Timing of soft tissue augmentation around implants: A clinical review and decision tree.

PURPOSE: The goal of soft tissue augmentation is to improve the volume around implants and thus achieve better aesthetic and functional properties. The present review aims to make recommendations and guide clinicians in performing soft tissue augmentation procedures, focusing on the importance of timing. OVERVIEW: Soft tissue augmentation can be performed at different time points: before or after implant placement, at implant placement (immediate/delayed), at healing abutment connection or after final restoration. Before/after implant placement or at healing abutment connection are considered the gold standard time points at which to perform soft tissue augmentation due to the possibility of achieving complete coverage of the soft tissue graft or its substitute through simple flap elevation and the easy handling of tissue. On the other hand, performing soft tissue augmentation at implant placement or after crown delivery seems to be less predictable due to the different healing approaches and the unexpected shrinkage that occurs. CONCLUSION: Timing needs to be considered when performing soft tissue augmentation, taking into account the advantages and disadvantages related to operator experience, implant position and patient expectations. Employing a reliable approach at the appropriate time of intervention could limit complications.

Keratinized mucosa width assessment at implant sites using high-frequency ultrasonography.

BACKGROUND: The aim of this study was to describe the application of high-frequency ultrasonography (HFUS) for assessing keratinized mucosa (KM) width at implant sites. METHODS: KM width was measured at 28 implant sites exhibiting a peri-implant soft tissue dehiscence at baseline and 12 months after soft tissue augmentation. KM width assessment was performed with a periodontal probe [clinical assessment (clKM)] and with HFUS, based on the echointensity of the keratinized epithelium compared to the adjacent structures. KM width measurements on ultrasound scans were performed linearly (lnKM) and along the soft tissue profile [surface distance (sdKM)]. RESULTS: No statistically significant differences were observed between clKM, lnKM, and sdKM at baseline, while at 12 months, sdKM (5.313 ± 1.188 mm) was significantly higher than clKM (3.98 ± 1.25 mm) and lnKM (4.068 ± 1.197 mm) (P < 0.001 for both comparisons). A linear relationship between mucosal thickness (MT) and the difference between sdKM and lnKM was observed. In 95.2% of cases with MT > 2.51 mm, the discrepancy between sdKM and lnKM was at least 1 mm. CONCLUSIONS: HFUS is a noninvasive and valuable tool for measure KM width at implant site. Evaluating KM width along the soft tissue profile as a surface distance may improve the accuracy of the assessment.

The peri-implant mucosa color: A systematic appraisal of methods for its assessment and clinical significance.

BACKGROUND: Peri-implant mucosa color (PMC) seems to be one of the main parameters affecting the esthetic outcome of implant therapy. However, more emphasis should be given to its assessment and reporting. PURPOSE: To describe the available evidence on methods to assess and report the color of the peri-implant mucosa (PMC) and the respective clinical relevance. MATERIAL AND METHODS: A comprehensive electronic and manual search was performed to identify clinical studies reporting on PMC. RESULTS: A total of 121 studies were included. PMC was evaluated at the time of the follow-up visit (chairside) in 45.5% studies. PMC assessment was performed qualitatively, by comparing PMC with adjacent and/or contralateral gingiva (78.6%) or quantitatively, using spectrophotometry (20.7%) or a software on clinical photographs (0.8%). The most performed method to assess PMC was through esthetic indices (76.9%), either at the time of the follow-up visit (chairside) or at later time point using photographs. Quantitative reporting of PMC included averages of points from esthetic indices or color differences to natural gingiva expressed with the CIELAB color system. PMC assessment allowed describing color discrepancies compared to natural gingiva, evaluating color changes over time, and comparing the outcomes of different treatment modalities. PMC assessment through spectrophotometry was additionally utilized to assess the role of mucosal thickness (MT) on PMC. CONCLUSIONS: Various methods for PMC assessment and reporting were described, including visual assessment, mainly through esthetic indices, and spectrophotometry. PMC evaluation has allowed to demonstrate the factors affecting the color of the peri-implant soft tissue, such as the type of abutment/restoration, MT, and soft tissue augmentation.

Reliability assessment of the classification for facial peri-implant soft tissue dehiscence/deficiencies (PSTDs): A multi-center inter-rater agreement study of different skill-level practitioners.

BACKGROUND: Along with the popularity of dental implants, implant esthetic complications are also on the rise. Recently a classification was proposed to comprehensively evaluate these conditions, with the definition of peri-implant soft tissue dehiscence/deficiencies (PSTDs). The aim of this article was therefore to test the inter-examiner agreement when utilizing the established rubrics among 25 standardized cases and 34 clinicians of different skill levels. METHODS: Twelve periodontal residents, 12 general dentists, and 10 periodontists participated in this study. All examiners were provided with photographs of 25 single PSTDs and asked to rate all cases based on the proposed classification at a single timepoint. Variance components analysis was conducted with multilevel regression fit in a Bayesian framework to obtain uncertainty intervals for fractional variance contributions and interclass correlation values (ICC) to assess the agreement in the rating of all cases, among all examiners, different skill-level practitioners, and to compare their responses relative to the judgment of a gold standard examiner. RESULTS: Overall, the results showed reproducible and consistent responses among the 34 examiners, and in each subgroup of skill-level, comparable to that of the gold examiner. Nevertheless, periodontists and residents were more likely to agree with the response of the gold standard examiner in their assessments of class and subclass of the PSTDs. CONCLUSIONS: The proposed PSTD classification showed reproducible assessments among all examiners, and between examiners of the same skill-level. The response of the gold standard examiner was more in line with the assessment of the periodontists and periodontal residents.