A multi-centre randomized controlled trial comparing connective tissue graft with collagen matrix to increase soft tissue thickness at the buccal aspect of single implants: 3-Year results.

AIM: To compare connective tissue graft (CTG) with collagen matrix (CMX) in terms of increase in buccal soft tissue profile (BSP) when applied at single implant sites. MATERIALS AND METHODS: Patients with a single tooth gap in the anterior maxilla and horizontal mucosa defect were enrolled in a multi-centre randomized controlled trial. All were fully healed sites with a bucco-palatal bone dimension of at least 6 mm, and received an immediately restored single implant using a full digital workflow. Patients were randomly allocated to the control (CTG) or test group (CMX: Geistlich Fibro-Gide, Geistlich Pharma AG, Wolhusen, Switzerland) to increase buccal soft tissue thickness. Primary endpoints were increase in BSP at T1 (immediately postop), T2 (3 months), T3 (1 year) and T4 (3 years) based on superimposed digital surface models. Secondary endpoints included patient-reported, clinical and aesthetic outcomes. RESULTS: Thirty patients were included per group (control group: 15 males, 15 females, mean age 50.1 years; test group: 14 males, 16 females, mean age 48.2 years) and 50 could be re-examined at T4. The changes in BSP over time were significantly different between the groups (p < .001). At T4, the estimated mean increase in BSP amounted to 0.83 mm (95% confidence interval [CI]: 0.58-1.08) in the control group and 0.48 mm (95% CI: 0.22-0.73) in the test group. The estimated mean difference of 0.35 mm (95% CI: 0.06-0.65) in favour of the control group was significant (p = .021). No significant differences between the groups could be observed in terms of patients' aesthetic satisfaction (p = .563), probing depth (p = .286), plaque (p = .676), bleeding on probing (p = .732), midfacial recession (p = .667), Pink Esthetic Score (p = .366) and Mucosal Scarring Index (p = .438). However, CMX resulted in significantly more marginal bone loss (-0.43 mm; 95% CI: -0.77 to -0.09; p = .015) than CTG. CONCLUSIONS: CTG was more effective in increasing buccal soft tissue profile and resulted in less marginal bone loss than CMX. Therefore, CTG remains the gold standard to increase soft tissue thickness at implant sites. CLINICAL TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov (NCT04210596).

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

OBJECTIVES: To compare immediate implant placement (IIP) with early implant placement (EIP) for single tooth replacement in the aesthetic area in terms of aesthetic, clinical, and patient-reported outcomes. MATERIALS AND METHODS: Two independent reviewers conducted an electronic literature search in PubMed, Web of Science, Embase, and Cochrane databases as well as a manual search to identify eligible clinical studies up to February 2023. Randomized Controlled Trials (RCTs) comparing IIP with EIP were included for a qualitative and quantitative analysis. The primary outcome was vertical midfacial soft tissue change. Secondary outcomes were horizontal midfacial soft tissue change, vertical papillary change, pink esthetic score (PES), implant survival, buccal bone thickness, marginal bone level change, patient discomfort, chair time, and patient satisfaction. RESULTS: Out of 1185 records, 6 RCTs were selected, reporting on 222 patients who received 222 single implants (IIP: 112 implants in 112 patients; EIP: 110 implants in 110 patients) in the anterior maxilla or mandible. Patients had a mean age ranging from 35.6 to 52.6 years and were followed between 8 and 24 months. Two RCTs showed some concerns, and four showed a high risk of bias. Four studies could be included in a meta-analysis on the primary outcome and three only considered cases with an intact buccal bone wall. Meta-analysis failed to demonstrate a significant difference in terms of vertical midfacial soft tissue change between IIP and EIP (mean difference: 0.31 mm, 95% CI [-0.23; 0.86], p = .260; I2 = 83%, p < .001). No significant differences were found for PES (standardized mean difference: 0.92, 95% CI [-0.23; 2.07], p = .120; I2 = 89%, p < .001), implant survival (RR: 0.98, 95% CI [0.93, 1.03], p = .480; I2 = 0%, p = .980), and marginal bone level change (mean difference: 0.03 mm, 95% CI [-0.12, 0.17], p = .700; I2 = 0%, p = .470). Insufficient data were available for meta-analyses of other secondary outcomes. CONCLUSION: In low-risk patients with an intact buccal bone wall, there seems to be no difference between IIP and EIP in terms of aesthetic and clinical outcomes. The strength of this conclusion is rated as low since studies showed an unclear or high risk of bias. In addition, state-of-the-art therapy was only delivered in a minority of studies. Future RCTs should also provide data on patient-reported outcomes since these have been underreported.

Early implant placement versus ridge preservation and delayed implant placement: Analysis of profilometric, clinician- and patient-reported outcomes from a two-centre RCT.

OBJECTIVES: To compare early implant placement (EP) to alveolar ridge preservation and delayed implant placement (ARP/DP) in terms of contour changes, along with clinician- and patient-reported outcome measures (PROMs) until the delivery of the implant-supported restoration. MATERIALS AND METHODS: Patients with a failing single tooth in the maxilla or mandible were recruited in two centres. After tooth extraction, patients were randomly assigned (1:1) to either EP or ARP/DP. At abutment connection and crown delivery, the buccal contour changes at 3 mm below the mucosal margin (primary outcome) along with clinician- (ease of treatment) and patient-reported outcomes were assessed using numeric rating scales and OHIP-14. RESULTS: A total of 46 patients were analysed. The mean buccal contour at abutment connection decreased by -1.2 ± 0.6 mm in group EP and -1.6 ± 0.8 mm in group ARP/DP (estimated mean difference; 0.45 [95%CI, -0.02; 0.94]; p = .061) with no significant differences between the groups. ARP/DP was consistently easier than EP across all stages of the surgery (estimated mean difference; 2.0 [95%CI, 1.3; 2.7] p < .001): during flap elevation (EP: 4.8 vs. ARP/DP: 1.6), implant placement (EP: 5.7 vs. ARP/DP: 2.2) and wound closure (EP: 3.4 vs. ARP/DP: 1.6). Both interventions improved quality of life but patients who underwent ARP/DP were significantly more satisfied at the time of crown delivery (ARP/DP: 9.6 vs. EP: 9.1, p = .02). CONCLUSIONS: EP and ARP/DP show no significant differences in buccal contour changes, aesthetics and patient-reported outcomes. However, ARP/DP is an easier procedure at all stages of the surgery compared to EP and could therefore be the preferred therapy for less experienced clinicians.

Adjunctive locally and systemically delivered antimicrobials during surgical treatment of peri-implantitis: A systematic review.

AIM: To answer the following PICOS question: "In patients with peri-implantitis, what is the efficacy of surgical therapy with adjunctive systemic or local antimicrobials, in comparison with surgical therapy alone, in terms of pocket probing depth reduction, as assessed in randomized controlled trials (RCTs) with at least 6 months of follow-up?" MATERIALS AND METHODS: A systematic literature search was conducted. Reduction in mean probing pocket depth (PPD) was the primary outcome. Secondary clinical outcomes were changes in suppuration (%), changes in bleeding on probing (BOP) (%), marginal bone level changes (mm), disease resolution (%), and implant/prosthesis loss (%). Patient-reported outcome measures, possible adverse effects, and oral-health-related quality of life were also extracted if such data were available. RESULTS: Four RCTs assessing the use of locally (two RCTs) and systemically (two RCTs) administered antimicrobial adjuncts to surgical treatment of peri-implantitis, with 6-36-month follow-up, were included. Because of the substantial heterogeneity of interventions between the studies, meta-analysis could not be performed. A reduction in the mean PPD was observed following all the involved surgical treatments, irrespective of the addition of antimicrobials. Except for the effect of systemic antimicrobials on marginal bone level changes and local antimicrobials on BOP, the effect of systemic and local antimicrobials was equivocal for all secondary outcome measures. CONCLUSIONS: Based on the limited available evidence, the adjunctive use of the currently tested systemic or local antimicrobials during surgical therapy, in comparison with surgical therapy alone, in patients with peri-implantitis does not seem to improve the clinical efficacy. With regard the use of systemic antimicrobials, only 50% of the cases showed disease resolution after 1 year. There is a lack of studies that consider the sole use of local antimicrobials. Therefore, their true effect remains unclear.

Immediate implant placement with flap or flapless surgery: A systematic review and meta-analysis.

AIM: To assess the impact of mucoperiosteal flap elevation for single immediate implant placement (IIP) on buccal hard and soft tissue changes, and on clinical, aesthetic and patient-reported outcomes. MATERIALS AND METHODS: Two independent reviewers conducted an electronic literature search in Pubmed, Web of Science, Embase and Cochrane databases as well as a manual search to identify eligible clinical studies up to June 2022. Randomized controlled trials (RCTs) comparing IIP without flap elevation to IIP with flap elevation were included for a qualitative and quantitative analysis. The primary outcome was horizontal buccal bone change. Secondary outcomes were implant survival, vertical buccal bone change, pain, and clinical and aesthetic parameters. RESULTS: Out of 1029 records, 5 RCTs were selected reporting on 140 patients who received 140 single immediate implants (flapless: 68; flap: 72). Patients had a mean age ranging from 30 to 67 years and were followed between 6 and 12 months. Four RCTs pertained to (nearly) intact alveoli. Risk of bias assessment yielded low risk for two RCTs and high risk for three RCTs. Meta-analysis demonstrated a mean difference of 0.48 mm (95% confidence interval [CI] [0.13, 0.84], p = .007) in horizontal buccal bone change between surgical approaches, favouring flapless surgery. Meta-analysis failed to demonstrate a significant difference in implant survival between the groups (RR 1.00, 95% CI [0.93, 1.07], p = .920). Given the scarcity of data, meta-analyses could not be performed on other secondary outcomes. Available studies were consistent in the direction of the effect favouring flapless surgery for vertical buccal bone change as well as for pain. Clinical and aesthetic parameters were underreported. CONCLUSIONS: Based on CBCT data, flapless surgery resulted in more buccal bone preservation at immediate implants. However, the clinical relevance of this finding is unclear, since clinical and aesthetic outcomes were underreported.

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.

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

AIM: To assess the effect of immediate provisionalization (IP) on soft tissue changes, hard tissue changes, and clinical parameters following single immediate implant placement (IIP). MATERIALS AND METHODS: Two independent reviewers conducted an electronic literature search in PubMed, Web of Science, Embase, and Cochrane databases as well as a manual search to identify eligible clinical studies up to September 2021. Randomized controlled trials (RCTs) comparing IIP with IP (test) and IIP without IP (control) were included for a qualitative and quantitative analysis. The primary outcome was vertical midfacial soft tissue changes. Secondary outcomes included horizontal midfacial soft tissue changes, implant survival, mesial and distal papillary changes, Pink Esthetic Score (PES) at final follow-up, marginal bone-level changes, probing depth at final follow-up, and bleeding on probing at final follow-up. RESULTS: Of the 8213 records, 7 RCTs reporting on 323 patients who received 323 single immediate implants (IIP + IP: 161 implants in 161 patients; IIP: 162 implants in 162 patients) were selected with a mean follow-up ranging from 12 to 60 months. Risk of bias assessment yielded some concerns for five RCTs and high risk for two RCTs. Meta-analysis on the cases with intact alveoli demonstrated 0.87 mm (95% confidence interval [CI] [0.57; 1.17], p < .001) less apical migration of the midfacial soft tissue level for IIP + IP when compared to IIP alone. Implant survival, papillary changes, marginal bone-level changes, probing depth, and bleeding on probing were not significantly affected by IP. Insufficient data were available for meta-analyses on horizontal midfacial soft tissue changes and PES. CONCLUSIONS: IP may contribute to midfacial soft tissue stability at immediate implants. However, high-quality RCTs are needed since the strength of this conclusion is currently rated as low according to GRADE guidelines.

A randomized controlled trial evaluating hyaluronic acid gel as wound healing agent in alveolar ridge preservation.

AIM: To compare the results of administration of hyaluronic acid (HA) gel to no gel administration following alveolar ridge preservation (ARP) in terms of changes in wound dimensions over time. MATERIALS AND METHODS: Systemically healthy patients scheduled for ARP at one or two sites in the incisor, cuspid, or premolar area with at least one neighbouring tooth and >50% buccal bone present following extraction were included. ARP consisted of socket grafting with collagen-enriched, deproteinized bovine bone mineral and socket sealing by means of a collagen matrix. Following surgical therapy, sites were randomly allocated to the control group (no gel application) or the test group (0.8% HA gel applied onto the collagen matrix three times per day for 7 days). Bucco-lingual and mesio-distal wound dimensions were registered at T0 (immediately post operation), T1 (1 week), and T2 (3 weeks). Patient-reported outcomes, clinical outcomes, and hard and soft tissue changes were recorded up to 4 months (T3). RESULTS: In the control group, 20 patients (7 males, 13 females; mean age 53.30) with 23 sites, and in the test group 18 patients (9 males, 9 females; mean age 52.56) with 23 sites, were included. There were no significant differences between the groups in the changes in wound dimensions from T0 to T2 (bucco-lingual aspect: p = .340; mesio-distal aspect: p = .883). Three sites (13%) in the control group and six (26%) in the test group demonstrated complete wound resolution at T2 (p = .259). HA failed to show any effect on the number of analgesics taken (p = .175), patient-reported outcomes (p ≥ .263), alveolitis (p = .136), socket healing (p ≥ .424), soft tissue changes (p ≥ .064), or mucosal scarring (p = .548). However, significantly more horizontal bone loss at the coronal aspect was found in the test group (p ≤ .025). CONCLUSION: HA failed to promote wound resolution on a collagen matrix. This study was registered in ClinicalTrials.gov (NCT04467736).

A multi-centre randomized controlled trial comparing connective tissue graft with collagen matrix to increase soft tissue thickness at the buccal aspect of single implants: 1-year results.

AIM: To compare connective tissue graft (CTG) with collagen matrix (CMX) in terms of increase in buccal soft tissue profile (BSP) at 1 year when applied at single implant sites. MATERIALS AND METHODS: Patients with a single tooth gap in the anterior maxilla and horizontal mucosa defect were enrolled in a multi-centre randomized controlled trial. All sites had a bucco-palatal bone dimension of at least 6 mm, received a single implant and an immediate implant restoration using a full digital workflow. Sites were randomly allocated to the control (CTG) or test group (CMX) to increase buccal soft tissue thickness. The primary outcome was the increase in BSP at 1 year when compared with the pre-operative situation based on superimposed digital surface models. The changes in BSP over time were registered at a buccal area of interest reaching from 0.5 mm below the soft tissue margin to 4 mm more apical. Secondary outcomes included patient-reported, clinical and aesthetic outcomes. RESULTS: Thirty patients were included per group (control: 50% females, mean age 50.1; test: 53% females, mean age 48.2). The increase in BSP at 1 year was 0.98 mm (98.3% confidence interval [CI]: 0.75-1.20) for CTG and 0.57 mm (98.3% CI: 0.34 to 0.79) for CMX. The mean difference of 0.41 mm (98.3% CI: 0.12 to 0.69) in favour of CTG was significant (p < .001). Based on an arbitrarily chosen threshold for success of 0.75 mm increase in BSP, 89.7% of the patients in the control group and 10% of the patients in the test group were successfully treated (odds ratio = 77.90; 95% CI: 13.52 to 448.80; p < .001). Sites treated with CMX demonstrated 0.89 mm (98.3% CI: 0.49 to 1.30) more shrinkage between postop and 1 year than sites treated with CTG. In addition, CMX resulted in significantly more marginal bone loss (0.39 mm; 95% CI: 0.05 to 0.74; p = .026) than CTG. There were no significant differences between the groups in terms of patients' aesthetic satisfaction (p = .938), probing depth (p = .917), plaque (p = .354), bleeding on probing (p = .783), midfacial recession (p = .915), Pink Esthetic Score (p = .121) and Mucosal Scarring Index (p = .965). CONCLUSIONS: CTG remains the gold standard to increase soft tissue thickness at implant sites. Clinicians need to outweigh the benefits of CMX against considerable resorption of the graft. This study was registered in ClinicalTrials.gov (NCT04210596).

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

AIM: To identify the factors associated with buccal peri-implant soft tissue dehiscences (BSTDs) and their frequency of occurrence. MATERIALS AND METHODS: Randomized controlled trials, controlled clinical trials, cohort studies, and case series assessing the frequency of occurrence of BSTD were included. BSTD was defined as an apical migration of the peri-implant soft tissues of ≥1 mm from the baseline examination (final restoration) or in comparison with the adjacent or contralateral natural tooth. Frequency distributions of BSTD related to the presence or absence of any surgical, prosthetic, or anatomic factor that may have contributed to the development of BSTD were recorded. Random-effects meta-analyses using odds ratios (OR) were performed to investigate the association of certain factors with the development of BSTD. RESULTS: Twenty-four articles were finally included belonging to 22 clinical investigations. Patients at higher risk of developing BSTD were associated with thin biotype (OR = 2.85 [1.40, 5.8], n = 5, p = .003) and with buccally placed implants (OR = 14.37 [4.58, 45.14], n = 3, p ≤ .001). Patients without connective tissue grafting (CTG) had greater odds of developing BSTD (OR = 9.00 [3.11, 26.02], n = 5, p ≤ .001), while buccal bone plate thickness of <1 mm and immediately placed implants were not associated with greater BSTD (OR = 1.29 [0.35, 4.77], n = 2, p = .704 and OR = 1.56 [0.46, 5.26], n = 4, p = .477, respectively). The frequency of occurrence of BSTD varied across the included studies with a range from 0% to 61%. CONCLUSIONS: Thin tissue biotype and buccally placed implants were associated with BSTD, whereas CTG seemed to have a protective effect. Thin buccal plates and immediately placed implants did not demonstrate a higher risk of BSTD.

A randomized controlled trial comparing guided bone regeneration to connective tissue graft to re-establish buccal convexity at dental implant sites: Three-year results.

OBJECTIVES: To compare guided bone regeneration (GBR) to connective tissue graft (CTG) in terms of increase in buccal soft tissue profile (BSP) at three-year follow-up when applied at the buccal aspect of single implant sites demonstrating a minor horizontal alveolar defect. MATERIALS AND METHODS: Patients with a single tooth gap in the anterior maxilla and horizontal alveolar defect were enrolled in a single-blind RCT. All sites had a bucco-palatal bone dimension of at least 6 mm, received a single implant at least 3 months after tooth removal and were randomly allocated to the control (GBR) or test group (CTG) to re-establish buccal soft tissue convexity. Primary outcome was linear increase in BSP, meaning increase at the buccal aspect of the implant, based on superimposed digital surface models. Secondary outcomes were buccal bone and buccal soft tissue thickness, aesthetic and clinical parameters. RESULTS: Twenty-one patients were included per group at baseline. After three years, three patients in the GBR group and four in the CTG group were not willing to return for re-assessment. Hence, the final sample included 9 females/9 males (mean age 52) in the GBR group and 8 females / 9 males in the CTG group (mean age 49). The changes in BSP over time were not significantly different between GBR and CTG (p = 0.629). At three years, sites treated with GBR demonstrated 1.06 mm (95% CI: 0.83; 1.28) increase in BSP, whereas sites treated with CTG showed 0.99 mm (95% CI: 0.65; 1.35) increase in BSP (p = 0.699) compared to baseline. There were no significant differences between the groups for any of the parameters except for Mucosal Scarring Index, which was 1.63 (95% CI: 0.73; 2.53) lower for CTG (p = 0.002) at study termination. CONCLUSION: There was no significant difference in linear increase in BSP between GBR and CTG after three years. Hence, clinical decision-making should be based on other factors.

A questionnaire-based crossover study on the association of microbiological testing with prescription of systemic antibiotics following initial periodontal therapy.

AIM: (1) To assess prescription of systemic antibiotics following initial periodontal therapy with and without the availability of microbiological information; (2) To identify factors associated with prescription of systemic antibiotics following initial periodontal therapy. MATERIALS AND METHODS: Twenty-four clinicians were invited to complete a questionnaire on 20 patient records with respect to periodontal treatment planning, once with microbiological information available and once without. Randomization determined when the microbiological information was provided, and a 3-month washout period was respected between scoring sessions. Regression analysis was performed to identify factors associated with prescription of systemic antibiotics. RESULTS: Twenty-one clinicians completed both scoring sessions. Clinicians prescribed systemic antibiotics in on average 56% (95% Confidence Interval (CI) [0.51; 0.61]) of the cases having microbiological information, and in 52% (95% CI [0.47; 0.57]) of the same cases not having that information (p = 0.094). The odds for prescribing systemic antibiotics were 3.34 (95% CI [2.06; 5.42]) times higher when the clinician had at least 3 years of experience, 2.55 (95% CI [1.40; 4.66]) times higher for patients diagnosed with periodontitis stage IV when compared to stage III, 1.08 (95% CI [1.04; 1.11]) times higher for younger patients, 2.78 times (95% CI [1.37; 5.56]) times higher for non-smokers and 2.22 (95% CI [1.27; 3.85]) times higher when less than three teeth would require extraction. No significant associations with the prescription of systemic antibiotics were found for detection of A.actinomycetemcomitans (p = 0.287), grade of periodontitis (p = 0.499) and gender of the patient (p = 0.067). CONCLUSIONS: Based on a limited number of cases and clinicians, several patient and clinician related factors were associated with prescription of systemic antibiotics following initial periodontal therapy. However, microbiological testing was not.

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).

A multi-centre randomized controlled trial comparing connective tissue graft with collagen matrix to increase soft tissue thickness at the buccal aspect of single implants: 3-month results.

AIM: To compare connective tissue graft (CTG) with collagen matrix (CMX) in terms of changes over time in buccal soft tissue profile (BSP) when applied at single implant sites. MATERIALS AND METHODS: Patients with a single tooth gap in the anterior maxilla and horizontal mucosa defect were enrolled in a multi-centre randomized controlled trial. All sites had a bucco-palatal bone dimension of at least 6 mm and received a single implant and immediate implant restoration using a full digital workflow. Sites were randomly allocated to the control (CTG) or test group (CMX: Geistlich Fibro-Gide®, Geistlich Pharma AG, Wolhusen, Switzerland) to increase buccal soft tissue thickness. Primary outcome was increase in BSP at T1 (immediately after operation) and T2 (3 months) based on superimposed digital surface models. Secondary parameters included patient-reported clinical and aesthetic outcomes. RESULTS: Thirty patients were included per group (control: 50% females, mean age 50; test: 53% females, mean age 48). Even though surgeons applied thicker grafts when using CMX, sites treated with CMX demonstrated 0.78 mm (95% CI 0.41-1.14) more shrinkage between T1 and T2 than sites treated with CTG. The final increase in BSP was 1.15 mm (95% CI 0.88-1.43) for CTG and 0.85 mm (95% CI 0.58-1.13) for CMX. The mean difference of 0.30 mm (95% CI -0.01 to 0.61) at T2 in favour of CTG was of borderline significance (p = .054). There were no significant differences between the groups in terms of post-operative bleeding (p = .344), pain (p = .331), number of analgesics taken (p = .504), oedema (p = .227), and pink aesthetic score (p = .655). VAS for post-operative haematoma was 6.56 (95% CI 0.54-12.59) lower for CMX, and surgery time could be reduced by 9.03 min (95% CI 7.04-11.03) when applying CMX. However, CMX resulted in significantly more marginal bone loss (0.38 mm; 95% CI 0.15-0.60), deeper pockets (0.30 mm; 95% CI 0.06-0.54), and more mid-facial recession (0.75 mm; 95% CI 0.39-1.12) than CTG. CONCLUSIONS: CTG remains the gold standard for increasing soft tissue thickness at the buccal aspect of implants.

Soft tissue metric parameters, methods and aesthetic indices in implant dentistry: A critical review.

OBJECTIVES: The primary objective was to provide an overview of soft tissue metric parameters, methods, and aesthetic indices in implant dentistry. The secondary objective was to describe reliability and validity of aesthetic indices. MATERIALS AND METHODS: Two independent reviewers conducted an electronic literature search in Pubmed, Web of Science, Embase, and Cochrane databases up to October 2020 to identify studies on soft tissue metric parameters, methods, and aesthetic indices. Aesthetic indices were evaluated in terms of reliability and validity. Data extraction was performed by the same reviewers. RESULTS: Five metric parameters (papilla height, linear changes in soft tissue level, color assessment, soft tissue thickness, and profilometric soft tissue changes) registered by means of several methods (intra-oral registrations, radiographic assessments, digital analyses, and ultrasonic assessments), and 15 aesthetic indices (Papilla Index (PI), ad hoc questions scored with Visual Analogue Scales, Pink Esthetic Score (PES), Implant Crown Aesthetic Index (ICAI), Implant Aesthetic Score (IAS), Rompen Index, Subjective Esthetic Score, White Esthetic Score, Copenhagen Index, Complex Esthetic Index, Californian Dental Association Index (CDAI), Peri-Implant, and Crown Index, Functional Implant Prosthodontic Score, Implant Restoration Esthetic Index (IREI), and Mucosal Scarring Index (MSI)) could be identified. With respect to metric parameters and methods, intra-oral registrations were least accurate whereas profilometric soft tissue changes on the basis of digital surface models were most accurate. Six aesthetic indices showed good inter-rater reliability (PI, PES, ICAI, CDAI, IREI, and MSI). Good validity could only be shown for two indices (PES and CEI). Given this and on the basis of ease of use and ease of interpretation, PES qualified best for clinical research on single implants. None of the indices fulfilled the quality criteria for clinical research on multiple implants. CONCLUSION: Many soft tissue assessment methods with varying reliability and validity have been described and used, which hampers uniform reporting in implant dentistry. Clinical investigators are advised to measure linear and profilometric soft tissue changes using digital surface models, and to use a reliable and validated aesthetic index. Currently, PES qualifies best for aesthetic evaluation of single implants. An index is to be developed to assess the aesthetic outcome of rehabilitations on multiple implants.

A multicenter cohort study on the association of the one-abutment one-time concept with marginal bone loss around bone level implants.

OBJECTIVES: To investigate the association of the one-abutment one-time concept with marginal bone loss (MBL) around bone-level implants in relation to other factors. MATERIALS AND METHODS: Records from patients treated by four experienced implant surgeons between January 2016 and July 2019 were scrutinized. Subjects treated with two bone-level implant types with varying machined collar (subgroups: 0.5 and 0.8 mm) were considered, receiving a healing abutment (HA cohort) or a permanent abutment at the time of surgery (OT cohort). The primary outcome was MBL registered at 3 months and the longest follow-up. A clustered two-part regression model for semicontinuous data was used. RESULTS: Data pertaining to 160 patients (92 females, mean age 54) and 344 implants (125 in HA cohort, 219 in OT cohort) were available for evaluation. Mean MBL amounted to 0.52 mm (SD 0.68) after a mean follow-up of 20 (SD 9.2) months, with 33.8% of the implants showing complete bone preservation and 5.0% demonstrating >2mm MBL. OT was not related to the presence of MBL using MBL as dependent binary variable (0: no MBL; 1: MBL irrespective of its magnitude). However, OT significantly reduced the magnitude of MBL with 0.300mm when compared to HA (p = .023) in the cases where MBL was detected. Subgroup (p = .212), smoking (p = .789), history of periodontitis (p = .839), type of edentulism (p = .054), implant surgeon (p = .079), patient compliance (p = .617), and follow-up (p = .443) failed to show a significant association with MBL in the regression model. Ninety-eight % of the implants survived. CONCLUSION: Within the limitations of a cohort study, the one-abutment one-time concept was associated with a decrease in MBL at implant sites with bone loss. Therefore, the placement of a permanent abutment at the time of surgery seems relevant to limit marginal bone-level alterations.

Soft tissue management at implants: Summary and consensus statements of group 2. The 6th EAO Consensus Conference 2021.

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.

A controlled study on the diagnostic accuracy of panoramic and peri-apical radiography for detecting furcation involvement.

BACKGROUND: The aims of this study were (1) to determine the accuracy, sensitivity, and specificity of panoramic and peri-apical radiographs in diagnosing furcation involvement, as well as (2) to evaluate the possible impact of clinical experience on these diagnostic parameters. METHODS: An existing radiographic dataset of periodontitis patients requiring implant surgery was retrospectively examined for furcation involvement. Criteria for inclusion were the presence of a CBCT, panoramic and peri-apical radiograph of the site of interest within a one-year time frame. All furcation sites were classified using the CBCT, which was considered as the gold standard, according to Hamp's index (1975). Ten experienced examiners and 10 trainees were asked to assess furcation involvement for the same defects using only the corresponding panoramic and peri-apical radiographs. Absolute agreement, Cohen's weighted kappa, sensitivity, specificity and ROC-curves were analyzed. RESULTS: The study sample included 60 furcation sites in 29 multi-rooted teeth from 17 patients. On average, 20/60 furcations were correctly classified according to the panoramic radiographs, corresponding to a weighted kappa score of 0.209, indicating slight agreement. Similarly, an average of 19/60 furcations were correctly classified according to the peri-apical radiographs, corresponding to a weighted kappa score of 0.211, also indicating slight agreement. No significant difference between panoramic and peri-apical radiography was found (P = 0.903). When recategorizing FI Grades into 'no to limited FI' (FI Grade 0 and I) and 'advanced FI' (FI Grade II and III), the panoramic and peri-apical radiography showed low sensitivity (0.558 and 0.441, respectively), yet high specificity (0.791 and 0.790, respectively) for identifying advanced FI. The ROC-curves for the panoramic and peri-apical radiographs were 0.79 and 0.69 respectively. No significant difference was found between experienced periodontists and trainees (P = 0.257 versus P = 0.880). CONCLUSION: Panoramic and peri-apical radiography are relevant tools in the diagnosis of FI and provide high specificity. Ideally, they are best used in combination with furcation probing, which shows high sensitivity. Furthermore, clinical experience does not seem to improve the accuracy of a radiological diagnosis of furcation sites. TRIAL REGISTRATION: Patient radiographic datasets were retrospectively analyzed.

A 10-year prospective study on single immediate implants.

AIM: To evaluate the clinical, aesthetic and radiographical outcome of single immediate implant placement (IIP) after 10 years (a) and to identify putative risk factors for advanced mid-facial recession (b). MATERIAL AND METHODS: Periodontally healthy patients with a thick gingival biotype and intact buccal bone wall were consecutively treated with a single immediate implant and crown in the aesthetic zone (15-25). Flapless surgery and socket grafting with deproteinized bovine bone mineral were performed. Seven patients received a connective tissue graft (CTG) at 3 months due to obvious alveolar process deficiency (n = 5) or advanced mid-facial recession (n = 2). Clinical, aesthetic and radiographical outcomes at 10 years were compared to those at 5 years and CBCTs were taken at 10 years. RESULTS: Twenty-two patients (10 women; mean age 50) were consecutively treated and 18 could be re-examined. Two implants failed and two patients died. None of the parameters differed between the 5- and 10-year re-assessment (marginal bone loss: 0.31 mm; plaque score: 15%; probing depth: 3.4 mm; bleeding on probing: 32%; pink aesthetic score: 10.61; mesial papillary recession: -0.03 mm; distal papillary recession: 0.22 mm; mid-facial recession: 0.58 mm). Six implants (33%) demonstrated ≥1 mm mid-facial recession. Putative risk factors were merely based on descriptive statistics and included buccal shoulder position, no CTG, convex emergence profile and central incisor position. Three implants (17%) had no visible buccal bone on CBCT. One of these was too buccally positioned, another yielded peri-implant mucositis and another demonstrated peri-implantitis. CONCLUSIONS: Advanced mid-facial recession is common in the long term following IIP. Therefore, caution is required for IIP in the aesthetic zone.

A randomized controlled study comparing guided bone regeneration with connective tissue graft to re-establish buccal convexity: One-year aesthetic and patient-reported outcomes.

OBJECTIVES: To compare guided bone regeneration (GBR) with connective tissue graft (CTG) in terms of aesthetic and patient-reported outcomes (PROMs). MATERIALS AND METHODS: Patients with a single tooth gap in the anterior maxilla and horizontal alveolar defect were enrolled in a single-blind RCT. All sites had a buccopalatal bone dimension of at least 6 mm, received a single implant and were randomly allocated to the control (GBR) or test group (CTG) to re-establish buccal soft tissue convexity. Primary outcomes were Pink Esthetic Score (PES) and Mucosal Scarring Index (MSI) assessed after 1 year. Secondary outcomes included PROMs registered during the early stages of healing and after 1 year. RESULTS: Twenty-one patients were included per group (control: 11 females, mean age 51; test: nine females, mean age 48). Although there was no significant difference in the PES between the groups (control: 10.11; test: 10.48; p = .577), the MSI was significantly lower in the test (1.10) than in the control group (2.53) (p = .017). Based on descriptive statistics, the latter demonstrated wider scars, more colour mismatch and slightly more suture marks. However, these were not considered disturbing by the patients given similar VAS on soft tissue aesthetics (control: 84; test: 87). Oedema and haematoma were rated twice as high in the control group on at least two postoperative time points, and patients took more painkillers (7.10 vs. 4.86). OHIP-14 decreased in both groups between baseline and 1-year follow-up, indicative of less discomfort in daily life. Differences in MSI and PROMs between the groups may be explained by the need of a vertical releasing incision in order to achieve sufficient access for GBR, periosteal incisions and the use of biomaterials that may induce inflammation. CONCLUSION: GBR and CTG resulted in favourable aesthetic outcomes as assessed by professionals and patients. However, given additional vertical and periosteal incisions, GBR resulted in more scarring, postoperative discomfort and a higher need for painkillers.