Effect of connective tissue grafting on peri-implant tissue in single immediate implant sites: A RCT

Optimizing Implant Placement Timing and Loading Protocols for Successful Functional and Esthetic Outcomes: A Narrative Literature Review

Objective: This review article aims to analyze the existing relevant literature comparing the clinical outcomes and underlining the most common complications associated with immediate, early, and delayed dental implant placement in order to determine the most favorable timing for achieving optimal functional and esthetic results for the patient. Methods: A comprehensive review of the literature was conducted using PubMed-MEDLINE and Cochrane Library and a number of keywords, including "dental implant placement timing", "immediate implant", "early implant", "delayed implant", "clinical outcomes", "complications", and "implant success", focusing on studies comparing immediate, early, and delayed implant placement. The primary outcome variable was implant survival rate, while secondary outcome variables included implant success rate, complications, and patient-reported outcomes. Results: A total of 9774 articles were identified. The articles included a variety of studies, including randomized controlled trials, prospective cohort studies, and retrospective studies. Immediate implant placement was associated with a high survival rate (93.8-100%), but also with an increased risk of complications, such as gingival recession and implant exposure. Early implant placement (4-8 weeks or 12-16 weeks after extraction) showed similar survival rates (95-100%) and fewer complications compared with immediate placement. Delayed implant placement (more than 4 months after extraction) was the most commonly used protocol and demonstrated high survival rates (92-100%) with predictable outcomes. Implant success rates varied depending on the criteria used, but all types of placements showed acceptable success rates (83.3-100%). The choice of loading protocol (immediate, early, or conventional) also influences treatment outcomes. Conclusions: The timing of dental implant placement and loading should be individualized based on patient-specific factors, such as bone and soft tissue conditions, medical history, esthetic considerations, and patient preferences. Immediate placement can be successful in ideal conditions but requires careful patient selection and surgical expertise. Early and delayed placement offer more predictable outcomes and are suitable for a wider range of patients.

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.

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.

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).

Novel digital technique for measuring the volumetric healing process of free gingival grafts surrounding dental implants

The objective of the present study was to analyze and describe a new digital technique for analyzing the volumetric healing process of free gingival grafts in both donor and recipient locations surrounding a dental implant, as well as to compare the reliability of conventional and digital techniques for measuring the width of the free gingival graft in the recipient location throughout the healing process.

Materials and methods

Ten patients presenting with mucositis linked to a dental implant were included. A preoperative soft tissue width <2 mm, with probing pocket depth <5 mm, edema and inflammation and bleeding on probing was determined A digital impression was taken of both donor and recipient locations using an intraoral scan, generating a Standard Tessellation Language digital file both preoperatively (STL1) and after 1 week (STL2), 1 month (STL3), 3 months (STL4), and 6 months (STL5) of follow-up. Afterwards, the digital files (STL1-STL5) were aligned using a reverse engineering morphometric software, and Student's t-test was used to analyze changes in volume at the donor and recipient locations. Additionally, widths were measured both clinically and digitally so as to compare the reliability of these measurement techniques. The repeatability and reproducibility of both these measurement techniques were also analyzed using Gage R&R statistical analysis.

Results

Gage R&R found that the total variability of the digital technique was 0.6% (among the measures of each operator) and 7.6% (among operators); as variability was under 10%, the results were repeatable and reproducible. In addition, there were statistically significant differences between donor and recipient locations in healing process volume (mm3) after one week (p = 0.0110), one month (p = 0.0007), three months (p < 0.0001) and six months (p = 0.0004) of follow-up.

Conclusion

The digital measurement technique provided accurate, repeatable, and reproducible results when analyzing the volumetric and linear measures of the healing process in both the donor and recipient locations of a free gingival graft surrounding a dental implant, with significantly higher tissue volume in the recipient location.

Profilometric, esthetic, and patient-reported outcomes of the L-shape technique combined with delayed connective tissue grafting in the maxillary anterior region: A 3-year case series study

OBJECTIVE

To evaluate the profilometric, esthetic, and patient-reported outcomes of peri-implant tissues in the maxillary anterior esthetic zone following guided bone regeneration (GBR) using the L-shape technique combined with delayed connective tissue grafting (CTG).

MATERIALS AND METHODS

Profilometric and pink esthetic score (PES) measurements were performed at the time of implant surgery with GBR (T0) and at the 1- (T1), 2- (T2), and 3-year (T3) follow-up. Patient-reported outcomes were also assessed using the Oral Health Impact Profile-14 (OHIP-14) questionnaire. Statistical analysis over 3 years of follow-up assessed changes at time points (T0, T1, T2, and T3) and time periods (T0-T1, T0-T2, and T0-T3) using the Wilcoxon signed-rank test.

RESULTS

A total of 12 patients (57.5 ± 12.3 years) were included in this study. The mean profilometric change in peri-implant tissues over the 3-year follow-up period was 3.49 ± 1.11 mm, and the buccal contours were not significantly different between the comparison periods. The PES remained stable, while all OHIP-14 domain scores improved significantly.

CONCLUSION

Simultaneous implant placement and GBR using the L-shape technique combined with delayed CTG in the maxillary anterior region provides stable buccal profiles and consistent esthetics and improves patient-reported quality of life over a 3-year period.

CLINICAL SIGNIFICANCE

This study demonstrated that GBR using the L-shape technique combined with delayed CTG in the maxillary anterior region improved the buccal profile, esthetics, and patient-reported quality of life.

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.

Hard and soft tissue alterations using dual-zone concept versus connective tissue graft at maxillary immediate implant placement: A 1-year randomized clinical and volumetric trial

OBJECTIVES

To evaluate the esthetic outcome, as well as clinical, radiographic, and volumetric tissue alterations 1 year after immediate implant placement (IIP) with connective tissue grafting (CTG) versus dual-zone concept (DZ) at sites with thin labial bone in the esthetic zone.

MATERIALS AND METHODS

This randomized clinical trial included 30 patients treated with IIP simultaneous with either CTG or DZ (n = 15 each). Pink esthetic score (PES) was assessed 6 months after crown placement as the primary outcome. Amount of bone labial to the implant, labio-palatal ridge reduction, and crestal bone changes were measured via CBCT after 1 year. Volumetric analysis of linear labial soft tissue contour, interdental, and mid-facial soft tissue level changes, and total volume loss (mm3) were measured after 1 year.

RESULTS

Similar PES was observed in the CTG (12.53 ± 1.13) and DZ (12.13 ± 1.55) groups, with no significant difference (p = 0.42). Likewise, there were no statistically significant differences found between the two groups in labio-palatal bone reduction (mm&%), interdental papillae, and mid-facial gingival levels (p > 0.05). However, the mean vertical crestal bone changes in the CTG and DZ groups were -1.1 ± 0.6 mm and 0.2 ± 1.0 mm, respectively, with a statistically significant difference (p = 0.0002). Moreover, CTG revealed less linear and total volume (mm3) loss in the labial soft tissue which was statistically significant compared to DZ (p = 0.007).

CONCLUSION

Both groups demonstrated the same PES, nevertheless, volumetric analysis revealed twice total labial volume loss in DZ compared to CTG. It might be concluded that the use of CTG with IIP caused less horizontal reduction in the supra-implant complex compared to the DZ.

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.

Difference in Buccal Gingival Thickness between the Mandible and Maxilla in the Aesthetic Zone: A Systematic Review and Meta-Analysis

Background: Fragile gingival tissue is a risk factor for the development of gingival recessions. Despite the fact that gingival recessions are more commonly seen around anterior mandibular teeth, previous research has predominantly concentrated on the gingival dimensions in the anterior maxilla. The objective was to systematically compare buccal gingival thicknesses between the upper and lower jaws in individuals with healthy gingival conditions in the aesthetic zone. Methods: A comprehensive search of three databases was carried out until October 2023. Gingival thickness differences between the maxilla and mandible were evaluated by calculating the mean differences along with the corresponding 95% confidence interval (CI). Subgroup analysis was conducted based on the measurement area, measurement method, and tooth category. Results: A total of seventeen studies were included in this systematic review. Eleven studies were included in the quantitative analysis. Quantitative analysis comparing gingival thickness around 2100 teeth in the anterior mandible to 2056 teeth in the anterior maxilla revealed a statistically significant thinner buccal gingiva in the mandible (mean difference: 0.16 mm; 95% CI [-0.24, -0.07]; p = 0.0003). Conclusions: The present systematic review revealed a more delicate buccal gingiva in the anterior mandible. However, further scientific validation is required due to the considerable heterogeneity in study design and the potential presence of confounding variables.

Pre- and Postoperative Evaluation of Immediate and Early Implant Placement in Esthetic Areas with Pre-Extraction Facial Dehiscence: A Retrospective Clinical Study

The clinical requirement for a good esthetic result for immediate implant placement is the absence of dehiscence in the anterior facial alveolar bone. In the presence of dehiscence, it is recommended to use a connective tissue graft in addition to immediate implant placement or to change to early implant placement. However, the literature focusing on dehiscence is scarce, and the influence of different placement times and combined use of connective tissue graft on postoperative esthetics in cases with dehiscence is unclear. Therefore, we quantitatively evaluated the pre-extraction dehiscence morphology and postoperative changes in the facial tissue of implants in three groups: immediate implant placement (Group I), immediate implant placement with connective tissue graft (Group IC), and early implant placement (Group E). To this end, 52 implants were obtained (20 in Group I, 16 in Group IC, and 16 in Group E). A wider dehiscence increases the risk of soft tissue regression, which was one reason for choosing early implant placement. A combination of immediate implant placement and connective tissue graft, or early implant placement, tended to result in less soft tissue regression due to the thicker postoperative facial soft tissue volume.

Clinical performance of immediately placed and immediately loaded single implants in the esthetic zone: A systematic review and meta-analysis

OBJECTIVES

The aim of this study was to assess the following PIO question: In adult patients treated with an indication for single tooth extraction in the maxillary esthetic zone (15-25), what is the influence of an immediate implant placement and immediate loading protocol on the clinical performance (primary aim) and esthetic outcomes (secondary aim) focusing on investigations published after 2010.

MATERIAL AND METHODS

An electronic search in Medline (PubMed), the Cochrane Central Register of Controlled Trials, and EMBASE databases up to April 2022 was performed to identify clinical studies investigating the outcome of single implants subjected to immediate placement with immediate restoration/loading (Type 1A).

RESULTS

Sixty-three studies (10 randomized controlled trials, 28 prospective and 25 retrospective cohort studies) were included with a follow-up ranging from 12 to 96 months. One thousand nine hundred sixty-one implants reported survival rates of 99.2 (98.6-99.5) % at 1 year, 97.5 (95.9-98.4) % after 3 years, and 95.8 (93.3-97.4) % after 5 years; 1064 immediately loaded restorations presented survival rates of 98.9 (97.8-99.5) % after 1 year, 96.8 (93.6-98.4) % after 2 years, and 94.8 (89.6-97.4) % after 5 years. Comparing baseline to 12-month data using the Hedges' g effect size (95% CI), papilla height presented an overall effect size of -0.71 (-1.25, -0.1) mm, midfacial recession change of -0.15 (-0.66, 0.36) mm, and a 0.82 (0.37, 1.28) gain in PES.

CONCLUSIONS

Immediate implant placement and immediate loading can be considered a predictable and safe treatment option for single maxillary anterior restorations with adequate survival rates and favorable esthetics outcomes for up to 5 years.

Selection criteria for immediate implant placement and immediate loading for single tooth replacement in the maxillary esthetic zone: A systematic review and meta-analysis

OBJECTIVES

The aim of this study was to review available evidence for Type 1A (immediate implant placement and immediate loading) of single tooth replacement in the maxillary esthetic zone.

MATERIALS AND METHODS

An electronic search was conducted utilizing the databases of MEDLINE, Embase, and Cochrane to identify publications reporting on the outcomes of Type 1A for single tooth replacement in the maxillary esthetic zone. The success and survival rates of the included articles were reported, which were further categorized according to the clinical criteria reported in Type 1A. Mean survival rates were univariately compared between risk groups and additionally between studies published before and since 2012 using bias-corrected and study size-weighed bootstrap tests. A study time-correcting meta-analysis was then performed to obtain an overall effect for the study pool.

RESULTS

A total of 3118 publications were identified in the search, with a total of 68 articles included. A mean number of implants per study were 37.2 and mean follow-up was 2.8 years. All the included studies utilizing Type 1A report highly selective inclusion and exclusion criteria. Univariate risk group comparison determined that studies before 2012 report a significantly lower mean survival rate (difference of -1.9 percentage points [PP], 95% CI: [-0.3, -4.0], p = .02), facial gap dimension had an impact on survival rates (+3.1 PP [0.2, 5.3] for width >2 mm, p = .04), as well as presence of endodontic infection (+2.6 PP [0.9, 5.1], p = .004).

CONCLUSIONS

Type 1A has a high survival rate in studies reporting strict patient and site selection criteria. Further research is required to assess esthetic and functional success with Type 1A treatments.

Evaluation of esthetic outcome of delayed implants with de-epithelialized free gingival graft in thin gingival phenotype with or without immediate temporization: a randomized clinical trial

AIM

The current study investigates the effect of immediate temporization on the pink esthetics of delayed implants in patients with thin gingival phenotype in combination with a De-epithelialized Free Gingival Graft in the maxillary premolar area.

METHODOLOGY

The study population was randomly assigned into two groups. The two groups were treated with delayed implants with simultaneous placement of a de-epithelialized free gingiva graft. The test group was immediately temporized while the control group had no temporization. The pink esthetic score was assessed as the primary outcome. Additional secondary outcomes were assessed such as the keratinized tissue width and the soft tissue thickness.

RESULTS

Twenty implants were placed in the current study, split into 10 implants per group. The results showed that the Pink Esthetic Score of the IT group was 11.88 ± (1.13) and 11.33 ± (1.25) for the CTG group, which showed no statistical difference between the groups after 1 year of follow-up. There was also no significant difference between the two groups at 12 months regarding the keratinized tissue width and the soft tissue thickness.

CONCLUSIONS

Immediate and delayed temporizations have no effect on the Pink Esthetics of the delayed implants; however, immediate temporization allowed earlier provisional crown delivery. Soft tissue augmentation of the thin gingival phenotype improved esthetics for both groups. Trial registration Name of the registry: clinicaltrials.gov; trial registration number: NCT03792425. Date of registration: January 3, 2019. URL of trial registry record: https://clinicaltrials.gov/ct2/show/NCT03792425?term=NCT03792425&draw=2&rank=1.

Soft tissue esthetics around immediately provisionalized delayed implants with and without connective tissue graft: A randomized clinical trial pilot study

OBJECTIVE

Evaluate the peri-implant soft tissue esthetics following a single, immediately provisionalized, delayed implant with/-out subepithelial connective tissue graft (SCTG).

MATERIAL AND METHODS

The eligible patients were randomized into two groups. Immediate provisionalization was performed with (test group: SCTGG) or without SCTG (control group: NGG). The soft tissue esthetics was assessed by Pink Esthetic Score (PES) and Mucosal Scarring Index (MSI), at 6 and 12 months, following final implant restoration.

RESULTS

The SCTGG, compared to NGG, yielded a 0.2 increased PES at 12 months (95% confidence interval (CI): -1, 1.4) and a 0.2 decreased MSI score (95% CI -0.9, 0.5) with no statistically significant differences in PES and MSI between both groups (p > 0.05).

CONCLUSION

Soft tissue grafting around immediately provisionalized delayed implants could exhibit comparable results to immediate provisionalization alone in terms of peri-implant soft tissue esthetics using PES and MSI (ClinicalTrials.gov Identifier: NCT03770975).

Soft tissue augmentation with a volume-stable collagen matrix or an autogenous connective tissue graft at implant sites: Five-year results of a randomized controlled trial post implant loading

BACKGROUND

Interventions to augment the mucosal thickness around dental implants are indicated to optimize esthetics and maintain peri-implant health. However, there is a lack of clinical data on the long-term performance of soft tissue substitutes, such as volume-stable collagen matrix (VCMX), compared to autogenous grafts, such as subepithelial connective tissue grafts (SCTGs). This randomized controlled trial aimed to assess 5-year data on clinical and radiographic outcomes at implant sites previously augmented with VCMX or SCTG.

METHODS

Twenty patients were randomly assigned for soft tissue augmentation with VCMX or SCTG at single implant sites. Following abutment connection, final restorations were inserted (baseline; BL) and patients were reexamined up to 5 years (FU-5). Measurements included clinical data, marginal bone levels, mucosal thickness, and ridge contour changes. Nonparametric tests and estimates were applied for the statistical analysis.

RESULTS

The median buccal mucosal thickness increased by 0.3 mm (Q1: -0.8; Q3: 1.0) in the VCMX group (P = 0.656) and 0.3 mm (Q1: 0.0; Q3: 1.0) in the SCTG group (P = 0.188) between BL and FU-5 (intergroup P = 0.752), while the ridge contour decreased by a median of -0.3 mm (-0.9; -0.1) (P = 0.078) for VCMX and -0.3 mm (-0.4; -0.2) (P = 0.039) for SCTG (intergroup P = 0.817). Peri-implant health was maintained in both groups with stable clinical and radiographic outcomes and without significant differences between the treatments.

CONCLUSION

Despite the limited power and considerable dropout rate in the present study, soft tissue augmentation at implant sites with either VCMX or SCTG resulted in similar stable peri-implant tissues, favorable esthetics, and clinically negligible contour changes at 5 years post loading.

A multifunctional guided surgery to assist in the 3-dimensional positioning of dental implants and in obtaining a palatal gingival graft

Parameters such as the correct 3-dimensional positioning and the quality of peri-implant soft tissues are fundamental to the success of implant-supported restorations. Digital planning and guided surgery techniques can make the implant placement more accurate, and modifying the periodontal phenotype is often fundamental to increasing esthetics and peri-implant health, mainly in esthetic areas. This article describes a guided surgery technique that assists in the 3-dimensional positioning of implants and identifies the best anatomic area (volume and safety) for obtaining a palatal gingival graft.

Facial implant gingival level and thickness changes following maxillary anterior immediate tooth replacement with scarf-connective tissue graft: A 4-13-year retrospective study

OBJECTIVE

A scarf-shaped connective tissue graft can be placed at the facial and proximal aspect of the peri-implant soft tissue zone during immediate implant placement and provisionalization (IIPP) procedures in the esthetic zone to optimize implant esthetics without the need of flap reflection. This retrospective study evaluated soft tissue stability after scarf-connective tissue graft (S-CTG) in conjunction with IIPP procedures in the esthetic zone.

MATERIALS AND METHODS

Patients who received IIPP with S-CTG with a minimum 1-year follow-up were evaluated. Mid-facial gingival level (MFGL) change and mid-facial gingival thickness (MFGT) change were measured and compared at the pre-op (T0), IIPP + S-CTG surgery (T1), follow up appointment with MFGT measurement (T2), and latest follow-up appointment (T3). Implant success rate and graft necrosis were also recorded.

RESULTS

A total of 22 IIPP and S-CTG procedures in 20 patients were evaluated in the study. After a mean follow-up of 8.2 years (3.9-13.4) (T3), all implants remained osseointegrated (22/22 [100%]), with statistically insignificant mean midfacial gingival level change of -0.19 mm (-1.5 to 0.8). Statistically significant difference in midfacial gingival thickness (MFGT) was noted (2.5 mm [1.8-3.5 mm]) after a mean follow-up time (T2) of 2.3 years (1-8.6) when compared with MFGT at baseline (1.1 mm [0.6-1.3 mm]) (T1). Necrosis of S-CTG during initial healing phase was noted in 9% (2/22) of the sites.

CONCLUSIONS

Within the confines of this study, scarf-connective tissue graft at time of immediate implant placement and provisionalization can thicken the gingiva and maintain the gingival level at the critical soft tissue zone.

CLINICAL SIGNIFICANCE

Managing the soft tissue zone is as important as that of the hard tissue zone for peri-implant esthetics. Connective tissue graft is one of the methods that can enhance the final esthetic outcomes. This retrospective study has demonstrated that Scarf-CTG technique is an effective treatment modality to maintain soft tissue stability.

Anterior implant restorations with a convex emergence profile increase the frequency of recession: 12-month results of a randomized controlled clinical trial

AIM

To test whether the emergence profile (CONVEX or CONCAVE) of implant-supported crowns influences the mucosal margin stability up to 12 months after insertion of the final restoration.

MATERIALS AND METHODS

Forty-seven patients with a single implant in the anterior region were randomly allocated to one of three groups: (1) CONVEX (n = 15), implant provisional and an implant-supported crown both with a convex profile; (2) CONCAVE (n = 16), implant provisional and an implant-supported crown both with a concave profile; (3) CONTROL (n = 16), no provisional (healing abutment only) and an implant-supported crown. All patients were recalled at baseline, 6, and 12 months. The stability of mucosal margin along with clinical, aesthetic, and profilometric outcomes as well as time and costs were evaluated. To predict the presence of recession, multivariable logistic regressions were performed and linear models using generalized estimation equations were conducted for the different outcomes.

RESULTS

Forty-four patients were available at 12 months post-loading. The frequency of mucosal recession amounted to 64.3% in group CONVEX, 14.3% in group CONCAVE, and 31.4% in group CONTROL. Regression models revealed that a CONVEX profile was significantly associated with the presence of recessions (odds ratio: 12.6, 95% confidence interval: 1.82-88.48, p = .01) compared with the CONCAVE profile. Pink aesthetic scores amounted to 5.9 in group CONVEX, 6.2 in group CONCAVE, and 5.4 in group CONTROL, with no significant differences between the groups (p = .735). Groups CONVEX and CONCAVE increased the appointments and costs compared with the CONTROL group.

CONCLUSIONS

The use of implant-supported provisionals with a CONCAVE emergence profile results in a greater stability of the mucosal margin compared with a CONVEX profile up to 12 months of loading. This is accompanied, however, by increased time and costs compared with the absence of a provisional and may not necessarily enhance the aesthetic outcomes.

TRIAL REGISTRATION

German Clinical Trials Register; DRKS00009420.

Minimal invasiveness in soft tissue augmentation at dental implants: A systematic review and meta-analysis of patient-reported outcome measures

The aim of this study was to compare patient-reported outcome measures (PROMs) of soft tissue substitutes versus autogenous grafts for soft tissue augmentation procedures at implant sites. Comprehensive and systematic literature searches were performed until December 2021. A focused question was formulated based on the Population, Intervention, Comparison and Outcome criteria (PICO): In patients with dental implants undergoing soft tissue augmentation (P), do soft tissue substitutes (I) compared to autogenous soft tissue graft (SCTG [subepithelial connective tissue graft]) (C) limit the post-operative morbidity and other patient reported-outcomes measures (O). Randomized controlled clinical trials, prospective-, retrospective- and case-series studies were included. Meta-analyses were performed whenever possible and the results were expressed as weighted mean differences (WMD). A total of 29 clinical studies were included. For mucosal thickness gain, soft tissue substitutes significantly reduced the pain perception compared to SCTG (n = 4; WMD = 14.91 Visual Analog Scale [VAS] units; 95% confidence interval [CI] 6.42-23.40; P < .0006) based on a 0-100 VAS scale. Based on a 0-10 VAS scale, a borderline significance of pain reduction was found when soft tissue substitutes were applied (n = 4; WMD = 1.62 VAS units; 95% CI 0.01-3.23; P = .05). For keratinized tissue gain, soft tissue substitutes significantly reduced the pain perception after keratinized tissue augmentation compared to SCTG based on a 0-100 VAS scale (n = 2; WMD = 21.43 VAS units; 95% CI 12.58-30.28; P < .0001). Based on the 0-10 VAS scale, soft tissue substitutes significantly reduced the pain as compared to SCTG (n = 4; WMD = 1.65 VAS units; 95% CI 0.66-2.64; P = .001). Regarding pain medication, soft tissue substitutes required less painkillers (n = 6; WMD = 1.56 tablets; 95% CI 1.22-1.91; P < .00001) after soft tissue augmentation. The surgery time was significantly reduced when soft tissue substitutes were used (n = 5; WMD = 10.9 minutes; 95% CI 4.60-17.19; P < .00001). There were no significant differences in satisfaction, aesthetics, and quality of life (OHIP-14) between soft tissue substitutes and autogenous grafts following soft tissue augmentation at implants sites. Soft tissue substitutes, compared to autogenous grafts, significantly improve PROMs following soft tissue augmentation at implant sites. Soft tissue substitutes can reduce pain perception, amounts of painkillers and surgery time while achieving similar levels of patient´s satisfaction as autogenous grafts without impairing the clinical outcomes. The current evidence indicates that they constitute a valid and reliable alternative to minimize the invasiveness in soft tissue augmentation procedures at implant sites.

Minimal invasiveness in the alveolar ridge preservation, with or without concomitant implant placement

The aim of this systematic review was to evaluate the benefit of ridge preservation (RP) with minimally invasive (MI) approaches with or without concomitant implant placement on morbidity, esthetics, and patient-related outcomes. Three Internet sources were used to search for appropriate papers. The search strategy was designed to include any clinical study published on RP with MI approaches such as flapless surgery, socket shield and socket sealing techniques and, use of biological agents. Characteristics of the individual studies, regarding methodological aspects, quantitative and qualitative data were extracted. The potential risk of bias was estimated, and the acquired evidence was graded. Independent screening of 860 reports resulted in 26 included original articles. Nine publications evaluated MI approaches for RP without concomitant implant placement. Eleven studies evaluated interventions for RP with immediate implant placement (IIP). Six studies compared RP with IIP vs RP without IIP. This systematic review found that MI approaches in most of the studies failed to improve clinical variables regarding morbidity, esthetics, and patient-related outcomes. Based on the limited number of studies analyzed and the methodological discrepancies observed, it is not possible to confirm that MI approaches promote a significant benefit when applied to RP procedures.

Immediate implants with buccal defects filled with bone from the tuberosity or a xenograft: 1-year randomized trial

The aim of this study was to compare the use of autologous bone from tuberosity (TUBER) and deproteinized bovine bone mineral (DBBM) in immediate implants with buccal bone defects. A total of 31 patients with one single tooth in the upper anterior region indicated for extraction presenting tomographic buccal bone defect were analyzed. Immediate implantation was conducted for all patients. In one group, DBBM and a collagen membrane were inserted into the buccal defect; in the other group, a small block of bone from tuberosity was used. The primary outcome was facial-palatal ridge thickness (FPT) measured in casts 1 year after function. The implant success rate was 100% in both groups. FPT changes were <0.5 mm and did not differ significantly between groups. FPT reductions in the DBBM and TUBER groups were 1% and 0.6%, respectively, at the gingival margin and 5% and 2%, respectively, at 6 mm apical of the gingival margin (p > 0.05). No significant differences were observed between groups for patient's esthetic, satisfaction, pain and quality of life. Pink esthetic scores for the DBBM and TUBER were 11.5±1.7 and 10.8±1.9, respectively (p=0.37). It can be concluded that DBBM and TUBER did not differ in terms of ridge alterations, peri-implant clinical parameters and patient-reported outcomes.

Profilometric, volumetric, and esthetic analysis of guided bone regeneration with L-shaped collagenated bone substitute and connective tissue graft in the maxillary esthetic zone: A case series with 1-year observational study

PURPOSE

The aim of this study was to evaluate 1-year stability and maintenance of peri-implant soft and hard tissues after guided bone regeneration (GBR) with L-shaped collagenated bone substitute and subepithelial connective tissue graft (CTG) in the maxillary anterior region using profilometric, volumetric, and esthetic analyses.

METHODS

Fourteen peri-implant defects were grafted with L-shaped collagenated bone substitute, and 5 months after implant placement with GBR, reentry surgery in combination with CTG was performed in all participants. CBCT scans and STL files were acquired at baseline (after implant surgery, T1), reentry surgery (T2), and 1-year follow-up (T3). The profilometric and volumetric changes of the peri-implant tissues were measured, and the pink esthetic score (PES) was assessed at T3.

RESULTS

One year after GBR and CTG at the buccal aspect of the maxillary esthetic zone, the mean thickness of the hard tissue (HT) decreased (HT0: -0.87 ± 0.67 mm, HT1: -0.74 ± 0.75 mm, HT2: -0.92 ± 0.48 mm, 45-HT: -0.87 ± 0.73 mm) and the corresponding thickness of the soft tissue (ST) increased (ST0: 0.96 ± 1.06 mm, ST1: 0.85 ± 0.95 mm, ST2: 0.38 ± 0.82 mm, 45-ST: 0.12 ± 0.62 mm), and as a result, there was no statistically significant difference in the total tissue thickness between T1 and T3 (p < 0.05). The mean volumetric changes of the peri-implant tissues increased after 1-year of implant surgery (T1-T2: 1.52 ± 0.83 mm, T2-T3: -0.88 ± 1.04 mm, T1-T3: 0.64 ± 0.90 mm), and a statistically significant difference was shown in all compared time periods (p < 0.05). The mean PES score was 8.07 ± 1.54 at T3 (range, 6-10).

CONCLUSION

Within the limitations of this 1-year follow-up study, GBR with an L-shaped collagenated bone substitute and subepithelial CTG in the maxillary esthetic zone was beneficial for stable and maintainable peri-implant hard and soft tissues.

The influence of thin as compared to thick peri-implant soft tissues on aesthetic outcomes: A systematic review and meta-analysis

Objectives

In systematically healthy patients with an implant‐supported fixed restoration (P), what is the influence of thin (E) as compared to thick (C) peri‐implant soft tissues on aesthetic outcomes (O)?

Methods

Following an a priori protocol, a literature search of six databases was conducted up to August 2020 to identify prospective/retrospective clinical studies on healthy patients with an implant‐supported fixed reconstruction. Measurement of the buccal soft tissue thickness and an aesthetic outcome was a prerequisite, and sites presenting with a buccal soft tissue thickness of <2 mm or shimmering of a periodontal probe were categorized as a thin phenotype. After study selection, data extraction, and risk of bias assessment, random‐effects meta‐analysis of Mean Differences (MD) or Odds Ratios (OR) with their corresponding 95% Confidence Intervals (CI) were conducted, followed by sensitivity analyses and assessment of the quality of evidence.

Results

Thirty‐four unique studies reporting on 1508 patients with 1606 sites were included (9 randomized controlled trials, one controlled trial, 10 prospective cohort studies, 8 cross‐sectional studies, and 6 retrospective cohort studies). The mean difference of the pink aesthetic score (PES) after the follow‐up was not significantly different between thin (<2.0 mm) or thick soft tissues (≥2.0 mm) or phenotypes (12 studies; MD = 0.15; [95% CI = −0.24, 0.53]; p = .46). PES changes during the follow‐up, however, were significantly in favour of thick soft tissues (≥2.0 mm) or phenotypes (p = .05). An increased mean mucosal thickness was associated with an increased papilla index (5 studies; MD = 0.5; [95% CI = 0.1, 0.3]; p = .002) and an increase in papilla presence (5 studies; OR = 1.6; [95% CI = 1.0, 2.3]; p = .03). Thin soft tissues were associated with more recession, −0.62 mm (4 studies; [95% CI = −1.06, −0.18]; p = .006). Patient‐reported outcome measures (patient satisfaction) were in favour of thick soft tissues −2.33 (6 studies; [95% CI = −4.70, 0.04]; p = .05). However, the quality of evidence was very low in all instances due to the inclusion of non‐randomized studies, high risk of bias and residual confounding.

Conclusion

Within the limitations of the present study (weak study designs and various soft tissue measurements or time‐points), it can be concluded that increased soft tissue thickness at implant sites was associated with more favourable aesthetic outcomes.

Digital Workflow for Immediate Implant Placement and Chairside Provisionalization in the Esthetic Zone

Introduction

Immediate implant placement and immediate chairside provisionalization in the esthetic zone require meticulous treatment planning. A digital workflow that combines intraoral scans and a cone beam computed tomography scan can be used to visualize the surgical and restorative aspects of the treatment and to plan a prosthetically driven implant position. A digital workflow in implant dentistry enables the prefabrication of an individualized CAD/CAM temporary restoration, based on the planned implant position. This could be a predictable method to deliver a screw-retained temporary restoration, directly after static computer-assisted immediate implant surgery. Interventions. Three patients with a failing tooth in the maxillary esthetic zone were treated with immediate implant placement and chairside provisionalization using this digital workflow. After 3 months, a final restoration was placed. Clinical, radiographic, and patient-reported outcome measures were collected prior to implant treatment, 6 weeks after placing the temporary restoration and then 1 month and 1 year after placing the final restoration. Outcomes. At the 1-year follow-up, healthy soft tissues were observed, and peri-implant bone levels were stable. Patient satisfaction after the treatment was high.

Conclusion

The three reported cases demonstrate the potential for predictable immediate implant placement and chairside provisionalization using a digital workflow.

Dimensional ridge changes in conjunction with four implant timing protocols and two types of soft tissue grafts: A pilot pre-clinical study

AIM

To determine the effect of (1) implant placement timing and (2) the type of soft tissue graft in terms of ridge profile changes.

MATERIALS AND METHODS

Four implant treatment modalities were applied in the mesial root areas of the third and fourth mandibular premolars of 10 mongrel dogs alongside connective-tissue graft (CTG) and volume-stable cross-linked collagen matrix (VCMX): immediate, early, and delayed placement (DP), and DP following alveolar ridge preservation (ARP). All dogs were sacrificed 3 months after soft tissue augmentation. Standard Tessellation Language files from designated time points were analysed.

RESULTS

Compared with the pre-extraction situation, the median width of the ridge demontstrated a linear increase only in group ARP/CTG (0.07 mm at the 2-mm level), whereas all other groups showed a reduction (between -1.87 and -0.09 mm, p > .05). Groups ARP/CTG (0.17 mm) and DP/CTG (0.05 mm) exhibited a profilometric tissue gain in a set region of interest (p > .05). The net effect of CTG and VCMX ranged from 0.14 to 0.79 mm.

CONCLUSIONS

Dimensional ridge changes varied between treatment protocols. ARP with CTG led to the smallest difference in ridge profile between the pre-extraction and the study end time point. Both CTG and VCMX enhanced the ridge contour.

Connective tissue graft vs porcine collagen matrix after immediate implant placement in esthetic area: A randomized clinical trial

BACKGROUND

The use of connective tissue graft (CTG) with immediate implant placement and provisionalisation have shown promising results. It is not clear if the same outcome could be achieved using porcine-derived collagen matrix (PDCM) as grafting material.

OBJECTIVES

This study aimed to assess the esthetic and functional outcomes of immediate temporization of immediately placed fully tapered implants combined with bone and soft tissue augmentation, using either a CTG or a PDCM, in fresh extraction sockets of the anterior sites.

MATERIALS AND METHODS

Patients with a failing anterior tooth were included in this study. After extraction, they received an immediate implant with simultaneous hard and soft tissue augmentation and immediate provisional restoration. Patients were randomly assigned to one of the group. Soft tissue augmentation in the control group (CTG) consisted of a CTG, whereas PDCM was used in the test group. After 4 months, definitive restorations were delivered, and pink esthetic score (PES) was evaluated at T1, prosthetic delivery, and at 12-month follow-up (T2). In addition, crestal bone change, probing depth, bleeding on probing, plaque index, bleeding on provisional removal, and implant stability quotient were also recorded.

RESULTS

A total of 45 patients received the intended treatment (22 controls and 23 tests) 45 implants totally, with no implant failures at T2. PES mean ± SD after 1 year was noted to be 12.9 ± 1.2 for the CTG group and 12.1 ± 1.3 for the PDCM group (p = 0.507).

CONCLUSION

Within the limits of this trial, both treatment protocols resulted in comparable esthetic outcomes, with results showing PES >12 and stable clinical parameters after 1 year of follow-up.

Immediate implant placement vs. early implant treatment in the esthetic area. A 1-year randomized clinical trial

OBJECTIVES

To assess the impact of implant placement and temporization timing on esthetic outcomes of single maxillary anterior implants with intact bone walls and interproximal bone.

MATERIALS AND METHODS

Test group patients received an immediate implant with immediate provisional restoration and socket preservation, while patients in the control group received an early implant placement with guided bone regeneration and delayed loading. Patients were followed for 1 year after final prosthetic and pink esthetic score (PES), mid-buccal mucosal level (MBML), crestal bone changes (CBC), and peri-implant soft tissue parameters, and patient chair time was recorded.

RESULTS

Fifty patients received the intended treatment (25 test and 25 control). No implants failed. PES after 1 year was 12.8 ± 1.19 for the test group and 12.5 ± 1.36 for the control group (p = .362). MBML difference between baseline (after final crown delivery) and the 1-year follow-up was gain of 0.2 ± 1.02 mm for the test group (p = .047) and no change in the control group. CBC after 1 year were 0.1 mm ± 0.21 mm (mesial) and 0.2 mm ± 0.22 mm (distal) for the test group and 0.2 mm ± 0.25 mm (mesial) and 0.3 mm ± 0.19 mm (distal) for the control group, p = .540 (mesial) and p = .462 (distal). Test group required half the chair time (127 ± 13 min) when compared to the control group (259 ± 15 min, p < .001).

CONCLUSIONS

Within the limits of this trial, both treatment protocols resulted in excellent esthetic outcomes with PES >12 after 1-year follow-up.

Does simultaneous soft tissue augmentation around immediate or delayed dental implant placement using sub-epithelial connective tissue graft provide better outcomes compared to other treatment options? A systematic review and meta-analysis

OBJECTIVE

The clinical benefits of simultaneous implant placement and soft tissue augmentation using different treatment modalities are unclear. The current meta-analysis aimed to compare the effect of simultaneous soft tissue augmentation using subepithelial connective tissue graft (SCTG) around immediate or delayed dental implant placement with other treatment modalities on the peri-implant tissue health and esthetic.

METHODS

Up to May 2021, four databases (PubMed, EMBASE, Cochrane Central, and Google Scholar) were searched. Randomized control trials with follow-up >3 months, evaluating simultaneous implant placement (immediate or delayed) and soft tissue augmentation using SCTG compared with other treatment modalities were included. The predictor variables were SCTG versus no augmentation with/without guided bone regeneration (GBR) or other augmentation techniques (Acellular dermal matrix (ADM), Xenogeneic collagen matrix (XCM). The outcome variables were buccal tissue thickness (BTT), mid-buccal gingival level (MGL), marginal bone loss (MBL), and pink esthetic scores (PES). Cumulative mean differences (MD) and 95% confidence interval (CI) were estimated.

RESULTS

Twelve studies were included. SCTG along with immediate implant placement (IIP) or delayed implant placement (DIP) showed a statistically significant improvement in BTT (Fixed; MD, 0.74; 95% CI, 0.51; 0.97), MGL (Fixed; MD, 0.5; 95% CI, 0.21; 0.80), PES (Fixed; MD, 0.79; 95% CI, 0.29; 1.29), and less MBL (Fixed; MD, -0.11; 95% CI, -0.14; -0.08) compared to no graft (P<0.05). A statistically insignificant differences in BTT (Random; MD, 0.62; 95% CI, -0.41; 1.65), MGL (Fixed; MD, -0.06; 95% CI, -0.23; 0.11), MBL (Fixed; MD, 0.36; 95% CI, -0.05; 0.77) and PES (Fixed; MD, 0.28; 95% CI, -0.10; 0.67) was observed when SCTG along with DIP was compared with no augmentation plus GBR. Similarly, no statistically significant difference was observed when comparing SCTG along with DIP with acellular dermal matrix (ADM) concerning BTT (MD:0.71, P = 0.18) and KMW (MD: 0.6, P = 0.19).

CONCLUSION

There is a very low quality of evidence to provide recommendations on whether simultaneous dental implant placement (IIP or DIP) and soft tissue augmentation using SCTG is superior to no augmentation or is comparable to the other tissue augmentation materials in improving the quality and quantity of peri-implant tissues. Therefore, further, well-designed RCTs with larger sample sizes and long follow-up times are still needed.

Success Rates and Complications Associated with Single Immediate Implants: A Systematic Review

This study examined the success rates of single immediate implants and their associated biological, hardware and aesthetic complications. Using a developed search strategy, randomized controlled trials (RCTs) on single-unit immediate implants with at least six human participants, a minimum follow-up time of 12 months and published between January 1999 and January 2021 were identified. Data was extracted independently using pre-designed data extraction forms. Information on success rates and associated biological, hardware and aesthetic complications were obtained and assessed. Out of 191 potentially eligible studies, 26 RCTs assessing 1270 patients with a total of 1326 single implants were included and further evaluated. In this review, success rate was reported to be 96.7–100% over a total of 9 studies. However, there was a lack of consensus on a universal success criterion between authors emphasizing the need for agreement. The average follow up was 29 months and most reported complications were aesthetic (63 cases, 4.7%), whilst there were relatively fewer biological, (20 cases, 1.5%), and hardware complications (24 cases, 1.8%). Success rate is an uncommon clinical outcome with 9 out of 26 of the selected RCTs reporting it. In these studies, single immediate implants showed a high success rate with low numbers of biological and hardware complications, and high patient satisfaction with aesthetics were reported in the short-term follow-up of one year.

Management and prevention of soft tissue complications in implant dentistry

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

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".

Long-term outcomes of maxillary single-tooth implants in relation to timing protocols of implant placement and loading: Systematic review and meta-analysis

OBJECTIVES

The aim of the present systematic literature review was to determine whether long-term treatment results with single-tooth implants may differ depending on the timing of implant placement in relation to tooth extraction (immediate IP/early EP/delayed DP) and the timing of prosthetic loading (immediate IL/early EL/delayed DL).

MATERIAL AND METHODS

Electronic and manual searches were performed to identify studies reporting on long-term results (survival rate and/or marginal bone resorption after ≥3 years) of maxillary single-tooth implants in the aesthetic zone using defined placement and loading protocols. Comparative trials were subjected to meta-analyses whilst data from single-arm studies were pooled to evaluate differences between timing protocols.

RESULTS

A total of 7 controlled trials were considered for meta-analyses: immediate loading was compared to delayed loading in 3 studies on immediate placement (IPIL vs. IPDL, p = .306) and in 2 studies on delayed placement (DPIL vs. DPDL, p = 1.000) whilst 2 studies compared early versus delayed placement with delayed loading (EPDL vs. DPDL, p = .600), however, without significant differences. Pooled data analysis of 29 studies (965 implants) did not show differences between timing of placement or loading as well as marginal bone remodelling. No impact of the one abutment - one time concept, flap design and simultaneous bone or soft tissue augmentation could be established.

CONCLUSIONS

Insufficient data are available for meta-analytic comparison of all combinations of implant placement and loading protocols.

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.

Immediate implant placement in fresh alveolar sockets with a minimal split-thickness envelope flap: A randomised controlled clinical trial

OBJECTIVES

Comparing PES/WES scores, modified success rate, survival, success, buccal bone thickness and patient-reported outcomes of immediate dental implants placed in fresh alveolar sockets using a flap or a minimal split-thickness envelope flap (MSTEF).

MATERIALS AND METHODS

Implants following random assignment into a flap or MSTEF group were placed immediately in anterior and premolar areas. Guided bone regeneration and autogenous connective tissue graft were used in all cases. A temporary prosthesis was provided followed by the final prosthesis at 16-18 weeks. Success and survival rates together with radiographic buccal bone thickness and patient satisfaction were evaluated at 12-month post-loading. The aesthetic outcome was evaluated through the Pink (PES) and White (WES) Aesthetic Score by 8 blind clinicians of different training background and incorporated in modified success criteria.

RESULTS

28 implants were placed on 28 patients. No statistically significant differences were noted in PES (10.54 control versus 10.80 test), WES scores (6.97 control versus 6.95 test) or success criteria including aesthetic parameters (modified success criteria) for the different specialty groups (Range 69%-92%). In addition, no statistically significant differences were noted in survival (100%), success (100%), buccal wall thickness between control (0.72 ± 0.22) and test group (0.92 ± 0.31) and patients' reported outcomes.

CONCLUSIONS

Immediate dental implant treatment with flap/ MSTEF provided similar mean PES/WES scores, modified success rate, survival, mean buccal bone levels and patients' satisfaction. However, aesthetic failures were common in both groups.

CBCT analysis of the tissue thickness at immediate implant placement with contour augmentation in the maxillary anterior zone: a 1-year prospective clinical study

Background

Immediate implant placement with simultaneous contour augmentation such as guided bone regeneration (GBR) or connective tissue grafting (CTG) has been widely performed. However, few prospective studies have evaluated both peri-implant bone and soft tissue changes between the preoperative and postoperative periods. The purpose of this study is to quantify the horizontal dimensional changes of the facial bone and soft tissue following immediate implant placement with contour augmentation.

Material and methods

Twenty patients who underwent immediate implant placement in the anterior maxilla received GBR and CTG (test group) or GBR only (control group). Cone-beam computed tomography (CBCT) scans were taken preoperatively and 1 year after the definitive prosthesis connection, and then, they were superimposed. On the CBCT images of the two stages, the horizontal distance from the implant platform to the facial bone surface (BW) and the horizontal soft tissue width (GW) were measured at the implant platform level and 2 mm apical to the implant platform level. The sum of BW and GW (=TW) was used to assess the facial mucosal contour.

Results

BW decreased significantly from preoperative to 1 year after prosthesis connection with a mean decrease of 0.47 mm (P =0.021) in the control group and a mean decrease of 0.50 mm (P = 0.019) in the test group at the implant platform level. GW increased significantly with a mean increase of 1.37 mm (P =0.005) in the test group at the implant platform level. TW decreased significantly with a mean decrease of 0.46 mm in the control group (P =0.049) but increased significantly with a mean increase of 0.87 mm in the test group (P =0.005) at the implant platform level.

Conclusions

Immediate implant placement with CTG showed a soft tissue gain of 1.37 mm compensated for bone resorption, thus still preserving the preoperative mucosal contour. CTG should be performed with immediate implant placement in cases where preoperative mucosal contours need to be maintained.

WITHDRAWN: Consensus Report of Working Group 2: Soft Tissue Management

Objectives

The task of working Group 2 at the 6th Consensus Meeting of the European Association for Osseointegration was to comprehensively assess the effects of soft tissue augmentation procedures at dental implant sites on clinical, radiographic and patient‐reported outcome measures (PROMs) including an overview on available outcome measures and methods of assessment.

Materials and methods

Three systematic reviews and one critical review were performed in advance on (i) the effects of soft tissue augmentation procedures on clinical, radiographic and aesthetic outcomes, (ii) reliability and validity of outcome measures and methods of assessment and (iii) PROMs applied in clinical studies for soft tissue augmentation procedures at dental implant sites. Major findings, consensus statements, clinical recommendations and implications for future research were discussed in the group and approved during the plenary sessions.

Results

The four reviews predominantly revealed:

Soft tissue augmentation procedures in conjunction with immediate and delayed implant placement result in superior aesthetic outcomes compared to no soft tissue augmentation in the zone of aesthetic priority.

Soft tissue augmentation procedures have a limited effect on marginal bone level changes compared to implant sites without soft tissue augmentation. Clinically relevant parameters (gingival index, mucosal recession) and plaque control improve at implant sites when the width of keratinised mucosa is increased.

A variety of aesthetic indices have been described with good reliability. Pink Esthetic Score and Complex Esthetic Index are the most validated aesthetic indices for single implants, though. Superimposed digital surface scans are most accurate to assess profilometric tissue changes.

PROMs following soft tissue augmentation procedures have been assessed using various forms of questionnaires. Soft tissue augmentation had a limited effect on PROMs.

Conclusions

Soft tissue augmentation procedures are widely applied in conjunction with implant therapy. Depending on the indication of these interventions, clinical, radiographic and aesthetic outcomes may improve, whereas the effect on PROMs is limited.

Immediate implant with provisionalization and soft tissue grafting after 4-year follow-up

INTRODUCTION

This paper presents a case report of immediate implant placement (IIP) with a provisionalization technique to restore function and esthetics with follow-up after 4 years.

CASE PRESENTATION

Minimally traumatic extraction was performed with IIP, soft-tissue grafting, and immediate provisional crown. Six months after optimal healing, the patient was submitted to an esthetic restorative work through veneers in lithium disilicate. Fourteen-month and 4-year follow-up visits revealed stability of the peri-implant soft-tissues with peri-implant health status, with the evaluation of the pink and white esthetic score, yielding to mean scores, respectively, in 14 months of 11.62 ± 2.07 (pink esthetic score [PES]) and 18.25 ± 1.46 (PES/white esthetic score [WES]) and in 4 years of 11.0 ± 1.32 (PES) and 17.62 ± 0.65 (PES/WES). Intraoral digital radiographs showed minimal crestal bone level changes throughout the follow-up period. Thus, IIP is a sensitive technique procedure, and a 3D implant position is crucial for success.

CONCLUSION

Immediate implant with grafting to fill the gap and soft tissue augmentation led to less horizontal changes and stable mucosal margin, and immediate provisionalization helped to maintain soft tissue architecture, and proper case selection is key for clinical success.

Alveolar ridge preservation in defect sockets in the maxillary aesthetic zone followed by single-tooth bone level tapered implants with immediate provisionalization: a 1-year prospective case series

Background

Clinical studies of single-tooth replacement in compromised bone using bone level tapered implants in the aesthetic zone are scarce.

Aim

To assess clinically, radiographically and aesthetically over 1 year the performance of a bone level tapered implant in the maxillary aesthetic zone in sites after alveolar ridge preservation.

Material and methods

Thirty patients (16 male, 14 female) with a failing tooth and large bone defect after removal received alveolar ridge preservation. After 3 months, implants were placed with immediate provisionalization. Definitive restorations were placed after 3 months. The treatment was evaluated 1 year following the definitive restoration.

Results

All the patients attended the 1-year follow-up. One implant was lost (96.7% implant survival rate). The mean implant stability quotient value was 68.9 ± 8.74 at implant placement. The mean marginal bone level change was minor (− 0.07 ± 0.12 mm). The mean mid-buccal mucosa changed with + 0.01 ± 0.45 mm. The median Pink Esthetic Score and White Esthetic Score after 1 year were 6 [4; 7] and 8 [7; 9], respectively. The patients’ mean overall satisfaction (0–100 VAS scale) was 86.6 ± 10.3.

Conclusion

Bone level tapered implants with immediate provisionalization perform well after alveolar ridge preservation in the maxillary aesthetic zone, according to implant stability, clinical, radiographic, aesthetic and patient-centred outcomes.

Trial registration

NTR, NL8755. Registered on 1 January 2016

Efficacy of different surgical techniques for peri-implant tissue preservation in immediate implant placement: a systematic review and meta-analysis

INTRODUCTION

Preserving peri-implant tissues after immediate implant placement (IIP), especially in aesthetic zones, is a topic of interest.

OBJECTIVES

This systematic review investigated the effects of currently available surgical procedures for preserving peri-implant tissue or ensuring dimensional stability following immediate implant placement.

MATERIALS AND METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement's guidelines were followed, and articles were sought on the PubMed and Cochrane databases with no date restrictions. Only randomised clinical trials that evaluated changes in soft and hard tissues around immediately placed implants were included. Statistical analyses were performed, and the studies´ quality was assessed using the Cochrane Collaboration tool. The agreement between reviewers was assessed based on Cohen's kappa statistics.

RESULTS

Of the 14 studies that met the inclusion criteria, 11 were analysed in the meta-analysis (kappa = 0.814; almost perfect agreement). The use of connective tissue grafts resulted in a significantly greater improvement of the facial gingival level (MD = -0.51; 95% CI: -0.76 to -0.31; p = < .001), and the placement of bone grafts significantly reduced the horizontal resorption of the buccal bone (MD = -0.59; 95% CI: -0.78 to -0.39; p < .001).

CONCLUSION

Connective tissue grafts and bone grafts positively influence tissue preservation around immediately placed implants. Neither the flapless technique nor palatal implant positioning resulted in significant improvements to any of the investigated parameters. Additional longitudinal studies are required.

CLINICAL RELEVANCE

This meta-analysis is useful for discerning the effects of soft tissue augmentation, bone grafting, the flapless technique, and palatal implant positioning on preserving peri-implant tissues after immediate implant placement.

The esthetic biological contour concept for implant restoration emergence profile design

OBJECTIVE

Emergence profile design is important for stable peri-implant tissues and esthetically pleasing results with dental implant restorations, influenced by factors, such as, implant position and surrounding soft tissues. Different aspects of the emergence profile have been described, but detailed explanations of the different zones and corresponding designs are missing. This article describes the esthetic biological contour concept (EBC), differentiating important areas of the emergence profile and recommending particular designs for those zones.

OVERVIEW

The EBC concept considers specific parameters for proper design of the emergence profile of implant-supported restorations. Understanding the different zones of the emergence profile and their relation to factors like implant position, implant design, and soft tissue thickness is key. The suggested guidelines are geared toward providing more stable and esthetic results when restoring dental implants in the esthetic zone.

CONCLUSIONS

Each of the zones described in the EBC concept have a specific function in the design of the emergence profile. Understanding the importance and specific design features of the EBC zones facilitates esthetic and biologically sound treatment outcomes with interim and definitive implant restorations.

CLINICAL SIGNIFICANCE

Proper emergence profile design supports esthetic outcomes and provides favorable biological response to implant-supported restorations.

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

OBJECTIVE

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

OVERVIEW

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

CONCLUSIONS

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

CLINICAL SIGNIFICANCE

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

A case series of profilometric changes in two implant placement protocols at periodontally compromised non-molar sites

Information regarding profilometric changes at a soft tissue level following implant placement with different protocols is insufficient. Therefore, this study aimed to comparatively investigate the profilometric tissue changes with respect to late implant placement following alveolar ridge preservation (LP/ARP) and early implantation (EP) in periodontally compromised non-molar extraction sites. Sixteen patients were randomly assigned to the following groups: implant placement 4 months post-ARP (group LP/ARP) and tooth extraction and implant placement 4–8 weeks post-extraction (group EP). Dental impressions were obtained immediately after final prosthesis insertion and at 3, 6, and 12 months. At the time of implant placement, bone augmentation was performed in the majority of the patients. Profilometric changes of the tissue contour were minimal between the final prosthesis insertion and 12 months in the mid-facial area (0.04–0.35 mm in group LP/ARP, 0.04–0.19 mm in group EP). The overall tissue volume increased in both groups (1.70 mm³ in group LP/ARP, 0.96 mm³ in group EP). In conclusion, LP/ARP and EP led to similar stability of the peri-implant tissue contour between the final prosthesis insertion and at 12 months. Moreover, the change of peri-implant tissue on the soft tissue level was minimal in both modalities.

Influence of Immediate Implant Placement and Provisionalization with or without Soft Tissue Augmentation on Hard and Soft Tissues in the Esthetic Zone: A One-Year Retrospective Study

The purpose of this clinical research was to evaluate peri-implant marginal changes around immediate implants placed either with the application of SCTG or XCM or without soft tissue grafting. A total of 48 patients requiring a single implant-supported restoration in the anterior jaw were selected for inclusion. Three surgical procedures were performed, as follows: type 1 implant with subepithelial connective tissue graft (SCTG), type 1 implant with xenogenic collagen matrix (XCM), and type 1 implant without soft tissue augmentation (NG) (control group). The marginal change of peri-implant soft tissue, facial soft tissue thickness (FSTT), peri-implant health status, esthetics, and patient satisfaction were assessed at one year after surgery. All of the placed implants showed a survival rate of 100%. No significant differences in FSTT were recorded between the SCTG group and the XCM group after treatment (P > 0.05), while the NG group presented a significant difference (P < 0.05). Patients in the NG group lost significantly more in the buccal marginal level than did patients in the SCTG group and those in the XCM group (P < 0.05). The favourable success rate recorded in all groups confirmed immediate tooth replacement as a choice of treatment for a missing anterior single tooth. The NG group presented significant changes of FSTT and buccal marginal level, while XCM constituted a viable alternative to SCTG.

Facial mucosal level of single immediately placed implants with either immediate provisionalization or delayed restoration: An intermediate-term study

BACKGROUND

Immediately placed single implants with either immediate provisionalization (test) or delayed restoration (control) were followed for up to 1 year in our previous randomized clinical trial. Peri-implant tissues continue to remodel after implants are in function. Therefore, the primary aim of this study was to evaluate the facial mucosal level changes in the intermediate term between the two groups and to study potential factors influencing the mucosal level change.

METHODS

Patients who had already completed the previous clinical trial by receiving a single immediately placed implant were re-invited to this study. The facial mucosal level as well as the other peri-implant hard and soft tissue dimensions and conditions were measured clinically, radiographically and with ultrasound. These data were compared between the test and control implants. The mucosal level change as the function of the final crown contour, measured as the abutment-crown angle (ACA), was estimated with a linear regression model.

RESULTS

Twenty-eight patients (n of test/control = 16/12) with a mean 30-month follow-up were recruited. The mean mucosal level change was -0.38 mm (control) and 0.06 mm (test), without statistical difference between the two groups. The other clinical, radiographic, and ultrasound parameters were not statistically different. ACA was statistically significant associated with the recession (P = 0.02). The estimate effect was 0.25 mm per 10° increase (adjusted R²  = 0.18; 95% CI, 0.02 to 0.49 mm). After adjusting for vertical implant position, implant abutment angle and the group, the effect became borderline significant (P = 0.09).

CONCLUSIONS

Peri-implant tissues, including the mucosal level change of immediately placed implants with either immediate provisionalization or delayed restoration remained stable and did not differ between the groups in the intermediate term. The final crown angle, influenced by implant position and abutment angle, might be associated with mucosal margin level change.

Immediate implant placement in conjunction with guided bone regeneration and/or connective tissue grafts: an experimental study in canines

Purpose

This study was conducted to assess the effect of hard and/or soft tissue grafting on immediate implants in a preclinical model.

Methods

In 5 mongrel dogs, the distal roots of P2 and P3 were extracted from the maxilla (4 sites in each animal), and immediate implant placement was performed. Each site was randomly assigned to 1 of the following 4 groups: i) gap filling with guided bone regeneration (the GBR group), ii) subepithelial connective tissue grafting (the SCTG group), iii) GBR and SCTG (the GBR/SCTG group), and iv) no further treatment (control). Non-submerged healing was provided for 4 months. Histological and histomorphometric analyses were performed.

Results

Peri-implant tissue height and thickness favored the SCTG group (height of peri-implant mucosa: 1.14 mm; tissue thickness at the implant shoulder and ±1 mm from the shoulder: 1.14 mm, 0.78 mm, and 1.57 mm, respectively; median value) over the other groups. Bone grafting was not effective at the level of the implant shoulder and on the coronal level of the shoulder. In addition, simultaneous soft and hard tissue augmentation (the GBR/SCTG group) led to a less favorable tissue contour compared to GBR or SCTG alone (height of peri-implant mucosa: 3.06 mm; thickness of peri-implant mucosa at the implant shoulder and ±1 mm from the shoulder: 0.72 mm, 0.3 mm, and 1.09 mm, respectively).

Conclusion

SCTG tended to have positive effects on the thickness and height of the peri-implant mucosa in immediate implant placement. However, simultaneous soft and hard tissue augmentation might not allow a satisfactory tissue contour in cases where the relationship between implant position and neighboring bone housing is unfavorable.

Immediate implant placement with or without connective tissue graft: A systematic review and meta-analysis

OBJECTIVES

To assess the effect of connective tissue graft (CTG) in terms of vertical mid-facial soft tissue change when applied at the buccal aspect 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 January 2020. Randomized controlled trials (RCTs) and non-randomized controlled studies (NRSs) comparing IIP with CTG and without CTG over a mean follow-up of at least 12 months were included for a qualitative analysis. Meta-analyses were performed on data provided by RCTs.

RESULTS

Out of 1814 records, 5 RCTs and 3 NRSs reported on 409 (IIP + CTG: 246, IIP: 163) immediately installed implants with a mean follow-up ranging from 12 to 108 months. Only 1 RCT showed low risk of bias. Meta-analysis revealed a significant difference in terms of vertical mid-facial soft tissue change between IIP + CTG and IIP pointing to 0.41 mm (95% CI [0.21; 0.61], p < .001) in favour of soft tissue grafting. This outcome was clinically relevant since the risk for ≥1 mm asymmetry in mid-facial vertical soft tissue level was 12 times (RR 12.10, 95% CI [2.57; 56.91], p = .002) lower following IIP + CTG. Soft tissue grafting also resulted in a trend towards less bleeding on probing (MD 17%, 95% CI [-35%; 1%], p = .06). Meta-analyses did not reveal significant differences in terms of pink aesthetic score, marginal bone level change and probing depth. Results were inconclusive for horizontal mid-facial soft tissue change and papilla height change. Based on GRADE guidelines, a moderate recommendation for the use of a CTG following IIP can be made.

CONCLUSION

CTG contributes to mid-facial soft tissue stability following IIP. Therefore, CTG should be considered when elevated risk for mid-facial recession is expected in the aesthetic zone (thin gingival biotype, <0.5 mm buccal bone thickness).

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.