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

Efficacy of Acellular dermal matrix simultaneous with implant placement: A systematic review and meta-analysis of clinical trials

PURPOSE

The vertical soft tissue thickness over the implant is essential for long-term procedure success and for biological integration of the suprabony soft tissue component, consequently, development of alternatives to autogenous soft tissue grafts such as allogeneic and xenogeneic grafts were needed. Acellular dermal matrix (ADM) is utilized to provide structural support for angiogenesis, revascularization and tissue remodeling in soft tissue augmentation, recession, and increasing the keratinized tissue width. At this point, the aim of this systematic review was to evaluate the amount of soft tissue height (STH) gained after augmenting the ADM in combination with the dental implants.

METHODS

A systematic search was performed in five databases. The primary outcome measure was STH change. Secondary outcomes included marginal bone loss (MBL) and pocket probing depth (PPD) at implant sites.

RESULTS

Six studies, with 200 participants, and reported pre- and post-operative mean of vertical tissue thickness, MBL, and PPD around implants were included in the meta-analysis. The pooled mean difference (MD) of STH was 0.84 (95 % CI:0.28 to 1.39) with a p-value < 0.0001. A total of three studies, reported MBL. The pooled MD of MBL around implants, comparing the mean change from baseline to 12 months. The random effect model revealed a MD of 0.07mm (95 % CI: -0.21 to 0.35 mm, p= 0.6325). Calculation of pooled MD of PPD at implant sites, comparing ADM groups to the control groups in three studies; the random effect model revealed a MD of -0.13mm (95 % CI: -0.47 to 0.22 mm, p= 0.4742).

CONCLUSION

While Acellular dermal matrix significantly improves vertical soft tissue thickness, it does not significantly impact marginal bone loss or pocket probing depth.

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.

Real-world Use of AlloDerm Acellular Dermal Matrix in Head and Neck Procedures in the United States

Background

Real-world literature evaluating the use of AlloDerm SELECT Regenerative Tissue Matrix in head- and neck-related procedures is limited. To inform patient care decisions, this study evaluated healthcare resource utilization (HCRU) in US adults undergoing head- and neck-related procedures using AlloDerm.

Methods

A retrospective claims analysis was conducted using MarketScan Commercial and Medicare Supplemental Databases (study period: October 1, 2015, to March 31, 2022; index period: November 1, 2015, to March 1, 2022). Adults aged 18 years or older with (1) medical claims for AlloDerm and a skin substitute on the same day during the index period, (2) a head/neck procedure diagnostic code, and (3) 30 or more days of continuous enrollment before and after first AlloDerm use index date. Descriptive statistics were used to describe surgery types and 30-day follow-up reoperations, graft complications, and all-cause HCRU.

Results

Among 431 patients (51.7% women), mean (SD) age was 52.2 (15.8) years. AlloDerm was most used with oral cavity reconstruction (35.3%), septal perforation repair/rhinoplasty (16.5%), and parotidectomy (13.0%). Most procedures were performed in outpatient settings (hospital, 90.0%; ambulatory surgical center, 8.6%). Over 30 days, less than 1% of patients (4 of 431) required reoperation with AlloDerm; 0.5% (2 of 431) had graft-related complications. Most (75.6%) patients had an outpatient visit; few had an emergency room visit (7.9%) or inpatient claim (3.0%).

Conclusions

Real-world evidence indicates that AlloDerm is used in head- and neck-related procedures in US adults, particularly oral reconstruction. Postprocedure complications and reoperations are uncommon during the follow-up period.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Soft-tissue augmentation for increasing keratinized tissue around dental implants: A systematic review

Background

This systematic review aims to comprehensively assess the efficacy of soft-tissue augmentation procedures in enhancing the width of keratinized mucosa (KM) surrounding implants with compromised soft-tissue status.

Materials and Methods

A thorough search was conducted on MEDLINE through PubMed and EMBASE via Ovid, supplemented by manual article searches. Inclusion criteria comprised human studies published in English within the past decade (up to July 2023), focusing on soft-tissue grafting techniques for augmenting keratinized mucosal width. The Joanna Briggs Institute critical appraisal tools were employed to evaluate the risk of bias in selected studies.

Results

The review includes 27 studies, comprising nine prospective clinical studies, 13 randomized controlled trials (RCTs), and 5 case series. Notably, interventions demonstrated an augmented KM ranging from 0.89 mm to 7.7 mm. Optimal outcomes were observed with apically positioned partial-thickness flaps and vestibuloplasty (VP) utilizing xenogeneic collagen matrix (XCM) or free gingival graft (FGG). However, heterogeneity in study designs precluded meta-analysis.

Conclusion

Despite the limitations, this study emphasizes the potential to augment KM width through apically positioned partial-thickness flaps and VP techniques employing XCM or FGG. Further RCTs with extended follow-up are needed to refine treatment approaches, improve outcomes, and address gaps in understanding graft integration mechanisms and strategies to minimize graft shrinkage.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Bicalcium Phosphate as an Asset in Regenerative Therapy

After a loss of a tooth, alveolar bone resorption is immutable, leaving the area devoid of sufficient bone quality and mass for a successful and satisfactory implant or any other dental treatment. To treat this problem of irreversible bone loss, bone grafting is the primary solution and a well-accepted technique. The use of bone grafting procedures has increased in recent years. This review is about the various bone grafting techniques and best-situated material available currently along with their trump cards and limitations. In the thorough discussion regarding bone grafting materials and their substitutes, one alloplastic material has shown unbeaten and the most satisfactory properties than any other material, "bicalcium phosphate" (BCP). BCP is a mixture of hydroxyapatite (HA) and beta-tricalcium phosphate (B-TCP) usually obtained through sintering calcium-deficient apatite (CDA) at or above 700°C or by other methods such as hydrolysis or precipitation. The review also shows comparative studies done to understand the effect, most adequate balance, and impact of ratios of HA/B-TCP on the properties, structure, and success rate of this material. The objective of the review is to enlighten the principal characteristic of the most likely used bone graft material presently, i.e., BCP. The most impeccable characteristic of BCP is its capability to osteointegrate, which results in a superior interface. This interface depicts a dynamic process that includes physicochemical reactions, crystal-protein interactions, cell and tissue colonization, and bone remodeling. BCP has certain essential properties that could be put forth as its advantage over any other substitute. These properties include bioactivity, osteointegration, osteoinduction, osteogenesis, and biodegradation, which are mostly governed by modifying the HA/B-TCP ratio. Other applications of BCP are feasible, such as in drug administration and scaffolds for tissue engineering.

Bone Grafts in Dental Medicine: An Overview of Autografts, Allografts and Synthetic Materials

This review provides an overview of various materials used in dentistry and oral and maxillofacial surgeries to replace or repair bone defects. The choice of material depends on factors such as tissue viability, size, shape, and defect volume. While small bone defects can regenerate naturally, extensive defects or loss or pathological fractures require surgical intervention and the use of substitute bones. Autologous bone, taken from the patient's own body, is the gold standard for bone grafting but has drawbacks such as uncertain prognosis, surgery at the donor site, and limited availability. Other alternatives for medium and small-sized defects include allografts (from human donors), xenografts (from animals), and synthetic materials with osteoconductive properties. Allografts are carefully selected and processed human bone materials, while xenografts are derived from animals and possess similar chemical composition to human bone. Synthetic materials such as ceramics and bioactive glasses are used for small defects but may lack osteoinductivity and moldability. Calcium-phosphate-based ceramics, particularly hydroxyapatite, are extensively studied and commonly used due to their compositional similarity to natural bone. Additional components, such as growth factors, autogenous bone, and therapeutic elements, can be incorporated into synthetic or xenogeneic scaffolds to enhance their osteogenic properties. This review aims to provide a comprehensive analysis of grafting materials in dentistry, discussing their properties, advantages, and disadvantages. It also highlights the challenges of analyzing in vivo and clinical studies to select the most suitable option for specific situations.