Search Results (15)

Background: Patients with a thin gingival phenotype and a narrow buccal alveolar plate are highly susceptible to periodontal complications during orthodontic expansion. Traditional biomechanics often fail to maintain root control in thin alveolar housing. This report presents two clinical cases illustrating soft- and hard-tissue responses to a novel biomechanical approach, the Bone Protection System (BPS), designed to reduce buccal cortical overload during expansion. Case Presentation: Two adult patients with a thin gingival phenotype assessed by a standardized periodontal probe transparency test and narrow alveolar ridges underwent orthodontic expansion. Patient 1 was treated with the full BPS protocol in both arches. Patient 2 received BPS only in the maxilla, while the mandible was treated conventionally, creating an intra-individual control model under identical systemic conditions. Soft-tissue phenotype and cortical plate response were evaluated clinically and radiographically when applicable. Results: In Patient 1 clinically, the vestibular phenotype showed clear thickening and stabilization. In Patient 2, the maxillary arch treated with BPS exhibited progressive thickening of the vestibular phenotype, whereas the mandible treated conventionally presented thinning and increased translucency—features consistent with buccal compression in thin alveolar bone. No soft- or hard-tissue augmentation procedures were performed in either case. Conclusions: The Bone Protection System may contribute to improved periodontal safety during orthodontic expansion in thin-biotype patients by reducing buccal cortical loading and supporting adaptive soft-tissue and bone responses. Preliminary observations suggests that BPS has potential value for possibly expanding the biological limits of safe tooth movement. Further studies on larger cohorts are warranted. Full article

Gingival recession, particularly in patients exhibiting a thin periodontal phenotype, is a prevalent and challenging complication associated with orthodontic treatment, among other factors. Recent advances in biostimulation therapies aim to support soft tissue augmentation by increasing gingival thickness (GT) and keratinized tissue width (KTW) while minimizing the need for invasive surgical procedures. This narrative review explores the available clinical evidence regarding several biostimulation techniques, including injectable platelet-rich fibrin (i-PRF), microneedling (MN), concentrated growth factors (CGF), atelocollagen, hyaluronic acid (HA), and low-level laser therapy (LLLT), with a particular focus on their potential adjunctive role in orthodontic patients with a thin periodontal phenotype. While i-PRF and microneedling—used alone or in combination—have shown promising short-term soft tissue thickening and reduced patient morbidity when compared with conventional grafting procedures, the available evidence is largely derived from small, randomized trials, pilot studies, and non-orthodontic cohorts, limiting the strength of comparative conclusions. Minimally invasive biostimulation techniques may represent potential adjunctive strategies for soft tissue management in selected clinical scenarios. Nevertheless, current evidence remains limited and heterogeneous, and robust, long-term, orthodontic-specific clinical trials are required before these approaches can be considered reliable alternatives to established surgical protocols or validated preventive strategies against gingival recession. Full article

Background: This study evaluates the increase in gingival thickness following the administration of injectable atelocollagen. Materials and Methods: A retrospective analysis was conducted using the medical records of 60 patients with a thin gingival phenotype at baseline, treated between 2017 and 2025. All patients received a standardised protocol for soft tissue thickness modification using atelocollagen injections. Based on the continuation of maintenance therapy, patients were divided into Group A (n = 30), consisting of patients who received booster doses at six-month intervals following completion of the full treatment protocol, and Group B (n = 30), consisting of patients who did not continue maintenance therapy. The observation period for all patients was five years. Gingival thickness was assessed by periodontal probe transparency using a standard WHO probe (WHO 621) and the Hu-Friedy Colorvue Biotype Probe. Longitudinal changes were analysed using linear mixed-effects models (LMMs) for continuous outcomes and generalised linear mixed-effects models (GLMMs) with a binomial distribution and logit link for binary outcomes, accounting for repeated measurements at the patient level. Results: Significant effects of Group and Time, as well as their interaction, were observed for the proportion of sites with a thick gingiva (Group effect: F (1,93.14) = 57.94, p < 0.001; Group × Time interaction: p < 0.001). GLMM analysis confirmed a significant Group × Time interaction (χ² = 23.11, p < 0.001), indicating sustained gingival thickness improvement in Group A and a gradual decrease in effectiveness in Group B. Conclusions: Injectable atelocollagen represents a reliable, effective, and user-friendly method for long-term modification of gingival thickness, particularly when supported by maintenance therapy. Full article

Background: Crown lengthening (CL) in esthetic areas has become a versatile procedure with applications in many clinical situations. Knowledge concerning different periodontal phenotypes, and the supracrestal tissue attachment (STA)—former biological width—has allowed for a better understanding of surgical management, allowing for the individualization of surgical therapy. This review presented an individualized surgical approach to CL in esthetic areas based on evaluating the phenotype and current considerations about the STA, correlating them to suggestive surgical techniques. Methods: For an individualized surgical approach, it is primarily necessary to understand STA, including the relationship and distance between the cementoenamel junction (CEJ) and the bone crest (BC) and the position of the free gingival margin (FGM); secondarily, it is necessary to verify the periodontal phenotype to prepare surgical planning (gingivectomy or osseous resection/contouring). Three periodontal phenotypes are recognized, presenting different biological behaviors due to specific characteristics implicitly correlated to soft tissue management. Results: Then, after assessing the distance from the CEJ to the BC, the position of the FGM, and the periodontal phenotype, it is possible to individualize the treatment according to the phenotype. In cases of a thin and scalloped periodontium with delicate gingiva, there might be the presence of bone dehiscence, fenestration, and instability in the healing of the gingival margin, bringing extra attention to tissue manipulation and suggesting a minimally invasive technique (no flap). A partial-thickness flap is recommended for a thick and scalloped periodontium, keeping the periosteum adhered to the bone. For periodontium B (fibrous and dense gingiva and tissue resistant to injuries), the surgical approach recommended is an open full-thickness flap with osteotomy for horizontal and vertical bone volume removal. Then, observing first the specific parameters, such as the STA, CEJ, BC, FGM, and KTW, and then the characteristics of periodontal phenotypes, it is possible to determine the individualized surgical strategy and a reasonable surgical approach to tissue manipulation in clinical CL surgeries. Conclusions: The surgical approach must be defined according to individualized planning since several variables can influence the dynamics of the periodontal tissues. Full article

This study evaluates the preferences of dentists regarding the interdisciplinary treatment of patients with gingival recession (GR) and a thin periodontal phenotype, based on their specialization. A cross-sectional study was conducted among Polish dentists, between May and October 2022, using an online survey. The dentists were first asked to provide details regarding their specialization and the length of their professional career. In the second part of the survey, they responded to questions about the preferred timing of a consultation and soft tissue augmentation in patients who planned to undertake orthodontic treatment (OT). Moreover, factors undermining the decision-making process regarding soft tissue augmentation and the methods used for the evaluation of periodontal tissues were assessed. In total, 554 dentists completed the survey, among whom 328 were orthodontists and 226 were periodontists/oral surgeons. A third of the surveyed periodontists/oral surgeons (33%) reported that they receive referrals from orthodontists prior to OT and 39% of orthodontists indicated that they refer patients for soft tissue augmentation before commencing OT. The majority of periodontists/oral surgeons (51%) and the most significant proportion of orthodontists (45%) agreed that the ideal timing of soft tissue augmentation is dependent on each specific case. Both groups of surveyed dentists considered “planned tooth movement” as the most important factor in clinical decision-making. Among the periodontists/oral surgeons, the most popular methods to assess periodontal tissues were: 3D radiological examination, the visual method, and gingival transparency with the use of a periodontal probe. On the other hand, the surveyed orthodontists preferred the visual method, followed by 2D radiological examination, and then by 3D radiological examination. The majority of surveyed periodontists/oral surgeons and orthodontists agreed that the ideal timing of soft tissue augmentation in patients undertaking orthodontic treatment should be decided on a case-by-case basis, with planned tooth movement being the determining factor. Full article

Peri-implant soft tissue deficiency (PSTD) is a significant factor impacting aesthetics, particularly in the anterior zone, where labial bone resorption and thin peri-implant phenotypes are common. The occurrence of a gray color around the implant fixture due to PSTD can be aesthetically concerning in the esthetic zone. In cases involving natural teeth, autogenous soft tissue grafts such as subepithelial connective tissue grafts (SCTGs), free gingival grafts (FGGs), and coronally advanced flaps (CAFs) are commonly utilized. However, there are limited reports of using bone grafts in conjunction with these techniques for modifying the gingival phenotype around both teeth and implants. In the presented cases where PSTD resulted in visible gray coloration of the implant fixture in the esthetic zone, mechanical and chemical decontamination of the exposed implant surface was performed using a titanium brush and tetracycline (Tc) HCl. Subsequently, to enhance peri-implant mucosa thickness and mask the titanium color, simultaneous SCTG and bone grafting procedures were conducted. Within the limitations of these case reports, successful esthetic outcomes were achieved and maintained without recurrence for 3–6 years following the simultaneous subepithelial connective tissue graft and bone graft procedures. These findings suggest the potential efficacy of this combined approach in addressing PSTD and enhancing aesthetic results around dental implants, though further studies are needed to validate these outcomes. Full article

The relevance of assessing the gingival phenotype prior to the initiation of periodontal, orthodontic, or prosthetic therapy has been clearly demonstrated. However, publications on this subject are either old or concerned with the means of assessing the gingival phenotype or the main factors likely to modify it. The main objective of this systematic review of the literature was therefore to investigate the prevalence of different gingival phenotypes in adults in good general health and with a healthy periodontium. A systematic review of the literature was performed following the guidelines of PRISMA recommendations using an electronic search strategy on four databases (PubMed, Scopus, Cochrane Library, and Embase) complemented by a manual search. Three independent authors were involved in study selection, data extraction, and bias assessment. Results: Of 807 articles, 17 of them, published between 2012 and 2023, involving 3277 subjects from 11 countries and 9766 dental sites, fulfilled the inclusion criteria. The prevalence of the gingival phenotype could not be determined at the level of an individual or a dental arch because all the publications assessed this phenotype only at the level of certain dental sectors, and were not chosen at random. The maxillary central incisors and maxillary or mandibular first molar sectors were associated with a high and thick gingival phenotype, independently of the dental morphology, gender, and age of adult subjects. Furthermore, in these regions, this gingival phenotype tended to be associated with a thick vestibular bone table. In contrast, maxillary and mandibular incisors and premolars more often had a thin gingival phenotype. For other teeth, the results were less conclusive. It is important not to rely solely on the overall appearance of the dentition but to independently assess the thickness and height of the gingiva at each dental site requiring intervention. Finally, this study highlights a key point, namely the need for further longitudinal studies to determine the prevalence in healthy adults. For practicality and feasibility reasons, these studies should be designed according to therapeutic needs, dental sector by dental sector, and within homogeneous source populations. PROSPERO registration: CRD 42023392602. Full article

This longitudinal study aimed to compare the association between gingival phenotype (thin vs. thick) and periodontal disease severity in patients undergoing fixed orthodontic therapy (FOT) and Invisalign treatment over a six-month follow-up period. Clinical periodontal parameters, including full mouth plaque score (FMPS), full mouth bleeding score (FMBS), gingival index (GI), probing pocket depth (PPD), clinical attachment loss (CAL), gingival recession (GR), keratinized tissue width (KTW), transgingival probing, and gingival biotype assessment, were recorded at baseline and 6 months into treatment for both orthodontic groups and a control group. Statistical analysis evaluated differences in parameters between groups and across time points. In the thick phenotype, both Invisalign and FOT groups showed a significant mean reduction in FMPS (baseline to 6 months) by −24.8707 and −12.3489, respectively (p < 0.05). The gingival index decreased significantly for both groups, with Invisalign and FOT showing reductions of −0.83355 and −1.10409, respectively (p < 0.05). FMBS (baseline to 6 months) decreased significantly for Invisalign and FOT, with mean differences of −9.10298 and −12.6579 (p < 0.05). Probing pocket depth (baseline to 6 months) was also significantly reduced for both Invisalign and FOT groups while CAL showed non-significant differences in both groups (p > 0.05). Similar changes were seen in the thin phenotype too. This study highlights the positive influence of both Invisalign and fixed orthodontic therapy on periodontal health, particularly in patients with thin and thick gingival biotypes. These findings, with significant reductions in key periodontal parameters, offer valuable insights to guide orthodontic treatment decisions and enhance patient outcomes. Full article

A coronally advanced flap combined with a subepithelial connective tissue graft is considered the gold standard for achieving root coverage on exposed root surfaces. Nevertheless, challenges arise when this technique is applied to multiple teeth and when the palatal soft tissue is very thin. Several surgical modifications have been reported to simultaneously achieve both single or multiple root coverage and widening of the keratinized gingiva. In this context, there have been no reported cases utilizing the submerged technique with partially de-epithelialized free gingival grafts. We intend to introduce a submerged technique involving partially de-epithelialized free gingival grafts for the modification of soft tissue phenotypes in the maxillary anterior region. Full article

Gingival phenotype (GP) is determined based on the thickness and width of the gingival tissue. An evaluation of GP is essential for adequate treatment planning and outcome monitoring, including orthodontic treatments in a paediatric population. The present study aimed to compare the reliability of the visual and TRAN methods with that of the ultrasound biometer measurements in the early transitional dentition phase. One hundred ninety three generally healthy, 7-year-old children were examined. An assessment of GP was performed by a paedodontist and a periodontist. The average thickness of the gingiva was 0.76 ± 0.36 mm, which was classified as a thin GP. The agreement between a visual assessment and the biometric ultrasound measurements reached the highest (94%) level when assessing a very thin GP (Spearman’s rank correlation coefficient r = 0.37, p < 0.01). Similarly, 99% agreement in the diagnosis of a thin GP was recorded for the TRAN and ultrasound methods (Spearman’s rank correlation coefficient r = 0.49, p < 0.001). In total, 86% of cases diagnosed as having a thick GP using the TRAN method turned out to be thin according to the ultrasound measurements. The dentist’s specialization and professional experience in the assessment of GP were irrelevant (Spearman’s rank correlation coefficient r = 0.49, p < 0.001). All methods tested in the present study were proven to be easy to perform and well accepted by the children. The visual assessment and TRAN methods, despite the fact that they enabled the diagnosis of a thin GP (crucial for treatment planning), cannot be recommended during the teeth replacement period. A misdiagnosis of thick GP may deprive a young at-risk patient of special supervision, which may develop into mucogingival deformities. A biometric ultrasound, although expensive, allows for reliable assessment of the gingiva thickness when needed. Full article

Among the complications of orthodontic treatment, mucogingival problems with gingival recession in the mandibular anterior teeth are challenging for clinicians. Mucogingival problems can lead to esthetic deficits, thermal hypersensitivity, tooth brushing pain, and complicated plaque control. Herein, we present a case of a 16-year-old female with gingival recession in the left mandibular central incisor after orthodontic treatment. The preoperative clinical findings showed a thin soft tissue biotype with root prominence in the mandibular anterior area. The interdental area was relatively depressed. After reflection of the full-thickness flap, root coverage using a bone graft substitute and subepithelial connective tissue graft obtained from the palatal mucosa was performed. The 6-month and 5-year postoperative clinical findings showed improved soft tissue phenotype. The cross-sectional CBCT scans 5 years after surgery showed a well-maintained labial bone plate in the mandibular incisors. Within the limitations of this case report, for patients with gingival recession in the mandibular incisors after orthodontic treatment, a successful biotype modification can be achieved with a combined procedure using subepithelial connective tissue graft with bone graft substitutes. Full article

Gingival recessions (GR) are often associated with the presence of non-carious cervical lesions (NCCL). The latter result in the disappearance of the cement–enamel junction (CEJ), with consequent difficulties both in measuring the recession itself and in performing root coverage techniques. The restoration of cervical lesions is consequently an important aspect in the treatment of GR, with the re-establishment of a “new” CEJ. This pilot study aimed to verify whether restorative therapy alone, with the execution of a restoration that mimics the convexity of the natural CEJ and thanks to a slight horizontal over-contour, can stabilize a clot in the intrasulcular site and consequently is able to change the position of the gingival margin in a coronal direction. In periodontally healthy patients, with a non-thin gingival phenotype, 10 GR-associated NCCL restorations were performed using a protocol inspired by concepts of prosthetic conditioning, with a progressively reduced convexity (“coronally dynamic restoration”) and de-epithelialization of the gingival sulcus. We observed that 70% of the treated teeth showed a reduction in crown length after 15 days (−0.267 mm), without an increase in probing depth. While considering the limitations of the sample and the need to evaluate the different parameters that can affect the result, the coronally dynamic restoration of NCCL with GR was able to influence the position of the gingival margin in a coronal direction. Full article

Thin gingival phenotype (GPh) may contribute to periodontal tissue breakdown and recession development. Thus, the early identification of thin GPh in children can allow proper preventive care and the identification of children at risk during orthodontic treatment. The present long-term study aimed to monitor GPh changes, i.e., thickness (GT) and width of attached gingiva (AGW) during the early transitional dentition phase, as well as its potential associations with the mucogingival deformities. Materials and Methods: 83 systematically healthy children were examined twice with an interval of 2 years. Probing depth, GT and AGW at mandibular incisors, vestibular depth, type of lower lip frenum attachment and mucogingival defects were recorded. Results: 95.2% of participants at baseline and 93.9% at 2-year examination expressed thin GPh. During the transition from the deciduous to permanent dentition, GT and AGW declined, but the GT of permanent incisors already erupted at the baseline examination increased in the observation period. Conclusions: Gingival phenotype undergoes changes in the early transitional dentition phase. In spite of the thin gingival phenotype, only single pseudo-recessions and primary shallow vestibule were noticed. Full article

The objectives of this study were to assess gingival recessions (GR) and periodontal status in patients previously treated with non-extraction orthodontic treatment and retention at a follow-up of a minimum of two years after the end of treatment. Data from patients aged between 16 and 35 years with a previous non-extraction orthodontic treatment and at least 2 years of retention and full records before and after treatment were collected. The casts were digitalized using the 3Shape TRIOS^® intraoral scanner and the Viewbox4 software was used for the measurements. The following parameters were scored: inclination of the lower and upper incisors (IMPA and I^SN) and anterior crowding (Little index). The included patients were recalled for a clinical periodontal follow-up examination and the following parameters were evaluated: buccal and lingual GR (mm) of incisors and canines, bleeding of probing score, plaque score, and gingival phenotype. The digital cast analysis showed a mean Little index of 7.78 (SD 5.83) and 1.39 (SD 0.79), respectively, before and after treatment. The initial and final cephalometric analyses showed an I^SN of 103.53° and 105.78° (SD 7.21) and IMPA of 91.3°and 95.1°, respectively. At the follow-up periodontal visits, the patients showed an overall low oral hygiene with bleeding at probing in 66.6% and plaque in the anterior area in 76.2% of patients. From the total examined 240 teeth of the frontal sextants, three patients had GR (from 1 to 6.5 mm): in the upper arch two at canines and one at central incisor, whereas in the lower arch two at central and one at lateral incisors. The gingival phenotype was thick in 55% of cases. The lingual-to-lingual retainers at follow-up were present in 61.9% of patients. A slight increased risk for buccal GR development was found only in correlation with the presence of fixed retainer and thin gingival phenotype mainly in patients with gingivitis. Thus, non-extraction orthodontic treatment performed with controlled forces and biomechanics seems to not affect the development of GR or the periodontal health after retention. Full article

The concept of gingival phenotype and width of keratinized gingiva influencing the diagnosis and treatment in the periodontal scenario is relatively new. Soft and hard tissue dimensions of oral tissues are considered essential parameters in daily clinical practice. Factors such as the biotype category and the width of the keratinized gingiva help dentists seek the perfect therapy plan for each patient to achieve long-term stability of periodontal health. Several methods have been proposed to categorize phenotypes and each phenotype is characterized by various clinical characteristics. This review aims to discuss the possible association between the gingival phenotype and the width of keratinized gingiva along with the results appeared. After a rigorous search in major electronic databases, the results of the included studies indicated that the width of keratinized gingiva seems to be associated with the periodontal phenotype, with thick biotypes being characterized by a more pronounced keratinized gingival width. However, the heterogeneity of the included studies did not allow to make a conclusion about a direct relationship. Full article