Diagnostic methods/parameters to monitor peri-implant conditions.

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

Disease recurrence during supportive therapy following peri-implantitis treatment: A retrospective study.

AIM: Supportive therapy is key to prevent disease recurrence after peri-implantitis treatment. The primary objective was to quantify disease recurrence during supportive peri-implant therapy (SPIT) after peri-implantitis treatment. A secondary objective was to assess the success/failure of cumulative interceptive supportive therapy (CIST) after peri-implantitis treatment. METHODS: Compliers (whether regular or erratic) with SPIT after peri-implantitis treatment during ≥12 months were retrospectively evaluated. CIST was prescribed whenever residual pockets ≥6 mm concomitant with profuse bleeding on probing (disease recurrence) were identified. Patient- and implant-related factors were analyzed to explore their associations with disease recurrence and the need for CIST. RESULTS: Disease recurrence was considered in 28 patients (40 implants). Of these, 14 patients (23 implants) further demonstrated radiographic evidence of progressive bone loss (≥1 mm). This represented an overall disease recurrence following peri-implantitis treatment of ~20% and ~ 10% at patient and implant levels, respectively. Smokers, patients diagnosed at baseline with periodontitis grade C, and males were significantly more prone to exhibit recurrence. Patients undergoing CIST due to instability were not likely to respond favorably (~70% continued to exhibit residual pockets). CONCLUSION: Disease recurrence during SPIT following peri-implantitis treatment on selected cases is ~20%. Patients undergoing CIST due to instability are not likely to respond favorably.

Supportive therapy following peri-implantitis treatment: A retrospective study on compliance.

BACKGROUND: The compliance rate with supportive therapy following peri-implantitis treatment (SPIT) remains unknown. The present retrospective study was carried out to assess the compliance rate and the factors influencing compliance in a private practice setting. MATERIALS AND METHODS: Patients were divided into three groups according to compliance rate: regular compliance (RC ≥2 SPIT/year), erratic compliance (EC <2 SPIT/year), and non-compliance (NC <1 SPIT/year). Overall, 17 patient- (n = 8) and site-related variables (n = 9) were explored as potential confounders of compliance. The Chi2 test was applied to assess the association between categorical variables and determine the odds ratio (OR). RESULTS: The study comprised 159 patients restored with 1075 implants, of which 469 were treated for peri-implantitis and met the inclusion criteria. A total of 57.2% were RC, 25.8% EC, and 17% NC. The multivariate analysis showed that smoking and grade C periodontitis reduced the likelihood of RC (OR = 0.28, p < .001) when compared to complete edentulism or non-smoking. Moreover, age demonstrated being associated with follow-up when SPIT was interrupted in EC and NC (OR = 0.94, p = .007). CONCLUSION: Comprehensive information, provided prior to peri-implantitis treatment, regarding the importance of adhering to SPIT after peri-implantitis treatment to achieve/maintain peri-implant health, resulted in ~60% regular compliance rate (NCT05772078).

Peri-implantitis and maxillary sinus membrane thickening: A retrospective cohort study.

OBJECTIVE: The objective of this study is to investigate the association of peri-implantitis (PI) and sinus membrane thickening and to assess the resolution of membrane thickening following intervention (implant removal or peri-implantitis treatment) aimed at arresting PI. MATERIALS AND METHODS: Forty-five patients with 61 implants in the posterior maxillary region were retrospectively included in the study. Twenty-four patients were diagnosed with peri-implantitis (PI) and 21 had peri-implant health (PH). Cone-beam computed tomography (CBCT) scans were evaluated to assess maxillary sinus characteristics, including membrane thickening, sinus occupancy and ostium patency. The CBCT scans taken 6 months after intervention aimed at arresting disease (implant removal or treatment of PI) in the PI group were also appraised and compared to baseline scans. RESULTS: At baseline, all parameters evaluating membrane thickness disorders yielded significant differences between groups (p < .001). Patients with posterior maxillary implants diagnosed with PI were 7× more likely to present membrane thickening compatible with pathology when compared to patients with healthy implants (OR = 7.14; p = .005). Furthermore, the likelihood was 6x greater in implants diagnosed with PI to exhibit moderate membrane thickening (OR = 6.75, p = .001). The patients receiving interventions aimed at arresting PI experienced significant enhancement in all radiographic parameters related to the sinus cavity at the 6-month follow-up (p < .001), though these variations were similarly independent of whether treatment consisted of PI treatment or implant removal. CONCLUSIONS: Maxillary sinus membrane thickening and the permeability/obstruction of the ostium are frequently associated with the presence of PI in posterior implants. Interventions targeting disease resolution effectively reduce membrane thickness to levels compatible with maxillary sinus health.

Selecting biomaterials in the reconstructive therapy of peri-implantitis.

Peri-implantitis is a pathogenic inflammatory condition characterized by progressive bone loss and clinical inflammation that may compromise the stability of dental implants. Therapeutic modalities have been advocated to arrest the disorder and to establish peri-implant health. Reconstructive therapy is indicated for bone defects exhibiting contained/angular components. This therapeutic modality is based upon the application of the biological and technical principles of periodontal regeneration. Nonetheless, the comparative efficacy of reconstructive therapy and nonreconstructive modalities remains unclear. Therefore, the aim of this narrative review is to address major clinical concerns regarding the efficacy, effectiveness, and feasibility of using biomaterials in peri-implantitis therapy. In particular, the use of bone grafting materials, barrier membranes, and biologics is comprehensively explored.

Techniques on vertical ridge augmentation: Indications and effectiveness.

Vertical ridge augmentation techniques have been advocated to enable restoring function and esthetics by means of implant-supported rehabilitation. There are three major modalities. The first is guided bone regeneration, based on the principle of compartmentalization by means of using a barrier membrane, which has been demonstrated to be technically demanding with regard to soft tissue management. This requisite is also applicable in the case of the second modality of bone block grafts. Nonetheless, space creation and maintenance are provided by the solid nature of the graft. The third modality of distraction osteogenesis is also a valid and faster approach. Nonetheless, owing to this technique's inherent shortcomings, this method is currently deprecated. The purpose of this review is to shed light on the state-of-the-art of the different modalities described for vertical ridge augmentation, including the indications, the step-by-step approach, and the effectiveness.

Minimal invasiveness in the reconstructive treatment of peri-implantitis defects.

Peri-implantitis is a plaque-associated pathologic condition occurring in tissues around dental implants, clinically characterized by increased peri-implant probing pocket depth and progressive loss of supporting bone. Consequently, to arrest further disease progression and to increase the chance to obtain re-osseointegration, surgical reconstructive procedures have been adopted. In particular, following a paradigm gathered from periodontal therapy, recent protocols have underlined the importance of a minimally invasive approach to optimize the outcomes of therapy while minimizing the risks of postoperative complications. The present review summarizes the level of evidence on the surgical reconstructive protocols focusing on the new approaches aiming to minimize surgical trauma and patients' postoperative discomfort, underlining the pros and cons of each treatment modality.

Complications and treatment errors in peri-implant hard tissue management.

Bone augmentation procedures aim to regenerate the deficient alveolar ridge to properly place dental implants that are completely surrounded by bone. However, these are invasive and technically demanding surgeries that are not free of either complications or treatment errors. Careful patient selection and preparation is a mandatory process to reduce the rate of complications in bone regeneration procedures, irrespective of the technique used. It is important to assess the cost benefit of the intervention and to evaluate the potential impact on the patient's quality of life, especially in the elderly and medically compromised patients. Most common postoperative complications are wound dehiscences, which may be reduced, at least partially, by proper knowledge of the surgical technique and the craniofacial anatomy. Other complications that may appear are postoperative infections or nerve injuries. The aim of this narrative review is to summarize the best available scientific evidence on the incidence of complications, as well as the ideal strategies for their prevention and management. Depending on the severity of the complication, treatment approaches may vary and can include drug prescription or even surgical re-entries to remove exposed barrier membranes or contaminated bone grafts. Adequate prevention and proper management of complications associated with bone augmentation interventions are a requirement for clinicians carrying out these demanding procedures. A series of cases illustrating proper management of complications in different clinical scenarios is presented.

Emerging factors affecting peri-implant bone metabolism.

Implant dentistry has evolved to the point that standard implant osseointegration is predictable. This is attributed in part to the advancements in material sciences that have led toward improvements in implant surface technology and characteristics. Nonetheless, there remain several cases where implant therapy fails (specifically at early time points), most commonly attributed to factors affecting bone metabolism. Among these patients, smokers are known to have impaired bone metabolism and thus be subject to higher risks of early implant failure and/or late complications related to the stability of the peri-implant bone and mucosal tissues. Notably, however, emerging data have unveiled other critical factors affecting osseointegration, namely, those related to the metabolism of bone tissues. The aim of this review is to shed light on the effects of implant-related factors, like implant surface or titanium particle release; surgical-related factors, like osseodensification or implanted biomaterials; various drugs, like selective serotonin reuptake inhibitors, proton pump inhibitors, anti-hypertensives, nonsteroidal anti-inflammatory medication, and statins, and host-related factors, like smoking, diet, and metabolic syndrome on bone metabolism, and aseptic peri-implant bone loss. Despite the infectious nature of peri-implant biological complications, these factors must be surveyed for the effective prevention and management of peri-implantitis.

Guided bone regeneration in implant dentistry: Basic principle, progress over 35 years, and recent research activities.

Bone augmentation procedures are frequent today in implant patients, since an implant should be circumferentially anchored in bone at completion of bone healing to have a good long-term stability. The best documented surgical technique to achieve this goal is guided bone regeneration (GBR) utilizing barrier membranes in combination with bone fillers. This clinical review paper reflects 35 years of development and progress with GBR. In the 1990s, GBR was developed by defining the indications for GBR, examining various barrier membranes, bone grafts, and bone substitutes. Complications were identified and reduced by modifications of the surgical technique. Today, the selection criteria for various surgical approaches are much better understood, in particular, in post-extraction implant placement. In the majority of patients, biodegradable collagen membranes are used, mainly for horizontal bone augmentation, whereas bioinert PTFE membranes are preferred for vertical ridge augmentation. The leading surgeons are using a composite graft with autogenous bone chips to accelerate bone formation, in combination with a low-substitution bone filer to better maintain the augmented bone volume over time. In addition, major efforts have been made since the millenium change to reduce surgical trauma and patient morbidity as much as possible. At the end, some open questions related to GBR are discussed.

Minimal invasiveness in vertical ridge augmentation.

Vertical ridge augmentation is one of the most challenging procedures in implant dentistry because of the advanced skills required by the operator and the fact that bone augmentation is aimed outside the bony contour, in an environment of reduced blood supply. What is more, the flap management required to ensure soft tissue closure frequently leads to associated comorbidities in terms of swelling and hematomas. For these reasons, and even if autologous onlay block grafts are still the gold standard, new techniques and biomaterials have favored the development of potentially less invasive approaches. The present work evaluates the most recent strategies in vertical ridge augmentation to reduce invasiveness and complications, including diagnostic/treatment planning considerations, surgical techniques, digital tools (eg, customized titanium meshes/membranes or bone blocks), and future trends in the field of tissue engineering and cell therapy.

Influence of buccal bone wall thickness on the peri-implant hard and soft tissue dimensional changes: A systematic review.

BACKGROUND: The significance on the association between the peri-implant bucco-lingual dimension (BLD) at the stage of implant placement and the occurrence of biological and esthetic complications is yet unknown. MATERIAL AND METHODS: Systematic screening of electronic sources was carried out to identify clinical and preclinical studies reporting on the baseline BLD and/or buccal bone thickness (BBT) values. A secondary objective was to assess the effect of simultaneous grafting at sites with deficient or no buccal bone wall (BBW) at baseline. The primary outcome variables were BBT, BLD, and buccal vertical bone loss (VBL) at re-evaluation. Moreover, radiographic, clinical, and patient-reported outcome measures (PROMs) were evaluated. RESULTS: Overall, 12 clinical and four preclinical studies met the inclusion criteria. Inconsistencies were found in defining the critical BBT across the clinical and preclinical data evaluated. The clinical evidence demonstrated that during healing, dimensional changes occur in the alveolar bone and in the BBW that may compromise the integrity of the peri-implant bone, leading to VBL and mucosal recession (MR), particularly in scenarios exhibiting a thin BBW. The preclinical evidence validated the fact that implants placed in the presence of a thin BBW, are more prone to exhibit major dimensional changes and VBL. Moreover, the clinical data supported that, in scenarios where dehiscence-type defects occur and are left for spontaneous healing, greater VBL and MR together with the occurrence of biologic complications are expected. Furthermore, the augmentation of dehiscence-type defects is associated with hard and soft tissue stability. PROMs were not reported. CONCLUSIONS: Dimensional changes occur as result of implant placement in healed ridges that may lead to instability of the peri-implant hard and soft tissues. Sites presenting a thin BBW are more prone to exhibit major changes that may compromise the integrity of the buccal bone and may lead to biologic and esthetic complications.

Influence of buccal bone wall thickness on the peri-implant hard and soft tissue dimensional changes: A systematic review

BACKGROUND: The significance on the association between the peri-implant bucco-lingual dimension (BLD) at the stage of implant placement and the occurrence of biological and esthetic complications is yet unknown. MATERIAL AND METHODSS: Systematic screening of electronic sources was carried out to identify clinical and preclinical studies reporting on the baseline BLD and/or buccal bone thickness (BBT) values. A secondary objective was to assess the effect of simultaneous grafting at sites with deficient or no buccal bone wall (BBW) at baseline. The primary outcome variables were BBT, BLD, and buccal vertical bone loss (VBL) at re-evaluation. Moreover, radiographic, clinical, and patient-reported outcome measures (PROMs) were evaluated. RESULTS: Overall, 12 clinical and four preclinical studies met the inclusion criteria. Inconsistencies were found in defining the critical BBT across the clinical and preclinical data evaluated. The clinical evidence demonstrated that during healing, dimensional changes occur in the alveolar bone and in the BBW that may compromise the integrity of the peri-implant bone, leading to VBL and mucosal recession (MR), particularly in scenarios exhibiting a thin BBW. The preclinical evidence validated the fact that implants placed in the presence of a thin BBW, are more prone to exhibit major dimensional changes and VBL. Moreover, the clinical data supported that, in scenarios where dehiscence-type defects occur and are left for spontaneous healing, greater VBL and MR together with the occurrence of biologic complications are expected. Furthermore, the augmentation of dehiscence-type defects is associated with hard and soft tissue stability. PROMs were not reported. CONCLUSIONS: Dimensional changes occur as result of implant placement in healed ridges that may lead to instability of the peri-implant hard and soft tissues. Sites presenting a thin BBW are more prone to exhibit major changes that may compromise the integrity of the buccal bone and may lead to biologic and esthetic complications.

Group 1 ITI Consensus Report: The role of bone dimensions and soft tissue augmentation procedures on the stability of clinical, radiographic, and patient-reported outcomes of implant treatment.

OBJECTIVES: The aims of Working Group 1 were to address the role (i) of the buccolingual bone dimensions after implant placement in healed alveolar ridge sites on the occurrence of biologic and aesthetic complications, and (ii) of soft tissue augmentation (STA) on the stability of clinical, radiographic, and patient-related outcomes of implant treatments. MATERIALS AND METHODS: Two systematic reviews were prepared in advance of the Consensus Conference and were discussed among the participants of Group 1. Consensus statements, clinical recommendations, recommendations for future research, and reflections on patient perspectives were based on structured group discussions until consensus was reached among the entire group of experts. The statements were then presented and accepted following further discussion and modifications as required by the plenary. RESULTS: Dimensional changes of the alveolar ridge occurred after implant placement in healed sites, and a reduction in buccal bone wall thickness (BBW) of 0.3 to 1.8 mm was observed. In healed sites with a BBW of <1.5 mm after implant placement, increased vertical bone loss, and less favorable clinical and radiographic outcomes were demonstrated. Implants with buccal dehiscence defects undergoing simultaneous guided bone regeneration, showed less vertical bone loss, and more favorable clinical and radiographic outcomes, compared to non-augmented dehiscence defects during initial healing. At healthy single implant sites, probing depths, bleeding and plaque scores, and interproximal bone levels evaluated at 1 year, remained stable for up to 5 years, with or without STA. When single implant sites were augmented with connective tissue grafts, either for soft tissue phenotype modification or buccal soft tissue dehiscence, stable levels of the soft tissue margin, and stable or even increased soft tissue thickness and/or width of keratinized mucosa could be observed from 1 to 5 years. In contrast, non-augmented sites were more prone to show apical migration of the soft tissue margin in the long-term. Favorable aesthetic and patient-reported outcomes after STA were documented to be stable from 1 to 5 years. CONCLUSIONS: It is concluded that dimensional changes of the alveolar ridge occur after implant placement in healed sites and that sites with a thin BBW after implant placement are prone to exhibit less favorable clinical and radiographic outcomes. In addition, it is concluded that STA can provide stable clinical, radiographic, aesthetic, and patient-reported outcomes in the medium and long-term.

Digital evaluation of facial peri-implant mucosal thickness and its impact on dental implant aesthetics.

OBJECTIVE: The aim of the present study was to describe and compare the features of the buccal peri-implant mucosa to natural gingiva in the aesthetic area. MATERIAL AND METHODS: Forty-nine periodontally healthy patients were included in this cross-sectional study. Mucosal and gingival dimensions at the mid-facial aspect were evaluated clinically and radiographically. Color assessments were performed using a reflectance spectrophotometer, and patient aesthetic satisfaction was further checked. RESULTS: Implant sites revealed significant thicker mucosa when compared to tooth sites both at 1.5 (p < 0.001) and 3 mm (p < 0.001) apical to the mucosal margin. Both conventional and digital methods presented a good reliability. The spectrophotometric data revealed a statistically significant color difference between the peri-implant mucosa and the gingiva. However, there was no further significant relation between these color changes and the mucosal thickness. CONCLUSIONS: Peri-implant mucosa revealed a darkish, greenish, and bluish discoloration when compared to the gingiva. More satisfactory patient´s aesthetic evaluation was reported in sites with thicker and comparatively lighter mucosa when compared to the adjacent dentition. CLINICAL RELEVANCE: This article focuses on variables affecting color stability and aesthetics around dental implants. These can be assessed to identify the need for peri-implant phenotypic modification.

Outcome indicators of non-surgical therapy of peri-implantitis: a prospective case series analysis.

OBJECTIVES: This study aims to identify patient and implant indicators influencing the non-surgical therapeutic outcomes of peri-implantitis at 6 months of follow-up. METHODS: This case series involved patients with at least one implant diagnosed with peri-implantitis according to the 2017 World Workshop criteria. Non-surgical therapy consisted of mechanical debridement of the peri-implant pockets combined with metronidazole 500 mg 3 times a day for 7 days. At baseline and at 6 months, clinical and radiographic variables were collected to calculate treatment success (probing pocket depth reduction to 5 mm without bleeding on probing or < 5 mm irrespective of bleeding on probing at all implant sites, and lack of bone loss progression). The primary outcome was treatment success (%) at 6 months. The influence of the patient and implant/prosthetic variables upon disease resolution was assessed through simple and multiple logistic regression analyses at patient and implant level, using generalized estimation equations models. RESULTS: A total of 74 patients and 107 implants were analyzed at 6 months. Disease resolution was established in 25.7% of the patients and 24.1% of the implants. Patients with stage IV and grade C periodontitis, inadequate oral hygiene at baseline, and wide diameter (≥ 4.5 mm) presented significantly greater treatment failure, whereas smokers and former smokers demonstrated a tendency toward failure. At 6 months, there was a significant decrease in probing pocket depth and bleeding on probing of 1.08 ± 1.06 mm and 14%, respectively. Radiographically, a significant gain in marginal bone level of 0.43 ± 0.56 mm was observed. CONCLUSION: Disease resolution after non-surgical treatment of peri-implantitis is negatively influenced by the loss of support of the adjacent periodontium, poor baseline oral hygiene, and wide diameter implants (≥ 4.5 mm). CLINICAL RELEVANCE: This study helps to discriminate the clinical situations in which non-surgical treatment is less likely to achieve treatment success at short term.

Clinical considerations in the surgical management of peri-implantitis lesions in the esthetic zone.

OBJECTIVE: The treatment of peri-implantitis is commonly associated to soft tissue changes as part of disease resolution. These changes may alter harmony in the esthetic area, and thus may negatively affect patient satisfaction. This technical note presents the key features that may lead to an unsatisfactory esthetic outcome when managing peri-implantitis in the anterior zone. CLINICAL SIGNIFICANCE: It is essential to consider four pivotal elements in securing therapeutic success through the resolution of inflammation while maintaining esthetics: (1) patient-related factors, including patient willingness to treat and the smile line; (2) implant-related factors that influence implant position; (3) site-related factors related to defect configuration; and (4) prosthetic-related factors referred to the prosthetic emergence profile and the type of prosthesis. A comprehensive examination must be carried out preoperatively to assess the impact of the surgical treatment upon the esthetic outcomes. CONCLUSION: The clinician must be aware of the key features that condition the esthetic outcome when managing peri-implantitis.

Impact of peri-implant soft tissue characteristics on health and esthetics.

OBJECTIVE: To review the impact of key peri-implant soft tissue characteristics on health and esthetics. MAIN CONSIDERATIONS: The keratinized mucosa width (KMW), the mucosal thickness (MT), and the supracrestal tissue height (STH) are essential components of the peri-implant soft tissue phenotype. An inadequate KMW (<2 mm) has been associated with local discomfort upon oral hygiene performance and increased risk for the onset of peri-implant diseases. A minimum buccal MT (≥2 mm) is generally required to prevent esthetic issues related to the effect of transmucosal prosthetic elements on the color of the mucosa and can also contribute to long-term mucosal stability. STH is directly related to marginal bone remodeling patterns during the early healing process that follows the connection of transmucosal prosthetic components. Short STH, generally defined as <3 mm, has been consistently associated with marginal bone loss resulting from the physiologic establishment of the mucosal seal. Insufficient STH may also derive into the fabrication of unfavorable transmucosal prosthetic contours, which frequently results in unpleasing esthetic outcomes and predisposes to submarginal biofilm accumulation. Peri-implant soft tissue dehiscences (PISTDs) are a type of peri-implant deformity that are associated with esthetic issues and often occur in sites presenting KMW, MT, and/or STH deficiencies. PISTDs should be correctly diagnosed and treated accordingly, usually by means of multidisciplinary therapy. CONCLUSION: Understanding the impact of different dimensional and morphologic features of the peri-implant mucosa on health and esthetic outcomes is fundamental to make appropriate clinical decisions in the context of tooth replacement therapy with implant-supported prostheses.

Influence of immediate postoperative gingival thickness and gingival margin position on the outcomes of root coverage therapy: A 6 months prospective case series study using 3D digital measuring methods.

BACKGROUND: To assess linear and volumetric changes following the treatment of gingival recessions (GRs) by means of a modified coronally advanced tunnel technique combined with acellular dermal matrix (MTUN + ADM). MATERIALS AND METHODS: Patients presenting GR type 1 (RT1) GRs underwent root coverage surgery consisting of MTUN + ADM. Clinical measurements were made, and intraoral scans were obtained at baseline, postoperatively, and 6 weeks, 3 and 6 months after surgery, to evaluate changes in probing depth (PD), keratinized tissue width (KTW), recession depth (RD), recession area (RA), marginal gingival thickness (MGT), and mucosal volume (MV). The impact of patient-level and surgical-site variables upon percentage root coverage (% RC) and the likelihood of achieving complete root coverage (CRC) were explored. RESULTS: A total of 20 patients (n = 47 teeth) were treated. After 6 months, RD and RA decreased, while KTW, MGT, and MV increased. The mean % RC was 93% at 6 months and CRC was found on 72.3% of the sites at 6 months. The postoperative MGT changes at 1.5 and 3 mm were significantly correlated to % RC and CRC at 6 months. Each additional mm of postoperative gain of gingival thickness resulted in a 4-fold increase in the probability of achieving CRC. Additionally, gingival margin positioned ≥0.5 mm coronal to the cementoenamel junction immediately after surgery was a strong predictor of CRC. CONCLUSIONS: The MGT gain at 1.5 and 3 mm achieved in the immediate postoperative period is a significant predictor of CRC at 6 months when treating multiple GRs via MTUN + ADM. CLINICAL SIGNIFICANCE: The Scientific rationale for the study relies on the lack of 3D digital measuring tools in the assessment of soft tissue healing dynamics after root coverage therapy. The principal findings of this study can be summarized as follows: tooth type, tooth position, and post-operative gingival margin position and gingival thickness and volume changes are predictors of CRC. Therefore, the practical implications are that the more thickness and more coronal advancement achieved immediately after root coverage surgery, the higher chance of achieving CRC.

Management and sequelae of dental implant removal.

Inappropriate and unnecessary implant therapy driven by an erroneous belief that dental implants provide enhanced function and esthetics over diseased or failing teeth has led to a growing burden of implant complications across the globe. Specifically, esthetic and biological complications frequently lead to the unfavorable prognosis of dental implants. Often, these cannot be managed predictably to improve the condition or satisfy patients' demands. In such circumstances, implant removal needs to be considered. Currently, minimally invasive methods based on reverse torque engineering are key to preserve peri-implant soft and hard tissues. Implant replacement is now feasible, as evidenced by the high survival rates of implants placed at previously failed sites. Notwithstanding these data, clinicians should still consider carefully the expendability of an implant and whether its replacement will satisfy the prosthetic, biomechanical, and esthetic demands of the patient. In the scenario where future implant placement is desired, protocols undertaken for soft/hard tissue grafting and implant placement should be based upon defect morphology and soft and hard-tissue characteristics. Currently, however, a lack of knowledge of the biological events and dimensional changes that arise following implant removal renders decision-making complex and challenging, and recommendations remain largely based upon empirical speculation. This chapter will review the indications for implant replacement for prosthetic, biomechanical, and esthetic complications, alongside considerations in decision-making, planning, implementation, and outcomes of implant replacement.