Efficacy of soft tissue substitutes, in comparison with autogenous grafts, in surgical procedures aiming to increase the peri-implant keratinized mucosa: A systematic review

Timing of keratinized mucosa augmentation and peri-implant outcomes: A systematic review and meta-analysis

PURPOSE

This study aimed to compare different surgical timings for keratinized mucosa (KM) augmentation and assess the impact on peri-implant parameters stability.

METHODS

Electronic searches were conducted through MEDLINE (via PubMed), Scopus, Embase, and Web of Science up to June 13, 2024, which was completed with a manual search. The inclusion criteria focused on randomized and non-randomized human clinical studies that assessed outcomes of KM augmentation, with at least 3-months follow-up. The analysis included changes in KM width over time and several secondary outcomes.

RESULTS

Twenty-five studies satisfied the inclusion criteria. The studies included 855 patients and 1588 implants. The KM width significantly increased after surgery, regardless of the time or method of intervention (MD: 5.17, 95% CI: 4.59, 5.75, p<0.001). The second-stage surgery, particularly with the use of autogenous graft, indicated the lowest reduction in KM width up to 3 months after surgery, while a significant shrinkage was found when the augmentation was performed post-restoratively.

CONCLUSION

The evidence suggests that second-stage surgery is acceptable for KM augmentation, whereas the post-restorative phase is generally not the primary option. In cases where suboptimal soft tissue conditions are detected, it is advisable to either undertake KM augmentation or refer the patient for additional assessment before proceeding with the delivery of the restoration. Due to limited data, it is not possible to come to a definitive conclusion about the other surgical phases.

Biomaterials for Guided Tissue Regeneration and Guided Bone Regeneration: A Review

This review aims to provide an overview of the types of membranes, bone substitutes, and mucosal substitutes used for GTR and GBR and briefly explores recent innovations for tissue regeneration and their future perspectives. Since this is a narrative review, no systematic search, meta-analysis, or statistical analysis was conducted. Using biomaterials for GTR and GBR provides a reduction in postoperative morbidity, as it contributes to less invasive clinical procedures, serving as an alternative to autogenous grafts. Moreover, randomized clinical trials (RCTs) and systematic reviews are essential for the evaluation of new biomaterials. These studies provide more robust evidence and help guide clinical practice in the selection of safer and more effective biomaterials, allowing for the personalization of treatment protocols for each patient.

Clinical Observations of Soft Tissue Dimensions Around Teeth and Implants After Free Gingival Graft

INTRODUCTION AND AIMS

The histological and morphological differences in soft tissue between natural teeth and peri-implant may result in different clinical effectiveness to free gingival graft (FGG). This research aims to investigate the different efficacy of FGG in augmenting keratinized tissue width (KTW) between tooth and implant sites while evaluating its medium-term stability over a 2- to 5-year follow-up.

METHODS

In this study, 29 patients underwent FGG to address insufficient clinical scenarios when KTW <2 mm at the buccal aspect, including 37 implant sites and 33 natural teeth sites both in posterior regions were included. The KTW and gingival margin position (GMP) of these sites was assessed by measuring the intra-oral photographs which were taken at 0 days (T0), 3-month (T1), 6-month (T2), 12-month post-surgery (T3), and 2 to 5 years follow-up (T4).

RESULTS

The results revealed that KTW increased significantly in both groups. However, the natural teeth group showed significantly less graft shrinkage (GS) than the implants group. (Teeth: 2.05 ± 0.51 mm and 25.42% ± 6.45%; Implants: 3.18 ± 0.65 mm and 38.92% ± 5.39%, P <.01). From T1 to T4. The gingival margin coronally advanced by 0.47 ± 0.51 mm and 0.18 ± 0.43 mm for the natural teeth and implants group, respectively (P<.05).

CONCLUSIONS

A greater KTW reduction after FGG was observed at implants versus natural teeth. And, the graft surrounding implants after crown restoration was stable for up to 2 to 5 years.

CLINICAL RELEVANCE

By comparing the changes in KTW around natural teeth and implants following FGG to investigate whether there are differences between them and the degree of differences. Additionally, this allows us to explore whether the restorations impact the effect of FGG. This research can assist clinicians in selecting an appropriate amount of soft tissue during surgery to achieve treatment goals, reduce postoperative discomfort for patients, and enhance predictability in clinicians' ability to increase keratinized tissue. Furthermore, by observing changes in the position of GMP around natural teeth and implants, the effectiveness of FGG in root coverage can be understood, thus improving the predictability of FGG for root coverage.

Efficacy of Collagen Matrix for Establishing Keratinized Mucosa at Dental Implants: A 5-Year Randomized Controlled Trial

OBJECTIVES

To compare the 5-year outcomes of collagen matrix (CM) and free gingival graft (FGG) used to augment the keratinized mucosa (KM) around posterior dental implants.

MATERIALS AND METHODS

Thirty patients (44 implants) with inadequate KM (< 2 mm) on posterior dental implants were randomized into two groups that received KM augmentation with CM or FGG. Clinical measurements comprising the KM width (KMW), buccal mucosal thickness (MT), and clinical parameters were examined in a 5-year follow-up. Marginal bone loss (MBL) was evaluated with standardized radiographs using the paralleling technique. Patient-reported outcomes (PROs) during the first week post-surgery and at the 5-year follow-up were evaluated.

RESULTS

KMW increased significantly during the follow-up period in both groups. The FGG group had a significantly greater KMW than the CM group at the 1, 2-month follow-up and after the 6-month follow-up. KM shrinkage was observed, and was greatest within the first 2 months post-surgery in both groups. At the 5-year follow-up, the KM shrinkage was significantly different between the groups (FGG: 47%; CM: 70%) (p < 0.01). The MT increased significantly in the FGG group. The clinical parameters and MBL were similar between the groups. The bleeding score in the FGG group was higher than that in the CM group (p < 0.05) within the first 2 days post-surgery, while other PROs scores were similar between groups in the first week post-surgery. At 5-year follow-up, all patients were highly satisfied with the treatments.

CONCLUSIONS

FGG was superior to CM in terms of the KM augmentation and MT increase. Except for a slight difference in self-reported bleeding during the first two post-operative days, CM didn't demonstrate other significant advantages in PROMs.

TRIAL REGISTRATION

ChiCTR1800018285 (date of registration: 9/9/2018, retrospectively registered. URL: https://www.chictr.org.cn/showproj.html?proj=24156).

Therapeutic effectiveness of keratinized mucosa augmentation for functioning dental implants: A systematic review and meta-analysis

PURPOSE

This study aimed to provide the latest updates on the therapeutic effectiveness of keratinized mucosa (KM) augmentation using autogenous soft tissue grafts for dental implants retaining prostheses.

STUDY SELECTION

A systematic search of electronic databases was conducted on autogenous soft tissue grafts to create and/or augment KM for functioning dental implants. Two investigators independently extracted data from the selected 11 clinical studies, including 290 participants, from the initially retrieved 573 publications.

RESULTS

A lack of KM surrounding dental implants was associated with greater mucosal inflammation. A free gingival graft (FGG) was used to increase the KM width, and a connective tissue graft (CTG) was used to manage peri-implant mucosal recession (MR). The weighted mean gain in KM was 2.6 mm from the selected FGG studies, with a significant reduction in mucosal inflammation and no changes in crestal bone levels for up to 4 years. The weighted mean reduction in MR was 2 mm in selected CTG studies.

CONCLUSIONS

A lack of KM negatively affects soft tissue health around dental implants. FGG was effective in increasing KM and reducing mucosal inflammation, whereas CTG was effective in decreasing MR.

Management of Soft Tissue Defects Around Single Implants: A Systematic Review of the Literature

OBJECTIVES

The aim of this systematic review was to assess the effectiveness of the available techniques for the management of peri-implant soft tissue defects around single implants in the anterior region.

MATERIAL AND METHODS

A comprehensive search was conducted in PubMed (MEDLINE), Web of Science (all databases), and Cochrane, using keywords and MeSH terms related to the topic. This systematic review included prospective interventional studies with a minimum of 10 patients and at least 6 months of follow-up.

RESULTS

A total of 13 articles were included, with eight focusing on outcomes related to buccal soft tissue dehiscence coverage procedures and the remaining five investigating interventions aimed at augmenting soft tissue thickness. Coronally advanced flap in combination with connective tissue graft was the most effective technique for buccal soft tissue dehiscence coverage in the medium and long term. In terms of increasing soft tissue thickness, both connective tissue graft and acellular dermal matrix demonstrated satisfactory short-term outcomes; however, their long-term efficacy remains unclear.

CONCLUSIONS

Soft tissue augmentation procedures resulted in satisfactory outcomes, in terms of buccal soft tissue dehiscence coverage and soft tissue thickness increase, around single implants in the esthetic area. Peri-implant plastic surgery has improved both the esthetic appearance and quality of life of patients.

PROSPERO REGISTRATION CODE

CRD42023398424.

Volumetric changes of porcine collagen matrix and free gingival grafts for soft-tissue grafting to increase the width of keratinized tissue around dental implants: a retrospective clinical study

AIM

To compare three-dimensional changes of aporcine derived collagen matrix (CM) and free gingival grafts (FGG) for increasing keratinized tissue (KT) at dental implants over a 24-month follow-up period.

MATERIALS AND METHODS

This retrospective study enrolled 25 patients exhibiting 41 implants with deficient KT width (i.e., < 2 mm) who underwent soft tissue augmentation using either CM (11 patients/15 implants) or FGG (14 patients/26 implants). The primary outcome was tissue thickness change (mm) at treated implant sites between 1- (S0), 12- (S1), and 24-months (S2). Secondary outcome was the changes of KT width over a 24-month follow-up period.

RESULTS

Dimensional analyses from S0 to S1 and from S0 to S2 revealed a mean decrease in tissue thickness of -0.05 ± 0.35 mm and - 0.31 ± 0.41 mm in the CM group, and - 0.23 ± 0.38 mm and - 0.22 ± 0.81 mm in the FGG group, with no significant differences found between the groups (S0-S1: p = 0.14, S0-S2: p = 0.58). Within S1 and S2, the CM and FGG groups displayed comparable tissue thickness reduction (CM: -0.32 ± 0.53 mm, FGG: -0.02 ± 0.21 mm; p = 0.07). The FGG group exhibited a significantly greater KT gain 24-months compared to the CM group (CM: 1.50 ± 1.14 mm, FGG: 4.04 ± 1.65 mm; p < 0.001).

CONCLUSIONS

CM and FGG were associated with comparable three-dimensional thickness changes over a period of 24 months. A significantly wider KT band could be established in the FGG group.

A conservative approach for keratinized tissue augmentation: Report of two cases

BACKGROUND

Free gingival graft harvested from the palate is considered the most predictable method to augment the keratinized tissue (KT). However, the anatomical limitations of the palate, and associated patient morbidity and complications restrict clinicians from performing these procedures in adolescents. Color mismatch with the native tissues resulting in poor esthetic appearance is another concern. To overcome these limitations, this article reports a surgical approach known as labial gingival graft (LGG) as an alternative to palatal graft.

METHODS

Two adolescent patients presenting with absence of attached gingiva and shallow gingival recession in the mandibular incisor region were treated with LGG harvested from the labial KT of teeth adjacent to those requiring KT augmentation.

RESULTS

The procedure was well tolerated by the patients. At the final follow-up (3.5- and 2 years from baseline), a significant gain in KT with complete root coverage was achieved in both patients. Both professional and patient-centered esthetic evaluations revealed excellent color match making the grafted area imperceptible from the adjacent mucosa.

CONCLUSIONS

The proposed technique was found to be simple and predictable, and was associated with minimal morbidity and no complications. Clinicians may consider performing LGG procedure when sufficient KT can be harvested from adjacent donor site. The selection of such techniques is of particular relevance in children who are vulnerable to complications associated with more invasive procedures.

KEY POINTS

Why are these cases new information? To the best of our knowledge, this article is the first to present the use of labial gingival graft harvested from adjacent keratinized mucosa in adolescent patients. What are the keys to successful management of these cases? Proper case selection in terms of sufficient amount of keratinized tissue to harvest as labial gingival graft from adjacent teeth. Use of smaller instruments, small-sized needles, and sutures under magnification to minimize trauma to the tissues /graft. Preparation of an immobile periosteal bed and suturing protocol that minimizes the dead space and ensures revascularization of graft. What are the primary limitations to success in these cases? A prerequisite of the presence of thick gingiva and sufficient dimensions of KT around the adjacent teeth further limits its applicability in all cases.

The expanded mesh free gingival graft: A novel approach to increase the width of keratinized mucosa

BACKGROUND

The importance of an adequate amount of peri-implant keratinized tissue and attached mucosa has recently been emphasized. This manuscript presents preliminary findings of a novel approach for increasing the width of keratinized mucosa (KM) around dental implants using a mesh free gingival graft (mesh-FGG).

METHODS

Two healthy adults were treated as part of this study. After implant placement, a large edentulous alveolar ridge with shallow vestibule and minimal amount of KM was treated in both subjects (one in the posterior mandible and the other in the anterior mandible) with the combination of an apically positioned flap and a mesh-FGG. Clinical, esthetic and patient-reported outcomes were observed at approximately 4-month time points.

RESULTS

All sites healed uneventfully after the treatments. In both cases, increased vestibule depth, soft-tissue thickness, and width of peri-implant KM were obtained. The patients did not report any accessory discomfort. Four months following the grafting procedure, good overall esthetic outcome was observed with minimal color disparity and graft demarcation.

CONCLUSIONS

Width of KM around dental implants can be increased using a mesh-FGG. Randomized controlled clinical studies comparing mesh-FGG to conventional FGG and other commonly applied techniques are required to assess the long-term efficacy of this novel technique in terms of soft-tissue thickness, width of peri-implant KM, and patient-reported outcomes.

KEY POINTS

Principal Findings: Meshed-FGG allowed an expansion of the length of the harvested graft. This results in coverage of large recipient sites, increase in height of KM and good aesthetic integration of the graft.

Soft Tissue Augmentation After Tooth Extraction Improves Implant Health: Findings From a Clinical Trial

Background Soft tissue augmentation is a critical procedure in dental implantology aimed at improving peri-implant health and aesthetics. Various materials are used for this purpose, but their comparative effectiveness remains under-researched. This study aimed to evaluate the effects of soft tissue augmentation utilizing two different materials after tooth extraction on peri-implant clinical and radiographic outcomes. Methodology A randomized controlled trial was conducted with 30 participants requiring extraction of non-restorable mandibular posterior teeth. Participants were randomly assigned to receive connective tissue graft (CTG), Fibro-gide (FG), or spontaneous healing (SH) in a 1:1:1 allocation ratio. Two months post-treatment, dental implants were placed. Six months after the functional loading of the dental implant, peri-implant health was assessed using the Plaque Accumulation Index, bleeding on probing (BOP), pocket depth, mucosal recession, and marginal bone level. Results At the six-month follow-up, the SH group exhibited significantly higher Plaque Index and BOP percentages (6.43 ± 1.23 and 70%, respectively) compared to the CTG group (0.40 ± 0.32 and 8.3%, respectively) and FG group (0.45 ± 0.44 and 9.7%, respectively). The mean probing pocket depth was also significantly higher in the control group (5.13 ± 0.64 mm), while the CTG and FG groups showed minimal changes (3.83 ± 0.39 mm for both groups). Additionally, gingival recession was higher in the control group (0.65 ± 0.18 mm) compared to the CTG and FG groups (0.03 ± 0.08 mm for both groups). Radiographic analysis revealed greater marginal bone loss in the control group (0.40 ± 0.05 mm) compared to the CTG and FG groups, which demonstrated minimal bone loss (0.17 ± 0.08 mm and 0.20 ± 0.00 mm, respectively). Conclusions The study findings indicate that FG is as effective as CTG in maintaining peri-implant health, outperforming SH. These findings suggest that FG can be a viable alternative to CTG in soft tissue augmentation after tooth extraction, offering a new option for clinicians in the management of extraction sites before dental implant placement.

Efficacy of Xenogeneic Collagen Matrices in Augmenting Peri-Implant Soft Tissue: A Systematic Review and Meta-Analysis

BACKGROUND

Xenogenic collagen matrices (XCMs) are gaining popularity for soft tissue augmentation in dental implants; yet, gaps exist in our understanding of their comparative effectiveness.

OBJECTIVE

This systematic review and meta-analysis focuses on studies that utilize soft tissue augmentation techniques for dental implants to improve keratinized mucosa width (KMW), soft tissue thickness (STT), and soft tissue volume (STV). We compared porcine collagen matrices with autogenous grafts when no bone grafts were utilized.

MATERIALS AND METHODS

We searched databases such as PubMed, Scopus, and the Cochrane Central Register of Controlled Trials for randomized controlled trials and controlled clinical trials published between January 2013 and July 2023 that assessed the efficacy of XCM in peri-implant soft tissue augmentation. The primary outcome included KMW changes while the secondary outcome was STT/STV changes. Statistical analyses were conducted using a random- or fixed-effects model, and heterogeneity was assessed using I2 statistics.

RESULTS

Nine studies were included in the qualitative analysis, and six were included in the meta-analysis. No significant intergroup differences were observed (p > 0.05), but a significant difference was observed in favor of KMW ≥ 2 mm. Heterogeneity among the studies varied at the 6- and 12-month follow-ups, with I2 values of 78% and 0%, respectively. The pooled mean difference between the XCM and autograft groups was -0.96 (-1.71 to -0.21), which shows that there was a larger increase in KMW in the autograft group compared with the XCM group (p < 0.05).

CONCLUSIONS

Collagen matrices are less effective than autogenous grafts at increasing keratinized tissue and STT/STV, but the two techniques yield comparable aesthetic outcomes. Additional studies are necessary to better guide clinical practice and improve patient outcomes.

A modified geometric technique to increase peri-implant keratinized mucosa

OBJECTIVE

The free gingival graft (FGG) has been identified as the most effective method for increasing keratinized mucosa width (KMW). However, the challenge emerges in cases of extensive keratinized mucosa deficiency, where efficient utilization of the patient's limited keratinized tissue to achieve optimal results is crucial. This article introduces a modified geometric technique to address this clinical issue.

CLINICAL CONSIDERATIONS

Utilizing geometric principles, the modified technique involves dividing the rectangular graft into two triangular or trapezoidal sections, which are then reassembled to form an approximate diamond shape. Through strategic cut and splice, the graft is reshaped to suit the recipient site.

CONCLUSION

Preliminary observations in cases employing the modified geometric technique have increased the KMW around implants. This method enhances graft utilization and offers a viable clinical option for surgical plans aimed at widening keratinized mucosa in instances of large-area KMW deficiency.

CLINICAL SIGNIFICANCE

This article proposed a modified method to increase KMW, which may be an optimal choice for patients with insufficient KMW in large area, avoiding the waste of limited graft, decreasing patient morbidity, and effectively widening keratinized mucosa.

Soft tissue management around dental implant in esthetic zone - the current concepts and novel techniques

It has been said, 'Bone sets the tone, but tissue is the issue.' In the field of implantology, while significant breakthroughs have been achieved in hard tissue regeneration, clinicians find it more challenging to handle soft tissue complications around dental implants. Successfully managing soft tissue around dental implants requires clinicians to have comprehensive knowledge of proper implant placement, prosthetic design and tissue management, and a high level of surgical skills for soft tissue augmentation and grafting. Autogenous gingival grafts can be utilized in various clinical situations, providing surgeons with great potential and freedom to enhance the quality and quantity of peri-implant soft tissue. Emerging trends, such as digital tools for treatment planning, minimally invasive surgical approaches, and innovative biomaterials, can also contribute to a more pleasing outcome. By elucidating these multifaceted considerations, this review will serve as a valuable resource for clinicians aiming to achieve functional and aesthetic excellence in implant-based oral rehabilitation.

A Novel Prehydrated Porcine-Derived Acellular Dermal Matrix: A Histological and Clinical Evaluation

It is well known that soft tissue quality and quantity around dental implants is of paramount importance for later peri-implant health. For this purpose, the clinical and histological outcomes of the peri-implant mucosa, following soft tissue augmentation for soft tissue improvement with a novel prehydrated porcine acellular dermal matrix graft (PPADMG) in conjunction with simultaneous implant placement, were evaluated in this case series. Twenty-two patients were included in the study. They underwent a late implant placement protocol combined with PPADMG for soft tissue augmentation. A punch biopsy was taken at the time of uncovery of the submerged healed implant after a mean of 157 days healing time. Supracrestal soft tissue height (STH) was measured at the time of implant placement and uncovery. All sites showed a clinical increase in STH. The histological structure of the biopsies resembled a similar structure as found in the healthy oral mucosa. No unexpected tissue reactions could be found. Within the limits of this clinical and histological study, it may be concluded that STH improvement with this novel porcine-derived acellular dermal matrix, in combination with simultaneous implant placement, is a viable option to create a peri-implant tissue thickness and stability.

Tooth- and implant-related prognostic factors in treatment planning

Following a comprehensive patient examination, including the assessment of periodontal and peri-implant diseases as well as considering the patient's needs, a pretherapeutic prognosis for each tooth and implant is given. Teeth and implants with a secure pretherapeutic prognosis require simple procedures and may be regarded as secure abutments for function and with a doubtful pretherapeutic prognosis usually need a comprehensive therapy. Such teeth and implants must be brought into the category with a secure prognosis by means of additional therapy such as endodontic, restorative, and surgical procedures. Teeth and implants with a hopeless pretherapeutic prognosis should be extracted/explanted during the initial phase of cause-related therapy (i.e., infection control). For example, teeth with vertical root fracture or unrestorable caries and implants with mobility or unrestorable malposition fall into the category of hopeless units. The primary goal of periodontal and peri-implant therapy should be to arrest disease progression. The latest consensus statement highlights that periodontitis can be successfully controlled and treated teeth can be retained for life. Nevertheless, for patients with uncontrolled contributing factors, the endpoints might not always be achievable, and low disease activity may be an acceptable therapeutic goal. Similarly, the management of peri-implantitis frequently requires surgical intervention following nonsurgical therapy due to incomplete treatment outcomes. Different surgical modalities can be effective and lead to significant improvement; however, achieving complete resolution of peri-implantitis is challenging, not always predictable, and can depend on multiple baseline factors. Therefore, this review aims at summarising available evidence on the rationale for incorporating systemic, lifestyle-related, clinical, and radiographic prognostic factors into treatment planning of patients diagnosed with periodontal and peri-implant diseases.

Soft Tissue Substitutes in Periodontal and Peri-Implant Soft Tissue Augmentation: A Systematic Review

BACKGROUND

Different extracellular matrix (ECM)-based technologies in periodontal and peri-implant soft tissue augmentation have been proposed in the market. The present review compared the efficacy of soft tissue substitutes (STSs) and autogenous free gingival grafts (FGGs) or connective tissue grafts (CTGs) in mucogingival procedures to increase keratinized tissue (KT) width around teeth and implants.

METHODS

Two independent examiners performed an electronic search on MEDLINE and the Cochrane Library based on the following PICOS format: (P) adult patients; (I) soft tissue substitutes and FGGs/CTGs; (C) STSs vs. CTGs; STSs vs. FGGs; STSs vs control; (O) KT width gain; (S) systematic reviews, randomized controlled trials. Studies published before November 2023 were included.

RESULTS

Around teeth, all biomaterials showed superior performance compared to a coronally advanced flap (CAF) alone for treating gingival recessions. However, when compared to CTGs, acellular dermal matrices (ADMs) yield the most similar outcomes to the gold standard (CTGs), even though in multiple recessions, CTGs continue to be considered the most favorable approach. The use of STSs (acellular matrix or tissue-engineered) in combination with apically positioned flaps (APF) resulted in significantly less gain in KT width compared to that achieved with FGGs and APFs. Around dental implants, free gingival grafts were deemed more effective than soft tissue substitutes in enhancing keratinized mucosa width.

CONCLUSIONS

Based on the available evidence, questions remain about the alternative use of soft tissue substitutes for conventional grafting procedures using free gingival grafts or connective tissue grafts around teeth and implants.

A decision-making tree for evaluating an esthetically compromised single dental implant

OBJECTIVE

To develop a comprehensive decision-making tree for evaluating mid-facial peri-implant soft tissue dehiscence in the esthetic zone and provide a systematic approach for assessing various clinical case scenarios, determining appropriate treatment strategies, and considering factors such as the need for soft tissue augmentation, prosthetic changes, or implant removal.

CLINICAL CONSIDERATIONS

This clinical decision tree illustrates numerous case scenarios with various esthetic complications around an esthetically compromised, but clinically healthy single implant and provides clinicians with possible solutions as a predictable map for horizontal and vertical soft tissue augmentation in order to manage different clinical circumstances. According to current evidence, the key to treating such esthetic complications is the use of an adequate pre-surgical prosthetic interdisciplinary approach with proper surgical techniques in order to optimize soft tissue dimensions and create better esthetic results. This may be accomplished through a purely surgical, combination of surgical and prosthetic, or purely prosthetic approaches.

CONCLUSIONS

The present report describes a series of successfully treated peri-implant esthetic complication cases in accordance with the decision-making tree that the authors recommend in order to achieve better long-term esthetic outcomes.

CLINICAL SIGNIFICANCE

The combination of adequate pre-surgical prosthetic interdisciplinary collaboration and proper surgical technique is critical in the optimization of sufficient soft tissue dimensions and contributes to a more highly esthetic result. This study demonstrates a clinical decision-making tree to provide comprehensive, effective therapy of an esthetically compromised dental implant by using one of the following approaches: purely prosthetic, purely surgical, or a combination of surgical and prosthetic with or without abutment removal.

Technical Note on Simplified Free Gingival Graft Using Tack Fixation (sFGG)

Free gingival graft (FGG) is the gold standard procedure for the reliable augmentation of lost keratinized mucosa (KM) around dental implants. This conventional surgical approach has its drawbacks, including limitations in manipulation, the requirement for suturing, postoperative discomfort, and pain. This case report aimed to evaluate the efficacy of a simplified free gingival graft (sFGG) in addressing the issue of inadequate keratinized mucosa around dental implants. Fixation tacks were used to perform the sFGG procedure. Initially, a partial-thickness flap was created and apically repositioned. The gingival graft was harvested from the palate with a narrow profile and securely affixed to the recipient site using 5 mm long fixation tacks. Significant gains in keratinized mucosa were achieved and successfully maintained within 1 year. Consequently, the sFGG technique emerges as a simple and reliable treatment approach for managing inadequate keratinized mucosa around dental implants.

Long-term evaluation of peri-implant keratinized mucosa stability after free epithelialized graft and keratinized mucosa shifting procedures: A retrospective study up to 13 years

OBJECTIVES

This study aimed to assess the risk of less than 2 mm keratinized mucosa (KM) width occurrence after free epithelialized graft (FEG) and keratinized mucosa shifting (KMS) procedures using survival analysis. In addition, KM dimensional changes were evaluated.

MATERIALS AND METHODS

This study included 76 implants in 36 patients with insufficient KM (<2 mm). The implants underwent either FEG or KMS procedures. The mid-buccal KM width was measured from surgery to the end of a one 13-year follow-up period.

RESULTS

Mean follow-up durations were 9.2 ± 3.9 years for FEG and 6.3 ± 4.2 years for KMS. Two implants in FEG and nine implants in KMS exhibited a KM width of less than 2 mm during follow-up. The hazard ratios for KMS compared to FEG were 6.48 (crude) and 6.54 (adjusted), both statistically significant (p < .05). The incidence rate of KMS (4.06%) was higher than that of FEG (0.63%), with an average incidence time of 3.38 years for KMS and 8.82 years for FEG post-surgery. FEG showed a significant shrinkage within 6 months (33% ± 22%), whereas KMS demonstrated a gradual decrease over 13 years (34% ± 25%). FEG exhibited significantly greater width change than KMS during a 5-year follow-up (p < .05).

CONCLUSIONS

FEG and KMS enhanced PIKM but exhibited different long-term reduction patterns. FEG demonstrated rapid shrinkage, while KMS displayed gradual and continuous reduction. Moreover, KMS presented a higher risk and incidence of KM width less than 2 mm compared to FEG.

Three-dimensional changes of a porcine collagen matrix and free gingival grafts for soft tissue augmentation to increase the width of keratinized tissue around dental implants: a randomized controlled clinical study

BACKGROUND

Emerging clinical data points to the relevance of the presence of keratinized tissue (KT). Although apically positioned flap/vestibuloplasty along with free gingival graft (FGG) is considered as a standard intervention for augmenting KT, substitute materials appear to be a viable treatment alternative. So far, there is a lack of data investigating the dimensional changes at implant sites treated with soft-tissue substitutes or FGG.

AIM

The present study aimed at comparing three-dimensional changes of a porcine derived collagen matrix (CM) and FGG for increasing KT at dental implants over a 6-month follow-up period.

MATERIALS AND METHODS

The study enrolled 32 patients exhibiting deficient KT width (i.e., < 2 mm) at the vestibular aspect who underwent soft tissue augmentation using either CM (15 patients/23 implants) or FGG (17 patients/31 implants). The primary outcome was defined as tissue thickness change (mm) at treated implant sites between 1- (S0), 3- (S1), and 6-months (S2). Secondary outcomes considered changes of KT width over a 6-month follow-up period, surgical treatment time, and patient-reported outcomes.

RESULTS

Dimensional analyses from S0 to S1 and from S0 to S2 revealed a mean decrease in tissue thickness of - 0.14 ± 0.27 mm and - 0.04 ± 0.40 mm in the CM group, and - 0.08 ± 0.29 mm and - 0.13 ± 0.23 mm in the FGG group, with no significant differences noted between the groups (3 months: p = 0.542, 6 months: p = 0.659). Likewise, a comparable tissue thickness decrease was observed from S1 to S2 in both groups (CM: - 0.03 ± 0.22 mm, FGG: - 0.06 ± 0.14 mm; p = 0.467). The FGG group exhibited a significantly greater KT gain after 1, 3 and 6 months compared to the CM group (1 month: CM: 3.66 ± 1.67 mm, FGG: 5.90 ± 1.58 mm; p = 0.002; 3 months: CM: 2.22 ± 1.44; FGG: 4.91 ± 1.55; p = 0.0457; 6 months: CM: 1.45 ± 1.13 mm, FGG: 4.52 ± 1.40 mm; p < 0.1). Surgery time (CM: 23.33 ± 7.04 min.; FGG: 39.25 ± 10.64 min.; p = 0.001) and postoperative intake of analgesics were significantly lower in the CM group (CM: 1.2 ± 1.08 tablets; FGG: 5.64 ± 6.39 tablets; p = 0.001).

CONCLUSIONS

CM and FGG were associated with comparable three-dimensional thickness changes between 1 and 6 months. While a wider KT band could be established with FGG, the use of CM significantly reduced surgical time and patients´ intake of analgesics.