18  PMID:31543617
Background: The objective of our study was to evaluate and compare the effectiveness of coronally advanced flap (CAF) with or without the use of platelet-rich fibrin (PRF) membrane in the treatment of multiple adjacent recession defects (MARD) clinically and by cone-beam computed tomography (CBCT). Materials and Methods: Twenty healthy patients having 75 MARD were allocated randomly to CAF with orthodontic button group (CAFB) or CAFB + PRF membrane group (CAFB + PRF). Clinical parameters such as gingival recession depth (GRD), probing depth (PD), and keratinized tissue width (KTW) were calculated at baseline, 3 months, and 6 months. The distance from the facial alveolar crest of bone to gingival margin bone and gingival thickness (GT) at three different points were assessed by CBCT at baseline and 6-month postsurgery. Esthetic outcome and postoperative discomfort were evaluated using root coverage esthetic score and visual analog scale, respectively. Results: Percent root coverage achieved in CAFB category was 93.17% ± 13.23% and that in CAFB + PRF group was 95.68% ± 10.13% at 6 months, with no notable difference. Similarly, no difference was found in either group in GRD reduction, PD, and CAL postoperatively. Use of PRF resulted in statistically highly significant (P < 0.001) increased GT at 6 months' time point as compared to participants treated with CAF without PRF, which indicates clinical and esthetic benefits achieved through the procedure. Conclusions: CAFB can be used successfully to treat MARD with predictable outcome. Additional benefit in terms of gain in KTW and GT can be achieved when PRF membrane is used as an adjunct.
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Clinical efficacy of periosteal pedicle graft with subepithelial connective tissue graft in gingival recession coverage
Priyanka Prakash, Saroj K Rath, Manish Mukherjee
September-October 2019, 23(5):442-447
DOI:10.4103/jisp.jisp_676_18  PMID:31543618
Introduction: Correction of gingival recession (GR) involves eliminating the cause of recession and it often requires surgical correction. Subepithelial connective tissue graft (SCTG) technique by Langer and Langer provides excellent esthetics and is considered most predictable in obtaining marginal tissue recession coverage. However, the requirement of a second surgical procedure for harvesting CTG remote from planned site of recession coverage increases the chances of postoperative infection. There is also a limitation in the amount of graft that can be harvested and an increased operative time contributing to patient discomfort. Materials and Methods: Overcoming these difficulties has become possible with the introduction of “periosteal pedicle graft” (PPG). The study is a split-mouth design where patients with bilateral, isolated GR defects were treated using two different surgical techniques, i.e., PPG versus the SCTG in obtaining GR coverage. The objective was to analyze the comparative amount of root coverage and the gain in width of attached gingiva achieved by both the techniques. Results: All the clinical parameters evaluated were comparable between SCTG and PPG when recorded at 6 and 9 months posttreatment. Conclusion: Both techniques produced satisfactory and predictable results. PPG eliminated the need for the 2nd operative site, lesser intraoperative time, and hence, patient comfort was enhanced.
  - 3,440 352
Comparison of microsurgical and macrosurgical technique using bioactive synthetic bone graft and collagen membrane for an implant site development: A randomized controlled clinical trial
Deepali Jain, Ranjana Mohan, Vikram Deep Singh
September-October 2019, 23(5):448-460
DOI:10.4103/jisp.jisp_738_18  PMID:31543619
Background: Implant site development can be effective in minimizing postextraction alveolar ridge resorption in the esthetic region. Microsurgical approach has demonstrated substantial improvement in soft-tissue architecture. Aim and Objectives: The aim of the present study was to evaluate and compare the efficacy of microsurgical technique with conventional one for implant site development utilizing biphasic hydroxyapatite/beta-tricalcium phosphate bone graft substitute and collagen membrane. Materials and Methods: Thirty extraction sites were planned for implant placement and randomly divided into control (macrosurgical/conventional) and test (microsurgery) sites. Clinical measurements were recorded at four different points of extraction socket, i.e., mesiobuccal, midbuccal, distobuccal, and midlingual/palatal at baseline, 3, 6, and 9 months. Postoperative neovascularization at control and test site was evaluated by ultrasound Doppler flowmetry at baseline, 10th day, and 1 month. Radiological assessment of bone density (Hounsfield units) was measured at control and test sites at baseline, 6 and 9 months by computed tomography. Data was subjected to statistical analysis. Results: Significant socket fill at all the four different sites was observed and found to be statistically significant at test as compared to control group with better tissue contour after 3, 6, and 9 months. Test group demonstrated better neovascularization (P < 0.05) with significantly higher bone density (P = 0.000) at different time intervals. Conclusions: The results indicate that the augmentation of extraction sockets, not only improved the quality of bone in both the techniques but the utilization of microsurgical instruments and microsutures under magnification definitely enhanced the quality of soft tissues which is imperative for successful implant placement and its survival.
  - 1,797 236
Evaluation of a curcumin-containing mucoadhesive film for periodontal postsurgical pain control
Anu Anil, Sheela Kumar Gujjari, Madhugiri Prakash Venkatesh
September-October 2019, 23(5):461-468
DOI:10.4103/jisp.jisp_700_18  PMID:31543620
Background: Management of pain and discomfort is important to make the postoperative period as pleasant as possible. Nonsteroidal anti-inflammatory drugs are traditionally prescribed; however, they are associated with numerous side effects. As a result, nutraceuticals such as curcumin are widely used for its well-known safety and medicinal values. Hence, the aim of this study is to evaluate the efficacy of a curcumin mucoadhesive film for postsurgical pain control. Materials and Methods: This was a split-mouth study, consisting of 15 systemically healthy patients with 30 sites, who were randomly allocated into test (curcumin mucoadhesive film) and control (placebo mucoadhesive film) groups using coin toss method. A questionnaire was given to patients to evaluate the postoperative pain and swelling and the number of rescue medications taken. Statistical analyses used were Friedman test, Wilcoxon signed-rank test, and McNemar's test. Results: No adverse effects were reported and healing was uneventful in all patients. The Numerical rating scale pain score showed significantly lesser pain at 1, 2, 3, 4, 5, and 24 h in the test group. Significantly more number of analgesics was consumed in total in the control group than that in the test group. Conclusion: Within the limitations of this study, it may be concluded that curcumin mucoadhesive film showed promising results in reducing postoperative pain and swelling over a period of 1 week, hence showing its analgesic effect after periodontal surgeries.
  - 2,291 375
A 12-week, multicenter, normal-use evaluation of a manual toothbrush with angled bristle design
Ajay Madanlal Kakar, Smruti Krishnan Nair, Saurabh Saraf
September-October 2019, 23(5):469-474
DOI:10.4103/jisp.jisp_529_18  PMID:31543621
Background: Comparative clinical studies play a major role in evaluating the relative efficacy of commercially available manual toothbrushes to improve periodontal health. A manual toothbrush with angled, CrissCross® bristles has been shown to offer significant benefits relative to other toothbrushes. This study assessed whether the benefits could also be observed in real-world, normal use conditions in a large population. Materials and Methods: Generally, healthy adult participants were recruited from 24 dental institutions across India and given the manual toothbrush with angled bristles to use. Their periodontal health was assessed subjectively by dentists, using response categories, at the start of the study (baseline) and after 12 weeks of normal use. Participants themselves were also questioned. Data analyses were descriptive. Results: A total of 2157 participants took part in this multicenter study. At 12 weeks, oral hygiene status and gingival health were categorized as good to excellent in at least 85% of participants compared with 61%–62% at baseline, and no staining was found in 40% of participants compared with 30% at baseline. Oral health improvements were seen in 75% of participants. Most participants reported their brushing experience as giving good-to-excellent satisfaction (85%), improved brushing (82%), and a cleaner mouth (81%) and said they would recommend the brush (90%). Conclusions: In this uncontrolled real-world study, improvements were observed in oral health and hygiene following the use of the manual toothbrush with CrissCross bristles over 12 weeks. The results lend support to earlier findings of comparative clinical studies that demonstrated the beneficial effects of this toothbrush for periodontal health.
  - 3,563 247
Periodontal conditions in adolescents and young Brazilians and associated factors: Cross -sectional study with data from the Brazilian oral health survey, 2010
Kelly Cristine Knack, Clarice Elvira Saggin Sabadin, Karine Lima Sírio Boclin, Elenusa Souza Oltramari, Michele Natara Portilio, Lilian Rigo
September-October 2019, 23(5):475-483
DOI:10.4103/jisp.jisp_753_18  PMID:31543622
Background: Diseases of the gingival tissues are considered a global public health problem concern. These diseases show great differences in their distribution and prevalence in the different localities investigated. This study aimed to estimate the prevalence of the periodontal conditions of gingival bleeding and dental calculus in Brazilian adolescents and young people, as well as to verify the associated factors. Materials and Methods: This is a cross-sectional population-based study that used secondary data from the National Oral Health Survey (SB Brazil 2010) performed by the Ministry of Health. This study assessed 7328 adolescents aged 12 years and 5445 young people aged 15–19 years. The characteristics of the periodontal conditions were obtained by the community periodontal index, which provided the outcome variables of gingival bleeding and dental calculus. The predictor variables were demographic, socioeconomic, and oral clinical data. Results: The results showed a high prevalence of gingival bleeding (32%) and dental calculus (33.1%) in the individuals assessed. In addition, as observed after adjusting to the Poisson regression model, the variables of 12 years of age, no tooth loss, fewer household residents, >6 years of education, and no need for dental treatment were considered protective factors for gingival bleeding and dental calculus. Conclusions: The variables of nonwhite skin color, certain regions of the country, and low monthly household income were considered risk factors for the outcomes. Boys presented a higher prevalence of dental calculus than girls.
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Dream it, believe it, and build it
Anil Melath
September-October 2019, 23(5):391-392
  - 1,490 83
44-year journey of palatal connective tissue graft harvest: A narrative review
Komal Puri, Ashish Kumar, Manish Khatri, Mansi Bansal, Mohd Rehan, Srinivasa Tenkasale Siddeshappa
September-October 2019, 23(5):395-408
DOI:10.4103/jisp.jisp_288_18  PMID:31543611
Connective tissue graft (CTG) is considered the gold standard for soft-tissue correction and augmentation surgeries, but involves a secondary donor area and its associated complications. The techniques to harvest CTG have undergone a large number of modifications over a period of 44 years since the time it was introduced by Edel in 1974 to increase the width of keratinized gingiva. This review compiles all the techniques of graft harvest from the palate and their modifications which have been introduced in the last 44 years till date. This review is based on systematic reviews, comparative human studies, and case reports describing any new technique of graft harvest. Publications till April 2018 were selected and further reviewed. In addition, specific related journals and books were searched upon. In order to minimize the pain, bleeding, and morbidity associated with donor site, several researchers proposed harvesting of the connective tissue by means of different techniques, each precisely different from others in terms of design, incisions, and procedure of harvest. Although the latest techniques are minimally invasive with reduced incision lines, less compromised blood supply, accelerated healing, and no sloughing of the overlying flap, they are technique sensitive which requires higher expertise to execute.
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Concluding note: Time to look back and move ahead
Abhay Kolte
September-October 2019, 23(5):393-394
DOI:10.4103/jisp.jisp_348_19  PMID:31543610
  - 1,394 75