[Assessment of microhaemodynamics and oxygenation in tissues after the vestibuloplasty with the use of a free dermal autograft in patients after the reconstructive jaw surgery with the use of the revascularized autografts]. / Otsenka sostoyaniya mikrogemodinamiki i oksigenatsii v tkanyakh posle vestibuloplastiki s ispol'zovaniem svobodnogo dermal'nogo autotransplantata u patsientov posle rekonstruktivnoi operatsii na chelyustyakh s primeneniem revaskulyarizirovannykh autotransplantatov.

Purpose of the study: to study the features of microhaemodynamics and oxygenation in soft tissues in the area of the plastically reconstructed jaw after the vestibuloplasty. MATERIALS AND METHODS: The study included 40 patients aged 20 to 65 (21 males and 19 females). The patients were divided into two groups: I group (14 patients) - patients after reconstructive surgery with the use a fibula autograft without the inclusion of a musculocutaneous «islet¼; II group (26 patients) - patients after reconstructive surgery with the use a fibula autograft with the inclusion of a musculocutaneous «islet¼. To correct the prosthetic bed soft tissues, all patients underwent vestibuloplasty with the use of a free dermal autograft. To study microcirculation in tissues, the laser Doppler flowmetry (LDF) method was used. Microcirculation status was assessed by microcirculation index characterizing the level of tissue blood flow; parameter «σ,¼ which determines the oscillability of the flow of red blood cells and by coefficient of variation, characterizing vasomotor activity of microvessels. According to the Wavelet analysis of LDF-grams the blood flow bypass was determined. An oxygenation study was carried out in the tissues of the plastically restored jaw by optical tissue oximetry, the results of which determined the oxygenation index and the specific oxygen consumption index. RESULTS: According to LDF data after vestibuloplasty, it was found that in I group, the microcirculation in soft tissues of the plastically reconstructed jaw restored in 21 days, and in II group in 2 months, which persisted at 6 months. In I group, the level of oxygenation and specific oxygen consumption normalized in 21 days, and in II group in 2 months, which persisted at 6 months. CONCLUSION: Based on the results of this functional study, it was found that before vestibuloplasty microcirculation and oxygenation indices in II group patients were lower than those in I group patients. After vestibuloplasty with the use of a free dermal autograft, microcirculation indices in II group patients restored in 2 months, while in I group patients those indices restored in 21 days.

Technical Note on Vestibuloplasty around Dental Implants Using Erbium YAG Laser-Assisted Periosteal Fenestration (LA-PF).

Various vestibuloplasty techniques have been reported to increase the attached mucosa (AM) and vestibular depth around dental implants. However, these surgical methods have disadvantages, such as limitations in manipulation, necessity of suturing, postoperative discomfort, swelling, and pain. This study aimed to evaluate the efficacy of laser-assisted periosteal fenestration (LA-PF) in treating patients with a shallow vestibule and insufficient AM around dental implants. LA-PF was performed using an Erbium YAG laser (Er:YAG laser). First, a partial-thickness, apically positioned flap was used. A horizontal periosteal fenestration was performed using an Er:YAG laser to expose the bones. Periosteal suturing was not required. After 12 months, sufficient AM and deep vestibules were obtained and maintained. Thus, the LA-PF technique may be a simple and predictable treatment modality for shallow vestibules with insufficient AM around dental implants.

Three-dimensional changes of a porcine collagen matrix and free gingival grafts for soft tissue augmentation to increase the width of keratinized tissue around dental implants: a randomized controlled clinical study.

BACKGROUND: Emerging clinical data points to the relevance of the presence of keratinized tissue (KT). Although apically positioned flap/vestibuloplasty along with free gingival graft (FGG) is considered as a standard intervention for augmenting KT, substitute materials appear to be a viable treatment alternative. So far, there is a lack of data investigating the dimensional changes at implant sites treated with soft-tissue substitutes or FGG. AIM: The present study aimed at comparing three-dimensional changes of a porcine derived collagen matrix (CM) and FGG for increasing KT at dental implants over a 6-month follow-up period. MATERIALS AND METHODS: The study enrolled 32 patients exhibiting deficient KT width (i.e., < 2 mm) at the vestibular aspect who underwent soft tissue augmentation using either CM (15 patients/23 implants) or FGG (17 patients/31 implants). The primary outcome was defined as tissue thickness change (mm) at treated implant sites between 1- (S0), 3- (S1), and 6-months (S2). Secondary outcomes considered changes of KT width over a 6-month follow-up period, surgical treatment time, and patient-reported outcomes. RESULTS: Dimensional analyses from S0 to S1 and from S0 to S2 revealed a mean decrease in tissue thickness of - 0.14 ± 0.27 mm and - 0.04 ± 0.40 mm in the CM group, and - 0.08 ± 0.29 mm and - 0.13 ± 0.23 mm in the FGG group, with no significant differences noted between the groups (3 months: p = 0.542, 6 months: p = 0.659). Likewise, a comparable tissue thickness decrease was observed from S1 to S2 in both groups (CM: - 0.03 ± 0.22 mm, FGG: - 0.06 ± 0.14 mm; p = 0.467). The FGG group exhibited a significantly greater KT gain after 1, 3 and 6 months compared to the CM group (1 month: CM: 3.66 ± 1.67 mm, FGG: 5.90 ± 1.58 mm; p = 0.002; 3 months: CM: 2.22 ± 1.44; FGG: 4.91 ± 1.55; p = 0.0457; 6 months: CM: 1.45 ± 1.13 mm, FGG: 4.52 ± 1.40 mm; p < 0.1). Surgery time (CM: 23.33 ± 7.04 min.; FGG: 39.25 ± 10.64 min.; p = 0.001) and postoperative intake of analgesics were significantly lower in the CM group (CM: 1.2 ± 1.08 tablets; FGG: 5.64 ± 6.39 tablets; p = 0.001). CONCLUSIONS: CM and FGG were associated with comparable three-dimensional thickness changes between 1 and 6 months. While a wider KT band could be established with FGG, the use of CM significantly reduced surgical time and patients´ intake of analgesics.

Collagen Matrix Vascularization in a Peri-Implant Vestibuloplasty Situation Proceeds Within the First Postoperative Week.

PURPOSE: Vestibuloplasty is a frequently performed surgical procedure to create or increase soft tissue mucosal sealing around dental restorations. Collagen matrices have exhibited comparable clinical results as free gingival grafts in the context of intraoral tissue augmentation. However, the process of matrix vascularization, the basic requirement for local healing, is incompletely understood. Therefore, this study investigated collagen matrix perfusion in a clinical intraoral setting. MATERIALS AND METHODS: In a prospective cohort study, vestibuloplasty was performed during implant exposure using prefabricated collagen matrices. Matric perfusion was determined intraoperatively and at days 2, 5, 7, 14, 30, and 90 using a laser Doppler spectrophotometer measuring oxygen saturation, relative amount of hemoglobin, blood flow, and blood velocity as primary outcome variables. These parameters were compared with perfusion of the oral mucosa surrounding the matrices. Statistical analysis was performed by applying variance and regression models. RESULTS: In 10 patients (average age, 60.9 yr), vestibuloplasty was performed exclusively in the anterior mandible. Blood flow and tissue oxygen saturation in the augmented zones markedly increased until postoperative day 5 and approximated perfusion values of the adjacent mucosa at the following 2 time points. Likewise, matrix oxygen saturation markedly increased until day 7 and subsequently converged to perfusion parameters of the surrounding mucosa at the following time points. CONCLUSION: Flow signals in incorporated collagen matrices occurred on day 2 after vestibuloplasty and further increased until days 5 to 7. Therefore, matrix perfusion mainly occurs within the first postoperative week, converging to perfusion levels of the surrounding mucosa with minimal alterations during the following course.

Injerto de Piel en Territorio Oral: Presentación de un Caso / Skin Graft in Oral Cavity. Case Report

RESUMEN: Los injertos de piel consisten en la toma de un segmento de epidermis y dermis logrando una separación completa del sitio dador y del aporte vascular, transfiriéndolos a un sitio receptor. Existen dos tipos de injertos de piel: de espesor parcial y de espesor total. En cavidad oral se utilizan en reconstrucción de lengua, piso de boca, mucosa bucal y defectos producto de maxilectomías. Se presenta el caso de un paciente sexo masculino 26 años que acudió por secuela de tejidos duros y blandos secundarios a trauma facial hace 7 años. Al examen se observó pérdida de fondo de vestíbulo en sector mandibular anteroinferior y pérdida de piezas anteroinferiores. Bajo anestesia general, se realizó vestibuloplastía más injerto de piel de espesor parcial abordando el antebrazo izquierdo de donde se tomó el injerto de piel con el dermatomo. Se llevó el injerto a boca posicionándolo con la dermis hacia la zona cruenta del sitio receptor, cubriendo la cara interna de labio denudada y fijándolo con sutura continua. Se instaló splint de acrílico en el área para mantener colgajos en posición fijándolo con 3 tornillos de 15 mm. Debemos considerar todos los requisitos funcionales de la cavidad oral al momento de planificar una reconstrucción. El injerto de piel de espesor parcial permite tener una buena resistencia, movilidad adecuada y menor contracción por cicatrización. El paciente evoluciona de manera satisfactoria con una clara mejoría en la función labial, en la morfología del vestíbulo oral y en su estética.

ABSTRACT: Skin grafts consist in taking a segment of dermis and epidermis, achieving a complete separation of the donor site and vascular supply, and transferring them to a receptor site. There are two types of skin grafts: split-thickness and full-thickness. In the oral cavity, they are used in tongue reconstruction, oral mucosa reconstruction, floor of mouth reconstruction and in defects product of maxillectomies. We present a case of a 26-year-old male patient who presented sequelae of hard and soft tissues secondary to facial trauma. Clinical examination showed a compromised vestibule and loss of anterior mandibular teeth. Under general anesthesia, soft tissue management consisting of vestibuloplasty and a split-thickness skin graft was performed. The skin graft was taken from the forearm with a dermatome. The graft was then taken to the mouth with the dermis towards the wounded area of the recipient site, covering the inner face of the denuded lip and fixing it with sutures. An acrylic splint was installed in the area to keep the flaps and skin graft in position, fixing it with three 15 mm screws. We must consider all functional requirements of the oral cavity when planning a reconstruction. The split-thickness skin graft allows for good resistance, adequate mobility and less contraction due to scars. The patient evolves with definite improvement in labial function, the morphology of the oral vestibule and in its aesthetic.

Clinical and histologic evaluation of different approaches to gain keratinized tissue prior to implant placement in fully edentulous patients.

OBJECTIVES: This work aimed to investigate the effectiveness and predictability of different treatment modalities for gain of keratinized tissue (KT) in fully edentulous jaws prior to dental implant placement: apically positioned flap (APF), APF plus xenogeneic collagen matrix (XCM), and APF plus free gingival graft (FGG). MATERIALS AND METHODS: In fully edentulous patients with insufficient zones of KT at the prospective implant positions, four treatment modalities were performed in the lower jaw: APF, XCM, FGG, and an untreated control group (control). APF and XCM were applied in the first molar positions, FGG and control in the canine positions. Assessed outcomes up to 3 months post-surgery included changes in width of KT (over a 3-month period), histomorphometric analysis of harvested soft-tissue biopsies (at 3 months postoperatively), and patient-reported outcomes measures (PROMs). RESULTS: For the primary outcome, changes in KT width demonstrated an increase of 1.93 ± 1.6 mm (APF), whereas XCM and FGG showed an increase of 4.63 ± 1.25 mm and 3.64 ± 2.01, respectively. Histomorphometric analyses revealed a thickness of the epithelium ranging between 375 ± 122 µm (APF), 410 ± 116 µm (XCM), 336 ± 122 µm (FGG), and 413 ± 109 µm (control). All biopsies showed a regular muco-periosteal structure with a keratinized epithelium of comparable thickness in all groups. CONCLUSION: All three methods were suitable to increase the width of KT, although APF alone rendered roughly 50% less gain compared to XCM and FGG. CLINICAL RELEVANCE: The use of XCM in conjunction with an APF represents a valuable treatment option for the gain of keratinized tissue in edentulous sites.

A retrospective comparison of three modalities for vestibuloplasty in the posterior mandible: apically positioned flap only vs. free gingival graft vs. collagen matrix.

OBJECTIVES: This work aimed to comparatively evaluate the three modalities of vestibuloplasty around implants in the posterior mandible. MATERIALS AND METHODS: Forty patients who presented with a shallow vestibule and insufficient keratinized gingiva were divided into three groups: apically positioned flap only (APF group), APF with free gingival graft (FGG group), and APF with collagen matrix (CM group). The width of KT was measured at baseline, immediately after surgery (T0), and 6 months (T6) and 12 months after surgery (T12). An esthetic evaluation (color match, contour, and texture) was conducted. RESULTS: Most of the shrinkage occurred within 6 months. The FGG group demonstrated less shrinkage of KT up to 12 months compared to the APF and CM groups. The APF and CM groups exhibited a prolonged and similar rate of shrinkage. The APF and CM groups also showed significantly better esthetic profiles. CONCLUSIONS: Within the limitations of the present study, FGG may be the most predictable modality for increasing KT in the posterior mandible, but it should be emphasized that the posterior mandible does not require high esthetics. CLINICAL RELEVANCE: The effect of apically positioned flap and collagen matrix may be diminished by several factors in posterior mandible, such as low vestibule and high muscle pull. For increasing the dimension of keratinized tissue in posterior mandible, conventional free gingival graft may be more predictable compared to other options.

Vestibuloplastia peri-implantar associada à regeneração tecidual guiada no tratamento da peri-implantite / Peri-implant vestibuloplasty and guided tissue regeneration in the peri-implantitis treatment

Levando em consideração que a peri-implantite é de etiologia multifatorial, embora o fator determinante seja o biofilme dentário, é interessante buscar formas de minimizar as perdas ósseas ocorridas. Desta maneira, ainda que ressalvas possam ser feitas à possibilidade concreta de se obter uma regeneração tecidual guiada, pode-se entender como uma alternativa válida para buscar, pelo menos, estabilizar o processo de progressão desta perda. Concomitantemente a este procedimento, e tendo em vista a indicação de vestibuloplastia para melhor prevenção da recidiva de peri-implantite, foi possível obter um resultado favorável dentro do objetivo proposto, em uma única intervenção cirúrgica. Material e métodos: paciente do sexo feminino, com 68 anos de idade, fumante moderada (8-10 cigarros/dia), se apresentou com exsudato purulento na face mesiovestibular do implante 46. Debelada a fase aguda por meio de fisioterapia local, a paciente foi submetida à cirurgia peri-implantar visando à interceptação da perda óssea por meio de "regeneração tecidual guiada" associada à vestibuloplastia, com a utilização de enxerto gengival subepitelial. Resultados: foi possível obter estabilização da perda óssea, bem como diminuição na profundidade de sondagem, além da redução de exsudato no implante em discussão. Conclusão: além disso, a vestibuloplastia criou melhores condições anatômicas estruturais devido ao tecido ceratinizado obtido e, sobretudo, criou um favorável acesso à escovação em toda a extensão dos quatro implantes, antevendo- -se melhor possibilidade de preservação do resultado.

Taking into account that the peri-implantitis is of multifactorial etiology, although the determining factor is the dental biofilm, it is interesting to look for ways to minimize the bone losses that have occurred. Thus, although safeguards can be made to the concrete possibility of obtaining a guided tissue regeneration, it can be understood as a valid alternative to seek to at least stabilize the process of progression of this loss. Concomitantly to this procedure and in view of the indication of vestibuloplasty for better prevention of recurrence of peri-implantitis, it was possible in a single surgical intervention to obtain a favorable result within the proposed objective. Material and methods: a 68-year-old female patient, moderate smoker (8-10 cigarettes/day) presented with purulent exudate on the mesiobuccal surface of the implant in the region of the 46. After the acute phase, through local physiotherapy, the patient underwent to peri-implant surgery aiming the interception of bone loss by means of "guided tissue regeneration" associated with vestibuloplasty with the use of subepithelial gingival graft. Results: it was possible to obtain a stabilization of the bone loss, as well as a decrease in the depth of probing, besides the reduction of exudate in the implant under discussion. Conclusion: the vestibuloplasty created better anatomical structural conditions due to the keratinized tissue obtained, and above all, the favorable access to brushing throughout the four implants, predicting a better possibility of preservation of the result.

Expansion of the peri-implant attached gingiva with a three-dimensional collagen matrix in head and neck cancer patients-results from a prospective clinical and histological study.

OBJECTIVES: Attached peri-implant gingiva has proven to have an influence on the long-term stability of dental implants. In patients with head and neck cancer, a functional peri-implant gingiva is even more of critical importance. The aim of the presented prospective study was to investigate a three-dimensional xenogeneic collagen matrix for augmentation around dental implants in patients with former head and neck cancer. MATERIAL AND METHODS: Eight patients presenting with insufficient peri-implant gingiva underwent vestibuloplasty on 51 implants using a xenogeneic collagen matrix. The clinical performance and the shrinking tendency of the matrix were analyzed in a cohort study. Furthermore, eight biopsies from the augmented regions were examined histologically to determine the biomaterial-related tissue reaction. RESULTS: Initially after vestibuloplasty, a mean width of attached gingiva of 4.4 ± 0.94 mm could be achieved. At clinical follow up investigation 6 months after vestibuloplasty, a mean width of 3.9 ± 0.65 mm attached peri-implant gingiva with a mean shrinking tendency of 14 % could be detected. Histological analysis of the biopsies revealed a well integrated collagen22 matrix covered with epithelium. Within the compact layer, mononuclear cells were observed only, while the spongious layer was infiltrated with a cell-rich connective tissue. CONCLUSION: Within its limits, the presented study revealed that the investigated collagen matrix is suitable to enlarge the peri-implant attached gingiva in head and neck cancer patients without adverse reactions or a multinucleated giant cell-triggered tissue reaction. CLINICAL RELEVANCE: The application of the investigated three-dimensional collagen matrix in vestibuloplasty achieved a sufficient amount of peri-implant attached gingiva in head and neck cancer patients. The favorable tissue reaction and the low shrinking tendency make the collagen matrix a promising alternative to autologous tissue grafts.

Natural teeth-retained splint based on a patient-specific 3D-printed mandible used for implant surgery and vestibuloplasty: A case report.

RATIONALE: With respect to improving the quality of oral rehabilitation, the management of keratinized mucosa is as important as bone condition for implant success. To enhance this management, a natural teeth-retained splint based on a patient-specific 3-dimensional (3D) printed mandible was used in vestibuloplasty to provide sufficient keratinized mucosa around dental implants to support long-term implant maintenance. PATIENT CONCERNS: A 28-year-old male patient had a fracture of the anterior andible 1 year ago, and the fracture was treated with titanium. DIAGNOSES: The patient had lost mandibular incisors on both the sides and had a shallow vestibule and little keratinized mucosa. INTERVENTIONS: In the first-stage implant surgery, 2 implants were inserted and the titanium fracture fixation plates and screws were removed at the same time. During second-stage implant surgery, vestibuloplasty was performed, and the natural teeth-retained splint was applied. The splint was made based upon a patient-specific 3D-printed mandible. At 30-day follow-up, the splint was modified and reset. The modified splint was removed after an additional 60 days, and the patient received prosthetic treatment. OUTCOMES: After prosthetic treatment, successful oral rehabilitation was achieved. Within 1 year and 3 years after implant prosthesis finished, the patient exhibited a good quantity of keratinized gingiva. LESSONS SUBSECTIONS: The proposed splint is a simple and time-effective technique for correcting soft tissue defects in implant dentistry that ensures a good quantity of keratinized mucosa.

[Dental implantation and soft tissue augmentation after ridge preservation in a molar site: a case report].

For ideal implant rehabilitation, an adequate bone volume, optical implant position, and stable and healthy soft tissue are required. The reduction of alveolar bone and changes in its morphology subsequent to tooth extraction will result in insufficient amount of bone and adversely affect the ability to optimally place dental implants in edentulous sites. Preservation of alveolar bone volume through ridge preservation has been demonstrated to reduce the vertical and horizontal contraction of the alveolar bone crest after tooth extraction and reduce the need for additional bone augmentation procedures during implant placement. In this case, a patient presented with a mandible molar of severe periodontal disease, the tooth was removed as atraumatically as possible and the graft material of Bio-Oss was loosely placed in the alveolar socket without condensation and covered with Bio-Gide to reconstruct the defects of the alveolar ridge. Six months later, there were sufficient height and width of the alveolar ridge for the dental implant, avoiding the need of additional bone augmentation and reducing the complexity and unpredictability of the implant surgery. Soft tissue defects, such as gingival and connective tissue, played crucial roles in long-term implant success. Peri-implant plastic surgery facilitated development of healthy peri-implant structure able to withstand occlusal forces and mucogingival stress. Six months after the implant surgery, the keratinized gingiva was absent in the buccal of the implant and the vestibular groove was a little shallow. The free gingival graft technique was used to solve the vestibulum oris groove supersulcus and the absence of keratinized gingiva around the implant. The deepening of vestibular groove and broadening of keratinized gingiva were conducive to the long-term health and stability of the tissue surrounding the implant. Implant installation and prosthetic restoration showed favorable outcome after six months.

Use of a 10,600-nm CO2 Laser Mandibular Vestibular Extension in a Patient With a Chromosomal Abnormality.

Vestibuloplasty involves a series of surgical procedures designed to restore alveolar ridge height by lowering the muscles attached to the buccal, labial, and lingual aspects of the jaws. The technique is indicated in cases of insufficient vestibular depth that may result from atrophy of the alveolar ridge and/or high attachment of muscle or movable mucosa. This article focuses on a carbon dioxide (CO2) laser vestibular extension procedure performed in a patient with Klinefelter syndrome, which is caused by a chromosomal abnormality. The 10,600-nm CO2 laser is shown to offer several advantages over a conventional scalpel and other laser wavelengths for soft-tissue pre-prosthetic surgery, including vestibular extension.

Soft tissue augmentation procedures at second-stage surgery: a systematic review.

OBJECTIVES: The aim of this systematic review was to evaluate the efficacy of different soft tissue augmentation/correction methods in terms of increasing the peri-implant width of keratinized mucosa (KM) and/or gain of soft tissue volume during second-stage surgery. MATERIALS AND METHODS: Screening of two databases, MEDLINE (PubMed) and EMBASE (OVID), and hand search of related articles, were performed. Human studies reporting on soft tissue augmentation/correction methods around submucosally osseointegrated implants during second-stage surgery up to July 31, 2015 were considered. Quality assessment of the selected full-text articles was performed according to the Cochrane collaboration's tool to assess the risk of bias. RESULTS: Overall, eight prospective studies (risk of bias: high) and two case series (risk of bias: high) were included. Depending on the surgical technique and graft material used, the enlargement of keratinized tissue (KT) ranged between -0.20 and 9.35 mm. An apically positioned partial-thickness flap/vestibuloplasty (APPTF/VP) in combination with a free gingival graft (FGG) or a xenogeneic graft material (XCM) was most effective. Applying a roll envelope flap (REF) or an APPTF in combination with a subepithelial connective tissue graft (SCTG), mean increases in soft tissue volumes of 2.41 and 3.10 mm, respectively, were achieved. Due to the heterogeneity of study designs, no meta-analysis could be performed. CONCLUSIONS: Within the limitations of this review, regarding the enlargement of peri-implant KT, the APPTF in the maxilla and the APPTF/VP in combination with FGG or XCM in the lower and upper jaw seem to provide acceptable outcomes. To augment peri-implant soft tissue volume REF in the maxilla or APPTF + SCTG in the lower and upper jaw appear to be reliable treatment options. CLINICAL RELEVANCE: The localization in the jaw and the clinical situation are crucial for the decision which second-stage procedure should be applied.

Long-term outcomes after vestibuloplasty with a porcine collagen matrix (Mucograft® ) versus the free gingival graft: a comparative prospective clinical trial.

OBJECTIVES: Porcine collagen matrices are proclaimed being a sufficient alternative to autologous free gingival grafts (FGG) in terms of augmenting the keratinized mucosa. The collagen matrix Mucograft® (CM) already showed a comparable clinical performance in the early healing phase, similar histological appearance, and even a more natural appearance of augmented regions. Predictability for long-term stability does not yet exist due to missing studies reporting of a follow-up >6 months. MATERIAL AND METHODS: The study included 48 patients with atrophic edentulous or partially edentulous lower jaw situations that had undergone an implant treatment. In the context of implant exposure, a vestibuloplasty was either performed with two FGGs from the palate (n = 21 patients) or with the CM (n = 27 patients). Surgery time was recorded from the first incision to the last suture. Follow-up examinations were performed at the following time points: 10, 30, 90, and 180 days and 1, 2, 3, 4, and 5 years after surgery. The width of keratinized mucosa was measured at the buccal aspect of each implant, and augmented sites were evaluated in terms of their clinical appearances (texture and color). RESULTS: The groups showed similar healing with increased peri-implant keratinized mucosa after surgery (FGG: 13.06 mm ± 2.26 mm and CM: 12.96 mm ± 2.86 mm). The maximum follow-up was 5 years (5 patients per group). After 180 days, the width of keratinized mucosa had decreased to 67.08 ± 13.85% in the FGG group and 58.88 ± 14.62% in the CM group with no statistically significant difference. The total loss of the width of keratinized mucosa after 5 years was significant between the FGG (40.65%) and the CM group (52.89%). The CM group had significantly shorter operation times than the FGG group. Augmented soft tissues had a comparable clinical appearance to adjacent native gingiva in the CM group. FGGs could still be defined after 5 years. CONCLUSIONS: The FGG and the CM are both suitable for the regeneration of the peri-implant keratinized mucosa with a sufficient long-term stability. With the CM, tissue harvesting procedures are invalid, surgery time can be reduced, and regenerated tissues have a more esthetic appearance.

Soft tissue grafting to improve the attached mucosa at dental implants: A review of the literature and proposal of a decision tree.

BACKGROUND: Scientific data and clinical observations appear to indicate that an adequate width of attached mucosa may facilitate oral hygiene procedures thus preventing peri-implant inflammation and tissue breakdown (eg, biologic complications). Consequently, in order to avoid biologic complications and improve long-term prognosis, soft tissue conditions should be carefully evaluated when implant therapy is planned. At present the necessity and time-point for soft tissue grafting (eg, prior to or during implant placement or after healing) is still controversially discussed while clinical recommendations are vague. OBJECTIVES: To provide a review of the literature on the role of attached mucosa to maintain periimplant health, and to propose a decision tree which may help the clinician to select the appropriate surgical technique for increasing the width of attached mucosa. RESULTS: The available data indicate that ideally, soft tissue conditions should be optimized by various grafting procedures either before or during implant placement or as part of stage-two surgery. In cases, where, despite insufficient peri-implant soft tissue condition (ie, lack of attached mucosa or movements caused by buccal frena), implants have been uncovered and/or loaded, or in cases where biologic complications are already present (eg, mucositis, peri-implantitis), the treatment appears to be more difficult and less predictable. CONCLUSION: Soft tissue grafting may be important to prevent peri-implant tissue breakdown and should be considered when dental implants are placed. The presented decision tree may help the clinician to select the appropriate grafting technique.

Full-mouth rehabilitation of a patient with ectodermal dysplasia with dental implants.

Oral findings in patients with ectodermal dysplasia (ED) include complete or partial hypodontia, anodontia, loss of vertical dimension of occlusion, protuberant lips, malformed and widely spaced conical-shaped teeth, and underdeveloped alveolar ridges. These patients present a substantial challenge in dental treatment. This case report presents oral rehabilitation of a 22-year-old male patient diagnosed with ED using an implant tooth-supported telescopic partial denture at the mandible and a tooth-supported telescopic partial denture at the maxilla. Implants in the mandible were placed at the sites of the right and left lateral incisor teeth. Following implant placement, the remaining buccal bone dehiscence was filled with deproteinized bovine bone graft and covered with resorbable membrane. To manage the vestibular insufficiency and to increase the keratinized mucosa in maxilla, bilateral acellular dermal matrix allograft was used on the right and left buccal aspects. The treatment described here improved the patient's functional and esthetic status while significantly restoring his oral health and self-esteem.

Palatal osteotomy with vestibuloplasty for the treatment of severe maxillary atrophy: a new twist on an old technique.

Nowadays, upper denture instability secondary to severe maxillary atrophy is treated, in most cases, with dental implants. However, a significant number of patients cannot afford this procedure. Palatal bone deepening through a U-shaped osteotomy has been described previously. The procedure increases retention by improving the suction effect of the palate and prevents anteroposterior and lateral movement of the denture. By combining this procedure with a secondary epithelialization vestibuloplasty, the labial aspect of the ridge is also extended and it does not require a skin graft. This article describes a modification of the palatal vault osteotomy through the presentation of a case.

Efficacy of soft tissue augmentation around dental implants and in partially edentulous areas: a systematic review.

AIM: To review the dental literature in terms of efficacy of soft tissue augmentation procedures around dental implants and in partially edentulous sites. METHODS: A Medline search was performed for human studies augmenting keratinized mucosa (KM) and soft tissue volume around implants and in partially edentulous areas. Due to heterogeneity in between the studies, no meta-analyses could be performed. RESULTS: Nine (KM) and eleven (volume) studies met the inclusion criteria. An apically positioned flap/vestibuloplasty (APF/V) plus a graft material [free gingival graft (FGG)/subepithelial connective tissue graft (SCTG)/collagen matrix (CM)] resulted in an increase of keratinized tissue (1.4-3.3 mm). Statistically significantly better outcomes were obtained for APF/V plus FGG/SCTG compared with controls (APF/V alone; no treatment) (p < 0.05). For surgery time and patient morbidity, statistically significantly more favourable outcomes were reported for CM compared to SCTGs (p < 0.05) in two randomized controlled clinical trials (RCTs), even though rendering less keratinized tissue. SCTGs were the best-documented method for gain of soft tissue volume at implant sites and partially edentulous sites. Aesthetically at immediate implant sites, better papilla fill and higher marginal mucosal levels were obtained using SCTGs compared to non-grafted sites. CONCLUSIONS: An APF/V plus FGG/SCTG was the best-documented and most successful method to increase the width of KM. APF/V plus CM demonstrated less gain in KM, but also less patient morbidity and surgery time compared to APF/V plus SCTG based on two RCTs. Autogenous grafts (SCTG) rendered an increase in soft tissue thickness and better aesthetics compared to non-grafted sites.

Early bone resorption of free microvascular reanastomized bone grafts for mandibular reconstruction--a comparison of iliac crest and fibula grafts.

OBJECTIVES: Patients with continuous bone defects of the mandible after ablative tumor surgery need bony reconstruction for proper function and aesthetics. Free microvascular reanastomized bone grafts provide a clinically proven option for such patients, yet the optimal source of donor tissue has not yet been established. The aim of this study was to evaluate and compare the bone volume stability of vascularized bone grafts, particularly in the early highly resorptive phase, from the iliac crest (DCIA) and the fibula and to assess the implantologic rehabilitations. MATERIALS AND METHODS: Thirty-six patients with mandibular continuity defects due to tumor resection were reconstructed by the use of vascularized bone grafts; 21 patients received DCIA flaps and 15 patients received a composite free fibular flap, depending on the size and location of the defect. Bone resorption was assessed using digital panographs. Radiographs were taken immediately after bone reconstruction, 6 months postoperatively, prior to implant surgery, and at prosthetic loading. RESULTS: After a mean observation period of 6 months, vertical bone resorption was 6.79% for the patients of the iliac crest group (DCIA), 10.20% after 11 months, and 12.58% after 17 months. Fibular grafts showed a bone resorption of 5.30% after a mean observation time of 6 months, 8.26% after 11 months, and 16.95% after 17 months. Eighteen patients received 71 implants for implant-retained dental reconstructions. CONCLUSIONS: Microvascular reanastomized bone grafts represent a reliable treatment option for reconstruction in cases of large defects of the mandible, with low graft resorption in the early healing phase. Additionally, the compared grafts provide sufficient bone volume to permit implant rehabilitation.

Complex mandibular reconstruction after a partial mandibulectomy with a fibula free graft: a clinical report.

This report describes the surgical and prosthetic reconstruction of a partial mandibular resection due to an osteomyelitic variant with a free fibula microvascular graft, dental implant placement, and reconstruction with a computer-aided design/computer-aided manufacturing (CAD/CAM) partial fixed dental prosthesis. A team composed of a prosthodontist, oral and maxillofacial surgeon, and otolaryngologist was required to treat and restore the patient to near normal comfort and function.