The dimensions of keratinized mucosa around implants affect clinical and immunological parameters

A Strip Free Gingival Graft and a Xenogeneic Collagen Matrix to Increase Keratinized Tissue After Vertical Bone Augmentation

After vertical bone augmentation (VBA) surgery, loss of both keratinized tissue (KT) and vestibule depth (VD) take place. This article evaluated KT gain, patient satisfaction, and aesthetic outcomes after a modified apically repositioned flap (ARF) in combination with a strip-free gingival graft (FGG) harvested from the palate and a xenogeneic collagen matrix (XCM) to correct mucogingival distortion (MGD) after VBA. This technique minimizes patient morbidity by reducing the need for extensive masticatory mucosa grafts. The study included 12 patients with ≤3 mm KT after vertical augmentation procedures. Keratinized tissue gain and tissue thickness were measured. Patient morbidity and aesthetic outcomes were also evaluated. Twenty-four months after surgery, significant VD gain was observed, obtaining a vertical KT augmentation of 5.38 ± 2.06 mm, although tissue thickness increase was only 0.42 ± 0.42mm. Regarding patient satisfaction, aesthetic results evaluating tissue color and texture were satisfactory; the pain was slight, obtaining a score of 2.10 ± 1.13 out of 10, measured using a Visual Analogue Scale (VAS). The present retrospective case series study shows that using an apically repositioned flap combined with a strip FGG and an XCM might offer a valid means of achieving KT gain.

Effect of Sagittal Root Position, Angle, and Bone Thickness on Peri-implant Tissue Phenotype and Bone Level in Socket Shield Technique: A Retrospective Case Series

There were only a few studies investigating the effect of sagittal root position (SRP), sagittal root angle (SRA), and buccal bone thickness (BBT) on peri-implant tissues using the socket shield technique (SST). This retrospective case series aimed to evaluate the SRP, SRA, and BBT in socket shield cases and examine the effect of these anatomical factors on the peri-implant tissue phenotype and bone level. Data from 27 patients (14 women, 13 men) treated with SST in the maxillary esthetic region between July 2019 and September 2021 were included. Clinical indices (modified plaque and bleeding indices, probing depth, keratinized mucosa width, mucosal thickness) and periapical radiographic recordings (marginal bone level) taken immediately after permanent prosthesis placement and 1 year later were used. Cone beam computerized tomography images were used to examine BBT, SRP, and SRA before implant placement and horizontal and vertical bone levels before implant placement and 1 year after prosthetic rehabilitation. The data were divided into groups based on BBT (<1 and ≥1 mm) and SRA values (<10° and ≥10°). There were no significant differences in 1-year clinical factors between the SRA <10° and SRA ≥10° groups. However, higher vertical bone loss was found in the SRA ≥10° group (P = .01, d = 0.53). There were no significant differences in clinical or radiographic factors between the BBT <1 mm and BBT ≥1 mm groups. In conclusion, BBT showed no significant effect on tissue phenotype and bone level, but SRA affected bone level in socket shield cases.

The Significance of Keratinized Mucosa in Implant Therapy: Narrative Literature Review and Case Report Presentation

Background/Objectives: Implant treatment in patients who require teeth extraction due to periodontitis presents a significant challenge. The consideration of peri-implantitis is crucial when planning the placement of dental implants. The predictability of implant treatment relies on the suitability of both hard and soft tissue quality. The aim of this article is to present a case report demonstrating a secure treatment protocol for implant procedures in patients with periodontitis requiring the extraction of all teeth, soft tissue management targeted at increasing the keratinized mucosa zone, and the provision of a reliable prosthetic solution. The secondary objective is to review the relevant literature regarding the significance of keratinized mucosa surrounding dental implants and its association with the occurrence of peri-implantitis. Case presentation: A 65-year-old female with generalized periodontitis, stage IV grade C and very poor oral hygiene came for treatment and rehabilitation of the lower jaw. CBCT revealed periodontal lesions and labio-lingual ridge dimensions in the region of teeth 34-44 from 8.0 to 10.2 mm. The first surgery included teeth extraction and periodontal lesions enucleation with simultaneous placement of four implants in the positions of teeth 32, 34, 42, 44. The second-stage surgery involved increasing the keratinized mucosa using two free gingival grafts. Conclusions: The present case report described the treatment process of the patient with periodontitis, including immediate implantation in the infected region, soft tissue augmentation using free gingival grafts and the ultimate placement of a bar-retained overdenture for final restoration. After two years of observation, despite questionable hygiene, no symptoms of gingival inflammation were detected. Furthermore, there is limited information in the literature regarding the correlation between inadequate keratinized gingiva and the occurrence of peri-implantitis.

Association of Peri-Implant Keratinized Mucosa Width and Mucosal Thickness with Early Bone Loss: A Cross-Sectional Study

Objective: The objective of this study was to evaluate the effects of keratinized mucosa width (KMW) and mucosal thickness (MT) around dental implants on marginal bone loss (MBL). The evaluation was performed one year after loading by comparing clinical, radiographic, and biochemical parameters. Methods: The study included 87 implants in 87 patients undergoing regular follow-ups without hard or soft tissue augmentation one year after loading. Clinical measurements included plaque index (PI), gingival index (GI), bleeding on probing (BoP), probing depth (PD), KMW, and MT. MBL was assessed with periapical radiography. The peri-implant crevicular fluid (PICF) was analyzed for tumor necrosis factor-alpha (TNF-α), receptor activator of nuclear factor-kB ligand (RANKL), osteoprotegerin (OPG), and microRNA-27a. Results: The MBL of implants with thin MT (<2 mm) was higher than that of implants with thick MT (≥2 mm) (p < 0.05). A significant negative correlation (r: -0.217) was established between MT and MBL. No significant association was found between KMW and MBL (p > 0.05). No significant associations was found between KMW and MT with TNF-α, RANKL, OPG and RANKL/OPG (p > 0.05), with the exception of increased microRNA-27a levels in implants with KMW ≥ 2 mm (p < 0.05). Conclusions: Implants with a thick MT had a lower MBL. There may be an association between adequate KMW and high miRNA-27a levels. The relationship between MBL and miRNA-27a remains unclear.

Influence of keratinized mucosa on peri-implant diseases: a retrospective cohort study in humans

OBJECTIVE

The present study aimed to assess the relationship between keratinized mucosa width and peri-implant diseases, namely peri-implant mucositis and peri-implantitis.

MATERIALS AND METHODS

Ninety-one dental implants in function for ≥ 6 months from 40 partially or completely edentulous non-smoker subjects (24 females and 16 males) were evaluated clinically and radiographically. The width of keratinized mucosa, probing depth, plaque index, bleeding on probing, and marginal bone levels were assessed. Keratinized mucosa width was categorized as ≥ 2 mm or < 2 mm.

RESULTS

There was no statistically significant association between keratinized buccal mucosa width and peri-implant mucositis or peri-implantitis (p ≥ 0.37). In the regression analysis, peri-implantitis was associated with longer implant function time (RR: 2.55, 95% CI: 1.25-11.81, p = 0.02) and implants in the maxilla (RR: 3.15, 95% CI: 1.61-14.93, p = 0.003). Mucositis was not associated with any of the factors analyzed.

CONCLUSION

In conclusion, in the present sample, keratinized buccal mucosa width was not associated with peri-implant diseases, suggesting that a band of keratinized mucosa may not be necessary to maintain peri-implant health. Prospective studies are required to better understand its role in the maintenance of peri-implant health.

Clinical study on the association between keratinized mucosa and peri-implant health when external hexagon implants are installed in the posterior region of the maxilla and mandible: a cohort study

This study evaluated the association between keratinized mucosa (KM) and peri-implant health of external hexagon implants in the posterior region in 84 patients with 242 implants. Modified plaque index (MPI), modified sulcular bleeding index (MSBI), probing depth (PD), keratinized mucosa (KM) width, and peri-implant bone loss were evaluated. The implants were divided according to the KM: (1) absence of KM, (2) KM width >0 and <2 mm, and (3) KM width ≥2 mm. Of the 242 implants evaluated, 63 (26.0%) had no KM band, 56 (23.1%) had KM width <2 mm, and 123 (50.8%) had KM width ≥2 mm. One hundred and sixty-seven (69.0%) were used in multiple unit restorations and 75 (31.0%) in single tooth restorations; 66.9% were placed in the mandible and 33.1% in the maxilla. For single tooth and multiple unit implant restorations, MPI (P=0.069 and P=0.387, respectively), MSBI (P=0.695 and P=0.947, respectively), PD (P=0.270 and P=0.258, respectively), and mesial bone loss (P=0.121 and P=0.239, respectively) were not affected by the KM width. On the distal surface, bone loss was influenced by the absence of KM when single tooth implant restorations were used (P=0.032). No association was found between KM width and the peri-implant tissue health.

Maxillary labial peri-implant hard and soft tissue alteration observed on cross-sectional dimension: a 2-year prospective observational study

OBJECTIVES

To evaluate how peri-implant hard and soft tissue height (BH, MH) alter after final prostheses placement related to labial hard and soft tissue thickness (BW, MW).

MATERIALS AND METHODS

Forty-five platform-switched implants were classified into four groups according to BW and MW: type 1 (thick BW and thick MW), type 2 (thick BW and thin MW), type 3 (thin BW and thick MW), type 4 (thin BW and thin MW). Tissue resorption was evaluated on cone-beam CT images taken at final prostheses placement, at 1-year follow-up, and at 2-year follow-up. Kruskal-Wallis test and post hoc Mann-Whitney test were applied; significance was set to 0.05.

RESULTS

BH resorption was 0.13 ± 0.12 mm in type 1, 0.26 ± 0.17 mm in type 2, 0.09 ± 0.09 mm in type 3, 0.94 ± 0.19 mm in type 4. Differences between type 1 and 4, type 2 and 4, and type 3 and 4 were statistically significant (p < 0.001, p = 0.005, p < 0.001, respectively). MH resorption was 0.10 ± 0.09 mm in type 1, 0.36 ± 0.16 mm in type 2, 0.12 ± 0.12 mm in Type 3, 0.79 ± 0.23 mm in type 4. Differences between type 1 and 2, type 1 and 4, type 2 and 3, type 2 and 4 and type 3 and 4 were statistically significant (p < 0.001).

CONCLUSIONS

Significantly less BH/MH resorption occurs around implants with thick BW/MW than those with thin BW/MW in 2 years. Implants with thick peri-implant soft tissue resulted in significantly less tissue resorption in second year after final prostheses placement.

Complications and treatment errors in peri-implant soft tissue management

Inadequate quality, quantity, or aesthetics of the peri-implant soft tissues can result from a combination of factors related to the outcome of treatments performed before, during, or after implant placement. In this paper, we describe in detail the treatment errors that can pave the way for the onset of mucositis or give rise to soft tissue complications such as peri-implant soft tissue discoloration or dehiscence, graft exposure, or scar formation. By tracing the error back to the planning or surgical stage, clinical insights on surgical soft tissue management are provided to avoid or treat complications that affect the status of the peri-implant soft tissues. Mastering the learning curve and knowing the limitations of each technique are fundamental for preventing added treatment failures that can result in increased patient morbidity and overall discontent.

Accuracy of cone-beam computed tomography in determining gingival thickness: a systematic review and meta-analysis

OBJECTIVE

To assess the accuracy of cone-beam computed tomography (CBCT) for determining gingival thickness.

MATERIAL AND METHODS

Searches were undertaken in PubMed/MEDLINE, EMBASE, LILACS, Web of Science, Scopus, LIVIVO, and gray literature (Google Scholar and ProQuest) for studies considered eligible according to the following criteria: cross-sectional observational studies, which compared CBCT accuracy with that of transgingival probing when determining gingival thickness, in adult patients with good periodontal health. No language or time restrictions were applied in this systematic review. The risk of bias was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for analytical cross-sectional studies.

RESULTS

Six articles were included for qualitative synthesis, involving a pooled sample of 132 patients with a mean age of 29 years (18-51 years). Of these 6 studies, 5 were eligible for quantitative analysis. The meta-analysis showed no statistically significant difference between CBCT and transgingival probing measures of gingival tissue (mean difference of 0.10 (95% CI-0.17-0.38). No significant level of heterogeneity was detected (Tau²-P = 0.0662; I² = 0%; H²-P = 1.000; Q-P = 1.134). According to the GRADE criterion, confidence in the cumulative evidence was considered low.

CONCLUSIONS

CBCT is an accurate method for determining gingival tissue thickness, comparable to the reference standard (transgingival probing).

CLINICAL RELEVANCE

CBCT could be considered for gingival thickness measurement when bone thickness is also needed, and thereby aid in the assessment of gingival biotype without the discomfort and anesthesia needed in transgingival probing.

TRIAL REGISTRATION

This protocol was registered at the PROSPERO database (International Prospective Register of Systematic Review) under registration number CRD42022326970. Available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022326970 .

Effectiveness of using platelet-rich fibrin to increase keratinized tissue around the tooth in the modified apical reposition flap method: A split-mouth, randomized controlled trial

OBJECTIVES

One of the simplest methods to increase keratinized gingiva is the modified apically repositioned flap (MARF) technique. In this method, the periosteum remains exposed, which may lead to postoperative pain and discomfort. In the presence of bone dehiscence, bone resorption and gingival recession may occur. Hence, this study aims to use platelet-rich fibrin (PRF) to promote wound healing in the MARF technique and overcome its disadvantages.

MATERIAL AND METHODS

In this randomized controlled trial study, 10 patients (six males and four females with a mean age of 33.9 ± 11.13) with less than 2 mm of attached gingiva bilaterally were treated by the MARF + PRF membrane (test group), on the one hand, whereas, on the other hand, it was treated only by MARF (control group). Clinical parameters of keratinized gingiva include thickness, width, and vestibule depth before and 8 weeks after the intervention were measured.

RESULTS

The attached gingival width increased significantly in both groups (1.7 mm in the MARF and 2.3 mm in the PRF) and this was greater in the PRF group (p < .05). Gingival thickness in the PRF method was significantly higher than in the control group (p < .05). Probe depth, vestibular depth, and postoperative pain were not different in both groups. Wound shrinkage in the MARF group (51%) was significantly higher than in the PRF group (30%) (p < .05).

CONCLUSION

Using PRF with the MARF method significantly increased the width and thickness of the gingiva and reduced shrinkage compared to MARF only. Postoperative pain and vestibular depth changes were similar in both groups.

Impact of peri-implant soft tissue characteristics on health and esthetics

OBJECTIVE

To review the impact of key peri-implant soft tissue characteristics on health and esthetics.

MAIN CONSIDERATIONS

The keratinized mucosa width (KMW), the mucosal thickness (MT), and the supracrestal tissue height (STH) are essential components of the peri-implant soft tissue phenotype. An inadequate KMW (<2 mm) has been associated with local discomfort upon oral hygiene performance and increased risk for the onset of peri-implant diseases. A minimum buccal MT (≥2 mm) is generally required to prevent esthetic issues related to the effect of transmucosal prosthetic elements on the color of the mucosa and can also contribute to long-term mucosal stability. STH is directly related to marginal bone remodeling patterns during the early healing process that follows the connection of transmucosal prosthetic components. Short STH, generally defined as <3 mm, has been consistently associated with marginal bone loss resulting from the physiologic establishment of the mucosal seal. Insufficient STH may also derive into the fabrication of unfavorable transmucosal prosthetic contours, which frequently results in unpleasing esthetic outcomes and predisposes to submarginal biofilm accumulation. Peri-implant soft tissue dehiscences (PISTDs) are a type of peri-implant deformity that are associated with esthetic issues and often occur in sites presenting KMW, MT, and/or STH deficiencies. PISTDs should be correctly diagnosed and treated accordingly, usually by means of multidisciplinary therapy.

CONCLUSION

Understanding the impact of different dimensional and morphologic features of the peri-implant mucosa on health and esthetic outcomes is fundamental to make appropriate clinical decisions in the context of tooth replacement therapy with implant-supported prostheses.

Impact of local predisposing/precipitating factors and systemic drivers on peri‐implant diseases

BACKGROUND

Strong evidence suggests the infectious nature of peri-implant diseases occurring in susceptible hosts. Epidemiological reports, though, indicate that peri-implantitis is a site-specific entity. Hence, the significance of local factors that may predispose/precipitate plaque accumulation and the impact of systemic drivers that alter the immune response are relevant in the prevention and management of peri-implant disorders.

PURPOSE

The purpose of the present review is to shed light on the significance of local and systemic factors on peri-implant diseases, making special emphasis on the associations with peri-implantitis.

METHODS

The biologic plausibility and supporting evidence aiming at providing a concluding remark were explored in the recent scientific literature for local predisposing/precipitating factors and systemic drivers related to peri-implant diseases.

RESULTS

Local predisposing factors such as soft tissue characteristics, implant position and prosthetic design proved being strongly associated with the occurrence of peri-implant diseases. Hard tissue characteristics, however, failed to demonstrate having a direct association with peri-implant diseases. Robust data points toward the strong link between residual sub-mucosal cement and peri-implant diseases, while limited data suggests the impact of residual sub-mucosal floss and peri-implantitis. Systemic drivers/habits such as hyperglycemia and smoking showed a strong negative impact on peri-implantitis. However, there is insufficient evidence to claim for any link between metabolic syndrome, atherosclerotic cardiovascular disease, and obesity and peri-implant diseases.

CONCLUSION

Local predisposing/precipitating factors and systemic drivers may increase the risk of peri-implant diseases. Therefore, comprehensive anamnesis of the patients, educational/motivational programs and exhaustive prosthetically-driven treatment planning must be fostered aiming at reducing the rate of biological complications in implant dentistry.

Physiopathology of peri-implant diseases

BACKGROUND

Peri-implant health is characterized by the absence of clinical signs of soft tissue inflammation. Peri-implant diseases are initiated by the presence of bacterial biofilms and share a similar etiology as that involved in the onset of periodontal diseases.

PURPOSE

To summarize available evidence on the physiopathology of peri-implant diseases with emphasis on similarities and differences with periodontal diseases.

MATERIALS AND METHODS

Evidence on the biologic mechanisms involved in the pathogenesis of peri-implant mucositis and peri-implantitis were explored in the recent scientific literature.

RESULTS

Findings of studies in animals and in humans indicate that experimental peri-implant mucositis leads to a larger inflammatory connective tissue infiltrate and to a higher frequency of bleeding sites around implants compared with teeth. Tissue destruction at experimental peri-implantitis sites is more pronounced compared with that at experimental periodontitis sites. Although human periodontitis and peri-implantitis lesions share similarities with respect to etiology and clinical features, they represent distinct entities from a physiopathologic point of view.

CONCLUSIONS

Diagnosis of peri-implant health requires a clinical examination to confirm absence of peri-implant soft tissue inflammation. In order to make a correct diagnosis and select the appropriate therapeutic steps to manage peri-implant diseases, knowledge of their pathogenetic mechanisms is required.

Soft tissue features of peri‐implant diseases and related treatment

BACKGROUND

The need for soft tissue grafting at implant sites for preventing and treating peri-implant diseases is a currently investigated and debated topic.

PURPOSE

The aim of this manuscript is to explore the inflammatory mechanisms at the peri-implant soft tissue compartment, to distinguish the structural components of the peri-implant soft tissue phenotype and their role on peri-implant health, and to appraise the clinical indications and expected outcomes of soft tissue augmentation procedures at peri-implant diseased sites.

MATERIALS AND METHODS

This narrative review depicts the inflammatory biomarkers and mediators in the peri-implant crevicular fluid utilized to diagnose peri-implant disease and that have been shown to be associated with peri-implant soft tissue phenotype modification and disease resolution. The impact of the peri-implant soft tissue phenotype, involving keratinized mucosa (KM) width, attached mucosa (AM), mucosal thickness (MT), and supracrestal tissue height (STH), on peri-implant health, esthetic, patient's comfort and disease prevention are discussed. The manuscript also illustrates the use of ultrasonography for the detection of peri-implant health/disease and the evaluation of the treatment outcomes following surgical therapies.

RESULTS

Current evidence indicates that soft tissue phenotype modification at implant sites with inadequate KM width, AM and MT can be beneficial for promoting peri-implant health and improving patient's comfort and hygiene procedures. Treatment approaches and outcomes from the available literature on soft tissue phenotype modification in combination with conventional techniques at sites with peri-implant mucositis or peri-implantitis are presented and discussed in detail.

CONCLUSIONS

Soft tissue grafting can be beneficial in preventing and treating peri-implant diseases. Clinical recommendations based on the disease, soft tissue phenotype characteristics and bone defect morphology are provided for a comprehensive hard- and soft-tissue-oriented treatment of peri-implant disease.

Significance of barrier membrane on the reconstructive therapy of peri-implantitis: A randomized controlled trial

BACKGROUND

The objective of this trial was to investigate the clinical and radiographic significance of using a mixture of mineralized and demineralized allografts in combination (M) or not (NM) with a resorbable cross-linked barrier membrane in the reconstructive therapy of peri-implantitis defects.

METHODS

A two-arm randomized clinical trial was performed in patients diagnosed with peri-implantitis that exhibited contained defects. Clinical parameters were recorded at baseline (T₀ ), 6 months (T₁ ), and 12 months (T₂ ). Radiographic parameters were recorded at T₀ and T₂ . A composite criterion for disease resolution was defined a priori. A generalized linear model of repeated measures with generalized estimation equation statistical methods was used.

RESULTS

Overall, 33 patients (n_implants  = 48) completed the study. At T₂ , mean disease resolution was 77.1%. The use of a barrier membrane did not enhance the probability of disease resolution at T₂ (odds ratio [OR] = 1.55, p = 0.737). Conversely, the odds of disease resolution were statistically associated with the modified plaque index recorded at T₀ (OR = 0.13, p = 0.006) and keratinized mucosa width (OR = 2.10, p = 0.035). Moreover, women exhibited greater odds to show disease resolution (OR = 5.56, p = 0.02).

CONCLUSION

Reconstructive therapy by means of a mixture of mineralized and demineralized allografts is effective in clinically resolving peri-implantitis and in gaining radiographic marginal bone level. The addition of a barrier membrane to reconstructive therapy of peri-implantitis does not seem to enhance the outcomes of contained bone defects (NCT05282667).

Connective tissue graft versus xenogeneic collagen matrix for soft tissue augmentation at implant sites: a randomized-controlled clinical trial

OBJECTIVES

The purpose of this randomized clinical trial (RCT) is to compare xenogeneic collagen matrix (XCM) versus subepithelial connective tissue graft (SCTG) to increase soft tissue thickness at implant site.

MATERIALS AND METHODS

The study was a randomized, parallel-group controlled investigation. Thirty patients underwent buccal soft tissue thickness augmentation at the stage of implant placement by two different methods: SCTG (control group) and XCM (test group). Primary outcome was the amount of buccal soft tissue thickness gain, 3 months after the intervention. Secondary outcomes were the operation time, the amount of keratinized mucosa (KM), pain syndrome (PS), and patients' quality of life (QL). Histologic evaluation was also performed.

RESULTS

The amount of soft tissue thickness gain was 1.55±0.11 mm in SCTG group, and 1.18±0.11mm in XCM group. The difference between the SCTG and XCM was -0.366 (-0.66 to -0.07; p=0.016). Operation time with XCM was 8.4 (3.737 to 13.06) min shorter than that with the SCTG (p=0.001). KT, PS, and QL for both groups were not statistically significantly different at any time point (p>0.05). At histological examination, the general picture in both groups was similar. No significant differences between the studied groups in most indices, except for the average and maximum formation thickness, cellularity of the basal, mitotic activity and also maximum length of rete ridges.

CONCLUSION

Within limitations, this study demonstrates that the use of SCTG provides a statistically significant superior soft tissue thickness gain than XCM for soft tissue augmentation procedures around implants.

CLINICAL RELEVANCE

XCM can be used as the method of choice for increasing the thickness of soft tissues.

Onlay platelet-rich fibrin membrane versus free gingival graft in increasing the width of keratinized mucosa around dental implants: A split-mouth randomized clinical study

Background. This study aimed to compare the use of the platelet-rich fibrin membrane (PRF) versus the free gingival graft (FGG) during the second stage of the dental implant to increase the amount of keratinized mucosa around dental implants. Methods. Fifteen patients with bilaterally missing teeth and deficient width of the keratinized mucosa (KM) were recruited for a spit-mouth randomized controlled trial. After implant placement on the control sides, onlay FGG was used, whereas, on the other side (study side), onlay PRF membranes were applied to augment the KM. One month and three months after augmentation, the increase in keratinized mucosa width, bone level around the implants, and soft tissue health were evaluated and compared. The shrinkage percentage was also calculated for both grafts. Results. There was a significant increase in the width of KM in the FGG and PRF groups; however, it was observed that FFG resulted in significantly better results than PRF, with no significant difference in peri-implant soft tissue health or bone level. Conclusion. Within the limitations of this study, it was concluded that the onlay PRF membrane could increase the keratinized mucosa width around dental implants with the advantages of a lower surgical time and less postoperative discomfort and pain for the patients in comparison to the FGG. However, FGG had a significantly higher ability to augment and increase keratinized mucosa around dental implants.

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.

The role of keratinized mucosa width as a risk factor for peri-implant disease: A systematic review, meta-analysis, and trial sequential analysis

Background

Studies have examined the benefit of having keratinized peri‐implant mucosa width with mixed results.

Purpose

This study examines whether the lack of a prespecified (2 mm) amount of keratinized mucosa width (KMW) is a risk factor for peri‐implant diseases.

Methods

A systematic electronic and manual search of randomized or nonrandomized controlled or noncontrolled clinical trials was conducted. Qualitative review, quantitative meta‐analysis, and trial sequence analysis (TSA) of implants inserted at sites with <2 mm or ≥2 mm of KMW were analyzed to compare all the predetermined outcome variables. The level of evidence concerning the role of KMW in peri‐implant health was evaluated via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system guide.

Results

Nine studies were included in the qualitative analysis and four in the meta‐analysis and TSA. No significant inter‐group difference (p > 0.05) and a low power of evidence were found for probing depth, soft‐tissue recession, and marginal bone loss. A significant difference favoring ≥2 mm KMW had a lower mean plaque index (MD = 0.37, 95% CI: [0.16, 0.58], p = 0.002) (3 studies, 430 implants, low‐quality evidence). GRADE system showed very low and low quality of evidence for all other outcome measures.

Conclusion

Based on the available studies, the impact of amount of KMW (either <2 mm or ≥ 2 mm) as a risk factor for developing peri‐implant disease remains low. Future control studies with proper sample size and longer follow‐up are needed to further validate current findings.

Management and prevention of soft tissue complications in implant dentistry

The management and prevention of soft tissue complications is of key importance in modern implant dentistry and influences biologic and esthetic outcomes. The assessment of the soft tissue conditions from a quantitative and qualitative perspective should, therefore, be part of the overall treatment plan. Such an assessment dictates a potential indication as well as an ideal time point for additional soft tissue management. A proper risk assessment and management of the soft tissues at the planned implant site are of key importance prior to any implant‐related surgery. Cases with peri‐implant soft tissue complications generally involve: (a) a lack of attached and keratinized mucosa; (b) insufficient volume; (c) development of mucosal dehiscences; or (d) a combination of (a), (b), and (c). In case of soft tissue deficiencies, these should be addressed as early as possible to increase the predictability of the surgical interventions. This article reviews the main causes for peri‐implant soft tissue complications and presents different therapeutic options for the management of various clinical scenarios.

Classification Based on Extraction Socket Buccal Bone Morphology and Related Treatment Decision Tree

Background: Alveolar ridge preservation (ARP) can successfully reduce volumetric ridge changes. However, there is still no consensus on what technique is the most advantageous for each specific clinical scenario. Hence, the aim of the present paper was to provide a treatment decision tree to guide the choice of predictable ARP procedures based on extraction socket buccal bone morphology and integrity. Material and Methods: Three socket types (ST) are proposed and discussed based on buccal bone morphology (intact, dehiscence or fenestration). Results: A decision tree for ARP was developed in order to merge ST classification with suitable treatment modalities. In the decision tree, the issue of when to allow unassisted healing or ARP was discussed. Described methods included bone grafting and collagen plug, and absorbable membrane or non-resorbable membrane, with or without flap elevation. Conclusion: A decision tree for ARP procedures was provided to guide clinicians towards the most conservative and predictable treatment approach based on remaining socket anatomical structures after extraction.

Dimensional Changes in Free Epithelialized Gingival/Mucosal Grafts at Tooth and Implant Sites: A Prospective Cohort Study

BACKGROUND

A study was made of the dimensional changes in free epithelialized gingival/mucosal grafts (FEGs) used to augment keratinized tissue (KT) at tooth and implant sites, and of the confounders influencing the dynamic changes over 6 months of follow-up.

MATERIAL AND METHODS

A prospective cohort interventional study was made of implant and tooth sites needing keratinized tissue augmentation by means of an apically positioned flap and FEG. Six intraoperative variables were recorded at baseline (T0). In addition, graft width (GW), graft length (GL) and graft dimension (GD) were assessed at three weeks (T1), three months (T2) and 6 months of follow-up (T3). Univariate and multivariate analyses were performed to explore associations between the demographic and intraoperative variables and the outcomes over the study period.

RESULTS

Based upon an a priori power sample size calculation, a total of 56 consecutive patients were recruited, of which 52 were available for assessment. A total of 73 graft units were included in 122 sites. At T3, the mean change in GD in FEG was 40.21%. In particular, the mean changes in GL and GW were 12.13% and 33.06%, respectively. Statistically significant changes in GD were recorded from T0 to T1 (p<0.0005) and from T1 to T2 (p<0.0005), but not from T2 to T3 (p = 0.13). The change in GD at T3 was 33.26% at tooth and 43.11% at implant site level (p = 0.01). Age and GW assessed at T0 proved to be related to the changes in GD and GW in the univariate and multivariate analyses. The univariate analysis showed the avascular area (AA) to be related to the changes in GD and GW at the implant sites, while graft thickness (GT) was associated to changes in GD and GW at the tooth sites in the univariate and multivariate analyses.

CONCLUSIONS

Free epithelialized grafts are exposed to dimensional changes that result in a reduction of approximately 40% of the original graft dimension - the changes being approximately 10% greater at the implant sites than at the tooth sites (NCT04410614). This article is protected by copyright. All rights reserved.

Width and thickness of the gingiva in periodontally healthy individuals in a central Indian population: a cross-sectional study

OBJECTIVES

The present study was performed to determine the gingival dimensions (width and thickness) among young individuals in a central Indian population.

MATERIALS AND METHODS

Periodontal probing depth, width of the keratinized and attached gingiva, and gingival thickness were recorded on maxillary and mandibular teeth from central incisor to first molar unilaterally in 75 systemically healthy individuals (32 males and 43 females; 19-30 years of age). Comparisons were made gender-wise, arch-wise, tooth-wise, and site-wise using either the Student's t test or the ANOVA.

RESULTS

Keratinized and attached gingiva were wider in the maxilla than in the mandible both at proximal and at mid-buccal aspects (p < 0.001). At the tooth level also, gingiva was wider at the maxillary teeth than the corresponding mandibular teeth and at proximal aspects than at the mid-buccal aspect (p < 0.001). Regarding the thickness, gingiva was thicker among males, in the mandible, and at inter-proximal sites (p < 0.001). In either arch, maximum thickness was observed at the incisor region and least at the canine region.

CONCLUSIONS

Dimensions of the gingival tissues vary between different populations and between different areas of the dentition within the same subject. These variations need to be better understood because these aspects may have an important bearing on periodontal treatment planning as width and thickness of gingiva are important in terms of maintenance of periodontal health.

CLINICAL RELEVANCE

The dimensions of the clinically healthy gingiva are important in clinical practice as they can influence the progression of periodontal disease as well as impact the outcome of periodontal and restorative and orthodontic therapy.

The Effect of Three Surgical Therapies to Increase Keratinized Mucosa Surrounding Dental Implants with Peri-Implantitis: A Pilot Study

Background and Objectives: The purpose of this pilot study was to evaluate the clinical outcomes of three different methods for increasing the keratinized mucosa (KM) surrounding dental implants with peri-implantitis. Materials and methods: Twenty implant sites with peri-implantitis were divided into: (1) porcine collagen matrix (CM) group: seven implant sites; (2) apically positioned flap (APF) group: eight implant sites; and (3) free gingival graft (FGG) group: five implant sites. The KM width and clinical parameters (probing pocket depth (PPD) and bleeding on probing (BOP)) were measured at time points: before surgery (T0) and 30 (T1), 60 (T2), 90 (T3), and 180 (T4) days after surgery. Results: Regarding KM width, all the groups had significant differences for increasing horizontal and vertical KM width. The CM and FGG groups had greater KM than the APF group. There was a decrease in PPD in all three groups. APF and FGG showed significant differences in PPD at T1 and T2 compared to T0. Only the FGG group showed a significant difference in PPD at T3 and T4 compared with that at T0. BOP values were also reduced in all the groups at T1-T4 compared to T0. The APF and FGG groups showed a significant decrease in BOP. Conclusions: Three surgical therapies presented favorable results for increasing the KM surrounding implants. Compared with the FGG group, the CM showed similar results in increasing the KM around the dental implants with peri-implantitis.

Peri-Implant Mucosa Augmentation with an Acellular Collagen Matrix

Peri-implant keratinized mucosa (PI-KM) may support implant survival. Acellular collagen matrices (aCMs) have been widely used to facilitate soft tissue regeneration. The aim of this study was to investigate clinical outcomes obtained with the use of an aCM (mucoderm^®) to enhance PI-KM. In this retrospective non-randomized case series, 27 restored implants in 14 patients (eight males and six females, mean age = 56 years) with a PI-KM width ≤ 1 mm were followed for 6 months. It was demonstrated that aCM grafts augmented PI-KM effectively (mean increase of 5.4 mm; >533%) without a significant change in bleeding on probing (BOP) from baseline. The mean aCM shrinkage was 3.9 mm (42%). Gender, area, arch, and BOP did not influence PI-KM augmentation or aCM shrinkage significantly. The present results demonstrated that the examined aCM was effective and predictable for attaining a band of keratinized tissue, while avoiding graft donor site harversting.

The effect of soft tissue augmentation on the clinical and radiographical outcomes following immediate implant placement and provisionalization: a systematic review and meta-analysis

Background

Nowadays, due to the esthetic and social demands of patients, conventional staged protocols seem to be increasingly replaced by faster, one-step protocols. The purpose of the present systematic review is to assess the peri-implant soft tissue changes after immediate implant placement and provisionalization (IIPP) comparing patients treated with or without a sub-epithelial connective tissue graft (SCTG) when replacing a single tooth in the esthetic region.

Methods

The present systematic review was written following the PRISMA checklist. Immediate implants placed with a connective tissue graft and without one were compared. The researched primary outcomes were the mid-buccal mucosa level (MBML) facial soft tissue thickness (FSTT) and marginal bone loss (MBL). The weighted mean differences (WMD) were estimated for all three outcomes.

Results

The change in the mid-buccal mucosa level in the intervention group was significantly higher (WMD 0.54; 95% CI 0.33–0.75), with no indication of heterogeneity (I² = 16%). The facial soft tissue thickness increased significantly in the intervention group (WMD 0.79; 95% CI 0.37–1.22). The marginal bone loss was significantly higher in the control group (WMD 0.13; 95% CI 0.07–0.18), with no indication of heterogeneity (I² = 0%).

Conclusions

The results of the meta-analyses showed a statistically significant reduced change of the marginal bone loss and vestibular recession, as well as higher soft tissue thickness, when a graft was used. The included studies had a short observation time; therefore, studies with longer follow-ups are needed to confirm these findings.

A single application of chlorhexidine gel reduces gingival inflammation and interleukin 1-β following one-stage implant placement: A randomized controlled study

BACKGROUND

Chlorhexidine (CHX) is a broad-spectrum antimicrobial agent commonly used in medicine. Application of (CHX) during abutment connection reduced the bacterial load at the implant-abutment interface. We hypothesize this treatment may consequently reduce peri-implant soft tissue inflammation and marginal bone loss.

PURPOSE

To evaluate the effect of a single application of CHX gel inside the dental implant internal hexagon on peri-implant tissue.

METHODS

Forty patients were recruited to this randomized, double-blinded, clinical trial. At the time of implant installation, a 4-mm healing abutment was connected to the implant. In the test group, chlorhexidine gel 1% was applied inside the implant hex, whereas control implants did not receive any gel. Clinical and radiographic measurements included soft tissue recession (REC), plaque index (PI), gingival index (GI), plaque index (PI), keratinized mucosa width (KM), probing depth (PD), and a peri-apical parallel x-ray. Peri-implant crevicular fluid (PICF) was collected for cytokine analysis. t-Test was used to compare changes from baseline to 3 months. Mann-Whitney U test and t test were used to compare test and control groups.

RESULTS

Twenty patients in the test group and 17 in the control group completed the study. One implant in the control group failed to osteointegrate. There were no significant differences between the control and test groups for REC changes, bone loss, and PD. GI was significantly lower in the test group after 1 week (1.79 ± 0.24 vs 0.75 ± 0.18, respectively) and 3 months (1.18 ± 0.21 vs 0.25 ± 0.12, respectively) although PI was equal. At 3 months, interleukin 1-β (IL1-β) was higher in the control group (p < 0.01) and a positive correlation was found between GI and IL1-β (r_s  = 0.60424, p = 0.00032).

CONCLUSIONS

Application of chlorhexidine gel reduced inflammation and IL1-β levels in the peri-implant soft tissue.

Efficacy of free gingival graft in the augmentation of keratinized tissue around implants: A prospective clinical study

Background

Effectuating adequate width of keratinized tissue (WKT) can lead to a healthy and stable implant/soft tissue interface which is important for the long term success of the implant. The use of free gingival grafts (FGG) for widening the WKT around dental implants increases the amount of attached gingival tissue and prevents clinical attachment loss.

Aim

The aim of the study was to assess the ability of FGG to create a healthy implant/soft tissue interface.

Methods and Material

A total of 10 edentulous sites in 10 patients with inadequate keratinized tissue indicated for replacement of missing teeth were treated. An implant was placed in edentulous sites and the keratinized tissue was augmented using FGG at the second stage of implant surgery. WKT was recorded at baseline, 3rd month and 6th month post-operatively. Plaque index (PI), gingival index (GI), probing depth (PD) and papillary index (PPI) and were recorded at 3 and 6 months post-operatively to evaluate the health of peri-implant tissues. Paired t-test was used for standard deviation and the level of significance was taken as 5% (P < 0.05).

Results

The WKT at 3 (3.2±1.61mm) and 6 months (3±1.56 mm) compared to the baseline was statistically significant (P = 0.034). The other parameters PI, GI, PD, PPI showed no clinical significance from 3 and 6 months (P > 0.05).

Conclusions

Augmentation of FGG created a significant gain in the WKT which resulted in a healthy implant/soft tissue interface.

Histologic composition of marginal mucosal tissue augmented by a resorbable volume-stable collagen matrix in soft tissue thickening procedures in humans: a morphometric observational study

AIM

This study aims to examine the composition of lining and masticatory mucosa at the pre- and post-soft tissue augmentation procedures with a volume-stable cross-linking collagen matrix (VCMX) in humans.

MATERIALS AND METHODS

In 12 patients, single implant sites were augmented with a VCMX. Biopsies were obtained including masticatory (MM) and lining (LM) mucosa before augmentation and at 12 weeks post-augmentation procedures. Rete pegs density (RPD), length (RPL), and blood vessel density (BVD) were histomorphometrically analyzed at both time points. Picrosirius red staining under polarized light microscopy was used to evaluate collagen fiber organization. The effects of time and tissue type were evaluated by ANOVA with repeated measures.

RESULTS

Both MM and LM areas demonstrated an increase in mean RPL following augmentation, 382.6 µm ± 95.1 vs. 290.5 µm ± 79.3 and 335.6 µm ± 94.2 vs. 292.9 µm ± 77.0, respectively (p < .05). There was a significant difference in the numbers of RP per 1 mm length (RPD) between the MM (9.2 ± 1.7) and LM (6.1 ± 2.8) mucosa but not between the pre- and post-VCMX augmentation time points. The mean BVD in the LM was greater than in the MM (5.5 ± 2.4 and 6.3 ± 2.4 vs. 3.4 ± 3.3 and 3.7 ± 1.8, respectively, p < .05) but not between time points. The collagen fiber arrangements pre- and post-augmentation were not significantly different.

CONCLUSION

Augmentation with VCMX did not alter the composition of lining and masticatory mucosa at implant sites.

CLINICAL RELEVANCE

A thick soft tissue phenotype around the implant neck is an important factor to maintain peri-implant health. A non-autogenous cross-linking collagen matrix is proposed as an alternate graft substitute in soft tissue augmentation procedures in order to improve implant soft tissue phenotype.

Clinical evaluations of free gingival grafting before implant placement to increase keratinized tissue width in molar regions: A retrospective case series

OBJECTIVES

To evaluate the dimensional changes of the keratinized tissue width (KTW) in molar regions after augmentation by free gingival grafts (FGG) before implant placement.

MATERIAL AND METHODS

In seventeen patients, twenty implant sites in molar regions with KTW ≤3 mm at the buccal aspect received FGG 2 months before implant placement. KTW at the buccal aspect was measured before FGG (T0), immediately before implant placement (T1), at the time of impression taking for final prosthesis fabrication (T2), and at the end of the follow-up period after loading (T3, 12-48 months). Changes in KTW before and after FGG, as well as the alterations during the follow-up period after loading, were analyzed. Shapiro-Wilk test, paired Student's t test, and Wilcoxon signed-rank test were used for the data analysis at α = 0.05.

RESULTS

KTW at the buccal aspect of the alveolar ridge was observed with a significant gain of 5.9 ± 1.3 mm at T1 (p < .001). The shrinkage of KTW from T2 to T3 was 8.5%, which was limited but statistically significant (p = .008). KTW at the buccal aspect of implant restorations was 5.0 ± 1.5 mm at T3.

CONCLUSIONS

Within the limitations of the present study, our data suggest that using FGG to increase KTW in molar regions before implant placement had a predictable result. The buccal KTW had a limited reduction and was ≥3 mm with more than 12 months of follow-up after loading.

The peri-implant phenotype and implant esthetic complications. Contemporary overview

OBJECTIVE

To provide a contemporary and comprehensive overview of the hard and soft tissue biological structures surrounding an osseointegrated dental implant (peri-implant referred to as the peri-implant phenotype), in the context of peri-implant esthetic complications.

OVERVIEW

The individual components of the peri-implant phenotype (keratinized mucosa width, mucosal thickness, supracrestal tissue height, and the peri-implant buccal bone) have been linked to different aspects of implant esthetics, as well as health-related aspects. At the time of implant therapy, respecting the biology of the peri-implant hard and soft tissues, and anticipating their remodeling patterns can alleviate future esthetic complications.

CONCLUSIONS

While the current literature may not allow for a point-by-point evidence based-recommendation for the required amount of each peri-implant structure, bearing in mind the proposed values for the components of the peri-implant phenotype, at the time of and prior to implant therapy can lead to more predictable treatment outcomes, and the avoidance of esthetic complications.

CLINICAL SIGNIFICANCE

Knowledge of hard and soft tissue components surrounding and osseointegrated dental implant, and their underlying biological remodeling process is crucial for carrying out a successful therapy and alleviating possible future esthetic challenges.

Keratinized tissue gain after free gingival graft augmentation procedures around teeth and dental implants: A prospective observational study

AIM

The primary goal was to compare the amount of keratinized tissue width (KTW) gain after free gingival graft (FGG) procedures around implants and teeth after 6 and 12 months of healing.

MATERIALS AND METHODS

Patients with mucogingival defects (<2 mm of KT) around teeth and implants underwent a gingival augmentation procedure by means of a FGG. Clinical measurements were performed with an individual stent to determine keratinized tissue width (KTW), length (KTL), graft shrinkage (GS) and gingival margin position (GMP) at 2 weeks, 6 weeks, 3 months, 6 months and 12 months after surgery.

RESULTS

Twenty-nine patients (35 sites) participated in this prospective study. After surgery, KTW decreased and GS increased significantly in both treatment groups during the whole follow-up period, but the biggest changes were observed at 6 weeks. When comparing both treatment groups, implant sites showed significantly more reduction in KTW and more GS. Thus, at 12 months, KTW and GS reduced 2.03 ± 2.1 mm and 36.74 ± 38.2% in the teeth group and 2.91 ± 12.03 mm and 61.8 ± 36.25% around implants, respectively.

CONCLUSIONS

A significantly greater reduction in KTW and more GS might be expected at implant sites.

Peri-implant mucosal response to implant-supported overdentures: A systematic review and meta-analysis

OBJECTIVES

To systematically review and evaluate the effects of different types of attachments, implant numbers and loading protocols on the peri-implant mucosa of implant-supported overdentures (ISODs).

BACKGROUND

The impact of peri-implant tissue health on the ISOD treatment outcome is unclear, and current evidence is inadequate on this aspect.

MATERIALS AND METHODS

A systematic literature search for randomised controlled trials or prospective studies was conducted in indexed databases from 1995 to April 2020. The focused question was as follows: How does the peri-implant mucosa respond to implant-supported or implant-tissue-supported complete overdentures based on different types of attachments, implant numbers, and loading protocols, in terms of clinical outcomes achieved [plaque index (PI), gingival index (GI), probing pocket depth (PD) and bleeding index (BI)]? A random- or fixed-effects model was applied to measure the significance of standardised mean differences (SMD) of PD between the groups.

RESULTS

Seventeen studies met the eligibility criteria. The SMD for PD between splinted/bar and unsplinted/stud attachments was 0.10 mm (95% CI: -0.27 to 0.47; P = .60) and between 2- and 4-implant groups was 0.15 mm (95% CI: -0.16 to 0.45; P = .34), which were not statistically significant. Significant difference (P = .003) was observed between immediate/early loading and delayed loading (SMD = 0.46 mm [95% CI: 0.16 to 0.75]).

CONCLUSIONS

Probing depth for the immediate loaded implants was significantly higher than for the delayed loading group. No attachment type, implant number or loading protocol seemed to have a clear advantage over the other, in terms of other peri-implant mucosal outcome measures.

Therapy for peri-implantitis: Significant radiographic bone fill after keratinized mucosa augmentation surgery with supportive implant therapy (SIT): A novel approach

none.

Breaking the wave of peri-implantitis

Peri-implant diseases are prevalent with a weighted mean prevalence rate of 43% across Europe and 22% across South and North America. Although the main etiologic agent is bacterial biofilm, a myriad of factors influence the initiation and progression of the disease. Unfortunately, the treatment of peri-implant diseases is at best favorable in the short term with a high rate of persistent inflammation and recurrence. Therefore, it is sensible to consider and control all potential factors that may predispose an implant to peri-implant tissue inflammation in an attempt to avoid the disease. This paper reviews recent evidence on factors that may predispose implants to peri-implantitis and measures that can be taken to prevent it.

Changes in mucogingival junction after an apically positioned flap with collagen matrix at sites with or without previous guided bone regeneration: A prospective comparative cohort study

AIM

To assess changes in the position of the mucogingival junction (MGJ) after an apically positioned flap (APF) with collagen matrix performed at sites with or without previous guided bone regeneration (GBR).

MATERIALS AND METHODS

Dental implants were placed with or without GBR (group GBR or non-GBR) depending on the available ridge width in 30 patients with a limited width of keratinized mucosa (MGJ placed more coronally than the expected prosthetic margin). An apically positioned flap with collagen matrix was performed in both groups. Changes in the position of the MGJ from the day of an apically positioned flap up to 1, 3, and 12 months thereafter were assessed on digital scans (primary endpoint). Secondary endpoints were the width and thickness of the keratinized mucosa, and the position of the mucosal margin.

RESULTS

The position of the MGJ changed significantly from baseline to the first month, by 5.25 ± 2.10 and 4.40 ± 1.41 mm in groups GBR and non-GBR, respectively. Thereafter, the position remained stable in both groups up to 1 year (changes from baseline of 5.46 ± 2.28 and 4.58 ± 1.92 mm, respectively; p = .34). The position of the mucosal margin did not differ between groups GBR and non-GBR (-1.57 ± 2.04 and -1.75 ± 2.08 mm, respectively; p = .84), nor did the width of the keratinized mucosa (1.20 ± 1.03 and 0.99 ± 0.66 mm, p = .91) or its thickness (1.28 ± 0.44 and 1.40 ± 0.78 mm, p = .87).

CONCLUSION

Apically positioned flap combined with a collagen matrix results in a more apical position of the MGJ at sites with or without GBR. Following a coronal shift during the first month after the apical positioning of the flap, the level of the MGJ remained stable.

Evaluation of the effect of keratinized mucosa on peri-implant tissue health using a multivariate analysis

PURPOSE

This study investigated the relationship between peri-implant tissue health and the presence of keratinized mucosa (≥ 2 mm) using multivariate analysis.

METHODS

A total of 334 dental implants placed in 111 partially edentulous patients (34 males, 77 females) and restored with fixed prostheses were included in this study. The patients were recalled 12-146 months after completion of the prosthodontic treatment. Clinical parameters included modified plaque index (mPI), modified bleeding index (mBI), probing pocket depth (PPD), and radiographic bone loss (BL). The effects of the following potential explanatory variables on these parameters were analyzed: the presence of keratinized mucosa, age, sex, oral hygiene status, history of periodontitis, cigarette smoking, implant site, and time elapsed since prosthesis delivery. Statistical analysis included multivariate ordinal logistic regression and generalized estimating equations. Significance wa s established when two-sided p-values were less than 0.05.

RESULTS

The mPI, mBI, and PPD in the presence or absence of keratinized mucosa did not show statistically significant differences. However, the presence of keratinized mucosa was significantly related to BL (odds ratio 4.33, p < 0.01).

CONCLUSIONS

The results of our study suggest that the presence of keratinized mucosa is useful for reducing bone resorption and can help to maintain peri-implant tissue health.

Does timing of implant placement affect esthetic results in single-tooth implants? A cohort evaluation based on mPES

OBJECTIVE

This study sought to use the mPES to assess various maxillary implant surgical results and placement timing in the esthetic zone.

MATERIALS AND METHODS

This cohort study was conducted on 146 patients undergoing immediate, early, and late implantation. They received maxillary single-tooth implants in the anterior region during the past 5 years. Patients were clinically examined to determine their mPES and patient-/implant-related parameters. Simple and multiple nominal regression analyses were applied to show how such parameters correlated with mPES.

RESULTS

The results were found to be in three categories namely the most clinically excellent, acceptable, and unacceptable. Although the most frequent clinically excellent results were noted in the late implantation (late 49.0%, early 25.6%, immediate 24.1%); early implantation was the group with the least frequent clinically unacceptable results (late 16.3%, early 4.7%, immediate 14.8%). The mean width of keratinized tissue was significantly more in patients with clinically excellent results (P-value = 0.01).

CONCLUSION

Within the limitations of this study, the author(s) drew the following conclusions: (a) the late implant placement was more likely to be reliable and esthetically acceptable, (b) early implant placement remained the safest method to prevent unaesthetic appearance, and (c) Width of keratinized gingiva (≥3 mm) was a significant factor to achieve implant esthetic results.

CLINICAL SIGNIFICANCE

Maxillary single-tooth implants in the anterior region often have optimal osseointegration and functional performance, but esthetic plays a significant role in the success of these implants. So the aim of the present study was to employ mPES to assess the effect of placement timing and other patient and implant-related variables on esthetic outcomes.

Effect of Nicotine on the Thickness of Gingiva: A Pilot Study

Introduction:

Gingival thickness plays a very important role in framing the protocol in various dental treatments such as implantology, prosthodontics, and more importantly in periodontics. During periodontal management, it is important to consider the gingival thickness of the patient, which can result in more satisfactory treatment outcomes. Smoking has its effect on periodontium, affecting the physical and functional properties. Assessing the relation between these two entities is becoming important. This clinical study is sought to compare the thickness of gingiva in systemically healthy smokers and nonsmokers.

Materials and Methods:

A total of 180 periodontally healthy patients were divided into smokers and nonsmokers, and subdivided into Group 1 (18–25 years), Group 2 (26–39 years), and Group 3 (>40 years). Gingival thickness was assessed 6 mm from the gingival margin in the midbuccal area between maxillary central and lateral incisor. Statistical analysis was performed to assess the difference in gingival thickness among smokers and nonsmokers and correlated with age.

Results:

The results showed the presence of changes in gingival thickness for all the age groups. But, a significant P value was not obtained for the age groups 18–25 and 26–39 years. In >40 years of age group, there was a statistically significant change in the P value (0.008) of the mean and standard deviation in smokers and nonsmokers ( significance: P < 0.001).

Conclusion:

On the basis of the results of this study, gingival thickness was decreased with age among smokers and nonsmokers. This study also proved that smoking has a negative influence on the gingival thickness.

Thinned-out skin paddle versus collagen matrix as an optimized peri-implant soft tissue following fibula osteoseptocutaneous free flap: 3-year retrospective study

The objective of this study was to compare the implant longevity following two methods of peri-implant soft tissue optimization following free fibula flap (FFF): thinning of skin paddle (SP) and collagen matrix (CM). All patients who underwent rehabilitation with dental implants after mandibular reconstruction with FFF between June 2009 to May 2014 were retrospectively reviewed. Two methods of peri-implant soft tissue optimization were applied: (1) SP group, (2) CM group. Outcome measurements were: modified plaque index (mPI), modified sulcus bleeding index (mSBI), probing depth (PD), marginal bone loss (MBL), implant success rate and complication rates. A total of 24 patients with 69 implants were included in the study, with 8.7% (n = 6) of implants lost in 3 years. No statistically significant difference was found regarding the outcome measurements in both groups. Failed implants presented with statistically significant higher mPI, mSBI, PD and MBL scores during prosthesis delivery and subsequent follow-ups (P<0.03). In the SP group, one patient experienced SP necrosis which later underwent soft tissue optimization using CM. CM is an alternative peri-implant soft tissue, while thinning of SP is feasible if thickness is well controlled.

Comparison between two different techniques for peri-implant soft tissue augmentation: Porcine dermal matrix graft versus tenting screw

BACKGROUND

The thickness of the soft tissues around dental implants is crucial for both the preservation of the marginal bone and esthetic profile. Many authors have showed the thickened soft tissues favor a better peri-implant bone stability; however, different thickening techniques can be used for this aim.

METHODS

Forty-seven patients were enrolled in this study, each one had one implant included in this analysis. According to the thickening procedure, patients were assigned into group A (porcine dermal matrix, n = 24) or B (healing abutment used as tenting screw to sustain the soft tissues, n = 23), soft tissue thickness was measured after flap elevation in a standardized way. Six months after implant placement, implants were uncovered and soft tissue thickness measured again.

RESULTS

At second stage, 6 months after implant placement, the mean vertical thickness was 3.01 ± 0.58 mm in group A and 2.25 ± 0.53 mm in group B. The difference between the two groups at 6 months was significant (P < 0.001). The mean vertical gain in group A was 1.33 ± 0.71 mm, whereas it was 0.43 ± 0.55 mm in group B. This difference was also statistically significant (P < 0.001).

CONCLUSION

The use of a healing abutment for "tenting effect" has limited efficacy to obtain a significant increase in soft tissue thickness. The use of a porcine dermal matrix at time of implant placement is effective to thicken peri-implant tissues.

The lack of keratinized mucosa is associated with poor peri-implant tissue health: a cross-sectional study

OBJECTIVES

The aim of this cross-sectional study is to determine the association between the absence of keratinized mucosa and peri-implant tissue health.

METHODS AND MATERIALS

This cross-sectional study comprised 412 implants from 200 patients from faculty-based clinics. Demographic, medical, and clinical information were collected. The modified sulcus bleeding index, modified plaque index, mucosal recession, probing depth, bone level, the width of keratinized mucosa, and implant status were evaluated by three calibrated examiners. Each implant was categorized into either of two peri-implant mucosa groups: keratinized mucosa (KM) or non-keratinized mucosa (NKM). The chi-square test was performed to the association between the keratinized mucosa groups and peri-implant clinical parameters and peri-implant status. Multiple logistic regression models were analyzed to test potential associations between peri-implant clinical parameters and the presence or absence of keratinized mucosa.

RESULTS

Thirty-two implants (7.8%) were categorized into the NKM group. The prevalence of peri-implantitis was 12.5% and 8.3% at the subject level and implant level, respectively. The NKM group was associated with more plaque accumulation, mucosal recession, interproximal bone level ≥ 3 mm, and peri-implantitis (p < 0.05). After controlling for confounding factors, the NKM group demonstrated higher plaque accumulation, mucosal recession, and interproximal bone level ≥ 3 mm with adjusted odds ratios of 2.98 (1.33-6.66), 3.20 (95% CI, 1.03-9.90), and 4.62 (1.70-12.58), respectively.

CONCLUSION

Within the limitation of this study, the lack of keratinized mucosa around the dental implants was significantly associated with more plaque accumulation, mucosal recession, interproximal bone level ≥ 3 mm, and peri-implantitis.

The effect of keratinized mucosa on the severity of peri-implant mucositis differs between periodontally healthy subjects and the general population: a cross-sectional study

Objective

The study aims to investigate the effect of reduced keratinized mucosa (KM) and other risk indicators on the severity of peri-implant mucositis in (i) the general population, (ii) in periodontally healthy patients, and (iii) in periodontally healthy patients without a history of periodontitis.

Materials and methods

Anamnesis and the following clinical parameters were taken: mucosal-index, bleeding on probing, local plaque index, oral hygiene-index, and width of KM. Mucositis severity score was determined for each implant. Multi-level and subgroup analysis was performed on the patient and implant level.

Results

Six hundred twelve implants in 130 patients were analyzed. Subgroup analysis showed significant associations between KM < 2 mm and the severity score in (ii) periodontally healthy patients (p = 0.014) and in (iii) patients without history of periodontitis (p = 0.017). Secondary outcome showed higher severity scores for patients with insufficient oral hygiene or without residual teeth (p ≤ 0.001), in maxillary implants (p = 0.04), and for the number of implants per patient (p ≤ 0.001).

Conclusion

Within the limits of the study, one may conclude that a reduced width of KM is a risk indicator for the severity of peri-implant mucositis in periodontally healthy patients and patients without a history of periodontitis.

Clinical relevance

The results indicate a band of ≥ 2 mm KM to reduce the severity of peri-implant mucositis in periodontally healthy patients.

Alveolar ridge dimensional changes after two socket sealing techniques. A pilot randomized clinical trial

OBJECTIVES

This pilot study aimed to assess dimensional changes following two different alveolar socket sealing techniques.

MATERIAL AND METHODS

Twenty-one patients requiring tooth extraction and implant placement were randomly allocated to two different alveolar ridge preservation techniques. In the control group, demineralized bovine bone mineral (DBBM) and a gingival soft tissue punch were used to fill and seal the socket, whereas in the test group, the extraction socket was filled with DBBM and sealed with a hemostatic gelatin sponge. Digitalized impressions were taken before and 6 months after tooth extraction. The comparison was made on horizontal and vertical dimensional changes.

RESULTS

The mean vertical loss was 0.8 ± 0.6 mm for the control group and 0.7 ± 0.5 mm for the test one. No statistical difference was found between groups for the vertical shrinkage. The horizontal dimensional narrowing of the alveolar socket was respectively 7.1/4.0/2.5 mm at levels 1, 3, and 5 mm from a coronal reference level for the control group. The test group showed dimensional changes of 4.8/2.3/1.3 mm at the three different levels, respectively. A significant difference was found at levels 3 and 5 mm. Referring to a visual analog pain scale, patients reported more severe pain in the control group (5.7/10) when compared with the test group (2.8/10). The difference was statistically highly significant (P ≤ 0.001).

CONCLUSIONS

A significant difference was found between control and test groups regarding the horizontal dimensional changes and the post-operative pain.

CLINICAL RELEVANCE

Regarding this primary result, the socket sealing technique with a hemostatic sponge provides an effective and inexpensive protocol with less post-operative pain.

[Progress on clinical application of orthodontic-implant combined therapy]

For complex implant cases, simple implantation could not achieve the desired therapeutic effect, and a multidisciplinary approach has become a general trend. Orthodontic treatment before implantation creates favorable conditions for subsequent implantation by increasing restoring three-dimensional space, improving occlusion of patients. It also stimulates the increase of autologous soft and hard tissue while biological potential of periodontal ligament is fully developed. The choice of operation time is vital to keep the level of soft and hard tissue at the implantation site, which improves the curative effect of implantation in terms of function and aesthetics. In this article, the orthodontic-implant combined therapy is briefly reviewed focusing on the three-dimensional space optimization, implant site enhancement by orthodontic extrusion and delayed orthodontic space opening.

The width of keratinized mucosa around dental implants and its influencing factors

BACKGROUND

A few evidence is available in the literature concerning the pattern of variation in the width of keratinized mucosa (KMW) around dental implants and factors that may affect the KMW.

PURPOSE

The purpose of this study is to investigate the KMW at the buccal aspect of dental implants and to analyze its influencing factors.

MATERIALS AND METHODS

The current study was a retrospective study conducted on 726 patients with 1252 dental implants. The following parameters were evaluated by reviewing the medical records of each patient, including the age, gender and smoking status of each patient, the reasons of teeth loss, the position of implants, the bone augmentation procedures, and the KMW. Binary logistic regression analysis with the generalized estimating equations was utilized to analyze the factors that may affect the KMW of dental implants.

RESULTS

The KMW of implants located in the maxilla was significantly higher than that of implants located in the mandible (P < .01), except for the upper and lower canines. The logistic regression analysis indicated that the risk of the implants presenting inadequate KMW (<2 mm) in the periodontitis-caused tooth loss group was 1.91 times of the non-periodontitis-caused tooth loss group. The risk of implants presenting inadequate KMW after receiving simple and complex bone augmentation procedures was 1.65 and 2.62 times of the risk of implants without bone augmentation, respectively. The longer the follow-up period, the higher the risk of implants presenting inadequate KMW will be.

CONCLUSIONS

The KMW at the buccal aspect of implants is related to the position of implants. Tooth loss due to periodontitis, the bone augmentation procedures, and the process of functional period would increase the risk of implants presenting an inadequate amount of keratinized mucosa.

A new technique for peri-implant recession treatment: Partially epithelialized connective tissue grafts. Description of the technique and preliminary results of a case series

BACKGROUND

Data on implant recession coverage (RC) are very scarce.

PURPOSE

To present a new surgical approach and preliminary results for the treatment of peri-implant soft tissue recession via partially epithelialized connective tissue grafts (PECTGs).

MATERIALS AND METHODS

We harvested PECTGs from the palate using a double-blade scalpel. All donor sites were sutured and covered with a stent. Dissection lines were placed minimally coronal to the mucogingival border. The recipient areas were prepared epiperiostally. All PECTGs were sutured with the keratinized mucosa (KM) portion toward the local KM tissue and were subsequently widely covered by the local mucosal tissue layer.

RESULTS

Fifteen patients with 22 implants were available for follow-up. The recession depth at baseline was 2.4 ± 1.1 mm (median: 2.5). After a mean observational period of 5 years, we found a mean recession value of 0.4 ± 0.5 mm (median: 0). We found a mean increase in the peri-implant KM width of 2.2 ± 1.1 mm (median: 1.5). In all cases, progression of the recession had stopped. None of the grafts was lost. The mean RC was 2 ± 0.9 mm (median: 1.5 mm) [88 ± 20% (median: 100)]. Complete RC was found in 64% of the implants. The results have remained stable for up to 13 years.

CONCLUSION

Soft tissue recession around dental implants may successfully be treated using the PECTG technique.