Clinical and volumetric analysis of peri-implant soft tissue augmentation using an acellular dermal matrix: A prospective cohort study

Using the Modified Apical Access Technique to Treat Peri-Implant Mucosa Defects: Description of the Technique and Three-Dimensional Quantitative Measurement of Buccal Augmented Tissue

The importance of augmenting the peri-implant soft- and hard-tissue architecture is now widely accepted. However, while most contemporary research supports this premise, clinicians are encountering peri-implant soft tissue defects with increasing frequency, which they are therefore required to reconstruct. These complications can result from the difficulty of establishing an appropriate diagnosis and treatment plan or from suboptimal clinical situations (implant malposition, insufficient vestibular alveolar bone thickness or inadequate mucosal thickness). In this context, it is the peri-implant soft-tissue phenotype that most influences esthetic and health-related results in the short and long term. This article describes two clinical cases in which a modification of the apical access technique is presented that may be useful in clinical scenarios requiring large gains in mucosal thickness. Use of the modified bilaminar apical access with de-epithelialized free gingival graft technique showed promising results, with a significant increase in mucosal thickness and satisfactory outcomes in esthetics and peri-implant health.

Soft tissue augmentation with a volume-stable collagen matrix or an autogenous connective tissue graft at implant sites: Five-year results of a randomized controlled trial post implant loading

BACKGROUND

Interventions to augment the mucosal thickness around dental implants are indicated to optimize esthetics and maintain peri-implant health. However, there is a lack of clinical data on the long-term performance of soft tissue substitutes, such as volume-stable collagen matrix (VCMX), compared to autogenous grafts, such as subepithelial connective tissue grafts (SCTGs). This randomized controlled trial aimed to assess 5-year data on clinical and radiographic outcomes at implant sites previously augmented with VCMX or SCTG.

METHODS

Twenty patients were randomly assigned for soft tissue augmentation with VCMX or SCTG at single implant sites. Following abutment connection, final restorations were inserted (baseline; BL) and patients were reexamined up to 5 years (FU-5). Measurements included clinical data, marginal bone levels, mucosal thickness, and ridge contour changes. Nonparametric tests and estimates were applied for the statistical analysis.

RESULTS

The median buccal mucosal thickness increased by 0.3 mm (Q1: -0.8; Q3: 1.0) in the VCMX group (P = 0.656) and 0.3 mm (Q1: 0.0; Q3: 1.0) in the SCTG group (P = 0.188) between BL and FU-5 (intergroup P = 0.752), while the ridge contour decreased by a median of -0.3 mm (-0.9; -0.1) (P = 0.078) for VCMX and -0.3 mm (-0.4; -0.2) (P = 0.039) for SCTG (intergroup P = 0.817). Peri-implant health was maintained in both groups with stable clinical and radiographic outcomes and without significant differences between the treatments.

CONCLUSION

Despite the limited power and considerable dropout rate in the present study, soft tissue augmentation at implant sites with either VCMX or SCTG resulted in similar stable peri-implant tissues, favorable esthetics, and clinically negligible contour changes at 5 years post loading.

Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

The Scientific Investigation Committee of the American Academy of Restorative Dentistry offers this review of the 2021 dental literature in restorative dentistry to inform busy dentists regarding noteworthy scientific and clinical progress over the past year. Each member of the committee brings discipline-specific expertise to coverage of this broad topical area. Specific subject areas addressed, in order of the appearance in this report, include COVID-19 and the dental profession (new); prosthodontics; periodontics, alveolar bone, and peri-implant tissues; implant dentistry; dental materials and therapeutics; occlusion and temporomandibular disorders; sleep-related breathing disorders; oral medicine and oral and maxillofacial surgery; and dental caries and cariology. The authors focused their efforts on reporting information likely to influence daily dental treatment decisions with an emphasis on future trends in dentistry. With the tremendous volume of dentistry and related literature being published daily, this review cannot possibly be comprehensive. Rather, its purpose is to update interested readers and provide important resource material for those interested in pursuing greater details on their own. It remains our intent to assist colleagues in negotiating the extensive volume of important information being published annually. It is our hope that readers find this work useful in successfully managing the patients and dental problems they encounter.

Minimal invasiveness in soft tissue augmentation at dental implants: A systematic review and meta-analysis of patient-reported outcome measures

The aim of this study was to compare patient-reported outcome measures (PROMs) of soft tissue substitutes versus autogenous grafts for soft tissue augmentation procedures at implant sites. Comprehensive and systematic literature searches were performed until December 2021. A focused question was formulated based on the Population, Intervention, Comparison and Outcome criteria (PICO): In patients with dental implants undergoing soft tissue augmentation (P), do soft tissue substitutes (I) compared to autogenous soft tissue graft (SCTG [subepithelial connective tissue graft]) (C) limit the post-operative morbidity and other patient reported-outcomes measures (O). Randomized controlled clinical trials, prospective-, retrospective- and case-series studies were included. Meta-analyses were performed whenever possible and the results were expressed as weighted mean differences (WMD). A total of 29 clinical studies were included. For mucosal thickness gain, soft tissue substitutes significantly reduced the pain perception compared to SCTG (n = 4; WMD = 14.91 Visual Analog Scale [VAS] units; 95% confidence interval [CI] 6.42-23.40; P < .0006) based on a 0-100 VAS scale. Based on a 0-10 VAS scale, a borderline significance of pain reduction was found when soft tissue substitutes were applied (n = 4; WMD = 1.62 VAS units; 95% CI 0.01-3.23; P = .05). For keratinized tissue gain, soft tissue substitutes significantly reduced the pain perception after keratinized tissue augmentation compared to SCTG based on a 0-100 VAS scale (n = 2; WMD = 21.43 VAS units; 95% CI 12.58-30.28; P < .0001). Based on the 0-10 VAS scale, soft tissue substitutes significantly reduced the pain as compared to SCTG (n = 4; WMD = 1.65 VAS units; 95% CI 0.66-2.64; P = .001). Regarding pain medication, soft tissue substitutes required less painkillers (n = 6; WMD = 1.56 tablets; 95% CI 1.22-1.91; P < .00001) after soft tissue augmentation. The surgery time was significantly reduced when soft tissue substitutes were used (n = 5; WMD = 10.9 minutes; 95% CI 4.60-17.19; P < .00001). There were no significant differences in satisfaction, aesthetics, and quality of life (OHIP-14) between soft tissue substitutes and autogenous grafts following soft tissue augmentation at implants sites. Soft tissue substitutes, compared to autogenous grafts, significantly improve PROMs following soft tissue augmentation at implant sites. Soft tissue substitutes can reduce pain perception, amounts of painkillers and surgery time while achieving similar levels of patient´s satisfaction as autogenous grafts without impairing the clinical outcomes. The current evidence indicates that they constitute a valid and reliable alternative to minimize the invasiveness in soft tissue augmentation procedures at implant sites.

Full-Thickness Oral Mucoperiosteal Defects: Challenges and Opportunities

Regenerative engineering strategies for the oral mucoperiosteum, as may be needed following surgeries, such as cleft palate repair and tumor resection, are underdeveloped compared with those for maxillofacial bone. However, critical-size tissue defects left to heal by secondary intention can lead to complications, such as infection, fistula formation, scarring, and midface hypoplasia. This review describes current clinical practice for replacing mucoperiosteal tissue, including autografts and allografts. Potentially paradigm-shifting experimental regenerative engineering strategies for mucoperiosteal wound healing, such as hybrid grafts and engineered matrices, are also discussed. Throughout the review, the advantages and disadvantages of each replacement or regeneration strategy are outlined in the context of clinical outcomes, quality of life for the patient, availability of materials, and cost of care. Finally, future directions for research and development in the area of mucoperiosteum repair are proposed, with an emphasis on identifying globally available and affordable solutions for promoting mucoperiosteal regeneration. Impact statement Unassisted oral mucoperiosteal wound healing can lead to severe complications such as infection, fistulae, scarring, and developmental abnormalities. Thus, strategies for promoting wound healing must be considered when mucoperiosteal defects are incident to oral surgery, as in palatoplasty or tumor resection. Emerging mucoperiosteal tissue engineering strategies, described in this study, have the potential to overcome the limitations of current standard-of-care donor tissue grafts. For example, the use of engineered mucoperiosteal biomaterials could circumvent concerns about tissue availability and immunogenicity. Moreover, employment of tissue engineering strategies may improve the equity of oral wound care by increasing global affordability and accessibility of materials.

Use of Xenogenic Collagen Matrices in Peri-Implant Soft Tissue Volume Augmentation: A Critical Review on the Current Evidence and New Technique Presentation

Plastic peri-implant surgical procedures aiming to increase soft tissue volume around dental implants have long been well-described. These are represented by: pedicle soft tissue grafts (rotational flap procedures and advanced flap procedures) and free soft tissue grafts (epithelialized, also called free gingival graft (FGG), and non-epithelialized, also called, connective tissue graft (CTG) or a combination of both. To bypass the drawback connected with autologous grafts harvesting, xenogenic collagen matrices (XCM)s and collagen-based matrices derived from porcine dermis (PDXCM)s have been introduced, as an alternative, in plastic peri-implant procedures. Aim: This review is aimed to evaluate and to critically analyze the available evidence on the effectiveness of XCMs and PDXCMs in soft tissue volume augmentation around dental implants. Moreover, a clinical case with a new soft tissue grafting procedure technique (Guided Soft Tissue Regeneration, GSTR) is presented. Material and Methods: An electronic search was performed on the MEDLINE database, SCOPUS, Cochrane Library and Web of Science. The electronic search provided a total of 133 articles. One hundred and twenty-eight not meeting the inclusion criteria were excluded. Seven articles of human randomized clinical trials were selected. A total number of 108 patients were treated with CTG, and 110 patients with XCM. Results: in peri-implant soft tissue augmentation procedures, XCMs seem an effective alternative to CTGs, associated with lower patient morbidity and lower operative times.

Comparison of general and aesthetic effects between flapless and flap techniques in dental implantation: a meta-analysis of randomized controlled trials

Background

Information about the aesthetic effects of flapless in implant surgeries is scant. Differences of the survival rate (SR) and crestal bone loss (CBL) between the two techniques were also controversial. Thus, this review was aimed to compare the general and aesthetic effects of flapless and flap approaches in implant surgeries.

Materials and methods

Following the principals of PRISMA, literature databases were searched for the eligible randomized controlled trials (RCTs) comparing the clinical performances of flap and flapless techniques. After that, relevant data of selected studies were pooled and analyzed to compare SR, bleeding on probing (BOP), probing depth (PD), visual analogue scale (VAS), papillae presentation index (PPI), keratinized mucosa (KM) width and CBL between the two techniques.

Results

Fourteen RCTs were included. No significant difference was found in SR (RR = − 0.01, 95% confidence interval (CI) (− 0.05, 0.04)), BOP (OR = 0.40, 95% CI (0.15, 1.02)), KM width (WMD = − 0.42, 95% CI (− 1.02, 0.17)) between two groups. Subgroup analysis revealed that the difference of CBL was insignificant in two groups (WMD = − 0.13, 95% CI (− 0.63, 0.38)). However, flap techniques would lead more peri-implant PD (WMD = − 0.37, 95% CI (− 0.51, − 0.23)). Subgroup analysis also indicated lower VAS scores in flapless group after 1 day (WMD = − 1.66, 95% CI (− 2.16, − 1.16)) but comparable pain experience after 3 days (WMD = − 0.59, 95% CI (− 1.33, 0.16)). Mean difference of PPI (WMD = 0.32, 95% CI (0.28, 0.35)) between the two groups was significant.

Conclusions

The flapless procedure showed a superiority in preserving gingival papillae, reducing postoperative pain and peri-implant PD compared to the flap procedure, while exhibiting comparable effects on SR, BOP, KW width changes and CBL. Flapless technique is more recommended at the ideal soft and hard tissue implanting sites.

Porcine Acellular Dermal Matrix: An Alternative to Connective Tissue Graft-A Narrative Review

Porcine acellular dermal matrix has recently been introduced in dentistry as an alternative to the gold standard connective tissue graft especially for the use in gingival recession treatments and soft tissue augmentation in implant surgery. Connective tissue grafts are inconvenient and require a second surgical site leading to greater morbidity, longer surgical procedures, and a more painful postoperative phase for the patient. Other options such as allografts have ethical concerns and are less available in Europe. Thus, dental professionals have sought other techniques and materials. Porcine acellular dermal matrix results in periodontal recession treatment with a gain in recession coverage as well as increased keratinized tissue and soft tissue augmentation. This leads to more keratinized mucosa and greater tissue thickness. Many studies have been published using collagen matrices, but a few strictly use porcine acellular dermal matrix, which have been studied in prospective randomized clinical trials with a large number of patients and longer follow-up periods (more than 5 years). Nevertheless, more data are needed to confirm that the porcine acellular dermal matrix is a suitable alternative although its favourable results to date suggest a positive future.