Implant associated soft tissue defects in the anterior maxilla: a randomized control trial comparing subepithelial connective tissue graft and acellular dermal matrix allograft

Autogenous graft versus collagen matrices for peri-implant soft tissue augmentation. A systematic review and network meta-analysis

OBJECTIVE

The primary objective of this review is to compare autogenous soft tissue grafts (connective tissue graft - CTG and free gingival graft-FGG) with different type of matrices (acellular dermal matrix-ADM, xenograft collagen matrix-XCM, volume-stable collagen matrix-VCMX) used to increase peri-implant soft tissues.

MATERIALS AND METHODS

A search on electronic databases was performed to identify randomized and non-randomized controlled trials (RCTs and CCTs, respectively) with either parallel or split-mouth design, and treating ≥ 10 patients. A network meta-analysis (NMA) was used to compare different matrices. Soft tissue thickness dimensional changes and keratinized width (KMW) changes were the primary outcome measures. The secondary outcomes were to evaluate: a) PROMs; b) volumetric changes; c) surgical operating time; and d) different periodontal measurements.

RESULTS

A total of 23 studies were included in the qualitative analysis, and 16 studies (11 RCTs and 5 CCTs) in the quantitative analysis. A total of N = 573 sites were evaluated for NMA. CTG resulted the best material for increasing peri-implant soft tissue thickness, at 180 and 360 days after surgery. The use of an ADM showed good results for buccal thickness increase, primarily in the first three months after surgery. Vestibuloplasty + FGG resulted in the most effective technique for peri-implant KMW augmentation, after 180 days.

CONCLUSIONS

While CTG demonstrated better performance in all the comparison and FGG showed to be the best graft to increase keratinized mucosa up to 90 days, ADM and VCMX may be used to increase soft tissue horizontal thickness with lower patients' morbidity.

LIMITATIONS

The limits of this NMA are the following: a) limited number of included studies; b) high heterogeneity among them (number of patients, treatment sites, surgical techniques, outcome measures, and follow-ups).

CLINICAL RELEVANCE

Many studies compared the efficacy of autogenous and non-autogenous grafts in terms of gingival thickness, volume, and keratinized width increase. However, there is still not clear overall evidence on this topic. This NMA helps clinicians to choose the right material in different peri-implant soft tissue procedures. Recommendations for future studies are mandatory.

Challenges and success in periodontal plastic surgery

To truly understand a field of study, one must delve into its past and examine the challenges and successes that have shaped its current practices. In the case of periodontal plastic surgery, recognizing how challenges induced changes over the last 70 years-from the 1950s to today-is essential to fully comprehend its evolution. This editorial provides a perspective on the field, highlighting the interrelationships between influential surgical techniques and advancements in research methodology. With each event building upon the last, the evolution of periodontal plastic surgery is a story of scientific progress and ongoing research, fostering a sense of community and shared knowledge.

Coronally advanced flap versus tunnel technique for the treatment of peri-implant soft tissue dehiscences with the connective tissue graft: A randomized, controlled clinical trial

AIM

To evaluate the efficacy of coronally advanced flap (CAF) versus tunnel technique (TUN) in covering isolated mid-facial peri-implant soft tissue dehiscences (PSTDs).

MATERIALS AND METHODS

Twenty-eight participants presenting with isolated non-molar implants exhibiting PSTDs were enrolled and randomized to receive either CAF or TUN, both with a connective tissue graft (CTG). The primary outcome of the study was the percentage of mean PSTD coverage at 12 months. Secondary endpoints included the frequency of complete PSTD coverage, changes in keratinized mucosa width (KMW) and horizontal mucosal thickness (MT), as assessed with transgingival probing, 3D optical scanning and ultrasonography, professional aesthetic evaluation and patient-reported outcome measures (PROMs).

RESULTS

At 12 months, the mean PSTD coverage of the CAF and TUN groups was 90.23% and 59.76%, respectively (p = .03). CAF-treated sites showed a substantially higher frequency of complete PSTD coverage (p = .07), together with significantly greater gain of KMW (p = .01), increase in MT (p = .02), volumetric gain (p < .01) and professional aesthetic outcomes (p = .01). Both interventions showed an improvement in patient-reported aesthetics and a reduction of the anxiety related to the appearance of the implant compared to baseline, with the CAF group obtaining significantly higher scores (p = .03 for both PROMs).

CONCLUSIONS

CAF + CTG resulted in superior PSTD coverage outcomes, greater gain in KMW and MT, and better PROMs than TUN + CTG for the treatment of isolated PSTDs (ClinicalTrials.gov NCT03498911).

Etiology and Treatment of Peri-Implant Soft Tissue Dehiscences: A Narrative Review

Implant soft tissue dehiscences compromise not only the aesthetics of the supported restorations but implant survival in the long run. The aim of this narrative review was to briefly present the causative factors of buccal peri-implant soft tissue dehiscences (PSTDs), how these are classified, and the current therapeutic approaches. Implant malposition and the thin peri-implant phenotype are the two major determinants for the occurrence of PSTDs, but other risk factors have also been identified. The most common surgical procedure for treating PSTDs is the split-thickness coronally advanced flap combined with either a connective tissue graft or acellular dermal matrix materials. However, depending on the class and subtype of the dehiscence, the combination of surgical techniques with modifications in the restoration may further ameliorate the final result. In general, within a five-year follow-up period, most techniques lead to a satisfactory aesthetic result, although full coverage of the implant/abutment surface is not always achievable, especially in more extended lesions.

Effectiveness of soft tissue augmentation procedures for coverage of buccal soft tissue dehiscence around dental implants. A systematic review

OBJECTIVE

This systematic review evaluated the effectiveness of soft tissue augmentation procedures for complete coverage and mean coverage of buccal soft tissue dehiscence (BSTD) in patients with implant-supported restorations.

METHODS

Three databases were surveyed for randomized (RCTs), non-randomized controlled clinical trials (CCTs), cohort studies, case-control studies, and case series with a minimum of five patients per control or test group. Studies dealing with soft tissue augmentation procedures to cover BSTD-occurring during implant function and not due to the result of peri-implantitis-were included. Risk of bias was evaluated with RoB 2 or the National Institutes of Health's Quality Assessment. Whenever possible exploratory meta-analyses were performed to evaluate weighted mean effects (WME) for the different outcomes. The primary outcomes were percentage of complete coverage and mean coverage of BSTD.

RESULTS

Seven articles were included. Only one study was a RCT, with a high risk of bias. Meta-analyses showed that after 1 year (2 studies, n = 36 patients; WME = 70; 95% confidence interval [CI] = 50; 90; p = 0.23) as well as after 5 years (3 studies, n = 54 patients; WME = 70; 95%; CI = 60; 80; p = 0.44), complete coverage of BSTD could be achieved in 70% of the cases.

CONCLUSION

Based on limited evidence it can be concluded that BSTD can be substantially reduced with the use of soft tissue augmentation procedures. Further research with comparative trials using larger samples and longer follow-up periods is needed to study the stability of soft tissues in the long term.

Soft tissue augmentation around osseointegrated and uncovered dental implants: a systematic review

OBJECTIVES

The aim was to compile the current knowledge about the efficacy of different soft tissue correction methods around osseointegrated, already uncovered and/or loaded (OU/L) implants with insufficient soft tissue conditions. Procedures to increase peri-implant keratinized mucosa (KM) width and/or soft tissue volume were considered.

MATERIALS AND METHODS

Screening of two databases: MEDLINE (PubMed) and EMBASE (OVID), and manual search of articles were performed. Human studies reporting on soft tissue augmentation/correction methods around OU/L implants up to June 30, 2016, were considered. Quality assessment of selected full-text articles to weight risk of bias was performed using the Cochrane collaboration's tool.

RESULTS

Overall, four randomized controlled trials (risk of bias = high/low) and five prospective studies (risk of bias = high) were included. Depending on the surgical techniques and graft materials, the enlargement of keratinized tissue (KT) ranged between 1.15 ± 0.81 and 2.57 ± 0.50 mm. The apically positioned partial thickness flap (APPTF), in combination with a free gingival graft (FGG), a subepithelial connective tissue graft (SCTG), or a xenogeneic graft material (XCM) were most effective. A coronally advanced flap (CAF) combined with SCTG in three, combined with allogenic graft materials (AMDA) in one, and a split thickness flap (STF) combined with SCTG in another study showed mean soft tissue recession coverage rates from 28 to 96.3 %. STF combined with XCM failed to improve peri-implant soft tissue coverage.

CONCLUSIONS

The three APPTF-techniques combined with FGG, SCTG, or XCM achieved comparable enlargements of peri-implant KT. Further, both STF and CAF, both in combination with SCTG, are equivalent regarding recession coverage rates. STF + XCM and CAF + AMDA did not reach significant coverage.

CLINICAL RELEVANCE

In case of soft tissue deficiency around OU/L dental implants, the selection of both an appropriate surgical technique and a suitable soft tissue graft material is of utmost clinical relevance.