Buccal soft tissue dehiscence defects at dental implants-associated factors and frequency of occurrence: A systematic review and meta-analysis

Three Factors for Long-Term Dental Implant Success: Up to 40-year Follow-up

This article provides clinicians with 3 main factors that relate to long-term success. Long term in this article represents the lifespan of the patient, often requiring more than 40 years of function on the implant restoration. Literature is reviewed and used to provide evidence for these recommendations. Cases are presented to demonstrate these critical factors.

A multi-centre randomized controlled trial on alveolar ridge preservation with immediate or delayed implant placement: Need for soft-tissue augmentation

AIM

To assess the impact of the timing of implant placement following alveolar ridge preservation (ARP) on the need for soft-tissue augmentation (STA) and to identify the risk factors for horizontal and vertical soft-tissue loss.

MATERIALS AND METHODS

Patients with a single failing tooth in the anterior maxilla (15-25) were treated at six centres. Following tooth extraction, they were randomly allocated to the test group (immediate implant placement, IIP) or control group (delayed implant placement, DIP). ARP was performed in both groups and implants were immediately restored with an implant-supported provisional crown. Six months after tooth extraction and ARP, a panel of five blinded clinicians assessed the need for STA on the basis of anonymized clinical pictures and a digital surface model. Lack of buccal soft-tissue convexity and/or mid-facial recession qualified for STA. Pre-operative and 6-month digital surface models were superimposed to assess horizontal and vertical soft-tissue changes.

RESULTS

Thirty patients were included per group (test: 20 females, 10 males, mean age 53.1; control: 15 females, 15 males, mean age 59.8). The panel deemed STA as necessary in 24.1% and 35.7% of the cases following IIP and DIP, respectively. The difference was not statistically significant (odds ratio [OR] = 1.77; 95% confidence interval [CI] [0.54-5.84]; p = .343). Loss of buccal soft-tissue profile was higher following DIP (estimated mean ratio = 1.66; 95% CI [1.10-2.52]; p = .018), as was mid-facial recession (mean difference [MD] = 0.47 mm; 95% CI [0.12-0.83]; p = .011). Besides DIP, regression analysis identified soft-tissue thickness (-0.57; 95% CI [-1.14 to -0.01]; p = .045) and buccal bone dehiscence (0.17; 95% CI [0.01-0.34]; p = .045) as additional risk factors for mid-facial recession. Surgeons found IIP significantly more difficult than DIP (visual analogue scale MD = -34.57; 95% CI [-48.79 to -20.36]; p < .001).

CONCLUSIONS

This multi-centre randomized controlled trial failed to demonstrate a significant difference in the need for STA between IIP and DIP when judged by a panel of blinded clinicians. Based on objective soft-tissue changes, patients with thin buccal soft tissues, with a buccal bone dehiscence and treated with a delayed approach appeared particularly prone to soft-tissue loss.

Prosthetic Soft Tissue Management in Esthetic Implant Restorations, Part I: Presurgical Planning, Implant Placement, and Restoration Timing. A Narrative Review

OBJECTIVES

This two-part review article delineates various techniques to enhance esthetic outcomes in anterior implant treatments. Part I concentrates on presurgical measures, case selection, implant placement, and restoration timing. Part II discusses post-surgical steps, the temporary restoration phase, the emergence profile contour, abutment types, and impression techniques.

MATERIAL AND METHODS

A comprehensive search was conducted using Medline/PubMed, Embase, Scopus, and the Cochrane Library. The primary keywords included were "Dental Implants," "Dental Prosthesis, Implant-Supported," "Esthetics, Dental," "Dental Impression Techniques," and "Tissue Management."

RESULTS

Initially, 1472 studies were identified, from which 187 were selected based on publication year and title relevance. After removing duplicates, 84 abstracts were reviewed in full text, culminating in 59 studies being thoroughly analyzed.

CONCLUSIONS

Optimal esthetics in implant restorations are attainable through meticulous treatment planning, precise surgical execution, and systematic restorative steps, ensuring predictable outcomes. Factors such as a thick gingival biotype, an intact facial bone wall, and atraumatic extraction significantly contribute to superior esthetic results. Immediate implant placement combined with immediate provisionalization provides the most predictable outcomes by supporting and maintaining soft tissue architecture. Conversely, delayed implant placement and provisionalization often require extensive manipulation of collapsed soft tissues to achieve desired esthetics.

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.

The use of digital technologies in peri-implant soft tissue augmentation - A narrative review on planning, measurements, monitoring and aesthetics

OBJECTIVE

To identify the different uses and modalities of digital technologies to diagnose, plan and monitor peri-implant soft tissue conditions and aesthetics.

METHODS

A comprehensive narrative review of pertinent literature was conducted, critically appraising key digital technologies that may assist peri-implant soft tissue augmentation and assessment. An electronic search on four databases including studies published prior to 1st July 2023 was performed and supplemented by a manual search.

RESULTS

Predominantly, tools such as cone beam computed tomography (CBCT), intraoral scanning (iOS), intraoral ultrasonography and digital spectrophotometry were commonly to assess and monitor peri-implant soft tissues. The main clinical and research applications included: (i) initial assessment of mucosal thickness, supra-crestal tissue height and keratinized mucosa width, (ii) evaluation of peri-implant soft tissue health and inflammation, (iii) monitoring profilometric changes and midfacial mucosal margin stability over time and (iv) aesthetic evaluation through colour assessment. While evidence for some digital tools may be limited, the integration of digital technologies into peri-implant soft tissue management holds great promise. These technologies offer improved precision, comfort and speed in assessment, benefiting both patients and clinicians.

CONCLUSION

As digital technologies progress, their full potential in peri-implant soft tissue augmentation and their value will become more evident with ongoing research. Embracing these innovations and their potential benefits is recommended to ensure that during progress in implant dentistry, patient care is not hindered.

Diagnostic methods/parameters to monitor peri-implant conditions

The diagnostic accuracy of clinical parameters, including visual inspection and probing to monitor peri-implant conditions, has been regarded with skepticism. Scientific evidence pointed out that primary diagnostic tools (chairside) seem to be highly specific, while their sensitivity is lower compared with their use in monitoring periodontal stability. Nonetheless, given the association between pocket depth at teeth and implant sites and the aerobic/anaerobic nature of the microbiome, it seems plausible for pocket probing depth to be indicative of disease progression or tissue stability. In addition, understanding the inflammatory nature of peri-implant diseases, it seems reasonable to advocate that bleeding, erythema, ulceration, and suppuration might be reliable indicators of pathology. Nevertheless, single spots of bleeding on probing may not reflect peri-implant disease, since implants are prone to exhibit bleeding related to probing force. On the other side, bleeding in smokers lacks sensitivity owing to the decreased angiogenic activity. Hence, the use of dichotomous scales on bleeding in the general population, in contrast to indices that feature profuseness and time after probing, might lead to false positive diagnoses. The definitive distinction between peri-implant mucositis and peri-implantitis, though, relies upon the radiographic evidence of progressive bone loss that can be assessed by means of two- and three-dimensional methods. Accordingly, the objective of this review is to evaluate the existing clinical and radiographic parameters/methods to monitor peri-implant conditions.

Immediate versus early implant placement for single tooth replacement in the aesthetic area: A systematic review and meta-analysis

OBJECTIVES

To compare immediate implant placement (IIP) with early implant placement (EIP) for single tooth replacement in the aesthetic area in terms of aesthetic, clinical, and patient-reported outcomes.

MATERIALS AND METHODS

Two independent reviewers conducted an electronic literature search in PubMed, Web of Science, Embase, and Cochrane databases as well as a manual search to identify eligible clinical studies up to February 2023. Randomized Controlled Trials (RCTs) comparing IIP with EIP were included for a qualitative and quantitative analysis. The primary outcome was vertical midfacial soft tissue change. Secondary outcomes were horizontal midfacial soft tissue change, vertical papillary change, pink esthetic score (PES), implant survival, buccal bone thickness, marginal bone level change, patient discomfort, chair time, and patient satisfaction.

RESULTS

Out of 1185 records, 6 RCTs were selected, reporting on 222 patients who received 222 single implants (IIP: 112 implants in 112 patients; EIP: 110 implants in 110 patients) in the anterior maxilla or mandible. Patients had a mean age ranging from 35.6 to 52.6 years and were followed between 8 and 24 months. Two RCTs showed some concerns, and four showed a high risk of bias. Four studies could be included in a meta-analysis on the primary outcome and three only considered cases with an intact buccal bone wall. Meta-analysis failed to demonstrate a significant difference in terms of vertical midfacial soft tissue change between IIP and EIP (mean difference: 0.31 mm, 95% CI [-0.23; 0.86], p = .260; I2 = 83%, p < .001). No significant differences were found for PES (standardized mean difference: 0.92, 95% CI [-0.23; 2.07], p = .120; I2 = 89%, p < .001), implant survival (RR: 0.98, 95% CI [0.93, 1.03], p = .480; I2 = 0%, p = .980), and marginal bone level change (mean difference: 0.03 mm, 95% CI [-0.12, 0.17], p = .700; I2 = 0%, p = .470). Insufficient data were available for meta-analyses of other secondary outcomes.

CONCLUSION

In low-risk patients with an intact buccal bone wall, there seems to be no difference between IIP and EIP in terms of aesthetic and clinical outcomes. The strength of this conclusion is rated as low since studies showed an unclear or high risk of bias. In addition, state-of-the-art therapy was only delivered in a minority of studies. Future RCTs should also provide data on patient-reported outcomes since these have been underreported.

Coverage stability of peri-implant soft tissue dehiscence: A systematic review and meta-analysis

OBJECTIVE

The occurrence of peri-implant soft tissue dehiscence, especially in the esthetic zone, can be challenging. This study sought to investigate how the passage of time affects the outcomes of treatment for peri-implant soft tissue dehiscence coverage.

MATERIALS AND METHODS

A literature search was performed up to April 2023 via PubMed, Scopus, and Web of Science to retrieve studies reporting the data on peri-implant soft tissue dehiscence of at least 2-time points (baseline and follow-up). Clinical trials with a minimum of 5 participants, reporting at least 1 primary outcome, and with a minimum follow-up of 3 months were included. The primary outcomes were the changes in dehiscence depth, complete coverage, and mean coverage at different time points.

RESULTS

Seven studies with 112 participants and 119 implants were included. Dehiscence depth increased insignificantly between 3 to 6 months. Although the dehiscence depth increased from 6 to 12 months in the tunnel group, it decreased in the coronally advanced group, and a slight decrease was observed from 12 to 72 months. Soft tissue thickness was the predictor for soft tissue margin stability. However, no significant relationship was found between the baseline dehiscence depth and complete coverage.

CONCLUSIONS

Within the limitations of this study, it seems prudent to wait at least 6 months to achieve a stable soft tissue margin.

CLINICAL SIGNIFICANCE

The occurrence of peri-implant soft tissue dehiscence, especially in the esthetic zone, can be a challenging complication. It is important not only to achieve coverage but also to ensure that the treatment results remain stable in the long term, in order to satisfy both patients and clinicians. A reasonable approach would be to wait for at least 6 months to achieve a stable soft tissue margin.

Bone regeneration in implant dentistry: Which are the factors affecting the clinical outcome?

The key factors that are needed for bone regeneration to take place include cells (osteoprogenitor and immune-inflammatory cells), a scaffold (blood clot) that facilitates the deposition of the bone matrix, signaling molecules, blood supply, and mechanical stability. However, even when these principles are met, the overall amount of regenerated bone, its stability over time and the incidence of complications may significantly vary. This manuscript provides a critical review on the main local and systemic factors that may have an impact on bone regeneration, trying to focus, whenever possible, on bone regeneration simultaneous to implant placement to treat bone dehiscence/fenestration defects or for bone contouring. In the future, it is likely that bone tissue engineering will change our approach to bone regeneration in implant dentistry by replacing the current biomaterials with osteoinductive scaffolds combined with cells and mechanical/soluble factors and by employing immunomodulatory materials that can both modulate the immune response and control other bone regeneration processes such as osteogenesis, osteoclastogenesis, or inflammation. However, there are currently important knowledge gaps on the biology of osseous formation and on the factors that can influence it that require further investigation. It is recommended that future studies should combine traditional clinical and radiographic assessments with non-invasive imaging and with patient-reported outcome measures. We also envisage that the integration of multi-omics approaches will help uncover the mechanisms responsible for the variability in regenerative outcomes observed in clinical practice.

Differences in Physical Activity Patterns among Korean Adolescents during and after COVID-19

Due to the COVID-19-induced social distancing restrictions, adolescents' physical activity declined and their level of health and fitness decreased. In March 2023, the Korean government established the beginning of the post-COVID-19 era by declaring that indoor masks were now "recommended" rather than "mandatory". Consequently, adolescents, whose physical activity decreased during COVID-19, began to participate in such activities again. This study aimed to verify the differences in adolescent physical activity during COVID-19 and after COVID-19. To achieve the study's purpose, an online survey was conducted twice, using the International Physical Activity Questionnaire, for 1143 Korean adolescents in 2022 and 2023. The following results were derived through frequency analysis, descriptive statistical analysis, and an independent variables t-test. First, moderate-to-vigorous physical activity was higher during the post-COVID-19 period than during COVID-19 (p = 0.018). Second, high-intensity (p = 0.018), moderate-intensity (p = 0.030), and low-intensity (p = 0.002) physical activities and total leisure-time physical activities (p = 0.003) were all higher during the post-COVID-19 period than during COVID-19. Third, high-intensity (p = 0.005), moderate-intensity (p = 0.003), low-intensity (p = 0.003) activities and total physical activities in school (p = 0.001) were all higher during the post-COVID-19 period than during COVID-19. Fourth, there was no difference in the commuting times for cycling (p = 0.515) and walking (p = 0.484) and the total physical activities during commuting (p = 0.375) during and after COVID-19. Based on these results, the methods to help adolescents form correct habits for leading a healthy life are discussed.

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.

Immediate implant placement with or without immediate provisionalization: a systematic review and meta-analysis

OBJECTIVES

To assess the effect of immediate provisionalization (IP) on soft tissue changes, hard tissue changes and clinical parameters following single immediate implant placement (IIP).

MATERIALS AND METHODS

Two independent reviewers conducted an electronic literature search in Pubmed, Web of Science, Embase and Cochrane databases as well as a manual search to identify eligible clinical studies up to September 2021. Randomized Controlled Trials (RCTs) comparing IIP with IP (test) to IIP without IP (control) were included for a qualitative and quantitative analysis. The primary outcome was vertical midfacial soft tissue changes. Secondary outcomes included horizontal midfacial soft tissue changes, implant survival, mesial and distal papillary changes, Pink Esthetic Score (PES) at final follow-up, marginal bone level changes, probing depth at final follow-up, and bleeding on probing at final follow-up.

RESULTS

Out of 8213 records, 7 RCTs were selected reporting on 323 patients who received 323 single immediate implants (IIP + IP: 161 implants in 161 patients; IIP: 162 implants in 162 patients) with a mean follow-up ranging from 12 to 60 months. Risk of bias assessment yielded some concerns for 5 RCTs and high risk for 2 RCTs. Meta-analysis on the cases with intact alveoli demonstrated 0.87 mm (95 % CI [0.57; 1.17], p < 0.001) less apical migration of the midfacial soft tissue level for IIP + IP when compared to IIP alone. Implant survival, papillary changes, marginal bone level changes, probing depth and bleeding on probing were not significantly affected by IP. Insufficient data were available for meta-analyses on horizontal midfacial soft tissue changes and PES.

CONCLUSION

IP may contribute to midfacial soft tissue stability at immediate implants. However, high-quality RCTs are needed since the strength of this conclusion is currently rated as low according to GRADE guidelines. This article is protected by copyright. All rights reserved.

Occurrence, associated factors and soft tissue reconstructive therapy for buccal soft tissue dehiscence at dental implants: Consensus report of group 3 of the DGI/SEPA/Osteology Workshop

OBJECTIVES

To systematically assess the literature and report on (1) the frequency of occurrence of buccal soft tissue dehiscence (BSTD) at implants, (2) factors associated with the occurrence of BSTD and (3) treatment outcomes of reconstructive therapy for the coverage of BSTD.

MATERIALS AND METHODS

Two systematic reviews addressing focused questions related to implant BSTD occurrence, associated factors and the treatment outcomes of BSTD coverage served as the basis for group discussions and the consensus statements. The main findings of the systematic reviews, consensus statements and implications for clinical practice and for future research were formulated within group 3 and were further discussed and reached final approval within the plenary session.

RESULTS

Buccally positioned implants were the factor most strongly associated with the risk of occurrence of BSTD, followed by thin tissue phenotype. At immediate implants, it was identified that the use of a connective tissue graft (CTG) may act as a protective factor for BSTD. Coverage of BSTD may be achieved with a combination of a coronally advanced flap (CAF) and a connective tissue graft, with or without prosthesis modification/removal, although feasibility of the procedure depends upon multiple local and patient-related factors. Soft tissue substitutes showed limited BSTD coverage.

CONCLUSION

Correct three-dimensional (3D) positioning of the implant is of utmost relevance to prevent the occurrence of BSTD. If present, BSTD may be covered by CAF +CTG, however the evidence comes from a low number of observational studies. Therefore, future research is needed for the development of further evidence-based clinical recommendations.