Effect of connective tissue grafting on buccal bone changes based on cone beam computed tomography scans in the esthetic zone of single immediate implants: A 1-year randomized controlled trial

Hard and soft tissue alterations after the application of different soft tissue grafting materials during immediate dental implant placement: a systematic review and Bayesian network meta-analysis

BACKGROUND

The aim of this review is to compare the clinical outcomes of different soft tissue grafting materials (connective tissue graft (CTG), platelet-rich fibrin (L-PRF), allogenic and xenogenic substitutes) applied in immediate implant placement with each other.

METHODS

Through an electronic search regarding the study's main question ("In patients with non-restorable teeth, who receive immediate dental implants (P), what is the best adjunctive soft tissue grafting approach among different autogenous, allogenous, and xenogenous grafts (I), to achieve the desired hard and soft tissue structure (O), compared to sites without grafting (C)?") in PubMed, Scopus, and ISI Web of Science, randomized controlled clinical trials (RCTs) using different soft tissue grafts were identified and analyzed using a Bayesian random-effect network meta-analysis framework. The pink esthetic score (PES), marginal interproximal bone level changes (MIBL), buccal bone thickness changes (BBT), keratinized tissue width changes (KTW), soft tissue thickness changes (STT), papilla height changes (PH), midfacial gingival margin level changes (MGML) were defined as desired outcomes of the study; except for the MIBL with 12 - 24 months of follow-up, 6 - 12 months is considered for other outcomes.

RESULTS

After duplication removal, 903 studies were identified through the electronic search; from which 21 RCTs were included in the review. Among all comparisons in different outcomes, only CTG demonstrated a significantly higher gain in STT compared to not placing soft tissue graft. However, CTG in MIBL, KTW, STT, PH, and MGML, and uni-layer xenogenic collagen matrix in PES were the superior treatments, according to the treatment ranking based on surface under cumulative ranking (SUCRA).

CONCLUSIONS

At the time of immediate implantation, there is no significant difference between different soft tissue grafts regarding the clinical outcomes of implants. However, the utilization of CTG can be suggested in cases with thin soft tissue. The acceptable efficacy of allogenic and xenogenic materials and the non-significant difference between them and CTG indicate supporting evidence for the application of these materials to specific clinical situations simultaneously with immediate implantation.

SYSTEMATIC REVIEW REGISTRATION

CRD42024568586.

Effect of different wound closure interventions on the clinical outcomes following immediate implant placement in the aesthetic area: A network meta-analysis based on thirty-four studies

OBJECTIVE

The purpose of this study was to systematically compare and assess the effect of various wound closure interventions on the clinical outcomes following immediate implant placement (IIP) in the esthetic zone.

DATA

Studies comparing the clinical effect of different interventions in the process of wound closure in IIP were included.

SOURCES

A systematic search was conducted in PubMed, EMBASE, Cochrane Library, Web of science, China National Knowledge Infrastructure (CNKI), Chinese Science and Technology Periodical Database (VIP), and Wanfang Database.

STUDY SELECTION

A total of 34 studies involving 1213 implants and eight interventions were included in the network meta-analysis (NMA). The agreement between reviewers reached a kappa value of 0.84. In terms of reducing marginal peri-implant recession (MPR), as the primary outcome, NMA showed that connective tissue graft (CTG) [MD = -0.44, 95 % CI (-0.56, -0.33)], collagen matrix (CM) [MD = -0.32, 95 % CI (-0.46, -0.17)] and CGF [MD = -0.11, 95 %CI (-0.16, -0.06)] showed significant less MPR than the control group, and CTG [MD = -0.33, 95 %CI (-0.46, -0.20)] and CM [MD = -0.20, 95 %CI (-0.36, -0.05)] were also associated with less MPR compared to concentrate growth factor (CGF). The optimal intervention to prevent MPR was CTG. Among the secondary outcomes, CTG was determined as the optimal intervention to increase gingival thickness (GT), CGF ranked as the promising intervention to reduce marginal bone loss (MBL) and improve pink aesthetic score (PES).

CONCLUSION

The use of CTF could enhance soft tissue stability by minimizing MPR and increasing GT in the process of wound closure in IIP, and CGF could better prevent MBL and improving PES. However, the findings related to CGF were based on a limited number of studies.

CLINICAL SIGNIFICANCE

CTG and CGF ought to be worthy of clinical promotion to intervene wound closure of IIP in esthetic area, with the ability of improving the peri-implant soft and hard tissues. However, clinicians should still consider the specific clinical situation when selecting the most appropriate intervention or alternative materials.

Immediate Implant Placement with Soft Tissue Augmentation Using Acellular Dermal Matrix Versus Connective Tissue Graft: A Systematic Review and Meta-Analysis

This systematic review investigates the efficacy of using connective tissue grafting (CTG) versus an acellular dermal matrix (ADM) for soft tissue management in immediate implant placement (IIP). The study focuses on comparing the soft tissue thickness (STT) and keratinized tissue width (KTW) changes post-implantation. Adhering to the PRISMA guidelines, a comprehensive literature search was conducted, targeting randomized clinical trials and cohort studies involving soft tissue grafting in conjunction with IIP. Data extraction and analysis focused on STT and KTW measurements from baseline to follow-up intervals of at least 6 months. The statistical analyses included the weighted mean differences and heterogeneity assessments among the studies. The meta-analysis revealed no significant difference in the STT gain between CTG and ADM at 12 months, with the weighted mean differences favoring the control group but lacking statistical significance (CTG: 0.46 ± 0.53 mm, p = 0.338; ADM: 0.33 ± 0.44 mm, p = 0.459). The heterogeneity was high among the studies, with discrepancies notably influenced by individual study variations. Similarly, the changes in KTW were not significantly different between the two grafting materials. Conclusions: Both CTG and ADM are viable options for soft tissue management in IIP, with no significant difference in efficacy regarding the soft tissue thickness and keratinized tissue width outcomes. Future research should aim to minimize the heterogeneity and explore the long-term effects to better inform clinical decisions.

Effect of soft tissue volume on midfacial gingival margin alterations following immediate implant placement in the esthetic zone: a 1-year randomized clinical and volumetric trial

BACKGROUND

The current trial evaluated the midfacial gingival margin changes, volumetric, radiographic and clinical alterations 1-year following immediate implant placement with customized healing abutment (IIP + CHA) either solely, or in combination with xenograft (IIP + Bonegraft) or with connective tissue grafting (IIP + CTG) at sites with thin labial bone in the esthetic zone.

METHODS

Thirty-nine non-restorable maxillary teeth indicated for extraction in the esthetic zone were included. Participants were randomly assigned into three equal group; IIP + Bonegraft (Control), IIP + CTG and IIP + CHA. Midfacial gingival margin changes(mm) as primary outcome, labial soft tissue contour change(mm), interdental tissue height changes and total volume(mm3) were assessed. Amount of bone labial to the implant and crestal bone level changes were also recorded. All outcomes were measured 1-year post-operative.

RESULTS

The midfacial gingival margin changes demonstrated a significant difference (P ≤ 0.05) between the groups showing -0.98, -0.74 and -1.54 mm in sites treated with IIP + Bone graft, IIP + CTG and IIP + CHA respectively after1-year. While labial soft tissue contour change (mm), total volume (mm3) and distal interdental tissue height changes (mm) revealed a significant difference after one-year between the studied groups, yet mesial interdental tissue height changes showed no difference (P > 0.05). Both IIP + Bone graft and IIP + CHA groups revealed a significant positive correlation between the total volume loss (mm3) after 1 year and mid-facial gingival margin changes (P ≤ 0.05). However, no significant correlation was observed in the IIP + CTG group (P = 0.63). CBCT measurements showed a significant difference in crestal bone changes between the three groups (P ≤ 0.05), yet, there was no significant difference regarding mean amount of bone labial to the implant(P > 0.05).

CONCLUSIONS

This investigation suggests that the mere presence of CTG simultaneous with IIP in the anterior maxilla reduced the midfacial gingival margin alterations (mm), besides, CTG decreased the overall volume loss (mm3) by 5-folds compared to the other studied groups after one year. Meanwhile, using CHA alone with IIP failed to maintain the peri-implant soft tissues contour.

TRIAL REGISTRATION

The current trial was retrospectively registered at Clinical trials.gov (ID: NCT05975515, Date: 27-July-2023).

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.

Association of Connective Tissue Grafts in Immediate Implants: Systematic Review and Meta-Analysis

BACKGROUND

The increase in soft tissue (ST) around implants can benefit peri-implant health and aesthetic results. The objective was to compare the gingival and esthetic health benefits of immediate implant placement (IIP) with simultaneous or delayed connective tissue graft (CTG) compared to IIP without CTG.

METHODS

A systematic review was carried out by two reviewers in Medline-Pubmed, Scopus, and Cochrane. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were considered. Randomized Clinical Trials (RCTs) that were published between April 2017 and February 2024 were used. Studies that analyzed the performance of a simultaneous or deferred CTG after the placement of an implant in the aesthetic zone, with or without immediate provisionalization, without previous regeneration, with a follow-up of 6 months, and that were performed in humans were included.

RESULTS

Quantitative analysis was performed using data provided by the RCTs. The five RCTs that were selected analyzed a total "n" of 245 subjects who met the inclusion criteria and focused on the subject of the study. In the quantitative analysis, four RCTs were included. The studies evaluated buccal gingiva levels when placing the IIP with and without CTG, obtaining a mean buccal gingiva level difference of 0.09 mm (95% CI: -0.54 to 0.72, p = 0.05), statistically not significant, but with a favorable trend.

CONCLUSIONS

The use of CTG associated with the II can maintain the gum level but not increase the volume. CTG is favorable for achieving successful esthetic results when immediate placement of an implant with a provisional prosthesis is planned.

Integrated correlation analysis of the thickness of buccal bone and gingiva of maxillary incisors

OBJECTIVE

This study aimed to validate the integrated correlation between the buccal bone and gingival thickness of the anterior maxilla, and to gain insight into the reference plane selection when measuring these two tissues before treatment with implants.

METHODOLOGY

Cone beam computed tomography (CBCT) and model scans of 350 human subjects were registered in the coDiagnostiX software to obtain sagittal maxillary incisor sections. The buccal bone thickness was measured at the coronal (2, 4, and 6 mm apical to the cementoenamel junction [CEJ]) and apical (0, 2, and 4 mm coronal to the apex plane) regions. The buccal gingival thickness was measured at the supra-CEJ (0, 1mm coronal to the CEJ) and sub-CEJ regions (1, 2, 4, and 6 mm apical to the CEJ). Canonical correlation analysis was performed for intergroup correlation analysis and investigation of key parameters.

RESULTS

The mean thicknesses of the buccal bone and gingiva at different levels were 0.64~1.88 mm and 0.66~1.37 mm, respectively. There was a strong intergroup canonical correlation between the thickness of the buccal bone and that of the gingiva (r=0.837). The thickness of the buccal bone and gingiva at 2 mm apical to the CEJ are the most important indices with the highest canonical correlation coefficient and loadings. The most and least prevalent subgroups were the thin bone and thick gingiva group (accounting for 47.6%) and the thick bone and thick gingiva group (accounting for 8.6%).

CONCLUSION

Within the limitations of this retrospective study, the thickness of the buccal bone is significantly correlated with that of the buccal gingiva, and the 2 mm region apical to the CEJ is a vital plane for quantifying the thickness of these two tissues.

Influence of connective tissue grafts on implants in the aesthetic area: A systematic review. Are connective grafts essential?

Background

Achieving adequate aesthetics with implants in the anterior sector continues to be a challenge. One of the most studied and currently used techniques is the use of autologous connective tissue grafts to improve the peri-implant soft tissues in this area. Our objective is to analyze whether these techniques have a predictable impact on the tissues and aesthetics; and if it is worth performing them.

Material and Methods

A bibliographic search was carried out, including different digital portals.

Results

A total of 8 articles were analyzed. This procedure did not have an impact on the hard tissue but did have an impact on gingival recessions and soft tissue thickness. Regarding aesthetics, the results are controversial. It seems that they can slightly improve the PES (Pink Esthetic Score or Pink Index). Also, a negative impact on the texture of the soft tissue has been found.

Conclusions

It is necessary to individualize each case (especially depending on the gingival biotype) since taking a connective tissue graft from the palate entails discomfort for the patient, and this technique is not free of complications. Key words:Dental implants, aesthetics, connective graft.

Evaluation of buccal bone resorption in immediate implant placement in thin versus thick buccal bone plates: An 18-month follow-up prospective cohort study

OBJECTIVES

The current guidelines recommend that immediate implants be placed in patients with thick (>1 mm) buccal bone due to the inevitable tissue remodeling that follows tooth extraction. The aim of the current study was to investigate the effect of buccal bone thickness on bone resorption in immediate implant placement and compare two measuring techniques of the aforementioned resorption.

MATERIALS

The present study was designed as a prospective nonrandomized, controlled clinical trial. A total of 30 implants were split between the two study arms, thin buccal bone and thick buccal bone. The primary outcome was to assess vertical bone changes radiographically by cone beam scans preoperatively, at 2 months and 18 months after implant placement in patients with thin and thick buccal plate. Secondary outcomes included the change in the thickness of the buccal bony plate, marginal bone loss, and pink esthetic score.

RESULTS

Only 26 implants were statistically analyzed as one early failure was observed in each group. Furthermore, 2 patients of the thick group withdrew from the study. Cone beam computed tomography measurements revealed that at 2 months the vertical bone loss was 1.09 for the thin group and 0.85 for the thick group. The buccal bone plate resorption of the thin group was 0.39 mm while it was 0.52 mm for the thick group. The buccal bone plate was 1.25 mm in the thin group and 1.88 mm in the thick group. The PES did not show any significant difference with very good esthetic results.

CONCLUSION

Within the limitations of the current study, the amount of buccal bone plate resorption and the subsequent thickness obtained after implantation in both groups suggest successful long-term results. The two measuring techniques have proven to be comparable and reliable in the measurement of buccal bony plate changes. https://classic.

CLINICALTRIALS

gov/ct2/results?cond=&term=NCT04731545&cntry=EG&state=&city=&dist=.

The influence of connective tissue grafting on the reconstruction of a missing facial bone wall using immediate implant placement and simultaneous bone reconstruction: a retrospective long-term cohort study

PURPOSE

This retrospective cohort study evaluates the influence of connective tissue grafts (CTG) on bone regeneration at implant sites with total loss of the buccal bone wall treated with flapless immediate implant placement (IIP) and reconstruction with autogenous bone chips (AB) within a follow-up of up to 13 years.

METHODS

Sixty implants were inserted in 55 patients in sites with total loss of the buccal bone wall between 2008 and 2021. The implants were inserted and the buccal gaps were grafted by AB. A subgroup of 34 sites was grafted additionally with CTG using tunnel technique. Primary outcome was the vertical bone regeneration in height and thickness. Secondary outcome parameters were interproximal marginal bone level, recession, soft tissue esthetics (PES), width of keratinized mucosa (KMW) and probing depths (PPD).

RESULTS

Mean follow-up period was 60.8 months. In 55 sites a complete vertical bone regeneration was documented. The mean buccal bone level increased by 10.6 mm significantly. The thickness of the buccal bone wall ranged between 1.7 and 1.9 mm, and was significantly thicker in sites without CTG. Interproximal marginal bone level was at implant shoulder level. The mean recession improved significantly by 1.2 mm. In sites with CTG, recessions and PES improved significantly more.

CONCLUSIONS

Additional CTG in extraction sites with total buccal bone loss followed by IIP with simultaneous AB grafting led to improved PES and recession, but also to a thinner buccal bone wall compared to sites grafted just with AB.

Single immediate implant placement in the maxillary aesthetic zone with and without connective tissue grafting: Results of a 5-year randomized controlled trial

AIM

To assess the 5-year effects of grafting connective tissue while undertaking single immediate implant placement and provisionalization at the mid-buccal mucosa level (MBML). Secondary outcomes were buccal bone wall thickness (BBT), marginal bone level (MBL) and patient satisfaction.

MATERIALS AND METHODS

Sixty patients with a single failing tooth in the maxillary anterior region were provided with an immediately placed and provisionalized implant. At implant placement, the patients randomly received either a connective tissue graft from the maxillary tuberosity (n = 30, test group) or no graft (n = 30, control group). The alveolar socket classification was mainly Type 2A. Data were collected before removing the failing tooth (T0 ), and at 1 (T1 ), 12 (T12 ) and 60 (T60 ) months after final crown placement. The primary outcome was the change in MBML compared with the pre-operative situation. Additionally, the change in BBT, MBL, aesthetics (using the Pink Aesthetic Score-White Aesthetic Score), soft-tissue peri-implant parameters and patient satisfaction were assessed.

RESULTS

At the 5-year follow-up, 27 patients could be analysed from each group. In each group, one implant was lost during the osseointegration period, within 3 months of placement, resulting in an implant survival rate of 96.7% in both groups. MBML change at T60 was -0.6 (-1.1 to -0.1) mm in the control group and 0.1 (-0.4 to 0.5) mm in the test group (p = .008). BBT and MBL, aesthetics, soft-tissue peri-implant parameters and patient satisfaction showed stable results and satisfied patients, without clinically relevant differences between the groups.

CONCLUSIONS

This 5-year follow-up study shows that grafting connective tissue when replacing a single failing tooth with immediately placed and provisionalized implant results in favourable peri-implant tissues and fewer MBML changes.

Two adjacent implant-supported restorations in the aesthetic region: A 10-year prospective case series

INTRODUCTION

The treatment outcome of two adjacent implant-supported restorations in the maxillary aesthetic region was assessed regarding peri-implant soft and hard tissues, and satisfaction during a 10-year follow-up period.

METHODS

Twenty patients missing two adjacent teeth in the maxillary aesthetic region and treated with two implant-supported restorations were followed prospectively. The patients' clinical and radiographic parameters, as well as their satisfaction, were scored for a 10-year follow-up period.

RESULTS

Seventeen patients' data were available for the 10-year follow-up. The survival rate of the implants and restorations was 100%. The 10-year mean peri-implant bone change at the side facing the adjacent tooth was +0.11 ± 0.57 mm and at the side facing the adjacent implant was -0.08 ± 0.50 mm. The peri-implant soft tissues were healthy and the patients' satisfaction was high, but the papilla-index showed compromised inter-implant papillae and low Pink Esthetic Scores. These figures were of the same magnitude at all time points.

CONCLUSION

While it is difficult to obtain sufficient inter-implant papillae and satisfactory Pink Esthetic Scores, the initial treatment results remained stable and the patients were satisfied with the final result throughout the 10-year follow-up period.

Long-term evaluation of combined prosthetic-surgical approach and soft tissue augmentation in the esthetic zone

Background

There is no standard protocol for immediate implant placement and subsequent loading in the smile zone. We aimed to evaluate the long-term outcomes of simultaneous implant placement, soft tissue grafting, and immediate prosthetic loading in the esthetic zone.

Methods

Thirty-five implants were placed in the maxillary aesthetic zone. Twenty-two patients were evaluated using the Pink Esthetic Score (PES) and White Esthetic Score (WES). Also, the degree of peri-implant bone resorption and patient survey were applied for the esthetic and functional outcomes.

Results

The esthetic and harmonizing outcomes were achieved according to the mean total PES/WES value (17.9±2.0). The mean overall PES was 8.5±1.66. The papilla level had the highest mean score (1.8±0.36). Furthermore, the combination of root convexity/color and soft tissue color and texture was one of the key values in evaluating the effectiveness of this method (the mean value was 1.5±0.5). The mesial and distal papillae were 1.6±0.5 and 1.8±0.4, respectively. None of the 35 implants reached below 6 points (which is considered an esthetically unsatisfactory result). The mean WES score was 9.5±0.57. The average degree of total peri-implant bone resorption was 1.05±0.3 mm after 12 months. According to the questionnaire, all the patients smiled without hesitation and were satisfied with the treatment (100%).

Conclusion

This study showed that restoring one or more teeth in the smile zone using the concept of one-stage implant placement, soft tissue flap augmentation, and loading with provisional crowns was an esthetically successful and predictable method.

Dental Restorations

Fulfilling a patient's request for a healthy, functional and esthetic smile represents a daily challenge for dental practitioners [...].

Clinical efficacy of soft-tissue augmentation on tissue preservation at immediate implant sites: A randomized controlled trial

AIM

This randomized controlled trial aimed to investigate the efficacy of soft-tissue augmentation (STA) with a subepithelial connective tissue graft (SCTG) or an acellular dermal matrix (ADM) on reducing tissue alterations at an immediate implant site.

MATERIALS AND METHODS

This trial had three groups: (i) immediate implant with SCTG (ICT group); (ii) immediate implant with ADM (IAD group); (iii) immediate implant without STA (control group). Forty-six patients were randomly assigned to each group. Implants were placed at the maxillary anterior or premolar areas and restored after the 6-month visit. Clinical outcomes, including buccal soft-tissue contour, peri-implant mucosal level, soft-tissue thickness and keratinized tissue width, were measured at baseline and at 3-, 6- and 12-month follow-up visits. Radiographic bone levels were measured at baseline and at 6- and 12-month follow-up visits. Patient-reported outcomes were also collected.

RESULTS

STA procedures increased peri-implant mucosal thickness and maintained buccal soft-tissue contours. Compared to the control group, STA groups did not prevent peri-implant mucosal recession or interproximal bone resorption. Generally, no significant differences in clinical outcomes were detected between the ICT and IAD groups. Most patients were highly satisfied with the immediate implant procedure and outcomes without significant differences between groups.

CONCLUSIONS

STA at immediate implant sites enhanced soft-tissue thickness and maintained soft-tissue contours but did not prevent peri-implant mucosal recession or interproximal bone resorption. Long-term follow-up should be performed since these results were reported for only up to 1 year.

Buccal bone thickness and mid-facial soft tissue recession after various surgical approaches for immediate implant placement: A systematic review and network meta-analysis of controlled trials

AIM

To evaluate the relative efficacy and confidence in the precision of the results of different surgical interventions for immediate implant placement in the anterior area.

MATERIALS AND METHODS

Electronic searches were performed in PubMed, Embase, and Cochrane CENTRAL. Randomized controlled trials comparing different surgical techniques in anterior jaws for type 1 implant placement were included. Outcome measures included implant survival (primary outcome), buccal bone thickness (BBT) reduction, and mid-facial soft tissue recession (MSTR). Risks of bias assessment, network meta-analysis (NMA), sensitivity analysis, and quality-of-evidence assessment were performed.

RESULTS

Twenty-two studies reporting on 948 subjects and 5 surgical interventions were included. Fourteen early failures were reported. Compared with open-flap surgery without tissue augmentation (F-N) and looking at BBT preservation, NMA showed that there was moderate confidence that flapless surgery with hard tissue augmentation (FL-HTA) was better than flapless surgery without tissue augmentation (FL-N) or open-flap surgery with hard tissue augmentation (F-HTA) (mean difference -0.8 mm, 95% confidence interval: -1.1 to -0.5 mm; -0.6 mm, -0.9 to -0.4 mm; and -0.5 mm, -0.7 to -0.3 mm, respectively). There was moderate confidence that flapless surgery with hard and soft tissue augmentation (FL-HTA&STA) could significantly prevent MSTR compared with FL-HTA (-0.5 mm, -0.7 to -0.3 mm) and FL-N (-0.6 mm, -1.2 to -0.04 mm). However, there was no significant additional benefit in BBT with the FL-HTA&STA approach compared to the FL-HTA approach (-0.30 mm, -0.81 to 0.21 mm).

CONCLUSIONS

For immediate implant placement in the anterior areas, the FL-HTA approach better preserves BBT (moderate confidence); adding STA improves the stability of the mid-facial soft tissue level (moderate confidence) but at the expense of BBT (low confidence).

Alveolar bone remodeling in virtually planned, bone-grafted vs non-grafted guided flapless implant surgery in the anterior maxilla: a cross-sectional retrospective follow-up study

PURPOSE

In patients who underwent virtual planning and guided flapless implant surgery for teeth missing in the anterior maxilla, we compared buccal bone loss between those treated with and without autogenous bone augmentation.

METHODS

Of 22 patients with teeth missing because of trauma or aplasia, 10 (18 implant sites) were reconstructed with buccally placed bone graft harvested from the mandibular ramus, and 12 were non-reconstructed (16 sites). Baseline cone-beam computed tomography allowed for implant planning using the NobelClinician® software and was performed again at 1 year after functional loading. The marginal bone level was assessed radiographically at post-implant baseline and at follow-up.

RESULTS

At follow-up, buccal bone loss differed significantly between groups at the central level of the implant (p = 0.0005) but not at the coronal level (p = 0.329). The mean marginal bone level change was 0.6 mm, with no significant between-group difference (p = 0.876). The actual implant position often deviated in the vertical or sagittal plane by an average of 0.3-0.6 mm from the planned position.

CONCLUSION

Compared with non-reconstructed patients, reconstructed patients experienced significantly more buccal bone loss at the central level of implants. The groups did not differ at the coronal level or in marginal bone loss, possibly because of the more augmented bone at the central level among reconstructed patients. Differences between planned versus actual implant positions should be considered in situations of limited bone volume at the planned implant site.

Soft and hard tissue changes after immediate implant placement with or without a sub-epithelial connective tissue graft: results from a 6-months pilot randomized controlled clinical trial

AIM

The present pilot RCT aimed to investigate the influence of a connective tissue graft (CTG) in combination with the immediate implant placement (IIP) on hard and soft tissues healing, without a bone replacement graft in the gap between the implant and the socket walls.

MATERIAL AND METHODS

Thirty patients requiring extraction of one anterior tooth (from premolar to premolar) were randomly assigned to one of the two treatment groups (test: IIP+CTG; control: IIP). Cone-beam computed tomography (CBCT) and optically scans were performed before tooth extraction and at 6-months follow-up. Then, DICOM files were superimposed in order to allow the evaluation of osseous ridge and buccal bone changes, while the superimposition of DICOM and STL (Standard Tessellation Language) files allowed for evaluating of soft tissue contour. For testing the differences between the two groups, the non-parametric test as Wilcoxon rank-sum test, was used.

RESULTS

Twenty-six out of the thirty enrolled patients, attended the 6-month follow-up visit. The 4 patients of control group that were lost to follow-up, were analyzed under the intention-to-treat principle. No statistically significant differences between the groups were observed for the vertical buccal bone resorption (p=0.90), as well as for the horizontal buccal bone resorption at all measured levels. Significant differences were found between test and control groups in the horizontal dimensional changes of osseous ridge at the most coronal aspect (p=0.0003 and p=0.02). Changes of tissue contour ranged between -0.32 and -0.04 mm in the test group, and between -1.94 and -1.08 mm in the control group, while changes of soft tissue thickness varied between 1.33 and 2.42 mm in the test group, and between -0.16 and 0.88 mm in the control group, with statistically significant differences for both variables at all measured levels. At 6 months, the mean volume increase was 6.76±8.94 mm³ and 0.16±0.42 mm³ in the test and control groups, respectively, with statistically significant difference.

CONCLUSIONS

The findings of the present study indicate that the adjunct of a connective tissue graft at the time of immediate implant placement, without bone grafting, does not influence vertical bone resorption. Within the limits of the present study, it can be suggested that the adjunct of a connective tissue graft at the time of immediate implant placement, without bone grafting, reduces the horizontal changes of the alveolar ridge. Moreover, it allows maintenance of the tissue contour due to an increase in soft tissue thickness.

Clinical evaluation of the buccal aspect around immediate implant using dual zone therapeutic concept versus buccal gap fill to bone level: A randomized controlled clinical trial

OBJECTIVE

Soft tissue esthetics for immediate implant is considered challenging when restoring a tooth in an esthetic zone. This study aimed to evaluate the buccal aspect after immediate implant using the dual-zone therapeutic concept compared to grafting the buccal gap to the bone crest.

MATERIALS AND METHODS

Twenty-four patients were randomly assigned into either immediate implant with the dual-zone therapeutic concept (DZ, test group) or with bone grafting till buccal bone crest with immediate temporization (BCG, control group). Pink esthetic score (PES), buccal bone loss (BBL), mid-facial recession (MFR), soft tissue thickness (STT), keratinized tissue width (KTW), post-operative swelling (POS), and patient satisfaction (PS) were evaluated for 1 year.

RESULTS

At 12 months the PES in the test group was 11.36 ± 1.69, and 10.80 ± 1.55 in the control group, with no statistically significant difference (p = 0.45). MFR in the DZ and BCG groups was 0.27 ± 0.34 and 0.45 ± 0.44 after 12 months with no statistical significance difference (p = 0.195). The STT assessment showed a statistically significant increase in both groups, however the intergroup comparison was statistically not significant (p = 0.23). The mean KTW in the DZ and BCG groups was 4.55 ± 1.08 and 4.20 ± 0.82 mm, respectively with no statistical significance (p = 0.42). There was no statistical significant difference in patient satisfaction between the two groups except in question number 10 concerning the post-operative swelling which was higher in the DZ group (p = 0.009).

CONCLUSIONS

Both treatment modalities are considered reliable methods to achieve good soft tissue esthetics. However, both treatment modalities were not effective in preventing facial bone resorption despite the use of bone graft.

A Novel Approach to Immediate Implants: The CastleWall Surgical Technique

Objective: The purpose of this study was to investigate the volumetric stability around immediate implants, in which a 360-degree socket-shield was retained using the CastleWall Surgical Technique (CWST). Material and methods: This retrospective study examined the results of the CWST used for 25 consecutive patients, involving 31 immediate implants. Silicone impressions taken prior to extraction, and at a review appointment were converted to STL files and compared. The median follow-up time was 14.2 ± 5.5 months. Volumetric changes and gingival recession on both buccal and lingual sites were measured. Papillary height changes were also evaluated from available photographs taken before and after treatment. Patients in the study completed a Visual Analogue Scale (VAS) for evaluation of post-operative discomfort and overall satisfaction with this procedure. Results: All implants integrated successfully without complications. Mean loss of buccal and lingual tissue was 0.30 ± 0.32 mm and 0.17 ± 0.27 mm, respectively. Mean recession at the mid-buccal and mid-lingual gingival margin was 0.66 ± 0.64 mm and 0.87 ± 0.84 mm, respectively. Mean recession of the mesial and distal papilla was 0.26 ± 0.55 mm and 0.29 ± 0.52 mm, respectively. Patients reported 97.74 ± 5.60% satisfaction with this procedure using the Visual Analogue Scale (VAS), with minimal post-operative discomfort. Conclusions: The results of this study showed excellent soft tissue stability and aesthetics were achieved using the CWST, with minimal postoperative pain. The other main advantage of retaining a 360-degree socket-shield, is there is more available surface area to lock the implant to the shield to prevent shield migration over time.

Influence of soft tissue augmentation procedures around dental implants on marginal bone level changes-A systematic review

OBJECTIVES

This systematic review assessed the influence of soft tissue augmentation procedures on marginal bone level changes in partial or fully edentulous patients.

MATERIAL AND METHODS

We identified three relevant PICO questions related to soft tissue augmentation procedures and conducted a systematic search of four major electronic databases for clinical studies in systemically healthy patients receiving at least one dental implant and a minimum follow-up of one year after implant placement. The primary outcome was mean difference in marginal bone levels, and secondary outcomes were clinical and patient-related outcomes such as thickness of peri-implant mucosa, bleeding indices, and Pink Esthetic Score.

RESULTS

We identified 20 publications reporting on 16 relevant comparisons. Studies varied considerably and thus only two meta-analyses could be performed. This systematic review showed that: Soft tissue augmentation either for augmentation of keratinized mucosa or soft tissue volume inconsistently had an effect on marginal bone level changes when compared to no soft tissue augmentation, but consistently improved secondary outcomes. The combination soft and hard tissue augmentation showed no statistically significant difference in terms of marginal bone level changes when compared to hard tissue augmentation alone, but resulted in less marginal soft tissue recession as shown by a meta-analysis. Soft or hard tissue augmentation performed as contour augmentations resulted in comparable marginal bone level changes.

CONCLUSIONS

Peri-implant soft and hard tissues seem to have a bidirectional relationship: "Bone stands hard, but soft tissue is the guard".

Linear and profilometric changes of the mucosa following soft tissue augmentation in the zone of aesthetic priority: A systematic review and meta-analysis

OBJECTIVES

To assess the outcomes of soft tissue augmentation, in terms of change in level and thickness of mid-buccal mucosa, at implants sites in the zone of the aesthetic priority.

MATERIAL AND METHODS

MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials databases were searched (last search on 1 June 2020). Inclusion criteria were studies reporting outcomes of different materials and timing of grafting in patients undergoing soft tissue augmentation at implant sites in the aesthetic zone with a follow-up of ≥1 year after implant placement. Outcome measures assessed included changes in level and thickness of mid-buccal mucosa, implant survival, peri-implant health and patients' satisfaction.

RESULTS

Eighteen out of 2,185 articles fulfilled the inclusion criteria. Meta-analysis revealed a significant difference in vertical mid-buccal soft tissue change (0.34 mm, 95% CI: 0.13-0.56, p = .002) and mid-buccal mucosa thickness (0.66 mm, 95% CI: 0.35-0.97, p < .001) following immediate implant placement in favour of the use of a graft versus no graft. Mean difference in mid-buccal mucosa level following delayed implant placement (0.17 mm, 95% CI: 0.01-0.34, p = .042) was also in favour of the use of a graft versus no graft. With regard to mucosa thickness, the use of a graft was not in favour compared with no graft following delayed implant placement (0.22 mm, 95% CI: -0.04-0.47, p = .095). Observed changes remained stable in the medium term.

CONCLUSION

Soft tissue augmentation in the zone of the aesthetic priority results in less recession and a thicker mid-buccal mucosa following immediate implant placement and less recession in mid-buccal mucosa following delayed implant placement compared with no graft.

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.

Effect of connective tissue grafting on buccal bone changes based on cone beam computed tomography scans in the esthetic zone of single immediate implants: A 1-year randomized controlled trial

BACKGROUND

Connective tissue grafting has a beneficial effect on the peri-implant mucosa, but the effect of grafting the buccal mucosa on buccal bone thickness (BBT) has not been investigated, although BBT is proposed to be a key factor for the soft-tissue contour. The aim of this trial was to assess the outcome of a connective tissue graft (CTG) in the esthetic zone of single immediate implants on the change of BBT according to cone beam computed tomography (CBCT) scan analysis.

METHODS

In a 1-year randomized controlled trial, 60 patients received an immediately placed implant and provisionalization, either combined with CTG (test group) or without CTG (control group). CBCTs were taken preoperatively (T_pre ) and 1 year after definitive restoration (T₂ ). Any change in BBT was assessed at different implant levels. Additionally, the change in mid-buccal mucosal level (MBML) and approximal marginal bone level were assessed.

RESULTS

Fifty-five patients were available for statistical analysis (test group, n = 28; control group, n = 27). At T₂ , the average change in BBT was significantly larger in the test group (-0.84 ± 0.61 mm) than in the control group (-0.46 ± 0.54 mm, P = 0.02). A MBML gain of 0.07 ± 0.85 mm in the test and a MBML loss -0.52 ± 1.16 mm in the control group was observed at T₂ . Average loss of marginal bone was 0.05 ± 0.33 mm and 0.01 ± 0.38 mm, respectively.

CONCLUSIONS

The application of CTG in the esthetic zone of immediately placed and provisionalized implants is accompanied with more loss of BBT, but at the same time better maintains the mid-buccal mucosal level.